Healthcare organizations spent more than 20 billion dollars adopting electronic health record systems from 2008 to 2016.
Although the 2009 American Recovery and Reinvestment Act gave health systems a financial incentive to achieve Meaningful Use of Electronic Medical Records, many healthcare organizations have struggled to capture value. As the capabilities and sophistication of EMRs continue to grow, there is a widening divide between healthcare organizations that harness the capabilities for a competitive advantage and those that are crippled by poor usability, workflows and adoption.
The Cost of EMR Replacement
To meet the requirements of the Meaningful Use program, most EMRs were implemented using a Big Bang approach, and very rapidly. But this approach has produced several unintended consequences and widespread user dissatisfaction. In 2013, with the process well underway throughout the nation, two thirds of doctors polled said they used EMR systems unwillingly, with 87% of these aggravated physicians complaining about usability and 92% of physician practices complaining that their EMRs were “clunky” and/or too difficult. Specifically, only 35% reported that it had become easier to respond to patient issues, one third said they could not more effectively manage patient treatment plans, and despite the belief that technology would permit caregivers to spend more time with their patients, only 10% said this was occurring.
Recently, three prominent Boston-area physicians wrote about “Death by A Thousand Clicks.” They argued that when doctors and nurses turn their backs on patients to pay attention to a computer screen, they cannot offer the “time and undivided attention” required to provide the right care. They complain that multiple prompts and clicks in an Electronic Health Record system can adversely affect patients and contribute to physician burnout.
The medical side was not alone in expressing dissatisfaction. Hospital executive and IT employees who had replaced their EMR systems reported higher than expected costs, layoffs, declining revenues, disenfranchised clinicians and serious misgivings about the benefits gained:
• 14% of all hospitals that replaced their original EMR since 2011 were losing inpatient revenue at a pace that would not support the total cost of their replacement EMR
• 87% of hospitals facing financial challenges now regret the decision to change systems
• 63% of executive-level respondents admitted they feared losing their jobs as a result of the EMR replacement process
• 66% of the system users believe that interoperability and patient data exchange functionality have declined
Today, HDOs are at a crossroads. They can start over with a new EMR or optimize the one they have.
Many HDOs are cash-strapped and the transition from fee for service to value-based care exerts downward cost pressures, exacerbating the problem. But patchwork fixes have not improved matters. Alternatively, some attempted to do too much too quickly and became frustrated because they lacked the depth of experience and knowledge to perform remediation. And, as KPMG concluded after studying the problem, “The length of time to resolve the issues increased and frustrations mounted as clinical, senior management, IT and human resources staff found themselves spinning their wheels.”
Nevertheless, a recent survey conducted by KPMG in collaboration with CHIME, shows 38% of 112 respondents ranked EMR/EMR optimization as their top choice for the majority of their capital investments for the next three years.
The Benefits of EMR Clinical Optimization
The case for optimization is strong. Optimization should help HDOs meet regulatory requirements, enhance the quality and cost-effectiveness of patient care and increase the ROI on technology. Furthermore, optimization of medical records ought to increase patient satisfaction because information will be more transparent and more accessible. If this proves true, it will take less time to obtain care and patients will also experience more intuitive, user-friendly payment systems.
Optimization should also contribute to higher levels of satisfaction among physicians whose work flows will be more flexible, whose hours will be reduced and who will more easily secure information because it has become more transparent.
How is it panning out in practice, now that more and more health care organizations are committing to the clinical optimization of their EMRs?
The short answer: even better than any dared hope:
• Nurses are saving 28-36 minutes per shift
• Lab test use and drug costs have declined by 15%
• The average length of stays has been reduced by 5% to 10%
• The incidence of adverse drug events dropped by 334 to 481 annually
• Turnaround time for orders was cut by at least one hour
• Vaccination compliance reached 99%
• Costs of paper forms were reduced by 67%
• Charge capture improved to 64%
• Costs of transcriptions were cut by 61%
• Administrative staff (82%) reported noticeable improvements to the operational or financial capabilities of their practice management and EMR systems
Matching these striking improvements for healthcare organizations is the evidence from physicians:
• 59% report cost savings by eliminating management and paper records storage
• 70% report faster, more accurate service billing and overall time savings
• 53% report increases in worksite efficiency
• 71% describe their EMR vendor to be “meeting or exceeding” their expectations for EMR optimization
How Optimization Can Work
Committing to the optimization of EMR systems is not like waving a magic wand. It must be executed with a clear notion of what must be done and how to do it. We see two focal points that will lead to success:
Application Portfolio Rationalization:
At most HDOs, IT operations feature an assortment of disconnected applications, with most large organizations deploying thousands across the enterprise. But these systems are costly to maintain and represent an ever-growing, significant liability the longer they exist. With consolidation of organizations into large integrated care delivery networks and growing dissatisfaction with the efficiency of existing electronic healthcare record systems, many of these clinical applications can and are being retired. Thoughtfully rationalizing some of those siloed legacy systems can produce a significant reduction in TCO. For example, the total cost of ownership can range from $1MM to hundreds of millions per year, often requiring ~50% of incremental annual IT operating costs on top of licensing costs. Archival of legacy data allows for legal decommission of legacy systems, resulting in savings of 80-95% when compared to the cost of systems’ licenses and infrastructure.
Efficiency and Automation:
EMR optimization can generate cost reductions up to 10% through gains in operational efficiency. Time-stamped, event data-driven workflow optimization - Clinical Cycle Management (CCM) – produces measurable productivity and efficiency gains, but more importantly, enhanced clinical decision support. Profiling an EMR application allows for robust and rich usage data gathering, including clicks, mouse movements, and time spent.
Analysis of these workflows, using a temporal query tool, allows for identification of bottlenecks, poor workflows, and other time sinks. It shows both individual user activity, as well as aggregate data, and lets you define logical EMR “tasks.” It provides the basis for realizing workflow optimization efficiency gains through workspace modification, training, automation through macros and EMR UI Augmentation. Such analysis also facilitates the ability to introduce real-time clinical decision support through workflow interventions. Taking this a step further, clinician generated clinical automation would completely automate a clinician decision.
Measuring Success
An implemented EMR does not guarantee a return. Organizations that fail to properly integrate and leverage EMR capabilities can quickly find themselves in post-implementation purgatory, paralyzed by disenchanted users and underwhelming provider performance. Adopting a data-driven approach to optimization provides organizations with the ability to diagnose and correct problems by measuring and evaluating performance across specific metrics.
Suppose, for example, that the workdays of providers are unsustainability long, or, that despite the installation of an EMR, productivity is no better than it was before the new system was adopted. This situation can be addressed if the new EMR collects – as it must – easily reportable data. There should be operational data gathering that records messaging and tasking to illuminate workflow opportunities and project goals to be benchmarked prior to optimization efforts. If workdays are still too long and productivity is still too low, the EMR must be set up to diagnose specific windows of time – system hours per day and/or the proportion of encounters that include the use of EMR documentation tools (versus free text).
If providers report that the amount of time they spend with patients has decreased and that patient wait times have increased, the EMR must be programmed to assess total patient time per encounter and total clinician time per encounter. If the nursing staff reports that it is taking longer to follow up with patients, there must be records of the average time it is taking to respond to patient calls and of the average time required to contact patients regarding abnormal test results. If care teams express concern that they are not effectively managing their diabetic patients, for example, it is essential that compliance rates with preventing screening measures and average HbA 1c scores are accurately captured.
Conclusion: Driving Outcomes Through Optimization
EMRs have not yet achieved their full potential, providers are weary of their inefficiencies, and more resources must be spent to optimize the original investments. But, a properly integrated and fully utilized system can establish the foundation for significant and sustained organizational improvements in Health Delivery Organization efficiency, end-user satisfaction, and data quality – and the full utilization of an EMR to its capacity will rationalize and justify investment. To accomplish this, HDOs must address the deficiencies that threaten productivity, including proper training and IT support, full utilization of automation capabilities, and workflow optimization. If this is done, it will result in an increase in provider capacity. And by increasing provider capacity by an additional three visits per day (averaging $150 per visit in reimbursement), HDOs have the potential to increase revenue by more than $60,000 per provider each year.
For many EMR end-users, performance is still impeded, causing continuing and often mounting frustration. An AMGA Physician Retention Survey found 11.5% provider turnover rate among advanced practice clinicians. Losing and replacing a single provider costs a minimum of $250,000 but the actual cost often exceeds $1 million. A focus on provider retention through enhanced RMR interaction produces truly significant returns; increasing retention by just four providers equates to $1 million to $4 million in savings in costs associated with provider loss and replacement.
With the move from fixed-fee reimbursement to value-based care, HDOs are required to demonstrate and document their effectiveness measuring and reporting outcomes. With outcomes measures directly linked to financial incentives and reimbursement rates, data liquidity and quality is of greater importance, rendering accurate information an invaluable asset. Insight into performance and outcomes data allows HDOs to achieve quality metrics and foster sustained performance improvement.
A robust EMR optimization strategy can – and will -- help HDOs realize the promised value from implementation of an EMR. EMR optimization is the driver of strategic value and can – and will -- become a sustainable competitive advantage through leadership, innovation and measurement.
About Galen Healthcare Solutions
Galen Healthcare Solutions is an award-winning, #1 in KLAS healthcare IT technical & professional services and solutions company providing high-skilled, cross-platform expertise. For over a decade, Galen has partnered with more than 300 specialty practices, hospitals, health information exchanges, health systems and integrated delivery networks to provide high-quality, expert level IT consulting services including strategy, optimization, data migration, data archival, project management, and interoperability. Galen also delivers a suite of fully integrated products that enhance, automate, and simplify the access and use of clinical patient data within those systems to improve cost-efficiency and quality outcomes. For more information, visit www.galenhealthcare.com. Connect with Galen on Twitter, Facebook and LinkedIn.
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