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EHR Failures: Can We Do Better Than the Average?

July 31, 2008
by E2556BEF60524A5689D02EEBDAEFEDB6
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Several weeks ago I posted the following comment about the difference between the CBO’s and RAND’s analysis of EMR/EHR value:

The PROBABILITY is that when many organizations take on the very complicated, expensive and difficult task of implementing an EHR, some of them will fail. And those failures will bring down the average expected benefit. Since more failures occur early in a technology’s life cycle, the average benefit for all previously implemented EHRs may be very small, or even negative.

The demonstrated POSSIBILITY is that an individual hospital or system can realize substantial benefits from an EHR. The growing body of evidence of EHR benefits exists mainly in individual studies of components of an EHR (such as CPOE, safety alerts, or electronic clinical documentation), or specific types of benefits (such as ADE prevention, or order communication timing, or nursing efficiency). Taken together, these studies contain compelling proof of EHR benefits.

To further develop this point: It’s difficult to distinguish between EHR failure rates that apply to physician practices vs. hospitals, but here are some of the percentages that are quoted:

- Oh no! Half of all current EMR’s fail! Technology for Doctors, 2007

- 19% of EMRs are uninstalled; 30 percent are not used by at least some physicians, Medical Records Institute, 2007

- Avoiding EMR meltdown: How to get your money’s worth (“About a third of practices that buy EMR systems stop using them within a year”) AMNews, 2006

- The failure rates of EMR implementations are…close to 50%.” Proceedings of the 11th Annual Symposium on Health Information Management Research, 2006

- “Industry experts estimate that failure rates of EMR implementations range from 50-80%.” A Commonsense Approach to EMRs, 2006

- “50% of EMR system implementations result in failure.” International Journal of Technology Assessment in Health Care, 1997

To use the lowest figure cited, let’s say that approximately twenty percent of hospital EHR installations fail and the system is removed. In these cases it’s likely that the entire investment in hardware, software, implementation costs, lost productivity (and other costs more difficult to measure) is lost. If this average investment is ten percent of annual revenues (or $100 million for a $1 billion IDN) the other 80 percent of EHR implementations must generate a return of 2.5 percent of annual revenues each just to get back to even.

And if the failure rate is 40 percent then the other 60 percent must generate a return of almost 7% of annual revenues for the collective return to be zero. But wait, there’s more: only the clear system failures, those that generate little or no benefit, are likely to be ripped out. The partial failures, those systems that are only partly used, where CPOE and physician documentation are never used, or where some physicians never use the system, may limp along for years, generating a slightly negative or slightly positive return. And the percentage of these “low benefit” installations is likely to be at least as large as those hospitals where the EHR is uninstalled.

Under these conditions, the relatively small number of very successful installations is not enough to pull the average EHR return into positive territory, and the CBO is right in concluding that “By itself, the adoption of more health IT is generally not sufficient to produce significant… savings”.

But what if you could increase the chances of success? Make it much more likely that your EHR would succeed than fail? Then the benefits demonstrated by the successes are well worth the investment. That’s the question at hand for hospital executives: “Can we do better than the average?” I believe the answer is yes, especially since the bar is set so low, but it will require a different approach to EHR implementation, one focused on system value (benefits) instead of just technical success or process changes.

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Thanks for taking the time to share your valued experience and knowledge with a PM shlub like me that is struggling to help client PM shlubs, also like me, to implement EMR.

You will also appreciate that it is no small task for the said shlubs. Self deprecating for sure, but an honest assessment of my work for the last fifteen years. Front line needs assessment, ion, contracting, implementing, and then starting all over again in order to get the next spoke of the wheel in place to complete an EMR in a community hospital setting.

Thanks for taking the time to help.

Excellent analysis... As a long time owner of a technology training company and former CIO of an international technology training company I can say that what you are seeing in the EHR implementations is no different than what industries saw years ago in implementations of ERP applications such as SAP, Oracle, Bond and etc. Maturity has solved a part of their issue by understanding that a technology implementation is 80% change management/education and 20% technology.

Training is a key component to the success of a technology implementation that encompasses the change management and teaching the end user how to effectively utilize the new technology. The old "super user" training model does not work, but time and time again I hear and see that change management and training are merely an after thought at the end of an implementation. Assessing the trainee population is overlooked and an assumption that all users already have the requisite knowledge of computer usage is wrong... In fact in recent surveys, over 30% of the working public cannot effectively use a computer or navigate the internet, but yet we question why the adoption rate for an EHR implementation is so low and ends up in failure. Many implementations depend on a system analyst to design and configure the workflow and associated applications set up, then create training materials and deliver training! No wonder we have failures. Such little thought or importance put into what might be the most critical aspect is a formula for failure. Professionally designed courseware utilizing advanced adult education concepts, creating standard content templates, and measuring the effectiveness of training are all a part of a well defined implementation.

A few key considerations:

Who needs to be trained?
What do they need to know to do their job?
When do they need to be trained?
What is their base knowledge of the technology?
What do we need to do to have them at a minimum knowledge level prior to go live?
What resources are required?
How are we going to register, track assess and monitor training?
How are we going to deliver training?
How are we going to get our delivery staff prepped?
Do we have Executive buy in?
Are employees and management aware of the time commitment to get trained?
Do we have an effective communication plan including gathering and using feedback?
How are we going to measure the effectiveness of our Change Mgmt/Training program?
Have we adequately budgeted for training?

This discussion is a brief summary of considerations. I have written a number of white papers on the subject and would be happy to share them with you.

speaking for myself, I think it would be great if you posted/linked to your white papers that's what this forum is all about

Dear Guru,

I'd agree with Anthony's idea - why not link to one or more of your papers right here? Or if they aren't on the web, I'm sure we could figure out a way to post them - how would that work, Anthony?

guru - let me know what you are trying to do and if you need technical help

OK - thanks Guru I've uploaded the PDFs into your posting above

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