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Electronic Health Records – Is Your Organization Committed to Adoption or Just Implementation?

Posted on September 13, 2018 I Written By

The following is a guest blog post by Heather Haugen PhD from Atos Digital Health Solutions.

Several years ago, a reputable IT vendor offered our organization a trial version of their software in exchange for our feedback. The software provided equipment monitoring that would be valuable to us. Initially, we were excited because the functionality aligned with our needs and the application was robust enough to grow with us. It seemed that the software would fulfill our need. The new software system served IT directly, so our Director of IT led the implementation and kept our senior management team updated on the progress. We were impatient to get access to the dashboard of data the vendor promised. But months later, we were still waiting.

The price tag had lured us in, but we quickly realized the high cost in maintenance and labor required to make the application truly valuable. This story drives home a concept that we all understand, but often overlook; sometimes we underestimate the “care and feeding” required to maintain a valuable investment, putting the entire project at risk. In fact, we all need to remember the importance of sustainability after the initial excitement about an investment’s value. It is common to under-appreciate the effort it will take to maintain the value of our investments.

Let’s consider the shift in thinking required to move from implementing an Electronic Health Record to maintaining high levels of adoption over the life of the application. Many organizations focus on the implementation cost without truly appreciating the long-term cost of maintaining these large, complex systems.  We often see this in healthcare organizations, no matter what size.  Costs that are often underestimated include IT resources required for system maintenance; recruiting and retaining talent for new areas; ongoing training for new employees; upgrades for resources, training, and hardware; time and resources for optimizing systems and workflow; and expertise in finance and reporting needed to gain the value promised by the EHR.

In the world of EHR adoption, we often spend too much time focusing solely on implementing new software solutions. We know how to prepare well for the go-live event, but after go-live, organizations typically discontinue the investment of time and resources required to see the process through to the adoption phase. When this happens, users tend to fall back on work-arounds and ineffective workflows, and new users receive insufficient training. The process of adoption requires a radically different discipline, where the real effort begins at go-live.

After we successfully implement a new technology, our tendency is to move on to the next project. In a world where it is common to juggle multiple projects, we actually feel some relief in moving it off our list of highest priorities. What we need is a plan to sustain the long-term changes required.  A sustainment plan addresses two important areas. First, it establishes how the organization will support the end users’ ongoing needs for the life of the application. This includes communication, education and maintenance of materials and resources. Second, it establishes how and when metrics will be collected to assess end user adoption and performance. By planning and executing a sustainment plan, we can avoid the steady deterioration in end user adoption that otherwise occurs over time.

Effective sustainability plans require resources, time, and money. Keep in mind that adoption is never static; it is continually either improving or degrading in the organization.  Without a plan for training sustainment, a series of upgrades can quickly lead to decreased proficiency among end users, completely eroding the value of the application over time. Leadership must plan for and fund the investment in sustainment because the ultimate goal is improved performance. Many organizations only achieve modest adoption levels after a go-live event. To truly achieve sustained adoption levels, it takes relentless focus on improving quality of care, patient safety, and financial outcomes. The most successful sustainability plans are part of the organization’s initial budgeting and planning stages for EHR.

Sustainment means more than maintaining the status quo. If sustainment becomes a passive process, it is a waste of resources. The difference between a highly effective sustainment plan and one that is just mediocre is metrics. Consistently measuring end-user knowledge and confidence creates a barometer for proficiency levels and provides the earliest indication of adoption, or use of the application according to best practices. Ultimately, performance metrics are powerful indicators of whether end users are improving, maintaining, or regressing in their adoption of a new system. If the warning that proficiency is slipping comes early in the process, we have an opportunity to react quickly to address the problem. Knowledge and confidence metrics ensure that the organization is progressing toward high levels of adoption, overcoming barriers, and achieving the efficiencies promised by EHR adoption.  Metrics allow us to adjust quickly and proactively; they are the first indicator of falling back into old behaviors that are inconsistent with sustainable adoption.

Metrics also keep us on track when performance does not meet expectations. Let’s consider two different scenarios to illustrate this idea. In both scenarios, the go-live event was successful, but specific performance metrics did not meet expectations. In the first scenario, the system is being used inefficiently. This may be due to inadequate training and subsequently lower end user proficiency. Measuring end user proficiency allows us to identify “pockets” of low proficiency among certain users or departments and ensure they receive the education they need to become proficient. Once users are proficient, we can refocus our attention on the performance metrics. The second scenario is less common and also more difficult to diagnose: our metrics show that users are proficient, but specific performance measurements are still not meeting expectations. In this case, we need to analyze the specific metric. Are we asking the right question? Are we collecting the right data? Are we examining a very small change in a rare occurrence? There may also be delays in achieving certain metrics, especially if the measurements are examining small changes. Normal delays can wreak havoc if we start throwing quick fixes at the problem instead of staying the course and having the confidence in the metrics that will bring about desired results.

Ultimately, leaders must commit the resources, time, and effort to adoption that lasts long after go-live ends.

About Heather Haugen
Heather Haugen is the Chief Science Officer for Digital Health Solutions for Atos. She is also the author of Beyond Implementation: A Prescription for the Adoption of Healthcare Technology.

Inbal Vuletich serves as the editor for Atos Digital Health Solution publications.

About Atos Digital Health Solutions
Atos Digital Health Solutions helps healthcare organizations clarify business objectives while pursuing safer, more effective healthcare that manages costs and engagement across the care continuum. Our leadership team, consultants, and certified project and program managers bring years of practical and operational hospital experience to each engagement. Together, we’ll work closely with you to deliver meaningful outcomes that support your organization’s goals. Our team works shoulder-to-shoulder with your staff, sharing what we know openly. The knowledge transfer throughout the process improves skills and expertise among your team as well as ours. We support a full spectrum of products and services across the healthcare enterprise including Population Health, Value-Based Care, Security and Enterprise Business Strategy Advisory Services, Revenue Cycle Expertise, Adoption and Simulation Programs, ERP and Workforce Management, Go-Live Solutions, EHR Application Expertise, as well as Legacy and Technical Expertise. Atos is a proud sponsor of Healthcare Scene.

The More Hospital IT Changes, The More It Remains The Same

Posted on June 23, 2017 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

Once every year or two, some technical development leads the HIT buzzword list, and at least at first it’s very hard to tell whether that will stick. But over time, the technologies that actually work well are subsumed into the industry as it exists, lose their buzzworthy quality and just do their job.

Once in a while, the hot new thing sparks real change — such as the use of mobile health applications — but more often the ideas are mined for whatever value they offer and discarded.  That’s because in many cases, the “new thing” isn’t actually novel, but rather a slightly different take on existing technology.

I’d argue that this is particularly true when it comes to hospital IT, given the exceptionally high cost of making large shifts and the industry’s conservative bent. In fact, other than the (admittedly huge) changes fostered by the adoption of EMRs, hospital technology deployments are much the same as they were ten years ago.

Of course, I’d be undercutting my thesis dramatically if I didn’t stipulate that EMR adoption has been a very big deal. Things have certainly changed dramatically since 2007, when an American Hospital Association study reported that 32% percent of hospitals had no EMR in place and 57% had only partially implemented their EMR, with only the remaining 11% having implemented the platform fully.

Today, as we know, virtually every hospital has implemented an EMR integrated it with ancillary systems (some more integrated and some less).  Not only that, some hospitals with more mature deployments in place have used EMRs and connected tools to make major changes in how they deliver care.

That being said, the industry is still struggling with many of the same problems it did in a decade ago.

The most obvious example of this is the extent to which health data interoperability efforts have stagnated. While hospitals within a health system typically share data with their sister facilities, I’d argue that efforts to share data with outside organizations have made little material progress.

Another major stagnation point is data analytics. Even organizations that spent hundreds of millions of dollars on their EMR are still struggling to squeeze the full value of this data out of their systems. I’m not suggesting that we’ve made no progress on this issue (certainly, many of the best-funded, most innovative systems are getting there), but such successes are still far from common.

Over the longer-term, I suspect the shifts in consciousness fostered by EMRs and digital health will gradually reshape the industry. But don’t expect those technology lightning bolts to speed up the evolution of hospital IT. It’s going take some time for that giant ship to turn.

Hospital EMR Adoption Chart

Posted on October 9, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

One way to look EHR adoption in the US is that 75% of hospitals have adopted at least a basic EHR. Or as Dan Munro observes from the chart below, 66% of hospitals still don’t have a “comprehensive EHR.” What’s your perspective on EHR adoption?

Every Hospital Should Adopt EHR

Posted on March 13, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

While I’m sure this tweet will rub many the wrong way, I found it incredibly thought provoking. I have no idea who this person is that tweeted it, but I think that his tweet represents the majority of Americans who know very little about EHR and Health IT.

From a layman’s perspective, in every industry the use of IT has benefited that industry. Those not living in the EHR world just automatically think that by applying IT to something that we’ll see a huge benefit. Those of us in the EHR industry no doubt have a much more nuanced feeling about the benefits of EHR. I’m sure the guy who tweeted above won’t be happy with the meaningful use hardship exemptions which will defer organizations from being #finedheavily.

While I agree with the idea that we need broad EHR adoption, I think we have to be careful trying to rush any EHR implementation. A rushed EHR implementation is far worse than no EHR.

Epic Implementation Problems Lead To Lower Hospital Credit Rating

Posted on November 7, 2013 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

Of late, stories have begun to crop up about troubled Epic implementations and the financial problems that these shaky implementations can cause. In fact, we’re aware of at least one Epic investment which may have led to the departure of a CIO from a Maine hospital.

Now, we’re told that a troubled Epic implementation has led to the lowering of a hospital’s credit rating. Standard & Poor’s has lowered Winston-Salem, NC-based Wake Forest Baptist Medical Center’s debt from AA- to A+, primarily due to the problems Wake Forest has had in rolling out Epic, according to Becker’s Hospital Review.

According to a statement from Wake Forest, the EMR implementation had a bigger impact on the hospital’s finances and operations than it had anticipated, leading to poorer overall fiscal performance than expected for 2013. Earlier this year, the CIO for Wake Forest resigned in the wake of the Epic debacle.

Wake Forest spent about $13.3 million to bring Epic on board, and roughly $8 million on Epic-related expenses, but that doesn’t seem to have been the main reason the install caused financial problems. We know from a report in the Winston-Salem Journal that since the Epic rollout, the hospital said that it had lost $26.6 million in margin due to volume disruption caused by Epic-related problems.

The Epic implementation wasn’t the only reason for the downgrade. It came partly due to cuts in NIH research funding, lower volume growth, a lower provider tax and sequestration cuts, according to hospital CFO and vice president for finance Edward Chadwick. But clearly, the disruptions caused by the Epic install have been major.

S&P did show Wake Forest some mercy, changing its financial outlook from “negative” to “stable.”  The agency is predicting that the hospital should rebound financially in 2014 as the disruptive effect of the Epic install decreases.

25% Of Hospitals Stalled On EMR Progress

Posted on October 22, 2013 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

As most readers know, HIMSS has developed a proprietary scale which it uses to track how far along hospitals are in their EMR adoption process.

As I discussed previously, the predictable has happened when it comes to progress. Hospitals with extensive resources, notably academic medical centers and large suburban chains, have climbed the eight-step ladder of the scale, known as the HIMSS Analytics EMR Adoption Model (EMRAM), while smaller and rural facilities have moved more slowly.

Now, there’s evidence suggesting that making progress on EMRAM is harder than it seemed previously. New research from HIMSS comparing quarterly EMRAM progression of 4,811 hospitals during the last five years (Q2 2008 and Q2 2013) has concluded that a surprising number of hospitals are basically stuck in place.

The new report has found that 73.7 percent of  U.S. hospitals have advanced by at least one stage over the past five years, and that half of those who advanced climbed the scale by two or three stages. Another 20 percent of those advancing moved up four or more stages during the five-year period studied.

Right now, the largest number of hospitals (at 34.5 percent at Q2 2013) fall into EMRAM stage 3, which includes nursing/clinical documentation, CDSS (error checking) and PACS available. Stage 4 through 6 account for 43.3 percent all together, the most populated level being stage 5, closed loop medication administration, with 18.7 percent.

That being said, 25 percent of hospitals had made no progress whatsoever over the last five years. What’s more, four percent of hospitals have remained at EMRAM stage 0 (completely paper-based). As I see it, these are fairly surprising results given the Meaningful Use pressures hospitals face.

Meanwhile, only 2.1 percent of hospitals had what HIMSS Analytics regards as a “complete EMR” — one which includes CCD transactions to share data, data warehousing and data continuity with the ED — in place as of the second quarter of this year.

So, how’s your facility doing?  Is it able to progress toward higher EMR goals? Or is it mired down with the 25 percent?

Are Your Doctors Feeling Ignored?

Posted on September 13, 2013 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

If you surveyed a large number of hospital IT leaders, I’d wager that most would claim that they take their clinicians’ EMR preferences seriously. After all, it doesn’t do a hospital a lot of good to install a system that throws doctors and nurses a productivity-lowering curve ball.

There’s lots of ways hospitals can involve doctors and nurses in the EMR selection and go-live process, but I think we can agree that it’s important to involve them somehow throughout. The thing is, a preliminary or perfunctory effort isn’t likely to have much effect.  Getting doctors on board, then losing interest in their needs in a year or two, seems a bit counterproductive, doesn’t it?

Well, if one of our readers (a physician) is any indication, hospitals are developing a terrible track record for keeping clinicians in the loop over time, even if they started out gung-ho. Listen to the story told by one of our EMR and HIPAA commentors:

I made a major effort over a period of years (since we went live in February 2001) to be involved [with our EMR rollout]. I was the Chair of a local users group until the group disbanded in frustration at being ignored. I was on the EHR and IT Steering Committees. I devoted countless (unpaid) hours to behind the scenes work, managing custom lists, writing letters, designing and fixing templates. I went to the annual national user’s meetings (on my own dime) to collect ideas and learn more. I took programming courses to improve my ability to contribute.

At the beginning, I (and a core of others) were recruited, appreciated and heavily involved in decision making. As time went on, however, our involvement was marginalized to issues of how to deploy the decisions made by those who used the data. Those who actually use the EHR to care for patients are less and less involved.

As if that wasn’t frustrating enough, the institution didn’t offer clinicians any meaningful input when it came to choose an outpatient EMR:

A small group (including a minority of clinicians) worked in private to narrow the candidate EHRs to two, which were presented to the medical staff for ‘feedback’ with brief non-hands-on demos and no actual system for clinicians to provide concrete feedback. The existence of the project was not made known to the users until time for picking a new EHR from two options, and at no time were the users contacted to find out what worked well or poorly in the current system, and what should be sought in a new system.

In my discussions with providers at other institutions, I get the impression that this is a fairly common approach.

I may be a journalist, not a CIO, but it seems pretty obvious to me that giving doctors meaningful input into which tools they’ll be using is a no-brainer.  How about you readers?  Do the doctors at your facility feel ignored when you make health IT decisions that will affect them?

Hospital IT Investment Shoots Up

Posted on August 26, 2013 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

Struggling to keep up with the demands of Meaningful Use and ICD-10, hospitals are investing a disproportionate amount of money in health IT, according to a story appearing in Healthcare IT News.

It’s not that hospitals have been on an overall spending spree. Capital investment for medical equipment overall (including non-IT technology) dropped from 30.4 percent to 27 percent in 2013, while medical equipment costs fell from 44.5 percent to 13.8 percent, according to Advisory Board Company figures.

But capital spending per bed for IT grew 62 percent between 2010 and 2011, while total capital spending grew only 2.6 percent, according to Chantal Worzala, director of policy at the American Hospital Association, who spoke with the publication.

What makes these big-dollar investments particularly galling is that CIOs aren’t sure whether all of this IT spending is going to produce a return on investment, according to Healthcare IT News. According to a January 2013 survey by Beacon Partners of more than 200 hospital CIOs, only 40 percent of them measure ROI on EMRs implemened, and even less (36 percent) are confident that their ROI calculations are accurate.

That being said, many CIOs have taken the position that ROI is less important than “strategy enablement,” according to Jim Adams, executive director of research and insights at the Advisory Board Company, who spoke with the magazine.

One key purpose for making these investments is to make sure they have the right infrastructure in place to shift from fee-for-service to accountable care, Adams said. Added IT infrastructure is being  used to prepare to manage the greater financial risk hospitals will be facing under ACO-type models, he suggested.  And at least some of these dollars are being spent on EMR optimization which can help meet that goal.

Another major area of spending within health IT is data security, including mobile device management software to support BYOD, data loss prevention tools and encryption software, HIN reports.

We should know pretty soon whether hospitals made the right IT bets, as the forces pushing them to spend are cresting. But if they find that they need to rethink their strategy, let’s hope they didn’t bet the farm on what they have;  as my colleague John points out, there’s a myth floating around out there that the more expensive an EMR is, the better it is.

Study: Meaningful Use Drives Hospital EMR Adoption

Posted on July 12, 2013 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

If there was any doubt, the following data may remove it: Meaningful Use is driving hospital EMR adoption. A new report by the Robert Wood Johnson Foundation concludes that the number of hospitals which  have implemented at least a basic EMR has tripled since 2010, when the MU incentive program kicked off, Reuters reports.

The number of hospitals with some form of EMR in place hit 44 percent in 2012, climbing 17 percentage points from 2011. Hospitals most likely to have at least a basic EMR in place are large, non-profit teaching hospitals in urban areas, found the report.

Meanwhile, twenty-seven percent of hospitals are now linked via some form of HIE to other hospitals, up from just 14 percent in 2010, according to researchers. They found that test results and summary patient care records were most commonly exchanged

The study, which was coauthored by the Harvard School of Public Health and Mathematica Policy Research, also found that doctors have come a long way toward greater EMR use, with roughly 38 percent having at least a baseline EMR in place.

All that being said, the growth in EMR adoption isn’t exactly burning up the track. While there’s clearly been significant progress in EMR adoption over the past few years, the fact that adoption among hospitals is still below 50 percent despite the incentives and industry pressure in place speaks volumes.

And if my colleague John Lynn is right, we’re already past the “Golden Age” of EMR adoption in which the early adopters and even much of the majority come board. In his view, getting those on board who haven’t come yet is going to be akin to climbing Mount Everest:

“The reality is that those who wanted to adopt EHR already have adopted EHR. That means we have left a group of practices and hospitals that for the most part aren’t EHR convinced.”

If John’s right, and I suspect he is, we’re looking at a whole new battle to win EMR hearts and minds. It’s going to be a struggle to be sure.

HHS Says EMR Adoption Reaching “Tipping Point”

Posted on June 21, 2013 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

More than 80 percent of hospitals accepting Medicaid or Medicare  — and half of doctors’ offices — should have EMRs in place by the end of the year, HHS announced.

According to HHS, 9 percent of hospitals had EMRs in 2008, but now 80 percent have demonstrated Meaningful  Use. Meanwhile, 17 percent of physicians used EMRs in 2008, but now 50 percent have demonstrated Meaningful Use.  To date, more than 291,000 providers and 3,800 hospitals  have received incentive payments. These are interesting numbers when compared with the state EHR adoption reports.

“We have reached a tipping point in adoption of electronic health records,” said HHS Secretary Kathleen Sebelius, according to a report in USA Today.

According to ONC head Farzad Mostashari, who spoke with the newspaper, EMRs have already begun to affect the safety and quality of care where they are deployed.  In the past, when patients went to the emergency department, often no one knew his or her medical history, which was often scattered across different doctors’ offices.

“There were hundreds of thousands of medical errors,” Mostashari told USA Today. “Electronic records cut errors by half.”

This year may offer cause to celebrate, but next year looks more challenging. Though the state of interoperability is still relatively primitive, providers are expected to have their EMRs connected to other systems and other providers by then. While some doctors and hospitals are already part of working HIEs, getting anywhere near a majority connected, much less all, is going to be a very, very challenging exercise.

Let’s see what the headlines say in May 2014!