Selecting an Electronic Medical Record System for the Physician Practice
Ethel Johnson, RHIA, CCS-P
The healthcare industry is committed to the goal of improved quality of healthcare, patient safety, and cost effectiveness. Implementation of the electronic health record (EHR) is high on the list of priorities and is viewed as the tool that will significantly contribute to achieving this goal. As a result, there has been a push by the federal government, physician and professional healthcare organizations and alliances, as well as the health information technology industry, to encourage physicians and their practices to transition from paper to an electronic medical record (EMR) within the EHR structure. What is the difference between the EMR and the EHR. Sometimes these terms are used interchangeably; however, there is a distinct difference. An EMR is site specific—for example, a physician practice. There could be multiple individual sites where an EMR resides (from the primary care physician to the specialty practice). The EHR encompasses all of the EMRs and other health information, such as pharmacy records, payer/financial historical health information, etc. Therefore, the EHR is the electronic medical record containing all of an individual’s health information (the sum of all of the EMRs).
In May of 2003, the Department of Health and Human Services (DHHS) asked the Institute of Medicine (IOM) to provide guidance on the key care delivery related capabilities or “basic functionalities” of an electronic health record system.1 This was necessary in order to provide a “functional model” of an EHR system that would assist providers in the purchase of systems. This supported the belief that if providers were armed with information about the functional capabilities of the software, they would be better equipped to compare systems, resulting in making decisions about acquiring systems appropriate for their practice needs. The model would function as a guide to vendors in developing future systems consistent with provider expectations. The focus of the IOM committee was “care delivery functions.&rdquo. The foundation for considering “core functionalities” of EHR systems was to first consider the uses of an EHR, such as care delivery, patient care support processes, financial processes, etc. The committee concluded that the core functionalities should address the following areas:
- Improvement of patient safety
- Support delivery of effective patient care
- Facilitate management of chronic conditions
- Improve efficiency
- Feasibility of implementation
Based on these areas, the IOM committee identified eight categories of core functionalities, including:
- Health information and data
- Results management
- Order entry/management
- Decision support
- Electronic communication and connectivity
- Patient support; administrative processes
- Reporting and population health management
The details of this guidance can be reviewed in the IOM’s letter report “Key Capabilities of an Electronic Health Record System.”
In addition, Health Level 7 (HL7) has also identified minimum functions of the electronic health record, representing the standard within the healthcare industry. A list of the HL7 minimum functions can be found on the following Web site: http://hl7.org/ehr/documents/Documents.asp. This functional model represents the benchmark in evaluating the functionality of EHR systems, recognizing that there isn’t a system in the market that has met all of its requirements.2
In April 2004, President Bush challenged the information technology industry to take necessary steps toward ensuring that every citizen in the US would have an EHR by 2014. As a result, he appointed David Brailer, MD, PhD, and the National Coordinator for Health Information Technology for the Department of Health and Human Services, to coordinate efforts in this regard and to establish what is known as the Nationwide Health Information Network.
Also among those who recognize the value of the EHR to achieve the goals of quality, safety, and cost effectiveness, the American Health Information Management Association (AHIMA), Healthcare Information Management Systems Society (HIMSS), and the National Alliance for Health Information Technology (the Alliance) teamed up to advocate and work towards an independent process of certifying ambulatory EHR systems. The group that now holds the federal contract to certify ambulatory electronic record systems is the Certification Commission for Healthcare Technology (CCHIT). CCHIT is considered the certification authority for electronic health records and networks within the private sector.
It is expected that this process will accelerate initiatives toward the electronic health record. The actual certification process is intended to place a stamp of approval on EHR systems as it relates to the following basic categories:
- Functionality: refers to the system capabilities or specific tasks performed by the system
- Interoperability: refers to data exchange and addresses compatibility with other products
- Security: addresses data security/privacy
It seems to be the consensus within the healthcare industry that with the establishment of these standards, voluntary certification of EHR systems will add credibility, reduce financial risks, and allow physicians to accelerate their efforts to move forward with confidence when purchasing systems. This is particularly the case among physician organizations.
The certification handbook and the final criteria for the initial phase of CCHIT’s work were completed May 1, 2006 and are available for review at the following Web site: http://www.cchit.org.
It is important to note that since this is the initial phase of the above mentioned work, the criteria listed in the handbook are considered to be broad and may not address all of the needs of medical specialties.3
Accelerating movement toward the EHR has added to the complexity of the selection process, in that the number of systems on the market has increased. However, selecting a system does not have to be a daunting task. The first and most obvious question that needs to be answered is. Where do we start. Well, you do not start with the vendor. Acquiring any major systems purchase must begin with a process. Why would you need to establish a process. Establishing a process or approach minimizes financial risks to your practice and prepares you for the migration from paper to the electronic record. The following approach may be considered in preparing to purchase a system:
- Designate a work team and establish a strategic work plan
- Research the basic functionality of EMR and EHR systems
- Become acquainted with the terminology or technology language
- Conduct a readiness assessment and analysis of workflow
- Identify criteria for selecting a system
- Identifying potential vendors
- Prepare a request for proposal (RFP)
- Prepare for vendor demonstrations
- Make your selection
The overall objective of the discussion that follows is two-fold:
- Outline an approach for evaluating and selecting an electronic health recor. system for the physician practice, with each of the aforementioned points are discussed at length
- Specify criteria for evaluation and selection of a system that meet the requirements for your practice
Designate a Work Team and Establish a Strategic Work Plan
Once a practice has made the decision to migrate from paper, the process of selecting a system begins with organizing a multidisciplinary work team. It is important to organize a team of individuals under the leadership of a physician who will collaborate to establish a working plan. Choose individuals from your key areas, where applicable. These individuals may include your office manager, the administrator of the group, and a nurse. If the practice does not have an HIM professional, it is advisable to engage the services of one, to act in an advisory capacity. Identify the role of each person on the team. This can begin by determining each member’s knowledge of systems. Once your team is organized, work together to develop an overall plan.
Review the Basic Functionality of EMR and EHR Systems
Key to the preparation process is researching functionality of the EMR and EHR systems.
A review of the core functions of a EHR system as outlined in the Institute of Medicine’s report, “Key Capabilities of an Electronic Health Record System”;4 HL7’s EHR System Functional Model,5 in addition to the criteria developed by CCHIT will add tremendous value to your selection process, in that it will help everyone to understand how the system will benefit the practice. Review of these documents will assist your practice in identifying your requirements. A good way to establish consensus and cohesiveness among the team is to discuss your findings during your designated meeting times.
Become Acquainted with the Terminology or Technology Language
This is an important part of the preparation process. There is common terminology associated with EMR components6 as well as the health record/information industry in general. Understanding the language will benefit discussions with potential vendors. This will also assist you in knowing the right questions to ask. Reliance solely on the vendor could cause you to overlook critical factors relevant to your practice. Contacting your physician professional association can further benefit your research process in this area. Many of the sites address the terminology.
Conduct a Readiness Assessment and Analysis of Workflow
If you are considering an EMR for your practice, there are probably some goals that you have in mind. What would you like to accomplish. Are you looking for solutions that will improve or optimize operating efficiency. As these questions are answered, it is also necessary that a practice conduct a readiness assessment in addition to analyzing the workflow. The following may be considered when conducting a readiness assessment:
- The size of the practice (volume of visits)
- The number of staff
- Current systems, existing applications, networks
- Functions that are outsourced (billing, transcription)
- Forms used
- How coding is accomplished
Perform an analysis of the work flow within the office. Review each of the steps of a patient’s encounter, in addition to the billing and collections process. Identify problems and consider solutions. Take the time to assess your infrastructure, current procedures, and forms used. Examine the types of data you currently collect, the way you collect this data, and the way that the data is used. Your goal is to look at how you are conducting your business process and to consider improvement opportunities—for example, quality of care, billing and reimbursement—without replicating inefficient processes. Based on the information gathered, identify specific strategies for positioning the practice for moving forward. Ultimately, you are trying to determine if certain processes require redesign.
Identify Criteria for Selecting a System
As indicated earlier, the IOM’s core functionalities, HL7’s functions, and CCHIT criteria are the documentation that will help to determine the criteria relevant to the needs of a practice. Prioritize the needs of the practice as you consider what is required versus a system feature you would like to have. Selecting a vendor’s product that has been certified by CCHIT will reduce risk to the practice; however, keep in mind that according to the CCHIT handbook, the initial criteria are broad and may not be appropriate for certain specialty situations.7 It is recognized that many vendors are focusing on certain specialties. Construct a detailed tool listing the criteria. A weighted rating system can be applied to each and then scored. Designing a rating system will help you to determine how the vendors compare to one another. Read through each proposal carefully before grading each vendor. After the grading, the vendors must be ranked.
Identifying Potential Vendors
Because there are a numerous systems on the market, further scrutiny is required in order to narrow your options when it comes time to submitting your request for proposal (RFP). Consider a potential vendor after you have reviewed “top vendor” lists in journals and attended trade shows. A practice will also want to refer to the certification information provided through CCHIT.8 Vendors considered should be based on the size of the practices to which their products are marketed. Therefore, you wouldn’t submit an RFP to a vendor that develops products primarily for small practices if your practice is large. There are also information sources that rate EHR systems.9
Prepare a Request for Proposal (RFP)
Once you have determined your business requirements and have documented criteria for evaluation and selection, you are ready to prepare an RFP. This document defines the service and products desired. The RFP will also inform the vendors under consideration about your practice in general. In addition, it will describe the current systems, hardware, and network information. The detail that you provide the vendor is essential, as they will be able to provide you with product information specific to your needs and practice profile. Professional physician organizations are also an excellent source of information. Furthermore, your RFP will indicate the proposal deadline, vendor presentation preferences, your evaluation procedures and criteria, proposal specifications (that include the format, to whom and how the proposal should be delivered), and how questions regarding the RFP will be answered. Also ask detailed questions regarding technical requirements, interfacing capabilities (with your practice management system), security, maintenance, and support. Provide the essential information concerning your present operating environment. This would include your current infrastructure, equipment, and software specifications.
Prepare for Vendor Demonstration
As vendors submit their proposals, use your evaluation tool (based on criteria stated in the proposal) to rate their products. Each vendor should understand the evaluation criteria. Allow vendors to make presentations to the entire work team.
Now you are ready to attend demonstrations of the vendor’s product. Preparing a demonstration worksheet before hand will help with your team discussions back at the office. The demonstration worksheet should contain the core criteria that the team agreed was important (as indicated on the evaluation tool). In addition, include a section for comments and further questions that you may have. Where possible, ask to see demonstrations of the product in a live environment as well as simulated demonstrations set up in your office. Following the presentations, the team will rank the vendor presentations by comparing the selection criteria to what it saw.
Make Your Selection
Making a final selection will involve reviewing the data tabulated from your assessment as well as the demonstration worksheets completed by the team members. There are other factors that need to be considered in making your final selection, such as cost and feedback from reference checks. Inquire about vendor experience with practices similar to yours. Does the content exist for your specialty. Is the product capable of integration with your practice. Finally, pay close attention to customer support issues and upgrade possibilities. Attending a user group meeting would be tremendously beneficial.
Ultimately, selecting an electronic medical record system for a physician practice involves orientation, a careful assessment, evaluation, and planning before you make a final decision on a product. Following a systematic process in preparation for migration will undoubtedly limit the number of problems experienced by the practice. Finally, input from professional associations, consultants, other specialties, CHHIT, etc., will provide the appropriate support and assistance.
- Institute of Medicine, The National Academy of Sciences. “Key Capabilities of an Electronic Health Record System.&rdquo. Washington, DC: The National Academies Press, 2003.
- Mon, Donald T. “The Difference between the EHR Standard and Certification.” Journal of AHIMA 77, no. 5 (May 2006): 66–70.
- Certification Commission for Healthcare Technology. Certification Handbook, Ambulatory EHR Products 2006, version 1.2, available from http://www.cchit.org.
- Institute of Medicine, National Academy of Sciences. “Key Capabilities of an Electronic Health Record System.” Washington, DC: The National Academies Press, 2003.
- Health Level 7. “Electronic Health Record Functional Descriptors,” available a. http://hl7.org/ehr/documents/Documents.asp.
- McCoy, Michael; Bomentre, B. J., Crous, Kate. “Conversational IT.” Journal of AHIMA 77, no. 4 (April 2006):25–27.
- Certification Commission for Healthcare Technology. Certification Handbook, available from http://www.cchit.org.
- Available at http://www.himss.org; http://www.elmr-electronic-medical-records-emr.com ; http://www.medrecinst.com/conferences/tepr/index.asp.
AHIMA HIM Practice Transformation Work Group. “A Checklist for Assessing HIM Department Readiness and Planning for the EHR.&rdquo. Journal of AHIMA 76, no. 6 (June 2005): 56E–H.
Amatayakul, Margret. “EHR? Assess Readiness First.” Healthcare Financial Management 59, no. 5 (May 2005): 112–113.
Blair, Robin. “Worth the Wait.” Healthcare Management Technology 26, no. 1(Jan 2005): 48–50.
Waton, Kathleen. “Tap, Tap, Tap to Better Patient Documentation.&rdquo. Health Management Technology 26, no. 11, (November 2005): 16–18.
Johnson, Ethel. "Selecting an Electronic Medical Record System for the Physician Practice." AHIMA's 78th National Convention and Exhibit Proceedings, October 2006.