Electronic Medical Records System Implementation at Stanford Hospital and Clinics Net Present Value (NPV) / MBA Resources

Introduction to Net Present Value (NPV) - What is Net Present Value (NPV) ? How it impacts financial decisions regarding project management?

NPV solution for Electronic Medical Records System Implementation at Stanford Hospital and Clinics case study

At Oak Spring University, we provide corporate level professional Net Present Value (NPV) case study solution. Electronic Medical Records System Implementation at Stanford Hospital and Clinics case study is a Harvard Business School (HBR) case study written by Haim Mendelson, Stefanos Zenios, Lyn Denend. The Electronic Medical Records System Implementation at Stanford Hospital and Clinics (referred as “Emr Shc” from here on) case study provides evaluation & decision scenario in field of Technology & Operations. It also touches upon business topics such as - Value proposition, IT, Operations management, Strategic planning.

The net present value (NPV) of an investment proposal is the present value of the proposal’s net cash flows less the proposal’s initial cash outflow. If a project’s NPV is greater than or equal to zero, the project should be accepted.

NPV = Present Value of Future Cash Flows LESS Project’s Initial Investment

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Case Description of Electronic Medical Records System Implementation at Stanford Hospital and Clinics Case Study

In 2005, Stanford Hospital and Clinics (SHC) was internationally recognized as a leading medical institution in terms of its clinical capabilities and specialty expertise. However, the organization was lagging many of its competitors in terms of its operations and information technology (IT). While other major health care providers of a similar caliber had begun to transition to integrated electronic medical records (EMR) systems, SHC was using a patchwork of disjointed and outdated software programs to manage inpatient and outpatient care, as well as its back office functions. Dr. Kevin Tabb, who was the chief quality and medical information officer at the time, along with other executives within the organization, recognized the importance of adopting an EMR system. Yet the implementation of such a system would require a sizable investment over multiple years and would necessitate a major organizational disruption. In parallel with building a business case to justify the cost of the new system (see OIT-101A), Tabb and his colleagues had to think carefully about the implementation strategy that would lead to the successful adoption of the EMR system. This case explains EMR systems, describes SHC's vendor selection process, introduces Epic System Corporation's EMR offering, and explores the key issues that SHC considered in developing its implementation strategy, including the appropriate rollout approach and timing, how to manage system configuration and customization, and how to most effectively staff the project.

Case Authors : Haim Mendelson, Stefanos Zenios, Lyn Denend

Topic : Technology & Operations

Related Areas : IT, Operations management, Strategic planning

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Calculating Net Present Value (NPV) at 6% for Electronic Medical Records System Implementation at Stanford Hospital and Clinics Case Study

Years	Cash Flow	Net Cash Flow	Cumulative     Cash Flow	Discount Rate @ 6 %	Discounted Cash Flows
Year 0	(10026436)	-10026436	-	-
Year 1	3468706	-6557730	3468706	0.9434	3272364
Year 2	3965466	-2592264	7434172	0.89	3529251
Year 3	3945095	1352831	11379267	0.8396	3312378
Year 4	3243247	4596078	14622514	0.7921	2568955
TOTAL			14622514		12682948

The Net Present Value at 6% discount rate is 2656512

In isolation the NPV number doesn't mean much but put in right context then it is one of the best method to evaluate project returns. In this article we will cover -

Different methods of capital budgeting

What is NPV & Formula of NPV,
How it is calculated,
How to use NPV number for project evaluation, and
Scenario Planning given risks and management priorities.

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Capital Budgeting Approaches

Methods of Capital Budgeting

There are four types of capital budgeting techniques that are widely used in the corporate world –

1. Net Present Value
2. Internal Rate of Return
3. Profitability Index
4. Payback Period

Apart from the Payback period method which is an additive method, rest of the methods are based on Discounted Cash Flow technique. Even though cash flow can be calculated based on the nature of the project, for the simplicity of the article we are assuming that all the expected cash flows are realized at the end of the year.

Discounted Cash Flow approaches provide a more objective basis for evaluating and selecting investment projects. They take into consideration both –

1. Magnitude of both incoming and outgoing cash flows – Projects can be capital intensive, time intensive, or both. Emr Shc shareholders have preference for diversified projects investment rather than prospective high income from a single capital intensive project.
2. Timing of the expected cash flows – stockholders of Emr Shc have higher preference for cash returns over 4-5 years rather than 10-15 years given the nature of the volatility in the industry.

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Formula and Steps to Calculate Net Present Value (NPV) of Electronic Medical Records System Implementation at Stanford Hospital and Clinics

NPV = Net Cash In Flowt1 / (1+r)t1 + Net Cash In Flowt2 / (1+r)t2 + … Net Cash In Flowtn / (1+r)tn
Less Net Cash Out Flowt0 / (1+r)t0

Where t = time period, in this case year 1, year 2 and so on.
r = discount rate or return that could be earned using other safe proposition such as fixed deposit or treasury bond rate. Net Cash In Flow – What the firm will get each year.
Net Cash Out Flow – What the firm needs to invest initially in the project.

Step 1 – Understand the nature of the project and calculate cash flow for each year.
Step 2 – Discount those cash flow based on the discount rate.
Step 3 – Add all the discounted cash flow.
Step 4 – Selection of the project

Why Technology & Operations Managers need to know Financial Tools such as Net Present Value (NPV)?

In our daily workplace we often come across people and colleagues who are just focused on their core competency and targets they have to deliver. For example marketing managers at Emr Shc often design programs whose objective is to drive brand awareness and customer reach. But how that 30 point increase in brand awareness or 10 point increase in customer touch points will result into shareholders’ value is not specified.

To overcome such scenarios managers at Emr Shc needs to not only know the financial aspect of project management but also needs to have tools to integrate them into part of the project development and monitoring plan.

Calculating Net Present Value (NPV) at 15%

After working through various assumptions we reached a conclusion that risk is far higher than 6%. In a reasonably stable industry with weak competition - 15% discount rate can be a good benchmark.

Years	Cash Flow	Net Cash Flow	Cumulative     Cash Flow	Discount Rate @ 15 %	Discounted Cash Flows
Year 0	(10026436)	-10026436	-	-
Year 1	3468706	-6557730	3468706	0.8696	3016266
Year 2	3965466	-2592264	7434172	0.7561	2998462
Year 3	3945095	1352831	11379267	0.6575	2593964
Year 4	3243247	4596078	14622514	0.5718	1854337
TOTAL					10463029

The Net NPV after 4 years is 436593

(10463029 - 10026436 )

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Calculating Net Present Value (NPV) at 20%

If the risk component is high in the industry then we should go for a higher hurdle rate / discount rate of 20%.

Years	Cash Flow	Net Cash Flow	Cumulative     Cash Flow	Discount Rate @ 20 %	Discounted Cash Flows
Year 0	(10026436)	-10026436	-	-
Year 1	3468706	-6557730	3468706	0.8333	2890588
Year 2	3965466	-2592264	7434172	0.6944	2753796
Year 3	3945095	1352831	11379267	0.5787	2283041
Year 4	3243247	4596078	14622514	0.4823	1564066
TOTAL					9491491

The Net NPV after 4 years is -534945

At 20% discount rate the NPV is negative (9491491 - 10026436 ) so ideally we can't select the project if macro and micro factors don't allow financial managers of Emr Shc to discount cash flow at lower discount rates such as 15%.

Acceptance Criteria of a Project based on NPV

Simplest Approach – If the investment project of Emr Shc has a NPV value higher than Zero then finance managers at Emr Shc can ACCEPT the project, otherwise they can reject the project. This means that project will deliver higher returns over the period of time than any alternate investment strategy.

In theory if the required rate of return or discount rate is chosen correctly by finance managers at Emr Shc, then the stock price of the Emr Shc should change by same amount of the NPV. In real world we know that share price also reflects various other factors that can be related to both macro and micro environment.

In the same vein – accepting the project with zero NPV should result in stagnant share price. Finance managers use discount rates as a measure of risk components in the project execution process.

Sensitivity Analysis

Project selection is often a far more complex decision than just choosing it based on the NPV number. Finance managers at Emr Shc should conduct a sensitivity analysis to better understand not only the inherent risk of the projects but also how those risks can be either factored in or mitigated during the project execution. Sensitivity analysis helps in –

What will be a multi year spillover effect of various taxation regulations.

Understanding of risks involved in the project.

What are the uncertainties surrounding the project Initial Cash Outlay (ICO’s). ICO’s often have several different components such as land, machinery, building, and other equipment.

What are the key aspects of the projects that need to be monitored, refined, and retuned for continuous delivery of projected cash flows.

What can impact the cash flow of the project.

Some of the assumptions while using the Discounted Cash Flow Methods –

Projects are assumed to be Mutually Exclusive – This is seldom the came in modern day giant organizations where projects are often inter-related and rejecting a project solely based on NPV can result in sunk cost from a related project.

Independent projects have independent cash flows – As explained in the marketing project – though the project may look independent but in reality it is not as the brand awareness project can be closely associated with the spending on sales promotions and product specific advertising.

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Negotiation Strategy of Electronic Medical Records System Implementation at Stanford Hospital and Clinics

References & Further Readings

Haim Mendelson, Stefanos Zenios, Lyn Denend (2018), "Electronic Medical Records System Implementation at Stanford Hospital and Clinics Harvard Business Review Case Study. Published by HBR Publications.