The evolution of Electronic Medical Record Systems (EMR’s) rose out of the US, driven by the particular structure of the health system that pervades there. As time went by, the requirement to support the health insurance revenue cycle in the US and adapt to regulatory requirements mean that these systems were never designed around the clinician or the patient – they are enterprise software platforms designed to meet the needs of their particular market drivers.
Add in the wave of consolidation across the healthcare market in the US and you have many many reasons why large-scale enterprise platforms that are already embedded in the market become the major industry players. The patient and the clinician never got a look-in – the market dynamics gave the expected results.
Now, it has normally been the case that because of US based technology company hegemony that they are a natural first choice in vendor selection for overseas markets. Market research firms such as IDC, Gartner and Forrester have sourced their tech market analysts primarily from the US as they have built out their market/technology teams.
So it is understandable why everybody followed the same well-worn path with respect to EMR technology platforms – look at what the US does and use that as a template for what the rest of the world should do.
Except in the EMR space, the US market is the anomaly, rather than the base case. The dynamics alluded to above that drove the adoption and success of EMR systems in the US are fundamentally different or absent entirely in most other health systems. Ergo, plugging a US-evolved EMR into a non-US health system is likely to lead to, at best, slow realisation of benefits, at worst, carnage.
Let’s take the worst case first. A health system boldly decides to pursue a digital health strategy and embarks on an EMR procurement process. Due to the sums involved, this means a significant procurement process with all attendant oversight. On selection of vendor, then decisions on design take place. For non-US hospitals, this is a considerable undertaking, involving many decisions and compromises that will not be tested for many years. Once this process is complete (let’s charitably suggest a 12-month process), then the design configuration begins and implementation planning commences. Here’s the tricky bit: to this point and during this phase, the engagement of end-users is either non-existent or consists of a small coterie of technophiles. In effect, the ones most likely to adapt to the system.
Most nurses and doctors have not had a platform to express their opinion on any decisions made on the EMR design or implementation until they are about to use the system – they have neither the experience, exposure nor the time to make an assessment on it until this stage. Unfortunately, due to the nature of the technologies involved and the time taken for any modifications, the point at which end users are “engaged” is exactly the time at which there is no realistic rollback option – the system is about to go-live.
This is when carnage can ensue, when confusion reigns at all stages, and unfortunately when the battle for hearts and minds is often lost. At this stage it becomes obvious that there are many changes necessary to make the system usable, and contractually, the healthcare provider is put between a rock and a hard place: suck up paying for ongoing change control fees from the vendor (who will insist that the problems are “user issues” not system issues), or abort the entire thing (and their reputation with it). In most cases, unless management have changed in the interim (which is possible as the scenario above could last over 5 years), the former will be chosen. The resultant effect has plunged some such providers to the brink of bankruptcy.
The more benign scenario involves a lowering of ambition very early on in the implementation planning phase, such that the project never implements the benefits for which the procurement was designed to achieve, meaning the healthcare provider has just implemented a very very expensive glorified ERP system.
This is a process which does not fail to repeat itself time and time again – and the cycle can only be broken by re-evaluating what it is we want an EMR to be, and whom it should serve. If we are to suggest that it is an electronic system that not only reflects the current health record (a mix of paper and electronic), is so easy to use and familiar that you can “onboard” yourself, whether patient or doctor, and one which doesn’t represent a risk to financial stability of the organisation, then...