The great hunt for an EMR

Benefits, new mandates, and lower prices make now a good time to buy an EMR

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Even though only one in five American doctors are currently using one, electronic medical records (EMR) systems are hardly new. The EMR has been around in some fashion for more than 30 years. Today, there are somewhere between 200 and 500 U.S.-based EMR vendors, depending on whom you ask. The actual number is hard to pinpoint since the definition of the EMR is still—even after all these years—up for debate.

In theory, the EMR sounds like a no-brainer: accurately record detailed and legible clinical notes; populate a comprehensive, lifetime digital record for every patient, which includes medication history, lab tests, and radiology images and can be secured and shared between multiple providers to improve quality of care; provide access to disease management and outcomes information to help medical practitioners make good clinical decisions; prevent medical errors by having complete patient histories on hand, and so on. Yet in practice, only a small percentage of technology-loving doctors are using them.

It's not hard to understand why: Historically, EMR systems have been too expensive and hard to implement for the average provider organization to adopt. They didn’t fit in with typical workflow and, to boot, could take up more, rather than less, of a physician's precious time. Fortunately, as the healthcare information technology industry matures, this is all changing.

A good time to buy an EMR system

There are many reasons why now is a good time to look into purchasing an EMR system. For one, there are finally lots of robust choices on the market, many of them using common technology platforms such as Microsoft Windows and Microsoft SQL Server and de facto standard development environments such as Microsoft .NET and Sun Java.

I spoke with a colleague, Mike Uretz, whose Seattle-based consulting firm, The EHR Group, focuses on EMR vendor selection and contract negotiation. In his view, as EMR systems have migrated from proprietary databases and technologies to mass-market ones, the systems are now easier to implement and support.

Also, in the face of stiff competition, EMR software prices have dropped—in some cases more than 50 percent lower than just a few years ago, Uretz tells me. Along those lines, he adds, vendors are also offering critical services such as user training and support at reduced prices for smaller practices.

If those factors aren’t convincing, providers might want to consider the reality that increasingly, EMR adoption is becoming a federal and industry mandate. Within five years you may not be able to practice without one. On the government side, the Bush administration has been pushing for widespread EMR implementation, with various initiatives and legislation in the works to make it happen. On the industry side of things, "pay-for-performance" requirements from payers will eventually bring stiff penalties to providers who do not conform to quality-of-care and documentation standards now in development. Never before has there been this clamor that we must modernize our healthcare system. The imperative for change is ripe: 80 percent of U.S. doctors today are still on pen and paper.

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What to look for in an EMR

Today, EMR systems are finally living up to the promise of ease-of-use and increasingly can run on small devices and over wireless networks—two areas that have traditionally impeded physician adoption of the systems. However, buyer beware: Much-needed consolidation hasn’t yet occurred in the EMR vendor space. There are scores of small, unproven EMR vendors dying to get your business. Don't consider them, however, if they only have a few clients. Go with a company that you believe is going to be around for a while.

As far as EMR features and functions are concerned, think easy, fast, portable, and flexible. Some things to look for in an EMR system include:

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How to pick a winner

Of course, before you decide on the features and functions your practice needs, it's imperative to conduct a workflow and needs analysis. And that means getting individuals involved from multiple functions across the healthcare practice: administrators, accountants, practitioners, and partners who might have access to the system. The most important level of involvement should come from the caregivers themselves who will be using the systems day in and day out.

You must also have physician champions—that's tough, unfortunately, because the benefits of the EMR often go to everyone but the doctor. The payers and patients are getting better information, but the doctor’s payback is not always clear or immediate.

A bad system might slow you down, and that's pretty bad when time with patients is all you have to sell. However, a good system can improve a physician's productivity, allowing him or her to see patients faster and get to information more easily. Once physicians understand this benefit, they should have an incentive to participate in the selection process.

Next, don't let the vendor drive the process, Uretz advises. Physicians too often spend a lot of time in vendor-led and controlled demonstrations and not enough time presenting their own requirements. Uretz suggests instead: Bring some typical scenarios from your practice to the vendor and have the vendor demo how the system will perform under those conditions.

Finally, be sure to go through the usual (but often neglected) due diligence on the vendors that make the short list. Research the company's history, financials, key executives, and clients; also get an understanding of how the vendor will support you in terms of services and upgrades.

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Negotiation and contracts

Now for the fun part: signing on the dotted line. How much can you negotiate these days? A lot, in Uretz’s experience. License fees, support packages, custom interfaces, training, and other services are all up for discussion.

The support agreement is perhaps the most important document that you will sign. Make sure that it is comprehensive; it should state assurances, escalation policies, problem resolution, and how you will receive updates, new versions, and patches.

When it comes to contracts, nothing is unreasonable or not worth questioning. For instance, consider including a clause on source code escrow. This will detail what happens if the vendor goes out of business or is acquired and how a third-party organization will hold the vendor’s intellectual property and documentation to protect you.

There are also creative ways to ensure contracts are less one-sided. You can suggest caps on fee increases, Uretz advises, and milestone payments at key project phases instead of a large upfront payment.

Selecting an EMR can be grueling work. Depending upon the bandwidth of the people involved and the responsiveness of the vendors, however, Uretz says you can do it over the course of two to four months. No matter how much time it takes, don't short-shrift any step in the process. Because now and especially going forward, the EMR is the cornerstone of every healthcare provider organization. In fact, it’s one of the most important decisions a physician can make in his or her practice.

Note

To contact Mike Uretz, please send him an e-mail at mikeu@EHRgroup.com.

Dr. Bill Crounse, M.D. Dr. Bill Crounse, M.D., is senior director, worldwide health for Microsoft Corporation. Dr. Crounse is responsible for working with industry partners and healthcare organizations to help them benefit from using Microsoft technologies and solutions. Prior to joining Microsoft, Dr. Crounse was vice president and chief medical information officer for Overlake Hospital Medical Center and the Overlake Venture Center in Bellevue, Wash. Also, read Dr. Crounse's Healthcare Web log to get more insights into the latest technologies and trends in the healthcare industry.

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