Becker's Hospital Review

42 HEALTH IT "is included a small army of consultants, new hardware and almost 30 solutions implemented in a nine-month period," says Mike Maksymow, vice president and CIO of Beebe Health- care. e health system met its go-live goal, achieved meaningful use and stayed on budget. e process of vendor selection and due diligence took ap- proximately two years, but once the contract was signed with Cerner, Mr. Maksymow and his team aggressively worked toward go-live on a nine-month deadline. "We kept our project on track. One of the biggest things was to not think of this as an IT project," he says. "It is an organization- al program that needs a multidisciplinary team." Beebe's multidis- ciplinary team pulled resources from a physician advisory group and every corner of the system's governance structure. Mr. Maksymow's advice for staying on target? Rigor upfront. "Understand the scope, set expectations and engage your physicians and governance," he says. "Limit scope creep; you need laser focus on your project." Even the best laid budgetary plans can go astray. Instead of allowing this possibility to lurk unaddressed, actively plan ahead. Ensure an appropriate level of contingency is budgeted within the capital investment forecast, says Eric Goodwin, vice president of information services at Charlotte, N.C.-based Carolinas Health- Care System. Cerner is the foundation of the EHR in place at Car- olinas. Over the multiyear, multiphase project, Carolinas Health- Care invested approximately $250 million in capital, an amount within the health system's forecasted budget. "Each phase of our EHR journey was relatively focused in terms of our objectives; our budgets were realistic and forecasted over multiple years. Budgets accounted for the initial capital in- vestments in hardware, soware, internal and external services," says Mr. Goodwin. "Additionally we projected the incremental annual operating costs that would be necessary to ensure ongoing customer education as well as support and upgrades." Carolinas held monthly senior staff-level budget conversa- tions to ensure the project remained on track. Each conversation focused on a review of expenditures, financial forecasts and anal- ysis of available funds. Mr. Goodwin and his team also explored ways to compensate for the significant cost of the EHR. "Financially, we committed to our board-specific measures and goals that helped offset our EHR investment. ese includ- ed, for example, reduced transcription expense as well as CMS' meaningful use incentives," he says. Why EHR implementations overshoot the budget Millions of dollars on the line leave little margin for error, and no one is quick to accept responsibility when costs creep up. "Some vendors are intentionally opaque, but there are far more unintentional than intentional budget overruns," says Paul Merrild, senior vice president of enterprise solutions with athen- ahealth. "e far more common scenario is a legitimate misfore- cast of related costs, and especially of the personnel required to run the technology post go-live." ree common reasons EHR implementations stray from the budget include: • Change in scope. If a project's scope changes mid-imple- mentation (i.e. a hospital decides to implement the EHR at additional locations), the price point changes. • Shortage of client resources. "A client may not be able to allocate as many resources as they thought they could," says Mr. Neal. "ey may need to go to a third party to get those additional resources." Resources on the client end could range from time to manpower. • Training expectations. "A major [budget] deviation could be when you come to the point of training and ed- ucating end-users," says Mr. Neal. "e original expec- tations might not be sufficient for training thousands of nurses and physicians." One of the biggest budgetary mistakes is planning only up to the go-live date. IT is a means to an end, rather than an end to itself. If an EHR is implemented by its go-live date, but doesn't deliver on results — more spending is inevitable. "Soware vendors have a massive misalignment of incen- tives," says Mr. Merrild. "ey get a huge check upfront for licens- es and consulting. ey are incented to get customers live on their product, not to get them to high-performance aer the go-live date like a vendor charging a percentage of collections." Handling budgetary derailment Hospital and health system leaders may play a role in bud- getary drama, but it is important vendors have skin in the game. "Hold vendors accountable. Set success milestones and pay- ment milestones," says Mr. Merrild. Make expectations clear up- front, and ensure vendors understand their role in keeping the implementation on track, not only from a budget and timeline perspective, but from an outcomes perspective as well. "Anchor the project on the value you expect to achieve, whether clinical or financial," says Mr. Neal. Governance plays an essential role in the success or failure of a large scale project like this. Is leadership prepared to make difficult decisions quickly? Indecision can be a budgetary bane. Is leadership prepared to listen to and incorporate vendor best practices? "It is human nature to think what you have done before is the best thing for the future, but there is a set of guidelines that come with the EHR system you chose. Question them and understand them, but they are there for a good reason," says Mr. Neal. Governance that can react quickly and listen is more likely to stem budget leakage and steer EHR implementation back toward its original price point. n

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