Why a Thin Line Separates EHR Optimization, EHR Replacement

Healthcare providers will have their reasons for choosing EHR replacement or EHR optimization, but a thin line may be all that separates them.

By Kyle Murphy, PhD on

For the past years, industry analysts have predicted a rise in EHR replacement activities that have failed to come to fruition. Most recent reports now point to a shift in the thinking of healthcare organizations and providers about their current EHR technology.

Last summer, Black Book Rankings released findings that large providers were growing increasingly satisfied with their EHR systems, a dramatic change from two years previous when 92 percent of multispecialty groups expressed EHR dissatisfaction. As of 2015, only 18 percent were considering an EHR replacement system.

The difference maker? EHR optimization activities — 71 percent of surveyed physicians described their EHR vendor to be “meeting or exceeding” their expectations for EHR optimization while 82 percent of administrative staff reported noticeable improvements to the operational or financial capabilities of their practice management and EHR systems.

The findings complement those of an Impact Advisors survey of healthcare CIOs. Members of the College of Healthcare Information Management Executives (CHIME) by and large identified realizing return on investment for EHR investments as their organizations' top IT priority (70%) and reported that they were currently focused on EHR optimization (92%).

EHR optimization is a top priority for healthcare CIOs

EHR dissatisfaction numbers were similarly telling. A majority of respondents agreed with the statement that their EHR investments benefitted their clinical/operational and revenue cycle activities at their organizations.

Read: Ensuring Physician EHR Use Doesn’t Lead to Physician Burnout

This growing focus on EHR optimization, however, does not necessarily signal the end for EHR replacement, albeit at a slower pace.

"There are upgrades, vendor switches, and still untapped physician markets for web-based products. That being said, it's like any other software market now that the direct incentives are over and as such, vendors need to sell on value," Kalorama Information Publisher Bruce Carlson said in support of findings predicting an annual growth rate for the EHR replacement market of seven to eight percent over the next five years.

While these various reports fail to reach a consensus on EHR optimization and EHR replacement, they succeed in highlighting the paths available to healthcare organizations and providers for getting the most out of their EHR technology — new or old.

EHR Replacement Gotcha of Data Migration

While the aims of EHR optimization and EHR replacement share many similarities, each presents pros and cons for its EHR end-users.

A major consideration for any organization considering an EHR replacement has to be EHR data migration from the outgoing system to the incoming one.

"As much as we have this HL7 format and everything is supposed to be built on the same type of platform, there are some many data fields that don’t always match," Jerrilyn Ivey, Director of Consulting Services at Culbert Healthcare Solutions, tells EHRIntelligence.com.

"You’ve got to be able to sit down and do that mapping, and doing thorough testing to make sure that it’s done," she continues. "All of that requires a great deal of time. Data migration sometimes gets the short end of the stick and people don’t give it enough time in their project plan to thoroughly vet and test it out."

One such area is scheduling and the reason why is clear. "You have providers who are maybe scheduled out six months. You’ve got to convert all those appointments over to the new system. That’s one of those necessary fields," adds Ivey.

While certain EHR data is not integral to a patient's care moving forward, it still must be preserved for HIPAA purposes. However, that avenue of EHR data retention is not available for bits of data that have an immediate impact on care coordination and delivery, such as appointments.

According to Ivey, teamwork goes a long way toward remediating potential downstream problems. "Everyone needs to work as a team to make sure that you have time and resources dedicated to data migration," she maintains.

Ivey's insights echo those of the Director of Technical Services at Wolters Kluwer, which itself is in the process of migrating data between two health information systems — the retiring EndoWorks and replacement ProVation MD.

"Definitely, the top challenges are with data integrity," Eric Kizewski explains. "Obviously, bringing two disparate systems together that have never had any interoperability previously is a challenge. Many of the EndoWorks systems that we’re working with now have never had any kind of interface to another system before."

Leading features sought in EHR replacement technology according to Black Book Rankings

The EHR replacement process tends to reveal wrinkles in the outgoing system and data capture activities of its end-users.

"That’s probably the biggest gotcha," claims Kizewski. "Many of patient IDs and demographic records have been manually keyed in. That’s all data that has been entered for years. There are tens of thousands of those records.

Fortunately for Wolters Kluwer, the company has recourse to a proprietary tool for exporting data from EndoWorks before populating fields in the EHR replacement system. That being said, manual labor continues to play a necessary role in ensuring EHR data integrity and patient safety.

Read: 4 Steps for Ensuring a Successful EHR Optimization Project

"We do that in a test environment and then we share that with the customer and they are able to take a look at that and identify anything that might be incorrect or anything that they may want to clean up on the frontend," Kizewski says of the EHR data migration process. "From there, it’s planned around a go-live event. We take a look at how much data we have and really go from there. Some of these have ten years and tens of thousands exams, and some are much smaller."

EHR data migration is but one step in the EHR replacement process. Clinicians and administrative staff still have the task of learning new technology and becoming efficient users. As such, the EHR replacement process remains littered with potential setbacks.

"That’s probably the biggest gotcha. Many of patient IDs and demographic records have been manually keyed in. That’s all data that has been entered for years. There are tens of thousands of those records."

First, providers must maintain the health data security and privacy of protected health information (PHI) during the transition between the two EHR systems.

Second, organizations must manage change management internally and not rely on EHR vendors to change its health IT culture. Without a culture of change, an EHR replacement project isn't likely to take.

Third, a lack of specific and effective timelines can sink the EHR replacement project. Here, EHR vendors can play a valuable supporting role in helping providers set realistic deadlines that allow for flexibility as needed.

Fourth, the EHR replacement process can prove cathartic so long as organizations are prepared to move on from their past failures and successes but keep lessons learned in mind. In other words, ignoring history leads to repeating itself.

Lastly, a lack of executive buy-in from the C-suite can serve to undermine the success of the EHR replacement project.

EHR Optimization in Search of ROI

Sometimes, a rip-and-replace scenario is impossible to avoid. Practices merge. Health systems make strategic acquisitions. Others look to consolidation. In these instances, EHR optimization is not possible. But as the aforementioned research shows, health IT leadership believe there to be ample opportunity for their organizations to get more out of their current technology.

For industry analysts, EHR optimization opportunities generally fall into three categories.

"There's the usability/efficiency bucket of keeping our providers and our end-users happy and more efficient and productive," Impact Advisors Physician Executive Tonya Edwards, MD, MMM, told  EHRIntelligence.com in early December. "Then there's the bucket of cost avoidance — let's improve workflows to increase utilization and decrease variability. Then there's the bucket of let's try to increase revenue because we have not made this big transition from volume to value yet. We're in the midst of it, so we still have got to drive volume."

And little appears to have changed. Ivey at Culbert Healthcare Solutions views three areas as the top-of-mind EHR optimization priorities for healthcare organizations.

From an EHR usability standpoint, EHR optimization efforts can make effective inroads by simply reducing the number of clicks physicians and clinicians must make to reach a desired electronic record or file. A lack of EHR usability could easily stem from using an EHR technology right out of the box.

"There are lots of ways you can reduce clicks. It can be in the workflow. It can be in the way they are navigating. It can actually be the way the system was built."

"When you are taking something out of the box, you have prescriptive workflows, workflows that are designed for that out-of-the-box system," Ivey maintains. "So when you come in and you're able to look at streamlining a workflow, customizing a system to complement that streamlined workflow, you're able to then reduce some clicks."

Navigation, for example, is an obvious area for removing unnecessary clicks.

"Physicians are trained and remember one specific way of doing it," Ivey continues. "There may be two or three, but they are going to train them on one. Even getting to a specific area in the EHR, you can reduce one or two clicks simply by going about it in a different way. There are lots of ways you can reduce clicks. It can be in the workflow. It can be in the way they are navigating. It can actually be the way the system was built. You can design the build to be more customized in a way that it allows physicians to get through it with less clicks."

As for improving utilization and decreasing variability, alert fatigue is a popular topic at the moment.

A recent study found that  physicians spend approximately 66.8 minutes per day processing notifications from EHR use. Researchers calculated that primary care physicians received a mean of 76.9 notifications per day and 15.5 notifications were related to test results. Specialists received 29.1 total notifications per day and 10.4 notifications were related to test results.

According to Ivey, failing to address physician fatigue as a result of these notifications can have serious consequences for patient safety. The root cause? Not putting in the time upfront during an EHR implementation to address these alerts.

"That goes right back to coming right out of the box," she argues. "A lot of times organizations are forced to do that because they don’t have that initial time upfront to do that customization. That’s where that optimization phase comes in and it’s so crucial. But you are able to come, visit with them, and figure out what is cumbersome for them and see what we can do to fix it."

The issue of alert fatigue becomes especially palpable for specialty physicians for whom EHR technology is rarely engineered.

"Sometimes physician specialties, like orthopedics, tend to be fast paced — they see a lot of patients; they see a lot of patients very quickly — you’ve got to be able to build them some templates, some things in the system that allow them to get through their workflow quickly. Otherwise, physicians are going to be your loudest complainers," adds Ivey.

Unsurprisingly, considering the industry-wide shift in healthcare reimbursement models, improving revenue cycle management represents the third most popular target for EHR optimization.

Read: EHR Implementation Projects Impact EHR Optimization Efforts

"And then a lot of it is revenue as well — areas where they can decrease the number of rejected claims, help the providers be able to not only provide documentation for the appropriate codes but also efficiently and effectively, how to get that in the system and ultimately be able to affect their numbers and revenue," Ivey says.

Something as simple as implementing a tracking system can go a long way toward highlighting inefficiencies in claims management leading to unbilled charges, which could number in the hundreds of thousands of dollars for larger organizations.

"We have to optimize it and we have to utilize it in order to make it functional for us and make us not want to throw it out with the bath water."

While the drivers of EHR replacement projects regularly fall in one of these three categories, any will emerge as a result of performing a thorough EHR optimization assessment and even prevent EHR replacement activities. "Some organizations can potentially keep their EHR if they did a thorough optimization assessment and mitigation of what’s required for it," Ivey claims.

For the consultant like Ivey, EHR optimization signifies an opportunity to get the most out of EHR investments for the betterment of providers and patients.

"They are a very powerful tool, and there are lots of ways we can get our job done if we just use the system," she asserts. "We have to optimize it and we have to utilize it in order to make it functional for us and make us not want to throw it out with the bath water."

Healthcare providers will have their reasons for choosing EHR replacement or EHR optimization, and vice versa. However, a thin line may be all that separates sticking with current technology from opting for a new system altogether.

Jerrilyn Ivey, Director of Consulting Services at Culbert Healthcare Solutions