According to Gartner, “Pressures to contain healthcare costs are being felt globally. Healthcare providers are under intense scrutiny to address rising costs, eliminate waste and improve organizational performance.”
Growing Technical Debt
After years of big-bang, out of the box implementation (driven by meaningful use incentives), merger and acquisition (both from a provider and a vendor perspective), best of breed IT strategies, and antiquated & narrow legacy applications, most health system IT operations are faced with an increasingly complex portfolio of disconnected applications, on incompatible platforms, often with overlapping functionality. As a result, there are intelligent, talented, well-paid people who are performing mundane, manual, repetitive, non-value add tasks such as report running, writing of extracts, managing & monitoring interface & data feeds, etc. As the delivery of healthcare becomes increasingly complex, the benefits offered by an integrated EHR system that can provide a longitudinal view of patient charts and enable insights into population health increase. A best-of-breed approach can be costlier, not as provider friendly, and can pose challenges for coordinated patient care.
Rationalization of Clinical Systems
With the transition from volume to value looming, healthcare organizations are faced with rationalization of the IT portfolio to reduce costs through EHR optimization, replacement & consolidation. Providers need information systems that provide a more complete picture of their patient populations and enable them to understand new cost structures. Most large health systems have anywhere from 250 to 5,000 IT applications deployed across the enterprise, with total cost of ownership (TCO), ranging between $5MM to $500MM per year. It’s estimated that rationalization of these systems can lead to 10% to 15% in reduction of TCO over a 5-year period. With increased complexity, those with the capital to replace are doing so to achieve the benefits offered by an integrated EHR. Those healthcare organizations (HCOs) without the capital to replace are instead pursuing EHR optimization to survive, with capital instead primarily earmarked for risk analytics and care management tools. For these HCOs, pursuit of simplification of the IT stack and automation is critical to survive.
Examples in Practice – Replacement & Consolidation
Gene Thomas, VP & CIO at Memorial Hospital at Gulfport, simplified his IT portfolio through replacement in going from three EHR systems to one.
“We have recently — and that means June 14, 2014 — converted and did a very large, big bang, house-wide EMR replacement. We replaced three existing systems, and the three systems are between our ED, our inpatient venue, and our clinic footprint, and went completely house-wide with Cerner Millennium installation for electronic medical record in almost all venues of care.”
“I’ll tell you, in our case we’re pretty laser focused in that we knew we wanted to go an integrated system; with best of breed and disparate systems, it was easy to make a decision to get away from that. We knew we wanted the most integrated system possible, so we took the approach of, if Cerner had a solution, we were taking it. If they didn’t have a solution but had a partner they’d integrated with, we would take that partner’s solution as if it were theirs (theirs being Cerner’s), unless that decision could cause potential patient harm or have a negative quantifiable financial impact. So we wanted the most integrated system possible.”
Deanna Wise, EVP & CIO, Dignity Health, enabled care transformation and positioning for the future by moving all hospitals and clinics onto a single clinical platform.
“We’re deploying Cerner across all of our facilities. We’re nearing the end; of our 39 acute-care hospitals, we have eight facilities to go. It’s been a five-year, $1.83 billion initiative, and we’ve been able to remain on track.”
“One thing people tend to underestimate is training as you’re deploying these systems, and at-the-elbow support when you begin to roll them out. That plays a tremendous role in helping to understand where the gaps are as people learn these new processes. It really is people, process, and platforms. I think many CIOs fail from the standpoint of implementing systems and expect that they will be used. In order to be successful with something that is so interwoven within the day-to-day business, you really have to focus on the training and the process change that goes along with it.”
An article published in EHR Intelligence points to care delivery and streamlining of operations as drivers as opposed to the replacement decision being solely based on dissatisfaction:
Not all decisions to replace an EHR system are based on dissatisfaction. Sometimes, choosing a new EHR vendor and solution is motivated by a healthcare organization’s mission to improve the delivery of care across the entire continuum and scale its operations toward managing the health of entire patient populations.
According to Tripp Jennings, MD, System Vice President and Medical Informatics Officer for Palmetto Health, the health system in Columbia, S. C., based its decision to replace its array of EHR and health IT systems with one system (in this case, one provided by Cerner) in order to streamline its operations and the exchange of health information between its own providers as well as other hospitals and care settings.
This notion is further supported by Gail Carlson, chief nurse executive at 54-bed Alegent Creighton Health Midlands Hospital in Papillion, Neb., in an article published in Modern Healthcare:
“Interoperability between EHRs has become crucial for their successful integration of operations—and sometimes requires dumping legacy systems that can’t talk to each other.”
The Alegent system, which includes 11 hospitals in Nebraska and Iowa, has been using multiple EHRs since 2001. But now they are switching to Epic’s integrated ambulatory and inpatient EHR systems and scrapping their existing systems, which came from multiple vendors.
As the demand for interoperability grows, many hospital IT officials are struggling to knit together legacy systems that often have multiple and non-communicative EHRs. That is forcing many to consider switching from multiple vendors to a more comprehensive vendor that can serve all their facilities’ EHR needs.
Today, clinicians at Alegent are primarily served by a Siemens EHR for inpatient and NextGen for ambulatory care. “We have a lot of different ancillary services that have their own programs” Carlson said. The EHRs may be “best-of-breed,” highly specialized software that provides excellent service in specific areas such as emergency departments, obstetrics or lab work. But communication between them is “inconvenient,” she said. “Using Epic will eliminate that.”
Examples in Practice – EHR Optimization
Julie Hollberg, MD, CMIO, Emory Healthcare embarked on an EHR optimization project which brought 32 different specialty-focused views of the electronic chart to its 1,650 physicians across 5 acute care hospitals and more than 90 ambulatory sites.
“Previously, we would document the diagnosis of a paper encounter form; they would write the diagnosis on radiology; they would write the diagnosis or history on a referral,” Hollberg explains “Now with moving toward better utilization of the problem list and the electronic charge capture, they can associate those diagnoses with each individual order or bill very quickly.”
“The advantages of that is that each division or department is able to customize what data they want face-up to increase the efficiency in terms of the amount of time it takes to navigate the chart,” she maintains. “We’re also dovetailing this with our ICD-10 rollout and moving from paper to CPOE in the ambulatory setting and showing them how they can leverage the EHR to document once and carry that data throughout the patient visit.”
Denni McColm, CIO, Citizens Memorial Hospital discusses what it takes to foster innovation (particularly on a small budget), with the organization’s journey with Meditech
I think it’s sort of a cultural thing. I have been to Kaiser Permanente, it has a beautiful innovation center that cost millions and millions of dollars where they can test out new things. We obviously don’t have those kind of resources. It’s almost the opposite — it’s because we’ve had to stretch our dollars that we’ve been able to innovate and make things work that maybe others wouldn’t think to make work. Even with some functionality of our own EMR system, people will say, ‘wow, you made that work,’ and we’re like, ‘well, yeah, that’s all we had.’
According to a recent PricewaterhouseCoopers report on EHR data, current EHR optimization opportunities are likely showing themselves now that the EHR Incentive Programs have ceased flooding the EHR marketplace with billions in EHR incentives.
“But now that the dust has settled and many providers have successfully hurdled their initial implementations, those providers are objectively assessing their EHR systems and identifying areas that may not have delivered the value they had hoped for,” they write. “It is a prudent approach, because there are typically opportunities to enhance EHR systems at any stage of an implementation — with the ultimate goal of improving outcomes.”
Conclusion – Action is Needed to Stay Competitive
Health systems that made significant investments in upgrading their information technology infrastructure and installing EHRs—sometimes spending hundreds of millions of dollars—are finding their technology needs are continuing to escalate. It is no longer sufficient to have an EHR system largely utilized for electronic data capture, with clinical decision support tacked on. Instead, HCOs must pursue workflow improvements to drive down operational costs as well as sophisticated data analytics to reduce the cost of care and improve quality.