"It's a large number," Henry Ford CIO Mary Alice Annecharico acknowledged in a recent interview with Healthcare IT News, about the health system's more than $350 million EHR initiative. Annecharico went on to say that Henry Ford chose not to float bonds or borrow for the project, but rather to use operating capital to implement the system. "That means we chose not to do other things," she said. "That means we chose not to build and acquire new organizations that would have a very large capital investment while we're putting this system in."

She said it was a decision supported by leadership and endorsed by the board. "We want to be able to serve the community, and this is the grounding platform for us being able to do that," she said.

As Edmund Billings, MD, sees it, the amount of money and complexity that goes into these types of implementations is not right for mid-sized health systems. Kaiser and Partners might be able to afford these massive EHR rollouts, but smaller health systems struggle.

Billings, who serves as CMIO of Medsphere Systems, which markets OpenVista, an open-source EHR model that has its roots in the VA's VistA technology, admits to a certain bias toward an open approach.

"I believe that the single source, proprietary, milk-'em-dry model is going to hit a wall," he told Healthcare IT News. "Particularly when the organizations are not going to be able to go fee-for-service to cover it, or they don't have the endowment."

Going live
Kaveh Safavi, MD, (pictured at left) who leads the health industry business for North America for Accenture, a global consulting and outsourcing firm, says Accenture tends to serve very complex, very large systems. Lately, Accenture has worked mostly on Epic and Cerner implementations, but its consultants have also worked on deploying Allscripts and Meditech.

"The general rule of thumb," he says, "is whatever you spend on your technology, you're going to spend twice as much on the task of implementation."

"What is often described as a 'glitch,'" he said, "could be a glitch at the level of technology implementation, but it's often at the level of the processes themselves. So translating business rules into technology rules … it's not really a technology problem, but the technology has to catch it."

Most organizations change their revenue cycle system either ahead or at the same time they deploy a new EHR, he said. "Because there's such a close tie between diagnoses and procedures and charges and bills, they're often linked together. Now, one may precede the other, but many organizations are often making a decision, which requires a substantial change if not a complete replacement of the revenue or billing cycle process ahead of the electronic medical record at the same time, or sometimes close to it."

As Safavi sees it, "The harder work is more in the process than in the technology configuration. There's more technology, actually on the process side than on the technology side."

Devore Culver, (pictured at right) executive director and CEO of HealthInfoNet, Maine's health information exchange, agrees. He doesn't know what the problems were at Maine Medical Center, but as former CIO at Eastern Maine Healthcare and in previous roles at Eclipsys and Cerner, he knows a thing or two about implementations.

"Large implementations frequently go weird places," he said. "Usually a couple things are at the core, one is you don't fully understand the implications for workflow. When you finally get it turned on, you find out that either you didn't entertain certain aspects of workflow as part of what the software could or couldn't do. Or perhaps, as important – and I've had this happen to me twice in my life – you don't fully understand the ramifications of a front-end implementation on back-end systems."

"When I put in my first patient clinical system in 1996, we had a little bump in accounts receivables for a few months," he admitted. "It wasn't outrageous, but it clearly was a factor. You just work through the mappings until you figure out what you missed. That's the problem with these complex structures. You don't always know what you're getting into until you get into it."

Safavi pointed out that large EHR deployments are much more common today. "It's a different conversation than it was 10 years ago," he said. "There used to be a big debate about whether you implement these things incrementally or whether you implement them across an enterprise in a much more rapid fashion – the so-called big bang."

Meaningful use has driven some of that approach, he said, and processes have been better developed on how to roll out on a much larger scale.

"Where you often see organizations struggle is when they're a little bit resource-constrained, and they can't actually invest in the process improvement and the process redesign necessary up front, but they're still committed to a big bang implementation, but they just haven't done the prep work," said Safavi.

Meaningful use puts some pressure on a number of aspects of implementation, he said. Organizations can't just deploy an EHR; they have to make sure it is configured to exchange information. That introduces another technology, which adds to the complexity. There's also the patient engagement piece of meaningful use: "Now they're all under pressure to figure out how to get some level of patient interaction."

Safavi said there are no "catastrophic" rollout failures today – not since the infamous $34 million Cedars Sinai breakdown of a decade ago, at least.
"It's much more about (the fact that) this is hard work; it takes a long time; everybody gets through it," he said. "There're no real options to avoid it. It's not the core technologies that are the problem. It's how we interact with it."