EMR Vendor Selection

Why is EMR so expensive? This question as it appears can seem simple in nature. While exploring this topic, you can find so many variations in the EMR products with feature and functions. Additionally, as a practice, the question of technical proficiencies needs to be addressed. If a product is more technically advanced than the user, the user will not receive the full usage of the application. If the product is not being used to its full functionality, nobody wins. If this happens, the practice is not satisfied, and the vendor now has an unsatisfied end user. This is why matching up the practice with the right EMR is so critical. The opposite effect can be just as frustrating. Cost is a fact in the investment of an EMR. An entry level EMR can cost as little as $3,000, and advanced level EMRs can cost over $100,000 for a solo physician practice. The word “expense” should be replaced with the word “investment”. Once a practice has converted to the EMR, they can now look back and understand the difference in those two, very different words. When the EMR is running at full functionality, the practice becomes very efficient. No more hunting for paper charts. A single “click” of the mouse, and the patient’s entire record is in the hands of the appropriate user. Multiple users can access the same record simultaneously as well; allowing for greater productivity. The investment now begins to pay dividends. Integrated EMR system vs. modular EMR selection Having a portion of the practice automated can be a benefit, just as it can be a challenge to overcome. There are many EMR vendors that have a Practice Management application built into their system. Many of these products can be a total replacement of existing applications. Some of the EMR vendors have taken a “best of breed” approach, meaning they have focused their efforts on a particular feature or function. Be advised that not all EMR vendors have the capability to integrate with an existing software product. This is all very important to identify prior to committing to an EMR vendor. Running separate systems simultaneously can bring much unneeded frustration if not appropriately integrated in the beginning. The number of modules that can e integrated can vary significantly from vendor to vendor. Consideration of the charge for an HL7 (as explained earlier in this document) interface should also be taken into account. The interface application can cost up to an additional $3000 to keep an existing software application. Proper management of this interface is important. Not, and won’t be, a commodity Delaying the decision to go to electronic medical records to wait for the prices to come down is only adding to the impending conversion. Every patient encounter is adding more paper to be scanned later at additional costs as well. The benefits of EMR are real and can easily be realized in your practice. As the laws of economics begin to play out in the scenario of “Supply vs. Demand” and vendors become busy with installations of EMR applications due to this increasing demand, they will raise the price to offset this demand, costing you more. You may also end up waiting for months and months to be installed or forced to go with a lesser product with faster installation times. Waiting for the prices to come down can hurt financially in the long term. Yes, new companies will pop up and offer great price incentives, however, these price incentives can cause the practice more hardship by buying an inferior product; they may need additional customization and testing. Your practice may become the “test practice”. This can translate into down time and further staff frustration. Your EMR purchase should be a good experience, but one misstep can lead to hardship. Beware of the “As is”, “Off the Shelf”, or “One size Fits all” Marketing Message There are hundreds of thousands of physician practices and no two are alike. With this being said, how can any EMR vendor claim to have a solution that can be “plug and play”? Each specialty has different needs and desires and the practice has different levels of technical aptitudes with which to contend. If a practice were considering one of these solutions, they should recognize the need to change the way their workflow and practice procedures. The cost of these types of systems is less than the competition due to the programming. Each practice operating differently should consider the unique customization they need to fit their practice. This customization is not an overwhelming task to the EMR vendor; nor is it an excessive expense to the practice. Be sure to explore the vendor’s willingness to complete the desired custom forms (templates), facts, and workflow. Remember the word investment. This system will become the life blood of the practice. Plan your work, then work your plan The decision to move to an EMR is a major undertaking. The selection of an EMR vendor is only one small step towards the EMR. Plan enough time to include the other factors of EMR. There are also considerations in computer hardware of many different variations, networking, training and implementation. Each of these factors plays a very important role in the successful transition from traditional paper charting to the EMR. Why should a practice seek out the assistance of a professional EMR consultant? Why not? The decision to move to an EMR is a big step. The practice is now recognizing the need to convert for many different reasons. This should be an exciting time in the practice, not a tumultuous uprising. Working with a professional organization during this time can remove much of the unease from the decision and implementation. Once the EMR selection has taken place, the true work has just begun. A bad experience in implementation can set the practice off on the wrong track. A professional organization can manage this process to ensure timeliness and completion. A practice moving to an EMR has many factors to consider. By hiring a professional EMR organization, the practice can get back to the practice of patient care. A professional EMR consultant has been through many EMR implementations and knows the ins and outs of the industry. This is paramount to the success of your EMR conversion. This undertaking should be considered as a step by step process. 1. Selection of EMR Vendors After spending hours upon hours of time listening to the sales pitch of trained sales representatives, the chance of selecting the wrong EMR is very high. How can you rest assured that your selection is a good one? There are many smooth talking sales representatives that promise the moon and can’t deliver. Once you have committed to an EMR vendor and trouble begins, your chance at retribution is slim at best. Be certain to look before you leap. This is not to say that all EMR vendors are the wrong choice, the question is are they the right choice for you, your special needs, your budget, your technical support requirements, and suited for your medical specialty. This is a huge undertaking. 2. Installation of EMR software This topic is not simple to most consumers of healthcare technology. There are many questions that must be answered regarding computer hardware needs, wants, desires, availability, practicality, budgetary goals, and expected lifespan of technology before you acquire one piece of this computer hardware. There can be many discussions regarding this ever so important decision. We will bring to the forefront the highest level of considerations. a. EMR installation Where to begin? Should a physician take this responsibility on themselves? What happens to the financial strength of the practice if the wrong technology is either bought or sold? These are two very different yet distinct realities. Is this a risk you are willing to take? Ask yourself this question before making a commitment. What is the life expectancy of this computer hardware investment? Can I expect 1-2 years before it is outdated or completely obsolete? With these very basic questions, when does a physician feel comfortable jumping into the EMR world? NOW is the answer. As demonstrated over the past 30 years, information/computer technology is an ever-evolving modern day phenomenon. This is not going to change anytime soon. The fact remains this - every day a physician continues to add paper to the patient chart, another eventual task to convert from paper to an electronic medical record. This equals more labor. Labor is very costly (no surprises here). Taken into consideration this task; think back one year and forward one year. The amount of paper added to existing charts and the addition of new charts can be overwhelming. The decision to move towards electronic patient records should be moving to the top of your practice priority list. The computer hardware is the tool of the trade and improvements in this technology should be embraced, not feared. The cost of paper and storage of the excessive amounts of paper can help to justify the cost of new computer technology. Simply stated, do the math. b. Acquiring computer hardware and managing the timelines There have been so many changes in computer hardware and so many sources to turn to when buying these tools, which is best? How much time are you willing to spend researching computer hardware? How much time do you want to spend researching? What if the wrong technology ends up in your hands? Now what? This is your practice we are discussing. Any disruption can cause a break in the revenue stream. With tight margins working against you to begin with, why run this unnecessary risk? There are experts in the computer hardware field that can help. This can be as simple as a phone call. For more sophisticated installation and networking needs, an outsourced IT company may be needed. Large clinics should have a full-time IT employee on staff. Recommendation: Do not buy the computer hardware until after the EMR has been selected! Each of the EMR vendors has different hardware requirements and minimum specifications. Minimum and optimal hardware designations need to be thoroughly scrutinized. The management of the timelines is equally important. Once the EMR has been selected and installation dates are confirmed, order the hardware. Keep in mind the laws of supply and demand. New great technology may be in short supply due to the demand, and the hardware provider may be back logged for weeks or even months. This is very important to keep in mind. c. Computer hardware setup and Network installation When selecting an IT company to setup your new computer hardware, be sure to check references. Obtain multiple proposals to compare pricing and service levels. Finding a good IT vendor is like finding a good auto mechanic. The good companies are worth their weight in gold. The wrong IT company can take advantage of you both financially and at the service level. Be sure to shop this job. d. EMR training for the doctor(s) and staff How much training is enough? Is the EMR vendor charging enough for the amount of training? Or are they undercutting the training charge only to leave room to come back and charge more? How do you know? Are you and your staff quick learners? Are you used to this technology? A staff member embracing this change vs. a staff member resisting this change can have very different learning curves. This should be an exciting time in the practice, and the desire to take this technology and grow from it is important. The technical proficiencies need to be accounted for. Being honest about your technology experiences and abilities is important for the practice and the training staff of the EMR vendor. This will allow for the right amount of training. This is good financially and will maximize the usage of the EMR. Disaster recovery for EMR is important to keep in mind Are you or will you be prepared in the event of a disaster? What will happen to your practice? What happens to the patient records? These questions should be addressed prior to the unexpected happening. Geography plays a critical role in the type of disaster recovery plan should be put in place. California is prone to earthquake preparedness, while the US Gulf States, for example, are prone to hurricanes and the list goes on. Use one person as the EMR vendor’s main point of contact The designation of one point person can make the research/evaluation process move more smoothly. This person has the ability to delegate different functions of the research, however, that point person should keep all of the information and timelines in mind when moving through the decision making steps. It also allows for the vendor to help with knowing the practice and the practice’s needs. This person can also keep efficiencies in the practice. Too many people getting involved can derive a convoluted outcome in final decisions. Preparing your questions in advance This topic can easily be discussed; however, actually acting on this topic can be another story. What questions to ask? In what order should you ask the questions? Keep in mind as you become more familiar with EMRs, the level and depth of questioning will become more sophisticated as well. Your questioning will change as you learn. This is a good thing. Once you begin to move through the process, your savvy will build. When considering the EMR think about how many times you have been through this in the past; probably never or maybe once. The vendor, on the other hand, is dealing with EMR everyday. In short, they know this technology better than any one and often use this knowledge to their benefit. Their bias will obviously come out as they describe why their product is the best on the market, and why you should buy from them. These questions should be broken into separate categories, i.e. budgetary, payment options, timeframes, computer hardware needs, current automation (replace of integrate with new), installation, networking needs, high speed internet access, routers, adequate training for doctor and staff, completion, and go live goals. Develop your top questions list in the beginning and organize the questions and their answers in an MS® Excel® spreadsheet. This will allow you to quickly include or exclude EMR vendors to your list of viable candidates. The last thing you want to do is sit through a demonstration of the EMR solution and come to the end and realize that this EMR vendor cannot provide your office with a solution to your most basic needs. This is time wasted. If there is anything that a physician’s practice does not want to waste besides money is time, and we all know that time is money. Keep your research as succinct as possible. These top ten priority questions will help you in so many ways. Because each practice is unique, there will be different priorities for each. A simple equation to apply is the 80/20 rule. Spend 80% of your time researching and developing your goals and path to take, spend 20% in action. Good preliminary questions to ask an EMR vendor: 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? Is your software CCHIT certified? If not, why? How often is the software updated? NEXT: Vendor Selection Part 2

EHR Pricing

How Much Will An EHR System Cost You?

September 14, 2009

By Ken Congdon, Healthcare Technology Online

In most instances, it's not too difficult for a business looking to make a significant software investment — say an ERP (enterprise resource planning) or CRM (customer relationship management) system — to put together an RFP and receive some solid, and fairly accurate, cost quotes in return. This has not been the case in healthcare, particularly when it comes to EHR software. Most of the hospital executives I speak with have been frustrated and overwhelmed by the EHR buying process. For example, when they ask vendors how much an EHR system will cost them they are typically given one of two responses — the vendor either does a song and dance to successfully duck the question or they provide the hospital with a pricing matrix containing so many variables it requires an advanced degree in calculus to decipher.

Why is this seemingly simple question so hard to answer? Well, unlike ERP and CRM systems that are mature and have most common system integrations standardized, EHR systems are still in their infancy. Therefore, the truthful answer to the EHR cost question is "it depends." It depends on the size of the hospital, the implementation cycle, the legacy systems involved, and whether the software you're evaluating has integrated with your legacy systems before.

The one universal truth in all scenarios is that an EHR system is going to be expensive — it's just a matter of how expensive. For example, I've heard of EHR system price tags for 500-bed hospitals ranging from $10 million to $70 million. What's the reason for such a huge discrepancy and how can you know whether your hospital requirements will correlate to an EHR system that costs $10 million, $70 million, or somewhere in between? The information below illustrates the reasons for EHR cost discrepancies and hopefully will provide you with a framework to get more concrete and consistent quotes for your EHR project based upon the requirements of your hospital.

Ensure You Compare Apples To Apples When It Comes To EHR Systems
One reason hospitals often become frustrated with the EHR evaluation process is because they compare EHR solutions that are built on completely different underlying technologies. There are three main frameworks for EHR systems: 1) server-based EHR systems, 2) ASP (application service provider)-based EHR systems, and 3) open source EHR systems. Each of these EHR system models has their own distinct pricing structure, capabilities, and internal IT requirements. For example, vendor-built, server-based EHR systems typically carry the heftiest license fees (upwards of $75,000 each) and overall costs ($25 to $50 million for a 500-bed hospital), and upgrades to these systems must be uploaded on a regular basis by IT personnel. However, vendors offering server-based solutions typically work closely with hospitals to build custom integrations to legacy systems, upgrade the system based on client feedback, and provide service and support to the system throughout its life cycle. ASP-based EHR systems have lower license fees (around $6,000 each) and, because the solution is hosted, the ASP automatically implements upgrades. However, with this model, EHR data resides on the ASP's offsite server, requiring the hospital to relinquish control of its data, including disaster recovery capabilities. The open source EHR model has proven to be an affordable alternative to proprietary vendor systems. In fact, 320-bed Midland Memorial Hospital in Texas is reported to have implemented an EHR system based on a commercialized form of the open source VistA EMR operating in all veterans hospitals across the country for approximately $6.4 million overall. The downside to this model is that it requires a great deal of internal IT labor and expertise to develop custom legacy integrations. Furthermore, the open source community — not a vendor — is typically responsible for upgrading the system over time. You can streamline your EHR evaluation efforts by first deciding which EHR model is best for your hospital and then only comparing EHR offerings built on a common model.

How Common Are Your Legacy System Interfaces?
An EHR system must interface with the disparate practice management, laboratory management, diagnostic, pharmaceutical, accounting, and other systems already in use at a hospital. The cost associated with these interfaces depends on the "uniqueness" of your legacy systems. For example, if you have a practice management system from a popular vendor, then it's more likely that an EHR provider has already developed integrations with that system. This will help keep your integration costs low ($2,500 range). However, if you use a lesser-known, discontinued, homegrown practice management application, then a vendor may need to develop integration scripts from scratch — raising your integration costs to $8,000 or more per application. By knowing the systems you'll need to integrate with an EHR prior to evaluation, you can make more informed vendor decisions and control your overall implementation costs.

Get What You Pay For When It Comes To EHR Implementation
From what I've learned, the average EHR system implementation cycle is between three and five years and the cost of implementation services can range from $3,500 to $10,000 for ASP systems and $20,000 to $40,000 for server-based EHR systems. However, different vendors may have very different ideas of what those implementation services will include. You'll want to clarify this deliverable with your vendor prior to signing a contract. Quality implementation services should include workflow analysis and redesign, template customization, and staff training and shadowing.

While I know the information contained in this article won't allow you to precisely calculate your potential EHR spend, hopefully it does help provide you with a starting point and game plan in which to collect some more specific and accurate answers to your EHR cost questions. Finally, it's important to remember that implementing an EHR system is a journey rather than a destination. In other words, you're never really "done" implementing an EHR system. Ongoing use of the system will always require additional integrations and upgrades that will carry with them recurring costs. The information contained in this article is only intended to help you evaluate costs for implementation of the initial system.

Vista EHR Clinical Case Registries

The Clinical Case Registries (CCR) application contains demographic and clinical data on VHA patients with certain clinical conditions. CCR is designed to allow multiple registries to be supported to track a variety of clinical conditions or disease states.

CCR uses pre-defined selection rules to identify patients with registry-specific conditions, such as a disease-related ICD-9 code or a positive result on an antibody test, and then adds these patients to the appropriate registry in a pending state. Pending patients are reviewed by the local registry coordinator and if the data confirms the diagnosis, the local registry coordinator confirms the patient in the registry.

CCR accesses VistA files that contain information regarding additional diagnoses, prescriptions, surgical procedures, laboratory tests, radiology exams, patient demographics, hospital admissions, and clinical visits. This access allows identified clinical staff to take advantage of the wealth of data supported through VistA when managing specific patient populations.

Data from the registries is used for both clinical and administrative reporting on both a local and national level. Each facility can produce local reports containing information related to patients treated in their system. Reports from the national database are used to monitor clinical and administrative trends, including issues related to patient safety, quality of care, and disease evolution across the national population of VHA patients.

CCR provides these key features:

·         Automates the development of a local list of patients with a specific condition.

·         Automatically transmits patient data from the local registry to a national database.

·         Provides robust reporting functions.

·         Facilitates the tracking of patient outcomes relative to treatment.

·         Identifies and tracks important trends in treatment response, adverse events, and time on therapy.

·         Monitors quality of care using both process and patient outcome measures.

Two of the larger Clinical Case Registries (CCR) are:  HepC, which tracks patients with Hepatitis C; and HIV, which tracks patients who have positive HIV titers.

Vista - HealthDataRepository

Health Data Repository

The Health Data Repository (HDR) is a national, clinical data storehouse which supports integrated, computable and/or viewable access to the patient’s longitudinal health record. The HDR will be the authoritative source of veterans’ clinical data when complete, and currently serves as the authoritative source for data from Department of Defense (DoD) Clinical Data Repository (CDR) and for the Home TeleHealth Program.

The overarching business need for the HDR is the integration of clinical patient data from across VA, as well as from participating external health care systems. Health care providers, including direct care providers within and outside of the VA, business office personnel, researchers, and management staff all require integrated clinical patient data to provide and improve health care delivery to veterans. This functionality does not currently exist in VistA, and is a cornerstone for the next generation HealtheVet.

HDR Interim Messaging Service (IMS)

HDR Interim Messaging Service stores clinical data in a standard messaging format from all VistA systems for a select number of clinical domains.  It provides patient-centric data in a computable form to user interfaces such as Remote Data Interoperability (RDI), Clinical Health Data Repository (CHDR), Home Telehealth, and VistAWeb to support patient care.

HDR Historical (Hx)

HDR Historical stores all clinical data from VistA not contained in HDR IMS and not identified for inclusion in HDR II. It provides historical clinical data in a computable and/or viewable access form to user interfaces such as RDI, CHDR and VistAWeb to support patient care.

HDR Data Warehouse (DW)

HDR Data Warehouse stores a copy of all clinical data in the HDR and makes it available for use by those performing warehousing activities such as research and management analysis. Relieved of the requirement to support such resource intensive data runs, the HDR real-time database can maintain better performance and response times to all direct care applications and systems.

HDR II

The ultimate database solution, HDR II is a relational database that replaces HDR IMS, and stores discrete data rather than messages. When deployed, it will enable providers to obtain integrated data views and acquire the patient-specific clinical information needed to support treatment decisions. HDR II will serve as the primary source of clinical data for the legal medical record. It will maintain data supporting core business functions and serve as a platform for new and re-engineered HealtheVet applications.

Vista Mother of all EHR EMR Softwares

HealtheVet-VistA (Future)

A strategy has been developed to move the Veterans Health Information Systems toward “HealtheVet,” an ideal health information system to support the ideal veterans health system. Collaboratively among the Department, field, and central office leadership and the Chief Information Officer, a proposed strategy has been developed for both VA and Veterans Health Administration needs. The strategy is built around five major systems and integrates five cross-cutting issues:

·         The Health Data System Health Data Repository (HDR) will create a true longitudinal health care record, including data from VA and non-VA sources. The Health Data System will support research and population analyses, facilitate patient access to data and sharing of information across VHA, and improve data quality and data security. The Health Data System will also emphasize “eHealth,” to include prescription refills, appointments, fillable forms online, and My HealtheVet (access to health record, on-line health assessment tools, and high-quality health information).

·      Provider Systems support health care providers' care for veterans and feed information to VistA today and the HDR in the future. These include CPRS, VistA Imaging, Blood Bank, Pharmacy, Laboratory, and Federal Health Information Exchange (FHIE).

·      Management/Financial Systems include four applications that are each ten or more years old, and will be replaced: the Financial Management System, Billing and Accounts Receivable (AR), and Fee Basis (paying providers).

·      Registration, Enrollment, and Eligibility Systems will be developed as a single, department-wide data system and demographic database that supports registration and eligibility for the three Administrations, and makes this information more accessible and consistent.

·      Common Services develops and maintains the underlying software infrastructure that supports both legacy and current veteran health-related applications. Though largely transparent to end users, Common Services provides essential infrastructure elements such as identity management, security, message routing, transformation, and data transport for clinical and administrative applications. Core common services are addressed through four programs:  Identity Management, Security Services, Messaging and Interface Services, and Other Common Services.

Requesting Software

VistA software applications publicized in this booklet are releasable through the Freedom of Information Act (FOIA), except as noted below. 

Information regarding the purchase of VistA and/or VistA Imaging software may be obtained from the

following Website:  http://www.foia.va.gov/FOIA_Frequently.asp

Under FOIA, certain records may be withheld in whole or in part from the requestor if they fall within one of nine FOIA exemptions. Two of these exemptions form the basis for withholding software by the VA:

·         Protects certain records related solely to VA’s internal rules and practices.

·         Protects trade secrets and confidential commercial or financial information.

Also removed are copyrighted dlls, mental health tests, CPT codes, and electronic signature hashing algorithms. (These are detailed in a Readme.txt file on the CDs.)

Note: VistA is a comprehensive, full-featured Health Information System and Electronic Health Record. The software must be properly configured to each healthcare setting by individuals knowledgeable about the software before the system is used to support healthcare delivery. VistA does not self-install.

Requests for agency records or additional information via FOIA should be directed to:

            Department of Veterans Affairs

            FOIA Services (005R1C)

            810 Vermont Avenue, NW

            Washington, DC  20420

EHR Implementation

EMR