How to Meaningfully Shop for an EHR

So you’ve been hearing all about the recent EHR buzz and decided to give it a try. Whether you are convinced that electronic records are the way to go, or you have reached a point where you are willing to give it a try, the first thing to do is buy one of those EHRs. You may be staring at a glossy brochure or website featuring a distinguished silver-haired doctor holding a cool little tablet computer andย  smiling reassuringly at the little old lady sitting comfortably in front of him, with a large 1-800 number on the bottom urging you to call now. Don’t.

Shopping for an EHR may be more complicated, but is not much different in nature than shopping for a car or a new type of breakfast cereal. Of course, you have been shopping for cereal since you were a toddler and probably bought your first car as a teenager, so the entire shopping process is almost second nature. Not so with an EHR. Just like cars and cereal boxes, there are hundreds of EHR products out there, and just like cars and cereals, you need not bother with most, and after you narrow the field down to three or four, it makes little difference which one you end up taking home. The qualitative road map below will lead you to those three or four obvious choices of EHRs best suited to your particular situation.ย  The final choice is yours to make.

The first thing you need to do is to honestly list why you want to invest in an EHR. Listing goals has two purposes, one is to help guide your selection and the other is to retrospectively assess your success or lack thereof. The more specific and measurable your goals are, the better they will serve you. Let’s look at some examples.

  • I want to receive the $44,000 stimulus money from CMS: This is a very precise goal and can be easily measured over the next 5 years. This goal also exemplifies the need to have enough information before you set a goal. You need to know that the amount of incentives is not fixed. Instead it depends on your patient mix, your charges, your ability to meet complex requirements, the date you start using your EHR and even the next election. You also need to know that these incentives are fully taxable.
  • I want to improve my practice’s efficiency: I’m sure that here you are envisioning getting rid of paper charts, automating billing, having lab results and other paper artifacts come in electronically, reduce phone calls, increase number of visits and maybe reduce payroll a little. The right EHR, correctly implemented and correctly utilized can help with many of these goals, but not all. Here we consider the fact that your goals must be realistic. Expecting to be able to see more patients with an EHR is not realistic and probably the opposite is true. Reducing payroll is also not a very likely outcome, since for every medical records person you may be able to let go, you would have to hire an “IT guy”, and if you are a small or solo practice, there is no one to fire anyway. Nevertheless, break this goal down into various efficiencies and quantify your expectations.
  • I want to increase reimbursement levels: This is a very doable goal. The point here is that if you want to be able to measure success, you should set a better defined goal. Are you referring to being able to safely code to a more appropriate level? If so what is your desired improvement? 10%? 20%? Are you referring to ability to participate in an Accountable Care Organization? Are you intent on obtaining performance bonuses from insurers or an HMO? Perhaps all of the above. Just make sure you list them with as much specificity as possible.
  • I want to improve patient care: That’s a great goal, but needs a lot of definition work. You may want to be able to spend more time with each patient, or you may write down that you want to improve the standard of care for all your diabetics, or perhaps you want to make sure that all the kids in your care get all their immunizations on schedule. There are too many options to list and they will depend on your specialty, the characteristics of your patient panel and your professional views on the practice of medicine. Try to be very specific here as well.

These goals are just the most common examples. I am certain that you will come up with many more and you should consult with everybody else in your practice as to their goals as well. As mentioned above, and very similar to car shopping, during the next few months, you will inevitably find out that some goals are unattainable and others will need to be sacrificed due to constraints.

If you had all the money in the world and no kids or dogs, you would probably drive something different than what you drive today. You knew your limitations when you went looking for a car and you should know them when searching for an EHR.

  • I don’t want to spend a fortune: This is the most common and most important constraint, but it does need a bit more detail. Do you want to make a capital investment now and pay less in the future, or do you want to get an EHR with no money down and pay a monthly fee? How much can you afford to pay upfront? Do you want to go into debt and take out a loan? What can you comfortably pay every month? What are the tax advantages of each approach? Would you compromise and drive the standard company car if it was free (read: the EHR the hospital is giving away)? Lots of decisions to be made here, but establishing a budget and sticking to it will protect you down the road.
  • I don’t want to deal with IT: If this is one of your personal constraints, it will narrow down the field in a hurry to only those EHRs that can be remotely hosted by the vendor or one of its business partners.
  • I want my data in my office: This is the flip side of the constraint above and will similarly remove quite a few EHRs that insist on “hosting” your data.
  • My partner refuses to use a computer: You will need an EHR that can accommodate both of you and a vendor that is willing to be understanding and work with you.
  • I want to install the EHR before flu season: Sounds simple, but you will find that accommodating your time lines may not be so easy when everybody is out there buying EHRs.

This list will get very long. Talk to everybody in your office and let the list grow. Your billers in particular may bring up goals and constraints that you would have never considered. The next step is to take all those goals and constraints and translate them into requirements for your EHR. To continue the car analogy, if your goal was that all three kids and the large dog fit comfortably in the back seat, then the requirement is that the car has room for at least 5 passengers in the back, which will then narrow down your choices to an SUV or minivan. Combine that with your budget of no more than $30,000 and a constraint that you only buy American, and you have arrived at your handful of car choices. Let’s look at a sample list of requirements for an EHR for a solo primary care practice in a remote rural area. You should come up with your own specific requirements.

Non-Functional Requirements
As the name suggests, these are general requirements which do not pertain to actual software functions.

  • No money down and no more than $500 per month for the whole thing
  • Ability to function with or without internet connectivity
  • Maximum 3 seconds for screens to load
  • Support dictation and hand-writing
  • Ability to access records from nursing home, hospital and home
  • All data and records, or a current copy, physically stored in my office.
  • Ability for multiple users to access charts simultaneously
  • Certified for stimulus incentives
  • Money back guarantees if not satisfied

Functional requirements
These are specific requirements for specific functions in the software. Most will be derived from your goals.

  • All 25 Meaningful Use requirements fully implemented
  • Coding advice in workflow and automatic E&M calculation
  • Automated claim creation, submission and electronic remittance
  • Ability to verify eligibility in real time
  • Connectivity to the hospital down the street to receive lab results
  • Longitudinal customizable flowsheets
  • Integrated Peds dose calculator
  • Good selection of customizable documentation templates
  • Ability to customize pick-lists for diagnoses, medications, diagnostic orders
  • Ability to create reminders for chronic disease management

Now that you have pages and pages of all sorts of lists, is it time to call that 1-800 number from the glossy add? Not yet. If you were shopping for a car, you could of course stop by the first dealer you see and have him educate you on your choices of minivans and SUVs. A smart shopper would first consult something like Consumer Reports or JDPower, talk to friends and family and if you are like me, look at cars on the highway and every parking lot you happen to find yourself in. Alas, there is no Consumer Reports for EHRs. If you search the web for advice, you will come across a bewildering array of “free” advice sites, most of them requiring that you “register” before obtaining any help. Although it is usually very hard to tell, virtually all of them are there to lure you into buying something, be it EHR software, or services, or unrelated products and sometimes they are just collecting addresses for marketing purposes. Stay away from anything you are not already registered with by virtue of being a practicing physician. But there are some respectable ways to get good advice too.

Colleagues – The best sources for collecting names of EHRs that you should consider (or rule out immediately) are your colleagues. Seek out physicians that are using EHRs and ask for information. Most will be eager to share stories and give you advice. If you subscribe to a specialty listserv, or forum, you could find good information there too. For these, make sure you know the person presuming to give you advice. Sometimes you can learn a lot by just following conversation threads. You should be able to come up with a couple of good prospects and a couple of names to stay away from.

Medical Associations – The AAFP for example has a great EHR survey they publish every year. It is completely untainted by any vendor involvement. You have to be a member to access the results and they are mostly geared to family practice and general Internal Medicine, but pertinent to most physicians. The most recent results are from 2009 and 2010 is due out soon. Find a way to get to that survey. Other specialty associations have their own surveys. They should also have good resources and articles to help you with the process. Some have partnerships with certain vendors. Do not assume that those vendors are necessarily better than others.

CCHIT – CCHIT is now one of three EHR certifiers, but their private certification is still the Cadillac of the industry. Unlike the government certification, which is pretty bare bones, CCHIT certifies for a multitude of functionalities and for several specialties, such as Cardiology, Pediatrics, Dermatology and Behavioral Health. Their website allows you to play with different Non-Functional Requirements to narrow the field down, and CCHIT is vendor neutral, so try it out and look for vendors that voluntarily committed to keeping up their comprehensive CCHIT certification (latest level is 2011).

Regional Extension Centers (REC) – Every state has one and it is funded by the government for the specific purpose of helping you out. If you are a primary care physician, you may be able to get some free consulting, but in any case you should be able to get some good information and a list of EHRs the REC selected. Those EHRs may, or may not work for you, but this is another data point in your research.

Remember to update and augment your original lists as you learn new things. When you aggregate all the information you now have, you will discover that you have in hand a list of about three to six EHR vendors that you are ready to contact and check out. If that glossy add with the 1-800 number is from one of them, then by all means go ahead and call now. Otherwise, toss it and never look back.

Margalit Gur-Arie was COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization. She shares her thoughts about HIT topics and issues at her blog, On Healthcare Technology .

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18 replies »

  1. fpabd.com is one of the site to get free premium account . they update regularly , that site has a huge account’s database.. most of them are working . in my opinion you should definitely visit their blog .

  2. Some things you should know when purchasing health insurance.
    1)Have worked for this company for 7+ years.
    2) They don’t treat their employees any better than their clients. (Refusing to pay out benefits/claims for trivial *and fraudulent* excuses. Make it a habit to pass the buck rather than address and expedite the situation).
    3) They do try to tell your Doctor how to treat you. (1st person witnessed account @ a corporate meeting).
    4) Sometimes the information they provide to your MD on how the Doctor should treat you *is wrong*. (Also first person witnessed event).
    5) If an employee points out any of this their job (at the very least) is in jeopardy.
    6) They are a *business* masquerading as a philanthropic organization. This is dangerous.
    7)While they cut things like trash pickup and towel service & deny benefits, their top executives make million+ salaries.

  3. Being located in the country a bit the automation that has finally come to the health care industry in this county has been a great thing. Not long ago we were still mailing records from the hospital to our family doctor.

  4. UK, where clinicians are not incentivised to embrace electronic medical records systems, private healthcare physicians and allied professionals are embracing a new web based medical records system (ClinicYou, http://www.clinicyou.com), which is a very good example of how software can enable lean healthcare delivery. The affordable, designlead software allows clinicians to create virtual practices and create professional networks, leading to greater flexibility in care delivery and clinicial collaboration using ClinicYou unified EMR and practice managment platform. Data enabling clinics is immensely powerful. Stimulus money is not wasted on this front, we in the UK wish our politicians would see this light.

  5. Great site.. my wife is a CMA and has been considering becoming a phlebotomist, the pay I believe is better and the work is less stressful from what I have discovered over the last couple of months. The training is only a year so I was even considering it myself. I created a site all about it for those intereted in learning more.. Any information at all will be appreciated.. regards, Dennis

  6. Checking with references is like checking references for a candidate for a job. You will get the best reference of a Vendor. Vendors are getting smart. They will send you not only to a good owner/provider, but also a practice where the entire staff loves them. So, it is not a simple thing. I suggest you develop a set of ‘curveball’ questions and something that may seem harmless, but you can get some good insight.

    Look, I’m a vendor and I work with these issues all the time.

  7. I send out all my letters, prescriptions, and investigation requests with bar codes on them so that the recipient can quickly scan in the patient details. Trouble is, most recipients lack bar code scanners .. and since I use a QRcode … most of the common scanners can’t read them! Still, if someone is smart enough out there, they can install the necessary software to automate the process should they want to.
    But I’ve never received a letter from any physician to me with the patient’s details barcoded .. still, one has to start some where. Maybe it’s time to switch to nhindirect …

  8. “Certification says nothing about workflow, usability and user preferences.”
    Yep. As I wrote recently:
    “Usability” is generally summarized conceptually with three overlapping, outcome-reinforcing characterizations:
    – Efficiency;
    – Effectiveness, and;
    – User experience
    In other words, task(s) time(s) to completion, error rates, comprehensiveness of necessary data captured and reportable, and user satisfaction across the breadth of functions (front/back office, MAs, nurses, mids, providers, OMs, IT support/admin staff, etc). The ONC-ATCB Meaningful Use certification addresses NONE of these issues beyond the NIST-tested capability of an EHR (or module) to be able to minimally capture and record the Meaningful Use data. Whether doing so requires two clicks or twenty, takes a user six seconds or sixty, and/or results in “x” number of entry errors along the way, are not considerations.
    I would love to see a comparative certified EHR assessment matrix comprised of elements such as workflow navigation clicks, task time-to-completion, error rates, user experience ratings, etc, for each MU criterion (inclusive of those that are essentially “once-only,” e.g., “turn on your Meds-Meds, Meds-Allergies Alerts functionality and thereafter leave it alone,” or “conduct one test of HIE”).

  9. Warren,
    Government requirements is easy to verify. The list of certified EHRs is here
    When you look at that list, only look at “Complete EHR”. All others are failing to meet some requirement. If you click on any product name you will see exactly what is missing. However, this certification guarantees very little, other than that the government will qualify you for incentives if, and this is a huge if, you satisfy all government Meaningful Use criteria.
    Certification says nothing about workflow, usability and user preferences.
    You can only infer those qualities, or their absence, from actual user opinions. I agree that it is time consuming to call around hundreds of doctors, and this is why unbiased surveys such as the AAFP conducts are a very good starting point. This particular survey asks physicians to rate their EHR on 13 criteria (Easy and Intuitive, Documentation, Finding Information, Ordering tests, eRx, Health maintenance, Disease management, e-Messaging, Practicing higher quality, Worth the expense, Training and support and General satisfaction). The survey is conducted with NO vendor involvement and is only available to AAFP members to fill out. Here is the link to the results, which seem to have been made public recently:
    There are other independent and unbiased organizations that conduct “clean” surveys.
    ACP – http://www.americanehr.com/find-an-ehr/ehr-top-10-ratings.aspx (you need a free registration)
    Medscape – http://www.medscape.com/viewarticle/709856_3
    The AAFP Center for Health IT – http://www.centerforhit.org/online/chit/home/tools/reviews.html (membership required)
    AAP – http://www.aapcocit.org/emr/readreviews.php
    There should be more at other medical associations and you should check the one for your specialty.
    One thing to note is that these surveys don’t always contain the same EHRs. Since the association is surveying its members without preconceived vendor lists, what you see is also indicative of what is most commonly purchased and installed in that specialty (pay attention to the N). This is a very important indicator that should not be missed.
    Again, I would stay away from any “ratings” or listings from any commercial or non-physician related site. The “reviews” on those sites are usually provided by the vendors themselves. That is not what you want.

  10. I’ve tried to get a comparison (side-by-side) of EHR systems using resources online and it is practically impossible. One article I found on Information Week (http://www.informationweek.com/news/galleries/healthcare/EMR/showArticle.jhtml?articleID=228800771) looked at “17 Leading EHR Vendors” but it didn’t give a review in the traditional sense, nor could I find out why those 17 were chosen. There’s much information out there but limited specifics on why a system works well and what are its shortcomings in comparison with others.
    The biggest problem I read about (and want to avoid) is on the user end. Other than calling around, how do we pick an EHR system that meets all the government requirements and meets our needs with regards to workflow, interaction with patients, and integration/sharing of information?

  11. Tom, you just nailed one of my pet peeves when it comes to user interface design. Those same whiz-kids are now all obsessed with “coolness” of the, preferably, browser based fancy GUI. Everything has to have sliding frames, Flash, Silverlight and Web 2.0 (or 3.0) gadgetry, or it gets classified as legacy. Everything looks like the website where you order pizza or pick a movie to watch.
    My usual reaction to such design was always to ask if the designer wouldn’t mind spending 8 hours every single day, heads down, using the proposed slick, colorful and mouse, or touch, driven (and sometimes flashing) gizmo.
    Techs and billers, being the most hardcore users of medical software, always ask for “hot keys” and the ability to work without having the screen get in the way.
    Go figure… ๐Ÿ™‚

  12. Steve brings up something I think is important and also overlooked in workflow analysis.
    In the bad old days when clinical information systems (and I am mostly familiar with radiology systems) ran on minicomputers tucked in big closets, and the terminals were ugly green or amber screens 80 letters wide and 24 lines tall with no mouse and certainly no sizzle, barcodes were used to do more than data entry.
    You’d see sheets with two or three column of barcodes printed on them, each with a title underneath, taped to a wall or counter beside every one of those very un-sexy terminals. You’d also see barcodes on orders, films, film jackets, employee identification tags, and other things.
    The sheets of barcodes were used to actually control the operation of the clinical system. These systems were essentially command driven — if you really wanted to you could find a way in where you could actually type on a keyboard something like this:
    ARRPAT MRN=123456780JUN01, ORD=20110212CT0008, ….
    and then hit “enter”.
    This surface ugliness that reveals inner beauty ๐Ÿ˜‰ was itself hidden behind programs that constructed that command-line for the techs or whomever else.
    The trick is that the command given to the system to like ARRPAT can have an alias given it by that program that constructs the command line. So when the command line builder program sees “011211” it says to itself “Ah, so he wants me to send the system the ARRPAT command. That requires two parameters, MRN and Order Number…” (sorry, but I have anthropomorphized software all my life)
    Well, you can barcode “011211”, so those sheets were covered with barcoded shortcut commands that could be invoked by simply scanning the sheet on the wall, and two bars on the order in your hand. The upside of this scheme is that the tech uses one input device to do just about everything — he doesn’t have to put that down, pick this up, move here, click there, put that down, position fingers over keyboard, type, pick up barcode wand, scan code on order, put down barcode wand…
    After about two weeks on the job, the techs didn’t have to read the titles underneath those barcodes either, they just knew which position on the sheet to scan the way a touch typist knows what key to push without reading the keycap. This was very, very quick.
    This is the sort of thing the whiz-kids at GM studied 100 years ago in manufacturing but gets entirely lost by most Business Analysts in software design. The BA reduces this in a requirements document to “Select arrival function, scan MRN bar, scan Order Number bar, hit OK. Alternatively, the MRN and Order Number may be entered into the dialog boxes using the keyboard.”
    All the features of a modern GUI are great for programs that are used infrequently or in the utter absence of support personnel or peer mentors. They’re simply unnecessary, even harmful, in a “production” environment like a medical lab.
    The attitudes that give rise to this particular design error come from a lack of historical knowledge (a redundant phrase, I know), a bias towards the new with the presumption that it is better, and a belief that “users” are dolts. In other words, it is ignorance coupled with thoughtlessness. I can hold forth for about 30 minutes on this topic. But enough.
    It doesn’t have to be awful…

  13. Steve,
    I would suggest that before you go for the management opinion or the site visit, you call someone that actually does real work at that facility and chat informally. You may be able to save lots of gas money. The other thing I would suggest is to talk to more than one facility with the same product. Look for those with a reputation for excellence and of similar size as your facility. Much of the success of an implementation depends on the facility’s approach to EHR, business and medicine in general.
    I don’t know enough about your circumstances to offer concrete advice and in any case, I wouldn’t be able to recommend some vendors (by name) over others.
    As to ACA, I read the whole thing when it came out and I don’t recall a specific mandate that everybody must have an EHR, although many provisions, and their future interpretations, will probably be easier to implement with computerized records.

  14. I have started this process several times to look for EHRs for our OR. I get the names of other facilities and visit them. Each time, the leadership tells me how wonderful they are. Meanwhile, my partner sits down and talks with the staff who are actually using them. He always gets a different story. They seem to be very time consuming for the first 30 minutes. I cannot figure out why no one is using barcodes or finding some way to cut down on data input. Most have some little glitch, like requiring you to walk back to the OR if you forget to hit the end button. Any suggestions for products to look at?
    OT- The staff at one of our affiliate hospitals thinks that the ACA requires that we adopt EHRs. Is there any such provision?