In the world of health IT, “build sprawl” refers to the unchecked growth of custom electronic health record (EHR) build — order sets, flowsheets, procedures, visit types and blocks, note templates, dashboards, and countless other elements — that accumulate over time across departments, facilities, and care settings. Each new build is often created with the best intentions: to meet a specific clinical or business need, accommodate provider preferences, or solve a short-term workflow challenge.
But over time, these customizations can spiral out of control, resulting in a bloated system that’s harder to manage, more prone to errors, and less responsive to change. The costs of build sprawl aren’t just technical, they’re clinical, financial, and operational. It impacts the experiences of both end users and patients, leading to overall dissatisfaction. Every unnecessary template or outdated workflow requires maintenance, testing, and training, diverting resources that could be better spent on innovation or patient care. When multiplied across an entire health system, those inefficiencies translate into real dollars and diminished productivity, as well as decreased patient happiness and poorer outcomes.
Tackling build sprawl isn’t just about taking one big step, however. It’s about combining strategic moves with smaller, achievable wins. Returning to Foundation is a crucial part of the puzzle, helping set the system up for long-term growth and innovation. But it’s equally important to recognize the other levers that can be pulled: smaller actions that deliver quick, meaningful results along the way.
Maintenance doesn’t discriminate
Every build record in your EHR — regardless of whether it's used daily or never at all — contributes to your maintenance burden. During routine upgrades or optimization cycles, active and legacy configurations should be tested to ensure functionality and compatibility.
That orphaned order set from a pilot program three years ago? The visit types you no longer use? Those charge review rules that were added despite the similar ones that were in place from trying to tackle the same problem a year ago? Active records all still need regression testing during every system upgrade.
Multiply this by hundreds (if not thousands) of discrete build records, and the technical debt becomes immense. IT and clinical informatics teams spend countless hours vetting workflows and content that no one is actually using, just to avoid unintended breakage.
Periodic review becomes a herculean task
Every organization has the best intentions to follow naming and numbering conventions so it’s easy to find the right record. But over time, and depending on the discipline of the teams involved, that consistency drifts. The more records you have, and the less conventions are followed, the harder it becomes to find what you need.
Governance adds another layer: key EHR components like order sets, flowsheets, and documentation templates must be periodically reviewed for relevance, clinical appropriateness, and evidence alignment.
Even if a build isn’t being used but is active, it must still be reviewed, updated, and approved. Why? Because as long as it exists in production, someone could use it.
This due diligence isn’t optional; it’s a necessary safeguard against clinical variation and risk exposure. But the administrative overhead can be staggering, draining resources from more impactful quality and safety initiatives.
Inconsistent build = inconsistent care delivery
As organizations grow and expand due to mergers, acquisitions, and physical expansion, so too does build variation. When builds vary widely across locations — say, one hospital uses different admission order sets than another, or surgical documentation templates differ by department — clinicians who move between sites must adapt to different workflows, tools, and terminologies.
This inconsistency introduces:
- Operational friction: Clinicians waste time hunting for the right tools.
- Training burden: New staff require location-specific onboarding.
- Safety risk: Cognitive load increases, and standardization breaks down.
- Access issues: Sprawling scheduling build can make it more difficult for patients to get the care they need when they need it, leading to delays, frustration, and potential loss of patient loyalty.
- Revenue impact: Build sprawl in charging and claims workflows can delay revenue by creating duplicate or outdated rules, inconsistent edits, and one-off configurations that hold charges in workqueues or block claims from dropping. When each site uses its own version of triggers or billing rules, distinguishing real errors from build noise becomes difficult — and revenue gets held up simply due to lack of standardization.
- Support efficiency: The larger your build sprawl, the more specialized your IT team is likely to become on particular content areas. A support ticket might need to wait for the one analyst that knows the unique content or workflow of an operational area to address an issue. Not only is this a nuisance but can erode the relationship and confidence between IT and operations.
For example, it may have made sense during implementation to have separate libraries of Beacon protocols for different physical locations. But if you want to grow that service line, there are two choices: expand the use of inconsistent build or take on the difficult task of consolidating your libraries in a live environment before growing operations.
EHRs should enable consistent, high-quality care, not reinforce silos within your organization.
Data and analytics (D&A) suffer from build fragmentation
One of the most unintended consequences of build sprawl is its impact on data and analytics. We’ve seen this firsthand when trying to retrofit new analytics tools on a sprawled build. Healthcare organizations going through mergers or acquisitions also face this challenge. When clinical teams across the enterprise use different tools to document and order care, generating clean, comparable data becomes difficult.
For example, hospital A may use a custom “CHF Admission” order set while hospital B relies on free-text orders. Some providers document wounds using a structured flowsheet, others use narrative notes. Having an apples-to-apples conversation on operational metrics becomes nearly impossible when the underlying build, workflows, and supporting analytics are vastly different.
The result? Your data lake is full, but your insights are shallow.
Analytics teams spend disproportionate time normalizing and reconciling fragmented data before meaningful, enterprise-wide insights can emerge. Clinical variation gets masked in noise, quality improvement stalls, predictive models underperform, and value-based care metrics suffer — ultimately impacting both innovation and patient care.
Straightening out the sprawl
How can a healthcare system avoid EHR build sprawl and mitigate its costs? It starts with investing in strong build governance, operational buy-in, standardization strategies, and ongoing optimization processes that favor intentional design over unregulated customization.
Without clear governance, EHR environments can quickly become cluttered with redundant templates, inconsistent workflows, and one-off customizations, making maintenance costly and data unreliable. A thoughtful governance framework ensures that every change, no matter how small, aligns with organizational priorities, clinical best practices, and compliance standards.
Standardization brings order and predictability to complexity. When workflows, templates, and protocols follow consistent patterns across departments, clinicians spend less time navigating variation and more time focusing on patient care. It also simplifies system updates, reporting, and interoperability.
Finally, optimization should be an ongoing discipline, not a one-time project. Regularly reviewing system performance and end-user feedback allows organizations to refine what’s working and retire what’s not. This intentional, continuous improvement ensures the EHR remains a strategic asset, supporting care delivery rather than complicating it.
Undergoing a build sprawl reduction initiative can feel like an incredibly unwieldy task. Few organizations can really pause the critical projects and daily work to throw all their resources at getting back to standard consistent build (and we wouldn’t recommend it!). Increasingly, organizations are exploring the use of AI-enabled tools to help assess build sprawl, fragmentation, and duplication across the system, but these tools need to be applied thoughtfully and with strong domain context. Finding a partner who understands your specific nuance, can give you direction on which consolidation work will provide the most benefit, and can guide you on a roadmap for success can turn a “boiling the ocean” task into a more manageable project.
The bottom line
EHR build sprawl is more than a technical debt problem; it’s an operational, clinical, and financial liability. Each redundant or unused build element creates ripple effects across maintenance, governance, operations, and analytics, impacting revenue, patient care, patient experience and access, and long-term growth.
Organizations should invest in strong build governance, standardization strategies, and ongoing optimization processes that favor intentional design over unregulated customization. Every new build decision should be guided by one simple question:
“Is this adding value, or just adding work?”
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