October 2013

Breaking Up (With an EHR) Is Hard to Do
By Juliann Schaeffer
For The Record
Vol. 25 No. 14 P. 22

But experts say not cutting ties leads to a worse fate.

Lack of sufficient vendor support. Workflow inefficiencies. Changing needs.

The motivations may vary, but more health care organizations seem to be coming to the same conclusion: It’s time for a new EHR. We’re not talking your typical paper-to-electronic transformation either. This is a one-EHR-to-a-hopefully-better-EHR transition.

It’s not as uncommon as one may think. In fact, based on results from a recent survey of 17,000 EHR users in which almost one-quarter of respondents cited enough dissatisfaction with their current system to consider switching to a new EHR vendor, Black Book Rankings is calling 2013 “The Year of the Great EHR Switch.”

What are the contributing factors to EHR disenchantment and, more importantly, what considerations should health care organizations take into account before making such a mammoth decision?

What’s Behind the Switch?
According to Michael Brozino, president and CEO of simplifyMD, there are several reasons an organization may decide to transition to a different EHR system. “Inability to attest for meaningful use is a big one, but physicians and hospitals are also abandoning EHR systems that are too complex to use or too complex to support,” he says. “All software has the potential to have issues, but having unresponsive or cumbersome support becomes a problem.

“Many practices are finding that their system is inflexible and does not adequately support the functionality or workflow requirements of their particular specialty,” he adds. “Switches are happening when productivity is impacted and the practice ends up losing revenue month after month while still paying exorbitant software licensing fees and server costs.”

Indeed, just because a hospital is using an EHR doesn’t automatically mean all facets of an organization’s workflow are functioning well, explains Ira H. Kirschenbaum, MD, chairman of the department of orthopedic surgery at Bronx-Lebanon Hospital Center and author of The OMG EMR Template Book — Orthopaedics.

According to Kirschenbaum, the reasons an organization switches its EHR are not unlike the thought processes behind trading in a car or getting a new job: changing needs. “The EHR world has very little standardization, and the needs of organizations change over time,” he says, noting that the typical EHR buyer also is changing, which exacerbates the problem. “The initial buyers [used to be] individual practices,” he says. “We are now seeing a trend where a lot of hospitals and very large groups are buying up practices, so the buyer is changing from individual practices to very large hospital and medical delivery systems. With this, you have a buyer with different needs.”

Whereas a small practice’s predominant needs may relate to history and physical information and billing connections, they are just two pieces of the puzzle for a large hospital system trying to coordinate hundreds of integrations involving medication reconciliation, lab and radiology results, and interactions with hospital-based specialists, says Daniel Gee, MD, MBA, a partner with Creative Healthcare and the chief of staff for Thompson Peak Hospital in Scottsdale, Arizona.

“It’s a difference between a big computer program and a small phone app,” Kirschenbaum says. “One does everything for you; one does one thing for you. As you do everything, you do that one thing less efficiently. You add to that a third piece: the rate at which EHRs are evolving, which is fast and volatile,” he adds, noting that EHRs five years ago were proud to produce labs, whereas now they must incorporate patient portals, incremental meaningful use standards, and more.

The act of switching EHRs is sometimes referred to as “rip and replace,” according to Allison Viola, MBA, RHIA, vice president of policy and government affairs at the eHealth Initiative, who notes another reason an organization may decide to take a chance on a different EHR: “The type of system might not fit the particular health care setting.” For example, implementing an EHR designed for acute care in a long-term care setting faces long odds.

According to Amit Trivedi, health care program manager at ICSA Labs who also serves on the ICSA Labs American National Standards Institute–accredited certification body, choosing the correct EHR vendor is crucial. “Some entities are poised to be around for the long term, while others will not make it to stage 2 meaningful use,” he says, adding that the inclusion of data portability in meaningful use guidelines showed some foresight into the potential of this possibility. “If stage 1 meaningful use was about getting technology installed, and stage 2 focused on the actual exchange of data, stage 3 will require some organizations to reboot or rethink their long-term strategy based on the technology they implemented, especially if they find that their vendor is struggling to keep up,” he says.

Considerations Involved
According to Trivedi, the thinking that goes into an EHR switch should be at least as involved as that which went into the first implementation, if not more so. Software considerations are a good place to start. “Replacing an EHR is a major decision and should not be taken lightly,” he says. “Since software selection is so important, if it turns out that the software has issues that cannot be resolved in a timely or cost-effective manner, then it may be time for a change. This means that picking the next solution is even more critical; you only get so many chances.”

As such, Trivedi says it’s important to note what went wrong in the last selection so as not to repeat those mistakes, suggesting organizations ask themselves the following question: “Are there issues with the software, the vendor, or the level/quality of support?” he says. “Some issues can be resolved by escalating them with the vendor to get timelier and higher-level support, but some issues go beyond technical problems.”

Accountability and root cause analysis also should be addressed. “What is the underlying problem? Is the software not capable of meeting user needs? Is there a lack of training? Was it an implementation issue, an organizational issue, or a software issue? More often than not, the most complex part of a clinical software implementation is the challenge of dealing with the human component: getting buy-in, putting in the efforts to analyze and reengineer workflow, training, fatigue, etc,” Trivedi says.

Productivity and revenue also should be broached prior to an EHR switch, Brozino says. “When considering whether to switch EHR systems, both hospitals and practices must consider the effect on productivity and revenue,” he says. “Organizations must know the length of the system transition, the data and artifact migration process, and the long-term financial impact of the switch. Contractual commitments, too, are a consideration because some vendors include penalties in their agreements for early termination.”

According to Kirschenbaum, most hospitals will perform a needs assessment before committing to a decision as big as an EHR switch, which will affect many workflow and patient care facets. The key, he says, is making sure the review gets to the heart of what an organization actually needs vs. a vague mission statement that says little of what actually must be done. “Most of the needs assessments that I have seen through consulting and elsewhere are a bunch of global missions. Instead, hospitals need to look at who their various customers in their system are, and that can be knocked into a number of categories,” he says, noting physicians, frontline caregivers, administrators, finance personnel, and allied health as different customer groups. “Once you look at the customers, then you start your needs assessment by assessing the needs of your individual customers.”

The challenge is to conduct a needs assessment based on daily workflow, says Kirschenbaum, who suggests hospital leaders ask themselves one multipronged question: Does the EHR allow all hospital staff to get through their daily work make things safer for patients and more efficient for employees, and provide value? “Efficiency, value, and safety: That’s a needs assessment to me,” he says.

Brozino says staff comfort level and satisfaction with an EHR system should be taken into account as well, especially at smaller practices, which can’t afford to lose physicians and employees over a bad decision. “That’s why collaboration between clinicians and office staff is so important on this decision,” he says.

Because hospital staff opinion on technology deployments often is divided, Brozino believes the thoughts of those who use the product the most should be considered the most. “My view is that HIM’s customers are the physicians, nurses, and other clinicians,” he says. “Therefore, those using the product on a daily basis need to be satisfied and productive. That said, HIM plays a role as technical consultant and may better understand how the technology is affecting productivity. So, for example, if the software architecture is not sound or it conflicts with the hospital technical topology, then it becomes a liability to the organization as a whole.”

The key to an amicable work environment is collaboration. “The two sides need to collaborate on the selection process, and HIM ultimately needs to defer to the needs of the clinical staff users,” Brozino says. “The bottom line for all parties is that the product must meet the unique workflow requirements of that organization.”

The Influence of Meaningful Use
Will an EHR change affect an organization’s efforts to meet meaningful use? That largely depends on where a hospital is in the attestation process, but it should at least be among the topics considered before making a system switch. “Depending on where the physician or hospital is in the EHR meaningful use attestation process, an EHR system switch could cause them to miss opportunities to attest, reducing the amount of incentive dollars they expected,” Brozino says. “But if their current system won’t allow them to achieve the next meaningful use stage, then the risk associated with change may be one they have to take depending on the overall financial impact.”

However, Trivedi cautions that organizations focused on their long-term needs rather than short-term incentives will be better positioned for the future. “Many decisions are being driven by meaningful use,” he says. “Replacing an EHR is certainly a short-term setback, but usually the decision will have a longer-term payoff. It is important to realize that there is a vision and goal behind meaningful use that goes beyond incentive payments. Those organizations that are looking at the big picture and not just focusing on installation costs and incentive funds will be better poised for success.”

How long it takes to complete an EHR switchover depends on the size and scope of the practice or organization, but Viola says it can take up to one year or longer to go through the entire implementation life cycle, which involves “workflow analysis, custom development, training, testing, data conversions, go-live, go-live support, and more.”

Brozino agrees, noting that there’s no silver bullet when it comes to an EHR switch. “[The key] is to have the transition done right by qualified organizations,” he says. “Every vendor has different implementation approaches, and they need to sync with an organization’s schedule and environment. This project often requires a multiphase plan and an assigned accountable person or team managing the process.”

No matter the organization, an EHR switch will involve pain, according to Kirschenbaum. How much pain depends on what an organization is willing to invest in the switch. “Once you’re electronic, switching to a new system is half as painful as going from paper,” he says. “If you’re lucky, it’s 20% as painful. But there will be pain, and the pain will be directly related to how many resources you put into the deployment. It’ll be a dollar-for-dollar return on investment.”

He recommends organizations budget 25% of their purchase cost for training and deployment over a three-year period. “If you spent $100 million on an EMR, spend $125 million but $25 million is going to be for full-blown deployment. Anyone who thinks otherwise, they’re wrong. It’s about training, training, training.”

It’s important to develop a realistic timetable for such a complex endeavor, says Trivedi, who suggests organizations view EHR implementation as a journey, “and once started there really isn’t a finite end. Implementation and training takes a long time. Proper planning and organization and following a structured implementation route can make what seems a near impossible task manageable.”

Sticky Situations
Transitioning to a new EHR, whether it’s from a paper-based environment or a different EHR, is never simple, but some circumstances can make an already complex situation even stickier, such as when contract issues surface, as in the case of Milwaukee Health Services. As reported by the Milwaukee Journal Sentinel, its physicians recently had issues accessing the medical records of 40,000 patients when the contract with its EHR vendor expired. (They were in the process of switching to a different vendor.)

Brozino says EHR vendors should work through contract issues with a given practice or organization, with records remaining accessible through negotiations. “If an impasse is reached and significant time has elapsed, the vendor may choose to restrict to read-only, thus giving access to patient history but not allowing new patients to be entered,” he says. “An expiring contract, however, is no reason to prohibit access.”

It cannot be overstated how important it is to address this topic in EHR agreements, says Kirschenbaum, who has little sympathy for systems that overlook a legacy exit strategy. “Every contract that I have ever gone into with an EHR vendor has said the following: ‘Whenever we switch, whenever we leave, here is the body of information that we get and here is the method that we get it in and here is the cost,’” he says. “If you don’t have an exit legacy clause—meaning how to handle your legacy EHR when you leave—then you have made a foolish mistake.”

Mergers also can complicate matters, especially when organizations are using two different EHRs. Which system wins out? “An acquiring organization typically imposes their EHR system selection on the acquired group for a variety of reasons, mostly due to the efficiencies behind a uniform IT infrastructure and communication platform,” Brozino says, noting that, in some cases, a large health system may allow the acquired office-based practices to continue to use their legacy systems as long as the physicians are capturing the necessary data and can exchange data with the affiliated hospitals.

Ensuring a Smooth Transition
In addition to ensuring buy-in from all key players, from executives and organizational leaders to clinicians and other staff, Trivedi’s best advice for a smooth EHR switchover is communication. “Keep an open line of communication throughout the organization,” he says. “Make sure everyone understands what is going on and why it is happening, including patients.”

Besides devoting sufficient resources to the project, Trivedi recommends thoroughly researching all options before choosing a new EHR. “Do your due diligence when selecting a system and ensure that the vendor and product will be around for the long term,” he says. “Learn about the company’s history, current state, and future plans. How are they doing with meaningful use certification? Make sure the software you select will work for your practice, and that your vendor is a partner and is focused on your success.”

According to Kirschenbaum, there’s no time better allocated than that spent seeking out organizations in a similar situation that have lived to tell a tale of success. “You need to travel to a place that has done this well and watch and see what they did,” he says. “If, for example, you are merging two hospitals and going from red EHR and blue EHR and you’re combining to green EHR, there are probably five hospital systems in the country that went to green EHR from two other EHRs. You need to go there. You need to find out what they did, how they did it, how they’re doing now. And you shouldn’t buy [an EHR product] until you find a place that loves it, is successful, and went through the transition in a similar situation to yours. I can’t overestimate the value of benchmarking success experience.”

Viola agrees: “Interview other organizations that have conducted an EHR switch and get an understanding of what their challenges were, what they would do differently, what worked, and what didn’t.”

Brozino says any EHR switchover is pointless if an organization hasn’t taken the time to learn the lessons from its first implementation. “Every organization needs to understand the details of the new system and contract, confirm that it will solve the dilemmas of its current system without creating new problems, and remember that vendor representatives are trying to sell,” he says. “Don’t be sold.”

The Bigger Picture
While orchestrating a successful EHR switch may solve an organization’s immediate problems, Kirschenbaum says the greater lesson is in looking at the mismatch that currently exists within health care as organizations attempt to convert to EHRs. “In general, I think the lesson is that this is a very volatile time in EHRs because you have a lot of vendors that are looking to make quick money and a lot of hospitals that need to do serious work, and that’s a problem,” he says. “This is not Instagram. This is not Words With Friends. This is health care, and we have a big mismatch. People want to sell and go, and it’s a real problem because we’re going to run into issues related to the goals of the company vs. the goals of the health care organization.”

While conceding that he doesn’t know where the solution to this overarching predicament lies, Kirschenbaum sees the potential for legal recourse. “I have a feeling there will eventually be product liability laws on the responsibilities of EHR vendors,” he says, noting this largely depends on whether EHR products are determined to be medical devices.

“Akin to an EKG machine, an EHR is potentially a device and maybe should be looked at with the same liability requirements that we hold the medical device industry to,” he says. “When you really look at it, when Toyota sells a car and there’s a recall when someone got hurt, that’s a liability issue. What if EHR company X has a recall? What is their responsibility, irrespective of what you sign? What’s a patient’s responsibility? What are a patient’s rights if a vendor sells a faulty EHR? Where do I think this is going? I think EHRs will need to be viewed as devices in the medical industry.”

— Juliann Schaeffer is a freelance writer and editor based in Allentown, Pennsylvania.