Exploring the business case for ambulatory electronic health record system adoption.
Subject: Health care reform (Evaluation)
Medical records (Information management)
Electronic records (Usage)
Authors: Song, Paula H.
McAlearney, Ann Scheck
Robbins, Julie
McCullough, Jeffrey S.
Pub Date: 05/01/2011
Publication: Name: Journal of Healthcare Management Publisher: American College of Healthcare Executives Audience: Trade Format: Magazine/Journal Subject: Business; Health care industry Copyright: COPYRIGHT 2011 American College of Healthcare Executives ISSN: 1096-9012
Issue: Date: May-June, 2011 Source Volume: 56 Source Issue: 3
Topic: Event Code: 260 General services Computer Subject: Company systems management
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 271594419
Full Text: EXECUTIVE SUMMARY

Widespread implementation and use of electronic health record (EHR) systems has been recognized by healthcare leaders as a cornerstone strategy for systematically reducing medical errors and improving clinical quality. However, EHR adoption requires a significant capital investment for healthcare providers, and cost is often cited as a barrier. Despite the capital requirements, a tree business case for EHR system adoption and implementation has not been made. This is of concern, as the lack of a business case can influence decision making about EHR investments.

The purpose of this study was to examine the role of business case analysis in healthcare organizations' decisions to invest in ambulatory EHR systems, and to identify what factors organizations considered when justifying an ambulatory EHR. Using a qualitative case study approach, we explored how five organizations that are considered to have best practices in ambulatory EHR system implementation had evaluated the business case for EHR adoption. We found that although the rigor of formal business case analysis was highly variable, informants across these organizations consistently reported perceiving that a positive business case for EHR system adoption existed, especially when they considered both financial and non-financial benefits.

While many consider EHR system adoption inevitable in healthcare, this viewpoint should not deter managers from conducting a business case analysis. Results of such an analysis can inform healthcare organizations' understanding about resource allocation needs, help clarify expectations about financial and clinical performance metrics to be monitored through EHR systems, and form the basis for ongoing organizational support to ensure successful system implementation.

INTRODUCTION

The shift from a paper-based medical record to an electronic health record (EHR) is one of today's highest strategic and operational priorities for the US healthcare delivery system. Widespread implementation and use of EHR systems and associated clinical decision support technologies has been recognized by healthcare leaders as a cornerstone strategy for systematically reducing medical errors and improving clinical quality in the United States (Kohn, Corrigan, and Donaldson 2000; IOM 2001). The federal government has set aside nearly $27 billion in financial incentive payments to providers under the Health Information Technology for Economic and Clinical Health Act (HITECH) in an effort to facilitate the adoption and use of EHRs (Blumenthal and Tavenner 2010).

From an economic standpoint, EHRs are viewed as a means to improve efficiency and thereby reduce costs. Prior research has speculated and begun to demonstrate that the implementation of EHR systems may be associated with cost savings in a variety of areas including documentation costs, clinical costs, billing costs, customer service costs, and laboratory and radiology order entry costs (Kaushal, Shojania, and Bates 2003; Johnston et al. 2004; Schmitt and Wofford 2002; Zdon and Middleton 1999; Brailer and Terasawa 2003; Drazen and Fortin 2003). From a clinical standpoint, proponents of EHRs cite the potential to substantially improve quality and safety. Evidence is beginning to show that the major benefits of EHR and associated clinical decision support systems are increased adherence to guideline-based care (e.g., receipt of prevention services), enhanced patient monitoring, decreased medical errors, and improved communication and coordination of care (Chaudhry et al. 2006; IOM 2001).

EHR adoption requires a significant capital outlay for healthcare providers. In addition to direct costs associated with the hardware and software of the selected EHR system, anecdotal evidence suggests additional costs such as training and changes in productivity levels contribute to estimated costs of $40,000 to $100,000 per provider practice for implementation. Similarly, at the health system level, anecdotal evidence suggests that EHR implementation costs can range from $40 to $350 million, depending on system size, selection of EHR components and similar factors. Not surprisingly, the high cost of EHR systems is often cited as among the biggest barriers to ambulatory EHR adoption, especially for smaller physician practices (DesRoches et al. 2008; Gans et al. 2005; Bates 2005).

Despite the major capital investment requirements, a true business case for EHR adoption and implementation has not been made. Previous research suggests that the lack of a business case, or lack of an identifiable positive financial return on investment (ROI), can result in reluctance by healthcare providers to invest in quality-related programs or projects (Leatherman et al. 2003). Although a few published case studies suggest that the investment in EHR systems can result in a positive ROI for physician practices (Miller et al. 2005; Wang et al. 2003), a recent review of the EHR literature (Menachemi and Brooks 2006) and a large sample survey of physicians (Bates 2005) highlight the significant challenges providers face in establishing the business case for EHR systems. First, an EHR itself does not generate direct revenue. Second, some indirect financial benefits (e.g., improved efficiency or revenue capture) from EHR use are difficult to link to the EHR system while others (e.g., reductions in unnecessary procedures) do not accrue directly to the provider. Finally, EHRs require a high capital outlay and therefore have a higher hurdle to clear in terms of cash flows required to produce ROI. How, then, are healthcare organizations justifying their investments in ambulatory EHR systems?

We sought to learn more about healthcare organizations' decisions to invest in ambulatory EHR systems from those organizations that were considered to have exemplary ambulatory EHR system implementation processes. We were particularly interested in whether these organizations completed a formal business case analysis to support their investment decision, and whether specific financial or non-financial factors influenced the decisionmaking process.

METHODS AND ANALYSIS

Our investigation of the business case for ambulatory EHR system adoption was a key component of a larger study investigating exemplary EHR implementation practices in ambulatory settings that has been described elsewhere (McAlearney et al. 2010). We interviewed 43 organizational and clinical informants across five US health systems considered by the industry and peer organizations to have exemplary EHR system use in ambulatory care settings.

Case study sites were selected on the basis of multiple criteria. First, we generated an initial list of hospitals and health systems that had been publicly recognized for successful ambulatory EHR implementation. Sources consulted include the list of HIMSS annual Davies Award winners, Hospital and Health Network's annual Most Wired Survey, academic and trade publications, and interviews with vendors and other experts. Second, we conducted follow-up exploratory research to learn more about each potential site's organizational characteristics and their EHR implementation processes. Our final sample was selected to reflect variation on multiple dimensions including organizational size and complexity, stage of EHR adoption, structure of health system--physician relationships, geographic location, and willingness to participate in the study. Our final sample included five multihospital health systems that range in size from 660 beds to 2,000 beds. Each site provides a comprehensive range of inpatient, outpatient, and ancillary health services.

Once the sites were selected, the research team established a key contact at each site (e.g., CIO, EHR project lead), explained the purpose of the project, and then asked the key contact person to identify appropriate key informants within their organization. Key informants were organizational leaders or managers, including health system and physician practice administrators and clinical leaders (e.g., medical directors) (n = 21); information technology leaders (e.g., CIOs) and professional IT staff (n = 15); and clinical end users, including physicians and nurses (n = 7). Study site and key informant characteristics are presented in Exhibit 1.

Interviews were conducted between September 2008 and September 2009 and included a combination of in-person and telephone interviews. We used a semi-structured interview guide with open-ended questions to ensure consistency across interviews. The interview guide was pilot tested in the researchers' local market prior to being finalized. Our final interview guide included seven question domains including a domain asking questions about the business case for EHR adoption that serve as the basis for this study.

The vast majority of our interviews were conducted by two members of the research team and lasted 60 minutes. All interviews were recorded and transcribed verbatim to permit further analysis. Individual interview transcripts were coded by the study investigators to enable categorization and themes and subthemes within the data. We used the software program Atlas.ti (version 6.0) (Scientific Software Development 2009) to support this qualitative analysis process.

As part of the "business case" domain of the interview guide, we asked key informants questions to obtain their perceptions about the financial costs and benefits associated with adoption and implementation of the EHR system. We also asked questions about the perceived non-financial costs and benefits linked to the adoption and implementation of ambulatory EHR systems to supplement the questions about financial costs and benefits and ensure that our qualitative understanding of the business case for EHR adoption was complete. Given the exploratory nature of our study, questions included in the interview guide were open ended and allowed each respondent to make his or her own categorizations of costs and benefits, including determining whether they considered associated costs and benefits financial or non-financial.

For the purposes of our assessment of the business case that we present in this article, we focused on key informants' answers to questions about the financial and non-financial costs and benefits of ambulatory EHR system adoption and implementation, as described previously. Our analysis of respondents' answers to direct questions about the business case along with themes that emerged in other areas of the interviews and analyses related to this topic informed the results we present next.

RESULTS

The Business Case for EHR System Adoption

Based on multiple key informant interviews, we synthesized five overarching findings associated with these organizations' evaluation of a business case for adopting an ambulatory EHR system and the benefits expected from the system:

1. The rigor of formal business case evaluation varied.

2. There was a perceived financial business case for EHR system adoption.

3. The non-financial benefits for EHR system adoption made the most compelling business case for healthcare organizations.

4. External factors influenced ambulatory EHR system adoption.

5. Evidence demonstrating the benefits of EHR system adoption was limited.

We next discuss each of these key findings individually.

The rigor of formal business case evaluation by healthcare organizations for an ambulatory EHR system varied.

All the sites we interviewed performed a formal business case evaluation for investment in the EHR system. However, the degree of rigor and the evaluation varied considerably. As one key informant described, the business case evaluation "process was not as formal as one might expect" (see Exhibit 1). At one end of the spectrum, a simple analysis looking at physician charges pre-versus post-EHR implementation yielded an acceptable level of detail for the organization. The most rigorous evaluation involved extensive use of outside consultants to evaluate and quantify the expected benefits of EHR adoption. While this analysis produced a positive estimated return, no full project review--standard procedure for all capital investments at this organization--was performed. In general, the return on investment analysis for EHR systems was not held to the same standard as traditional capital investment decisions.

Several reasons were cited for the lack of in-depth analysis of the business case. Among the most commonly cited reasons were the following:

* EHR investment is inevitable {i.e., "not a matter of if, but when"). As one informant emphasized, "It's ridiculous. Why are we even discussing it or arguing about it? It's so intuitive!"

* Key drivers of EHR investment are not financially motivated. Specifically, improvements in clinical care and providing the ability for an organization to track quality indicators and improvements in patient safety were more important drivers than ROI for an EHR system, yet the financial effects of these non-financial items were notably difficult to track. As one informant noted, "I don't know how you can practice medicine in the twenty-first century without electronic medical records. I don't know how you can practice safe, cost-effective medicine without this tool."

* There is an expectation of cost savings, but it is difficult to identify and track the direct financial benefits associated with EHR use.

* An in-depth analysis is unnecessary since incentive payments under pay-for-performance (P4P) plans will more than cover the incremental cost associated with EHR system adoption for a physician practice.

There was a perceived financial business case for EHR system adoption in healthcare organizations. These sites generally believed that there would be a positive financial ROI for an EHR system. However, only one site reported an exact ROI figure, reporting a 5 percent ROI over a five-year time period. Another organization reported that incentive payments from insurers under a P4P plan were $400,000 per year and noted that these incentive payments more than covered the incremental expenditure of $60,000 to $100,000 required to bring a physician practice up to speed on the EHR system.

Across sites informants expressed a pervasive belief in expected direct and indirect financial returns from EHR system adoption. Specific areas noted for which sites expected a return based on cost savings included reduced transcription costs, reduced duplication of laboratory tests, improved coding and charge capture, improved revenue cycle, and increased incentive payments for quality indicator reporting. In Exhibit 2 we present representative quotes that illustrate key informants' perspectives about the direct and indirect financial considerations associated with the presumed business case for EHR implementation.

The non-financial benefits of EHR system adoption made the most compelling business case for healthcare organizations. Consistent across all sites and interviews was the notion that improved clinical care and coordination and the ability to capture healthcare quality metrics were the most compelling reasons to invest in the EHR system. As one informant explained, "The business case was much more about quality than it was about return." In addition, organizations noted how reporting requirements for Medicare reimbursement under the Physician Quality Reporting Initiative (PQRI) and P4P programs would be nearly impossible to complete without the EHR system. As summed up by one key informant, "It's no secret that ... the ability to capture quality data by which Medicare and almost every payer is measuring practices, as well as being able to capture any P4P monies available, will require an EMR."

Another important expected non-financial benefit of EHR system adoption was the ability to generate data to address population health issues or chronic disease management. As one informant specifically mentioned, the organization had "a desire to move to that level of care, to have more proactive population management."

In addition, the expectation of better integration between the ambulatory practices and the system or hospital was also commonly mentioned as a non-financial benefit presumed to be associated with the EHR implementation. As one administrator explained, a major reason for ambulatory EHR system implementation was "having the same workflow and tools that everyone uses across all sites." Similarly, another informant noted that the EHR was expected to enable "better communication amongst the physicians because the notes will all be shared."

External factors influenced and will continue to influence EHR system investment. Although the consensus across all sites was that investment in EHR systems was inevitable, several external factors were also noted that influenced and will likely continue to influence EHR adoption. These included the following:

* Current economic conditions have affected the rate of roll-out of ambulatory EHR systems to physician practices. While poor economic conditions had not put any EHR system investment on hold in the sites we studied, several sites did report having scaled back the number of physician practices they planned to bring on board during the next year as a way to reduce EHR costs.

* Anticipated reimbursement changes also appeared to motivate EHR system investment. Although many sites reported participating in plans that provided quality reporting incentives, respondents also noted that they expected to see penalties for non-reporting in the future.

* The economic stimulus package was another factor that sites anticipated would motivate further investment in EHR systems. Sites noted that they wanted to capitalize on the stimulus incentive, and reported that they believed the stimulus package would also be important in its ability to motivate other physician practices to invest in EHRs. As one key informant explained, the stimulus incentive is necessary "because regulators know that there is no real business case for physicians to invest in EHR as the direct benefit goes to insurance companies."

Evidence demonstrating the benefits of EHR system adoption is limited.

Very few sites had a systematic process for tracking the benefits, either financial or non-financial, of EHR system use. This was not surprising, given our finding across sites about the relative lack of rigor for a formal business case evaluation of the initial investment. Yet this finding likely reflects the limitations of cost accounting systems rather than reflecting sites' determinations that tracking such information is not important. As one respondent described, "I think in an ideal world we would've had a baseline [for costs] and all of that stuff but we don't live in an ideal world." Consistent with our finding that the motivation for EHR system investment tended not to be financial, the imperative to demonstrate the benefits of EHR system adoption was weak. As summed up by one respondent, "The business case was much more about quality than it was about return." To that end, most evidence illustrating the benefits of EHR system adoption was focused on clinical benefits such as tracking quality indicators, population, or disease management approaches.

DISCUSSION AND CONCLUSION

Despite the high capital commitment required for EHR system adoption and implementation, we found that the health systems we studied did not apply the same level of rigor to ROI analysis for EHR system adoption that they typically would for capital investment projects. This finding may reflect the challenges associated with estimating a ROI for health information technology investments (e.g., no direct revenue stream, benefits do not necessarily accrue to investing organization) that have been documented elsewhere in the literature (Menachemi and Brooks 2006). According to our multiple key informants, in the case of ambulatory EHR system investment, the sense of the inevitability of the technology adoption regardless of ROI results overrode organizations' perspectives about the need for a rigorous business case analysis.

Nonetheless, all organizations we studied perceived that a positive business case for EHR system adoption existed, and this positive business case was driven by considerations about indirect financial benefits. Specifically, the indirect financial benefits perceived to justify this business case included the potential for cost savings post-system implementation, the non-financial benefits of EHR system use related to improved clinical coordination, and the new ability to capture clinical quality metric data that are necessary to guide disease management programs and inform P4P incentive programs. This finding is consistent with previous studies that have found that organizational motivators such as mission or strategic benefits are rarely quantified in the business case analysis but are important factors in influencing hospitals' decisions to invest in quality improvement initiatives (e.g., Leatherman et al. 2003; Garrido et al. 2004).

Sites included in this study were considered exemplary in terms of their ambulatory EHR system implementation processes; therefore, it was surprising that that very few of these "best-practice" organizations could produce any evidence of a financial return on investment. Yet for the sites included in this study, the lack of a business case did not appear to affect EHR system adoption decisions. This finding may reflect the high strategic priority these organizations placed on EHR system adoptions. However, for other provider organizations that have not decided that an EHR system is a strategic priority, establishing a business case may be required to achieve leadership buy-in. Recent studies have found that an unclear ROI, among other financial concerns, is one of the leading barriers to EHR adoption among hospitals (Jha et al. 2009) and physicians (DesRoches et al. 2008). Determining the relative importance of strategic and financial priorities will clearly be important in the provider organizations' decisions to adopt ambulatory EHR systems.

External factors may also influence the imperative to demonstrate a business case. We found that while the current economic crisis did not affect these organizations' plans to adopt EHR systems, it did contribute to slower EHR system roll-out rates across physician practices. Clearly, the economic climate has constrained access to capital for most healthcare organizations, and when capital resources are constrained, organizations may be less able to invest in projects that fail to demonstrate a business case. If capital constraints are eased via financial incentives under the economic stimulus plan, organizations must still take precautions that the on-going investment in an EHR system can be supported by the organization.

There are several limitations to this study. This study included five health systems selected based on their exemplary EHR system adoption and implementation practices, not on exemplary financial management practices. Therefore, our findings may have been different had we used different selection criteria. We also studied health systems with an ambulatory practice component or relationships with affiliated physician groups. As independent physician practices may face different incentives for EHR system adoption, our findings about perceived and realized financial benefits from EHR system adoption may not be generalizable to practices that are not affiliated with a health system. Finally, few organizations were able to provide any concrete financial evidence of EHR system benefits. Thus, the inability to demonstrate a financial business case may reflect cost accounting systems' inability to capture necessary financial information rather than the true absence of a business case.

The inevitability of EHR system adoption should not deter managers from conducting a business case analysis. The inclusion of non-financial benefits, in particular, will likely be critical to demonstrate a positive business case. It should be noted, however, that the value of non-financial benefits is difficult to quantify; future research should focus on developing a methodology to account for non-financial costs and benefits so that these can be included in rigorous business case analyses. Results from a business case analysis will inform health systems about their resource allocation needs to support EHR system adoption and implementation. In addition, identifying the added financial and clinical benefits that can be expected from EHR system adoption will assist health systems in their attempts to develop performance metrics by which to evaluate the expected versus realized value of EHR system adoption--a best practice for any capital investment decision--and an effective means to maintain ongoing organizational support for EH R systems.

ACKNOWLEDGMENTS

We would like to thank all of our study participants, as well as the Center for Health Management Research for funding this research and the health system members of our Project Advisory Team for providing valuable feedback. Any errors in this research are solely attributable to the authors.

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PRACTITIONER APPLICATION

Brian T. Smith, executive director, Rush University Medical Group; vice president of medical affairs, clinical practice, Rush University Medical Center; assistant professor, Department of Health Systems Management, Rush University, Chicago, Illinois

Song and colleagues' assessment of exploring a business case for an ambulatory electronic health record (EHR) seeks to provide a framework and guiding principles for developing a complete model of the various reasons physician practices would invest in this technology. The list of benefits outlined includes a short-term financial review and the opportunity to outline metrics to measure the success throughout the journey.

As a practitioner, I have had the privilege of working with two academic physician groups who chose two different software vendors and made the decision to pursue the EHR journey long before the current federal incentive funds were available under the Health Information Technology for Economic and Clinical Health Act (HITECH). In both organizations, we developed guiding principles comparable to the business case parameters described in this article. In both cases, the results led us down a path for implementation. This involved challenging our workflows to ensure we were addressing any potential expense savings, building upon our quality, and improving systematic handoffs to decrease both medical and administrative errors. As a provider group we believed we needed an EHR for strategic purposes to support our competitive position. It held the promise to improve consumer satisfaction by enhancing geographically dispersed providers. It could also help us improve patient care by creating the opportunity to build population-based databases for treatment standards and evidence-based protocols in our teaching environments. Like the practitioners the authors interviewed, many of us believed EHR was inevitable but we also wanted to know that our reasons for implementation would make a difference in the way we practice and teach medicine.

The business case concept is intriguing and is something that can be used in the decision-making process, roll-out and implementation, post-go-live, and optimization. It can help us determine if our assumptions held true and how our delivery model or assumptions may have changed in this dynamic environment. With constant changes to practice standards and treatment protocols being driven by evidence-based research and new therapy treatments, it is critical to include the opportunity to capture data from structured databases to respond to the various pay-for-performance programs and Physician Quality Reporting Initiative (PQRI). Dependency on paper chart audits creates the risk of incomplete responses. As patients become more knowledgeable and inquisitive about their healthcare because of the increased pressure of consumerism and their individual costs for insurance or out-of-pocket expenses, these measurements will become more critical as providers respond to the various national organizations that measure and report on quality in an attempt to standardize provider performance.

The business case also allows for various levels of management, clinicians, and staff to follow the short-term capital investment and track ongoing operating expenses and productivity metrics associated with this type of technology. Think back to the initial cell phones that excited early adopters had hardwired into their cars--they were expensive, heavy, and useful for just a single function. It is amazing to see how quickly we reached a point when most of us could not imagine going even a day without all the tools our mobile devices now provide us. Looking forward, it is not difficult for me to imagine a time in the near future when electronic medical records will be as pervasive as mobile devices, and paper records will seem as archaic as rotary phones.

For more information about the concepts in this article, please contact Dr. Song ] at psong@cph.osu.edu.

Paula H. Song, PhD, assistant professor, Division of Health Services Management and Policy, College of Public Health, The Ohio State University, Columbus; Ann Schech McAlearney, ScD, associate professor, Division of Health Services Management and Policy, College of Public Health, The Ohio State University, associate professor, Department of Pediatrics, College of Medicine, The Ohio State University, and visiting professor, Ecole Polytechnique Federale de Lausanne, Switzerland; Julie Robbins, MHA, Division of Health Services Management and Policy, College of Public Health, The Ohio State University; and Jeffrey S. McCullough, PhD, assistant professor, Division of Health Policy and Management, University of Minnesota, Minneapolis
EXHIBIT 2

Representative Comments About the Financial and Non-financial
Considerations for Ambulatory EHR Adoption

Direct and Indirect Financial Considerations

* "We were less scientific on exactly where the cost improvements
were going to come from. While we thought we knew some [cost
improvement opportunities] in the business areas and the back
office, we had some guesstimates, but that was as far as we went.
We did not try to get real specific other than to make the push
that we thought we could take enough costs out to be able to make
some sort of a positive return."

* "On the operation side there was assumed transcription benefit
... in imaging, reduced number of tests. We also quantified the
benefits of lower paper medical records cost ... we anticipated
cost reduction."

* "We knew that eventually ... someone, whether it be the payers or
the government, was going to measure and reimburse for quality
measures."

* "There's no secret to anybody that to capture quality data by
which Medicare and almost every payer is measuring practices and to
capture any pay-for-performance monies available, you're going to
really need an EMR."

* "Related to billing and collections and dealing with an insurance
company, we waste tons of time arguing with the insurance companies
about what we did.... What we were able to demonstrate is with the
electronic medical record you had to get it right the first time.
You had it documented or you couldn't bill for it..."

* "We see some efficiencies because of the EMR--we have more
standardized ways of doing things. This helps to streamline in
organization and it allows for economies of scale... when you put
in new technology, it rolls out through all the ambulatory
(practices)."

* "Our ability to negotiate better rates in the marketplace would
be leveraged by the fact that we had electronic data."

Non-financial Considerations

* "I think that one of the most important benefits has been ...
non-financial benefits--has been in unifying the company .... This
has allowed us to look at ways that we could standardize healthcare
delivery. I think it helped us move forward in terms of what our
strategy is for the organization."

* "Part of it was ... to serve our mission and vision--providing
excellent patient care in an integrated system--we need an EMR."

* "Clinically ... for my patients, I have everything at my
fingertips. I don't have to thumb through a paper chart [to find
information]...."

* "From a strategic standpoint, [we now have] a different tool than
almost anybody else has. And I'm very excited long-term that the
data warehousing capabilities will give us a little bit of an edge,
whether we're talking about clinical outcomes or research studies
or clinical trials or business practices, because you've now got a
huge, accessible database that you never had in the past."

* "We have numerous goals ... having the same workflow and the
tools that everyone uses across all sites. [The EHR] enhances our
reporting capabilities and increases our numbers."

* "There was certainly interest in trying to extend the use of the
EMR outside of employee practices to better connect independent
physician groups with the network as a way to build loyalty."


EXHIBIT 1

Health System Characteristics and Description of Key Informants
and Business Case Evaluation Approach, by Site

   Health System           Key Informants           Business Case
   Characteristics           Interviewed         Evaluation Approach

1 * 3 hospitals,        Leaders/ managers (6)   * No reported ROI
    1,000 beds                                  evaluation; decision
                        Physicians/other        to invest in FUR
  * Contracted          clinicians (2)          driven primarily by
    physicians                                  clinical
                        IT/support (2)          considerations.
  * Primarily rural
    practices

2 * 4 hospitals,        Leaders/ managers (7)   * Informal ROI
    660 beds                                    analysis; current
                        Physicians/other        pay-for-performance
  * Employed            clinicians (3)          contracts covered
    physicians                                  EHR costs.
                        IT/support (3)
  * Urban and rural
    practices

3 * 10 hospitals,       Leaders/ managers (4)   * Formal ROI
    2,000 beds                                  evaluation performed
                        Physicians/ other       by outside
  * Contracted          clinicians (1)          consultants;
    physicians                                  projected positive
                        IT/support (4)          ROI but no capital
  * Urban and rural                             project review
    practices                                   performed.

4 * 4 hospitals, 900    Leaders/managers (3)    * Formal ROI
    beds                                        evaluation conducted
                        IT/support (1)          internally; results
  * Contracted                                  did not drive the
    physicians                                  investment decision,
                                                rather provided
  * Primarily urban                             guidance for expected
    practices                                   resource allocation
                                                needs.

5 * 8 hospitals,        Leaders/ managers (3)   * Formal ROI
    2,000 beds                                  evaluation conducted
                        Physicians/other        internally; reported
  * Contracted          clinicians (1)          skepticism of results
    physicians, with                            due to very broad
    increasing          IT/support (3)          assumptions. Decision
    interest in                                 to invest ultimately
    employment                                  driven by EHR as a
                                                strategic priority.
  * Urban and rural
    practices
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