What to do Now Before You Purchase an EMR System

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What to do Now Before You Purchase an EMR System

Glenn Susz, BSIT Julie Janeway, MSA, JD, ABD/PhD Karen Sparks, MBEd Overview The health care buzzwords of the moment are electronic medical records (EMR) and electronic health records (EHR). Electronic records are coming fast with the advent of the Presidents Stimulus Package and push to implement EMR/EHR in practices and health care institutions by 2014, and to create a functioning, interoperable National Health Information Network beginning in 2016. The goal here is to create a collaborative health care community where a patients clinical data is available to caregivers regardless of the location or source system, in a manner that meets existing security and privacy requirements. The legislation provides incentive payments to physicians who adopt and utilize EHR, and these bonus payments are tied to the reporting of quality data. Physicians who have a certified EMR/EHR program and who are reporting Medicare quality measures (PQRI) by 2011 or 2012 are eligible for a total bonus payment of $44,000 over five years. Physicians who dont adopt the technology in 2011 or 2012, but comply with the bill language before 2015 can receive a total bonus payment of $41,000 over five years.The incentive payments for physicians will end in 2016 and the penalties for noncompliance will begin in 2015. In 2015, penalties will be a 2 percent decrease of the allowed Medicare charges if the eligible professional does not participate and e-prescribe. The bill establishes a program to provide, among other things, education, awareness, access, equipment, and support to medical and health care providers. The legislation also creates the Office of National Coordinator for Health Information Technology (ONCHIT), which is in charge of the development and nationwide implementation of an interoperable health information technology infrastructure. Under this law ONCHIT will receive a total of $19 billion dollars earmarked for health IT. ONCHIT will receive $2 billion to fulfill its mission, and the remaining $17 billion will pay the bonus incentives to healthcare providers. The Secretary of Health and Human Services has been charged to generate the first set of standards, certification criteria, and implementation specifications no later than December 21, 2009. The HHS Secretary will also be submitting a report to Congress in early 2011 detailing the progress of the program, actions taken by the government to facilitate the implementation, discussing barriers to implementation and completion of the mission, and providing recommendations for fulfilling the goals of the legislation. Regardless of the fact that there is still no real definition of certified EMR/EHR technology that will qualify under the stimulus package, or when the actual payment schedule will be released for doling out stimulus funds, appropriate preparation for the implementation of EMR/EHR is required for success in the medical climate of the near future. So now you know what all the buzz is about, and why its buzzing, but it still may be helpful to understand the difference between an EMR, and EHR, and a PHR. Recently, the National Alliance for Health Information Technology (NAHIT) established definitions for electronic medical records (EMR), electronic health records (EHR) and personal health records (PHR). In theory, and by definition, there

is a difference and it should play into any providers clinical software selection. The NAHIT defines EMR, EHR, and PHR as follows: EMR: The electronic record of health-related information on an individual that is created, gathered, managed, and consulted by licensed clinicians and staff from a single organization who are involved in the individuals health and care. An EMR is generally a record of a single diagnosis or treatment protocol, most likely used by a specialist. Practices that take care of one unique health issue like a bariatric practice will do well with a stand-alone EMR. Certain specialists may not need information about patient history as much as they need specialty-specific workflows and templates, while others, like bariatric physicians and surgeons may need specialized templates and information screens to accommodate information from a variety of other specialty practitioners such as cardiologists, rheumatologists, and endocrinologists. EHR: The aggregate electronic record of health-related information of an individual that is created and gathered cumulatively across more than one health care organization and is managed and consulted by licensed clinicians and staff involved in the individuals health and care. An EHR provides a more comprehensive view into a patients health and history by pulling information from other systems, providing clinical decision support, and alerting providers to health maintenance requirements. It will help providers report and measure quality indicators for pay-for-performance incentives. PHR or ePHR: An electronic, cumulative record of health-related information of an individual drawn from multiple sources that is created, gathered, and managed by the individual. The integrity of the data in the ePHR and control of access to that data is the responsibility of the individual. To be most effective, a PHR should include cumulative health information ranging from past and current illnesses, treatments, diagnostics tests, health provider contact information, demographics, allergies, prescriptions, and more. Given the nature of the PHR, it is the individuals responsibility to decide what information is stored, and who has access to it. Microsofts HealthVault and Google Health are two prominent examples of PHRs. So why is there confusion regarding the use of the terms EMR and EHR? Despite the NAHIT definitions, the market is still figuring out which definitions to adopt based on common usage and understanding, rather than on actual definition. For the purposes of this article, we will be using the combined term EMR/HER, and discussing EMR/EHRs in the context of the individual bariatric practice, not in the context of a larger organization such as a hospital, health care system, or educational institution. Regardless of the terms being used or misused, the key decision process for selecting an EMR/EHR is to map out your organizations requirements and methodically assess systems against those criteria. Justin Barnes, Chairman of the HIMSS Electronic Health Record Association and VP of Marketing and Government Affairs at Greenway Medical Technologies, believes the future of health care IT is interoperability. Interoperability, or the ability to exchange data with other EMR/EHR programs, and the ability to eprescribe are key program qualifications for receiving stimulus funds under President Obamas plan. Interoperability is termed enterprise integration in the law and is defined as the electronic linkage of health care providers, health plans, the government and other interested parties to enable electronic exchange and use of health information among all the components in the health care infrastructure in accordance with applicable law. Interoperability is the ultimate goal to facilitate the National Health information Network, and to provide patients with better continuity of care, and better access to care.

It is also a key factor in creating more efficient and successful practices that provide better and more informed care for patients. For many bariatric practices to be successful, moving to electronic record keeping will require more than just selecting a vendor and installing the software. Much has been written about all the benefits of EMR/EHR and the incentives available from the Economic Stimulus Package. Even without all the hype, bariatric practice decision-makers should internalize the fact that the benefits are real and costeffective given the forthcoming stimulus funding. With all that being said, the problem practices and other health care institutions are encountering is that there is a head-long rush to install an EMR/EHR program and everyone is getting themselves in a panic. With little guidance on adequate preparation requirements for the selection of a technology platform, buyers rush in all willy-nilly and glassy-eyed from seeing the wonders the programs appear to be able to provide, and vendors are simply rubbing their hands with glee. The reason practitioners are experiencing so many problems with EMR/EHR implementation is that they arent prepared and dont really know what they want and need, nor how to make it work for them. Private practice, fee-for-service physicians are struggling with balancing productivity and technological advance versus quality of care. Traditionally, patient information is recorded in process, not later, so many physicians and other practitioners are reluctant to get in the electronic medical record game. Additionally, many feel that the use of EMR/EHRs shifts the paradigm from paying attention to the patient to paying attention to the computer. It doesnt have to necessarily be so. Cost is another major stumbling block with implementation. It has been estimated that purchasing and installing EMR/EHR will cost from $10,000 to over $30,000 per physician, and additional maintenance cost of $1,000 to $2,000 per month. Yet vendor costs only account for approximately 70% of the expenditure, the rest may come from storage costs, and maintenance fees. Knowing where all the costs lie, and whether or not you should be paying extra for them is part of doing your homework and making implementation a success. To gain the most advantage you will need to look at more than the financial cost and features offered by the EMR/EHR program. You need to look at the Total Cost of Ownership which includes all of the direct and indirect costs incurred from preparation through implementation, use, and retirement of the system. For example, bariatric practices should be looking at the direct financial costs of a wrap around program that includes features like: Automatic BOLD data entry Scheduling Demographics Patient History, Intake & Registration Patient Communication & Interaction Patient Information & Education Clinical Documentation Office & Procedure Workflow Messaging Document & Data Management E-scripting Billing & Coding Claims Management

Collections Comprehensive Reporting Administrative Components Voice Dictation Ancillary Product Management Marketing Interfaces Ease of Implementation Adaptive Work Flows Effective, Professional, In-Person Training On-going Technical Support Adaptability Ability to Customize Data Collection and Reporting Internet-Based System Secure Data Storage Privacy & Disaster Recovery Video Service Agreement Miscellaneous Features

And, bariatric practices should also be looking at indirect costs associated with things like implementation time frames. Consumers should be aware that the average time for full implementation of a new EMR/EHR software program runs something like this: Phase 1: Preparation: 60-90 days. Phase 2: System Selection: 30-90 days Phase 3: Implementation: 45-180 days Phase 4: Post-Implementation: 6-12 months.

So the estimates of the total calendar time from the beginning to the end of the implementation time frame (not counting Phase 4) is about 135- 360 days (3.5 - 12 months). This is a considerable commitment of time, and indirectly, money. Additionally, other time and effort has to be calculated into the Total Cost of Ownership. Practices should be aware of the implementation time frame, and its breakdown shows that EMR/EHR programs are not simply fix-all programs that can be purchased and implemented in a completely turn-key manner. With proper preparation, planning, and technology selection, the Total Cost of Ownership can be appropriately managed and better controlled, and many of the barriers to implementation can be avoided. With this in mind, what is needed is an understanding of what to do before the purchase decision is made. This guide will prepare you for a smooth implementation and a total understanding of the cost and effort required to successfully implement a new EMR/EHR program in your office. Start by doing a complete assessment of all the factors. This will help you and other decision makers to understand the mind set of EMR/EHR implementation, how people will interact with the system, the required organizational habits and changes, as well as employees ability and willingness to change. A simple approach to starting an assessment is to group issues and concerns for review by the

following categories: practice goals, people, process, and technology. This will help you to assess the true cost and effort of installing an EMR/EHR. These groups can be summarized as follows: Practice goals The direction and business objectives of the practice. Without a clear picture of where the practice is now, and where it is heading, appropriate process, business, finance, and technology planning cannot take place. Do you want to stay small? Do you want to have several locations? Do you want to add physicians? Do you want to expand the service lines offered? Do you want to franchise? Do you want to change locations or premises to a bigger or smaller space? These are the types of questions that must be explored in this category. People Organizational structure; human capital management; leadership development; recruiting; performance management; and training and development. This involves exploring all the key issues related to employee and staff involvement and interaction with the recordkeeping and data management process. Process The business activities performed by the enterprise - includes associated sequence, rules, data, service lines, workflow, and metrics information. A process can be defined as starting with a trigger event that creates a chain of actions that will result in something being prepared for a patient/customer of that process. Focusing on high frequency transactions can be of significant benefit to the standardization of the process, but remember that examination of the non-standard transactions (where service may be slipping most or the potential for significant failure in the process may exist) can provide significant benefit to the standardization and improvement of the process as well. In short, know the strengths and weaknesses of your current information collection and dissemination process. You have to look at improving the way you do business, not just automating what you already do that isnt really working anyway. If you automate a bad system, all you are doing is adding a technological component to an already bad system. Then it becomes easy to blame the program and continue to ignore the process. Technology Data, applications, hardware, and technical infrastructure to achieve the practices goals. Now that you know where you want to go, what you want to achieve, people and manpower issues are clear, and the process is developed and refined, technology can be introduced to ensure consistency in application of the process, and to provide the thin guiding rails to keep the process on track. The technology is only as good as the underlying process. Below is a basic checklist for your office to use in preparation for transition to EMR/EHR. PRACTICE GOALS Practice Direction What do you want to achieve with the practice? In what direction do you want to take the practice? Over what time period do you wish to achieve these goals? What tools and assistance will you need to achieve these goals? How big does your practice want to be? How fast are you growing? How fast do you want to grow? Is there a plan to add other physicians to the practice? What level of involvement are you willing to accept from outside resources to achieve your goals? What is your patient demographic?

Do you want to have ancillary service lines? Do you sell, or want to sell ancillary products in the practice?

PEOPLE Employee Involvement Who will be involved in the process? What are their roles? How do they work together? Do they have the requisite technological abilities to do the job? Do they have the requisite educational abilities to do the job (coding, billing, etc.) Do you have sufficient employees to ensure coverage at all times? Current Employee Skill Set Is your staff computer literate? Are they comfortable using computers? Will added staff or temp staff be required for data entry or use of the software? Can they use any computer programs besides word processing? Software Training Regardless of your staffs computer skills, time will be needed to train them in the use of the EMR. Can this be done during office hours, or will arrangements need to be made for afterhours, or off-site training? Will they require additional training based on their skill level? Are they willing to participate in additional training? Defined Roles & Responsibilities Who will own the various processes? Who will have responsibility for the planning, implementation, and performance? Who will manage the process? Are the current roles and responsibilities properly assigned for an efficient process? Will job duties have to be rearranged or reassigned upon EMR/EHR implementation? Will the process insure the doctor is informed but is not required for day-to day operations? Who will be responsible for ensuring the doctor stays informed. Commitment & Buy-In You and your staff will need to be completely committed to the changes required by an EMR/EHR implementation. What are the current attitudes toward EMR/EHR implementation? Are the key employees committed to improving the system and working together? Are they prepared to do the work to fix any problem? Patient Volume and Office Size Two simple items to be aware of are quantity of patients your practice services, and the staff using or having access to the software. Many software packages purchase price and/or license fees are based on various factors such as the number of patients tracked by the software, or number of physicians using the software. How many physicians are in your practice? Will they all be using the software? How many patients are in the practice?

What is the patient growth rate expected in the practice in the next year, 2 years, 5 years?

Patient Demographics Many EMR/EHRs offer a patient interface or portal, and utilize integrated patient email notification and reporting. These features can greatly benefit your practice, but only to the extent that they are, or can be used by your patient audience. What is the average age of your patient population? How computer literate and comfortable is your patient population? Is anyone in your practice willing or able to teach patients how to use the patient portal? Do you have a back-up plan for patients who cannot or will not use the patient portal? Time Frame Have you scheduled adequate time for appropriate preparation prior to program selection? Have you considered or planned for the actual time it will take to implement, convert, train, and reach the point of effective usage? PROCESS Business Processes and Workflow Software companies typically incorporate best practice processes into their products. Modifying your processes to work with the software may improve your processes. On the other side of the coin, a thorough understanding of your current processes can help you make better technology decisions. Do you plan to automate your existing processes, or do you plan to adapt your processes to the EMR? Will your paper flow adapt to the EMR? Is your process sufficient for your current and planned patient volume and business direction? Have you reviewed the most common transactions in the process for any opportunity for improvement? Have you reviewed the least common, non-standard, or unusual transactions in the process for any opportunity for improvement? Can the efficiency of your entire process be improved? What are the strengths and weaknesses of your process? Where might improvement be made with the utilization of an EMR/EHR? Security & Access Most practices already have some form of security procedures in place regarding access and dissemination of sensitive information. But with the ease of viewing, copying, printing, and forwarding information on computers you may be required to modify or enhance your procedures, both for electronic access as well as access to the facility. Do you currently have data security measures? Do you currently have premises security measures? Are the existing security measures sufficient or do they need to be enhanced? Do you have HIPAA measures in place to guard against the inadvertent release or disclosure of sensitive patient information? Will security measures have to change with the implementation of an EMR/EHR program? Internet Use Policy You may already have a computer on each employees desk that is connected to the internet. You should have an internal policy for internet use and not just during work hours. Do you have an internet use policy for work and non-work hours? Does your use policy cover non-business and inappropriate use? Do you have procedures in place to be able to monitor and enforce the policy?

Business Continuity / Disaster Recovery Plan You will need to insure that the software and your procedures allow you to meet mandated regulations regarding safekeeping and loss of data. In addition to that, you will also want to be able to define acceptable data loss or system outage to determine Recovery Time Objective (RTO) and Recovery Point Objective (RPO). These will help in designing your back-up strategy and network infrastructure. You may be meeting government regulations, but could still suffer a substantial loss of business and/or revenue without a BC/DR plan. Do you currently have a business continuity/disaster recovery plan? Will your current plan still be appropriate with the implementation of an EMR/EHR program? Measureable Metrics - It will help to determine project success if you can set some Critical Success Factors (CFS) and measurable metrics to track improvement in time savings, dollar savings, patient conversion, patient compliance, use of the EMR/EHR, and other factors. How do you currently measure success and progress? How can you improve the process? What are your critical success factors? Do they align with your practice goals and objectives? If you will create new critical success factors after implementation of an EMR/EHR program, how will you measure them? TECHNOLOGY

SaaS/Hosted Solution vs. Client/Server You will need to understand the pros and cons of a webbased, Software as a Service (SaaS) hosted solution versus a traditional In-House system. Hosted solutions are less likely to have post-installation problems and generally have lower capital expenditures. They also usually eliminate concerns over upgrades and obsoleteness; however, you should be aware that some vendors offer a scaled-down version from its client/server version. If you purchase such an option, be sure to obtain rights to the software code in case the vendor becomes insolvent or goes out of business. Your decision here will impact other technical aspects of the network hardware, installation, and some procedures. Workstations Once the office goes electronic: Will there be enough workstations to support the day-to-day business operations? Are the current workstations adequate to support the software in terms of memory, storage and performance as well as operating system (OS) version? Will upgrades and/or replacements be required? Is there enough physical space to put a workstation where it is needed? Do you need to purchase any other accessory items like webcams, microphones, etc.? Is the software best utilized through the use of a particular type of hardware (tablet with docking stations, system with built-in webcam and microphone, specific memory or graphics requirements, etc.)? Do you have sufficient electrical service and outlets for all of the workstations and equipment? Software Compatibility The EMR/EHR software should integrate with existing in-house software such as accounting, billing, and CRM applications, or you may not get the increase in efficiencies and maximum benefit from the system. This could also impact your workflow processes. Are your current software applications up-to-date? Are your current software applications of a standard nature, or are they custom applications?

External Connectivity Do you have requirements that the EMR/EHR software connect to external third parties systems such as hospital EHR systems, Regional Health Information Organizations (RHIO) and Health Information Exchanges (HIE), the Center for Disease Control (CDC), BOLD, or PHRs such as Google Health, Microsoft HealthVault, or WebMD? Is an EMR or EHR more appropriate for your organization? Network Infrastructure Above and beyond the cost of the software and workstations, you will need to understand any additional required changes to your network. Will you need Internet access? If you currently have access, is the bandwidth sufficient to support the new software and operations? Do you have a firewall that supports your Internet Use and Security Policy? Will you need redundant servers or Internet providers to support your defined Business Continuity /Disaster Recovery Plan? Does the program integrate with your web site? Data Migration/Conversion Have you considered the cost, time, and effort to convert existing patient data into the new system? Depending on the EMR/EHR, can the information be imported into the new system electronically, or will it have to be manually entered? Will documents have to be scanned and uploaded into the new system? Does the new system have fields or buckets for particular data you collect on a patient? Will the new EMR/EHR system electronically import data from a previously employed EMR/EHR system? Training Does the EMR/EHR vendor provide training? In what form is the training provided? (Internet, written training manual, in-person training by a professional technology trainer) How long will they provide training? What level of training is provided (basic, basic through intermediate, advanced)? Is training included in the price, or is it a separate charge? Is the training limited to a certain number of individuals in the practice? If the training is an additional cost, is it on a per session or per person basis? Technical Support The vendor from whom you purchase the EMR/EHR will most likely support their product, but you will need to have someone else available to support your workstations, printers, email, and network. Do you have hardware and internet provider support available? Do you have warranties on your hardware? Summary As you can see from the items listed above, there is a fair amount of effort and planning to be done in order to create your practices IT strategy. In the IT sector, the general consensus is that if you wait to implement your EMR/EHR program you will be behind and probably won't qualify for the maximum reimbursement provided in the stimulus package. According to Charles Christian, Director of Information Systems and CIO at Good Samaritan Hospital in southwest Indiana, "It's not time to

panic, but it is also not time to procrastinate. We are expected to do the work and show the outcome of that work before we get a nickel." With the 2011 deadline for the first stimulus package pay-out approaching, now is the time to start your assessment and planning in order to be ready to maximize your federal rebate for an EMR purchase, and benefit your practice and your patients. Often businesses don't want to take the time to properly analyze their requirements, goals and objectives before they embark on new projects. But can you afford not to take the time? Either you invest the time, effort, and money up front to get the right solutions, or you pay later for maintenance costs, ineffective operations, poor employee morale, an inability to make effective decisions, impaired success of the practice, and a negative effect on patient care. Its your call. REFERENCES NAHIT; http://www.nahit.org/ N Engl J Med. 2009;360(15):14771479; http://www.medscape.com/viewarticle/590855 CNSNews; http://www.cnsnews.com/public/Content/Article.aspx?rsrcid=43715 HIMSS Electronic Health Record Association; http://www.healthleadersmedia.com/content/231473/topic/WS_HLM2_TEC/HIMSS09-RecapStimulus-Interoperability-and-More.html Articlebase; http://www.articlesbase.com/ecommerce-articles/the-people-process-technology-puzzle32788.html Glenn Susz is VP of Business Development at APP Design, a software development company delivering innovative software solutions for such firms as Baker & McKenzie, Boise Cascade, WNYHealtheNet, Independent Health, HealthXnet, Mediware, and the first community healthcare networks: the Wisconsin Healthcare Information Network, Western New York HealtheNet , and Healthcare Extranets of New Mexico. He has over 25 years of IT consulting experience in the Healthcare, Financial Services, Securities & Commodities, and Education communities ranging from start-ups to Fortune 500 companies. Glenns business mantra centers on three words: experience, excellence, and commitment. Glenn can be contacted at: http://www.appdesign.com; glenn.susz@appdesign.com

Julie Janeway and Karen Sparks are the owners of LV Medical/Legal Consulting & Training, specializing in bariatrics and lifestyle medicine practice issues. Julie and Karen have extensive background and experience in bariatric practice and program consulting. They consult and train for practices, professional associations, and industry partners across North America. They are the authors of the number one weight loss surgery patient education book in the world: The REAL Skinny on Weight Loss Surgery: A Practical Guide to What You Can REALLY Expect!, They are also major contributing authors of the Encyclopedia of Obesity and contributing authors of Weight Loss Surgery: A Multidisciplinary Approach. Julie and Karen also have two other medical textbooks forthcoming. Let LV Medical/Legal Consulting & Training assist you in moving toward greater success. Remember, a person who graduated yesterday, and stops learning today, is uneducated tomorrow. Julie and Karen can be contacted at www.lvmedicaltraining.com; juliejaneway.lv@gmail.com