Customization vs. Standardization: Finding the Right Balance in Your EHR

Every healthcare organization implementing or optimizing an EHR system faces the same fundamental tension: Should we customize the system to match how our clinicians work, or should we standardize workflows to match how the system works?

It's one of the most contentious debates in healthcare IT. And the answer isn't as simple as choosing one approach over the other.

The Customization Appeal

The case for customization seems obvious. Clinicians have spent years developing workflows that work for their specialty, their patient population, and their practice style. When an EHR system doesn't support those workflows, frustration follows immediately.

A cardiologist wants specific order sets for different types of chest pain presentations. An emergency department needs triage documentation templates that match their acuity-based workflow. A surgical practice requires operative note templates with specialty-specific fields.

When customization works well:

Thoughtful customization can dramatically improve clinical efficiency and user satisfaction. Specialty-specific order sets reduce clicks and prevent errors. Documentation templates that match clinical workflows save time and improve note quality. Custom preference lists put commonly prescribed medications at clinicians' fingertips.

These customizations make sense because they align the EHR with evidence-based clinical practice while respecting the realities of different specialties and care settings.

The Hidden Costs of Excessive Customization

Here's what the sales demonstrations don't tell you: every customization comes with a price tag that extends far beyond the initial implementation cost.

Upgrade Complications:

When EHR vendors release new versions with enhanced features and security patches, heavily customized systems face significant challenges. Custom workflows may break during upgrades. Custom reports may need complete rebuilding. Custom interfaces with other systems may require expensive reconfiguration.

Healthcare organizations with extensive customizations often delay critical upgrades for months or years because the effort to validate and update customizations is overwhelming. This leaves them running outdated software with known vulnerabilities and missing important functionality improvements.

Training Complexity:

Every customization creates variation that staff must learn and remember. A nurse floating between units encounters different documentation workflows in each location. A physician covering multiple clinics finds different order sets and preference lists in each setting.

This variation multiplies training costs, extends onboarding timelines, and increases the likelihood of errors when staff work in unfamiliar areas.

Reduced Vendor Support:

EHR vendors provide robust support for standard configurations because they've tested them extensively across hundreds of organizations. Custom configurations receive limited support because vendors can't anticipate every possible variation.

When issues arise in customized areas, troubleshooting becomes more complex and time-consuming. Vendors may require organizations to replicate problems in standard configurations before providing support, adding delays.

Maintenance Burden:

Customizations require ongoing maintenance as clinical practices evolve, regulatory requirements change, and staff turnover occurs. Someone must understand why each customization exists, validate that it still serves its intended purpose, and update it as needed.

Many healthcare organizations discover years after implementation that nobody remembers why certain configurations exist or whether they're still necessary, but everyone is afraid to change them.

The Standardization Advantage

Standardized EHR configurations offer compelling benefits that customization advocates often overlook.

Easier Upgrades: Organizations using standard configurations can implement vendor upgrades more quickly and confidently. Standard workflows have been tested across many healthcare organizations, reducing the risk of unexpected issues.

Streamlined Training: Staff trained on standard configurations can more easily transfer knowledge between organizations. New hires with EHR experience can become productive more quickly.

Better Vendor Support: When issues arise in standard configurations, vendors can provide faster, more reliable support. They've seen similar problems before and know how to resolve them.

Leveraging Best Practices: Standard EHR configurations often reflect best practices learned across hundreds of healthcare organizations. Vendor-developed order sets incorporate evidence-based guidelines.

Finding the Right Balance

The goal isn't choosing between customization and standardization. It's determining which elements deserve customization and which benefit from standardization.

Customize for Clinical Necessity:

Some customization genuinely improves patient care and safety. Specialty-specific order sets that align with evidence-based guidelines make sense. Documentation templates that capture information required for appropriate care in different clinical settings are justified.

The key question: Does this customization directly improve patient care or safety in ways that standard configuration cannot?

Standardize for Efficiency:

Other areas benefit from standardization even when clinicians initially resist. Common medication lists, laboratory order catalogs, and basic documentation structures should be consistent across the organization. Standard clinical decision support alerts prevent alert fatigue from inconsistent configurations.

The key question: Will standardization create better outcomes through consistency, even if it requires some workflow adaptation?

Establish Clear Governance:

Successful organizations create governance processes for evaluating customization requests. These processes include clinical representation, IT expertise, and consideration of long-term implications.

Governance teams ask critical questions: What problem does this customization solve? Can we achieve the same goal through configuration of standard features? What are the ongoing maintenance requirements? How does this impact staff working across multiple areas?

Not every customization request gets approved, but clinicians appreciate transparent processes where their input is heard and decisions are explained clearly.

The Path Forward

The customization versus standardization debate will never be fully resolved because the right answer varies by organization, specialty, and specific use case.

What matters is approaching these decisions thoughtfully rather than defaulting to either extreme. Organizations that customize everything create unsustainable maintenance burdens. Organizations that refuse all customization frustrate clinicians and compromise efficiency.

The most successful healthcare organizations find the middle ground. They customize strategically where clinical benefit is clear. They standardize thoughtfully where consistency adds value. And they continuously evaluate whether customizations implemented years ago still serve their intended purpose.

Your EHR should support excellent patient care. Sometimes that requires customization. Sometimes that requires standardization. The key is knowing the difference.

References:

1. Bloomrosen M, Starren J, Lorenzi NM, et al. "Anticipating and addressing the unintended consequences of health IT and policy: a report from the AMIA 2009 Health Policy Meeting." Journal of the American Medical Informatics Association. 2011;18(1):82-90.

2. Hripcsak G, Vawdrey DK, Fred MR, Bostwick SB. "Use of electronic clinical documentation: time spent and team interactions." Journal of the American Medical Informatics Association. 2011;18(2):112-117.

3. HIMSS. "EHR Optimization: Best Practices and Lessons Learned."