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1/28/2011
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Farrah Jolly
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So Many Electronic Health Record Choices

Need help sorting one EHR vendor's pitch from the next? Seven vendors responded to our RFI--here's how they compare and what to ask before you buy.

With more than 300 electronic health record systems on the market, picking one that will meet a medical practice's specific needs is tough, especially for small groups that don't have full-time IT professionals to wade through the requirements and translate the vendor-speak. With deadlines fast approaching to qualify for a piece of the $27 billion in federal stimulus funds set aside to encourage EHR adoption, and with vendors lining up at the door ready with a hard sell, it's time for practices to get started.

To find out just how challenging picking an EHR is for small and midsize physician practices, InformationWeek Analytics sent out a request for information to more than 20 vendors for a fictional midsize practice--Wellness First Health Associates. We've compiled and analyzed information from the seven vendors that responded into a guide to selecting EHRs that provides insight into their products. We've also developed guidance to help healthcare professionals in small to midsize practices--solo practitioners to groups with as many as 50 doctors--assess their needs and determine what questions to ask vendors.

Now's The Time

Medical practices are eligible for as much as $63,750 per physician in federal incentive funds over six years if they qualify under the Medicaid program and $44,000 per physician over five years under the Medicare program. To qualify in 2011, practices must be using a qualified EHR system for at least 90 consecutive days this year--so it must be in place by Oct. 2.

Electronic health records make patients' files easily accessible and include up-to-the minute information on the latest office visit, test results, and medications. Doctors and staff don't have to waste time hunting down a patient's most recent blood work--it's right there. Files can be easily shared with practitioners across town and across the country. Pharmacists don't need to call to decode illegible scripts. And patients can get the results of their latest scans online rather than wait on interminable hold.

EHR systems provide a long-term view of a patient's health history compiled from various practitioners providing care. Information typically found in them includes doctors' notes on a patient's progress; logs of vital signs; problem, medication, and immunization lists; the patient's health history; and lab, radiology, and other test results. These systems often are integrated with billing and practice management software for an integrated workflow. They frequently incorporate a personal health record that lets patients add information and communicate with their doctors. They usually provide e-prescribing capabilities, and they sometimes tie into a health information exchange for sharing data with doctors outside the practice.

Slow Progress

Medical practices and other healthcare organizations are implementing EHR systems not just to get federal stimulus money, but also because they want to improve the quality of care they provide, facilitate information management, and optimize revenue. But so far, progress has been slow.

Last year, fewer than a quarter of office-based physicians in the U.S. were using electronic health records with basic functionality and only about 10% were using fully functional systems, according to preliminary data from the Centers for Disease Control and Prevention's National Center for Health Statistics. The federal government is trying to increase those percentages with the "meaningful use" incentive payments.

The U.S. Department of Health and Human Services' Office of the National Coordinator for Health IT is rolling out a detailed definition of meaningful use in three stages. To be eligible for full Stage 1 incentive payments, medical practices must meet 15 core requirements, as well as five additional objectives chosen from a menu of 10 options, by early October next year. Practitioners also must be using EHR products certified as meeting meaningful use goals and objectives.

But while the process is confusing, help is available. Many hospitals are providing seminars and other support services. Huntington Hospital in Southern California, for example, is sponsoring a "vendor click-off" that lets physicians do side-by-side comparisons of EHRs. There's also a national network of 62 federally funded Regional Extension Centers that provide EHR adoption assistance, particularly to primary care doctors.

With all these pieces in place, there's no excuse not to get started.

First Steps

Before talking with vendors, assess your practice's needs. The points below will help guide you to the questions you should ask vendors. Areas to pay attention to include:

>> The state of your infrastructure: Do you have adequate bandwidth and storage to support an EHR system? Are your PCs and servers up to the task?

>> Features, functions, and usability: Which features you need will vary depending on the specialty of the practice and services provided to patients. A general family practice has an ongoing relationship with patients and needs tools that provide for long-term tracking of care and ongoing communication with patients. An emergency medical center, which sees patients once or intermittently, is apt to put more emphasis on patient management and the ability to communicate with outside physicians. Make sure usability is factored in--all the latest features and functions won't mean a thing if your staff can't (or won't) use them.

>> Networking and interoperability capabilities: Should the new software interface with existing billing, scheduling, claims, and other internal systems or should those capabilities be part of one new system? Practices should check with vendors as to what capabilities are integrated into their products or provided as add-on modules. If connecting to an existing system is important, find out if interfaces are available or can be built.

>> Technology knowledge: How fluent are your physicians and staff in computer hardware, software, and Internet navigation? Assessing skills up front will help in picking an EHR that's easy for them to use and in providing the right level of training.

Many clinicians, especially those who were educated when technology wasn't widespread, struggle with computing basics. For example, when a physician at Scarsdale Medical Group, a multispecialty practice with 26 doctors at three sites, refused to convert to electronic lab orders and results retrieval, the group's executive director, Maria Trusa, told other doctors that this intransigence would set the implementation back six months and cost them money. "The other docs said they weren't stopping," Trusa says, and the stubborn one quickly fell in line.

Consider conducting a survey to assess your staffers' computing skills--such as their comfort in using a mouse and navigating the Web.

>> Partner systems: You'll need your system to interoperate with the hospitals, labs, testing facilities, billing services, and other service providers your practice works with. Find out which EHR systems your providers already work with and have interfaces built for. Also consider whether your practice will participate in a health information exchange and what EHRs are supported by that exchange.

In shopping for an EHR for his solo practice, colorectal surgeon Dr. Howard Kaufman wants it to integrate with Huntington Memorial's Meditech EHR system and workflow, since he's director of the hospital's Cancer Care Center. The system also must support his clinical research. That interoperability won't come cheap. "To meet all these other needs is two times the cost of a basic EHR just for my office," Kaufman says.

>> Deployment options: Should your practice use commercial on-premises software, open source software, or Web-based software as a service? The answer will depend on your budget, as well as your staffing and technology capabilities. On-premises software is more expensive because you have to buy, implement, and maintain the system and underlying hardware yourself.

SaaS EHRs require a monthly subscription fee but have lower up-front costs and fewer local hardware needs. These systems are more interoperable than earlier electronic medical record systems, and their service-oriented architectures make them easier to integrate and customize. However, SaaS can't be customized as easily as on-premises EHR software, and it raises security issues since the data is stored off site.

Open source EHR systems are also Web-based and are typically available at no charge or are less expensive than commercial options. However, these systems lack paid support and may require customization and expensive development to meet specific needs. So they may not work for small and midsize practices that don't have the IT staff to support and fine-tune them.

>> Maintenance and support: Do you have staff available to handle EHR system maintenance and troubleshoot problems? SaaS requires reliable Internet connectivity, so make sure that's not going to be an issue--an EHR system that's down could bring a busy day to a screeching halt.

If you don't have dedicated IT staff or outside support, you'll be looking to the EHR system vendor or a third party to provide it. Most vendors offer some post-implementation support.

It Ain't Easy

Physicians worry about spending more time in front of a PC than with patients. As one doctor, speaking at a Regional Extension Center education forum late last year, put it: "If I end up just playing with medical records, that would be the pits for me."

One area getting a lot more attention than it used to is EHR usability--think ease of navigation between screens, from vital signs to proactive care to entering progress notes and ordering prescriptions. Small and midsize practices can't afford to put a lot of extra time and resources into training because the technology is hard to use.

Overall, the more intuitive, easy to learn, navigate, and maintain that an EHR system is, the better. The only way to ensure a system meets your needs is to have the vendor provide a demo and let your staff--including your physicians--try it out.

Implementation will take several months for most practices but will vary depending on the vendor, the number of physicians and staffers in the practice, and how much existing hardware needs to be replaced.

Strike A Balance

We've developed the following best practices for buying an EHR system, coordinating people, process, and technology.

1. Look for vendors that know your practice. Start with vendors that can demonstrate experience with and systems catered to the type of work your practice does. Huntington Memorial's Kaufman says he hasn't seen many products that address his needs as a specialist. "It doesn't seem like some vendors did their homework," he says.

2. Evaluate the costs to acquire, deploy, maintain, and support the hardware and software. If new computers and other hardware are needed, now's the time to invest in them, along with any other infrastructure required to support the new EHR system.

Software costs are related directly to the size of the practice, the implementation cycle, the legacy systems involved, and whether the software you're evaluating has integrated with systems similar to yours at other practices so that the interfaces have already been built. In terms of software licensing costs, you'll likely want a vendor that offers a concurrent (rather than a named user) licensing model and support costs, so you can create pools of users who share licenses. You'll also want to ask if there will be additional licensing costs when the software is upgraded.

On the support front, if you don't have staff to maintain and support the system, factor in the cost of filling that gap.

Still, don't get too caught up in implementation costs. Total cost of ownership is more important because it has more of an effect on the return on your investment, says James Troup, CEO of Pediatric Alliance, a 12-site practice with 40 physicians.

3. Consider a cloud-based or hosted EHR setup. Cloud- and SaaS-based options let you get started faster. Because they're hosted by a vendor, medical groups don't have to install and maintain their own EHR systems and aren't responsible for building interfaces to partners' systems. They require less training because there's no new hardware to learn.

4. Get the right training for your staff. Most vendors offer basic training at no cost but charge extra for more extensive and on-site training. Determine how important on-site training will be to your practice before picking a vendor. Also understand how much ongoing technical assistance and training a vendor provides after the EHR system implementation, and what it charges for that.

5. Use a certified EHR. In addition to choosing a system certified as compliant with meaningful use requirements, look for one that meets Health Level Seven International (HL7), a standard approved by the American National Standards Institute that specifies basic functional requirements for EHR systems. Also look for EHR systems certified under the Certification Commission for Health IT program for testing functionality, interoperability, and security against criteria developed by its expert working groups.

6. Invest for the future. Check out the balance sheet and financial statement of any vendor you're thinking about doing business with. You want your EHR vendor to be around for the long haul.

Assess the scalability of the system you're considering. Will it meet future needs? Does it have features likely to be important in Stages 2 and 3 meaningful use requirements? Though those are still under discussion, some information is available on the direction they're heading, such as requiring data exchange and quality improvement capabilities. You'll want to determine whether the product you pick is likely to comply.

Bottom Line

Since most EHR systems include the basic features a small practice needs, focus on areas that will make a difference to your group, such as usability, customization, and scalability. Look for a system that's tailored to fit into your practice's workflow and eliminate redundant data entry. The key objective is to improve the efficiency of the daily routine, thereby reducing costs and providing improved patient care.

Realize that every phase of deployment won't go smoothly and that your EHR systems will remain a work in progress. It took Pediatric Alliance two years to achieve full adoption. Training and getting buy-in from part-time practitioners were particularly difficult, Troup says. Some physicians still need workarounds that reduce the EHR's effectiveness. For example, rather than force all doctors to learn ICD-9 diagnosis codes, the practice installed an add-on that lets users search on the synonyms, acronyms, and abbreviations that doctors regularly use for diagnoses.

Think big but start small. Set your sights on how effective your practice will become by going digital, but realize you won't achieve that vision overnight. --With Neil Versel

Farrah Jolly is a health IT portfolio manager with Fusion PPT, a strategy and technology solution firm. Write to us at iwletters@techweb.com.

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