Selecting an EHR: Now what?
Moderator: Bill Finerfrock
January 8, 2008
1:00 p.m. CT
Operator: Good day, ladies and gentlemen, and welcome to today’s
RHC technical assistance conference. One note, today’s call
is being recorded.
And now, I'd like to turn the conference over to our host today,
Mr. Bill Finerfrock. Please go ahead, sir.
Bill Finerfrock: Thank you, operator. And I want to welcome all
of our callers and participants in today’s presentation. Our
topic is “Selecting an EHR or Electronic Health Record, Now
What?” Today’s call is part one of a two-part series
on electronic health record and is going to be followed by a call
on Tuesday, February 5th, entitled “Implementing an EHR, Now
What?”
My name is Bill Finerfrock, and I'm the executive direction of
the National Association of Rural Health Clinics, and I’ll
be the moderator on today’s call.
Our presenter is Marian Weber. Marian is a principal with Health
Consulting Strategies. She is a nurse and also has an MBA and has
over 30 years of experience in health care as well as 15 years as
part of that in practice management, spent a fair amount of time
working with both federally health qualified centers and rural health
clinics. She is going to address steps for selecting and/or purchasing
electronic health record, medical record system, and there will
be an opportunity at the end to answer your questions.
The program is scheduled for one hour. We’ll have approximately
a 45 minute presentation with the remaining 15 minutes for questions
and discussion. This series is sponsored by the Health Resources
and Services Administrations Federal Office of Rural Health Policy
in conjunction with the National Association of Rural Health Clinics.
The purpose of this series is to provide RHC staff with valuable
technical assistance and RHC-specific information.
Today’s call is the 21st in the series which began in late
2004. As you know, there is no charge to participate in this program
to encourage you to refer others who might benefit from this series
to sign up and receive our announcement. If you’d like to
do that, you can go to www.ruralhealth.hrsa.gov/rhc.
During the question and discussion, we do ask that you identify
yourself by name and location, what state you’re calling from.
If you have questions on this topic or the next topic, that you’d
like to get in, please send us to info@narhc.org and put “RHC
teleconference question” in the subject line. I also want
to remind callers who have been following along. Hopefully, you’ve
all received the PowerPoint presentation that was sent last week
with a reminder about today’s call.
At this point, I'd like to turn over the call to our speaker,
Marian Weber, and look forward to your presentation, Marian.
Marian Weber: Thank you. Good afternoon. I hope all of you are
enjoying nice weather. I'm located in Northern Michigan and it’s
been a little crazy up here. Yesterday, we had torrential rains
and thunderstorms and tornado warnings and a week ago, we had a
blizzard.
I really am excited about this opportunity. The purpose of this
presentation is to talk about process for vendor selection; not
necessarily to talk about the specific software that’s available
but to talk about how you go about selecting a system and providing
the framework and tools that will make it a little less cumbersome,
a little bit less painful.
So, we’re going to go to the first slide. You’ve decided
to take the plunge. So you need to allow adequate time. This decision
will impact your practice for years to come. It’s very important
that you develop a specific plan and your plan should be logical
and systematic. It should have a typical timeline for implementation,
and that’s usually between 12 to 24 months.
I've known practices that have taken years to implement an HER
system, from the time that they’ve started investigating to
the actual system selection. So it’s going to vary. It’s
going to depend on the size of your clinic, whether it’s a
single specialty or a multispecialty clinic, whether you’re
independent or you’re provider-based organization, etc. So
there are a number of different factors that are going to effect
the time frame.
The other thing I really want to stress is that you need to use
available resources. Don't reinvent the wheel. There are many practices
out there that have gone through this process before you. There
are many associations and organizations that are available to assist
you with this process. The National Association of Rural Health
Clinics’ list serve is an excellent source for being able
to network with your peers. So that’s very important, to interact,
to ask questions, talk to as many people as possible, and stay focused.
Having gone through this process with a couple of different organizations,
I know it’s so easy to get sidetracked, especially if you’re
in charge. If you’re a practice administrator or if you’re
in charge of the operation you will feel pulled in lots of directions.
You have a million things going on at once.
So you need to make sure that when you’re going into this
process, that there is a strong feeling of commitment from the top
down including top-level management, your board, if you do have
a board structure within your organization if it’s a hospital-based
organization – that everyone is aware of what it’s going
to take and they all agree that they’re committed to the process.
The plan. The first step in developing your plan is you need to
identify who your decision makers are going to be. In other words
your project committee, it’s going to be made up of a number
of different people from within your organization depending on the
type of practice structure that you have.
The size of your practice will obviously influence your committee
mix. If you’re a one-or-two-provider organization and have
a limited number of management team members and limited number of
staff, then obviously, your committee isn’t going to be as
large as it would be if you were a provider-based rural health clinic
with multispecialties, and 80 to 100 providers. So that’s
going to influence who’s going to be on your committee.
You want to make sure that you have a very strong physician champion,
a physician who feels strongly about the commitment to move into
an EHR environment and who’s going to be able to provide the
resources that you’re going to need because it is a huge commitment.
You’re going to need to identify an EHR selection project
manager. That may be the practice administrator. That may be someone
who has very strong organizational skills within the committee.
You as a group will make that decision based on what your needs
are, but your project manager also has to be someone who is very
organized and has that ability to keep the project on task and is
committed to doing that.
You want to make sure that you have a very broad range of committee
members. It’s not going to just be management staff. You need
someone from reception, someone from your clinical support staff,
someone from your management team, someone from IT staff if you
have a formal IT department if you’re a larger organization.
If you’re a smaller organization, that may be someone who’s
pretty comfortable with the computer and is fairly familiar with
technology and all the different terminology.
You’re going to need to lay down the ground rules. It’s
just like any other kind of meeting, committee members need to respect
each other. They need to be on time for the meetings. You need to
stay focused and on task. There should be, formal agendas that are
put out ahead of time so that people are able to provide input prior
to the meeting and everyone understands how things are going to
go and how the process is going to evolve.
You also need to allocate time out of the schedule for committee
meetings. Many times, in practices that can be the difficult part.
If you have a provider who’s involved in the committee, it’s
very difficult to carve that time out of their busy schedule.
So you may need to meet, either early in the morning before the
clinic opens. You may need to stay later in the evening. You could
attempt a lunchtime meeting, but many times that does not work as
well, because if you’re running over with patients, it makes
it difficult to stay on task. But you as a group need to determine
what’s going to work best for you.
The other thing I want to comment on the next is that there’s
an aspect of behavioral effect that goes into this committee mix
too.
You need someone who’s going to be extremely analytical
who’s going to be that process thinker, who’s going
to look at all the details, who’s really good at thinking
things through.
And then you also need an optimist who maybe isn’t as detail-focused,
but who,sees the glass is always half full, and when things get
a little rough, when you hit a little bump in the road, they can
keep the committee on track and be the cheerleader for everybody.
And believe it or not, sometimes you even need someone who’s
a little bit more pessimistic, because sometimes they can point
out things or they can bring to the committee some issues and concerns
that they’ve been hearing out amongst staff. So it’s
really good to provide that balance between all of the different
members.
Set goals, that’s the next frame. What would you like your
technology to accomplish? This is really important and it takes
a lot of time to think this through thoroughly.
Think about the way you’re doing things now. You can even
map out an algorithm that goes through every step of the process
in your current clinic.
Begin right from the time that the receptionist receives a phone
call from a patient to when you’re checking them out. You
want to look at how much time you waste right now playing the great
chart race. I know that’s one huge reason for implementing
an electronic health record system.
You want to look at how do we track labs right now? Do we currently
receive our labs via the computer or is everything still paper?
You want to look at coding enhancement features.
How do you currently do your coding and audit within your clinic?
Do you have someone who is assigned to that? And is there a system
in place? How frequently do you look at your coding and how important
is that to your organization?
You want to look at medication management capability, the e-prescribing
segment, whether or not you’re going to include things for
contraindications for the different medications, whether or not
they have the capability of tracking medication refill history.
There are some systems out there that will actually flag the chart
if a patient is getting multiple refills that are considered be
more than the normal number of times within a year.
Many of these systems allow you to develop those parameters yourself.
That’s all part of the system setup.
So those are things that you’re going to want to be thinking
about before you actually develop your request for proposal, things
that you’re going to want to include in your list of “haves”
for your system.
Quality improvement systems for chronic disease management. This
is really becoming more important as we get further down the technology
line and as our (peers) actually are looking for quality within
our health centers and our clinics.
Many systems have ways to track quality indicators. As you know,
there is the QAPI program out there that has been developed by Medicare.
Although at this point in time, there isn’t the enhanced reimbursement
for rural health clinics. We don't know what’s going to happen
down the line, and this may end up being a very, very important
tool for clinics in terms of increasing their revenue enhancement
capability.
The other thing is that it’s really nice when you’re
looking at setting up PI programs within the clinics. We can capture
data that’s going to make it most efficient for us to develop
our PI program data.. Many clinics struggle with this because they
have things that they’re looking at, but in terms of having
a formal practice in place that isn’t painful; it just isn’t
existent many times with the paper chart. When you’re looking
at an electronic chart, there are many systems out there that have
that capability.
So those are things that you’re going to want to look at,
you know. What is our desire for that? And how do we use that now?
And how can we improve that in the future?
Patient information library. What resources do we feel are important?
Do we want to be able to have an online patient education file where
when a patient presents with a new diagnosis, let’s say they’re
a newly diagnosed diabetic and instead of having to go through your
files or search for educational material for them, it’s all
right there within your system. It’s all interconnected and
interfaced.
Patient e-mail or Web access capability. This is another thing
that’s fairly new in terms of technology, and this is where
patients can actually go into your port, your patient port, and
they can request a medication refill. They can actually schedule
their next appointment. They can ask a question of their physician
or provider and get an answer back through their own private patient
portal.
So those are some of the things that you’re going to want
to be thinking about as you’re looking for a system.
Another very important thing to do is to map your workflow. Like
I said previously, make sure you’re looking at how you’re
scheduling, make sure you look at how you’re currently triaging,
how you’re doing your current patient registration. Do you
do a formal registration the day before or when the patient calls
in for an appointment? Or do you wait until they’re standing
in front of you?
Your referral management. In the world of PPOs and HMOs and prior
authorizations this is a very important feature. You know, how are
we currently doing that? And how could we improve that? You want
to be thinking about all of these things.
Patient encounter documentation. Providers, what are the things
that they want to see within their template? Another thing that’s
really handy to do is if you have the capability currently, run
a report, to find out what your top 10 diagnoses are.
And then when you’re looking at a system, you want to look
at those templates. This list encompasses the majority of the time
that you spend with your pts.; 90 percent of our time with these
top 10 diagnoses. Let’s take a look at what they have already
formulated in terms of templates for chronic disease management
and see how well that fits in with how we’re currently doing
things.
Physician orders. How are we documenting orders right now? What’s
our double-check system? How do we make sure that the physician
has signed off if it’s a verbal order?
Results management. Do we currently have the capability to retrieve
results via the computer? Are we still using paper? What do we want
to see down the road?
Even if we currently are using paper, what is the capability for
a system to be able to interface with other systems?
Protocols. Do we want protocols? Do we want, chronic disease management
protocols that will be available online and within our system. Do
we want to setup templates that are set up to be able to cover these
protocols automatically?
Treatment plans. How integrated is the system? Is the system able
to take documentation within a template or within a patient visit
and automatically move that over to the patient history based on
the ICD-9 codes that are built into the system?
How well are we able to capture co-payments right now? When the
patient is checking out or checking in? Preferably checking in.
Are we going to be able to tell right away “Oh, there’s
a co-payment that’s needed that we need to be able to collect
from this patient” or an outstanding balance.
Claims processing. How well are things going to flow from the
actual documented patient visit to our billing process? A lot of
places will call it front office to back office, but how soon well
will the tracking flow?
Checkout process. What do we want to be able to look for in a
checkout process within the system? Do we want to be able to pull
up that patient visit, see what we’ve done, be able to collect
any payment that’s due right at the time, which is obviously
most ideal when you’re looking at revenue cycle management?
And then your medication management, the capability to e-prescribe
to numerous pharmacies, the capability to flag contraindications
within the medication list, and other things that we had mentioned
previously.
You want to do a thorough scan of your present environment. Look
at your current floor plan. Do you have a pod system? Do you have
a system right now that quite frankly isn’t really efficient
in terms of physical space?
Network connection. Even though a lot of clinics and organizations
are going to wireless, many times you still need the capability
to hardwire, especially if you have computer stations for your clinical
support staff or your provider.
So you want to look at that. You want to look at your IT staff
capabilities, and whether or not you need to bring in a consultant
because you’re a smaller clinic and don't have the capability
and staff to do it in-house.
Where do we need to place our connections? Where is it going to
provide optimal connectivity for us? You want to look at exactly
where your computers will be installed to determine wireless component
placement.
In fact, we took blueprints of our different workstations and
mapped it all out. We determined if this is the ideal placement
for computers. We determined how many computers we’re going
to need out at the workstation and that was very helpful.
You want to take a look at whether you’re going to be using
tablets versus a stationary workstation in the exam room. Do your
providers prefer something that’s already in the exam room
or are they going to prefer to carry the tablets with them?
There are many pros and cons of looking at the permanent stations.
If you’re looking at patient confidentiality, you’re
going to need to think about that. How are we going to ensure that
when a patient is in there waiting for the provider, they’re
not able to get into someone else’s record?” You need
to be thinking of all those kinds of things ahead of time.
You’re going to need to look at clinical support staff needs.
When the support staff has been checking the patient in, what are
they going to be using? If you determine that you want the providers
to use tablets or your providers have decided that “Yes, that’s
really the way that we want this to go”, you’re going
to be needing to think about OK, the providers are going to be in
the room documenting the visit at the same time that a clinical
support staff person is going to be in another room documenting
vital signs and getting chief complaints and those other things.
So how is that going to work in terms of flow? You’re also
going to need to look at placement of scanning stations. Where do
we need those set up? How many do we need?
This brings up the question of how are we going to utilize scanning?
Do we want to be able to scan the full chart and completely get
rid of the paper record? Are we going to look at scanning the last
two to three visits and then the last years’ worth of labs
and digital radiology components, consults, those kinds of things?
You need to be thinking about these things as you’re mapping
out what you’re looking for within an HER system. It will
really help as you get into the actual implementation and setup.
The time that you spend doing these things is really going to
make your implementation process much, much, much more efficient.
And obviously, these are things that you’re going to need
to get input from from more than just a physician or other members
of the committee.
So as you’re looking at your committee members and talking
about how this process is going to work, you’re also going
to look at the need for very good communication between both present
committee people and the actual physician staff, provider staff,
front office staff, clinical staff, etc.
So the better the communication, the more successful you’re
going to be.
You're going to need to prioritize your needs. Once you’ve
done your full environmental scan, and you have an idea of how you
want things to be then you need to determine what is most important.
Obviously, everybody wants everything, but, you know, financially,
you have to be realistic.
So you need to look at the budget that you’ve developed
and determine if your desired options are realistic. if you're a
hospital-based rural health clinic, your CFO is going to be very
involved. In a smaller clinic that maybe one or two providers, it’s
going to be the provider staff that have ownership in the organization
that are going to have a lot of say in what your financial budget
is going to be. But you need to take those things into consideration.
And so when you're prioritizing these things, you need to develop
an actual EHR functionality checklist.
And I know a lot of what we’re talking about today is probably
going to seem like a lot of paperwork, but in all reality, it isn’t.
It’s paperwork, but it’s going to help you stay on track.
It’s going to help keep you organized and as it comes down
to the final decision making process, it’s going to make that
function or that decision so much easier to make because you're
going to have actual data to fall back on.
You need to develop an EHR functionality checklist, and there
are many existing resources out there. There are many different
checklists that are out there that you can take a look at and make
a decision regarding which one you're going to use.
There’s one in MedQIC. The Certification Commission for
Healthcare Information Technology has a great EHR functionality
checklist. Medical Group Management Association has many resources.
HRSA also has many resources that are out on the Web on the HRSA.gov
Web site. When you type in “electronic health record”,
it will pull up many links for you.
The next step is taking a look at what’s out there and deciding
what fits your organization best in terms of the checklist. You
can obviously format it according to your needs, but like I said,
when I first introduced the talk, you really don't want to have
to reinvent the wheel. There are many good tools out there. Take
a look at what’savailable and determine which tool you are
going to use.
When you’re prioritizing your functions, you're going to
break them down into “What do we absolutely have to have?
What’s very critical for our operation? What would we like
to have? What would make things easier, more efficient?”
And some things may not be critical for you. You’d love
to have them, but in all reality, perhaps you can't afford them
and these are things you’re going to look at further on down
the line. So your ability to prioritize them ahead of time will
make things much easier.
The next step in this process is the development of a formal request
for proposal. Your request for proposal really needs to be based
on your requirements. That’s why you’ve taken all the
time and effort and gone through all the previous steps, really
looked at what you're currently doing, looked at what you feel you
need to have in order to make your practice more efficient and looked
at what do we really want to be able to get out of that system.
This is also going to allow a side-by-side comparison when you
actually get to the point of doing an analysis of systems. It will
be all laid out there for you in black and white.
There are many sample RFPs available also from HRSA, from MGMA.
There’s a Web site called Orchard Soft that has a very good
RFP form.
Once again, copy and print some of those off, take them back to
the committee and say, “Hey, what’s going to work for
us? What do we like best?” Make your choice that way.
And as I said, you can make changes to those documents that are
already out there and that will cut down the time that you're having
to spend developing them.
The next step would be actual selection of who the vendors are
that are going to be receiving your request for proposal. What you
want to be able to do is narrow down the number of candidates that
are going to receive this to, you know, something that’s manageable.
Usually four to five is a very manageable number.
There’s going to be a lot of work that goes into making
that decision.
There are over 200 electronic health record vendors available.
A lot of things are going to play into this decision , for instance,
your practice management interface capability.
If you currently use a practice management system that you like.
Obviously, you're going to be looking at the counterpart to that,
the electronic health record system that is offered by your vendor
and how well that interfaces, but I would also encourage you not
to not stop there.
Depending on where you are in the process, if your practice management
system is older, you know, five to six years old, 10 years old,
whatever. Or you determine that perhaps this isn’t the ideal
system for you, this is the optimal time to look at what’s
out there.
So you may not automatically want to select the electronic health
record that goes with the practice management system. That all depends
on what your individual situations are.
There may be electronic health record out there that will interface
very well with your current practice management system. And when
you compare these systems side by side, you recognize the fact that
there is another system out there, another vendor out there who
has capabilities that you prefer over your current practice management
system.
Practice size. Most EHR vendors will target a niche. There are
very, very robust, dynamic systems out there that can handle anything
from primary care to numerous specialties. There are some smaller
companies that, perhaps one of their target areas is the rural health
clinic environment.
So I encourage you once again to network, ask questions, call
fellow colleagues out there, call your state association. Find some
clinics that are using electronic health record software that are
comparable in size with yours?
You also want to look at the electronic health record rating.
You can look at ratings over the Internet. If you Google in, it’s
really simple. You just Google in “electronic health record
ratings” and that will bring up a number of Web sites that
have actually rated systems based on different functionalities.
So take a look at those. Do your homework. Make sure that you
talk to other practices and that you have collected a lot of information
regarding what system out there is going to best meet your need.
And now it’s time to narrow the field. You want to be able
to identify a person on the committee who’s going to receive
all the communications and proposals from the vendor. You want to
make sure that that’s very clear in your request for proposal.
Identify who the information needs to go back to. And that person
is going to be the conduit for the rest of the committee.
It gets very confusing if you have two or three people receiving
correspondence at the same time. That doesn’t necessarily
mean that that person is going to be making the decision. It just
means that they’re going to be the point person, and it really
helps keep the communications under control.
You want to develop an electronic health record evaluation form
that is going to assist you in comparing systems side by side. And
you're going to map out vendor one and vendor two, vendor three,
vendor four in all the different areas that you're looking at in
terms of functionality, cost, vendor characteristics. You're going
to rank those and then you’ll be able to compare those and
see who actually stands out in terms of ranking. So that’s
important.
You want to schedule a reasonable number of demonstrations from
your request for proposal list. I would suggest, if you're going
to narrow your list to four to five, that you want to look at, let’s
say the top three to four request for proposals have come back and
make sure that you schedule a demonstration for them.
You can also look at – a lot of vendors have demonstrations
on their Web site. So they have a demonstration that you can download
and take a look at without them actually coming into your organization
and do a full-blown demonstration.
So those are some other things that you can access and utilize
when it comes to narrowing the field.
Encourage all selection committee members to attend all of the
demonstrations. You want to make sure that you have a fair comparison
of all of the products. If you have committee members that are chronically
absent, they’re not going to be able to make that decision.
They’re not going to be able to give you input that’s
going to be able to compare the numerous systems across the board.
So – and, you know, as we talked about that previously,
that’s part of that whole committee selection process. You
have to make sure there’s a strong commitment, not, obviously,
if something happens and – something happened in their personal
life and they can't make the meeting, then, you're going to have
to work around that. But in terms of scheduling the demonstrations,
you want to make sure that everyone’s going to be able to
be available before you go ahead and set it up.
EHR demonstration. OK, now it’s show time. You’re
going to actually have the vendor coming into your organization
to show you their wares. You want to make sure that you’re
prepared. You want to have some pre-defined patient scenario based
on your actual practice experience.
You want to look at, perhaps, some patient visits that you’ve
encountered in the clinic and have them map it out for you. OK,
this is so and so, he is a 35-year-old, you know, juvenile-onset
diabetic who is currently on renal dialysis and he’s coming
in for a follow-up with his primary care physician. Help walk us
through this visit and what templates do you have available that
would make this visit documentation more efficient?
And in that way, they’re having to look at your needs and
show you how they can, be your vendor of choice. Look at what you’ve
prioritized in terms of what you feel is very important.
If you’ve decided that medication management is absolutely
a priority, but right now, you have a process that you would like
to improve, then make sure that they’re able to show you all
the functionalities of that.
Ask to see their sample report. Besides just going through and
walking you through actual use of the system, ask them, “Hey,
you know, we want to see. Let’s go back to that diabetic.
We want to be able to see if you have, let’s say, a fasting
blood sugar log that we can show the patient when they come in.”
So you can say, “Hey, Mr. Jones, look at this. I want to
show you what your blood sugars have been doing over the last year.”
Someone who is – hypertensive, how well have they been able
to keep their blood pressure under control over the last year? And
I know for a lot of people, what they see firsthand in black and
white has a huge impact on them. And for patients, it’s a
great tool for being able to provide some patient education.
Explore all of the system capabilities, as I mentioned earlier
– the note creation. You want to look at labs. How do they
handle labs? How do they handle health maintenance? How are you
able to track someone’s mammography, bone density, their HDL,
their profile over several years?
So you want to look at all the different capabilities and not
just the note. You want to look at other options that they have
for communication. How are we going to handle the telephone note?
How are we going to handle a triage request? How does your system,
work through these things? And how do things flow from one staff
person to another?
And then, once again, you're going to want to have a rating form
that’s all set up in advance. So as you’re going through
the demonstration process, everyone has one of these and is able
to rank the vendor demonstration based on what they’ve seen.
There’s an excellent example available on www.aafp.org. …
Bill Finerfrock: Marian, I think you just said aarp.org.
Marian Weber: Oh, I'm sorry. Correct myself. AAFP, American Academy
of Family Practice.
Bill Finerfrock: OK, thanks.
Marian Weber: You’re welcome. It is an option if you want
to take a look at that form and see how you can format it to meet
your needs once again.
And as you go through the demonstrations, I know, personally,
having sat in on several demonstrations, it’s so easy to forget
who offers what. “Oh, my gosh” you said “This
is from the other system”. So this is the way to be able to
document all of that and keep it straight.
If you have a large organization and you have an IT department,
many times they are very helpful in helping to format these forms
and take charge in getting them distributed and getting them back
and compiling the scores.
If you're a smaller organization, that’s probably going
to have to be something that falls to the project committee member
who is going to be the project manager. So it just depends on the
size of your organization how you're going to handle that.
You need to develop a list of additional questions for the top
two to three vendors – things that you want to ask them outside
of their format RFP. When they’re doing the demonstration,
you're going to want to be able to ask them, “OK, what are
your service capabilities? If we, you know, how often does the system
go down? What’s your backup? Do you have 24/7 support?”
And this is a biggie, “Do you charge extra for support?”
These are the things that you want to ask ahead of time before
you make a decision or they could be very, very costly for you in
the end.
Are any upgrades included automatically in your service fees?
Are these extra? How frequently do they upgrade the system? And
are you going to have to shut down when they’re doing the
upgrade?
Do they – are they able to do the upgrade during the night,
when you're not utilizing the system? Are they able to do the upgrade
on the weekend, when you’re not in the system? Or let’s
say you have an urgent care that’s open seven days a week.
Once again, you know, can they do it during the time when the clinic’s
not open?
A training plan. How do they implement their training? How many
staff, personnel are able to sit in on the trainings and what is
the cost of that? Do they have anyone who is currently utilizing
their system in the area?
Have they worked with other RHCs? Have they worked with other
independent RHCs versus provided-based RHCs? Because there are a
few differences between billing for those different types of organizations.
Do they have a testing plan? How do they make sure that this system
is functioning fully before you implement? That’s also very
critical.
Can the system be implemented in modules or does everything have
to be in place at one time? Can you evolve? Let’s say you
want to go in and you want to be able to use the templates and all
of the clinical functionality and, perhaps further down the road,
bring in the disease management module. Can you do that?
How financially flexible are they? Do they have payment options?
What are their payment options? Do they – some systems actually
will finance your system, do they do the financial backing themselves?
What are their hidden costs? Is there something that’s not
included that’s not spelled out in black and white? What exactly
do you get for the basic fee? And that’s also very critical.
Make sure you check references. Check at least three references
for every vendor and that should include physician users. Make sure
that your physicians are talking to other physicians peer to peer
“Hey, how easy is this to use? What, have you become frustrated
with it? What are some of the templates that you utilize most frequently?
What do you like about this system? What don't you like?”
Make sure you get your information technology group involved.
How reliable is the system? Does it ever “go down”?
How easy is this setup? How costly is this setup?
A senior management person to talk to their administrator. What
were some of your roadblocks in implementation? What were some of
the more difficult aspects?
And make sure that when you’re calling these people and
networking with one another, that you take notes. As I said previously,
it’s so easy to get conversations mixed up, to get systems
mixed up when you're going through this process. So make sure that
you write everything down. It will help when you go back to recall
and compare a system.
Bill Finerfrock: Marian, we’re coming up ((inaudible)) about
four minutes left and move to questions.
Marian Weber: OK, almost finished.
Bill Finerfrock: OK.
Marian Weber: Your vendor is always going to provide a list of
happy customers, but make sure that you outside of their references
and check some your own. You can do that through list serve. I've
seen it on the Rural Health Clinic list serve.
People are asking each other, “Hey, have you used this one?
What do you think about it?” Have a prepared list of questions
to ask when you're networking with your fellow colleagues.
Compare vendor satisfaction with different customers. Do they
like it? What don't they like? What do they like?
And then you're going to need to rank your vendors based on three
major categories – functionality, how well does it work? What’s
the total cost going to be after you’ve done your homework?
And what are their characteristics? Do they have great service?
What’s their training like?
How financially secure are they? This is a huge, companies are
eating up companies. You want to make sure that they’re going
to be there for you in the future.
The committee must determine how you rank the characteristics.
Like I said, you want to set up your three major areas.
There are also vendor selection test tools available on the previously
mentioned Web sites. Make sure you look at cost and you include
everything. Make sure it covers a long-term period, not just short
term.
Set up site visits, look at practices that are comparable to you.
Go out and visit them. Look at them when they’re actually
doing a patient visit. See how functional it is, what you like about
it, what you don't like about it. And then, fill out a final list.
Choose two ; having two helps strengthening your position during
negotiation.
Select your top-ranking system and then start negotiating your
contract. You want to verify your commitment to whatever is the
system is that you chose and make sure that everyone still feels
very strongly that this is your number one contender.
Discuss the choice. You may want to have a repeat demo just to
make sure that everybody’s still on track. And if concerns
are uncovered, be prepared to, perhaps, start midpoint again if
you need to.
You go through formal contract negotiation. Many of the larger
organizations, their CFO will be involved and have an attorney look
it over to make sure everything looks OK and make sure that you’ve
got everything within that request for proposal and that contract
that you’ve negotiated.
I don't think there’s anything else that we need to hit
on. I think at this time, we can open it up for discussion.
Bill Finerfrock: Thank you, Marian. That was a – it was an
excellent presentation. I know I learned a lot and I think there
was a lot of valuable information that we can – that folks
can take away.
At this time, we’d like to open up the lines for questions
and we would like to remind folks that you provide your name and
where you’re calling from prior to asking your question. So
operator, we can go ahead and open up the lines.
Operator: OK, ladies and gentlemen, if you would like to ask a
question at this time, please press star one on your telephone.
A voice prompt on your phone line will indicate that your line is
open. We ask that you please state your name before posing your
question. Once again, it is star one please.
And we’ll take our first question.
Female: Hi, this is Linda from California.
Operator: And colleague, your line is open, please go ahead.
Female: This is Linda from California.
Operator: We can't hear you.
Female: This is Linda from California. Can you hear me now?
Bill Finerfrock: We hear you, Linda.
Female: Hi, how are you? I guess what I'd like to know is who is
e-bay or Amazon.com so we just choose the right product? Has it
been there or down at all to the vendors?
Marian Weber: In terms of – I guess I'm not understanding
what you’re asking.
Bill Finerfrock: Who’s the best one out there? I mean, are
you looking for the name of a company?
Female: Yes, yes. I feel like we’re all researching all of
these different vendors and in the end of the process, there’s
going to be four or five that are successful. The rest of them are
not going to be in business.
Marian Weber: Absolutely. And that is why when we first opened
up the conference, we were talking about the need to follow the
process as it is outlined, and, I'd love to be able to say to you
“Hey, you need to pick such and such, you know, this is a
great vendor.”
But it depends. It depends on the size of your organization. It
depends on what you’re looking for. It depends on what you’re
able to afford. As we mentioned during the presentation, what I
would highly suggest is that you talk to some organizations that
are comparable in size, comparable in structure, and talk to the
people that are actually using it.
Make sure that your providers talk to fellow providers. Because,
I’ll tell what, it’s kind of like if mama ain’t
happy, nobody’s happy. It’s the same thing. You know,
if your providers are not impressed with it and don't like it, then
no matter how well the system is, I guess, supported elsewhere,
it’s not going to work for you.
Bill Finerfrock: Linda, let me ask you a question. How many vehicles
do you own?
Female: Two.
Bill Finerfrock: Two. Are they both the same identical vehicle?
Female: No.
Bill Finerfrock: Why not?
Female: Price.
Bill Finerfrock: Well …
Female: Functionality, yes.
Bill Finerfrock: You know, you may have one that’s based
on price. You may have one that gets better gas mileage, one that’s
more comfortable.
Female: There you go.
Bill Finerfrock: I think that the point here is that, you know,
you’re going to look at different systems and you're going
to base it on what your interest and desires are.
Female: I was in Kansas last September, though, and the same thing
was presented to all of us out there and we’re all trying
to make a decision on a vendor, you know, to all of these steps.
And I think many people have. But what is the outcome? Has that
vendor list been decreased at all? Nobody really knows.
Marian Weber: No, and actually, I think what you're going to find
is there obviously are going to be vendors that are added to that
list and there are going to be vendors that are being brought out.
One thing I would like to say, though, when you are looking at
a vendor, you want to make sure that you know what your rights are
in terms of being able to have access. So that if for instance they
go out of business or things don't work for them, that you still
have the architecture to be able to interface with another system
that's out there.
Female: OK, that’s a good point. Thank you.
Marian Weber: That’s huge. That’s huge.
Female: That’s huge.
Marian Weber: Look what’s happening with the banking system.
The same thing is happening within the EHR environment, so –
and that is one thing that I really wanted to stress on this call
is that there are some key points that you want to make sure that
you're looking for.
Female: And say that again, Marian, about the architecture that
…
Marian Weber: You want to make sure that you have the right to
carry that forward. In other words, that if the system goes defunct,
you have the ability to have another company come in and dump all
of your data and be able to interface so that you can, it’s
not going to completely crush your system and bring you down. So
those are things that you need to look at.
Female: Thank you.
Bill Finerfrock: OK. All right, go on to the next question. Thank
you, Linda.
Operator: Once again, ladies and gentlemen, star one please. And
there are no further questions at this time.
Bill Finerfrock: Well, I – one of the questions I’ll
ask Marian is – that I think comes up is this whole issue
of what they referred to as interoperability.
Marian Weber: Right.
Bill Finerfrock: And can you touch on that just a little bit? Of
what that means and what it is that people need to – is that
– should that be a barrier to making a decision or just something
to think about?
Marian Weber: It’s something you need to think about. And
what you need to think about is what we talked about it in the presentation,
we were talking about things like lab interfaces, your current practice
management system that you're using, digital radiology. How functional
or how well does it interoperate with other systems.
And you want to make sure that there’s a format that’s
HL7, I believe that that’s a format that allows you to be
able to interface with multiple systems as long as they all have
the same format. You want to make sure that the system that you
choose is capable of doing that. And unfortunately, many people
have been burned because they’ve been told, “Oh, yes,
we can interface. We can interface”, but you weren’t
able – they didn’t get down to enough detail.
In other words, you want to be able to say to your vendors that
you’re looking at “OK, these are the systems that we
need to interface with.” You know, how well are you able to
interface? And as more and more clinics and health centers and hospitals
go electronic, you want to be able to talk to each other. So you
need to make sure that the format is the same and is consistent
across all lines. So that is very, very important. And it’s
interesting because some various small companies have that capability.
It just depends on whether or not they have that, you know, HL7
format.
And I will be first one to say that I am not expert when it comes
to the actual information technology, but I do know that it’s
extremely important that you make sure that you get someone who’s
very knowledgeable to check all of that out for you before you make
your selection.
Bill Finerfrock: OK. Operator, any questions?
Operator: We have one more at this time.
Bill Finerfrock: Go ahead – go ahead, caller.
(Mike Rodmick): Hi, this is (Mike Rodmick) from Montgomery City,
Missouri.
Bill Finerfrock: Go ahead, (Mike).
(Mike Rodmick): I have a question. I know with the previous caller,
we discussed trying to limit the 200 vendors down to potentially
a smaller number for those of us exploring this, and I was wondering
if there were any specific references or guidance for EHRs that
have been successful in the rural health environment at least.
Having looked through the information on the American Academy
of Family Physicians Web site, they offer reasonable guidance for
primary care, but again, there was no list or any references that
I find that say, you know, for the specific unique stuff that we
run into as far as billing and everything else with rural health.
Marian Weber: Right. And once again,I would emphasize the need
to network with your colleagues and find out what is out there that
has worked for clinics that are comparable in size, comparable in
structure to your clinic.
(Mike Rodmick): So to your knowledge, there’s never been
a survey or anything like that among the rural health providers.
Bill Finerfrock: I'm not aware of any. ((inaudible)) I don't think
that that’s been done. But I think that – I know on
the Rural Health Clinic list serve, some folks have put some questions
up there regarding systems that they’ve used or are thinking
about and sought solicited feedback from others that may be familiar
with those. I think, as Marian has suggested, that is at least an
interim step. That’s a reasonable place to begin that process.
(Mike Rodmick): It just seemed too intuitive to me that there were
10 or 15 out of the 200 that repeatedly had done well in the group
that we’re looking at or that we’re speaking to today.
I don't know if there was a reference for that.
Bill Finerfrock: There hasn’t been. I think that’s
a good suggestion. What I don't know how many. I mean, this is one
of the questions we don't know is how many RHCs have already gone
down this path to be able to have enough of a base to get a reasonable
survey response from, but I think it’s something we need to
look at.
(Mike Rodmick): Thank you.
Bill Finerfrock: Marian, what is the normal time frame or the shelf
life for a system? How often should people contemplate the need
to either upgrade or get improvements to the system? How long of
a shelf life would – is there – are there any reasonable
estimates there?
Marian Weber: Typically, it’s very important, like we discussed
earlier, that you make sure that your upgrades are included free
in the software support.
Typically, once you purchase a system, as long as it’s an
aggressive vendor and they keep up with all of the billing requirements,
and that is very important. And that’s why I say, you know,
the more homework you can do, the better.
But if the system is able to keep you with all of those changes,
then they’re able to provide the upgrade and those upgrades
are free of charge, then, you're looking at five to 10 years that
it can be functional without having to actually – what really
determines that is how long is the vendor going to be able to reasonably
support the product?
In other words, keep up with those upgrades, make sure the system
remains functional if there are changes in Medicare or Medicaid
requirements, and you know, as long as they’re a strong contender
and they can do that, then, it can go on for years.
Bill Finerfrock: Do we see a lot of, you know, previous caller
mentioned, there are obviously a lot of companies out there and
some entries come in and some go. Do companies typically completely
go out of business or is the norm more that they get bought by somebody.
So rather than – it’s going to be more of a consolidation
environment rather than they’re here today and gone tomorrow.
Marian Weber: Right, what I've seen happen is I haven’t heard
of that many vendors actually just becoming nonexistent. Typically,
what happens is a larger organization will buy a smaller organization
out and then a lot of times, what happens is they choose, or because
of financial reasons or other reasons, to not maintain support of
the smaller system. But many times, they will give organizations
options.
In other words, you're on a system, it’s bought up by another
company, you know, they’re no longer maintaining support of
it. There’s been many times that you’ve talked to them.
You can negotiate implementing their premiere system at very little
or no cost. It all depends. That’s the typical scenario that
I have seen.
Bill Finerfrock: OK.
Marian Weber: So it really boils down to how well are they going
to support their product.
Bill Finerfrock: OK. Have we got any other questions, operator?
Operator: Not at this time.
Bill Finerfrock: If that’s the case, I want to thank Marian
Weber for her presentation today. I think, as I said, I've learned
a lot, and I thought it was extremely helpful, and I think for those
of you who listened in, I think you got some great suggestions and
ideas on how to proceed ahead.
Our next call, as we mentioned before, will be on February 5th,
and I want to emphasize, that is not our normal.
Normally, we’re every other month. But because this is an
add-on presentation going to the next step, we didn’t want
to wait the full two months before the presentation, so it will
be on February 5th at 2:00, and that one will be on implementing
once you’ve gone through this selection process and now you're
getting ready to bring it into.
You’ve identified your vendor. Now, you have to implement
it and steps and tips to go through for that process. And as normally,
we will send out the specifics; again, the reminders with Marian’s
slide for that call.
But, you know, I hope all of you have found this helpful. I want
to thank the Office of Rural Health Policy for their support for
this series.
A transcript and a recording of this call will be available and
sent out via the list serve as well as available for download from
the RHP site in the near future. It would encourage others who you
think maybe would benefit from this to listen in on these calls
and that, again, our next call will be on February 5th, “Implementing
an EHR, Now What?”
If you have ideas for topics for future calls, please send those
to info@narhc.org and we’ll – we will look into trying
to offer those at future – on future presentations.
Again, thank you all for your participation today and that will
conclude our teleconference.
Operator: Thank you.
Marian Weber: Thanks.
Operator: Ladies and gentlemen, that does conclude today’s
conference. We thank you for your participation. Have a great rest
of your day.
END
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