Evaluating EHR systems

Aug. 10, 2010

What practice owners should consider when looking at electronic health records systems.

Passage of the HITECH Act provides medical practices a windfall of incentives (ranging up to $44,000) to adopt and use a certified electronic health record (EHR) system in a meaningful way. Because of this, there has been a renewed effort from solution providers to promote solutions as a one-stop shop for all the needs of the practices. At the same time, practices are trying to implement a solution and reap the benefits ASAP. However, before the practices start scouting and evaluating products, it is important to understand that the implementation of an EHR product is a complex activity requiring dedicated effort and due diligence. The numbers of implementations that fail in the first year of their implementation provide testimony to this.

This article outlines a few criteria that every medical practice owner should look for in an EHR system in order to make an informed decision.

Setting the expectations
First, practices should clearly understand, define and highlight the reasons for an EHR implementation, and the benefits they expect from the implementation. The HITECH act and the monetary benefits should not be the criteria or the purpose for the implementation. The practices should start with the list of work flows they would like to get automated. The work flows can be evaluated based on their importance and their impact on the efficiency and profitability of the practice.

Standards compliance
The healthcare industry boasts one of the strongest compliance standards. The standards are based around two major factors: privacy of patient data; and interoperability and efficiency of the integrated systems (i.e., payers, pharmacies).

Some of the most important standards that an EHR product should be compliant with include:

HIPAA
Title II of the HIPAA Act, known as the Administrative Simplification (AS) provisions, establishes national standards for electronic health care transactions and national identifiers for providers, health insurance plans and employers. The act requires the patient information be kept private and secure. The Act also proposes strict civil and criminal penalties for violations. The standards are meant to improve the efficiency and effectiveness of the nation's healthcare system by encouraging the widespread use of electronic data interchange.

The HITECH act of 2009 proposes changes to the HIPPA Title II, extending the HIPAA rules to business associates of covered entities.

Meaningful usage (MU)
One of the preconditions (under the HITECH act) for availing the incentives is based on the EHR system meeting the various compliance details set by the ONC, and hence physicians have to ensure that the product being considered has the basic MU covered. The rules were finalized last month. The details can be found at http://www.cms.gov/EHRIncentivePrograms/.

ICD
HIPAA has mandated that the new standards (ICD-10) be adopted by practices by October 2013. Therefore, it is imperative that an EHR product is at least ICD-9 compliant and has the necessary apparatus and plan laid out for a future upgrade to ICD-10 before the set timelines.

Certification by federally recognized agency

Practices should ensure that the product is certified by a federally recognized certifying agency. However, Health and Human Services (HHS) has yet to announce the list of these agencies.

Recommendation
It is strongly recommended that practice owners insist that the EHR solution be certified, and the vendor should ensure that the product will be kept up to date with the latest releases in a timely manner without any significant cost to the practice owners.

Ease of use
Since EHR products are intended to increase the effectiveness of medical practices, it is very important that the products are easy to use for not only the physicians, but also for the support staff.

Some of the most basic requirements for the user interface (UI) include: Each operation should not take more than two to three page transitions; the information should not be cluttered and should be easy to read; the UI should be intuitive. For example, the form for insurance filing should match the physical form; the solutions should assist the staff in capturing the right data and avoiding accidental errors.

Ease of use applies to the administrative department, as much as it does to the physician; hence it is important that the support staff is able to use it more efficiently, providing the patients a better experience. Physicians should ask for a demonstration of the product and should not limit themselves to the glossy brochures used by the sales representatives. Physicians and staff should try an end-to-end entry of the encounter to gauge the effectiveness of the system.

Practice management
The beginning of any patient encounter is making an appointment. If this module is easy to use for the administrative staff, then it can mean more patients and more business for the practice.

In addition, systems that make the appointment scheduling module accessible to patients enable them to choose their appointment time and provide greater visibility for the patient, which can reduce “did not keep appointment” occurrences and administrative costs.

Insurance details retrieval
This is where the efficiency and timeliness of an EHR system matter the most. The easier it is to retrieve patient insurance records (insurance firms, sum insured, premium dues), the smoother the claims settlements process will be.

Seamless integration with existing work flows
A practice may have existing work flows in its systems, and if these have to be integrated with an EHR solution for the practice it is important to consider the ease of such integration and do an impact analysis of such integration.

Compatibility and extensibility for practice
A major criterion for selecting an EHR product should be based on the compatibility of the product with the needs of the practice. The products should also be customizable as per the requirement of the practice, (i.e., changing of work flow for approvals). Practices should insist on free customizations for basic changes and negotiate for other changes, which are more complex.

Decision support features
The decision support system generates relevant reports. The reports help in measuring the efficiency and performance of various operational factors. The system should also provide relevant reports that will provide relevant data for compliance of the MU of the EHR system.

Physicians should ask for a demonstration of the product and should
not limit themselves to the glossy brochures used by the sales
representatives. Physicians and staff should try an end-to-end
entry of the encounter to gauge the effectiveness of the system.

Electronic prescription
Electronic prescription allows the prescriber to electronically transfer the prescription over to the pharmacies. The speed of e-prescription (eRx) along with accuracy helps reduce cost, while also improving patients' safety. eRx also helps reduce paper work and improve efficiency among other benefits.

With the benefits it carries, eRx is becoming an integral part of EHR solutions and decision makers should evaluate this feature carefully.

Backup and restoration
Murphy's law states, “If something can go wrong, it will.” Hence, it is important that the solution has robust backup and restoration capabilities requiring minimal user intervention.

Integration
The solution's ability to integrate with external/third-party systems, such as clearing houses, payers and labs, will help practices streamline operations and gain faster access to information.

Recommendations
Some of these features might not look too appealing or relevant; however, it is highly recommended that decision makers evaluate the need for these features. The owners should insist on customer references that can be contacted to help in the evaluation of the products' efficiencies, relevance and maturity.

Licensing
Physicians should understand the licensing terms of the EHR product, including the license fee and license renewal frequencies. This will aid in better revenue forecasting and business planning. The products are usually licensed on the following terms: per user/per month, one-time fee and annual fees. Practice owners should understand which model works best for them in the long term. The owners should also check for discounts provided on longer commitments.

Training
Another important factor for a practice owner to consider is the amount of training required before staff can use the system effectively, and if the training costs are included in the licensing fees.

Implementation charges
Owners should also determine if there is an implementation charge levied by the solution provider during the implementation.

Upgrade/update charges
With changing standards and new guidelines and rules being rolled out by authorities on a regular basis, there is a constant need for upgrades to existing solutions. Practices should get a clear understanding of the inclusion of upgrade costs for any future compliance demands arising from updates to the MU definition or other healthcare and IT standards.

Financial health of the vendor
One of the most important factors is to ensure that the EHR vendor is financially stable, and some of the key factors to look for are: longevity of the company, customer list, annual revenues and management team.

Eye on the future
While selecting an EHR product, physicians will be well served if they factor in future possibilities. For example, is there a plan to accommodate another practice in future? If so, is the product extensible to accommodate such an inclusion?

Support
Most product vendors usually provide different levels and types of support based on the flavor of the product purchased by the customer. The nature of support (e-mail, voice) and service level agreements for resolution should be considered and finalized during the time of negotiations.

Recommendation
With the vendor's ability to squeeze in more charges at later stages of engagement, it is very important that practice owners seek clarifications and get comfortable with the factors highlighted above. These factors are most often missed during the decision-making process and can result in higher costs in the long run.

Technology
The clinical management systems are available on various technologies and each has its benefits and disadvantages.

SaaS (service-as-a-software)-based solutions
In SaaS-based solutions, the application and the data are hosted by the service provider at a remote site and are generally easier to implement as they require minimal infrastructure. As a result, a practice can get started with few hassles. In addition, these solutions can be more cost effective, as the cost is distributed over a period of time and have less administrative overhead.

Client server
In client server solutions the software is installed on a server inside the premises and is accessed by the users with workstations called clients, which are physically connected to the server over a high-speed network.

The main advantages for client server solutions are the security of data and speed of operations. These solutions can be beneficial when the practice is large, and they generally require internal IT specialists or third-party IT support.

Recommendation
Each of the technologies mentioned above have its own merits and demerits. While the Web-based solution might work better for individual practices, the bigger practices might benefit from an on-premise (LAN-based) solution. However, the decision makers need to evaluate these carefully before making a final selection.

Conclusion
The adoption of an EHR system by a practice should not be driven by the monetary benefits beings offered by the federal government. Instead, the goal for an EHR implementation should be to improve the efficiency and the cost effectiveness of the practice. Although this article provides various factors on which prospective solutions can be evaluated, the practices should evaluate the various options holistically keeping long-term benefits in sight. For further support, medical practices may also look to enlist the services of qualified independent consultants during the evaluation and implementation process. It is important that the management team provides full support during the implementation of the solution and not give up; initial problems are bound to happen.

Vivek Jain is program director, business application products, healthcare, MindTree.
For more information on MindTree solutions:
www.rsleads/008ht-211

Passage of the HITECH Act provides medical practices a windfall of incentives (ranging up to $44,000) to adopt and use a certified electronic health record (EHR) system in a meaningful way. Because of this, there has been a renewed effort from solution providers to promote solutions as a one-stop shop for all the needs of the practices. At the same time, practices are trying to implement a solution and reap the benefits ASAP. However, before the practices start scouting and evaluating products, it is important to understand that the implementation of an EHR product is a complex activity requiring dedicated effort and due diligence. The numbers of implementations that fail in the first year of their implementation provide testimony to this.

                

This article outlines a few criteria that every medical practice owner should look for in an EHR system in order to make an informed decision.

                

Setting the expectations

                

First, practices should clearly understand, define and highlight the reasons for an EHR implementation, and the benefits they expect from the implementation. The HITECH act and the monetary benefits should not be the criteria or the purpose for the implementation. The practices should start with the list of work flows they would like to get automated. The work flows can be evaluated based on their importance and their impact on the efficiency and profitability of the practice.

                

Standards compliance

                

The healthcare industry boasts one of the strongest compliance standards. The standards are based around two major factors: privacy of patient data; and interoperability and efficiency of the integrated systems (i.e., payers, pharmacies).

                

Some of the most important standards that an EHR product should be compliant with include:

                

HIPAA

                

Title II of the HIPAA Act, known as the Administrative Simplification (AS) provisions, establishes national standards for electronic health care transactions and national identifiers for providers, health insurance plans and employers. The act requires the patient information be kept private and secure. The Act also proposes strict civil and criminal penalties for violations. The standards are meant to improve the efficiency and effectiveness of the nation's healthcare system by encouraging the widespread use of electronic data interchange.

                

The HITECH act of 2009 proposes changes to the HIPPA Title II, extending the HIPAA rules to business associates of covered entities.

                

Meaningful usage (MU)

                

One of the preconditions (under the HITECH act) for availing the incentives is based on the EHR system meeting the various compliance details set by the ONC, and hence physicians have to ensure that the product being considered has the basic MU covered. The rules were finalized last month. The details can be found at http://www.cms.gov/EHRIncentivePrograms/.

                

ICD

                

HIPAA has mandated that the new standards (ICD-10) be adopted by practices by October 2013. Therefore, it is imperative that an EHR product is at least ICD-9 compliant and has the necessary apparatus and plan laid out for a future upgrade to ICD-10 before the set timelines.

                

Certification by federally recognized agency

                

Practices should ensure that the product is certified by a federally recognized certifying agency. However, Health and Human Services (HHS) has yet to announce the list of these agencies.

                

Recommendation

                

It is strongly recommended that practice owners insist that the EHR solution be certified, and the vendor should ensure that the product will be kept up to date with the latest releases in a timely manner without any significant cost to the practice owners.

                

Ease of use

                

Since EHR products are intended to increase the effectiveness of medical practices, it is very important that the products are easy to use for not only the physicians, but also for the support staff.

                

Some of the most basic requirements for the user interface (UI) include: Each operation should not take more than two to three page transitions; the information should not be cluttered and should be easy to read; the UI should be intuitive. For example, the form for insurance filing should match the physical form; the solutions should assist the staff in capturing the right data and avoiding accidental errors.

                

Ease of use applies to the administrative department, as much as it does to the physician; hence it is important that the support staff is able to use it more efficiently, providing the patients a better experience. Physicians should ask for a demonstration of the product and should not limit themselves to the glossy brochures used by the sales representatives. Physicians and staff should try an end-to-end entry of the encounter to gauge the effectiveness of the system.

                

Practice management

                

The beginning of any patient encounter is making an appointment. If this module is easy to use for the administrative staff, then it can mean more patients and more business for the practice.

                

In addition, systems that make the appointment scheduling module accessible to patients enable them to choose their appointment time and provide greater visibility for the patient, which can reduce “did not keep appointment” occurrences and administrative costs.

                

Insurance details retrieval

                

This is where the efficiency and timeliness of an EHR system matter the most. The easier it is to retrieve patient insurance records (insurance firms, sum insured, premium dues), the smoother the claims settlements process will be.

                

Seamless integration with existing work flows

                

A practice may have existing work flows in its systems, and if these have to be integrated with an EHR solution for the practice it is important to consider the ease of such integration and do an impact analysis of such integration.

                

Compatibility and extensibility for practice

                

A major criterion for selecting an EHR product should be based on the compatibility of the product with the needs of the practice. The products should also be customizable as per the requirement of the practice, (i.e., changing of work flow for approvals). Practices should insist on free customizations for basic changes and negotiate for other changes, which are more complex.

                

Decision support features

                

The decision support system generates relevant reports. The reports help in measuring the efficiency and performance of various operational factors. The system should also provide relevant reports that will provide relevant data for compliance of the MU of the EHR system.

                

Electronic prescription

                

Electronic prescription allows the prescriber to electronically transfer the prescription over to the pharmacies. The speed of e-prescription (eRx) along with accuracy helps reduce cost, while also improving patients' safety. eRx also helps reduce paper work and improve efficiency among other benefits.

                

With the benefits it carries, eRx is becoming an integral part of EHR solutions and decision makers should evaluate this feature carefully.

                

Backup and restoration

                

Murphy's law states, “If something can go wrong, it will.” Hence, it is important that the solution has robust backup and restoration capabilities requiring minimal user intervention.

                

Integration

                

The solution's ability to integrate with external/third-party systems, such as clearing houses, payers and labs, will help practices streamline operations and gain faster access to information.

                

Recommendations

                

Some of these features might not look too appealing or relevant; however, it is highly recommended that decision makers evaluate the need for these features. The owners should insist on customer references that can be contacted to help in the evaluation of the products' efficiencies, relevance and maturity.

                

Licensing

                

Physicians should understand the licensing terms of the EHR product, including the license fee and license renewal frequencies. This will aid in better revenue forecasting and business planning. The products are usually licensed on the following terms: per user/per month, one-time fee and annual fees. Practice owners should understand which model works best for them in the long term. The owners should also check for discounts provided on longer commitments.

                

Training

                

Another important factor for a practice owner to consider is the amount of training required before staff can use the system effectively, and if the training costs are included in the licensing fees.

                

Implementation charges

                

Owners should also determine if there is an implementation charge levied by the solution provider during the implementation.

                

Upgrade/update charges

                

With changing standards and new guidelines and rules being rolled out by authorities on a regular basis, there is a constant need for upgrades to existing solutions. Practices should get a clear understanding of the inclusion of upgrade costs for any future compliance demands arising from updates to the MU definition or other healthcare and IT standards.

                

Financial health of the vendor

                

One of the most important factors is to ensure that the EHR vendor is financially stable, and some of the key factors to look for are: longevity of the company, customer list, annual revenues and management team.

                

Eye on the future

                

While selecting an EHR product, physicians will be well served if they factor in future possibilities. For example, is there a plan to accommodate another practice in future? If so, is the product extensible to accommodate such an inclusion?

                

Support

                

Most product vendors usually provide different levels and types of support based on the flavor of the product purchased by the customer. The nature of support (e-mail, voice) and service level agreements for resolution should be considered and finalized during the time of negotiations.

                

Recommendation

                

With the vendor's ability to squeeze in more charges at later stages of engagement, it is very important that practice owners seek clarifications and get comfortable with the factors highlighted above. These factors are most often missed during the decision-making process and can result in higher costs in the long run.

                

Technology

                

The clinical management systems are available on various technologies and each has its benefits and disadvantages.

                

SaaS (service-as-a-software)-based solutions

                

In SaaS-based solutions, the application and the data are hosted by the service provider at a remote site and are generally easier to implement as they require minimal infrastructure. As a result, a practice can get started with few hassles. In addition, these solutions can be more cost effective, as the cost is distributed over a period of time and have less administrative overhead.

                

Client server

                

In client server solutions the software is installed on a server inside the premises and is accessed by the users with workstations called clients, which are physically connected to the server over a high-speed network.

                

The main advantages for client server solutions are the security of data and speed of operations. These solutions can be beneficial when the practice is large, and they generally require internal IT specialists or third-party IT support.

                

Recommendation

                

Each of the technologies mentioned above have its own merits and demerits. While the Web-based solution might work better for individual practices, the bigger practices might benefit from an on-premise (LAN-based) solution. However, the decision makers need to evaluate these carefully before making a final selection.

                

Conclusion

                

The adoption of an EHR system by a practice should not be driven by the monetary benefits beings offered by the federal government. Instead, the goal for an EHR implementation should be to improve the efficiency and the cost effectiveness of the practice. Although this article provides various factors on which prospective solutions can be evaluated, the practices should evaluate the various options holistically keeping long-term benefits in sight. For further support, medical practices may also look to enlist the services of qualified independent consultants during the evaluation and implementation process. It is important that the management team provides full support during the implementation of the solution and not give up; initial problems are bound to happen.

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