Knowledge Expansion The devil in the details: Know the hidden costs and potential pitfalls in switching EHRs Insight Article Electronic Health Records Sign in to save Cristy Good MPH, MBA, CPC, CMPE Marion Jenkins PhD, FHIMSS Thinking of switching EHRs? You’re not alone, but first know the hidden costs and potential pitfalls in the process Death, taxes and a smattering of expletives directed squarely at your EHR — in today’s healthcare world, nothing else is certain. To borrow a phrase from the lead-up to the Affordable Care Act: If you like your EHR, you can keep it. And if you don’t like your EHR? Then you’re definitely not alone. Consider the following: The near-endless stream of headlines about physician burnout and the role EHRs play in causing the condition. A recent survey of U.S. physicians — conducted October 2017 to March 2018 and published in Mayo Clinic Proceedings — found that EHRs score in the bottom 9th percentile of technologies for usability.1 In 2016, James Madara, MD, chief executive officer of the American Medical Association, called digital healthcare technologies — including “ineffective electronic health records” — the “digital electronic snake oil of the early 21st century.”2 The joint investigation by Fortune magazine and Kaiser Health News in early 2019 further highlighted the irritations and inefficiencies in the world of electronic records, aptly titled “Death by a Thousand Clicks.”3 The fact that physicians are suffering from the state of EHRs today is nothing new. That EHRs heavily contribute to doctor burnout has been evident since a 2013 study conducted by the RAND Corporation and the American Medical Association,4 in which EHRs were cited as leading causes for emotional fatigue and dissatisfaction with work. The pain isn’t limited to providers, either. The post-Meaningful Use blues are hard to escape for practice leaders who were sold on a broad array of promises that EHRs would solve all or most of the biggest challenges in healthcare in the years since the HITECH Act in 2009. The ONC has worked for more than a year on building a strategy to reduce regulatory and administrative burdens related to the use of EHRs and other health IT applications5 as required by the 21st Century Cures Act, but that does little good for frontline administrators fending off a burnout epidemic still happening in real time. Is there a dollar figure for replacing a full-time physician who decides to exit your practice over burnout or dissatisfaction with your EHR? Is there a dollar figure for the increased staff burden, including training, workarounds, downtime and other issues associated with your EHR? Has your practice lost money, in either tangible dollar amounts or in “soft costs” associated with EHR implementation and ongoing operational issues? If so, then the imperative for closely evaluating your options has become quantifiable. Time to go shopping? According to both published surveys and informal industry encounters, nearly everyone seems to express dissatisfaction with their current EHR, and it seems to span the entire practice organization, from the provider to the front desk. With this widespread dissatisfaction, how many practices will actually sit down, evaluate what their current system does right, pinpoint what a new system would need to do and build a robust checklist to head out into the marketplace to find something new? How many practices will take the time to include their legacy EHR vendor’s offerings — which may include a new version of what they currently use — in their analysis? If you are dissatisfied with your current EHR and are thinking of testing the market, or if you just want to reevaluate your current vendor’s offering in light of what’s now available, evaluating costs may be a good place to start. Consider this: Does your medical practice rely on pricing information that’s more than a decade old? Hopefully not. Yet when it comes to evaluating EHR systems, some of the numbers that frequently get used are radically out of date and likely will cause sticker shock. For example, the Office of the National Coordinator for Health Information Technology (ONC) formally cites several studies putting the cost of buying and implementing an EHR somewhere between $15,000 to $70,000 per provider,6 but the supporting studies include three from 2003 and one from 2007 — the most up-to-date supporting study comes from a 2011 Health Affairs report.7 Even recent white papers touted as pricing guides for the past year are based solely on per-provider cost, with notes about setup fees fairly hit or miss. What is more important to a practice leader exploring EHR options is a holistic view of the total cost of ownership: short- and long-term costs that go beyond out-of-box expenditures. There is no good EHR (yet) So, with all this dissatisfaction, and with all the advances in technology since HITECH in 2009, is there now a “good” EHR? Is there one “top” EHR that’s winning over all the business from all the “bad” ones? Is there an independent organization that has narrowed the field to the top two or three EHRs (out of the approximately 2,100 currently certified)?8 The short answers are “no,” “no” and “no.” (Remember the Mayo Clinic study? Physician respondents gave their EHRs an “F” grade. If there were an EHR with an “A” grade, it would stick out.) Why are EHRs so bad? Whose fault is it? Neither of these questions has a single answer, and attempts to identify one cause or point to one player — e.g., EHR vendors, physicians/clinical and business office staff, regulators — as the culprit obscures the fact that the origins are complex, and the solutions will require significant collaboration. The major ones: EHRs started life in the back office, where the screen flips and drop-down lists seem OK for desk-bound staff going through a relatively small number of highly repetitive tasks throughout the day. Providers (and other clinical users), by contrast, have to access many dozens of data sources, in mere minutes while moving among many locations — from multiple exam rooms, ORs, procedure rooms, dictation stations and imaging stations to a desk and back again. Even logging in is problematic. Under the guide of HIPAA, EHRs required every user to log in every time he or she accessed the system. This works fine if you sit at a desk all day, but it’s a disaster if you access 10 different devices in an hour. The HITECH Act, as part of the American Recovery and Reinvestment Act (ARRA) of 2009, jammed in the adoption of EHRs in a short period of time (roughly five years in healthcare, versus decades in most other industries), so there was precious little time for practices to change and optimize their workflows to take advantage of technology. In many cases, the major adoption criteria for a practice was to select an EHR that matched the current workflows to minimize implementation and training times. Therefore, in many cases, practices automated terrible processes. In other cases, practices did not kill off old processes — they just continued doing them in parallel with their EHRs. Regulations changed along the way, so to get Meaningful Use and (later) MIPS/MACRA dollars, EHR vendors had to devote engineering resources to creating dashboards to satisfy regulators rather than making EHRs easier to use. For evidence, look at any typical EHR screen. You almost expect to see the classic Minesweeper game to pop out. The main screen layout and functionality hasn’t changed much in 10 years since the passage of ARRA and HITECH. Contrast that to how much the usability of your smartphone has changed in 10 years. The profit motive to bring EHRs to market created a “land-grab” to get clients and for EHR companies to buy up smaller EHR companies. This created less than optimal products with less than optimal implementation teams, as well. Take two practices in the same specialty, of roughly the same size, that went live on the same EHR at roughly the same time: One is happy today and the other is not. Tracking back to root cause, many times it is the quality of the implementation team that makes the difference. Should you switch EHRs? If there is no “good” EHR, why would you switch? If everyone is dissatisfied. which seems to be the case, both subjectively and objectively, does switching EHRs even make sense? Wouldn’t you just be trading one set of problems for another? In general, that’s the unfortunate answer. However, there are several circumstances in which switching might make sense: Your EHR has been decertified by CHERT (check your specific version). You are many versions behind on your existing EHR and facing significant upgrade costs to become current. Your EHR company has had significant Department of Justice action, which may include fines, government oversight, etc. Your EHR provider has been bought out and there is uncertainty about the long-term survivability of the platform you use. Your current EHR is tied to another entity (e.g., hospital, another practice, etc.) and that relationship is changing or coming to an end, or they are switching EHRs, which is causing your practice to consider alternatives. You have lost a significant amount of subject-matter experts (SMEs) or staff who were tied to your current EHR, and/or a new core set of providers/staff are experts in other EHR(s). Your current EHR company has lost significant staff (or a similar issue) that has caused your ongoing support to become substandard or downright unworkable. If these or similar conditions exist, or if you feel it is time to do a serious evaluation of alternatives, then the rest of this article is for you. Determine a process and follow it Picking a new EHR can closely follow the process you used originally in EHR selection: Get buy-in from the physician leadership team; otherwise, don’t even bother. Pick a core team that represents all relevant stakeholder functions, including providers, clinical staff and business office staff. Make sure all roles are represented. Develop a rigorous evaluation process with objective tools (i.e., “weighted scorecards”). Force all vendors through the same process, including as many stakeholders as possible in each of the demos/evaluation sessions so their input can be incorporated into the analysis. Some other considerations: Set realistic time frames, at least six to 12 months after you start the process (not just talking about it or setting up your eval team). It is useful to have one “physician champion” — as well as a few people who view EHRs negatively — on the eval team. Your practice should empower the committee to make a recommendation to the board or other governing board. Your own experience in using an EHR for the past five to 10 years should allow you to develop a decent map of practice needs. Evaluating strengths and weaknesses of your existing system is also a good baseline. However, it is important to not get overly invested in weaknesses in your current system, as it may blind you to limitations in a new candidate system. For example, you may not like the way your current system manages appointment scheduling. A new candidate EHR might do appointments much better, which may cause you to miss the fact that it is terrible for billing, call center or provider usability. Develop your own list of criteria and set up a weighted scorecard to evaluate all candidate systems with the same set of criteria. (“Weighting” means a scoring metric of importance of an item to your practice — it could be as simple as high/medium/low importance.) Using this approach will help shift your focus from subjectivity (“we don’t like our current system”) to objectivity (“how does System X perform based on our practice’s needs?”) Uncovering all the costs Direct costs Licensing: Almost all EHRs now offer SaaS (Software-as-a-Service) subscription pricing, which is typically a fixed monthly fee based on number of providers, with a lower tier for mid-level providers. The cost of ongoing software updates is included in the monthly fee. Enterprise pricing, in which the practice pays more of an upfront fee and then ongoing annual maintenance and upgrade fees, is becoming less common. Implementation and training: These include costs of actual configuration of the new system to meet your practice needs, and training of your staff. An approach that has worked well is to identify “super-users” who become your key SMEs (Subject Matter Experts) in each primary area to help train other staff. Hardware and system upgrades: Unless you have consistently maintained your network, server, storage and backup systems, which is highly unlikely, a new EHR is going to require significant system upgrades. Even with cloud-based EHRs, in which the EHR vendor (or a third party) hosts the required server and storage infrastructure to run the EHR, you will likely need to examine your infrastructure needs. In particular, it is crucial to ensure your network is more reliable to take advantage of today’s more reliable cloud-based systems. Indirect costs Two of the most important indirect cost considerations include staff time expended selecting the system and the amount of time they are taken away from regular duties during implementation. Other indirect costs include: Reduced staff productivity due to learning a new system and workflow, as well as shorter office hours prior to and during implementation. Customization of the EHR, as many practices need more than what basic software offers. Implementation assistance, which may include outside IT contractors. Workflow redesign when changing to a different EHR. Data migration and conversion can be very costly and time consuming. You will need to determine how (or whether) to migrate existing patient information into the new system. Maintenance of existing EHR system and patient data. This is a critical factor, as many practices maintain their legacy EHRs for many years after a conversion. These costs need to include both hardware and licensing for the existing EHR. It may be possible to scale down the existing EHR to a “read-only” state to satisfy the requirement to maintain records for at least six years. Changes to all the add-ons, third-party software and custom interfaces, such as patient portal, telehealth functionality, population health management, quality reporting to payers, CDC, registries and state health departments, e-prescribing and more. Security tools for HIPAA and HITECH compliance. Summary Many practices have become so frustrated with their EHRs that they think they want a new one. There are some circumstances in which switching makes sense, but this is a daunting endeavor with many hidden costs, and existing frustrations make it hard to be objective. Taking your own experience of the past 10 years with other EHRs and evaluating your current EHR as a baseline is a rational approach. Upgrading your existing EHR to its most current version should be one of the options considered — as the saying goes, better the devil you know than the devil you don’t. If you decide to change systems, it is important to understand all the costs, both direct and indirect, as well as the business/clinical impact. Whatever the decision, that is the time for the members of the practice to be on board with the process ahead of them and support a successful implementation. Additional resources "EHR Contracts Untangled," [PDF] a guide for selecting and negotiating terms for an EHR contract, is available via ONC. Notes: Melnick E, et al. “The association between perceived electronic health record usability and professional burnout among U.S. physicians.” Mayo Clinic Proceedings. Nov. 14, 2019. Available from: mayocl.in/2KAeSDg. Dolan B. “American Medical Association CEO pans ‘ineffective’ EHRs, D2C digital health, and apps of ‘mixed quality’” MobiHealthNews. June 13, 2016. Available from: bit.ly/2RcGySM. Fry E, Schulte F. “Death by a thousand clicks: Where electronic health records went wrong.” Fortune. March 18, 2019. Available from: bit.ly/2YaQOMN. Friedberg MW, et al. “Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy.” RAND Corporation. 2013. Available from: bit.ly/37gPzzP. ONC. “Strategy on reducing regulatory and administrative burden relating to the use of health IT and EHRs.” Draft for public comment. November 2018. Available from: bit.ly/2CRCJKC. ONC. “How much is this going to cost me?” Updated Nov. 12, 2014. Available from: bit.ly/2qg3TZ3. Fleming NS, Culler SD, McCorkle R, Becker ER, Ballard DJ. “The financial and nonfinancial costs of implementing electronic health records in primary care practices.” Health Affairs. March 2011. Available from: bit.ly/32V9d0Z. ONC. “Certified Health IT Product List.” Available from: bit.ly/2Z2FAgA.