March 19, 2007

EMR Selection: Checking out the Lineup
By Elizabeth S. Roop
For The Record
Vol. 19 No. 6 P. 16

When it comes time to choose an EMR system, it takes a focused strategy to identify the perfect fit from the usual suspects.

With electronic medical records (EMRs), selecting the right system can often be as intimidating as the implementation process. With so many systems touting the same functions and features, it can be difficult to determine which most closely meets a practice’s or facility’s needs. Nor do most providers have the depth of understanding required to make that determination.

“What happens in a lot of practices is that one person goes out and looks at a couple of demonstrations and makes the selection without really understanding the full impact” the EMR will have on the practice, says Patricia Lohman, president and CEO of Outlook Associates, Inc. “It is often the physician who makes the decision based on what they need from a clinical perspective. But they don’t think of the administrative aspects.”

Unfortunately, most smaller groups and facilities don’t have the financial resources to hire the expertise to assist with the selection process, leaving them at the mercy of the vendors’ sales pitches. That is why, after seeing an increase in the number of calls from smaller organizations that ultimately could not afford their consulting services, Lohman decided “to take what we were doing in the larger market and bring it down to some simple tenets for people to follow.”

The end result was “Evaluating and Selecting an Electronic Medical Record System: A Guide for Small Physician Practices,” a 120-page workbook designed to be used by small physician practices as a hands-on guide throughout the system selection process.

Ten Steps to Success
The workbook, available on Outlook’s Web site (www.outlook-associates.com), boils down the process to 10 steps that guide decision makers through the rigors of selecting the right EMR for their organization.

1. Identify your selection team: Identify a key staff member from each area of your practice to help conduct the selection process. The size of the selection team depends on the size of the practice but should include a physician, nurse, and office administrator—“whoever is knowledgeable on how you do the actual processes in the clinic,” says Lohman. “It’s important to make sure you have a physician on the team. If it’s a solo practice, it’s easier. But when you have two or three doctors in a practice, someone is going to have to convince the other doctors that this is OK.”

2. Establish your EMR goals: These include the operational and/or financial improvements that the practice hopes to achieve by adopting an EMR. Some on the team may focus on order entry and others on billing. The important objective is to talk it through to gain a clear understanding of expectations. “You can get carried away with the bells and whistles and miss the core things,” Lohman says, citing a case where the office administrator was expecting a paperless environment, but the physician was focusing mainly on electronic access to test results. “Nobody really knew what it was going to do, so they tried to do everything and really accomplished nothing. You don’t want to wind up with no one really happy with the system because you didn’t have a consensus.”

3. Document your existing workflow: Define your practice demographics to facilitate accurate hardware and workflow planning, then review your existing workflows and office processes to identify the areas to be automated with the EMR. “This is where it’s important to have that team,” says Lohman. “The physician may not have any idea what happens at the front desk, but that front-desk encounter starts the record for the whole day.… If you don’t start with how it’s working now, you won’t have a clear path, and you take a chance on avoiding some key handoffs and points along the process.”

4. Define your system requirements: Clarify overall practice objectives along with growth and expansion plans to develop the general EMR system parameters for functionality and technology against which your selection team will evaluate each vendor system. “The workflow [analysis] will help get you through the functional requirements, what you want the system to do. But at the same time you do that and walk it through the clinic, you should start to determine where you need printers set up, how many devices you need, and what type,” says Lohman, adding that this step is also where you should start evaluating security needs.

5. Develop a vendor questionnaire: This should include questions about company history, financial viability, system costs, system functionality, and system technology.

6. Develop a candidate vendor list: Produce a short list of vendors your practice wishes to further examine. Numerous organizations, including the American Academy of Family Physicians and HIMSS, have published comparative lists that rate vendors on items such as integration and security. “It’s important to consider how [the EMR] integrates with your practice management system if you’re not going to trade that out,” says Lohman. “If it’s not going to exchange data pretty easily and in real time, you’ll find that it’s not going to work well.”

7. Request system demonstrations: Develop customized scenarios for each demonstration so you can determine how each system deals with each scenario. “The vendors invariably will show you the bells and whistles. But the jazzy stuff won’t buy you anything if you can’t get your patients in and bill them properly,” Lohman says. “You have to do the real life.”

8. Check vendor references: Have the vendor provide references. Depending on when the vendor questionnaire is returned, this may happen before or after the system demonstrations.

9. Conduct a client site visit: Visit a client site that is currently using the finalist vendor’s system to observe the system in a “live” environment.

10. Make your final decision: Meet to evaluate and summarize the previous steps to determine your vendor of choice. “What we find is that if you didn’t go through a really good due diligence process, you can really dither at the end,” says Lohman, who suggests establishing a numeric scoring system so you can simply tally the results to identify the top candidate.

Refining the Steps
The boiled-down 10 steps for EMR selection are “a good high-level overview of the steps to follow with any project, but obviously, there are many substeps under each one,” says Lydia M. Washington, MS, RHIA, CPHIMS, director of practice leadership at the AHIMA. “These substeps are the real work that must be done in order to ensure a successful project.”

For example, when establishing goals for the EMR, Washington suggests adding to the consideration mix how the EMR can help a practice accomplish its business goals. This may include items such as being able to provide data to support reimbursement under a pay-for-performance model or offering a new medical technology or patient service that has not been offered in the past.

Establishing the selection team should also go beyond identifying the members, adds Leslie A. Mack, RHIT, senior director of HIM at CareTech Solutions, Inc., an HIT and HIM services provider. It should also involve educating the team about both the variety of systems available and their functionality.

“A well-informed selection team can much more effectively pinpoint the value of each system’s features and functionality to the organization and will be less likely to succumb to sales hype and snazzy demos,” she says. Some steps also carry more weight than others in terms of their impact on the success of the selection process.

According to Washington, identifying the selection team, establishing the EMR goals, and documenting the existing workflow are “absolutely critical. Work done here will serve as the foundation for the other steps. This means getting the right people at the table to get buy-in for the project [and] having a deep understanding of why exactly you are doing the project and what you want to achieve.”

In terms of documenting existing workflow, the process should involve answering questions such as the following:

• What workflow changes need to be made to the organization’s current environment to properly prepare for the implementation of any EMR system?

• Are there backlogs that should be tackled?

• Are medical record forms bar coded?

• Who will lead the organization through these changes?

• How will the project be funded?

“The answers to questions like these—more than any others—will determine the success or failure of the new EMR system’s implementation,” says Mack. Mack also suggests adding three steps: development of a strategic plan, setting a timeline for system selection and implementation, and defining the implementation process and requirements.

The strategic plan is the most critical aspect of the selection process. It should be developed at the start of the process and “include the organization’s clear definition of an EMR and its strategic vision for the system’s use. In addition, the strategic plan should clearly identify the organization’s goals, strengths, weaknesses, opportunities, and threats relative to implementing an EMR system,” says Mack.

The strategic plan should address questions designed to identify the functionality the EMR should offer in relation to the organization’s strategic vision for the system, including the following:

• Is the organization looking to completely eliminate paper through use of online documentation, prebuilt templates with drop-down selections, free text utilizing a key or pen, annotations, dictation, and speech recognition?

• Is the hospital looking to move into combined use of online reports with paper-based documentation that will be scanned?

• Should the EMR system have specific workflow capabilities?

• Should it provide remote access?

As with the selection team, the strategic planning team is a critical component of the process and should include representatives from every discipline that will utilize the system, including caregivers, HIM, IT, and business office staff, according to Mack.

“In organizations large and small, the strategic planning group will likely become the EMR system selection group,” she says. “Managing the expectations of the organization’s selection and implementation teams and end users is a time-consuming but critical component to the success of any EMR system’s implementation.

“As an HIM professional whose experience is deeply rooted in serving hospitals, I have experienced system rollouts in facilities that did not include the right people in the selection process. The result? Systems were bought at significant cost but were never fully implemented because all major requirements were not clearly defined at the beginning of the project,” Mack adds.

Words of Wisdom
Whether you follow the 10 steps outlined here or develop your own plan for selecting an EMR, success or failure will depend largely on your selection team and how well they’ve done their homework on both the systems and the organization itself.

“Understand that these systems leave almost no part of the practice or organization untouched,” says Washington. “Workflow analysis to determine the impact on all parts of the practice is a step that cannot be overlooked or taken lightly and will require the participation and engagement, including time commitments, of everyone. It cannot be the work of just a few people.

“Lack of understanding of workflow and the required process improvements that must be identified and/or made before a system is implemented will delay its rollout and quite possibly result in costly project failure.”

— Elizabeth S. Roop is a Tampa, Fla.-based freelance writer specializing in healthcare and HIT.

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The 10 Steps in Action
Physician Associates of the Greater San Gabriel Valley didn’t have Outlook Associates’ 10 steps in front of them when they went through the process that culminated in the selection of the NextGen EMR for their member practices.

But the process they did follow aligns closely enough that “when I saw this, I knew it was pretty much what we did,” says Steven Davis, DO, MSHPE, chairman of the Pasadena, Calif.-based independent physician association, which has more than 800 physicians. Davis is also medical director of its IT arm, Physician Associates Clinical Integration Services (PACIS).

Selection team: Physician Associates’ selection committee included 14 individuals—physicians, office managers, medical billing, and Independent Physician Association (IPA) administrators—representing the various disciplines that would be affected by the EMR.

EMR goals: The EMR needed to meet a number of specific criteria, including the vendor’s financial strength and track record. Most important, though, was that the EMR “needed to be capable of handling the enterprise as far as multiple independent practices but also be usable and flexible for individual practices to use,” Davis says. “We also wanted to use the EMR and practice management system together.”

Documenting workflow: This is the one area where Physician Associates deviated from the steps but not because documenting workflow was not considered important. Rather, the IPA does an extensive readiness survey when a practice signs up for the EMR and already knew the demographics of their physician members.

System requirements: Physician Associates ultimately decided that an Application Service Provider (ASP) model was the best fit for its unique needs. Because its member practices already utilized the association’s online authorization system, it knew Internet access was already in place. The ASP model, and outsourcing hosting of the application, would result in a smoother, more successful implementation. Also, they didn’t want to deal with layers of interfaces. “We wanted the EMR and practice management to be a seamless system. They needed to talk well to each other and not have a lot of database or interface issues,” says Davis.

Vendor questionnaire: The information gathered in the first four steps all went into the vendor questionnaire, which sought to balance functionality with usability. “If the doctors weren’t going to use it, what’s the point of getting it?” says Davis. “There was one candidate that was extremely usable and looked pretty, and they sold it really well. It was an early leader, but it wasn’t good on the enterprise level and support level. So we couldn’t let ease of use and prettiness rule the day. It still had to have the technical ability to move forward.”

Candidate list: The selection committee initially compiled a list of the top 15 vendors, which was cut in half based on an early evaluation of the functionality and features offered by each. That list was further culled down to five, which were then invited in for demonstrations.

System demonstrations: The selection committee sat through several layers of Web, phone, and in-person demonstrations, tracking results against its detailed list of questions. “The first layer was just ‘give us your sales pitch and show us your product.’ Then we actually repeated it with scenarios we wanted to use that were pretty broad,” says Davis.

The final two candidates were then asked to participate in an “old-style Texas shootout,” featuring case-use scenarios defined by the IPA. They set up a computerized voting system that allowed the “audience” to rank each after watching the demonstrations. The decision in NextGen’s favor, Davis says, “came out very clear cut.”

Vendor references, site visits: Throughout the demonstration portion of the selection process, Davis says the selection team was calling vendor clients for references and conducting site visits with practices in their area using the system. “Seeing different people and how they set up theirs really helped us decide how to set up ours,” he notes.

Davis, who is a frequent speaker on EMR selection, says following the 10 steps—whether on your own or with the help of a consultant—is important not only to the success of the process but also for expanding your understanding of what an EMR can do and how it can benefit the organization.

“You’ve heard this before; you don’t know what you don’t know.… I like these 10 steps. Not everyone has to go through them, but by doing so, you go through a learning process that makes you more knowledgeable to make the decision,” he says. “The truth is you can take a wheel with the top four or five vendors and spin it and you’ll do OK.… You don’t want to micromanage your decision to the point that you’re making ‘indecisions.’ But you need to go through this process so you learn and get outside advice on what to do.”

— ESR