Curbside Consult with Dr. Jayne 3/11/24

Mr. H reported on this last week, but I’m still struggling with the story about Guam Memorial Hospital spending $5 million on an EHR that isn’t fit for purpose. As someone who used to do consulting work to help healthcare organizations with EHR system selection needs, it’s just baffling that this hospital’s project has reached this point.

You can try to blame the fact that there was a pandemic that caused delays, but that feels like a convenient excuse to try to cover problems that range from incompetence to willful neglect. There’s also the question on who will profit from the $20 to $60 million that it will take to replace the current system with one that will actually get the job done.

The system has been in place since October 2022. An administrator has stated that leadership determined it “really wasn’t built for an acute care hospital landscape” and would be more suitable for a behavioral health application. Because there isn’t funding to address the issues, caregivers are essentially stuck with it for the time being.

It feels like the basic tasks involved in system selection were somehow skipped: demonstrations, reference checks, and site visits with peer organizations that were currently using the system. This isn’t a magical new process for buying an EHR. I’ve done it at least a dozen times in the last two decades, and it’s pretty straightforward. Even if you claimed that the pandemic prevented site visits, you could still address a number of needs through a virtual site visit. In my experience, physicians rarely lie about the capabilities of an EHR unless they are being bribed.

I can’t throw the vendor under the proverbial bus without all the facts. It’s not entirely clear with of the vendor’s modules were actually purchased and how they were implemented.

I’ve personally been involved with EHR implementations where health systems did some pretty silly things, such as “forgetting” to include laboratory interfaces in their original Request for Proposal document, and grossly underestimating the volume of patient data that would need to be converted in order for physicians to work efficiently and for patients to be safe.

On the other hand, it feels like the facility might have skimped out on certain implementation steps as well as system selection steps, including elements such as workflow design, inclusion of patient safety and quality reporting features, and a little thing called user acceptance testing. Maybe issues were raised and leadership just plowed on through, though – I’ve certainly seen that happen a number of times.

As for the complicity of the vendor in this situation, I did a quick glance at its website, which may not at all resemble what the hospital had access to as it was selecting the system. There are plenty of areas of the website that channel language specific to behavioral health inpatient applications. There are consistent mentions of using DSM 5 to capture diagnoses in the chart rather than using ICD-10. There are also several mentions of the ability to document group visit notes, which typically don’t occur in the standard medical / surgical inpatient setting. The vendor does list a number of component products, however, and it looks like there may have been some mergers or acquisitions along the way, so that might be part of the issue too.

The news article notes that management is busy preparing a new RFP and therefore couldn’t offer additional comments on the downstream operations and billing impacts caused by the situation. I suspect they can’t offer comments because they’re actually preparing updates to their resumes as they consider pursuing other opportunities. The hospital is tied into a subscription-based contract, so they’re stuck with it until they can get a replacement live.

Hospital IT projects don’t happen overnight, and if the same leadership team remains in place, I’m sure it won’t be an efficient rip-and-replace at all. Even in the best of situations, you’re looking at an 18-month lead time to install a hospital system, just due to the sheer number of decisions that have to be made, the workflows that have to be mapped, the clinical data that has to be converted, and of course the ever-hellish hospital contracting process. That’s not allowing additional time for lots of questions to be asked, since the facility has already bought a lemon and stakeholders probably don’t want to buy another one.

Reading through the article, the organization has dealt with a number of technology problems in the past, including concerns logged during site visits from the Centers for Medicare & Medicaid Services (CMS). Those citations focused blame on the hospital’s previous EHR, which has since been discontinued. CMS cited the facility for failure to systematically track medical errors.

The administrator speaking to the media for the article noted that the new system had been recommended by the previous vendor. That’s problematic in my book, because when I have a vendor that’s failing to meet expectations, the last thing I want to do is to take their recommendation for a replacement. Apparently the two vendors were somehow affiliated, but trying to figure that out is beyond the scope of my investigative reporting motivation at this point. Apparently it was a no-bid contract situation, and that’s enough information for me. I can’t help but feel concern for and outrage on behalf of the patients who are now stuck receiving care in this environment, and the clinicians who have to try to make do with something that is clearly incapable of supporting them.

There are only a handful of comments on the article, and I wonder if any of them are from clinicians. If I had inside knowledge of the situation, I’d certainly be spilling it. I’m curious if we have any readers who work with the vendor in question or who have inside knowledge on the situation and would be happy to help you share your thoughts anonymously. Inquiring minds want to know: How do situations like this happen? Is there more to this story than meets the eye? Or is it simply a case of rampant incompetence? Leave a comment or email me.

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