Replacing an EHR comes with many challenges and costs
The vast majority of healthcare provider organizations use electronic health records and physician practice management systems to manage the care they give to patients.
Over time, functionality in the EHR and PPM systems can’t keep up with emerging demands, often compelling an organization to initiate a search for new systems. Often idyllically viewed as an easy answer to emerging challenges, switching systems often offers a gauntlet of challenges.
As healthcare organizations rethink their original—or even second or third—system choices, they often take on new—and sometimes, unexpected—problems and costs.
At Baptist Health System, a five-hospital delivery system with 45 primary care offices in Jacksonville, Fla., the investment in new systems—which included setting up multiple EHRs for different types of specialties—on a single platform was significant, recalls Roland Garcia, senior vice president and chief information officer.
“The return on investment is being able to have one platform,” he adds. “As we gathered data and achieved standardization, it was more efficient to manage the same platform used in our 220-provider practice.”
Operating costs and time were reduced by maintaining one platform with a shared chart and standardization of how to record treatments in the EHR. The platform supported a range of specialty practices, covering 438 providers in total.
The transition to a new platform, upgrading to the Allscripts TouchWorks EHR, was planned to take four weeks and actually took another two weeks, covering about 100 geographic locations. But the result ushered in a series of improvements for the organization, according to Garcia.
“We were able to better review workflows, capture charges and improve documentation to support the charges. We had voice recognition that gave efficiencies, a common chart for treating patients and improved network management for referralls because of a common platform.”
Allscripts also provided additional support, such as best practices for cardiologists based on what existing cardiology clients had learned.
Importantly, during the transition Baptist Health did not lose physicians. “We made a commitment to them,” Garcia said. “We will transition and make your life better.”
The first step to a better life was a decision to start with tackling problem lists. There was not a single way to generate a problem list. Too often, important information was missing. A physician may note that a patient is a diabetic but not mention what type of diabetes the patient had. Absent data governance, managing a comprehensive problem list is a big challenge, so it often doesn’t get done, Garcia cautions.
“Previously, we had everyone using their own EHR and their own workflows, and now we have a standard process for how workflow actually flows as everyone works off the same platform. In reality, you can’t devote enough resources to maintain multiple platforms to the highest level, but you can consolidate those platforms on one platform.”
Time to Take Stock
Some provider organizations that have used their EHR for years are supporting 3,000 or more applications via the EHR and supporting modules. “Think about that—it’s crazy,” says Michael Mytych, owner of Health Information Consulting in Menomonee Falls, Wis.
IT staffs are swamped—there’s no time for new initiatives or anything else but serving all those applications, making these providers strong candidates for a new EHR.
In Mytych’s view, there are only a small handful of vendors that hospitals, if they can afford it, should consider in the age of population health management and value-based care—on his personal short list is Epic, Cerner and, to a lesser extent, Meditech.
Some providers merge with other providers hoping to become more competitive, but such moves could drive the value out of investments that are better needed for succeeding with value-based care and population health. Simply put, the coming challenge of interoperability by itself is enough to justify a move to the top vendors, Mytych believes.
Other vendors may have lower costs of operations, but the return on investment might turn out to be disappointing, Mytych contends. “You may have lower cost, but be honest about the total cost of ownership of what you already have and the penalty cost you could have with the lack of interoperability.”
While some Meditech clients may kick the tires of other vendors, they generally stay because of the price difference compared with Epic or Cerner, or they may consider other hospital vendor systems, such as those of CPSI, athenahealth, McKesson or Medhost.
Overall, however, Epic and Cerner have made it easier for providers to jump on the platforms, have access to a wide variety of tools, Mytych says, contending providers just pay for maintenance, implementation and annual support fees, with no additional costs for licenses or streamlined licenses.
But of course, nothing is that easy. “When moving to a new platform, the planning process to go through and figure out total cost of ownership is a significant effort with lots of moving pieces,” Mytych says. “There are internal nuances across venues of care, with lots of embedded workflows, workarounds and knowledge of software. The record transition is tricky and will have an impact on your analytics program. And, think of all the clinical service lines that need to be interoperable with the EHR.”
Forced to Switch
Some providers still run on homegrown EHR systems, but they are a dying breed—many homegrown EHRs are difficult to maintain and keep them current with the EHR meaningful use requirements, says Dean Sittig, a professor of biomedical informatics at UT Health in Houston.
“When you build your own software, the costs are hard to budget, but when you buy a system, you’ll know how much you will spend this year and next year,” he explains. “This brings stability, even though it might cost more. It reduces uncertainty.”
For a major healthcare delivery system, the cost of an EHR and supporting modules can be breath-taking—approaching or surpassing $1 billion, and maybe another $1 billion for implementation, says Ross Koppel, an adjunct professor of sociology at the University of Pennsylvania specializing in health IT and the interactions of people, computers and workplaces. And those costs don’t count customization, as EHRs are not plug and play.
Integrating the EHR with other technology systems across the enterprise results in a slew of additional costs—that can involve linking to the pharmacy, lab, outside labs, suppliers, therapists, dietary, surgical and other entities.
Making an EHR swap will require more IT personnel than envisioned for implementing, optimizing and going live. There is a moving part waiting to be a problem in every facet of an EHR implementation or enhancement. “The number of moving parts is just extraordinarily high,” Koppel says.
Privacy considerations are among these moving parts, and the EHR is full of intimate secrets. Providers need to make provisions for keeping DNR orders or living wills in the EHR and available to patients. Parents may want their adult children to be able to see and share the parents’ records with caregivers. Teens may not be forthcoming in explaining their needs to the doctor if they know their parents may be able to see the child’s concerns.
With smaller enterprises or standalone hospitals, accessing the costs of a new EHR can be a gamble. Some entities don’t even tightly track costs because there are so many measures to assess—some may not want an accurate account of costs, believing it’s easier to keep things as estimates for management. Further, vendors’ assistance with cost estimates may not consistently be reliable, Koppel adds.
But the reality for many organizations when buying a new EHR is that the new software will cost four to five times more than the software for the original EHR, Koppel says.
When the new EHR goes live, the new challenge won’t be costs but productivity. Providers and other users have been trained on the new system, but it’s still new, and parts of it are confusing or just don’t work well, and a live environment can be very different from a training environment.
Clinicians often will experience reductions in patient visits after go-live, which means lower revenue coming in, and drops in productivity could slam the organization for three or four months, Sittig warns.
And then, there is billing. “Many providers will have a lot of billing problems because existing data hasn’t been mapped to the new billing system codes,” Sittig continues. “They haven’t mapped procedures, medications administered, the cost of a nurse changing a bed or floors cleaned by maintenance—all of this adds up. These are billables that aren’t being dropped with a charge into the EHR.”
And because a facility may have thousands of medications, lab tests, procedures and supplies not being accurately accounted for during this hectic period, it may lose 5 percent of its revenue, Sittig contends.
Looking for Band-Aids
Some executives in organizations that are experiencing problems believe that a new EHR will solve the problems, and they blame the EHR when that doesn’t happen, Sittig says. Hospitals may believe they will do better swapping out the old EHR, but they have underlying problems that the new EHR also may not address. “If you don’t have enough operating rooms, a new EHR won’t solve the problem,” he notes.
Organizations that do well with an EHR swap are successful not because of the EHR but because of what’s inside the EHR or in a data warehouse. It has some new data and a lot of legacy historical data, and that data can be used to measure and analyze employees, patients, vendors, processes, procedures and thousands of other queries.
The new EHR may have a range of alerts that remind physicians to make sure patients with hypertension are getting their medications. EHR data matched with an analytics professional can measure how long it takes the pharmacy to issue prescriptions or how long it takes the lab to report a value or measure if radiology tools are being efficiently used.
Administrators taking advantage of the capabilities of a new EHR can get the benefits that doctors get by measuring people, supplies, procedures, costs, outcomes and a range of other issues. Administrators can use that data to see which physicians can do a procedure with less or less expensive resources.
Transition costs may be comprised of many parts, but they can add up.
A study in the Journal of the American Medical Informatics Association, published in May 2018 and entitled, “Changes in hospital bond ratings after the transition to a new electronic health record,” examined the impact of an EHR implementation on hospital finances.
Researchers analyzed the effect of a new EHR on bond ratings and “net income from services to patients,” known as NISP, at 32 hospitals. Seven hospitals had a bond downgrade, seven others had a bond upgrade, and 18 experienced no changes in their bond ratings.
“Most hospitals in our analysis saw no change in bond ratings following EHR go-live, with no significant difference observed between EHR implementation and control hospitals,” according to the study.
Authors noted that given the large investments for a new EHR, hospitals are concerned of the impact of an implementation on their financial health. A reduction in a bond rating may affect the ability or cost of borrowing money.
In a secondary study, researchers sought to determine if a new EHR contributed to changes in NISP. “Our analysis of 32 hospitals that recently implemented a new inpatient EHR and a set of geographically matched controls did not detect a significant impact of EHR implementation on bond ratings or NISP,” they concluded.