What evidence shows that replacing the current EHR is better than improving it?

That question sounds simple. It isn’t.

An organization can have serious problems with its current EHR and still not have established that replacing it is the best solution.

Evidence that something is wrong is not necessarily evidence that replacement is the right answer.

The real comparison is not between today’s imperfect system and an idealized new one. It is between the credible alternatives available to the organization—including improving the current environment and transitioning to and operating a replacement.

A Problem Is Not Yet a Case for Replacement

An EHR can create genuine frustration, inefficiency, cost, clinical risk, or limitations without replacement necessarily being the best response. Before committing to a transition, it is worth separating two questions:

1. What is wrong with the current environment?

2. What evidence shows that replacement is better than the credible alternatives?

Those questions are related, but they are not the same.

A difficult workflow, for example, might reflect a limitation of the EHR itself. But it might also involve configuration, interfaces, incoming data, training, local processes, or some combination of them. The distinction matters because replacing an EHR is itself a major organizational change.

Compare Real Alternatives, Not an Old System with an Idealized New One

A replacement can look compelling when the comparison is framed as:

our current problems vs. the promised capabilities of a new EHR.

But that is not the decision the organization actually faces.

A more useful comparison is:

What would it take to improve the current environment?

versus

What would it take to transition to, configure, implement, learn, and operate the proposed replacement—and what evidence shows that the resulting environment would be better?

This does not create a presumption against replacement. The evidence may show that the current system has reached practical limits and that replacement is clearly justified.

The purpose is simply to make sure the organization is comparing real alternatives with real alternatives.

EHR Transitions Carry Their Own Risks and Costs

Replacing an EHR is not simply a software purchase. It is an organizational transition involving people, workflows, data, interfaces, training, operations, and patient care.

A 2023 systematic review of 40 peer-reviewed publications on transitions from one EHR to another found that the available evidence was heterogeneous and largely descriptive. The authors characterized EHR-to-EHR transitions as major organizational changes and found that reported outcomes varied rather than pointing to one universally predictable result.

A separate review of EHR transitions identified challenges involving areas such as financial burden, personnel, legacy-record access, data migration, cybersecurity, interoperability, workflow, training and support, and clinician burnout.

This does not mean an organization should avoid replacement. It means that the transition itself belongs in the comparison.

The Effects of a Transition May Take Time to Settle

Research also illustrates why transition effects should be considered over time rather than judged only at go-live.

In a 2020 study involving six Mayo Clinic sites transitioning to a new EHR, patient satisfaction with access to care declined after the transition. The reported absolute declines ranged from 3.4 to 8.8 percentage points, depending on the measure, with satisfaction returning to pre-transition levels approximately 9 to 15 months later.

That study does not establish that every EHR replacement will produce the same result. It does demonstrate something important for decision makers: even when a replacement is ultimately worthwhile, the path from the current environment to the desired future state can have measurable consequences.

A responsible comparison therefore asks not only:

“Which EHR do we want?”

but also:

“What will it take to get from here to there, and what should we expect along the way?”

The EHR Replacement Evidence Test

Before deciding to replace an EHR, a decision team can work through seven questions:

PROBLEM → CAUSE → IMPROVE → REPLACE → TRANSITION → COMPARE → RECONSIDER

The purpose is not to make replacement harder—or easier. It is to make the reasoning behind the decision visible and testable.

1. PROBLEM — What exactly are we trying to fix?

Describe the problem specifically enough that evidence can be collected. “Physicians hate the EHR” tells us that something is wrong, but not necessarily what is wrong.

Where does the difficulty occur? Who experiences it? How often? What are the consequences? Can someone walk the decision team through a real example from beginning to end?

A well-defined problem gives the organization something concrete against which possible solutions can be evaluated.

2. CAUSE — Why is the problem happening?

Before deciding that the EHR itself must be replaced, determine what is actually producing the problem.

A difficult workflow, for example, might involve the software itself, configuration, interfaces, data quality, training, staffing, local processes, or several factors working together.

This is where a simple question can be surprisingly powerful:

“Can you walk me through what happens from the beginning to the first sign of difficulty?”

Following the problem through the actual workflow can reveal where the difficulty begins—and can keep the organization from solving the wrong problem.

Identifying the cause does not mean defending the current EHR. If the platform itself is the limiting factor, that is important evidence for replacement. If the cause lies elsewhere, replacing the EHR without addressing it may simply carry the problem into a new system.

3. IMPROVE — What would it take to improve the current environment?

Before concluding that replacement is necessary, establish what realistic improvement of the current environment would require.

That may include configuration changes, workflow redesign, interface improvements, training, technical remediation, or other changes. The relevant question is not whether someone can imagine an improvement, but whether a credible improvement can actually be demonstrated.

If the current vendor proposes a solution, ask for specifics:

What would change? What problem would it address? What would it cost? How long would it take? How would we know whether it worked?

Where practical, consider whether a proposed improvement can be tested on a limited scale before making a larger commitment.

The incumbent vendor has an economic interest in retaining the organization as a customer. That does not make its recommendations wrong. It makes them worth verifying—just as the claims of a competing vendor should be verified.

4. REPLACE — What evidence shows that the proposed replacement will solve the problem?

A replacement should be evaluated against the problems the organization has actually identified—not merely against a general feature list.

If a proposed EHR is expected to improve a difficult clinical workflow, ask the vendor to demonstrate that workflow under realistic conditions. Where possible, involve the people who actually perform the work.

Ask:

What specifically would be better? Can we see it demonstrated? Have comparable organizations experienced the improvement? Can we speak with people who actually use it?

References from other organizations can be valuable, but their circumstances may differ. Consider their workflows, configuration, organizational structure, implementation experience, and the path they took to reach their present state.

The evaluation should also look beyond the problems that prompted the search. Solving one important problem does not necessarily produce a better overall environment. What new limitations, risks, costs, dependencies, or difficulties might accompany the proposed solution?

Consider areas such as reliability, usability, performance, clinical workflow, interoperability, security, staffing, training, financial impact, and vendor dependence according to their importance to the organization.

The goal is to move from:

“The new EHR can solve this problem.”

to:

“We have credible evidence that the proposed EHR can address the problems that matter without creating disadvantages that outweigh the benefits.”

5. TRANSITION — What will it take to get from here to there?

The comparison should include the journey to the proposed future state, not just the future state itself.

An EHR replacement can require data migration, interfaces, workflow redesign, testing, training, staffing, downtime planning, legacy-system access, security work, cutover preparation, productivity recovery, and substantial financial investment.

Ask:

What must happen before go-live? What could go wrong during the transition? What will temporarily become harder? How long might disruption last? What information or capability could be lost or degraded? What resources will be required?

Also consider what happens after go-live. A successful implementation does not necessarily mean that the organization has immediately reached its desired operating state. Optimization, additional training, workflow changes, interface work, and other adjustments may continue afterward.

The relevant comparison is therefore not simply:

Current EHR vs. new EHR

but:

Improving and operating the current environment vs. transitioning to and operating the proposed replacement.

6. COMPARE — Which alternative is better supported by the evidence?

Now bring the evidence together.

The organization is not choosing between a flawed current system and a perfect replacement. Each credible alternative has benefits, costs, limitations, risks, uncertainties, and consequences.

Compare the alternatives against the problems the organization is actually trying to solve and the outcomes that matter most.

Ask:

Which problems would each alternative solve? Which would remain? What new problems might each create? What would each cost—in money, time, disruption, staffing, risk, and organizational attention? What evidence supports those conclusions?

Not every consideration deserves equal weight. A minor inconvenience should not automatically offset a significant patient-safety concern, and a long feature list should not obscure a small number of issues that could materially affect the organization.

Where the evidence remains uncertain, record the uncertainty rather than converting an unknown into an assumption simply because a decision is approaching.

The objective is not to make every alternative look equally good. It is to make the reasons for the eventual choice clear enough to examine, challenge, and defend.

7. RECONSIDER — What evidence would cause us to change our minds?

Before the decision becomes difficult to reverse, ask a question that can be uncomfortable but extremely valuable:

What evidence would cause us to reconsider our preferred alternative?

Ask it of everyone.

Those favoring replacement should be able to identify evidence that would make improving the current environment worth reconsidering. Those favoring the current EHR should be able to identify evidence that would make replacement the stronger choice.

This can help separate a conclusion from a commitment to defend that conclusion.

Strong preferences are not necessarily evidence of bias or improper influence. They may reflect years of experience and legitimate concerns. But a sound decision process should still leave room for important evidence to change the conclusion.

This question can also make disagreement safer. Instead of requiring one person to challenge a powerful advocate directly, the decision process itself asks everyone to identify what could change their position.

The purpose is not indecision. It is to make sure the organization remains capable of learning until the point at which a responsible decision must be made.

Go Deeper Where Being Wrong Would Matter Most

Not every question in an EHR decision deserves the same amount of investigation.

Some issues may be answered quickly. Others may involve patient safety, clinical operations, security, interoperability, substantial financial commitments, organizational dependence, or consequences that would be difficult to reverse.

Those are places to slow down.

The goal is not to investigate everything endlessly. It is to match the depth of investigation to the consequence of being wrong.

A useful decision process therefore asks not only:

“Do we have an answer?”

but also:

“Is the evidence behind this answer strong enough for the consequences of being wrong?”

A Better Decision Is More Than a Better Product Comparison

The question at the beginning of this article is Question 2 in my workbook, Before You Choose an EHR — 50 Questions for a Better EHR Decision.

The workbook is not intended to tell an organization which EHR to buy—or whether it should replace its current system at all. It is designed to help decision teams identify important questions, follow answers where they lead, investigate uncertainty, compare credible alternatives, and preserve the reasoning behind consequential decisions.

The desired outcome might be replacement. It might be improvement of the current environment. It might be a different alternative that was not obvious at the beginning.

And sometimes the responsible conclusion is:

We don’t know yet. We need to find out.

That is not necessarily a failure of the decision process. Sometimes discovering what the organization does not yet know is one of its most valuable results.

Start with Three Questions

If your organization is considering an EHR decision, I have made three complete questions from the workbook available as a complimentary guide.

They address three very different areas of decision readiness:

• whether replacing the current EHR is better than improving it;
• ransomware and cyber-recovery readiness; and
• costs that may change after an organization becomes dependent on a vendor.

The guide is intended to be useful on its own. Use it with your team. Share it with colleagues. If it helps your organization ask better questions before an EHR decision, it has done something worthwhile.

For organizations that want to work through the broader decision, the complete workbook contains 50 questions across nine decision areas.

Before You Choose an EHR — 50 Questions for a Better EHR Decision

Complete First Edition — $59

Selected Research

Miake-Lye IM, Cogan AM, Mak S, et al. “Transitioning from One Electronic Health Record to Another: A Systematic Review.” Journal of General Internal Medicine. 2023;38(Suppl 4):956–964.

Huang C, Koppel R, McGreevey JD III. “Transitions from One Electronic Health Record to Another: Challenges, Pitfalls, and Recommendations.” Applied Clinical Informatics. 2020;11(5):742–754.

North F, Pecina JL, Tulledge-Scheitel SM, et al. “Is a switch to a different electronic health record associated with a change in patient satisfaction?” Journal of the American Medical Informatics Association. 2020;27(6):867–876.

Research and editorial assistance provided using AI tools. Conclusions and editorial responsibility remain with the author.