Health information technology duct tape: To customize or not to customize? That’s a good question

An increasing number of Health Care Organizations, particularly large practices and clinics, are replacing their Electronic Health Record systems to more effectively handle the work flow needs of physicians.

Since 2008, the percentage of acute care hospitals that have adopted EHRs has risen from 10% to 60%, while the percentage of physicians who have EHRs rose in the same period from 40% to 80%. In addition, a recent study predicts that the EHR replacement market will grow at an annual rate of 7%-8% over the next five years.

But what kind of replacement will it be? It would be nice if there were a warehouse that housed a choice of off-the-shelf one size fits all solutions from which to choose. But the reality isn't so convenient.

With more than 130 recognized physician specialties and subspecialties encompassing as many as 200 health careers, each of which entails detailed work that differs from institution to institution, there can be no one size fits all system that can manage the various specialties, disciplines, and centers of excellence. Practices with unique patient populations, distinct operating goals, or non-standard relationships with their community cannot possibly be served by an EHR solution that wasn't made to fit them.

And yet, healthcare organizations have opted for quick fixes. The "Big Bang" approach that takes a hospital fully live on an EHR all in one go, has been appealing because it involves everyone at the same time. For example, patients can continue to move throughout the hospital between different departments with their records centralized in one location. With all functionality available at go-live, everything should move more quickly. Onsite training can be conducted all at once, thus reducing costs and saving time. Any losses in productivity should be minimized because the staff won't need to learn new technologies.
Along with the "Big Bang," many organizations have chosen to implement "factory-built" health information technology, an off-the shelf solution with minimal deviation from its initial configuration.

As appealing as these rapidly deployable solutions must have appeared when they were first chosen, their theoretical advantages have been compromised in practice. For example, not everybody in the HCO adjusts to new systems at the same pace. While everyone tries to get up to speed simultaneously, the different rates of learning and adaptation have caused significant losses in productivity. If any errors or glitches crop up – and they inevitably do – they spill over into the entire system, affecting all operations. There have been reports of revenue losses equal to three months because the interfaces between the Practice Management System and the EHR were not thoroughly tested before going live.

In short, the adoption of new EHRs has led to a failure rate of 73%, caused, in the judgment of one expert study, by a combination of oversold EHR software, lack of buy-in from clinical teams, and extremely slow documentation completions.

In an interview with Healthcare IT News, Joanne Rohde, CEO of Axial Exchange, stated, "I think it's a myth that EHR vendors are gong to be able to provide everything. Large, branded vendors have made the mistake of dictating users' workflow rather than providing them with software that actually complements how they normally work."

Scott Ciccarelli, who writes the blog EMR Straight Talk, says, "Many EHRs are marvels of software, capable of doing incredible things, but the selection process that physicians typically employ is flawed, and the sales process capitalizes on this shortcoming. The salesperson dazzles them with a demo, or they take prospective purchasers to see a physician – typically, just one of two – who adeptly uses the software. This creates a false sense of ease-of-use, and the physician prospect leaves the site visit expecting that he or she will be able to use the EHR just as successfully. But not all physicians are alike – they may all be very intelligent and have tremendous medical expertise, but they are not all equal in technological inclination or skills."

There is an alternative to the rush to implement that has characterized and disappointed healthcare organizations – customization, a system that is made to fit each organization and its own particular challenges. Customization too brings rewards – and risks. Ideally, customization adjusts the EHR to facilitate efficiency but to some it may seem like mere patchwork, a roll of duct tape slapped on to hold everything together, with little assurance of permanence.

We define customization as within the application's native framework or extensibility capabilities. Typically, a system administrator is able to work within the application to configure both its appearance and behavior. Customizations are performed through areas such as interface logic, tasking, preferences, menus, navigation and note templates.

EHRs are delivered with templates that exist in "draft" forms and canned workflows that are built to the needs of the specialty. These templates are meant to be validated and set up based on the specific needs of the practice. Examples of more provider-tailored customizations include single-screen, single-click, automatic chart access, workflow automation through scripting, and other shortcuts that provide patient visit efficiency gains and as well as time reduction for completion of charts.

While EHR customization has plenty of benefits, to which we will turn shortly, there are downsides to consider. For every dollar spent on development, that's one more dollar that will be spent to maintain that aspect over a three-year period. Most HCOs will consider the initial costs of customizing, including development time and any ancillary tools required. Additional costs include the expense of regression testing when it comes time for upgrades and bug fixes. Customizations are often frequently broken from upgrades as well. In worst-case scenarios fields created to support the customization may no longer even exist, and unwanted or unexpected side-effects may appear.

These necessary long-term system changes should be a consideration of their own. Vendor updates can often cause rifts down the line with interfacing customized systems. Hence, customizations require a close relationship with EHR vendors to prepare for future changes to the software.

Time must also be considered with customization. Adaptation and training require firm commitments from providers, staff, and administrators.

That said, there are many tangible and compelling benefits that a customizable EHR can offer, including the flexibility that's tailored to workflow, which allows for better capturing of data and improved accuracy. With that, it makes practice-wide adoption easier. Providers will spend less time navigating the system and more time leveraging the personalized options. This gives them more time for considering decision support, enhancing quality of care. In turn, patients benefit because their physician is more focused on their interaction instead of navigating the technology. Personalizing EHRs give physicians a sense of ownership over how they practice medicine.

One other consideration is the impact this system will have on your organization. The goal is to have an implementation that will play a major role for years. Additional time, commitment, and costs should prove their value for years to come if the workflow and job satisfaction of healthcare providers is improved. Personalizing this system to best fit an organization will simplify workflow. Significant money has been spent on these systems, and now executives want to see the improvements in clinical and revenue cycle outcomes that were promised.

In research conducted by Kevin J. Bennett and Christian Steen in 2010, they found that customizing an EHR by adding a template led to improvements in chart completion rates. In the study, the system was personalized so that it contained disease-specific templates that providers could use to document care during office visits. Following the alteration, the number of charts completed within 30 days increased by almost five percent. The study concluded that the customization resulted in a significant financial benefit to the organization.

To customize or not to customize? Should the fact that every practice is unique be reflected in their health records system? The simple answer is yes. It is beneficial in growing the efficiency of providers and their staff as well as the experiences and health outcomes of patients. It also makes sense that the countless EHR tools--layouts, prescriptions, scheduling, and patient education-- should reflect the needs of providers and their patients.

Too often, purchasers are so beguiled by the elegance of a technology solution that they forget that the system they buy should reflect their needs, that it is not the organization that should be adjusting itself to the parameters of the software. An EHR that provides content and predefined data elements is handy but the adopter should be able to override those elements if necessary and define new elements as needed. The purpose of a new EHR is to avoid rigid externally defined workflow. End-users must be able to request treatments or supplies and perform unanticipated tasks without having to work around their system. The customized system must serve practitioners, not the other way around.

By definition, a customized system is customized by the those who will use it. That means time-consuming, mind-challenging contemplation, discussion, planning, implementation, and testing. And more testing. This may seem like a lot to do. Well, it is. It may therefore be tempting to do what so many healthcare organizations have been doing, buying pre-configured systems, no matter their costs, because they seem to be simpler. But seeming so doesn't make it so. Customization may seem painful, but the pain disappears quickly. In short, you can be miserable indefinitely or uncomfortable for a few months. To customize or not customize? It seems like a tough question, but it's not.

Galen Healthcare Solutions is a professional services and solutions company providing IT consulting services, including strategy, optimization, data migration, project management and interoperability for specialty practices, hospitals, health information exchanges, health systems and integrated delivery networks. For more information, visit www.galenhealthcare.com.

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