Every Year the Replacement Waits, the New Work Waits With It.

The finance committee is looking at a paper titled “Revised estimate”. It is the third paper with that title.

The first figure was approved eighteen months ago, on a list of modules and a demonstration. Since then the old system has been opened, and each opening found more.

The same week, the digital team’s plan for connected patient records and faster insurer claims is put back again. Both need the old system to change, and the old system is waiting for its replacement.

What We Found

We looked at two things: how replacement estimates behave in the public record, and what India’s digital-health programme and insurance regulator now ask of hospital and insurer systems.

The first figure is rarely the last. In one national government health record replacement in the United States, built on a packaged product, the original contract ceiling has since been raised to well over twice its first figure. Separately, the department now estimates tens of billions of dollars in total to complete deployment into the 2030s, including the cost of keeping the system running (press reporting, 2026). The programme is far beyond anything our readers run. It is simply the clearest public record we found of how far such a figure can travel.

Old systems are larger than any brief. One US healthcare organisation’s old administration system, described in a vendor’s case study, was built on thousands of old terminal screens, many unchanged for decades. An earlier, conventional modernisation effort had converted only a small share of its applications. We do not work in COBOL. We cite it for the scale: nobody holds thousands of screens in mind when a first estimate is made.

India’s digital-health programme now asks for connected records. On 17 July 2026 the National Medical Commission directed medical colleges to implement an “Ayushman Bharat Digital Mission (ABDM)-compliant Health Management Information System (HMIS)” in their hospitals. It published lists of non-compliant medical colleges, including colleges “still not using ABDM-enabled HMIS software”, and warned that its rating board “may initiate further action as per norms”.

There is also a reward for connected records. Under the Digital Health Incentive Scheme, hospitals “earn cash incentives for creating interoperable digital health records”. By 18 June 2026 the scheme had paid hospitals more than 107 crore rupees.

Insurers now work to the hour. The insurance regulator’s circular of May 2024 requires insurers to “decide on cashless authorisation requests within one hour” and to give final authorisation on discharge “within three hours of request from the hospital”.

What Waits While the Replacement Is Put Off

A deferred replacement is usually counted as money saved. The question that decides the matter is different: what can the hospital not do while the old system stays as it is?

Connected records. A record system that meets the national standard has to exchange records with the national network. An old system nobody wants to change, because its replacement is “next year”, is a hard place to start.

The incentive. A hospital whose system cannot create interoperable records cannot earn the incentive for creating them.

Faster claims. The insurer’s one-hour and three-hour clocks start with the hospital’s request, and the hospital’s billing system sits behind every request.

This is our reading of the evidence. It is not a measured market figure, and we do not put a rupee value on it here. That figure has to come from your own organisation.

Four Ways to Answer a Replacement That Keeps Waiting, Weighed

Option	When it fits	What it risks
Defer another year and keep paying to run the old system	A merger or a firm replacement date will settle the question soon	The new work waits, and the estimate does not get better
Approve the whole replacement at once, on one estimate	The system is small, well documented and standard	The whole sum is committed on the least information, and each discovery returns as a revised estimate
Wrap the old system: build the new connections around it and leave its core alone	The core is sound and only one connection is needed	The new work rests on a core that still ages, and each new piece depends on it
Read the system first, then replace it in stages, starting with the modules the new work needs	The system is old, built for the hospital, and changed for years	You pay for the assessment before you know whether you will go ahead, and the figure may be higher than the first estimate

Where You Are Now, and Where You Should Be

Before the next estimate goes to the committee, we would set a benchmark for the decision itself.

Measure	Typical starting point	Where it should be	How it is checked
Functions written down before pricing	None; the brief is written from memory	Every function in scope has its own numbered line before any price is set	The specification
The basis for the estimate	A list of modules and a demonstration	A written specification and a risk register, with a price for each stage	The staged plan and quote
The cost of staying	Not written down	Set beside the cost of replacing, in one document	The cost comparison
The new work waiting on the old system	Not linked to any part of it	Each planned piece listed against the module it needs	The staged plan
The size of one commitment	The whole replacement, or nothing	One stage, with the freedom to pause after any accepted module	The staged plan and quote
Share of the old system still running	All of it, until one go-live day	Falling module by module	Reported at every review

The starting points above are what we expect to find. In an engagement they are replaced by your own position, taken in the first review. The targets are what we would work towards with you. They are not results we have already achieved for a healthcare organisation.

How We Work With You

1. We listen: a free Reliability Review. A first conversation about the old system, the estimate that keeps being revised, and the work that is waiting on it. You leave with a short written note of what we found. You can start with a conversation about the system; we ask for read-only code access only when the assessment begins.
2. We research. We research your sector, the regulator’s position and what the public record says about firms in your situation. This article is an example of that work.
3. We read the system and propose: the Legacy System Specification Assessment. It produces a written specification of what the system does, a risk register, a cost comparison between keeping and replacing the system, and a staged plan with a fixed quote. AI does a first pass, our senior engineers review it and trace it to the code, and your own experts confirm it. Code access is read-only and logged, never used for training, and deleted within 30 days of the evaluation ending unless we engage. You get the options and our recommendation.
4. If you approve, we build. We replace a system one module at a time while the old one keeps running. We never do a single cutover. The work is billed by milestone, each milestone tied to a module you accept, and you can pause after any accepted module. Where a module touches clinical work, accepting it is your clinicians’ decision.
5. We review against the benchmark. Before work starts we set the benchmark. After each module we show you where each measure stands, and the filled-in benchmark is yours at the end.

The Review is free. Every paid step is fixed price, agreed at scoping. Stop after any step. The findings are yours. The assessment fee is credited in full against the first build stage if it starts within 90 days of the report.

What you need to bring: a budget for the assessment, approved separately from the replacement; read-only access to the code once the assessment begins; and planned hours from the people who use the system every day, clinicians included.

Meeting the Commission’s direction, or any other rule, is your organisation’s own work; we do not offer a compliance service.

What changes for the business:

Role	What they gain
CEO	A figure the board approves with a basis behind it, and a decision made one stage at a time.
CTO or CIO	An estimate built from what is in the system. Nobody has to own a guess.
CFO	A price for each stage and payment for accepted work, in place of an estimate that keeps growing.
COO	Training and running old and new side by side stay in the plan, because no overrun is squeezing them out.
Medical head	The time clinicians must give to the project is known in advance and planned, not taken at short notice.

The cases in this article, and what IOanyT does about that kind of problem:

The case	What IOanyT does
A US national government health record programme raised its contract ceiling to well over twice its first figure, and its department now estimates tens of billions of dollars in total, with deployment running into the 2030s (press reporting, 2026).	Our part is far narrower than this case. That programme put in a packaged health record product, which we do not implement. For applications an organisation built or had built, we assess before we price, list the unknowns in a risk register, and price each stage on its own.
The National Medical Commission published lists of medical colleges not compliant with its direction on connected records.	Our assessment shows which part of the old system stands in the way and what replacing it would take. Meeting the direction is the college’s own work.

IOanyT is a consultancy with its own engineering team: we study the problem, recommend, and prove it by building only what you approve. We price a replacement after we have read the system, so the first figure has a basis and every stage brings something.

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