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The Real Deal on EMR Implementations

January 31, 2008
by Vince Ciotti and Barry Mathis
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With ROI for large-scale IT projects still questionable, it's important to focus on quality improvements, not dollars and cents

Vince ciotti

Vince Ciotti

There is tremendous interest lately in electronic medical record (EMR) systems, with many hospitals seeking to acquire an EMR in conjunction with computerized physician order entry (CPOE), to both reduce paperwork and clerical effort.

Although this trend started with large medical centers, then spread to mid-sized community hospitals, today even small hospitals under 100 beds in size and critical access (under 25-bed) facilities are seeking such systems to stay competitive. Interest in EMRs and CPOE has been fueled by claims in the media of huge potential cost savings, such as the Rand Corporation's claim of $41.8 billion per year savings if 90 percent of providers embraced an EMR. Even presidential candidates are jumping on the EMR bandwagon, with both red and blue politicians extolling EMRs as the panacea for most of the ills in our healthcare “system.”

Barry mathis

Barry Mathis

Interestingly, most of the articles and speeches touting potential return on investment (ROI) from EMRs have been given by vendors, often through their surrogate “pilot site” hospitals, and consulting firms that stand to earn millions in the sale and implementation of each system. The oft-quoted Rand study was itself funded by vendors like Cerner, GE, HP and Xerox, causing some to question the objectivity and attainability of these large ROI claims.

The risk to hospitals and CIOs who believe these claims and promise such ROI to their CEOs and boards is that if cost savings are not accomplished in “X” years, not only is financial survival at risk in these days of decreasing reimbursement, but even careers are in jeopardy if implementations fail or cost savings are not met.

This article will attempt to present the other “ROI” of EMR and CPOE systems: Real Obstacles to Implementation, that is, challenges that must be met to implement even basic functions of an EMR, let alone achieve the claims of greatly reduced costs. Since we might be running for president ourselves some day and have to jump on the EMR bandwagon as well, for each of the obstacles given, we will list ways to overcome them or at least mitigate their effects.

Hopefully, this single article in the face of the media frenzy encouraging adoption of EMRs might temper the claims you make to your senior management and board of directors, so that if (when?) your EMR implementation experiences difficulties, you can quote how you warned them in advance and tried to lower their expectations.

EMR expectations

The primary assumption with EMRs is that physicians will use them in lieu of paper charts and obtain many benefits such as:

  • Reducing duplicate tests by seeing what other providers have ordered

  • Viewing patient history from past visits to improve patient care

  • Avoiding legibility problems with M.D.s' notoriously poor handwriting

  • Medical alerts popping up to remind physicians of contra-indications

A secondary assumption with EMRs is that nurses will obtain such benefits such as:

  • Eliminating duplicate order entry of M.D. scribbles on order sheets

  • More legible progress notes for nurses on succeeding shifts

  • Less time documenting to increase time at the bed side

  • More structured and organized notes for greater clarity

All of these expectations are admirable in that, if accomplished, they truly would improve things for hospitals, care givers and patients. And the theoretical ROI can be quickly seen:

  • Duplicate tests cost many thousands of dollars

  • Nursing overtime costs can be reduced

  • Lower malpractice rates, etc.

So why doesn't every hospital have an EMR installed? Why aren't those that do have them installed out-perform all others in productivity and quality?


During our work experience (see bios at the end of this article), we have assessed over a hundred hospitals with EMRs installed or in the throes of an implementation, and have observed first hand many obstacles to their adoption, such as:

Time — Physicians are experiencing the same dwindling reimbursement hospitals face, and they only have so many hours in a hectic day to make rounds at their hospitals and then see patients in their offices. Indeed, most M.D.s earn far more at the office than at the hospital due to complex professional fee billing via CPT codes, so they want to minimize their time at the hospital and maximize it at the office. Give these time-harried physicians the choice of scribbling an order on an order sheet in a chart, or spending several minutes signing-on (“What is my password at this hospital?”), navigating through multiple screens (“Don't these programmers know how a doctor thinks?”), clicking past repetitive alerts (“When are they going to fix this message?”), etc., and which would you chose?