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. [ed. note: unfortunately, doctors always seem to fall for the slick presentation and 'sales' price at the Academy Meeting - stick to your guns!]

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. [ed. note: recall your wish list from Part 1]
• 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.

Product Demonstrations

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. [ed. note: this is especially important if your EPM and prospective EHR are from different vendors]

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.

Reference Checks

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.

Site Visit(s)

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. [ed. note: this is arguably the most important part -how does it work in real life?]

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 call
• 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. [ed. note: don't forget to send a nice gift - chocolate chip cookies without nuts comes to mind]

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.

This article was written by Margalit Gur-Arie from On Health Care Technology. The original article can be viewed at How to Meaningfully Purchase an EHR System.

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 and  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 roadmap below will lead you to those three or four obvious choices of EHRs best suited to your particular situation.  The final choice is yours to make. [ed. note: the car purchase analogy is a great one; how would you answer the question, what kind of car should I buy? Do you need to carry passengers? Off-road or not? Cargo or not?]

Goals

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. [ed. note: yes, always start with goals - I bet most practices don't do this.]

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 timelines 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

[ed. note: these previous two make up your wish list. Be as thorough as you can - it will save you heartache later.]

Now that you have pages and pages of all sorts of lists, is it time to call that 1-800 number from the glossy ad? 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. [ed. note: I would add that there are some sponsored informational sites that work with most vendors and do offer some valuable advice. Just be sure you know where they are coming from and that the process is transparent.]

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. [ed. note: information from colleagues is critical. And don't forget to return the favor once your EMR project is up and running - allow other doctors to come and check out how you did it.]

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. [ed. note: sadly, these are probably less reliable as a source than the others may be.]

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 ad 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.

In part II, we’ll kick some tires, look under the hood and go for a test drive.

This article was written by Margalit Gur-Arie from On Health Care Technology. The original article can be viewed at How to Meaningfully Purchase an EHR System.