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Extending Your EHR to Independent Hospitals and Clinics: Five Considerations

May 17, 2012
by Susan Heichert, Mary Bear-Dukes, and Dawn Mitchell
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Best practices for meeting challenges of capital, cost of ownership, and meaningful use

Recently, Farzad Mostashari, M.D., National Coordinator for Health Information Technology within the Office of the National Coordinator, told the HIMSS’12 conference that the United States has made more headway with electronic medical records (EMRs) in the last two years than in the past 20.

The reason is clear: federal and state legislation are focused on achieving the “Triple Aim” of healthcare reform—better care for individuals, better health for populations, and slower growth in costs through improvements in care. In response, promising collaborative care models are emerging, including accountable care organizations (ACOs), patient centered medical homes (PCMHs), and others. Most experts agree that a key success factor for such models is high quality, interoperable health information technology (HIT), especially EMRs because of the ways they facilitate clinical integration and, in turn, improve patient outcomes across diverse settings.

With that in mind, some hospitals and health systems are looking to extend their own EMR solutions to independent hospitals and clinics. The practice became possible with the relaxation of anti-kickback statutes in 2006, but the sense of urgency has heightened in today’s environment. In fact, some organizations are even implementing new EMR solutions internally while extending the same solution to private practices simultaneously.

The benefits of extending top-notch, readily interoperable EMRs can be substantial.

Fig. 1. Benefits of extending readily interoperable EMRs

Nevertheless, achieving those benefits means overcoming some significant challenges.

A Shortage of Capital: Health systems, community hospitals, and physician practices already have their financial and human resources stretched thin across competing priorities and may struggle to dedicate the resources necessary for a successful effort.

Total Cost of Ownership: Independent hospitals and clinics (that is, your prospective clients in an extension strategy) still struggle to afford the implementation and ongoing costs associated with EMRs. Despite Stark Law Donation Exceptions introduced in 2006 (scheduled to be in place until the end of 2013), many limitations remain in terms of how much time and money a healthcare organization can donate to companion providers.

Meaningful Use: CMS defines “Meaningful Use” as providers demonstrating that they’re using federally certified EMR technology in meaningful and measurable ways and offers incentives for achieving this goal. Most independent hospitals and clinics are counting on those incentives to help offset costs, but while you can guarantee potential clients your technology is federally certified, you need to be clear that meaningfully using the EMR is your client’s responsibility.

This article describes a set of best practices for overcoming these challenges by zeroing in on the five most important considerations.

Fig. 2. Five onsiderations for establishing your roadmap.


Though an obvious first step, developing a roadmap for extending your EMR system should not be taken lightly because it can be particularly challenging. Health systems have to devote the time and resources necessary to do it right. There are five essential components.

Know the End Game: You have to know why you are pursuing an EMR extension strategy—and the why should not be to make money. Extending your EMR is an opportunity to build relationships with those providers who can help achieve the Triple Aims but might not be able to afford to implement and manage first-class EMRs on their own. Therefore, your primary objective should be to strengthen clinical alignment with these providers for continuity of patient care across a common platform. Building relationships and strengthening clinical integration with quality data positions the sponsoring and client organizations for a business and regulatory future that demands a new level of data-driven insight into quality and costs.

Identify a Target Market: The main criteria to define which independents to target with your solution should be their commitment to the Triple Aim as well as to the success of the partnership. Identifying providers who meet that criteria – and who are licensed and actively practicing in your service area—is critical.

Define the Offering: Once you’ve identified your best potential clients, a next step is to define your offering. If you’ve found clients who operate similarly to your health system, you can offer a relatively standard solution, which enables faster implementation and is less costly to support. But no one will be a perfect match, especially since small hospitals or private practices cannot be expected to operate like a large health system. Consequently, there must be some flexibility. Ideally, you will offer a standard integrated EMR and practice management solution with the ability to turn features on or off, along with ePrescribing and standard interfaces to lab and imaging systems. Optional services, customizations, and non-standard interfaces will require extra implementation and support, so weigh the pros and cons carefully. The goal is to find the right balance. Don’t try to be all things to all people, but don’t try to shove a square peg in a round hole.

Establish a Pricing Strategy: In pricing your offering, you’ll likely not want to be the price leader. Rather, consider the value you bring to the table: top-notch products and services, best practices and order sets, minimal headaches, and enhanced interoperability that facilitates stronger clinical integration. Most of your partners/clients would likely have to settle for a lesser solution if they were purchasing independently, nor would they necessarily have staff, funding, or expertise to implement on their own. Finally, carefully evaluate the cost to implement and support the solution and how much of the cost your organization is willing to subsidize. If you maximize the allowable subsidy amount, the cost to the customer will be less, but you also will be left with no contingency plans if an implementation requires more time than planned.

Develop a Marketing and Communication Effort: Once you have defined the target market and offering, you need to determine the best way to get the word out. Be careful not to underestimate the cost of marketing including the staff time required to manage responses. In addition, develop consistent messages that set realistic expectations with prospective clients and provide transparency around the total cost of ownership.


At the same time as you are developing a roadmap, you need to be very clear about how Stark Law Donation Exceptions, the federal anti-kickback act and Safe Harbor requirements apply.

For example, under the Stark Law exception you can subsidize up to 85 percent of the cost to implement and support the EMR, but remember that you must have clear criteria for the level of discounts you plan to offer. Be careful of any appearance of giving away software for patient referrals; that’s a clear violation of the anti-kickback statute. Stark exceptions were put in place to benefit the public, not a private practice or hospital. Therefore, there are many constraints surrounding what can be subsidized and what can’t.

In addition, as a sponsoring organization you must be able to show that you received fair market value for your products and services, so keep track of every hour and every dollar spent for implementation and support. An audit that identifies violations of these restrictions can result in substantial penalties.


Many organizations struggle with executing on actual business development since they are not accustomed to playing the role of a vendor. This aspect of an EMR extension strategy requires considerable time and effort, as well as expertise in the three main components: marketing, sales, and contracting. We’ve referenced organizations as clients and customers because they are, and you are a vendor in this case.

Marketing: In nearly all cases, you will need to develop professional materials to market your offering. These should include a brochure and a questionnaire tailored to hospitals or clinics. The brochures can be mailed, hand delivered, or distributed at town hall type meetings, which allows you to communicate your offering and address questions with multiple providers or hospitals in the area.

Sales: You will need dedicated resources to receive calls and visit sites to answer questions and assist potential customers in completing the questionnaire. Whether you decide to proactively sell to all organizations in the region or selectively pursue strategic clients, allocate the appropriate number of resources to review the offering in detail, conduct demos and, if necessary, work with the client to gain approval from their board.

Contracting: While the rest of the business development team is out marketing and selling the solution, your legal team should develop and review templates for all required contracts. Once a hospital or clinic has communicated their intent to collaborate and implement your EMR solution, you will need to tailor contracts for that customer and then have both parties review and sign. At that point the transition from business development to implementation begins.


Be aware that the strategy of extending your EMR to others implies important changes to your IT governance structure. Going outside of your organization alters how you set a strategic IT direction, prioritize, make decisions, and resolve issues. Among the things your governance team will need to do:

  • Review and approve components of the strategy and plan.
  • Review and approve the budget.
  • Define criteria for pilot sites. Which clients have a high probability of success? Who will be a change agent for the community? Is this a good test site based on size and services provided?
  • Review and approve timeline and sequencing recommendations.

In addition, all key stakeholders of the EMR should collaborate to support and optimize the solution. Among the concerns:

  • How is the system and support team performing against the Service Level Agreement (SLA)?
  • How often will new releases of software be available?
  • What changes should go into a given release?
  • Consider creating user groups to foster consistent, collaborative, evidence-based care processes where learning goes both ways.
Any organization that has had a full-scale EMR implementation understands how demanding the process can be. That does not change when extending the system to others. Three of the most significant challenges are staffing, approach and timeline development, and organizational change management.
Staffing: One key staffing decision is the hiring of client service managers to build effective relationships with clients, oversee the quality of services being provided on an ongoing basis, and proactively address client issues and concerns. This will be a new position for many organizations.
In addition, implementation teams will require the right blend of experienced resources, including project managers, IT experts, clinical informaticists, and trainers. The support team should be large enough to assist with go-lives, provide support, and handle billable requests for additional support and optimization. Consider creating a separate implementation team from your support staff to focus on affiliate customers.
Therefore, allow plenty of time for recruiting because these resources are in high demand. Also, allow adequate time for vendor training and certification if required. If you need to leverage consultants for implementation, use them sparingly with a focus on knowledge transfer, or to backfill internal resources since this could have a big impact on cost to the customer.
In addition, estimate the amount of time needed from:
  • Internal subject matter experts at the sponsoring organization. Confirm their availability up front since they will likely be busy implementing, optimizing, and/or supporting the organization’s internal initiatives.
  • The hospital or clinic staff where the EMR is being implemented. Review your project plan with them early on to set expectations and clear the schedules of key resources.
And because of the demands, consider a retention strategy that averts burnout as your team moves from one implementation to another. One simple approach is to have resources alternate between implementation and optimization and support.
Approach and Timeline Development: Above all, your focus should be on quality implementations. This approach means that it is critical that you invest time and resources up front to develop the plan, processes, and tools – and then test your approach in pilot sites. After pilot implementation, take time to debrief and incorporate lessons learned before rolling out to the community. Allow additional time for sites that want to add optional services or purchase a custom interface, as well as for specialty clinics. Finally, give careful consideration to the sequencing of your rollout and how many sites an implementation team can work with at once.
Organizational Change Management: Behind nearly every successful system implementation is a smart and ongoing plan for organizational change management. Implementing an EMR outside of your organization is no exception to this. The key components:
  1. Multi-Level Communication—You will need to consider internal, external and intra-client audiences. Internally, make sure the organization understands the strategy, goals and objectives—and that everyone’s role and responsibility is clearly defined. Communication with clients should be frequent and consistent, and transparency is critical in developing long-term partnerships. Set realistic expectations up front and manage to those expectations.  Consider developing a communications portal, where all interested parties can learn more about the initiative and get a status update.  Encourage communication between your customers and leverage each one’s experience as the others implement.
  2. Adoption—Implement with a focus on lasting adoption and benefit realization, understanding that this is a significant change for most. That change will be ongoing. Turning the system on is only the first step toward Meaningful Use. With that in mind, partner with the client to develop a training program that incorporates multiple options for learning the system and the workflows. Identify super users who can train others and help with optimization at regular intervals.  Engage the client regularly in the continuous process of improving the EMR and maximizing the value of the investment.

Fig. 3. Major takeaways.


Extending a healthcare system’s EMR to independent hospitals and clinics can result in substantial opportunities to improve the overall health of a community. The type of clinical integration necessary to reach that goal relies on the fast, easy exchange of high quality data among providers. This is what an EMR extension strategy makes possible, by extending first-class products and services to independents that could not otherwise afford to participate in an integrated EMR system.

Yet to succeed, all stakeholders must have a common goal, a willingness to develop long-term partnerships, and a clear understanding of the challenges, risks, and critical success factors. Planning, a deep understanding of the complex regulatory concerns, communication, new IT governance strategies, and effective implementations are as or more challenging here as they are in any change process.

That’s why it is so important to do this for the right reasons. While many of the best practices discussed here can be applied to any system implementation in any industry, if you choose to offer your EMR solution to independent hospitals and clinics, you should not view this as an opportunity for profit. Rather, strive to develop collaborative, long-term relationships with the right partners in an effort to prepare for the inevitable changes in healthcare service delivery, and with an end goal of improving the lives of individual patients and of the communities you serve.

Susan Heichert, BSN, MA, FHIMSS

Susan Heichert, BSN, MA, FHIMSS, is SVP and Chief Information Officer at Allina Health in Minneapolis, Minnesota where she was part of the team that implemented the Electronic Health Record. She received her Bachelor’s Degree in Nursing from the University of Maryland and a Masters from the University of Minnesota.  Susan has been working in healthcare for over 30 years in various capacities.

Mary Bear-Dukes

Mary Bear-Dukes is an Information Technology Director at Allina Health in Minneapolis, Minnesota where she has accountability for the Affiliate program and Application Support teams. She received her Bachelor's Degree in Human Services Administration from Metropolitan State University. Mary has been working in healthcare for over 20 years in various capacities.

Dawn Mitchell, MBA

Dawn Mitchell, MBA is a principal with Aspen Advisors, a healthcare consulting firm.  For over 25 years, Dawn has worked with leadership teams to optimize the business value of IT. She’s assisted academic, pediatric, and community hospitals and health networks, PBMs, and managed care plans on strategic planning and assessments, program/project management, governance, program management office, process redesign, and organizational change management. She’s assisted several healthcare organizations including Cleveland Clinic, Frederick Memorial and Resurrection Health Care in building their strategies to extend their Electronic Health Record to independent hospitals and clinics.

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