Selecting and evaluating electronic medical records systems for healthcare facilities

EMR

Electronic medical records (EMR) are the records involving a single healthcare event and is often used in conjunction with the electronic health record (EHR) which is the computerized entire medical history of an individual from all involved healthcare providers seen by the individual (Definition of EHR, 2010). For the basis of this paper, the EMR is the system being evaluated and examined.

As a future healthcare professional, the necessity of learning and utilizing the EMR is of the most importance. In the literature review, there will be numerous categories to help ask the right questions and get the best system for the facility.

Each healthcare facility will be different and have various factors that will need to be examined before an accurate EMR system can be gotten. The size of the practice, number of physicians and providers, and more will have to be taken into consideration. This section will be broken down into several topics in the hopes of gathering the most accurate assessment of the literature.

Selecting the right EMR for Practice

In regards to the 2009 stimulus package funded by the federal government, regional extension offices are to be opened to walk it through the entire process of choosing a system, implementing it, mapping work flows and optimizing the system to help achieve meaningful use. For current EMR users, the centers can help create a plan for optimizing current systems to meet meaningful use guidelines according to Pamela Dolen (Dolen, 2010, ¶4). The centers are not responsible for choosing a system for the healthcare provider but only as assistants in the evaluating, choosing and developing strategies for the particular office.

To get an accurate idea of the system and how it operates, the prospective buyer can request a product demonstration be performed by the vendor. The Healthcare Information

and Management Systems Society (HIMSS) recommends the following:

• Plan on spending about two hours with the vendor for the meeting and demo.

• Minimize distractions. Turn off pagers and cell phones; go off site for the demo if necessary.

• Make sure the right people are in the room. If you're not knowledgeable about billing, coding, compliance issues or scheduling functions, invite those who are to help you properly evaluate the product.

• Use your scorecard to keep track of your thoughts.

• Be proactive in telling the vendor what you want to see. Be the director of the show! Walk the vendor through a routine patient visit and see how easy the product is to use.

• Remember that often, non-clinical sales staff are not adept or comfortable with producing clinical documentation, which is the most important function to you, the provider.

Work hard to keep the vendor on track.

• Ask if you can keep a demo copy or ask the vendor to allow you to enter data. it's a good idea to develop a typical clinical scenario ahead of time and have the vendor show you how to enter that data.

To ensure that small practices do not disregard the benefits of having EMR, in the article, "EMR Electronic Medical Records Software for the small practice - the EMR Puzzle," the author declares

So, in our experience in helping over 15,000 physicians make the transition from paper to electronic, there are five key reasons for the ongoing "EMR Conundrum." These reasons significantly limit small practices from undertaking an EMR. Clearing up these issues will pave the way for a clearer process for each practice:

1. The EMR Process is Confusing: With a dismaying array of products claiming similar capabilities at a variety of price points, how can a small practice evaluate so many possibilities? And what are the odds of finding the RIGHT EMR for the practice? The key here is for physicians to spend as much effort finding a vendor that brings the right "process" of implementation to the table, as well as finding the right EMR program.

2. Lack of Thought-out Selection Criteria: Most practices have not implemented an EMR before. As such, identifying all the right questions at the beginning of the process is crucial. Product, process and vendor selection criteria are often given less consideration than merely acquisition and start up costs. "Total cost of ownership" (TCO) looks at costs over a three or five-year period, not just a purchase price assessment. Vendors who use subscription-based pricing or ASP (remote-hosted) models have an attractive purchase price, however, the costs are almost always higher in the long-term. Gathering product information is easy; but making a decision based on the needs, priorities and constraints of the practice with TCO fully understood is more essential to a successful process. Having a process that "starts with the end in mind," as author Steven Covey suggests, may be the most critical part of the EMR decision. That vision must include TCO and support as important considerations.

3. Uncertainty of Interfacing with Existing Systems Office Technology: Some vendors try to convince physicians that it is in their best interest to abandon the current technology in their office in favor of an integrated office solution. Replacing an existing technology such as practice management system (PMS), billing software, etc. can create a variety of problems. First, it means retraining front office staff on a new system in addition to their role with a new EMR. Second, this can often lead to a "rushed" implementation and/or running two systems parallel until fully transitioned. This is a huge burden and a source of great frustration for office staff. In addition, the practice must continue to run smoothly and patient scheduling must be maintained. Third, replacing a practice management system (PMS) often results in lost or inaccurate billing data, corrupted files and accounts receivable inconsistencies. Not only is replacing a PMS that is already performing risky and time-consuming, it may also ultimately result in settling for a new system that isn't as good as the one you had. All-in-one products have been designed around one application, with the others being far less functional than many "best of breed" products. With growing HL-7 industry standards and increasing partnerships among healthcare it vendors, interfacing between multiple programs has already been achieved. This, in turn, enables physicians to select whatever "best of breed" products are best suited to their practice.

4. Lack of an Implementation and Training Plan: In our opinion, the chief culprit in the majority of failed attempts at EMR implementation lies in trying to rush the installation and declining formal training. Additionally, there is not a solid implementation plan for every worker in the office. Many physicians labor under the mistaken assumption that EMR described as "easy to use" and "easy to learn" translate to "little training required." Feature-rich products that are easy to customize require training, as does learning any new technology. This, however is a small price to pay for freedom from dedicated it staff or constant vendor interference. Still, the key element in having such a powerful, flexible tool that will transform your clinical data-gathering process, is to give extra attention to "process" in the initial stages of implementation. Involving everyone in the office from the beginning and establishing a workable plan will lead to a smooth and successful implementation.

5. Fear That it is Not Worth the Effort: Most small practices feel that their "paper process" is working satisfactorily. Many consider occasional administrative glitches and problems tolerable. This is a costly assumption if providers are unaware of the tremendous impact an EMR will have on the three major axes of 5 any offices' success: financial performance of the practice, quality of care for patients and quality of life for physicians. These issues are addressed in more detail in a subsequent white paper in this series.

Advantages and disadvantages

One advantage of the EMR is the reduction in paperwork that has to be stored or filed. No more piles of records waiting to be filed and less worries about misplacing or losing a patients file.

The American Medical Society and the United States Department of Health and Human Services give the following benefits to the utilization of EMR and HER systems:

Replace paper-based medical records which can be incomplete, fragmented (different parts in different locations), hard to read and (sometimes) hard to find. Provide a single, shareable, up-to-date, accurate, rapidly retrieveable source of information, potentially available anywhere at any time. Require less space and administrative resources.

Potential for automating, structuring and streamlining clinical workflow.

Provide integrated support for a wide range of discrete care activities including decision support, monitoring, electronic prescribing, electronic referrals radiology, laboratory ordering and results display.

Maintain a data and information trail that can be readily analysed for medical audit, research and quality assurance, epidemiological monitoring, disease surveillance, etc.

Support for continuing medical education (Electronic Medical Records, 2010, Benefits of EMR Section).

The main disadvantage of converting to the EMR system relies on the competence of the medical office to convert the paper charts to the EMR system without losing or changing any information. Lost information can result in the wrong medicines, treatments, or diagnosis being performed and injury or death occurring (Silva, 2010, Going Paperless Section).

General Challenges of implementing the right EMR

One of the greatest challenges, especially for offices that have been practicing for a number of years is the transfer of the paperwork from the previous years to the new EMR system (Levine, 2010). Levine noted the following challenges when the vendor chosen sold out to a larger competitor:

1. Customer service, which had been excellent before, became almost nonexistent, and not nearly as professional, when available.

2. The new owner made the financial decision to no longer develop the software and to seek expensive accreditation from the EMR authority, Certification Commission for Health Information Technology (CCHIT). This seal of approval is absolutely essential if one is planning to seek the incentive awards from Medicare for implementation of an EMR (see below).

3. The new owner strongly encouraged all present owners of the software to transition to the company's far bigger, more complicated and definitely more expensive product. The company even offered to move all of the data from our program to its product seamlessly, for a substantial fee (Levine, 2010).

According to Dr. Paul Smith in the article, "Implementing an EMR System: One Clinic's Experience," the challenges for the setting up of the system can be characterized as:

Work-flow analysis and redesign. One of our most important jobs was to analyze every function of every job to understand how tasks were accomplished with the old system. The project team spent considerable time analyzing existing work processes, looking for opportunities for improved efficiency, designing new work flows that could be accomplished with the tools available in the EMR and developing a transition plan. .

Facility modification. To avoid the expense of major renovations, most practices will have to fit the EMR system into the existing space and floor plans, as we did. With our work-flow redesign complete, we had a good understanding of what the patient and staff flow would be with the EMR system functioning in our existing space.

Hardware selection and installation. The choice of hardware for the network and servers is mainly driven by the vendor's requirements and recommendations. Considering how fast this kind of hardware changes, we made sure we had the vendor's latest recommendations before purchasing anything.

Software configuration. Good EMR software can be adapted to your practice environment without expensive custom programming.

Security. EMR software should have the ability to limit access to various portions of the record to particular users. In our practice, each user was only allowed access to the areas of the chart and functions within that area that were required for his or her job duties.

Laboratory data management. We wanted all laboratory test results to be available as soon as we started using the EMR. This required either an electronic interface with each lab or a manual method of data entry.

Templates. A template is a set of structured text elements that prompt the user to add pieces of data to document the medical encounter. Some EMRs require templates for data entry, while others, such as the one we chose, are more flexible, allowing data entry by template, direct entry (typing), dictation/transcription or voice recognition. Developing templates (and even modifying existing templates) requires considerable time and effort.

Developing a backup system. The key is to have multiple methods of backup and recovery and test them before you go live.

Entering old data. The amount of old data to load into the EMR before going live depends on available time and money, and the needs and desires of the clinicians.

Evaluating EMR

The added features of the system need to be carefully studied to ensure that all the requirements of the office are available.

There are several requirements that must be considered when choosing an EMR system and according to HIPAA, they consist of the following:

The record must be totally collaborative to allow anyone in the office to open and chart without regard to others having the chart open.

There must be security. An audit trail.

It must be very customizable for the practice. Customizing must be simple and intuitive but a template which is customized now, cannot in any way harm the documentation done previously with that template.

It must be capable of collecting that information, slicing and dicing it with great discrimination, and conveying that information to other health systems software.

It must be capable of running client-server or self-contained on a laptop.

It must be affordable. This $25,000 or more per user is ridiculous. A government funded EMR should be affordable out of cash flow -- that is, no upfront purchase of the software, but rather, turnstile pricing.

It must be intuitive.

It must be "graded" in its operational capacity. A new user can use obvious features but as they mature in their EMR awareness, more features can be accessed. There is nothing like "need" to inspire to user to learn another step. That is, filling out a lab form is too slow and so if the user wishes to switch to a bidirectional lab interface, it should be available. If they don't care, then at least give them the option of the software filling out the lab request form.

It must be easy to assist users who experience difficulty. This is one of the most important items by far. The ease of assisting a user will make or break many EMR installations. My preference is to have the ability of the user, with a single click, to show their desktop to technical support, whether that technical support is in their large facility or in another prearranged site.

It must be easy to update, including all the SQL schema changes, executable versioning, new clinical content, and so much more without the use of it staff. If for every update, someone in the practice must go from computer to update it, updates will never get dispersed. Already the bar is too high.

It must be relatively simple to install, not requiring a dedicated it professional.

It must be capable of allowing the practice to be paperless. To design it short of that would ignore a significant percentage of the market. That means document management in the many forms of documents -- tif, jpg, doc, txt, pdf, Outllook emails, html, and even CCR. Additionally, it should be capable of outputing all those scripts, excuses, referrals, letters, and more. It should handle telephone triage (as it's called in pediatrics) without generating a sticky note for the chart. It must have a forms feature.

It should have alerts, messaging, and reminders for those who wish to use them.

It must be fast. You want no one complaining of speed. (Requirements of an Efficient EMR, 2009).

Right design

To help in the decision of which EMR is right for the practice, OpenClinical.org states,

"The eight core capabilities that EMRs should possess are:

Health information and data. Having immediate access to key information - such as patients' diagnoses, allergies, lab test results, and medications - would improve caregivers' ability to make sound clinical decisions in a timely manner.

Result management. The ability for all providers participating in the care of a patient in multiple settings to quickly access new and past test results would increase patient safety and the effectiveness of care.

Order management. The ability to enter and store orders for prescriptions, tests, and other services in a computer-based system should enhance legibility, reduce duplication, and improve the speed with which orders are executed.

Decision support. Using reminders, prompts, and alerts, computerized decision-support systems would help improve compliance with best clinical practices, ensure regular screenings and other preventive practices, identify possible drug interactions, and facilitate diagnoses and treatments.

Electronic communication and connectivity. Efficient, secure, and readily accessible communication among providers and patients would improve the continuity of care, increase the timeliness of diagnoses and treatments, and reduce the frequency of adverse events.

Patient support. Tools that give patients access to their health records, provide interactive patient education, and help them carry out home-monitoring and self-testing can improve control of chronic conditions, such as diabetes.

Administrative processes. Computerized administrative tools, such as scheduling systems, would greatly improve hospitals' and clinics' efficiency and provide more timely service to patients.

Reporting. Electronic data storage that employs uniform data standards will enable health care organizations to respond more quickly to federal, state, and private reporting requirements, including those that support patient safety and disease surveillance" (Electronic Medical Records, 2010, Key Capabilities Section).

Government requirements on any EMR

The government proposed a two phase process for the acquisition of the stimulus grant money for converting to the EMR systems and being able to collect Medicare and Medicaid EMR incentives. On March 2, the Health and Human Services Department outlined how it will roll out an EMR certification program to identify vendors and products that will allow doctors and hospitals to meet the government's "meaningful use" standards (Silva, 2010, Introduction). Silva can be quoted as saying,

"The first phase would create a temporary certification process under which David

Blumenthal, MD, the national health information technology coordinator, would authorize organizations to test EMR modules and give them a federal stamp of approval. The temporary phase would ensure the availability of certified technology before next year, when physicians can start becoming eligible for an estimated $14.1

billion to $27.3 billion in net Medicare and Medicaid incentives made available through the most recent federal stimulus package.

The second phase would replace the temporary certification program with a permanent one that establishes an outside agency to accredit certification bodies under expanded rules. HHS plans to make that change by the first quarter of 2012. The second phase also would permit certification bodies to certify other types of information systems besides EMRs (Silva, 2010, Introduction).

More certifications requirements are being evaluated by the government to be implemented at a future date.

The only requirements at the current time for the EMR system for the certifiers that will evaluate the EMR systems in the health provider's office are very thorough and have to be meet to stay accredited. The Office of the National Coordinator for Health Information Technology says that for certification bodies to be approved to green-light EMR systems, they must:

Maintain their accreditation.

Attend all mandatory ONC training and program update sessions.

Maintain a training program to ensure that their personnel are competent to certify EMRs.

Report to ONC within 15 days any changes that materially affect policies, procedures, personnel, organization, management, location, working environment or facilities.

Allow ONC and its authorized agents periodically to observe on site any certifications performed.

Provide to ONC, no less frequently than weekly, a current list of EMRs that have been certified, including the vendor name, date certified, product version and unique certification number.

Retain all records related to the certification of EMRs for a minimum of five years.

Submit an annual surveillance plan to ONC and annually report results ((Silva, 2010, Additional Information Section).

Conclusion

Setting up an EMR system is a long drawn out process that takes a lot of planning, researching, and studying to get the right system to suit the needs of the healthcare facility. The process for getting the best deal and the required system takes a lot of time and should not be taken likely.

Other questions to ask include:

What is the cost per physician license?

Do you have any existing clients in our specialty?

Does your system come pre-loaded with templates for my specialty?

Is your company the developers of the software or is it re-branded from another vendor?

Is your system client/server-based or ASP based?

Does your system include practice management software?

How many clients does your company have?

Is your system HL7 compliant?

How long has your company been in business?

Is your development done overseas?

Is support done overseas?

How often is the software updated?