The HIT Tipping Point: Intended and Unintended Financial Consequences

A question: What is the opposite of health IT return on investment?

The answer: Unintended financial consequences, or UFCs, for short.

The scenario: A sophisticated medical center health system begins to roll out an expensive proprietary EHR and shortly thereafter sustains an operating loss, leaving no choice but to put the implementation on hold. The operating loss is attributed to “unintended financial consequences” directly related to buying a very expensive EHR system.

This is exactly the situation at MaineHealth, who selected Epic. As recently reported by Healthcare IT News, in the last few weeks Maine Medical Center President and CEO Richard Peterson sent a memo to all employees saying the hospital …

… has suffered an operating loss of $13.4 million in the first half of its fiscal year. The rollout of MaineHealth's estimated $160 million electronic health record system, which has resulted in charge capture issues that are being fixed, was among several reasons Maine Med's CEO cited for the shortfall. “
Through March (six months of our fiscal year), Maine Medical Center experienced a negative financial position that it has not witnessed in recent memory,” Richard Peterson, president and CEO of the medical center, wrote in the memo to employees.

Peterson’s memo outlines the specific UFCs that explain, in part, MaineHealth’s operating loss:

  • Declines in patient volume because of efforts to reduce re-admissions and infections
  • Problems associated with being unable to accurately charge for services provided due to the EHR roll out
  • An increase in free care and bad debt cases
  • Continued declining reimbursement from Medicare and MaineCare, the state’s Medicaid program

These challenges are common to just about any medical system in the country, making MaineHealth potentially a harbinger of things to come for those hospitals and health systems that pay multi-millions of dollars for a health IT system.

The State of Maine is rightfully concerned about the developing financial scenario at Maine Medical Center and within MaineHealth. In a May 1 letter to the editor of the Boothbay (Maine) Register, local Selectman Stuart Smith questioned the EHR buying decision and associated operational costs that led Lincoln County Heathcare, a MaineHealth member, to close the local healthcare facility, St. Andrews Hospital.

I do question the $150 million figure. I think it is extremely high and Portland has had a real failure in its implementation. So much so that it looks like [Lincoln County Heathcare] will not have a real integrated EMR until 2015 and financial software problems exemplify a major failure of [MaineHealth] to create any real benefit to the state.

It becomes important to understand what MaineHealth and arguably many other health systems face financially with regard to total cost of ownership (TCO), return on investment (ROI) and those dreaded, apparently unpredictable, UFCs.

Based on some widely accepted industry conventions, we can sketch out what might be MaineHealth’s costs:

  • From the Peterson memo, upfront rollout costs for their system are pegged at around $160 million, which usually includes software licenses, interfaces, implementation and training. Often, these costs are paid by a health system’s nonprofit foundation.
  • Annual maintenance and support costs are customarily 18 - 20 percent of rollout costs, which would be $28.8 million, in this instance, or $144 million over five years.

But to fully understand MaineHealth’s total costs, we have to also include the cost of staffing to support the system. Former CIO Barry Blumenfeld described their team in a November 2012 interview with Healthcare IT News.

We have 125 people in a command center, so there are teams of people for each of the Epic applications literally sitting and waiting to correct anything that goes wrong.

To make it simple, and being somewhat conservative, let’s say the average salary for each MaineHealth staff member is $100,000.  Let’s also assume that if this many staff are needed to implement Maine Medical Center, at least as many will be needed to roll out and support the system for another eight MaineHealth hospitals and clinics over five years.  In this equation, total staffing would be $12.5 million per year or $62.5 million over five years. With a bit more math we can estimate MaineHealth’s TCO—all costs directly related to the EHR project annually and over 5 years.

TCOAnnual5 Years
System RolloutUpfront$160,000,000
Annual Maintenance & Support$28,800,000$144,000,000
MaineHealth Team$12,500,000$62,500,000
Total Annual Operating Costs$41,300,000NA
Total Cost of OwnershipNA$366,500,000


 In our back-of-the-napkin analysis, total annual operating expenses would be in the neighborhood of $41.3 million, meaning MaineHealth would have to create a combination of increased revenue and decreased expenses totaling $41.3 million annually for a positive operating gain. If we factor in the initial upfront costs under the assumption MaineHealth is financing that expenditure, positive ROI must be greater than the TCO of $366.5 million over five years, which requires increases in revenue and /or decreased costs averaging $73.3 million per year.

Keep in mind, these costs are not unintended; these are the intended financial consequences of buying and owning the system. In our calculations, we haven’t even included dollar values for declines in patient volume, fewer patient readmissions, inability to accurately charge for services, increases in free care and bad debt, and declining federal reimbursement.

And, according to former CIO Blumenfeld, MaineHealth expects to receive about $60 million in total for Meaningful Use, which might cover one year of the potential ROI gap, depending on how upfront costs are being covered.

What are the chances, then, when both the intended and unintended financial consequences associated with choosing an expensive proprietary EHR system total an estimated $73.3 million annually, that MaineHealth can ever actually achieve a positive ROI?  In the long run, will completely eliminating some sites of care contribute positively or negatively to ROI? How will it impact patient care for citizens of Maine?

The employees and patients of St. Andrews Hospital deserve an answer to these questions.

So, in light of the revealing MaineHealth situation, what questions should be asked by healthcare organizations that have not chosen an EHR?

  1. Can we justify hundreds of millions for an EHR that contributes greatly to a negative financial position?
  2. Shouldn’t a mature EHR that’s been rolled out to over a hundred organizations help control costs and lower financial risk?
  3. Shouldn’t the vendor help manage risk and adapt the EHR to our particular environment?
  4. Can we support these levels of EHR operating expenses in light of increasing constraints on reimbursement?


Perhaps this EHR was designed in less financially constrained times. Maybe it was created for organizations that have the financial resources to navigate UFC costs and complexity hiccups. But those are not the circumstances health IT faces now. Health care IT is at a tipping point where it must provide a clear path to positive ROI, support positive operating gains and help avoid UFC’s, not contribute to them.

In a Portland Press Herald article on the MaineHealth implementation from December of last year, Blumenfeld provides some insight into the mindset of organization leadership in making the EHR decision.

Blumenfeld said MaineHealth bought "the Cadillac" of electronic medical records systems, which has been adopted by several other leading national health care organizations, including the Cleveland Clinic, the Mayo Clinic and Geisinger Health System.

If this Cadillac is not too expensive to buy, it is certainly too expensive to own.

Stay tuned:  There is a Better Way.

Edmund Billings, MD, is chief medical officer of Medsphere Systems Corporation, the developer of the OpenVista electronic health record.


As in most cases, what is missing here is good Project Management. No one can forsee UCF’s, especially declining patient counts, but good Project Management would have forcast declining Federal revenue. Also, rolling out a system like this in phases, so that training and implementation is not like drinking from a fire hose, would help spread out the expense. Then things like not being able to accurately charge for services provided would not be that big of an issue. Phased implementation would also build a long-term relationship between the vendor and the customer.

Bottom line is that no one had an accurate picture of the bottom line going in.

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