You just put the last screw in the enterprise EMR. And the day you're finally finished — after millions of dollars and years of 12-hour workdays — you start the process of throwing it out and getting a new one.
Though just a few years ago this scenario might have made industry headlines, today it's not that unusual, as more and more CIOs are tasked with migrating a legacy EMR to a new one. And most agree that going from EMR to EMR is more complicated than going from paper to electronic records. Looking at the cost and difficulty, why are hospitals taking on this gargantuan task? And for those that do, where do they even start?
“The question every CIO should ask is ‘what's driving the decision?’ — because that defines where you start,” says Jonathan Thompson, vice president at Minneapolis-based Healthia Consulting. “Functionality is a key driver.” Thompson says a common reason for change is keeping (and growing) market share in the community; in which case, a hospital starts with its affiliated ambulatory strategy.
For Bert Reese, CIO of Sentara Healthcare, a seven-hospital system based in Norfolk, Va., that was exactly the case. Reese had a lot at stake: six of his hospitals had been on an Atlanta-based Eclipsys EMR since 1994 — and it was working well. “I had standardization across the board,” he says. “We were a poster child for Sunrise Clinical.”
But in 2004, the president of his health system decided on CPOE as an enterprise strategy, and Reese realized that for Sentara, primary care, homecare, and the physician practices had to be part of the plan. “What we concluded was that if you have an integrated environment across all the environments of care, one plus one equals eight,” he says. So Sentara changed its strategy from doing CPOE to implementing a fully integrated environment.
Some of Sentara's physician practices were already using GE Logician as an EMR. “We could have interfaced Logician, but that's never as good as an integration,” says Reese. “I went back to my boss and said, ‘Would you be willing to go backward to go forward?’” Sentara opted to sign on for a full Epic (Verona, Wis.) implementation. “This will cost us $237 million over 10 years — with an ROI somewhere north of $35 million a year of new revenue and decreased costs as a result.”
Know thy user
For other hospitals, functionality can bring about better documentation. At CentraState Healthcare in Freehold, N.J., CIO Neal Ganguly says his clinical staff was the driver. CentraState had been a Meditech shop since 1999, and Ganguly says the pain points were with nursing documentation, the EMR itself, and physician order entry. “It depends on how demanding your users are — and our users were very demanding,” Ganguly says. Though nurse productivity got him started on the project, it really just opened the door. “When we began to look at other systems, we realized we wanted a lot deeper analytic capabilities, and a lot more ability for customization of workflow.”
By 2003, Ganguly had decided to move forward with Siemens' (Malvern, Pa.) Soarian, a system that he felt was more user friendly for nursing documentation. His decision was not all that difficult for the hospital to swallow — he had the advantage of the “new” on his side. “I was lucky in a way because Meditech had been selected by my predecessor — it had gone live two months before I came on board.” CentraState had also just gotten a new CEO and COO, “so it was the perfect storm,” says Ganguly. The new administration wanted to use technology to deliver value and, according to Ganguly, the Board heard the justification and understood.
He had another factor in his favor: cost. “Lucky for us, our Meditech system wasn't that expensive,” says Ganguly. He concedes that the $3 million dollars CentraState had already spent on Meditech was significant, “but if we had McKesson or Cerner in place instead, where we might have spent $8 million, it might have been a lot harder to justify.”
For other systems, interoperability drives the change. Sharp HealthCare, a four-hospital system in San Diego had been working on an EMR strategy for 20 years. “But in the past two years,” says CIO Bill Spooner, “we decided that the current strategy had too many systems and too many interfaces.”
Sharp was using United Kingdom-based GE for order entry and pharmacy, but had clinical documentation from San Diego-based Clinicomp that had been developed for Sharp. “Despite the fact that it was an elegant documentation system, the combination of multiple systems was not functioning well from a workflow standpoint,” says Spooner. “We decided to make this migration to fewer systems.” Two years ago, Sharp began implementing Kansas City-based Cerner's EMR.
Spooner had another very important driver, one that many CIOs are dealing with today: he was opening a new hospital, designed in 2000 to be paperless. He says it soon became clear that the EMR strategy for the new hospital had to embrace the other hospitals as well. “We realized we either had to make that leap or redesign the hospital,” says Spooner. “And there wasn't a great deal of eagerness to redesign the hospital.”
No matter what the driver for a new system, someone has to be accountable for it. As Spooner says, “Ultimately I get the credit if it doesn't work.”