How to achieve EHR ROI in a post-go-live world: 6 Qs with HCTec's CEO Bill Grana

Healthcare organizations around the world have collectively invested billions in EHRs. Further investment is almost certain as the technology's documented ability to improve outcomes can help support more efficient, safer care models essential to the success of value-based care. The global EHR market is projected to reach nearly $24 billion by 2020, up from $15.56 billion in 2013, according to a Transparency Market Research report.

Hospitals and health systems will continue to make significant investments in EHRs as the industry becomes more reliant on data and more focused on personalized care. Many organizations that have already gone live with EHRs have yet to achieve full return on investment. Numerous provider organizations around the nation anticipated the technology would ultimately save money or pay for itself through process improvements. However, challenges associated with the technology — burnout among physicians and staff from increased clerical and administrative burden as well as the significant overhead associated with supporting enterprise EHRs— have undercut these expectations. The situation has left many hospital CIOs to navigate the liminal space between EHR go-live and the truly datadriven healthcare of the future.

EHR optimization cannot be achieved with quick, one-time fixes. These high-powered systems must be treated like any other piece of sophisticated equipment and maintained with regular "care and feeding," according to Bill Grana, CEO of HCTec, a national provider of healthcare IT workforce solutions based in Nashville, Tenn.

"Health systems face an enormous set of challenges just getting these EHR systems implemented and activated, but really that's just the beginning," said Mr. Grana during an interview with Becker's Hospital Review. "One could argue the post go-live challenges are even more significant."

With its staff of more than 500 consultants and 225-plus corporate team members, HCTec provides comprehensive healthcare workforce solutions to more than 1,000 hospitals around the nation. EHR optimization and support as well as achieving return on investment in health IT are among the company's areas of focus.

At Kansas City, Mo.-based Saint Luke's Health System, collaboration with HCTec helped the system develop a strategy to meaningfully increase overall productivity and employee satisfaction after a systemwide EHR go-live contributed to higher rates of dissatisfaction and turnover in the IT department. With HCTec solutions in place, staff were able to spend more time on productive tasks and less time working to address EHR maintenance issues. The strategy has contributed to an 80 percent reduction in staff turnover and helped yield a projected cost savings of $20 million over the span of five years.

Mr. Grana's background includes significant experience with high growth health IT companies. These include founder, leadership and board roles in software and technology enabled firms in the workplace population health management, occupational medicine, and laboratory markets. He recently spoke to Becker's about EHR optimization, HCTec's collaboration with health systems, and the future of health IT.

Editor's note: Responses have been lightly edited for length and clarity.

Question: Can you tell me about HCTec's partnership with Saint Luke's?

Bill Grana: Saint Luke's Health System comprises a number of hospitals and outpatient and ambulatory clinics in the Kansas City area. We have a longstanding relationship, working with them on both IT and revenue cycle. They engaged us a couple of years ago to help with a big challenge they faced in the ongoing maintenance, or what I like to call the ongoing care and feeding, that's required to keep these monolithic EHR systems like Epic healthy. You don't just implement them and let them go. Staff also must do the work of supporting the regular updates required to meet changing regulatory requirements and help end users take advantage of the new features, functionality and productivity enhancements that come along with those upgrades.

St. Luke's found they didn't have adequacy of resources for optimization work, which is really geared around how you configure and modify the system based upon the changing needs of your clinical and administrative users. So, we came in and provided a solution that deals with support and maintenance, which allowed their team to focus more on the value-driving work. It's increased satisfaction among the IT team dramatically, because that lower level work is not what analysts and higher-level IT folks get great joy out of having to perform on a daily basis. We're taking more of that rote work off their hands and giving them the opportunity to focus on things that really drive value and return on investment.

We've also helped them reduce attrition among their IT team, and we've reduced expected hard and soft costs over the initial five-year term of our agreement by about $20 million.

Q: What are some top pain points with the EHR among physicians, and how have you seen healthcare organizations work to resolve these issues?

BG: I think what the studies show thus far is that the EHR, in terms of what it means for a physician's workday and overall satisfaction, has not been a positive contributor. The amount of administrative and clerical work that physicians are doing today versus what they were doing pre-digitization of the clinical experience is far greater. Some studies say physicians are spending twice the time they once did on documentation. That's obviously not a positive thing.

On the flip side, I think the advantage that collecting data through the EHR provides to clinical users is meaningful and can help providers understand things like who in their patient population is doing better post-procedure and why.

I don't think it's fair to say that there’s a one-size-fits-all solution to the problem. I think it varies by specialty as well. It's difficult to create a single EHR system that works in every single unique care delivery environment.

We've also seen the establishment of clinical and non-clinical work groups that deliver feedback to IT organizations to help identify opportunities for optimization. More tactically, we've seen systems hire scribes to support key users. This allows physicians to focus on the patient and practice medicine as opposed to being computer and laptop jockeys.

Q: What are some of the maintenance issues associated with EHRs? How can healthcare organizations work to optimize and customize these systems?

BG: It's fair to say there's significant maintenance — almost daily — that must be done to keep an EHR system healthy. A recent study of a large California health system published in The American Journal of Managed Care found that on average 2.5 significant EHR changes were being made each day! We're finding that many healthcare systems simply underestimated their need for daily EHR support and how to practically provide it.

One of the consequences of all this maintenance is frustration among hospital IT staff that, pre-EHR implementation, had more time to do the things that advanced the value of IT within the organization. Now they're so bogged down with day-to-day maintenance issues and user support issues, they have little time to focus on the projects that really enhance the value of IT and allow the organization to optimize its return on investment for the EHR system.

I think organization leaders should partner more closely with end users. I would say they should first look to partner with clinicians and physician groups to truly understand the user experience. I think most physicians will agree that the EHR burdens them and detracts from job No. 1 — interacting with the patient. So, organizations should work to understand those challenges and put plans in place to enhance the system.

Part of HCTec's value is that we create capacity within our client's IT organizations to allow them to focus on the type of work that really addresses clinicians' concerns by freeing them from rote, mundane, day-to-day support and maintenance duties. Based on hospital needs, we can package our solutions and deliver experts with specialized knowledge as either individual consultants or as part of project teams, permanent hires, or remotely via our two U.S.-based contact centers.

Q: Can you elaborate a little more on the importance of ongoing EHR maintenance?

BG: With the ever-changing regulatory environment, both at federal and state levels, keeping up with these updates is critical. If you don't, you may be getting yourself in trouble from a regulatory perspective or inadvertently create a patient safety issue. The software updates are typically focused on introducing new features, functionality and capabilities that improve productivity, add efficiencies and improve user experience. This is somewhat akin to taking your car in at regularly scheduled service intervals. To the extent you fall behind on that, you're ultimately creating future debt for yourself.

There has also been a change in practice among the EHR vendors in terms of how they're doing those updates. In the past, the practice has been to do larger updates at lengthier cycles, so it might be an 18- to 24-month cycle before an update's release. We're seeing a movement to more of a quarterly cycle, where updates can be done in more bitesized chunks. This is easier to execute from a technical perspective. It's also easier on the end users since changes to the system are more incremental, which means the training and any kind of change management around it becomes less burdensome.

Q: How does a healthcare organization achieve ROI with its EHR?

BG: I would say that achieving ROI is unique to each hospital system depending on its structure and growth plans. There are hard and direct cost inputs, as well as soft and indirect costs — which I think are easy to discount — but the value of those soft or indirect costs are equally important in many cases.

Saint Luke's, for example, considers reduction in employee attrition to be a huge cost benefit. Sometimes hardcore finance people don't give as much credit to this metric, but a reduction in turnover by just a few percentage points can have enormous economic benefits.

Things that are broadly considered revenue enhancements are more throughput and productivity, improved quality of care, increased employee satisfaction and improved patient satisfaction and engagement. These are the normal benefits that an EHR can provide.

Q: What's next for health IT? What EHR-focused technologies or applications do you think show the most promise?

BG: I think there's a lot of near-term, low-hanging fruit around predictive analytics and machine learning. To a degree, all the data that's being taken in and digested by these systems can help drive more appropriate care and improve outcomes based upon whatever the clinical situation or condition may be. To me, it’s the opportunities presented by data that would be hard to come by without the EHR and its centralized collection of data that provide the most near-term value and promise.

I think we all believe the future is one where there is simply more digitization across the board within healthcare. This digitization will create opportunities for companies like HCTec.

Historically, health IT has been more focused on inpatient settings. I think that's changing. Hospital systems are investing more and more in outpatient and ambulatory care, and in care solutions that keep people healthy and out of the hospital. This change also shifts investment in IT.

Another trend we're seeing is investment in care convenience provided by tools like telemedicine. While telemedicine is still a tiny portion of overall care in the market, usage will increase as technologies continue to improve and people get more comfortable with the experience. We're already seeing it happen from an inpatient perspective with specialists that small town community hospitals can't afford. Now these organizations can use telemedicine to deliver patients access to these providers.

Conclusion: The importance of the right partner

In January, HCTec announced a partnership with another St. Luke's. Over the next three years, HCTec will provide support and maintenance services for Epic and related third-party applications at Bethlehem, Pa.-based St. Luke's University Health Network. St. Luke's turned to the workforce solution provider after recently purchasing three healthcare facilities that ran on a legacy EMR. The executive team had to decide whether to tap an outside partner to help facilitate a transition to Epic at the new facilities or rely on the organization's internal IT team to execute the project. Ultimately, the managed services model put forth by HCTec proved more cost effective.

"We were particularly impressed with HCTec's ability to deliver a large team rapidly," said Christine Brutschea, ACIO of St. Luke's University Health Network, in a January release. "HCTec is providing in-depth reporting to manage the services and maintain our high standard service level agreements. This attention to detail helps deliver a support experience that is seamless for our clinicians, team members and other end users."

With rapid changes in both technological advancements and regulatory requirements, health system leaders around the country are turning to outside partnerships with health IT companies like HCTec to ensure their organization's EHR investments achieve ROI. Health systems need not travel alone on the path to EHR optimization.

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