Functionality Failure: More EHR Users Ready to Replace

Surveys indicate widespread dissatisfaction plus there are EHR failure stories in the news all the time. Most recently, both the CEO and CIO of Athens Regional Health System in Georgia resigned in the wake of a trouble EHR implementation. Clinical leaders raised concerns about patient safety within two weeks of the go-live and the vendor brought in more support personnel to get the implementation back on track. News reports point to a lack of clinician buy-in as a primary source of the problems.

In a 2014 national EHR survey by MPI Group and Medical Economics, 70 percent described their EHR investment as not worth the effort, resources and costs. The top reasons for that response are system functionality (67 percent), cost (48 percent) and poor customer service (67 percent).

Back in 2013, a survey conducted by the American College of Physicians and AmericanEHR Partners found that satisfaction and usability ratings for certified EHRs have decreased since 2010 among clinicians across a range of indicators. Overall, user satisfaction fell 12 percent from 2010 to 2012. Users who are “very dissatisfied” increased 10 percent during the same time period.

The survey also revealed that the percentage of clinicians who would not recommend their EHR to a colleague increased from 24 percent in 2010 to 39 percent in 2012; 34 percent of users were “very dissatisfied” with the ability of their EHR to decrease workload—an increase from 19 percent in 2010; in 2012, 32 percent of the responders had not returned to normal productivity compared to 20 percent in 2010; and dissatisfaction with ease of use increased from 23 percent in 2010 to 37 percent in 2012, while satisfaction with ease of use dropped from 61 to 48 percent.

Yet another survey found that 23 percent of physician practices planned to trade in their current EHR system. The Black Book Rankings report found that 81 percent of those said they were on track to replace their EHR within the next year.

No surprise

Ryan Champlin, vice president of Cook Children’s Health Services in Fort Worth, Texas, is just one person not surprised by these survey results. Information is harder to find in EHRs or someone has to run a report to get to it. “It was easier on paper. The tools are getting in the way.” When the tools are pushed back and patients and doctors can communicate effectively at the point  of care, “that’s when people will like EHRs.”

Cook’s Children’s Health Care System has implemented and replaced a few EHR systems. The Fort Worth, Texas multispecialty pediatric does not have an academic program so is not a teaching hospital.

The organization’s first effort was not successful because few people had any experience with EHRs so Cook couldn’t get advice and guidance. “We had no experience,” says Champlin. “We didn’t know what we were trying to do and didn’t know what to ask for.”

They tried again with a vendor that was eventually acquired by another company but, again, no luck. “It was a wonderful product but extraordinarily challenging to run locally. The skillset needed to run it is so unique.”

It became clear Cook needed a product that was better supported and had more structure out of the box, he says. Other children’s hospitals were beginning to move toward one vendor, spending hundreds of millions and going to a 3 to 5 year implementation timeline. “We weren’t sure that was really the right path for us.” Cook has a large number of physicians on its board so they have a lot of influence. They were concerned about stories they’d heard about EHR implementations having drastic effects on productivity so they created a selection committee to study the market.

The vendor they chose didn’t have any large enterprise clients so Cook created a client-vendor relationship to help create a viable large-customer EHR. After signing a contract in June 2009, the hospital went live Feb. 1, 2010. All of the clinical support staff plus 100 doctors were brought on that first day and the rest of the subspecialties were added through the course of 2010. Each template had to be built because the vendor didn’t have other similar clients. By the end of the year, Cook Children’s was 100 percent live with a functional electronic medical record and had experienced an improved revenue cycle.

Headline-making transition

Partners HealthCare in Boston made headlines when the healthcare behemoth announced plans to migrate from its long-established homegrown system to a commercial system. The organization expects better interoperability, says Amy Miller, MD, PhD, a cardiologist and CMIO for inpatient clinical services at Brigham & Women’s Hospital. “That will be the biggest benefit people outside of information services see.”

Partners began building its systems because there were no other options. “We had to build it or we couldn’t have it,” she says, but core functionality has become a commodity. Today, it’s better to let vendors meet all the requirements of federal programs like Meaningful Use and “rely on our resources to focus on innovative things at edges of system.”

Some organizations within Partners have gone live on the revenue portion of the new system with more scheduled throughout this year. Organizations will begin to go live on the ambulatory clinical system in 2015 followed by inpatient later in the year. The plan “kind of rolls through various Partners hospitals so that all sites will be up around 2017 or 2018.”

The challenges are numerous, Miller acknowledges. Partners has hundreds of applications in use. “We have areas that have an incredibly customized system built to serve everything they could possibly imagine. Those people will lose that customization and some functionality.” On the other hand, there are people who have never been able to get a system for their area so the commercial system offers a great opportunity.

It will be challenging, she says, to manage everyone’s expectations. “Those incredibly customized systems exist in a silo [so the users] will get huge benefits from interoperability.” Those users also need to understand that the system will continue to grow and evolve, she says. “They have to have faith that we will optimize and evolve over time.”

Change management is a large part of the process. Providers who have complained about Partners’ systems are suddenly very attached to those same systems, Miller says. “People fear change so people are very uncomfortable.” Ideally, the organization would have done a massive “big bang” implementation to bring everyone live at the same time and not have to integrate the legacy system with the new system but “it’s simply too big.”

She expects that bridge period to be difficult. “When you’ve had legacy systems as long as we have, you don’t necessarily know where all the roots have grown. The process of finding out what currently exists, what should go away and what needed to stay and how things that needed to stay would talk to the new system and vice versa has been a challenging process.”

A big component of the change management strategy is figuring out how to keep people engaged throughout the implementation timeframe. “As we get closer, while it feels very fast, in reality it’s a huge length of time to try and keep a lot of people engaged. So it’s something of a balancing act to figure out who we need when and in what capacity. We don’t want to get to go live and find we’ve burned everyone out along the way.”

Changing perspective

Champlin cites two main reasons for EHR dissatisfaction: the EHR doesn’t get the job done because it was a poor choice for the organization and the normal change of opinion as users become more adept. “The more skilled user is more discerning,” he says, so users outgrow the product and start looking for something more.

The EHR market, however, is distilling, he says, and with good reason. “We need to narrow the field of EMRs so that the ones we have do the job really, really well. It is time for this space to mature so that individuals don’t have to worry about parts of their medical record being inaccessible. A few vendors makes for interchange and that’s really what we need for patient care.”

Miller cautions against the idea that the grass is always greener. Organizations need a good sense of why they’re making a change so they can manage expectations.

She does point to the idea that each implementation is unique. If an organization has struggled with an implementation, “it’s hard to know if it was the vendor’s problem or the implementation. Take a careful look at the issues before you assume that changing the software is going to change things.”

She, and Partners, is feeling the pressure but despite the national coverage of their implementation, “the greatest pressure I feel is from our clinicians who feel like we’ve had very strong systems and a great history in this. They’re the ones who have the highest expectations for us. Our clinicians and our patients are the ones I care about.”

Lots to consider

The EHR products certified to meet Meaningful Use requirements will drive the market, says Mary P. Griskewicz, MS, senior director of healthcare information systems for HIMSS. “It is a competitive environment right now.”

To get the most out of a purchase and make sure the product is a good match for your organization, there is a lot to consider.

Most EHR implementation problems come down to the same few factors, she notes. “The biggest mistake is that it’s a technology project. It’s not.” It’s all about people, processes and technology but a lot of the time, organizations go with the easiest system instead of looking at the opportunity to reengineer workflow and make other efficiencies.

Purchasing organizations should consider vendors’ sustainability and how quickly they make changes via service patches and upgrades. How are they handling privacy and security? “Those things that are high risk are the things they really have to take a look at.”

Due diligence is required to avoid replacing a system. Plus, “you have to look at why you’re doing this in the first place. What are you trying to accomplish?” Consider all the goals, she says, and then determine how you will execute and deliver.

That requires strong leadership. Griskewicz says some organizations are bringing in new leaders who have experience with IT implementations. “Make sure that you have the right team in place to help you execute this.” The right leader bring together teams with both technical and clinical representation and get buy in from clinical and ancillary staff. “Training is absolutely critical as is making sure you have support mechanisms.” She says people used to forget that hospitals don’t close and therefore require around-the-clock assistance. “That may mean you have to retool and rescale.”

Contracting is absolutely critical here, she says. “I recommend legal counsel that has recent experience with IT contracts. You really want to make sure the language is clear in your contract about your rights to the data.” For example, most good contracts will say that if the vendor goes out of business, the client gets the data back within a certain amount of time and any copies are then destroyed. “Make sure that is handled appropriately,” Griskewicz cautions.