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