“Cedars-Sinai Doctors Cling to Pen and Paper,” read a 2005 Washington Post headline. The article described how the Los Angeles academic health center shelved its initial home-built electronic health record three months after launch because physicians refused to use the clunky system.

Some 13 years and a new Epic EHR later, the mutiny is difficult to conjure. Cedars-Sinai Medical Center is among the first 162 hospitals to achieve HIMSS Stage 7 on its EMRAM scale, the highest level of EHR progress, and nearly 100 percent of clinicians now document orders electronically.

Yet CIO and Senior Vice President Darren Dworkin remembers the not-so-long-ago days when Cedars-Sinai measured EHR success primarily by the percentage of clinicians documenting on paper. “When we first implemented our EMR, we were focused on achieving adoption,” he says. “A lot of our measurements were engagement metrics.”

After spending 10 years building and optimizing its system to enlist clinician support, as well as adding data analytic, health exchange, and other capabilities, Cedars-Sinai expects to reap a hard-fought return on investment (ROI) in the form of dramatically improved patient outcomes and efficiencies as well as lower costs and increased revenues. “We’ve come a long way, and we have become a lot more focused—appropriately so—on realizing the value embedded within our EMR,” Dworkin says.

Cedars-Sinai

Cedars-Sinai’s journey illustrates how the ROI builds over time on the EHR, which has become a necessary — and multi-million to billion dollar — cost of doing business in healthcare. “It’s become a utility you need to have, sort of like how you need to have heat and air conditioning,” says HFMA’s Richard L. Gundling, senior vice president of healthcare financial practices.

Initial positive returns on EHR investments can be attained after switching from paper to electronic records and adopting basic analytic and population health capabilities (such as patient registries and clinical decision support). For instance, Cedars-Sinai has reduced unnecessary tests and treatments, such as CT scans and lab tests, and other organizations have improved vaccination and infection rates, increased billing collections and reduced inefficiencies.

But these early returns are rarely sizeable enough to cover EHR costs and are not even guaranteed. In a 2017 survey of 1,100 healthcare professionals, only 10 percent reported a positive or superb return. The rest described the ROI as terrible, poor or mediocre.

Patience and proactive planning are needed, say HIT leaders. A greater ROI is waiting around the corner, assuming organizations invest time and dollars in critical strategies and technologies.

Getting the Essentials Right

A key, but challenging, imperative in any IT implementation is, “Do you just pave the cow path or do you create a new path?” says Gundling. “In other words, do you electronically do what you’ve always done, or do you take advantage of the opportunity to change things?”

According to Blain Newton, executive vice president for HIMSS Analytics, focusing on processes and people is as important as adopting technology. “If you just come in and implement an EMR on top of the same processes you had with a paper-based system and don’t provide training to staff, you’re probably not going to realize value.”

Standardizing documentation. NOMS Healthcare, a multispecialty practice with locations across Northern Ohio, learned this lesson firsthand. In 2014, leaders realized they needed to replace their EHR. “Each provider had their own way of documenting,” says Rebecca Rohrbach, vice president of population health. “We were unable to extract accurate registries of patients with chronic conditions. For example, we were unable to extract patients with uncontrolled diabetes who had an A1c over nine.”

When NOMS launched a new EHR, eClinicalWorks, IT leaders focused on standardizing documentation, particularly for quality metrics the organization was tracking. “We’ve learned that it’s not just about documenting what you’ve done, but documenting it in a manner in which it can be easily extracted,” says Jennifer Hohman, MD, executive vice president.

This effort involved creating standardized templates and order sets within the EHR, as well as decision-support notifications. In addition, NOMS invested heavily in training all team members on the correct place to enter information.

Streamlining documentation. In the early years of EHR adoption, many hoped that the switch from paper to electronic records would reduce the documentation workload and improve efficiencies. Instead, documentation demands are rising, contributing to physician and nurse burnout rates. “We’re asking clinicians to do a lot more documentation, particularly around regulatory and billing [requirements], which has eroded hopes that we would achieve any time savings,” says Dworkin.

While healthcare organizations have little control over regulatory demands, they can try to reduce the total documentation burden by simplifying documentation when possible. For instance, when might clinicians check a box instead of typing paragraphs of explanation?

“Physicians, nurses, and other clinicians might get together and say, ‘What do we really need [in terms of documentation]? How can we take advantage of technology to streamline this?’” Gundling says.

Adopting a team approach to documentation can also ease the burden on physicians and other providers. “The provider is ultimately responsible, of course, but team members can help by gathering and entering the information for them,” Hohman says.

Redesigning care and operations. EHR implementation and optimization offers an opportunity to drive clinical improvement, stresses Henry Ford Health System CIO Paul Browne. “The technology is a means to the end, where the end is higher-quality, safer care at a lower cost,” he says.

Before launching its Epic EHR in 2011, the Detroit-based health system brought together clinical and operational leaders from across the organization to identify opportunities for standardizing and improving practices and processes. “Then we built the EMR to enable those things,” says Geoffrey Patterson, vice president of clinical transformation. “We think of our EMR as a hammer we use in building our house.”

For instance, the EHR has helped Henry Ford clinicians reduce venous thromboembolism (VTE) cases, or blood clots, by 30 percent among inpatients. Evidence-based protocols, workflows and order sets for preventing and treating VTEs were embedded into the EHR with alerts to remind clinicians to follow these standardized practices. In addition, a VTE risk assessment model was built and automated to proactively notify clinicians of patients at risk of developing a VTE.

Henry Ford’s cross-discipline improvement approach has been key to the organization’s success. The 200-person team that collaborated on the health system’s EHR launch reported up through the COO’s office (not the CIO’s), and was made up of approximately two thirds clinical and operational staff and only one third technology staff. “The No. 1 key is to have clinicians very, very involved from the inception of these efforts, and thoughtfully placing clinical leaders in roles where they’re leading the effort,” Browne says.

Addressing usability. While meaningful use incentives helped drive EHR adoption, usability got sidelined as vendors rushed to build systems that complied with federal requirements. “You’re starting to see a lot of larger vendors dedicating a lot of time and energy to solving some of the challenges around usability and interoperability,” Newton says.

In the meantime, healthcare organizations might consider developing physician champions to help fellow clinicians learn how to use the EHR and understand how the technology is impacting patients, recommends HIMSS Steve Wretling, chief technology and innovation officer.

Another usability hot button is alert fatigue. At Henry Ford, committees of clinicians develop best practices for alert usage in the EHR. IT staff also monitor how often alerts result in clinicians taking action. “You can fire alerts like flash bulbs, but they are not always useful,” Patterson says.

Defining and Tracking Success

As is typical of board of directors, Henry Ford trustees want to understand the return that the health system is getting from its EHR investment. “During the early days of the project, we reported progress to a board subcommittee,” Patterson says. “[They wanted to know] ‘Were we proceeding as we thought we would? Were we running up against any barriers?’ Once implementation started, we began reporting on the costs and benefits.”

Considering the business case of IT projects has now become part of the vocabulary at Henry Ford, Patterson says. “We project the benefits and, through the course of project delivery, we measure the return so we can track whether we were successful or if there are areas we can enhance.”

Weighing the ROI is an important exercise, Gundling says. “It makes sense to step back and ask, ‘Did we get what we thought we would?’ However, it’s not just about the return from the IT, but also how did you improve patient care and the patient experience? For instance, did you improve redundant testing? Did you reduce patient falls? It [your analysis] should be centered around quality and safety, followed by finance.”

Browne recommends thinking about both quantitative and qualitative returns when defining and measuring EHR success.

Quantitative ROI. “This looks at, ‘What metrics are we going to move, in what direction, and how fast?’ ” Browne says.

For instance, NOMS Healthcare significantly increased the percentage of patients receiving recommended pneumonia vaccinations from 33 percent to 83 percent between 2013 and 2016, in part by alerting team members and providers via the EHR when patients needed to be immunized.

NOMS leaders wanted to validate the effectiveness of this intervention in improving health outcomes and the cost of care. By digging deeper, they found that the hospitalization rate for bacterial pneumonia among NOMS patients decreased from 14.65 percent in 2013 to 6.46 percent in 2016 — during the same period the pneumonia vaccination rate rose.

Qualitative ROI. “In addition to identifying the metrics you want to move, you need to be able to describe a vision of what the future might look like,” Browne says. “How will people experience care differently? How do we enable that with technology?”

Stories or anecdote can be an effective way to describe qualitative returns, Browne says. “You might describe how clinical decision support caught a potential prescription error, preventing harm to a patient. Or you might tell a story about a future where patients don’t have to leave their home to visit with their doctor.”

Investing in Advanced Capabilities “We’re starting to see a lot of [EHR] optimization tools coming into play and really driving improvements in cost and quality, whether it be advanced analytical decision support or telehealth,” Newton says.

Dworkin believes two capabilities hold the greatest potential to drive ROI.

Interoperability. To ensure that other hospitals, ambulatory centers, pharmacies, and others can exchange needed information, Cedars-Sinai “has joined every conceivable network we can,” Dworkin says. To connect with organizations outside the Epic network, the medical center uses the Carequality interoperability framework, which links up disparate EHR vendors and government sources. Cedars-Sinai also readily creates point-to-point or custom interfaces.

“Our general philosophy has been, ‘It’s not our data. We’re just the custodians, and we are happy to pass it on at the patient’s request to anybody it makes sense to share with,’ ” Dworkin says.

Cedars-Sinai exchanges a record every three seconds 365 days a year. This “liquidity” of information is vital to reducing duplicate imaging and lab tests as well as ensuring that clinicians have detailed medical histories on patients to provide safe, effective care. “Having medical records easily shared between locations, especially in large, urban cities like Los Angeles where individuals tend to get care are more than one place, offers clear safety and ROI benefits,” Dworkin says.

Data analytics and decision support. In the area of decision support, Cedars-Sinai is focused on giving clinicians the right information at the right time to make appropriate and effective decisions. “The idea is to layer suggestions or reminders on top of our EMR that act as ticklers for busy practicing clinicians and give them some guidance and options they might not have otherwise considered,” Dworkin says. “If you can do this when the clinician is still in front of the patient, very often they can make a very real-time decision and alter their recommendation.”

For example, a home-grown clinical decision support software, called Stanson Health, is helping physicians weigh guidelines from the ABIM Foundation’s Choosing Wisely campaign, which has issued 540 evidence-based recommendations on tests and treatments to avoid. Developed by Cedars-Sinai’s Scott Weingarten, MD, senior vice president and chief clinical transformation officer, the software has helped the medical center significantly reduce unnecessary tests and treatments, including orders for blood transfusions and prescriptions for the sleep medication benzodiazepine for elderly patients.

“In our mind, these guidelines are going after the Holy Grail,” Dworkin says. “They pointing out practices that we shouldn’t do, not only because it will save money but also because it’s better for the patient not to do them.”
Preparing to Embrace Future Innovation As healthcare leaders think about further improving the ROI on their EHR investments, they need to be ready to adopt innovative technologies coming down the pike — from artificial intelligence to patient engagement platforms, says Wretling. “That means thinking about ‘How do I make sure that the technology and processes we have will integrate with new and disruptive technologies as they become available.’”

To prepare, IT leaders should create guidelines that spell out the integration and semantic standards (such as HL7, FHIR, LOINC and SNOMED) their organizations want to embrace. “This will allow them to make quick and easy purchasing decisions for technology that enables their overall future plan,” Wretling says.

Seeking input from clinical partners is also key to selecting new technology that will meet a true need, Patterson says. “Rarely do I go to my clinical partners and say, ‘Here’s this really cool technology that I think we should implement.’ Instead, we use a ‘seek first to understand before you are understood’ approach. We meet with clinical and operational leaders frequently to understand where some of their challenges are. Only then can we look for technology that can help. Technology needs to be an enabler, not a driver.”

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