Smart EMR Selection

May 1, 2009

You’re ready to buy an EMR. But how do you know which one is right for your practice?


The first time North Shore Cardiology invested in an EMR, its vetting process consisted of exactly one issue - seamless integration between its practice management system and the new EMR. Fluent communication across these two major pieces of medical software, the physicians reasoned, was critically important for paperless success. Surely, matching the brand would guarantee that success, with price and functionality fading to the background. “We ‘needed’ seamless,” recalls Jay Alexander, one of North Shore’s cardiologists. Done deal.

A few months later, the EMR lay essentially dead in the electronic water, with only two of the Chicago-based practice’s dozen cardiologists still consenting to use the system, which turned out to be as flexible as a lifetime civil servant at the passport office. Worse, the group lost about a half-million dollars on the failed endeavor.

“Boy, were we dumb,” says Alexander.

We certainly don’t agree with this harsh assessment. In fact, what happened to these “dumb” heart specialists could easily happen to you.

You’re beyond busy treating patients and running your practice. You know that an EMR would help you, but the choices are overwhelming. Your knowledge is piece-meal and rife with buzzwords. Web-based or installed? CCHIT-certified? E-prescribing? PQRI? Finally, you buy one that “looks good,” but the problem is, it doesn’t work right of the box. And you find yourself having a similar experience to the North Shore docs, with a frustrated staff and a seriously depleted bank account.

But it doesn’t have to be that way. North Shore rallied from its mistake, performed all the necessary due diligence, and is now very happy with its second choice, Minimally Invasive EHR by Medical Informatics Engineering. You, too, can learn to navigate through the selection process thoughtfully and logically to maximize your success. Here’s how.

Commit to the project

Going paperless changes your practice at every level. So the first step is to agree as a practice that you’re going to go for it. This in itself can be a challenge, especially in group practices, because you probably have large variations in age, attitude, and aptitude. “We’re like most cardiology groups,” says Alexander. “Young guys who had EMRs in their residencies, and old guys who couldn’t turn a computer on five years ago. We had a guy who couldn’t use a cell phone. You’re only as strong as your weakest person.”

So ask yourself: Why do you want an EMR? Perhaps some pivotal event convinced you of the need, as it did for Jeffrey Hyman, a practicing internist at Treat & Release Walk-in Clinic in Brooklyn, N.Y. (which is part of the 55-physician, multipractice University Physicians Group, of which Hyman is medical director). A few years ago, he needed a specific patient chart. “It was misfiled,” he recalls. “That was after having 5,000 misfiled charts before. That was the chart I needed; the patient was in the ER. It just pushed me over the proverbial cliff, and I said ‘that’s it.’”

And thus began Hyman’s search for the right EMR. He and the two other physicians with Treat & Release spent six months winnowing down all the choices, ultimately choosing iMedica.

Your ah-ha! moment might not be as dramatic as Hyman’s. But whether by calm discussion or a fiery baptism borne out of disaster, you’ll need to be naysayer-free to ensure ultimate success. Make sure all deciders are on board with the idea of going paperless, or at least that they have their tickets in hand, ready to board.

That said, also be sure to temper any über-enthusiastic physicians so you don’t make a snap decision based on incomplete knowledge. Tina Stuart, office manager for Ohio-based Springfield Urology, loved the fact that the three young, computer literate docs at her practice all wanted an EMR, but she found herself pulling on the reigns time and again. “They wanted it to happen yesterday. I kept having to remind them I couldn’t just press a button and make it happen.”

Understand what’s ahead

List everything you hope the system will do for you. What can’t you live without? Is PQRI something you want to participate in? E-prescribing? What are the drop-dead requirements for your specialty? Specialty practices have special needs, such as a pediatrician’s need to have age- and growth-adjusting benchmarks for young patients, for example.

If you’re in a less mainstream specialty, you might have to negotiate with a vendor to modify its EMR to fit your needs. Springfield Urology found that its specialty was a rarity when it comes to off-the-shelf products. Luckily, NextGen agreed to meet their needs, which worked out well for Springfield Urology. “But we had to wait awhile. It was supposed to be done by February, but the templates weren’t ready until July,” Stuart says. Still, worth waiting for. Here are two other important changes to keep in mind:

Work flow interruptions. There’s one aspect your new EMR will definitely affect, regardless of system choice: “All EMRs impact work flow. Anyone who says otherwise is full of it,” says Alexander. Map out your current work flow to see where certain steps might be eliminated - sometimes literally, such as the time it takes to walk a chart down and put it in the exam door folder-holder. Properly used, an EMR will significantly tighten your intra-office communication. “The back office knows what the front office is doing,” says Stuart. “A doctor can actually see if he has a patient ready. Little things like that sound silly, but people aren’t having to run around the office.”

A paperless work flow also eliminates material waste. Springfield Urology’s surgery scheduler experienced a dramatic change in her workday duties, much to her delight. “She had to make copies and copies of things to prepare for surgeries,” says Stuart. Now, everything the physicians need for the surgeries is instantly accessible. “A piece of paper can get lost; the computer never gets lost.”

Work flow changes also will occur right in the exam room. You’re used to charting by hand. You do it your own way, with abbreviations and symbology that make sense to you and those with whom you work. With an EMR, you’re forced to be more mindful and standardized. You’ll be stepped through the process. The EMR may ask you to make some decisions about how to proceed, depending on your inputs, a patient’s information, and alerts that may pop up suggesting this or that treatment option.

This is all good because you’ll create a more thorough note. But count on it slowing you down while you’re with your patient - a slow-down that may be permanent. “I don’t think you can be as fast on a system as on paper,” says Alexander. “There are so many other advantages, though - the ability to pull data and saving money on not pulling charts are other ways to help your bottom line.”


However, if your EMR is ill-suited for your specialty, then you’ll slow down due to frustration from not being able to navigate the system easily. This was North Shore’s main problem with its first EMR, says Alexander. “The EMR expected us to modify our work flow to the EMR.” Not good.

The money flow. The last preplanning consideration is, of course, the money. Prices vary widely, but “nothing’s cheap,” says Alexander. “You have to believe it’s going to cost you about $30,000 to $40,000 per physician eventually.” Not that you need drop this giant wad all at once. Instead, leverage the cost by investing in a system that offers a modular installation. An EMR so full-blown you suspect it might also whip you up a nice latte sounds great, but you’ll pay dearly if you want it all up front.

Bringing in the system little by little will keep your bookkeeper happy, and it will allow you and your staff time to absorb this paradigm shift gracefully. Don’t tick off your staff with too much change all at once. You’ll get resistance, tension, and money wasted in return.

Take a hard look at your current financial standing, and consult with your accountant about where the money might come from to cover your EMR purchase. This look should include some projection metrics, such as cost-benefit and ROI analyses. Calculate as best you can how your money flow will shift post-EMR. Some metrics to include:

  • Number of patients you see now, and how many you think you can see with the EMR.

  • Staff salaries, and reductions you might make due to increased efficiency in work flow.

  • Cost of handling a chart by hand, including the time it takes to pull it, transport it, lose it, search for it, refile it, etc.

  • Paper, copier maintenance, and other supply costs.

  • New revenue streams from being able to participate in bonus programs, such as PQRI or e-prescribing.

  • Temporary staffing needs to help convert all your paper into a digital form.

Naturally, you’ll want to set a budget. Include implementation, training, hardware, and licensing. This last one can be tricky. One EMR’s licensing may look cheaper at first glance. Find out if said license is “per user” or “per team.” A “per-user” license can significantly drive up cost.

Organize your search

To stay organized and on track when investigating the market:

Set up an EMR selection team. Ideally, the team will have one decider. This will help keep the process from languishing in committee for months. For smaller practices, though, it may make more sense to simply agree by consensus.

But holy cow, there’s so much you need to know. So split up the work. Three-physician Springfield Urology sat down and made lists of what each wanted, says Stuart. From this, they developed a vendor questionnaire. “We each took a point that was important to us, and tried to hit each company with it. I only asked two questions, and each doctor had two questions. That way, we didn’t all have to remember everything.”

Keep your answers in one place. Set up a spreadsheet to house your research, with one column per vendor candidate. Row headers will list aspects for which you need information: vendor history, financial stability, and future plans; certification; system pricing (based on modular installations, hopefully); system functionality and how it fits with your specific needs; technology needs (e.g., desktop/tablet PCs?, wireless vs. wired connection?); and support offerings. Create a separate binder for each vendor to hold any paper-based info each may give you.

Build your candidate list. “When you’re in the hallway doing rounds, or you’re at CME, ask, ‘Which one of you jokers uses an EMR?’” suggests Hyman. “That gives you a scratch list.” Or poll your medical society.

Also, see who’s in the news and what’s being said about this or that vendor. Seek out objective assessments, not just market-speak.

Vet each vendor candidate. Vendors have a product to sell and they’re going to present it in the most positive light possible. It’s your job to ask the right questions so you get a complete picture.

Also, investigate the stability of each company. “You see some [companies] who look like they’re building their EMRs in their basements,” says Hyman. “Look for the company behind the company.” One way to feel good about a company is to find out if its EMR has made the grade with certifying bodies, such as CCHIT, TEPR, AC Group, KLAS, and MS-Hug.

Find out whether you can get to the inner part of the company, says Hyman, because you may discover post-purchase that you need some programming adjustments. “Every doctor charts differently. It’s not standard like banking,” he says. “What’s the accessibility of the engineering team of the company? Too rigid? Stay away. This is not balancing a checkbook. This is how you write.”

Visit other practices. Seeing a product in action at an actual practice is key, but learn from the experience, notes Alexander. “When I went to a cardiology practice, that doctor was more interested in his note, in fitting his info into the note, than he was in the patient. I saw that and I was uncomfortable, but it didn’t hit me; I thought it was him. But it wasn’t.”

Stuart strongly agrees. “It was one of those things that you just have to experience because [all the vendors] say they’re good.”

Test drive each product. There’s nothing like a hands-on experience to tell you whether a product is right for you. “[A vendor] needs to give it to you for a few weeks. It’s like test driving a car. If you don’t do that, you’re making a mistake,” says Alexander.

Be patient

Sure, you’re excited to get rolling with an EMR, and who can blame you? But realistically, your selection process will take six months to a year if you want to end up with a decision you feel good about. It’s much more complicated than, say, a new practice management system. “With EMR it’s a completely different transition,” says Stuart. “There are a lot of little steps that have to be put into place. A lot that can be misunderstood.”

You want to do this right the first time, so take the necessary time to sort out what you want and who you want to do business with to keep you from suffering the same fate as North Shore. “You’re really only allowed a certain number of screw ups,” says Alexander, recalling his own first EMR financial fiasco. “Half a million - that’s the number.”

Shirley Grace is a former associate editor for Physicians Practice. She can be reached via physicianspractice@cmpmedica.com.

This article originally appeared in the May 2009 issue of Physicians Practice.