At the Helm

'My EHR is broken!': Why that's not the real issue, plus other answers execs need to know


Clinovations Managing Partner, Trenor Williams, MD, is a veteran of more than 300 EHR implementation and optimization engagements—and a new member of the Advisory Board family.

We sat down with Trenor to get the unfiltered answers to C-suite IT questions.


Q: What is the number one question that health care executives ask you?

Trenor Williams, MD: Well, it’s not really even a question, but more of a statement. Health care leaders are expecting a number of things from their EHRs—from increased provider productivity and efficiency, to quantifiable financial improvements, to better quality outcomes. If they’re not seeing those things happen, they call us and say "my EHR is broken."

What we find, though, is that our clients are really experiencing issues because they’re failing to optimize the EHR and how people use it. About 75% of the requests for help we get can be resolved with training, support and workflow redesign. The functionality is there, but the users don’t know how to use the EHR to full capacity. Then, clinical workflow issues make up another 10%. That means only 15% of optimization issues are directly related to the technology.

Q: I’m sure you’ve seen good and bad EHR implementations. What are some of the common mistakes you have seen?

Williams: After meaningful use incentives went into effect, many organizations implemented what we call a "vanilla," or un-customized, EHR very quickly to secure Meaningful Use money. Many intended to implement first and go back and optimize their systems later, but the reality is that new priorities always emerge, and many health systems just didn’t get back around to making their EHR work for them.

Moreover, health system leaders often neglect to put together a robust business case or value case for their EHR purchase. They may not have determined specific ROI metrics and created a process for reporting and accountability. Aside from building a new hospital building, EHR purchases are the biggest expenditure most health systems make. But now that EHRs have become a must-have, it’s common for health care organizations to bypass what would otherwise be a typical practice for such a large purchase. As a result, they are not working toward meeting those value expectations set forth in a business case.

Lastly, when health systems do plan for optimization, either during or after implementation, the plan is disproportionately weighted to the technology—more focus on clinical workflow and training is almost always needed. With that, some leaders approach implementation too rigidly, such as making an initial decision about how a workflow will be and then failing to be flexible of it doesn’t work.

Q: Many health systems today have multiple entities—outpatient facilities, physician practices, and hospitals—some of which were acquired. Do you recommend consolidating EHRs to one common platform? Does that mean they need to switch to a new system altogether?

Williams: We have seen better ROI when a health system’s various entities are operating on the same IT platforms. So, yes, at a basic level. But finding the right answer for your health system should be done on a case-by-case basis.

One thing I will say, if the right answer for your health system is to switch to a new EHR altogether, make sure you optimize the existing system while in the process of switching. It takes at least a year to make the switch, and through optimization, you can realize tangible improvement while getting ready for a new system.

Q: Earlier, you mentioned that health care leaders are looking for quantifiable financial improvements from their EHR. How can they realize these financial gains?

Williams: The obvious answer here is efficiency. We recently worked with a large, complex physician group on how they managed e-visits. They were doing pretty well, but when we visited a couple of specialty practices, we discovered that they had medical assistants spending three to seven hours per week extracting data from their EHR and putting it into manual logs. Talk about a cost savings opportunity! This is work that should be done within the EHR, freeing medical assistants to do more valuable work than figuring out when a patient’s last mammogram or colonoscopy was.

But in addition to that, we actually have identified specific initiatives that are revenue generating.

One example is capturing the appropriate complexity of Hierarchical Condition Categories (HCC). The goal is to get full credit for the complexity of your patients, closing care gaps, and understanding the total risk of your population. One health system moved from .89 to 1.3 on the HCC scale, and it resulted in more than $50 million over a few years. Even for systems only managing 5,000-10,000 lives, the investment in HCC complexity capture is often a multi-million dollar opportunity.

Another opportunity is the Medicare Annual Wellness Visit (AWV). Most organizations aren’t capturing more than 15% of Medicare patients eligible for an AWV because they haven’t optimized the workflow and technology. For mid-to-large medical groups, that equates to a $1 to $3 million annual opportunity.

Q: How can our C-suite members know if their organization’s EHR isn’t already 'optimized?'

Williams: There are a few key questions they can ask to understand if their people are using the EHR to its full capacity:

  • What kinds of measurable results are you seeing? Can you identify any at all?
  • Are your clinicians happy with the EHR, and what are their specific thoughts about it?
  • Is the system supporting your strategic initiatives? For example, have you figured out how to use the EHR to support your Clinically Integrated Network or Accountable Care Organization?

What are the 10 Commandments of EHR go-live?

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