Research and Observation
Here we are going to talk about the second stage of shopping for an EHR. We are going to assume that you did your homework, defined your goals and constraints and prepared a comprehensive list of requirements for an EHR (if you have not done so already, go back and read Part I). To continue our car shopping analogy, we are now ready to go kick some tires, and we start by calling on each of the three to six EHR vendors on your list. To your folder of lists, add a blank page for each vendor, to log your interactions with the various representatives you will begin encountering shortly. If the sales person is unresponsive and if it takes weeks to have someone call you back, most likely the situation will only deteriorate after they get a hold of your money, so keep good notes.
Calling an EHR Vendor
Whether you start by filling out a form on a website or by sending an email, eventually you will be on the phone with a sales rep. You should be the one directing the conversation. Inform the sales person of your specialty and practice size and explain that you are conducting an EHR search and his company is one of your candidates. Do not disclose the remainder of your list unless you are interested in a “confidential” long lecture on how horrible the competition really is. Your goal here is to obtain contact information (phone and email) of the regional sales executive, inform him/her that you will be sending out a Request for Information (see below) and set a date for your first clinical demonstration of the product. You can listen patiently, if you wish, to the details of this month’s “special offer”, but stick to your agenda and commit to nothing other than a demo. Remember to log your impression from this call, including the vendor’s willingness to accommodate your schedule and the expediency of setting up a demo date.
Request for Information (RFI)
All cars on a dealer lot have stickers on the window that describe the engine size, the trim, the optional packages, the gas/mileage performance, etc. When you look at an EHR vendor website, you will learn that the EHR has a scheduler, a documentation module, eRx, practice management, etc. In car parlance, it would be like saying that the car has an engine, a steering wheel, tires and seats. Not good enough. The role of the RFI is to extract the specifications of the EHR. Vendors are used to filling RFIs for large systems, but almost never from a small practice. It is high time to change that. A basic RFI should include the following questions at the very least:
- Company information – Years in business, number and location of employees by role, financial information, history of mergers and acquisitions, number of physicians employed
- Customer base – Number of installed practices by size, number of physician customers (not users in general), number of installed practices in your state, number of installed practices in your specialty, number of new practices installed in the last 12 months and a list of 5 references you can call, preferably in your area
- Training and Support policy – Standard support hours and cost, extended support hours and additional fees, type of support (phone, pager, email), response times and penalties, standard training package and cost for additional training, waiting time for new implementations and pricing for all standard and extended items
- Product – Deployment model (full license or subscription, locally or remotely hosted), frequency of upgrades, required hardware, required broadband and network, required third party software, optional modules, warranties and prices for everything
- Features/Functionality – You could go and list 20 pages of features and functions here, but you would be wasting your time and the vendor’s time. If you stuck to the advice in Part I, then your short list of vendors is towards the better end of the spectrum and has been CCHIT 2011 certified, which means all the nuts and bolts are there. Whether these nuts and bolts are optimally assembled is a different question and one not answered by an RFI. So here, stick to your list of requirements and only ask about features that are important to you.
- Trial Version – I am listing this separately because it is very important and a good quality indicator if the vendor is willing to grant you access to a trial version of the software, or a vendor hosted “sandbox” where you can test drive the product on your own. Always ask for this, but know that, unfortunately, very few vendors will allow it.
- Due Date – Clearly specify the date by which you want the vendor to respond. Two weeks is an adequate timeframe.
Your RFI should run about 5 pages long at the most and you will have to read the response and devise a way to score it, sum it up and compare across vendors.
In parallel with your RFIs, you should schedule at least 3 separate demos. Insist that your staff and partners, if any, are in attendance. All demos can, and should, be done over the Web at your convenience (lunch hour, early morning or after hours).
- Clinical Demo 1 – For this introductory demo allow the vendor to perform its standard canned demo, restricted to the EHR portion only. Do not confuse this with one of those public webinars that you can sign up for online. This demo should be scheduled and performed exclusively for your practice. You should allow the demonstrator to do “his/her thing” and present the product in the best possible light. If you don’t like what you see, be sure that it will never look or perform better and scratch this particular vendor right here. If all goes well, find a good time in the demo, towards the last third, and create a bit of unexpected action. For example, suggest that the diabetic patient being demonstrated brings up a lump under the left arm right before she leaves (by-the-way), or suggest that you want to prescribe a medication that you know has been discontinued, or recalled (nothing as obvious as Vioxx), or maybe mom wants the doctor to also look at little Tommy’s rash while she is here. Plan ahead and be creative. The purpose here is not to embarrass the vendor, but to see how the product deals with the less beaten path, which is of course the norm in your daily work.
- Clinical Demo 2 – Before you schedule this one, you need to create two or three scripts that are most common in your specialty and are not trivial in complexity. For example for a family doc, a good combination would be a diabetes-hypertension-obesity-depression visit with new symptoms, a catch-up immunizations pediatric visit and a third trimester OB visit with some complications and risk factors. You can use your actual charts to create the visit script, including assessment and plan, and it should not exceed 2 pages per visit. Send these scripts to the vendor ahead of time and ask that the demo should follow your script exactly as written.
- Administrative Demo 3 – Allow your office manager and biller a full demo hour, particularly if you do billing in-house. Your staff should come up with a list of items they want to see, but vendors usually have pretty comprehensive practice management demos. Encourage your staff to ask plenty of questions and make sure the vendors show the functionality, not just state that it is there.
While these demos are being coordinated and performed, make sure you update your log regarding vendor responsiveness. Have everybody in your office score all demos from all vendors and add these scores to the RFI scores. I know it sounds like hard work, and it is, but an EHR is an important purchase and deserves your full attention.
If all goes well, the vendor should have supplied you with contact information for several practices you can call, and you should call them all, speak to at least one physician and have your office manager and biller call their counterparts at those practices. But here is the rub; you should know that those are pre-screened favorable references. No vendor would volunteer a slate of unhappy customers. If you know colleagues that use the same EHR call them too. If you don’t, try calling your local Regional Extension Center (REC) and ask about practices that may be using the same EHR you are considering. It may take a bit of persuasion, but RECs should be able to deliver. If all else fails consider posting a question to one of your physician forums.
What should you ask during a reference call? You should make a checklist in advance that includes your goals and constraints and try to figure out how the reference practice is performing against your criteria. For the sample goals and constraints outlined in Part I, you would ask the following:
- How are you doing with Meaningful Use? Do you expect to get your stimulus check any time soon?
- Are you completely paperless? Do you want to be paperless? Are you getting lab results electronically? Is your phone call volume lower? Were you able to reduce payroll? Did you have to hire IT guys?
- Is your reimbursement higher now? Are collection rates better? Do you see more patients? Any bonuses from HMOs?
- Do you have more time with patients? Are disease management tools helping? Are patients satisfied? Is your staff happy?
- Was it worth the expense? Would you do it again? Would you do certain things differently? Would you recommend I do it?
- How long did the implementation take? Was the vendor helpful?
- Can you customize templates and workflows? Did you have to change how you do business? Is it working out for you?
Listen carefully, score all calls and add to your growing body of evidence.
At this stage in your shopping journey, you should have been able to eliminate all but two or three EHRs. If you didn’t, then now is the time to pick the top contenders and prepare to go see them in action. Logistically, this the most difficult task to accomplish, particularly for a small practice and particularly if you practice in a remote or rural area. After a long and arduous research, you will be tempted to skip this part. Don’t. This is the only opportunity for you to see if everything you were told is actually translatable to real life situations. Remember that vendors sell EHRs all day, every day and they have acquired certain mastery in presenting the product in the best possible light. It is never as good as it sounds, and you need to find out if it is good enough for you. Yes, you may need to close your office for a day or at least take part of the day off, but a wrong EHR choice could cost you tens of thousands of dollars in lost productivity, so this is a wise investment.
As with reference checking, you should have a checklist of what you want to ask and see, and you should take at least two or three members of your team with you on this “field trip”. Tactically divide the observation into three parts:
- Front Office – Watch an entire check-in process, an appointment being made and the triage of incoming phone calls
- Back Office – Watch the biller work and ask questions here and there. Make sure that you ask about coding, claim submission and follow-up, payment posting and patient accounts
- Clinical – You have to be able to be in the exam room with more than one physician and watch them review, document and order. Don’t forget the nurse, particularly if she/he is the one doing most of the ordering.
In all cases make sure you stand behind the person interacting with the EHR, so you can see the screen. Pay attention to their body language, the number of failed attempts to accomplish a task, computer sudden crashes (if any), time it takes to move from screen to screen, number of steps to complete a task and the general attitude of the user you are observing. If you are visiting a larger practice, try to locate a physician that was not part of the EHR selection committee and shadow him/her. It’s OK to carry a clipboard with your checklist around and make notes as you go. Try to find some time for casual conversation with the doctors at this practice. It would be perfect if you can take your host out to lunch, but the break room should be fine too. On the way back compare notes with your team members and make sure every little thing is documented while memories are fresh.
You now have all the information needed to make your decision. It is best practice to have a staff meeting and review your documentation and your scores for each vendor. If you are lucky, you will have a clear winner. If you are like most, you will be debating between two or three EHRs that seem equally acceptable. There is also a distinct possibility that you came up empty handed and nothing you saw looks like the optimal solution for you, in which case you should file your information in a safe place and wait for a better day and a better product and know that this was not an entirely futile exercise. One of these days, you will want to revisit the EHR concept and what you learned from this process will come in very handy.
If you have selected one or two products, it is time to contact the vendors and ask for a contract. Not a sample blank contract, but a signature ready contract, made for your practice with all the pricing information filled in. In Part III of this series, we will look at the last hurdle in your EHR search – obtaining a most advantageous contract.
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.