Recently, in partnership with CHIME, Galen Healthcare Solutions conducted a survey of information technology executives from healthcare provider organizations to learn more about their approaches to Application Portfolio Management (APM). Everybody participating agreed that they had too many redundant and/or obsolete applications, but most admitted they lacked the right resources to decommission them.

For example, a decisive majority (73%) said that reducing the costs associated with these legacy systems is a high priority, while a significant plurality (38%) agreed that those applications should be decommissioned, but only 10% reported fully operational management or rationalization initiatives up and running. Indeed, 41% admitted they lacked the skills to address APM. And while few would claim that using a spreadsheet to inventory and track application portfolios was particularly useful, half of the survey respondents acknowledged they continue to employ them.

Application bloat is undeniable. HIMSS has reported that the average hospital administers 16 different EHRs, not including those operated by pharmacies and labs. At the same time, new regulatory requirements, mergers and acquisitions, unsolved interoperability issues, security breaches, litigation and the uncertainty that has been caused by the ongoing COVID-19 pandemic, make it virtually impossible to identify any legacy platform that can be comfortably retired.

To obtain additional insights into the nature of this situation, Galen and healthsystemCIO conducted a webinar featuring Susan Carman, VP/CIO, Mohawk Valley Health System in New York and Stephanie Lahr, MD, CIO and CMIO, Monument Health in western South Dakota. Along with Justin Campbell, VP Strategy for Galen and Anthony Guerra, healthsystemCIO’s editor, they deconstructed the common puzzles that have made application portfolio rationalization initiatives so difficult to implement.

Barriers

The biggest barrier to implementation said Stephanie Lahr may be “understanding what we have been talking about, specifically, what do we have? You can’t rationalize, make decisions, grow or reduce if you don’t understand what applications live in your organization and how you are going to maintain that ever-changing list, especially if you have acquired other organizations.”

Not only is it critical to take stock of all the applications in your portfolio, said Justin Campbell, it is necessary to recognize that organizations are almost always in the midst of digesting new technology from new practices. “APM is not a one-time thing. People are at different stages in the process. Taking stock of newly-acquired applications, you have to learn what version you’re on, what dependencies there are, is it cloud-based?”

Susan Carman pointed out that even before you begin the necessary documentation of your stock you have to get past what she views as the greatest barrier of all: “reluctance to change. For example, you’ve moved on to a bigger and better EMR but you still have these legacy systems whose data and applications are familiar to you. Where are you going to put them so you can access their still usable data? In our situation, it’s complicated by the constant addition of new provider practices, all of which come with their own legacy data which they all want to bring with them.”

Campbell noted that such cultural inertia is not a new development. “Historically,” he said, “as organizations made the transition from legacy systems to EMRs, it happened as an afterthought. Systems would be implemented and then, after the fact, the organizations would address what the new system had just displaced. This is not a strategic plan. It did not address the questions that must be faced: what are we to do with the legacy systems we’re inheriting, are we going to integrate the data, or migrate it, or archive it.”

Knowing that they can still reach back and find legacy data is for many providers a necessary security blanket. But, at the same time, the overwhelming scope of all that information can be an albatross. Lahr said, “If I did a cardio catheterization on somebody fifteen years ago, I may want that report. But do I need it? It may be comforting to have all of that old stuff and the more accessible it is the better, however, no clinician has the time to go through scores of systems to find the right information.”

This indicates that everybody needs to retire legacy applications or to at least wean themselves from them. However, added Lahr, if the hospital finds itself in court, the content in those old applications may be essential. “This is another conversation we often have: ‘I hear you say you think you need it, but, do you?’ We have to partner with our compliance and legal team because clinicians are inclined to keep all the data forever even though that’s probably not in everybody’s best interests.”

Campbell added, “It cuts both ways. If you retain data, what’s the probability that it’s going to be of clinical use and, on the other end, what is the probably that the clinical data is going to be a liability to you?”

Opportunities

Following these observations about the cultural barriers to the implementation of APM, Anthony Guerra asked, “What is the biggest area of opportunity to increase the effectiveness of your application portfolio rationalization?”

Circumstances that have been allowed to rationalize inaction regarding legacy systems can also introduce conditions for fresh thinking. Carman noted the disagreements that sometime occur when a hospital acquires new practices but she said this situation can lead to a positive outcome.

“We are often taking on new provider practices. Some have been around for decades. What comes with them is a lot of their own data. Previously, we would gather their servers which were in their clinic and move them over to our data center and then scratch our heads and try to figure out what we were going to do with them. But we came up with an approach: every time there is a provider acquisition, we address data governance: what do we do with the data coming over to us which we now essentially own? Even before the acquisition is complete, as part of the negotiations for example, we insist that the data be converted to our cloud-based archival system,” said Carman.

Another area of opportunity for effective application portfolio management may be financial. “We know that operational transitions will keep going and going,” said Lahr, “But each, ideally, should give us the means to eliminate some costs and that in turn, should allow us to do more towards retiring and archiving older systems, and enhancing the scope and effectiveness of newer applications.”

What’s Next?

Carmen declared, “The process most organizations have currently is to leave it there and figure it out later. That is not a good place. There needs to be a plan. As soon as new data is acquired, whether it be from a physician’s office or even a new hospital, you must have a plan with a checklist of options.”

Collaboration among the various organizational departments is critical, she observed. “You have to partner with your HIM people to decide how much data you need, always understanding that once you bring it in, if there’s suddenly a need for discovery of some type, you are going to be liable for that data and you had better understand what’s there.”

A final consensus emerged on the urgency of the situation. As an example, Campbell emphasized the difficulty and complexity of “getting different ambulatory systems to interoperate with your enterprise-wide PACs or your radiology information system. This is probably harder than just rationalizing it. And it is a process that should begin upfront.”

Carmen urged that IT be involved in every software acquisition and added that there was great value in being friends with those who work in procurement.

Lahr offered the final words: “Do something. Just start.”