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Next-generation EHR: Overcoming the unsustainable

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Marc Gelinas, MHA, CPHIMS, CMPE, FACHE, Healthcare Practice Area Lead, Slalom Consulting

Over time, there have been many significant turning points in the healthcare industry. Some have been positive, like the Hill Burton Act, which resulted in many hospitals getting built. Others haven’t been as positive – like electroshock therapy that resulted in a lot of people getting buzzed in the wrong way. But few compare to the regulation that required eligible providers and eligible hospitals to install electronic health records (EHRs) to fulfill the Meaningful Use mandate.

With the Meaningful Use mandate – like so many other government mandates  – good intentions were corrupted by hasty implementation. As an unfortunate consequence, another CMS carrot-and-stick program has provided a great deal more stick than carrot. To make matters even worse, the vision of EHRs helping improve quality and reduce cost has only partially been fulfilled. Quality is improving, because we can better measure processes and outcomes with much more data that originates from the EHR. But the cost of purchasing, installing, customizing, and updating software platforms that are cobbled together and inelegantly developed has been staggering. Forced to purchase software to meet government mandates, hospitals and physician practices blindly launched into long-term investments that were more like Pandora’s Box than the Holy Grail. Independently published EHR satisfaction surveys are like presidential polls, telling us the best choice out of a less-than-satisfactory array of candidates.

All of that history notwithstanding, here we are. CMS continues to make increasing demands for more reporting with an increasing variety of metrics. Hospitals and physician groups continue to grudgingly invest enormous sums of money to modify, upgrade, or change their EHR platforms. The EHR software industry has a license to print money with government permission. The government and the provider sector beg for interoperability and user-friendliness to little avail. What is a healthcare provider to do?

 5 unsustainable EHR predicaments

  • Form doesn’t follow function. In an ideal world, form follows function. In the world of EHRs, software was created to carry out very basic functions, unlike in the past when software companies designed platforms to meet a particular provider’s needs and idiosyncrasies. Today, EHR design is the result of years of cobbling together new pathways and add-on menus. In the early years, features being sold were hastily created to fulfill emerging needs and were infamously known as vaporware. As CMS demands more documentation of processes and outcomes, EHRs have to be further modified. Given what we know, we would design an EHR with very different data entry workflows and significantly more logical ways to navigate the record. 
  • Customizing is very expensive. For each new change or improvement, specially trained in-house IT staff have to modify the software. If the provider doesn’t have this staff, consultants have to be hired. If the EHR vendor doesn’t allow on-site customization, providers have to pay the vendor to make the changes. Regardless of who makes the changes, every change is expensive.
  • Changing EHR software is extremely expensive and disruptive. For those brave enough to change EHR platforms to get better functionality, the expense is incredibly high – and the training time and disruption are daunting. For those able to make the investment – for the preparation, training, implementation, and adaptation – the time it takes is very disruptive. For many, the pain of staying with an old EHR platform is greater than the pain of converting to a new one.
  • User unfriendliness. The design of EHRs doesn’t match the customary patient journey through the clinical system of care and doesn’t provide the most logical flow of information into patient records. There’s nothing intuitive about the design and workflow. Physicians and nurses across the country cringe every time they’re asked to document another process and collect another piece of data. They know that it’ll require more time out of their day to be in front of the computer instead of in front of their patients. 
  • Vendors don’t have to play nice. EHRs are a little like razors and razor blades. Once you make the decision to use one brand of razors, you have to buy the blades that only fit that razor. Providers complain that EHR vendors are usually eager to provide more functionality, but rarely right away and it’ll be expensive. Interoperability is another example. One EHR vendor was noticeably absent from recent efforts to have all EHR vendors collaborate to make their systems more compliant with government demands for increased interoperability. The healthcare industry is obligated to comply with government mandates, but those obligations don’t apply to the providers of the tools we’re required to buy.

5 EHR solutions being developed

Although providers are frustrated, below are pioneering efforts they’re making to improve the situation:

  • Make buy decision: Oncology. EHR software is fairly generic. That means specialties like oncology don’t have access to an EHR specific to their needs. Customizing an EHR for these purposes is extremely expensive. One organization is investing heavily in developing an ambulatory EHR specific to oncology. It’ll be a full-featured package that combines documentation of clinical care, computerized physician order entry, and billing functions, to name a few.
  • Make buy decision: Mental health. Collecting mental health process metrics and quality outcome data is very difficult with current EHR software. We are working with mental health organization that’s trying to develop a mental health EHR to meet their specific needs – and hopefully the needs of many others. One organization is quietly and diligently investing in meeting the needs of mental health providers around the country. They’ve searched for years to find an easier and better solution. None exist, regardless of the assertions from traditional EHR vendors. From what we’ve seen so far, this will be ground-breaking.
  • Focus on ambulatory solutions. One organization – which recently went through a significant merger—has two different inpatient EHR platforms and a wide variety of ambulatory EHR platforms. It believes that the future is going to be dominated by early prevention and screening, population health management, chronic disease management, and patient self-management. More important, it’s confident that the majority of the future will be managed in the ambulatory environment. As a result, it’s focusing on standardizing ambulatory EHRs and creating mobile applications to make accessing medical records and making appointments as a means for improving the organization’s ability to engage physicians and patients in being an integral part of population health management. Inpatient services will never go away, but they also won’t be the center of healthcare delivery like they have been in the past.
  • New tools versus customization. Many healthcare organizations have become financially fatigued at the cost of each inpatient EHR upgrade – and the cost of customization is equally overwhelming. New vendors have been rising in growing numbers to provide better solutions with relatively low cost and greater user-friendliness. This requires hospitals to overlay a software solution on top of existing EHR platforms. However, the ease of implementation and application is seen as more palatable and more effective than gaining better collaboration and compliance from the current group of EHR vendors. 
  • What if: Starting over. Perish the thought? In the ultimate make-buy decision conundrum, there’s an underground movement by a few very large providers and a few brash software development firms to start all over. They asked simple questions: If we start from scratch, can we create an inpatient EHR that combines all the lessons learned over the past 10 years into a more functional and clinically logical workflow that also meets current and foreseeable CMS demands for data? If we take the best practices that we know already exist, can we create a platform that’s easier to use and less time-consuming for physicians and nurses? If it’s done right this time, would it be less expensive and easier to implement? Could a new, innovative platform be created that replaces existing, cumbersome software programs? Could a new EHR be developed that could easily be updated and upgraded across all users? The initial projections reportedly answer these questions with a resounding YES. Stay tuned. 

Bottom line

Few situations in the healthcare industry have been as tortuous and burdensome, in terms of development, as the EHR. Regardless of how we arrived at this unfortunate juncture, providers across the country are reaching a revolutionary point of dissatisfaction with the EHR and the vendors that supply them. Significant investments are being made to create patient-centric, provider-friendly, and cost-effective tools to replace the unsustainable conditions that exist today.