The mental health treatment market has evolved into a competitive environment. Top-tier providers realize that to compete they must not only remain current in the services and programs they offer, but they must be prepared to invest in the necessary infrastructure to support those services—including electronic health records. Despite EHRs' significant expenses, EHRs are a reality in our field.
Hundreds of EHR products are in the marketplace. An “off-the-shelf” product is mass-produced to sell at a relatively low price, and a large number of people can be trained to use this software or to be a support group. The problem with off-the-shelf software is that for organizations with a highly specialized requirement, the software probably does not have the required functionality.
No matter how technologically advanced or innovative, no vendor can meet all of the specific, individual needs of every provider in all 50 states, each with different EHR requirements driven by local agencies and accreditation entities. Even if a vendor adheres to state reporting regulations, HIPAA and privacy laws, guidelines from regional healthcare information organizations (RHIOs), and accrediting bodies' requirements, you still likely will need to customize off-the-shelf software to address local reporting requirements, support your organization's vision, or improve communication with local agencies, state hospitals, other behavioral health organizations, or payers.
You could spend two or three thousand dollars for one week of training to educate a staff member so that he has the skills to customize the off-the-shelf software application, only to find that you cannot modify the core database and are restricted from making any significant changes to the existing product. Thus, you become dependent on the vendor to make those customizations for you. You could join the vendor's national users' group and vote on changes to the core product, but this will not address your emergent and immediate needs. In the end, the vendor probably will have to make enhancements to the product so that your organization has the functionality it needs.
There are other options. Many providers have become better educated about what is available in the marketplace, and many of us have developed the skills to customize software to meet our unique and individual needs. If one has developed the expertise, why not “build” your own product? Custom-built software might have a higher cost per user because of a smaller user base and will require a greater time investment than an off-the-shelf product, but it could provide the specific functionality your organization desires.
During the developmental phase, the developer can interact with staff through focus groups to incorporate specific functionalities they want. Custom software developers can create an initial version that contains only the system's core and essential modules rather than the “kitchen sink,” and then assess additional user needs once the product is established and mainstreamed fully into your system. If the product is not designed from the outset to be easily updated with readily available technical resources, it is doomed to fail.
Obviously, adequate resources must be budgeted and expended to cover software development costs. Here is a simple way of looking at it: If a problem has cost you $1,000 a week for the past 52 weeks, is it worth paying another $5,000 or $10,000 to find a solution? If you have lost $50,000 a month in revenue over the past six months, is $20,000 a reasonable price to mitigate such a deficit? How much have you already spent/wasted in “patch” solutions? What is the long-term cost? How long would it take you to recoup the cost of the solution once the problem is fixed? It is imperative to factor the cost of lost productivity and decreased customer service into the equation.
Logically, any price up to the amount it is costing you will be a cost-benefit. You must decide how much it is worth to you to alleviate the problem. You have to determine your comfort level with the risk associated with the amount of customization in IT development. Each provider organization has a unique culture, which should determine the best direction in which to proceed.
My organization's IT staff has developed significant expertise in software development in the six years we have been using an EHR, so we have chosen to build our own solution. We will be beta testing it in November and taking it live for the entire center in February 2008. The vendor we currently use does offer customization, but we chose to bring this functionality in-house. This worked so well that other behavioral health centers in the state that use the same vendor sought us out to customize applications for them. When the decision was made to replace our current product, we analyzed all of our options and decided to build our replacement. New technology (both servers and development tools) are significantly cheaper today than the platforms most vendors use.
My organization is in a large metropolitan area, and therefore we have access to individuals trained on the latest technology. Current project management techniques allow us to adapt rapidly to change, grow the product quickly, and deliver a stable product. Our developers have access to the expertise we have developed over the years, which allows us to develop a product with in-house end-users as partners. Approximately one-fourth of our clinical and administrative staff are involved in the product's design and implementation, so to a large degree many of our development costs are “soft.”
I would not have entered into this project without the support of the staff and the board. Everyone involved understands the risks, but we have found success over the years as leaders willing to take that risk. My staff is excited and looking forward to November 1.