Electronic Health Record (EHR) Software Selection and PurchaseUnderstand practice needs and evaluate readiness for selection and purchase.

1. Strategies and tactics to simplify software and vendor selection

2. Six steps to assist in successful selection and purchase

3. Answers to common questions and concerns

4. Tools to measure practice need and readiness

This module outlines step-by-step strategies that can help ensure successful selection and purchase of an EHR for your practice. It includes comprehensive assessments for evaluating readiness for EHR adoption, understanding practice needs and selecting the right EHR vendor for your practice.

Effective use of electronic health records is a key element in achieving the quadruple aim: improving the patient experience, improving the health of populations, reducing overall healthcare costs, and improving professional satisfaction. EHRs can improve the storage and management of charts and provide remote access to patient information. They can also help physicians successfully participate in quality payment programs, such as Meaningful Use and the Merit-Based Incentive Payment System.

There is no “one size fits all” approach to EHR adoption. The strategies presented in this module are intended to help physicians and staff make informed decisions about their EHR selection. Each practice should consider its own unique needs and resources when deciding which EHR works for them.

1. Use resources to make an informed decision

2. Determine practice needs

3. Determine EHR requirements

4. Select an EHR vendor

5. Assess financial capabilities

6. Negotiate key contract terms

Seek help to make an informed decision about EHR selection and purchase. Below are available resources to consider:

• Quiz Ref IDRegional Extension Centers (RECs) can help physicians select, implement and demonstrate meaningful use of certified EHR software technology. They provide education, outreach and technical assistance to physicians in their service areas.

• Review the Office of the National Coordinator for Heath Information Technology (ONC) Playbook, which provides actionable steps and guidance to healthcare providers on how to implement and use health IT.

• Colleagues who have adopted an EHR can share experiences to help set and manage expectations.

• Local hospitals where physicians have privileges may provide special deals for purchase, service and support.

• National and specialty associations may offer guidance specific to the physician practice.

• The AMA has developed resources and partnerships to help physicians and practices navigate the health IT ecosystem.

• American EHR provides collated and organized health IT information to optimize decision-making among an online community of clinicians.

• The EHR user-centered design evaluation framework created by the AMA and Medstar, which increases transparency of EHR vendor usability processes.

Quiz Ref IDThere are two strategies for determining practice needs: measuring level of preparedness among physicians and staff and prioritizing practice needs.

Circulate a readiness survey among staff to determine the state of health IT adoption, prerequisites for change, potential barriers, user needs, time-sensitive factors and appropriate next steps.

Use a needs assessment to determine the most important and relevant characteristics of an EHR system for the practice. It can be helpful in determining whether EHR components/modules or a complete EHR software application is more appropriate for the practice. Identify critical areas of the practice that need to be prioritized as the practice begins using the new EHR.

Before completing the needs assessment for the practice, consider:

• Listing health IT currently used in the practice to select an EHR that has sufficient interoperability. Some practices already use a variety of health IT for managing patient information and medical care, such as e-prescribing and practice management systems (PMS). Without sufficient interoperability, physicians and staff could perform redundant administrative work. For example, choosing an EHR that doesn’t integrate with your PMS technology might require duplicate data entry or that reports be generated from separate systems. EHR vendors will be able to provide information about the compatibility of their product with other systems.

• Identifying health IT currently used by network providers and health care partners to select an EHR that can integrate or communicate with other systems. Without this capability, some paper-based processes will remain unchanged even with an EHR. For example, instead of transmitting laboratory tests and referrals electronically, physicians and staff will still need to send them via fax.

• Exploring local hospitals and health care systems that may be interested in partnering with the practice. They may prefer a certain type of EHR and may be willing to subsidize and/or assist with adoption. Partnering with other groups may help the practice negotiate a lower-cost option.

• Ensuring current IT infrastructure is secure. All of your patients’ personal health information (PHI) will be stored electronically, which may require a more secure network than what is already in place. Work with IT and the EHR vendor you choose to secure patient information and adhere to HIPAA requirements.

Quiz Ref IDSelect the type of EHR software and server host that will work best in the practice. Selection should be based on practice needs that are driven by current patient payment composition, level of preparedness and practice priorities.

Decide whether to purchase a modular or complete EHR (see Figure 1). Some practices may want to purchase a complete EHR to attain the full benefits of replacing the paper chart, while others may only purchase the modules necessary to meet the requirements for meaningful use or the QPP (e.g., order entry, patient education and patient portal). For example, physicians and staff that are satisfied with their current PMS and other components, such as e-prescribing, may add modules rather than replacing the existing system.

Determine where practice and patient information will be hosted. There are three hosting options: self-hosted, software as a service (SaaS) and outsourced (see Figure 2). In the self-hosted option, the server is housed in the practice and managed by practice staff. In the SaaS-hosted option, also known as cloud-based EHR, the physician practice accesses the software through the Internet. There is no need to maintain, update or own the software. In the outsourced option, the server resides at the application service provider (ASP) location that is managed by a third party. The ASP may offer services such as software support, data backup and disaster recovery. The EHR vendor may offer this option or have a partner who does. Each of the three server hosting options has advantages and disadvantages.

Your patients’ medical record data must be secure and protected from unauthorized access. You and a qualified attorney should also consider the following regarding HIPAA concerns, among others:

• Understand and clearly specify who is liable if the data is compromised.

• Understand that patient information may be compromised if it is co-mingled with that of other clients.

• Data should be encrypted and backed up.

Quiz Ref IDSelect a vendor that meets the needs of the practice. To do this, the practice must actively explore potential vendors, arrange vendor demonstrations to learn more about their product(s) and services, obtain proposals to better assess vendor capabilities and pricing and evaluate vendors to facilitate selection.

Gather information and learn about different vendors. Some practices contact colleagues who have adopted an EHR for vendor referrals and/or to inquire about their experience selecting and working with the vendor. Other practices conduct phone interviews to learn more about what each vendor has to offer. There are also practices that conduct online research. Practices seeking to participate in Medicare or Medicaid quality reporting programs, such as the QPP or meaningful use, should consult the ONC website’s comprehensive list of certified health IT products that can be used for these programs. Products that are not certified are generally not eligible for participation.

Schedule vendor demonstrations to help physicians and staff test and evaluate the alignment of the EHR product with the needs of the practice. For example, if your practice plans to use EHR apps, ask vendors if their product supports EHR app technology. To optimize the vendor demonstration experience, some practices provide vendors several workflow scenarios that are critical to their operations. This allows the vendor to customize their presentation and product demonstration.

Request proposals from the top three to four prospective EHR vendors. The practice may develop and distribute a request for proposal (RFP) to the vendors that clearly outlines EHR requirements and criteria for selection.

Determine the capabilities of the EHR vendors’ products and services, and evaluate the level of alignment with the needs and priorities of the practice. Some practices use a vendor evaluation matrix to assess EHR usability characteristics and functions offered by each vendor. Examples of functions and characteristics include charting, prescription management, clinical tasking, orders and results management, decision support and health record management. Physicians and their staff may learn that some vendors have richer content, such as progress note templates or decision support logic. Some physicians and staff conduct site visits to practices that have successfully implemented similar systems. Visiting practices with a mature EHR is helpful for comparing services and overall product functionality.

Quiz Ref IDAssess financial capabilities to better select an EHR that can create long-term practice sustainability. To do this, the practice must determine the cost of total ownership, explore financing options and conduct due diligence.

Determine the total cost of ownership to assess the impact of each EHR option in the practice.

This involves calculating:

• The capital cost of hardware and software licenses, such as desktop computers and mobile workstations

• Ongoing expenses such as software maintenance and/or service fees

• The cost of physician and staff time and materials needed to learn new system features and implement practice-wide procedures

• The expense of an implementation support provider that can help physicians and staff Effectively and efficiently use the new EHR during adoption

• The expense associated with connecting the new EHR to registries, health information exchanges, or other tools that the practice may be using to track patient outcomes and perform quality reporting

• The cost of migrating data into the new system

• The cost for appropriate privacy and security measures to ensure compliance with state and federal laws

Explore options for financing the EHR purchase. Some states offer low interest loans and local banks may offer business loans. Vendors sometimes offer low- or no-cost financing. Local foundations may provide grants. In addition, local hospitals and health care systems that are interested in partnering with the practice might consider subsidizing or assisting with implementation.

Conduct due diligence before signing the vendor contract. EHR vendors may not clearly define the total cost of an EHR purchase. Rather, they may charge numerous fees for specific products and services. Therefore, it is important for the practice to thoroughly review the vendor’s contract. The Texas Medical Association has compiled a list of fees to watch for when reviewing the EHR contract. These include:

• Licensing fees

• Equipment and third-party software fees

• Maintenance fees

• Professional services fees

• Implementation services fees

• Interface fees

• Fees for additional features

In addition, there may be fees associated with software fixes, upgrade charges and customization charges to fix problems or make the EHR more usable. It is strongly recommended that the practice defer to an attorney who can help ensure the practice is protected in the event something goes wrong with the purchase and that an exit clause protecting the practice’s interests is clearly outlined.

Negotiate the terms of your contract with the selected EHR vendor. Together with a qualified attorney, develop a definitive negotiation strategy that takes into consideration practice circumstances and resources, the vendor’s standard contract terms, state and federal laws, and your willingness to walk away if both parties can’t agree on terms. In addition to cost, you should negotiate additional services and support with the vendor. To maximize performance and minimize practice risk, include specific contract terms around vendor support and financial consequences during system downtime and failure and ongoing maintenance and performance monitoring. Uptime warranties and/or service level agreements are also helpful in protecting your practice from excessive downtime or less than optimal performance. Consider termination clauses and how patient data transfers to another EHR system will occur in the event the contract is terminated. You may also consider formally outlining responsibility for staff training during implementation and for future upgrades. A HIPAA business associate agreement between your practice and the vendor is also essential. For additional support in contracting with your EHR vendor, review the “EHR Contracts Untangled” guide from the Office of the National Coordinator for Health Information Technology.

Selecting the right EHR software and vendor requires careful consideration about your practice’s needs, EHR requirements and budget. Using this module as a guide will help you make informed decisions to ensure that you purchase the right EHR system for your practice. Once the EHR is purchased, the practice can start looking forward to implementing the new system.