Digital health: Struggle or a pipedream?

NEW YORK ( - Creating an electronic health record for every American by 2014 is a big part of Obama's agenda but it may be easier said than done.

For one, the cost can be prohibitive - easily running into the tens of millions of dollars. Getting physicians on board can be challenging. And the sheer magnitude of implementing the technology can be overwhelmingly cumbersome - translation: try creating a system for a hospital that serves 600,000 patients.

But that's not stopping some hospitals and health care networks from answering the call, especially when the government is pouring about $20 billion into the effort.

Adoption. Large hospitals, small hospitals and giant health care networks face unique issues.

St. Elizabeth Healthcare in Northern Kentucky, for example, plans to integrate EHR across three hospitals and 43 ambulatory care offices that include 1,000 physicians and serve roughly 600,000 patients. With such tremendous size, implementation has been a slow process.

"There are still a lot of paper processes and protocols that are not on a digital platform, so the true trick is getting all of those standards of care into the computer," said Alex Rodriguez, chief information officer at St. Elizabeth. "We've been exchanging data with area hospitals for 10 years, but this takes it to the next level. This is a fundamental shift in how our hospital conducts business."

Large hospital networks also have to perform a lot of wheeling and dealing before EHR can go live.

The Western North Carolina Health Network comprises 16 community-based hospitals in western North Carolina. Getting all of them to agree on how EHR would be used wasn't easy: Who gets access to the records? What kind of audits should be done to ensure that there's no abuse of the system? How will the data be displayed?

After four years of drafting legal agreements, the hospitals agreed that the patient data would live in the patient's home hospital, not in a central data warehouse, and would only be pulled on an as-needed basis.

If you think smaller hospitals have it easier, think again. Many of those smaller, independent facilities are located in rural areas. While they may be able to get an EHR system up and running quickly, getting local physicians to change old habits is a bigger challenge.

Memorial Hospital in Sweetwater County, Wyo., is a rural, county-owned hospital with just 99 beds. Because of its size, Memorial opted to go with a "big bang" approach, choosing to go live across the hospital in one fell swoop. Most larger hospitals roll out EHR in sections.

The vast majority of Memorial's staff had never worked at another hospital or used EHR before. Many had difficulty understanding the new processes in the first few months of implementation, making them resistant to change. Eventually, that did change.

Cost. Hospitals that set up EHR systems that comply to some basic standards by October 2010 are eligible for Medicare and Medicaid incentives from the Recovery Act. But the up front costs are the hospital's responsibility. That's not a cheap proposition.

For example, it will take a total of three years and cost $80 million for St. Elizabeth to complete its EHR process.

About $40 million went to Epic for the software and $1.5 million went to IBM (IBM, Fortune 500) for the hardware (and about $225,000 per year to IBM to service the network). The rest went to replacing old machines with new ones that worked with Epic's software.

Although St. Elizabeth started its EHR process before the stimulus plan's incentives were announced, it is a typical example of what types of costs big hospitals will face going forward.
Foresight proved to be cost beneficial for Western North Carolina, which went live with EHR in February 2006.

Implementation cost WNC just $3.5 million up front for MedSeek's software, with $400,000 per year for IBM's software licenses, hosting services and maintenance fees.

"We were very fortunate that we got it in early," said Gary Bowers, former executive director of WNC and current chief operating officer of Care Partners, a network of outpatient facilities within the larger WNC network. "IBM and MedSeek were both anxious to implement EHR for demo sites."

But even a price like that just wasn't a possibility at Memorial. The need was there, but money was tight. That's why the hospital's management opted for Medsphere's OpenVista software, an open source, commercialized version of the Veteran's Association EHR software. For roughly $2 million, and $150,000 in annual service fees, it took 1-1/2 years to implement, going live Feb. 1, 2008.

"Being small, a lot of systems were out of our reach," said Linda Simmons, vice president of operations and chief nursing officer at Memorial. "Open source became a very viable and attractive solution for us."

National plan. Despite the various challenges, all three hospitals said a national plan faces the same hurdles, but on a much grander scale.

"It's still difficult to set this up regionally, so it gets even more difficult when it goes nationally," said Dr. Bob Flowers, a physician at St. Elizabeth. "We still have to solve a lot of issues."

EHR at Memorial is about 60% compliant with orders, and management continues to build quick order sets for routine physician requests. But money and time are still major obstacles.

"It will be difficult to go across the nation in five years and get an electronic record everywhere you need it to be," said Simmons. "Rural hospitals will need more infrastructure in IT."

WNC believes it has already met the goals for the stimulus bill's October 2010 implementation deadline for Medicaid incentives, but they still need to connect their physician offices, which is where the most patient information lives.

"Technology is the easy part; the hard part is working with independent providers," said Bowers. "If we have issues between 16 hospitals that have a good working relationship, on a national level, my gosh, they're going to have a lot of struggles."