Liquid Vapor

For the uninitiated, every year HIMSS runs this big huge trade show for EHR and HIT vendors, which is to the HIT industry what Oscar night is to Hollywood. No, HIMSS does not award any prizes or trophies, but it occasions the same breath taking congregation of all industry glitterati in one place, complete with clever little parties and big extravagant shows. There were well over 30,000 people at this year’s HIMSS11 conference, and although I wasn’t one of them, I made sure to follow the events through the steady Twitter stream and many excellent blogs, reports and interviews, because what happens at HIMSS is good indication for what the HIT industry is doing and where it is going. So to summarize all the excitement, the established HIT folks are doing Meaningful Use, which has become yesterday’s news, with HIE being the next project on the books. Everything is being pushed to tablets and the cutting edge innovations are all about a myriad of small Mobile Health (mHealth) applications. Analytics and business intelligence is looming large on a horizon filled with provider consolidation, capitation and value-based medicine.

On the surface, this seems a very logical succession of events. Meaningful Use is collecting data, HIE will make it liquid and, as predicted, 1000 flowers of innovative mobile applications will eventually be blooming to bring the liquid data to consumers and innovators who will slice and dice it to provide us all with unimaginable medical utility. However, in the excitement of anticipation on those balmy Florida nights, it is easy to overlook the fact that this entire chain of events is based on one assumption: somewhere, somehow, someone will have to enter data into the system, consistently, accurately and in minute detail. For free. Is there a problem here?

Well, it depends on who you ask. The Meaningful Use regulators, encouraged by the stated intentions of many physicians and hospitals to seek Meaningful Use incentives, are probably assuming that data will be dutifully entered into HIT systems. HIT vendors seem even more certain in their assumption that data will accumulate in their systems, since very few, if any, are doing anything about data entry user interfaces. The same forms and templates sold four, five years ago remain unchanged in the Meaningful Use certified, and iPad enabled EHR versions of today. If you ask physicians and nurses, they will invariably tell you that they resent being turned into “data entry” clerks. And, yes, unlike other industries where computerization of records seemed to have worked wonders, in health care data entry must be done by the scarcest and most expensive resource in the system. Some of those expensive resources decided to do what highly paid executives have done decades ago: hire a stenographer, or in health care parlance, a scribe; interesting idea, but a partial solution at best, and a new source of errors and inaccuracy, at worst. So, how is it that 41% of physicians and 81% of hospitals believe that they can achieve Meaningful Use, which comes with rather prescriptive data collection requirements?

One answer would be that doctors and nurses everywhere are just fine with clicking on as many boxes as needed to qualify for government incentive funds. Clicking 4 Dollars may turn out to be a successful strategy. Another possibility would be that data collection requirements embedded in Meaningful Use are not so obvious to the naked eye. The place to look is the long list of Clinical Quality Measures. For example, a simple measure such as Adult Weight Screening and Follow-Up (NQF 0421), has the following description: “Percentage of patients aged 18 years and older with a calculated BMI in the past six months or during the current visit documented in the medical record AND if the most recent BMI is outside parameters, a follow-up plan is documented.” Sounds simple; the nurse weights everybody anyway, and the EHR calculates BMI on the fly, so no problems here. Or are there?

What is the meaning of “a follow-up plan is documented”? Does it mean that you type into the Plan section something like: “recommend 30 minutes walks every day and low fat diet”? Eh, not good enough. First the EHR needs structured data fields to perform calculations and your free text is unusable. Second, this is not a follow-up plan. A follow up plan would involve gastric surgery, referral to dietician, referral to exercise classes or at the very least a V65.3 added to a visit. All the sanctioned CPTs for these activities are provided by NQF (not sure how they end up in your chart though). Just a few more clicks, but we’re not done yet. Like most measures, this one has exclusion criteria, i.e. patients for whom you need not document a follow-up plan. So if you don’t document one, you must specify the reason. Did the patient refuse to discuss such plan, or was there a medical reason not to have a plan, or perhaps the patient suffers from a terminal illness? Need a couple more clicks here to complete this one measure. Does your certified EHR have all those boxes for you to click on?

This was one of the simpler quality measures. If you are interested in hospitals, you may want to look at this CSC report which uses VTE prophylaxis as an example of the mind numbing complexity of data elements required for accurate reporting. As far as Meaningful Use is concerned, if you don’t collect all data elements and your quality measures numbers are less than stellar, there is no harm done. The incentives are not dependent on perceived quality. However, if you’re a physician, maybe not today, maybe not tomorrow, but soon, your paycheck will be dependent on little else. And whether you are an EHR vendor, an HIE vendor, a data analytics middleman or a brand new mHealth vendor, your financial success will be inextricably tied to the amount and accuracy of data entered by clinicians at the point of care. You cannot make liquid that which does not exist.

Solutions? We could continue to apply pressure to practicing clinicians in the hope that the vapors will condense into droplets of liquid data. We could also look for objective liquid data somewhere else, but for some reason I am starting to think that those who want data, are more interested in patient and physician generated data, perhaps because of its inherent richness of intimate details. We could also create EHRs which will allow one-click documentation-by-exception of “normal” quality measure elements, similar to what we did for CMS reimbursement required data elements, and with similar results, i.e. 12 pages of irrelevant visit notes (Bingo!!). Or we could look for true innovation in human computer interaction which will make data collection a transparent byproduct of the practice of medicine. Until then, all the Internet pipes and all the tagged and untagged content flowing through them and all the master patient repositories and all massive provider directories will provide only incrementally better clinical utility than electronic faxing.

How to Meaningfully Shop for an EHR – Part III

(Seal the Deal)

We have arrived at the point of no return. You are now looking at an EHR vendor contract and no matter how well you negotiate this contract, once signed, it will be very difficult for you to change your mind and “get out” without incurring large financial penalties. Once you begin using the product, there will be more than just financial considerations barring you from switching to a different product, and the longer you use the EHR, the harder it will be to replace it. Even if you did a stellar due diligence as outlined in Part I and Part II of this series, there is still a significant chance that you selected an EHR that will not work very well for your practice, a company that will go out of business or be acquired, or a product that will be left behind as new vendors enter the market with new and innovative technologies. Does this mean that you should forget the whole thing and not buy an EHR? Not necessarily.  In a free-market economy, these risks are always present, whether you are shopping for an EHR, a car, cable TV, phone service or anything else. Your job as a consumer is to minimize your risks, but understand that you cannot completely eliminate risk in general.

First you need to understand exactly what you are buying. Much has been said about the difference between buying an EHR, through a license model, as opposed to buying the services of an EHR, through a Software-as-a-Service (SaaS) model. Is there a difference? Is one safer or cheaper than the other? To answer these questions, one must first understand the obvious: EHR is a software program which can only exist when installed on a piece of hardware. Whether the EHR exists on a computer under your reception desk, or in a datacenter over the rainbow, or in some nebulous Amazon Cloud, EHR is still a piece of software, made of many lines of code instructing the computer to perform certain actions at certain times. Wherever the EHR software resides, it will need a physical computer, electricity, ventilation, internet connectivity, lots of cables and other peripheral physical devices. And, yes, “virtual servers” also need computers to execute on. All those trendy clouds are nothing more than giant warehouses full of metal and plastic machines connected to the local electric company and the Internet through lots of colorful plastic cables, and the Internet itself is made of gazillions of similar machines, connected together through routers and switches and ocean floor cables and satellites.

So what are you buying when you buy an EHR? Simply put, you are buying the right to use the software. If you are buying your EHR through a SaaS, or Application Service Provider (ASP), model, you are also buying the rights to use the machines on which the EHR software resides. If you are buying your EHR via a license model, it is up to you to provide the plastic and metal and cables that house your EHR software, and all the additional services it needs to operate. You do not own the EHR software any more than you own Casablanca after you purchase the DVD – you can watch Ingrid as much as you want, but you cannot replace her with Beyoncé and you cannot prevent her from getting on that airplane. Not much different than “pay-per-view” or Netflix, other than the fact that if you “own” the DVD, you can cut it up in a million pieces, if you so choose. Now that you understand what you are about to spend money on, let’s see what can be done to obtain the most advantageous terms from the seller.

Standard Terms & Conditions
The following concepts are not unique to EHR contracts. They are the same concepts that you will find in a contract with the guy that is remodeling your kitchen, or an extended warranty on your new surround sound system, but their application is specific to the contracted service.

• Contract Period – You would think that if you went to great pains to identify a good product, you would want to lock the vendor into a long term commitment, but if you sign a contract for 50 years (yes, they do exist), it also means that you are locked in for the same period of time. Considering the opening statements to this article, this may not be the best course of action. To get the best of both worlds, you should strive for the shortest possible contract (12 months), with an option to automatically renew the contract every year at your sole discretion. The vendor will want to obtain the longest possible contract period. Most start with a 5 year period, which is an eternity in the software world, and an acceptable outcome of negotiations would be 2 to 3 years initial period with automatic renewal for the same. If you can get a 1 year renewable contract, consider yourself lucky.
• Price – A contract is also an itemized bill of sale outlining the products and services you receive, their individual pricing and a grand total. The contract should itemize all services and sub-parts required to provide you a complete service. Just like you would not buy a car that lists Tires as a third-party option that you need to buy on your own, you should not accept a contract that lists Claim Clearinghouse as an unquoted third-party option that you need to separately negotiate and obtain. The contract should also be very specific as to what an item hncludes. For example, $5000 for training is meaningless unless it specifies the number of hours, the means of delivery and the qualifications of the trainer(s). Similarly, you should avoid open-ended pricing on a time-and-materials basis, which is usually offered for custom interface and data migration work. Insist on a fixed price, and at the very least a “not to exceed” number. Every contract will include a clause allowing the vendor to increase price on an annual basis by at least the Consumer Price Index (CPI) percentage growth. Anything undefined in that clause, or above 5% is highway robbery. Based on the contract pricing, you should be able to easily calculate three indicators: 1st year cost, 2nd year cost (should be much lower than 1st) and 5 years Total Cost of Ownership (TCO). If you cannot calculate these three numbers, return the contract and ask for clarifications. 
Assuming all pricing information is available, what should you expect to be able to negotiate? Unfortunately, not much. First, your ability to obtain discounts is inversely proportional to your practice size. It is very unlikely that you will be able to obtain discounts on recurring costs such as monthly subscription or yearly maintenance because these are already offered at low margin and because any discounts here are very hard on the vendor’s earning projections. You should concentrate on one-time initial charges, such as training, implementation, data migration and in rare cases even the license price itself. If you cannot obtain actual discounts, try to get “free” stuff thrown in, like an extra day or two of training (there is no such thing as too much training), an interface, some project management or maybe a piece of hardware. Another good option is to spread out your initial investment into a 12 months period, interest free, payment plan. Be creative and use any advantages you may have (being an influencer in an IPA or hospital board or medical society, is a good bargaining chip).
• Schedule – A good contract should include vendor commitment to an implementation schedule, including go-live dates for the EHR and any interfaces you are purchasing. Considering that vendors are extremely busy and spread very thin in this HITECH era, you should insist on an enforceable commitment to implement your EHR within an agreed upon period of time, subject to significant financial penalties or breach of contract. The vendor will most likely insist on adding language committing you to meet your obligations necessary for a timely go-live, and this is fair.
• Workers – You would be hard pressed to find an EHR contract specifying any minimum requirements for vendor staff delivering services to you, and yet many implementations fail because vendor staff is unqualified to deliver these services. Right now there is a terrible shortage of qualified HIT resources and the temptation to cut corners is very real. You should insist on adding a clause guaranteeing that your trainers and implementers have a minimum of 3 years EHR implementation experience, at least 1 year with the current company, and carve out your right to review resumes, interview and dismiss any vendor staff assigned to your practice with no adjustments to the contracted schedule.
• Materials – The equivalent of materials in the EHR world is the content of your training and implementation. A contract should include a detailed project plan for your implementation and an itemized curriculum (including hours and delivery method) for your training. These documents should be incorporated in the contract as exhibits, not just provided to you independently for review. In addition, a list of minimum hardware requirements should also be an exhibit in your contract. You don’t want to find out after the contract is signed that you need to rip and replace every computer in your practice and pay for a dedicated T1 line to your office.
• Warranties/Service Level Agreements (SLA) – If you go back and recall that EHRs are software programs, you should understand that no software vendor can, or will, warranty that the software is free of defects or that it will operate continuously 100% of the time, not even Microsoft or Apple or even IBM. Here you should be looking for SLAs. There should be 3 or 4 severity levels of problems defined (complete shutdown, severely impaired with no workaround, workaround available, minor malfunction) with a predefined response time, a predefined resolution time and clear financial penalties for not meeting the SLAs. It is very important that you stick to your guns here, since the SLAs are defining the level of support you will receive down the road and a vendor that recoils from commitment here probably has a very good reason to do so.
• Regulatory Compliance – The only current regulations pertinent to EHRs, are HIPAA and Meaningful Use. Most contracts have the HIPAA commitment built in and various commitments for Meaningful Use, ranging from lip service to full money back guarantees. Read carefully and remember that Meaningful Use is only the beginning. There will be Meaningful Use Stages 2 and 3 and it is possible that somewhere down the line the FDA may want to oversee EHRs. Ideally, you would want a commitment to adhere to Federal and State regulations and a separate commitment to adhere to all Meaningful Use specifications (quote the statute) as updated by the Secretary of Health and Human services from time to time.

EHR Specific Terms & Conditions

• Data – Almost every EHR contract contains a glorious statement, meant to make you feel good, that all data in the EHR belongs to you. This statement is meaningless. To obtain tangible protection you need to have two additional clauses in the contract. One is a “not to exceed” price for all data extraction, including clinical, from the EHR in a standard format (CCD, HL7, CSV and PDF), with specific standards attached to specific data (CCD for clinical data, HL7 for demographics and insurance, CSV for all other structured data and PDF for all documents). Other than a fixed price, you should also insist on a “not to exceed” timeframe for completing the export and a commitment to work with your next EHR vendor. The second clause, which is generally ignored and most often with disastrous consequences, is a requirement that in case of a dispute with the vendor, you should be allowed full access to viewing the EHR until the dispute is resolved. Vendors have been known to cut access to the software for non-payment and any other breach of contract. You need to avoid this possibility. If you are contracting with a rather new or small vendor, you will be well advised to contractually commit the vendor to provide you with weekly full data dumps, in the above formats, that you can keep in your office. Do not accept copies of backups, unless you have a tested way to restore a full working database, and overwhelmingly you will not. Be advised that almost all EHR vendors will be monetizing your patient “de-identified” data in accordance with HIPAA restrictions. You may want to try and limit disclosure, request that physician data is also “de-identified” or request notification of secondary use of your data. Most likely, you will make no headway here.
• Hold Harmless - The infamous “Hold Harmless” clause that is supposed to shield vendors from any responsibility of harm to patients, is rarely present in ambulatory contracts. The lunatic fringe’s loud screams notwithstanding, most contracts only contain statements of vendor’s limited liability (usually 1 year worth of maintenance) for all damages to the business, including financial losses and malpractice judgments, arising from use of the product. Just like you cannot sue Microsoft if the lack of usability in Excel caused you financial loss and you cannot sue Intuit if a bug in TurboTax prevented you from filing on time (happened to me), you will not be able to seek financial compensation from an EHR vendor commensurate with your damages. The best you can do here is try to get the vendor to agree to increased liability (perhaps double the original), but you can be certain that any liability will remain limited.

Most important, whatever you do, please seek legal advice for this step. The above points are very general in nature and not comprehensive enough for you to adequately navigate the contract on your own. Remember that vendors have large legal departments and by forgoing legal advice you are placing yourself at significant disadvantage. Small practices often do not heed this advice, but large medical groups always use attorneys for contract negotiations. Call a colleague who works for a large group and get a referral to an attorney that is experienced in EHR contracts. It may end up costing you a couple thousand dollars, but considering that you are about to enter a contract worth upwards of $50,000 for each licensed provider over the next 5 years, and considering the ramifications to your business if you sign the wrong contract, the attorney fees are money well spent.
Good luck and happy hunting!

How to Meaningfully Shop for an EHR – Part II

(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.

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.

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.

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.

How to Meaningfully Shop for an EHR – Part I

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.

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.

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

Now that you have pages and pages of all sorts of lists, is it time to call that 1-800 number from the glossy add? 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.

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.

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.

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 add 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.

Nothing but Questions

Dr. Atul Gawande wrote an article in the New Yorker a couple of weeks ago. It’s a real story about real people, in real trouble, and the real doctors who choose to really care for them. And from this story we can draw a real lesson for a real solution to the real health care problem we are facing.
Unlike Dr. Gawande’s previous articles which fit nicely into policy, this one doesn't seem to generate nearly as much "buzz". Why is that?

Is it because the implication that if you want to save money in the long run, you need to go back to basics and actually take care of people on a basic human level?
Is it because this is too much hard work with no instant gratification from high-tech silver bullets?
Is it because we don't really want to put the patient at the absolute center of our efforts and would prefer to use representative data about the patient instead?
Is it because we prefer academic theory to execution, particularly when execution involves poor, dirty, drunken, sick people that need to be physically touched?
Is it because this flies in the face of both "personal responsibility" advocates and "get rid of mom and pop medicine" proponents?
Is it because it does not fit well with the patient as "consumer" paradigm?
Is it because it shines the light away from social media savvy crowds back to the simple realities of being poor and sick, and the true concept of "community"?
Is it because the doctors in the story are just plain good people, instead of greedy, patronizing, error-prone, rich doctors who don’t even wash their hands?
Is it because it implies that poverty is at the heart of the health care costs conundrum?
Is it because we all decided, in our respective left and right corners, that we know how best to solve the problem and a trifle little thing like evidence is not going to stop us now?

Perhaps the questions are wrong and perhaps there are no answers. Besides, the train has already left the station……