Now that your office has agreed upon the need for an office electronic medical records system, this, the fourth article in this series, addresses how to select a vendor or service provider. Specific needs for the practice should be defined prior to going through a selection process. Once those needs have been defined, some basic research will also make the choices much easier.
The time and effort spent in up-front research can help forestall protracted searches for the best product for your practice: if the vendor’s product mix is aimed for practices with 50+ physicians, and you are in solo practice, that vendor will probably not be a good match for your needs and budget!
There are basic needs that any EMR should meet. No matter whether an obstetrician or an ophthalmologist, an EMR needs to be able to electronically communicate with a scheduling and billing system, capturing data that can provide billing support. Capturing current and past health problems, medications, allergies, supporting laboratory ordering and reviewing of lab results in an electronic format, and at least basic electronic prescribing support are functions that every practice must have.
While the Certification Commission for Healthcare Information Technology (CCHIT) now tests for basic functionality and certifies vendor products meeting the tested items, it does not address some of the unique requirements that are the province of OB/GYN[i]. The CCHIT testing scripts that are required for certification only test the functionality, not the usability, of the vendor products. While there are discussions about CCHIT extending its reach and considering not only the product itself, but adding the implementation and the usability of the product after implementation as well, that is a potential future deliverable from that organization, and, today, reliance on the CCHIT alone will not provide the answers you need for vendor selection.
Beyond the basics, though, are also unique requirements from electronic medical records systems for obstetrics and gynecology, and rooting out vendors that provide the ability to support those requirements can be challenging. ACOG has published an article on its view of the specialty requirements for EHRs[ii]. Unfortunately, until CCHIT adds OB/GYN as a specialty endorsement (not slated until 2012[iii]), there are no externally validated organizations that assure the prospective purchaser (you) that the product meets all of your needs. Of course, should you be in a sub-specialty practice (MFM, REI), there are even fewer assurances offered on suitability; it will be up to you to sift through the vendors and product capabilities to match with your needs.
As various federal initiatives move forward, “meaningful use” of “certified electronic health records” systems will be required for reimbursement from federal payers (Medicare and Medicaid), and that usually trickles down to similar requirements from other payers as well. As this is being written, definitive definitions are still unknown, and may be in transition for some time. One may also expect a ratcheting up of needs and requirements over the next several years, so continued evolution of product requirements is likely.
Establish a process
The first item of business is to decide the methodology your practice will follow to establish requirements, and obtain a pool of qualified vendors from which to select the best product. One may choose to do all of the selection internally, or to employ the assistance of consultants that deal with this area. The decision on whether or not to send RFPs or RFIs will also be important, as someone (the practice staff or you, or the consultant) must create the requests, and read the responses. [iv] Some practices may find it financially beneficial to narrow the field to one or two vendors with whom they have experience or knowledge, as an extensive look at the universe of vendors will be expensive and time consuming.
Does the practice already have a practice management system in place? An advantage to keeping an existing PMS and interfacing to a new EMR is certainly that there is only one new system to learn (the clinical one). While there can be merit to interfaced practice management systems (PMS) to EMRs, there are also obstacles to overcome, including the problems from updates/upgrades to either system breaking linkages. If the existing PMS does not interface to the new EMR, or the cost to upgrade to a version that is significant, then the practice should look at a complete replacement system (both EMR and PMS).
Establishing the requirement of whether or not a single database is required will determine whether your existing PMS provider is still in the running: many vendors that have both PMS and EMR offerings are not on a single, integrated database, so if that is a requirement, you may end up replacing both to achieve that level of integration. Optimally, a single database for both clinical and financial information provides seamless integration and data-mining capabilities.
With the American Recovery and Reinvestment Act (ARRA) HITECH requirements for providing quality outcomes measurements for EHR incentives via Medicare or Medicaid bonus payments, the more sophisticated the EHR capabilities (including reporting requirements), the more able a practice will be meeting those requirements.
Establish Vendor, Product and Infrastructure Requirements
Whether or not a RFP process is followed, setting out requirements for optimizing your practice should consider the entire office technology and financial needs. The practice should include the technology infrastructure needed for connectivity (both inside the office (wired, wireless networks) and externally (internet connections, security, mobile)), and understand the impact on the budget for all of the related requirements (hardware, maintenance, education, etc.). In addition to impacting the Total Cost of Ownership (TCO), consideration of these factors should help guide management decisions based on the availability of technical resources to the practice.
Another question to be answered early in the process relates to the practice’s technology sophistication, and the interest of someone in the practice managing the actual hardware, software, network, wireless and connectivity technologies. If the practice does not have the interest, desire, or financial facility to manage these facets, then outsourcing to either a vendor that can perform all of these or a technology company that can manage them should be considered.
ASP or Client-Server?
A vendor that offers a Software as a Service (SaaS) solution, also known as an Application Service Provider (ASP), takes away a portion of the requirements for local support (such as local servers and backups of the server data, as well as maintenance and updates of the operating system and programs). As you may well know from basic issues in maintaining your personal computers, there are operating system updates that are required, anti-virus and anti-spam software, as well as data backups that SHOULD be done on a regular and consistent basis. If this portion is done by the ASP provider, that is one less issue for your office to be concerned about. Internet accessibility and reliability could be a consideration here, though, but disaster preparedness and recovery from regional problems (think Katrina) shows the benefit of distributing and storing data in a distant region. Client-server applications are those with a local (on-site) computer serving as the repository of the program, with data in a database stored there, and delivers the information to workstations (other PCs) or mobile devices for use. Client-server systems will require someone manage the entire process of updates, upgrades, backups.
If the vendor offers both ASP and Client-Server versions of the software, then the decision about which version to go with becomes one at the end of the process. If the practice has a valid reason to select one delivery method over the other, then vendors that do not offer the preferred route may be eliminated at the start of the process. Keep in mind that ultimately, the value of the software comes from its use as a tool. How to support the product is a cost-driven decision, and out-sourcing to the vendor or to other technology firms (preferably one that is specifically focused on physician technology needs) simply shifts the costs from internally generated (you or someone you pay through your payroll) to externally generated (the consultant, vendor, or service firm).
Just as patients can search for diagnoses and treatment options on the internet, so you can search for vendors on the web via a plethora of tools. And, just as patients may search and successfully identify the proper diagnosis for their problem and the optimum medication or therapy for treatment from their visits to the web or discussions with friends, there is value to consulting with an expert in the area of need. Do-it-yourself EMR vendor selections and implementations have the potential to be risky to your practice’s health, so caution is advised if you take this route.
Your consultant should help you go through the process of identifying the key elements needed for your practice, and identifying vendors that may meet those needs. While as discussed earlier, CCHIT certification does not yet exist for specialty endorsement in OB/GYN, but the concept behind CCHIT does provide some value to defining those vendors that have taken the time, effort, and money to go through certification.
Vendor financial stability should be a real concern in the current economic reality; consolidation of vendors will likely occur, and many smaller vendors will likely not have the resources to remain in business. Even having vendor source code in escrow will not help you that much if the company fails, for the cost of finding someone to step in and maintain the product would probably be more expensive than replacing with another system.
Once a short list of potential vendors has been established, the due diligence process for selection should include demonstrations of the system capabilities to the decision makers in the practice. It is vitally important to ensure a fair comparison between the final vendors, so scripts that should be followed by all vendors need to be developed (if you are following the multi-vendor “shoot-out” approach, rather than identifying a partner to work with approach). The demonstrations may be on-site at your office, or may be via internet sessions (particularly if the vendor is an ASP, as that is also the way your EMR service would be delivered). While having someone locally to ask question can be useful, it is also expensive, particularly if your office is remote from major metropolitan areas. Ultimately, that cost is reflected in the cost of the product.
Site visits are recommended, and it is especially important to visit an equivalent size and type of practice. References should be checked, and it is important to get a large enough sampling to be able to look at recent and older implementations, to gauge on-going support, frequency of product updates, responsiveness to customer feedback and requests, etc. Request a list of all clients (sequentially over a period of time) to look for failed or withdrawn customers as well as happily installed ones. Remember, though, that there are many reasons for failures, and often it is the fault of the physician office, not the vendor (refer to prior articles on readiness assessment and clinical transformation to understand why).
One may be able to achieve a financially better deal by winnowing down to two acceptable vendor solutions, and negotiating simultaneously with both. Much of the leverage to get the best value evaporates when the vendor knows it is the “vendor of choice” (VOC). A cautionary note, though: don’t get so wrapped up in squeezing every possible dollar from vendors, though, that you lose sight of the fact that this should be a good business decision and partnership for you both. Vendors are not going to go the extra mile in dealing with obnoxious and belligerent customers, any more than you want to take care of patients with similar demeanors.
Specific elements to look for in the contracts relate to payments by milestones (on signing, on training, implementation, substantial or meaningful use, etc.). Just as you shouldn’t pre-pay for a new roof on your house, you shouldn’t pre-pay for all of the EMR components, or you risk paying for product(s) or service(s) you never receive. Tying payments to the vendors for work performed and acceptance of the work as completed to that stage is a necessary step to ensure both parties are protected.
Be professional and courteous in your dealings with the vendors, during the sales process as well as during implementation, if you plan on having a good relationship for the many years you are going to be using the system!
After defining the selection process, doing due diligence and site visits, making a choice on preferred vendor(s), and negotiating a final contract, the next steps in the process revolve around the training, education, and implementation choices for the practice. Those issues will be touched on in the next of our series of articles.
--Michael J. McCoy, M.D.
[ii] “Special Requirements of Electronic Medical Records Systems in Obstetrics and Gynecology”, Journal of The American College of Obstetricians and Gynecologists, (publication pending, 2009).
[iv] “What’s Wrong with RFPs”, Journal of the American Health Information Management Association, May 2006.