Vendor Selection Criteria

From Clinfowiki
Jump to: navigation, search

Choosing an electronic medical record (EMR) vendor is an important task, with many aspects to consider. An EMR can completely redesign a hospital's practice, but can also optimize it in ways a paper-based system could not. With over 400 EMR vendors in the market, selecting the best option could be overwhelming. After clearly defining the needs of the company, the next step is to evaluate which vendors more closely match your list of priorities.[1] Here is a list of some of the important considerations when choosing, installing, implementing and upgrading an EMR system. [2]

Contents

Basic EHR Criteria

  • ONC‐ATCB certification (Six certifying bodies ) [1]
  • HIPAA privacy and security compliant [2]
  • Meaningful use reporting
  • Ability to generate county, state, and federal reports
  • Support HL7 messaging standard [3]
  • Support Secure Sockets (SSL) digital certificate
  • Audit trail capabilities[3]

Core Clinical Features

In 2003, the DHHS [4] asked the IOM [5] to provide guidance on the basic functionalities of electronic health records systems. The committee concluded that the core functionalities should address the following areas:

  • Improvement of patient safety
  • Support delivery of effective patient care
  • Facilitate management of chronic conditions
  • Improve efficiency
  • Feasibility of implementation and
  • Integration of hospital services

In the Journal of Healthcare Information Management Kranny et. al discussed the importance of an application in the EHR which will promote continuity of care. During the selection of a vendor it is imperative for the decision committee to find out if there is an integration of inpatient, clinical and outpatient interface systems. [4] The patient's progress in house and discharge summary should be accessible by his primary care provider upon discharge. Medications that were discontinued during hospitalization should be updated in the patient's outpatient medication profile so wrong medications are not refilled by the patient. In addition, when new medications are added to the patient medication regimen it should be accessible by the primary care provider and outpatient pharmacist.

The IOM committee decided that the core functionalities of EHR system should cover the following areas: [5]

  • Improvement of patient safety
  • Support delivery of effective patient care
  • Facilitate management of chronic conditions
  • Improve efficiency
  • Feasibility of implementation

Jain et al. (2010), in the article Evaluating EHR Systems, describes a few criteria to look for in EHR selection. Considerations for EHR selection should include privacy of patient data, interoperability, ease of use( for physicians and support staff) and efficiency of the integrated systems. Management support during implementation is crucial. [6]

Based on these areas, the they identified eight categories of core functionalities, including: [5]

  • Health information and data
  • Results management
  • Order entry/management
  • Decision support
  • Electronic communication and connectivity
  • Patient support; administrative processes
  • Reporting and population health management

Analyzing EHR Business Requirements

The evaluation team or decision team should consist of clinical healthcare professionals including house staff, technical support professionals, administrators, and finance department team from all areas of the institution. Each person brings to the table a different perspective of usage from their daily job responsibilities. Institution-wide involvement creates awareness and knowledge of EMRs and their benefits, as well as an understanding of the upcoming modifications in the workflows. In summary, the following tasks must be followed before starting EHR business requirements analysis:

  • Assemble an Evaluation Team
  • Define the Product, Material or Service
  • Define the Technical and Business Requirements
  • Define the Vendor Requirements
  • Publish a Requirements Document for Approval

Meeting Organizational Needs

  • Understand if and how a vendor's product will accomplish the key goals of the practice. Essentially, a test drive of your specific needs with the vendor’s product. Provide the vendor with patient and office scenarios that they may use to customize their product demonstration. [7]

System Integration

  • Ability to integrate with other products (e.g., practice management software, billing systems, and public health interfaces, ADT). One of the biggest headaches with systems are the inability to exchange information between third party applications. These could cause a lot of issues down the road.[7]

Go Live Support

  • Define implementation support (amount, schedule, information on trainer(s) such as their communication efficiency and experience with product and company). Will vendor provide go live support? It is very important to have vendor support during go live to help address the hundreds of issues that come up. [7]

EHR System Feature List

  • Information to be considered to store in the system:
    • Demographics details
    • Patient specific problem or CC (Chief Complaint) with ICD-9 or ICD-10 numbering
      • Acute/Chronic Indicator
      • Worsening/Resolving Indicator
      • Injuries List
      • Present Illness Description
    • Procedures
    • Diagnoses
    • Medications
    • Allergies
    • Family medical history
    • Consultations
    • Signs & Symptoms
    • Vitals
    • Progress Notes
    • Discharge Summaries
    • Appointments/Admissions/Visits
    • Advance Directives
    • Clinical Reminders [Immunizations, Screenings, Risks]
  • Result Management (lab, imaging, other diagnostic measurements, pictures, multimedia)
    • Review and search results easily by sorting test types, test time, test administers, test results and so on
    • Choose one or several test types, such as HGB, and/or WBC, and/or blood sugar and chart on their results for showing trends
  • Is the software configuration flexible to customize for future needs? How much customization to the EMR can the vendor offer to meet the institution’s needs? Will there be a surplus of unusable or insufficient components to the EMR? [8]
  • Is this EHR system compatible with any other systems such as adverse drug reaction system, case based reasoning system and rule based reasoning systems?
  • The proposed EHR software should bring minimal to no new limitations to the existing workflows of the institution [9]
  • Does the system meet all existing required operational tasks?
  • Does the EHR tested in any other provider sites?
  • Does the EHR allow for expandability to mobile devices, mobile medical applications and upcoming mobile technologies?
  • Does the EHR have integrated practice management to avoid having to interface with a 3rd party practice management system?[10]
  • Does the software provide a tool for workflow mapping/charting?
  • Is it possible to migrate existing legacy EMR system institute use to the new EMR database schema?
  • Can the software be easily configured/adapted to changing workflows?
  • Does the EHR provide on-screen flags to indicate patient visit status?
  • Does the EHR allow customization of work flows by the provider, clinician, or other health care professional?
  • Does the EHR documentation method support error checking for vital sign data entry?
  • Does the EHR/EMR system allow multiple terminals (physician, nurses' station, X-ray, labs, etc.) to log in to the same patient's record simultaneously? Certain systems only allow one terminal to access a patient record at a time - they must log out before any other terminal can access patient EHR/EMR. (For example, if a nurse forgets to log out at their station, the lab cannot access that patient's record.)
  • • Does the product have a standardized electronic patient handoff tool to facilitate physician workflow, increase physician satisfaction and ultimately potentially improve patient outcomes?

Vendor Assessment

  • Asking about product experiences and user experiences are crucial before selecting a vendor. [11]
  • An EHR evaluation tool should be utilized before selecting a vendor. EHR evaluation tools can be obtained from medical societies. [11]
  • Online form from HRSA available for establishing EHR specifications to help in vendor section. The form's name is 2011 EHR Selection Guidelines for Health Centers and can be downloaded from www.HRSA.gov [12]
  • Requesting a demo from the vendor keeps a potential buyer informed on prospective features an EHR possesses. [11]
  • Asking if the vendor is committed to training the institution's in house staff. [13]
  • Is there capability to tailor current features of EMRs to enable a smoother changeover from paper to electronic records and to facilitate meeting the criteria for meaningful use. [14]
  • Will the EHR meet present and future requirements? How user friendly is the EHR? [15]
  • Which category do you fall under should be one of the first questions you ask. Are you a small practice 1-15providers, a medium practice 15-100providers, or a large practice greater than 100providers ?[16] Once size of practice has been determined including the potential to reach the size should help you narrow down as to which vendors might best suit your needs.

Product Requirements

  • Is the EHR system HIE certified? The organization might need an EHR system that meets the national interoperability standards; a system with the capability of transferring health information within and across organizational and state boundaries. Implementing an HIE certified system will eliminate the need to create a custom interface in the future that may be very costly to the organization. An HIE certified system will "reduce adoption barriers due to high interface costs, low reliability, and unknown development costs for the vendor". [17]
  • Does the EHR system employ current technology and have all the core clinical functionality, including a fully integrated pharmacy/medication management interface?
  • Does the EHR package come with a fully integrated Computer Practitioner Order Entry (CPOE) system?
  • If you are a large academic teaching hospital, does the EHR meet the special It requirements? Specifically, does the EHR accommodate the numerous handoffs in care that are the result of resident education and regulatory requirements?[18]
  • An EMR at an academic medical center must be evaluated on its ability to conduct large-scale research with data capture and retrieval, as well as attaining regulatory compliance regarding billing.[18]

Vendor Proposal (Request)

  • Requesting a proposal is just as important as selecting the type of medication that will be used in your practice. When you ask for a proposal it is important that as a practice you are clear and concise as to what you and your practice will need. This process, though very monotonous is absolutely crucial to the flow and efficiency of your practice. It also gives you an inside knowledge to the various EHRs that are available and will give you the ability for good comparison to what is on the market [16]
  • A clear list of specific needs (EHR system requirement) should be written
  • Prepare a clear criterion of the system that will be used to make the selection
  • Make request to selected vendors


Privacy and Security

  • Does the system provide roadmaps for adherence to organizational policies (such as HIPAA)?
  • Does the vendor’s EMR source code comply with the Patient Safety & Quality Improvement Act of 2005 (PSQIA)?
  • The system shall allow an authorized administrator to enable or disable auditing for events or groups of related events to properly collect evidence of compliance with implementation-specific policies. Note: In response to a HIPAA-mandated risk analysis and management, there will be a variety of implementation- specific organizational policies and operational limits.
  • Internet Connectivity and Redundancy Contract - There are three main types of connections for clinical data connections: business class digital subscriber line (DSL), business class cable, and T1 connection. Redundant back up systems and procedures to ensure your data will be backed up in multiple locations and securely stored off-site.
  • Will the system allow staff administrators to create and manage users and user security profiles?
  • The system restore functionality shall result in a fully operational and secure state. This state shall include the restoration of the application data, security credentials, and log/audit files to their previous state.
  • If the system includes hardware, the system shall include documentation that covers the expected physical environment necessary for proper secure and reliable operation of the system including: electrical, HVAC, sterilization, and work area.
  • How well does the EMR work with antivirus, antispyware and other security software?
  • What is the vendor’s history with cyber attacks? [19]
  • Does the system allow for off-site access to files/data and how does the technology protect against external breech or diversion of patient information?
  • Does the system have role based permission and access? Different job roles should only be able to access what is required of their job. [20]
  • Are all messaging capabilities within the EMR encrypted? [21]
  • Does the system have the ability to audit / monitor user activity if needed?[21]
  • Does the system have time-stamp functionality (name, date, & time)? [22]
  • Is the system in compliance with the organization’s HIPPA policy?
  • How will the decrease the unauthorized disclosure of information?
  • What procedures does the vendor have to handle disaster recovery and high availability issues?
  • Does the vendor offer policy and procedures in regards to disposal of Protected Health Information?[23]
  • How often do users have to update password information and credentials?
  • What does the vendor offer in regards to data backup procedures to ensure privacy and security integrity?
  • How often are user ID’s audits performed for inactive users?[24]

CPOE

  • Computerized Physician Order Entry (CPOE), e-Prescribing
  • Computerized Physician Order Entry system that integrates and provides for two-way communication with the Pharmacy, Laboratory, Registration systems, and that allows for scanning and downloading of health information as needed. The EHR system should have a completely understood interface and provide for interoperability with all current and future systems and between clinics and providers.
  • CPOE will generally allow for the organization to specify a default dose for a medication order. [25].
  • The CPOE team will need to review what happens when non-formulary items are entered. The workflow for non-formulary items will also need to be determined. [25].
  • The EHR should have the capabilities to interface with the various labs the hospital or physician uses to order and receive patient lab work automatically.
  • Does the EHR have a referral management system so that within large organizations, specialty and primary care departments can easily communication with each other and have similar information on a patient that is using both offices to treat their illness?[26].
  • Does the system allow each provider to create customized order sets including laboratory order sets, procedure order sets, presurgical order sets, and postsurgical order sets? [27]

Clinical decision support (CDS)

  • Earlier Clinical Decision Support (CDS) Tools
  • Historical Challenges of Clinical Decision Support (CDS) Tools
  • Benefits of Various types of Clinical Decision Support(CDS) Tools
  • Decision Support (Drug Interaction, Drug information and other Prescription Supports, Clinical Guidelines [Plans & Protocols] and disease information, Diagnosis and differential diagnosis Support, Risk Assessments, Clinical Checklists, Medical References, etc)
  • Formulary Database Support
  • Electronic Communication (Provider-Provider & Patient-Provider Direct Communication, Health Data Exchange, Interface to Medical Devices, Notifications, Clinical Documentation such as Nursing Notes)
  • Patient Administration (ADT [Admit, Transfer, Discharge], Reservation & Scheduling, Billing, Waiting List Management, Records of Patient Activity, Master Patient Index across the Healthcare Organization)
  • Querying & Reporting (Research & Analysis, Statistics [Vital Statistics, National Statistics], External Accountability Reporting)
  • Telecare, Telehealth, and Telemedicine functionality. Home Monitoring device input/linking.
  • Patient Portal for online personal health record access
  • Clinical policies and procedures guidelines
  • Produce visit summary and complete medical record printout and data export on demand for patient use.
  • Electronic Health Record (EHR) systems should be capable of accommodating multiple users working concurrently within the system and within the same patient file or document. EHR systems should also be capable of protecting the integrity of data in the system so that no data loss occurs when multiple users are working concurrently with the same patient file or document.
    • Provide direct decision support explanation link to evidence based knowledge (through such as "infobutton",etc) about needed test information, such as purpose and methods of conducting that test, normal range of that test, clinical indications when abnormal results occurred and suggestions what to do, etc.
    • Provide abnormal alerts to providers and/or patients through various ways, such as online display, cell phone text messages, etc if the patients/doctors register for this service.
  • The organization will need to strike a balance between displaying so many alerts that it causes clinical care to slow. [25].
  • Does the EHR have an aspect of the CPOE that can manage patient protocols and treatment plans? [26].
  • Does the software have “Clinical/Business Intelligence” capability based on local clinic medical trends, e.g. if there is above normal upper respiratory infection clinic visits, perhaps a flu season is imminent and may warrant stocking of flu vaccine in the clinic?
  • Does the system support patient-specific dosing? When entering medication orders, can the system recommend dosages based on the patient's age, weight, and comorbidities? [28]

Data Storage and Retrieval

  • EHR systems should be capable of capturing, storing, indexing, retrieving and displaying externally created documents. Indexing of captured documents should include not only patient identifiers and descriptive information, but also date/time stamps and document type.
  • EHR systems should be capable of retaining all system data until such data is archived or intentionally purged from the system.
  • The system should load patient records in a timely manner to not interrupt workflow.
  • This system should present chronological data of patients like medicine history, progress of diseases.
  • Also, system provides gene information or drug allergies of patients to avoid ADE.
  • System should be compatible with old system to reduce re-entry time.
  • System should update regularly.
  • system should be able to have Patient prescription plan eligibility, prescription product formulary and external medication history.
  • System should be able to have insurance retrieval capabilities (i.e. insurance firms, sum insured, premium dues, etc.).[11]
  • Capability to integrate with other products such as practice management software, billing systems and public health interfaces.

Functional Requirements

Functional requirements are those processes that you want a system to perform [29]. The electronic health record’s architecture, or its relationship across any existing or future systems at the organization’s practice, directly influences what functions the EHR can support [30]. The following functional requirements have been broken into the following areas that correspond to EHR functional categories:

Clinical Documentation Requirements

Clinical documentation is used throughout healthcare to describe care provided to a patient,communicate essential information between healthcare providers and to maintain a patient medical record [31].

  • Document and View Medication History
    • Will the EHR have the ability to perform basic clinical documentation, including medication history?
    • Will the current, active medications be viewable on demand?
    • Will the system have the ability to display a complete medication history from information available within the EHR? [32]
  • Treatment plan
    • Will the system be able to document a treatment plan and create any new orders?
    • As part of that treatment plan, will clinician have the ability to confirm previous medications and prescribe any potential new medications or make dose changes, and the ability to electronically submit orders such as labs, radiology, physical therapy, and other supportive services?
    • Will the EHR be able to create structured treatment plan as part of patient encounter? [32]
  • Consult Note
    • Will the system be able to document a consult note with appropriate clinical information from the medical record, including a clinical recommendation, and surgical clearance? [32]
  • Chief Complaint, Problems, Vital Sign, History, Visits, Medication List, Allergies
    • Will the appropriate clinical staff be able to electronically document chief complaint, vital signs, reason for visit, new history, MD visits, problem list, and medication lists?
    • Will the system permit appropriate clinical staff to document, review and update patient problems, medications, and allergies or adverse drug reactions in the EHR?[32]
  • History of Present Illness/Review of Systems/Family History/Medical History/Surgical History/Social History and Physical Exam
    • Will the system allow the complete physical assessment, including all necessary examinations based on the current standards of care for the applicable condition, to be documented in a standardized manner with consistent nomenclature? [32]
  • Patient Educational Materials
    • Will the system have patient education material available within the application either from the application itself or from a third party solution? [32]
  • Does the system support various methods of documentation creation? Can documents be created through traditional dictation and transcription and imported into the patient record? Does the vendor support interfaces for importing documents?

Results Management Requirements

Results management is an important clinical activity that requires a structured approach in order to be effective. Results management is in accord with the precepts of Meaningful Use. Incorporation of clinical lab results into the EHR as structured data is an ongoing MU objective. [33]

  • Lab Results
    • Will the system send the lab request electronically?
    • Will lab results populate electronically into the EHR with flags for abnormal result?
    • Will Physicians be able to review and publish lab results as well result notes to patients electronically?[34]
  • LOINC Codes
    • Will the EHR accept LOINC-mapped electronic lab results if available from the source lab [32]?
  • Radiology Results
    • Will the system accept radiology results and reports electronically from imaging centers or through the HIE? [32]
    • Does the EHR support the direct viewing of DICOM medical images without having to log into the separate PACS system?[35]
    • Does the EHR has time tracking of performed or to be performed procedures that are happening in the imaging in the form of “in progress”, “completed” or “discontinued”?
    • Does the EHR consist critical result notification application?
    • Does the EHR allow insurance authorization upon imaging order?[36]
  • Reminder of next test due
    • Will the system set a reminder for recommended time frame for next lab test [32]?

Specialty Needs (Pediatrics)

EHRs in pediatric care may increase patient safety through standardization of care and reducing error and variability in the entry and communication of patient data.4-9 While EHRs may improve safety, implementation of general EHR systems that do not meet pediatric functionality and workflow demands could be potentially dangerous.Healthcare organization have to be careful to select prospective EMR vendor to determine if they have incorporated a variety of Pediatric specific workflows into their system. For instance,

  • Are EHR provide child'a age in years or EHR have the ability to determine ages in hours, days, weeks and months in addition to years?
  • Are dosing models consistent with taking care of a pediatric patient population?
  • are they provide pediatric specific EHR features such as Intake forms,Demographics that support various family structures,Well child / Preventative,Immunization administration and management,Growth Charts,Genetic information, maintenance, and reporting,School Physical,Sports Physical,Camp Physical,Daycare Physical,Reportable Communicable Disease management,Child abuse reporting forms,Referral entry and tracking,VIS (Vaccine Information Sheet),CDC link,Flack Pain scale,Behavioral tools,ADD/HD tools,Age Specific,Birth Data,Instrumentation integration (vital signs, EKG, spirometry, etc,Pediatric protocols for pediatric triage,Patient Portals,Pediatric Specific templates?

Specialty Needs (OBGYN)

There are unique requirements from electronic medical records systems for obstetrics and gynecology, and rooting out vendors that provide the ability to support those requirements can be challenging.Unfortunately, until CCHIT adds OB/GYN as a specialty endorsement (not slated until 2012),there are no externally validated organizations that assure the prospective purchaser that the product meets all of the required needs. Of course, should one be in a sub-specialty practice (MFM, REI), there are even fewer assurances offered on suitability; it will be up to the individual/organization to sift through the vendors and product capabilities to match with the stipulated needs.[37]

Specialty Needs (Anesthesiology)

Anesthesiology is a unique medical specialty, as it is a field of acute care for medicine. Due to the fast-paced nature of emergency situations, critical pieces of information to make decisions are necessary to determine a good or bad outcome. Elements such as body weight, drug metabolism, drug interactivity and allergies are emphasized. The communication of the anesthesia provider during the case is more profound between him/herself and the operating room staff (surgeon, circulating nurse, scrub technician) than with the patient.

EMR Requirements

Anesthesiology-specific workflow templates reduce errors by automatically populating patient data and supporting treatment.

  • Vital Signs Device Integration - Capture physiologic data—including ECG, oxygen saturation, heart rate, blood pressure, end-tidal CO2, temperature and respiration—from anesthesia machine to ensure appropriate levels of anesthetization.
  • Interaction with Current System EMR - After capturing the physiologic data from operating room specific devices, the EMR should integrate it automatically into the patient's chart to be part of the permanent medical record.
  • Alarms - Due to the potent nature of anesthetic drugs, alarms should be available to monitor drug-drug interactions and vital signs should have trend monitors to predict the possibility of impending cardiopulmonary arrest.
  • Timers - Medicines given in this specialty are very time-sensitive in their time of onset and duration of action. Having the capability of tracking the last dosage and time since the last dosage or due time of the next dosage would be extremely beneficial.

Other Clinical Functionality

  • Does the system promote delivery of safe care?
  • The system shall require documentation of the audit support functionality in the vendor provided user guides and other support documentation, including how to identify and retrospectively reconstruct all data elements in the audit log including date, time.
  • Can the system identify the chronic disease management subgroups?
  • Is the EHR scalable to different medical specialties and practice demographics (i.e., Neurology vs. Cardiology, small satellite practice vs. intensive care unit)
  • Can the system support future clinical models (i.e., Medical Home)?
  • Does the EHR system support accurate, consistent and effective clinical documentation by appropriately balancing data auto-population, structured data entry, and unrestricted physician entry of natural-language narrative?
  • Does the EMR have the capability to display data over time graphically, such as growth charts?
  • The system shall provide the ability to query for a patient by more than one form of identification
  • Can it integrate with external knowledge sources such as links to journal references or other knowledge base systems (such as John Hopkins Guidelines System) to provide more academic information and update on particular patient problem?
  • Does the EHR store the identity of the user and associate the ID with the additions or changes made to the system?
  • Can the EHR system be used to capture clinical trial data? How the clinical trial specific data is managed?
  • Does the EHR system have the ability to import and export data (interact) in a standard format to EHR systems from other vendors?
  • In outpatient departments, does the EHR have a patient-to-physician email and/or web access abilities for the outpatient department to communicate directly with the patient in case more information is needed or the office needs the patient to take some action?[26].
  • Does the vendor’s product provide the key functionality needed to achieve the organization vision?
  • Does the EHR provide outcomes data in terms of key metrics (cost savings, medication error reduction, disease management) in line with the vision of the organization?
  • How does the system import data from personal health devices?
  • Can patient data be directly imported from patient portals or personal health records?
  • Does the vendor provide an EHR system that can be integrated with and is interoperable with other systems?
  • Can the vendor provide an EHR system with standard terminology that is cross platform with other EHR systems?
  • Does the vendor provide safe log in for patients and clients?
  • Does the EMR could provide appropriate information on screen without cramming too much information?
  • If the EMR/EHR system allows users to access through mobile devices (through the web or an app), is the mobile version similar to the computer-based version? Is it user-friendly? Will mobile access require additional training, or will user feel comfortable with it after training on the computer-based version?
  • What type of system is built into the EHR for clinicians, staff and any other users to provide feedback?
  • Does the EMR/EHR integrate with off the shelf software currently in use? (i.e. Microsoft products, adobe, etc.) and will new software/upgrades need to be purchased to enable inter-operability?
  • Is the EMR capable of sending a Virtual Consultation Summary to another Physician via HIE?

Continuity of Care: Outpatient vs Inpatient EMR

If there is no communication between the ambulatory (outpatient) and the inpatient (hospital admissions) EMR services, the clinical information does not get accurately or completely transmitted between transitions of care. This need for continuity of care must be addressed by the EMR vendors by looking at the integration between their outpatient and inpatient clinical systems. The level of integration can be-

  1. at the user interface level (for example, separate inpatient and outpatient applications, minimal data sharing with separate databases, viewable in same shell)
  2. at the database level (such as having two separate applications and one database, with the ability to manually transfer data between applications)
  3. at the workflow level (with one application and one database, with data displays in the context of care setting and full accommodation for workflow)

A discharge note writer is needed to generate a transition of care document (discharge summary) so that the patient can be handed off from one setting of care to another. According to JCAHO (Joint Commission) medication reconciliation must be done at every transition of care. There is very little literature that addresses the direct financial ROI for an ambulatory EMR, as opposed to the inpatient arena, where more evidence exists.[38]

  1. Cerner Ambulatory and Cerner Inpatient

Cerner has recently deployed their “Cerner Integrated” platform that does “speak” to inpatient Cerner. Cerner deployed this to "improve the quality and accessibility of clinical documentation across the inpatient and outpatient venues of care while reducing costs of transcription and document scanning." Jim Shave, President of Cerner in Canada, stated “This integration between inpatient and outpatient systems will provide a seamless experience for patients and clinicians, particularly with the large volume of Ontario residents who use outpatient hospital care.” It is still fairly new and not a lot of hospitals and outpatient clinics have had the opportunity to experience the flow of this integrated platform but this is a step in the right direction for continuity of care. [39]

New Non Traditional Approach Overview

New adaptive methods to be considered regarding the successful HIT (Healthcare Information Technology) implementation: R.T.Blake et al., did an interesting case study about The Christ Hospital which underwent a world class successful HIT implementation. The Christ Hospital (TCH) is 555 bed nonprofit acute care hospital in Cincinnati, Ohio. It has successfully implemented HIT by firmly focusing to the goals set and following a strategic yet non-traditional methods in every area, and was exceptionally exemplary in collaboration with the different stakeholders. For more information on The Christ Hospital visit their website. [40] There are many adoptable methods for Healthcare Organizations (HCO) to be learnt from TCH HIT Implementation.

Stakeholder Analysis

It is important to recognize the role of key Healthcare Organizations (HCO) Stakeholders.[41] Stakeholders in healthcare can be broadly divided into internal and external. Internal stakeholders consist mainly of physicians, nurse, hospital administrators while external comprise of IT providers, vendors, and consultants. Physicians and nurses have direct contact with patient, more so nurses with monitoring, administering medications and discharge/after care services. There are many healthcare workers under the supervision of registered or licensed practical nurses.Hospital administrators have often challenging workforce, hospital missions, complex regulatory and day- to day operations which target directly or indirectly quality of patient care.Hospital administrators have often challenging workforce, hospital missions, complex regulatory and day- to day operations which target directly or indirectly quality of patient care. [41]

Separate vendors for each identified core IT implementation areas

Identification of core areas which are in dire need of HIT have to be recognized before the HIT implementation. And each area identified should be supervised by a different vendor.This can best be adopted in time bound projects and could prove cost effective.[41]

Personalization of HIT

For the smooth work flow which is primarily patient centered, the HIT should focus on the user friendly for physicians and nurses who can handle them with ease, so they contribute to the successful patient’s outcomes.[41]

Transparency in communication with stakeholders for collaboration

This is essential as there are various stakeholders involved, always giving scope for power struggles and may fail the implementation as well as integration and may eventually face resistance from end users.Enterprise governance with good leader even from non IT can work successfully if utilized from the start. Also, this will enable the focus on patient care rather than technology.Starting from vendor selection to discuss with them, the criteria upon which they were selected and capability to contribute as per needs, also prior feedback from end users, all stakeholders perspectives and opinions before, during and after implementation can build a strong interpersonal relationships with primary target of patient centered care environment.[41] The ability to have an openness for the reporting of problems in a particular level to the advisory committee/ any which can resolve them within hours rather than dragging them for days and weeks. These problems with solutions can be circulated among all the stakeholders.[41]


Nursing Functionality

  1. Supporting eMAR: supporting real-time electronic medication administration record and bar code medication administration technology.
    1. Does the system track refusal of medications? [42]
    2. Does the eMar have the ability to send encrypted messages directly to the pharmacy?
  2. Supporting bedside automation in medication delivery: Support data interface and real-time monitoring of smart infusion pumps and home infusion pumps
  3. Ease of use of Nursing flow sheets: Rows in the EHR to be filled by nurses for consistent patient care processes.[43]
  4. Ease of access and usability of EHR for nursing administration and clinical documentation for nurses. [44]
  5. Clinical decision support and risk assessment tools for issues related to nurse care delivery, such as falls, medication delivery, skin ulcers etc. [45]

Pharmacy Operation

Hospitals and physician practices need to keep their patients safe and well managed by using a pharmacy information system also called a medication management system. The system must have several core functions including in and outpatient order entry, dispensing, and inventory and purchasing management. The system must also be able to connect to other systems within the enterprise, including an EMR, computerized physician order entry (CPOE), barcode technology, and smart IV infusion pumps.[46]

  1. Connect to other systems within the enterprise including EMRs
  2. Computerized physician order entry (CPOE)
  3. Barcode technology
  4. Smart IV infusion pumps


Formulary Management

  1. Data repository for formulary information, maintain real time update of medication information with national drug information database
  2. Support periodic update of formulary, restricted formulary, and nonformulary medications
  3. Cross reference patient’s insurance formulary list to allow for generic medications to be selected when e-prescribing.

Drug dispense and delivery

  1. Support outpatient pharmacy operation functionality:
    1. Maintain outpatient prescription data
    2. Management of prescription fill, refill and dispense activities
    3. Support billing protocols with governmental and private insurance
  2. Support inpatient pharmacy operation functionality
    1. Maintain inpatient medication ordering data
    2. Real-time monitoring of IV and oral medication compounding and delivery
    3. Support real-time data interface with automatic dispensing cabinet

Research Functionality

  • Does the vendor bid include the product's ability to be used as a tool for research. If "no", is an add-on solution for research capability needed and will it entail extra cost. [47]
  • Does the EMR have informed consent alerts and documentation systems for clinical research?
  • If the proposed installation site is a research hospital, what are the research capabilities of the EMR?
  • How is research achieved?
  • How are reports produced?
  • How is data exported from the production system?
  • Which database is used for reporting? For research? Vendor or other?
  • Does the vendor provide natural language processing for entry data or document?
  • Support for research billing including research orders (6)
  • Does the EHR system provide data mining capabilities to support clinical research?
    • Are there limits on the fields that researchers can use?
    • How difficult is it to interface with the database?
    • Does the EMR have smart search abilities to search through physician notes for specific keywords while extracting research data.
    • Does the vendor assist in research endeavors, or is it left up to the institution?
  • Does the EMR have the flexibility to capture documents necessary for specific clinical trials like adverse events, enrollments, and etc? [6]
  • If research involves use of pathological/histological samples, does the EMR system tie into the laboratory management systems and database to allow for retrieval and processing of samples?
  • Does the EMR system provide functionality to identify clinical related concepts?
  • Does the EMR provide the flexibility to normalize the clinical concepts found in the document?
  • Does the EMR provide the assistance to automatically generate the de-identified document for research purpose?
  • Does EMR system provide functionality to implement study-screening parameter into patients’ registration, scheduling, medication lists, diagnostic codes (ICD) and clinical notes? [48]
  • Does EMR system provide functionality to contact potential candidates and notify the patient’s providers of potential study eligibility? [48]
  • Does EMR system provide capability to systematically captured study specific data and electronically exports deidentified study data to clinical trial electronic data capture system? [48]
  • Vendor's ability to support research is especially important for large academic hospitals. In academic settings, research productivity is evaluated on publication and funding. To assess the ability of each vendor’s EMR to support research, the same two criteria for assessing productivity can be used— 1) publications that were the result of or 2) funded research made possible through EMR use or data analysis from the EMR’s data warehouse. [49] To assess this one can follow Mt. Sinai's example in selecting a vendor as follows:
  1. After a rigorous investigation of vendor statements and industry statements, a standardized questionnaire was used to consistently ask about items specific to the site contacted. Sites suggested by vendors, as well as community listservs, were contacted; the user community was engaged.
  2. Literature search:
    • PubMed was used to search MEDLINE covering the fields of medicine, nursing, dentistry, veterinary medicine, the health care system, and the preclinical sciences.
    • Also queried was CRISP (Computer Retrieval of Information on Scientific Projects), a searchable database of federally-funded biomedical research projects.

Patient Quality Improvement

  • Link to patient education materials database or service and the ability to load practice specific documents for patient handouts. Must be able to access and print these from visit encounter interface.
  • Does EHR system provide better integration among providers by improved information sharing, viewable and up-to-date medication and allergy lists and order entry at point of care or off-site ?
  • Will the EHR system provide standardization of data, order sets, and care plans helping to implement common treatment of patients using evidence-based medicine ?
  • Are vendor-provided and supported order sets available?
  • Does EHR system provide access to experts for rural health care providers by sharing best practices and allowing for specialized care through telemedicine ?
  • Can EHR system manipulate and provide feedback on population management trended data and treatment and outcome studies for more convenient, faster, and simpler disease management?
  • Can the system pull from clinical documentation for billing, quality reporting and patient safety reporting?
  • How does the vendor use certified EHR technology in ways that can be measured significantly in quality and in quantity?
  • Will the system support utilization review with the Milliman and Interqual clinical criteria for Quality Management and discharge planning.
  • Does EMR system provide capability to aggregates data on the impact of specific evidence based/cost effectiveness intervention as compared to current population in management practice?

Public Health Research

  • Does the vendor support the ability to send de-identified bio-surveillance data to population health agencies to support epidemiologic research?
  • Does the vendor have the ability to send patient specific public health disease report(s) to a disease registry, as a part of a Public Health Information Network (PHIN)?
  • Does the vendor have the ability to report on Quality Improvement, such as infection control measures (i.e., Hospital Acquired Infection rates) or patient safety measures?
  • Does the vendor have the ability to report to the State, CDC Registry and external sources

IT and Technical Requirements

  • For already existing software functionality, does the vendor employ reliable and trustworthy software like an open-source MySQL or Apache server? Or do they develop their own system, or do we have to license a proprietary one (extra cost)?
  • How the vendor estimates the total amount of users and licenses needed? Will they be concurrent user licenses or asynchronic?
  • Will technical support remain active even if the Hospital is running a non-upgraded system? For how long?
  • Does the system use DICOM standards for the transmission of image data?
  • Does the system provide an imaging database or allow customized program attachments of imaging needs of specific departments in the hospital?
  • What are the hardware requirements?
  • How frequently does the vendor provide patch upgrades for the product?
  • Do the upgrades come with a fee?
  • Is the vendor’s application (system) platform independent?
  • Is the system using standards such as Snomed, ICD 10; HL7 Version 2 or 3; HL7 infobutton…)
  • How does the system handle multiple logins of the same user at different locations/instances?
  • How does the system handle user inactivity? (auto-logout, discarding\saving changes, draft creation)
  • Is the software capable of using biometric data for rapid login by providers who are mobile between patients/sites?
  • How does the system lend itself to automated back-ups? Does the vendor provide IT support team to implement specific back-up plans that will work with the hospital's IT team?
  • Can the system allow login remotely – off site transcription or home or other clinic?
  • Does the system provide the ability to identify all users who have accessed an individual's chart over a given time period, including date and time of access?
  • Does the vendor offer a Software as a Service (SaaS) solution, also know as an Application Service Provider (ASP), or a client-server solution?
  • With existing systems, how tightly integrated will the new EHR system be and what prep work is required to make the integration possible?
  • Does the system have modules for automatic update of knowledge sets at regular intervals, more like automatic update of antivirus definitions?
  • How often does the software need to be upgraded?
  • Does the software allow generation of customized reports such that desired information can be extracted periodically for performance improvement projects or performance monitoring.
  • Does the vendor utilize the desired technology?
  • Is remote access available for mobile devices?
    • Is this web-access or a dedicated app?
    • In what way is this mobile access limited? Does it have access to all functionality?
    • What devices can access the mobile apps? (e.g. iPad, iPhone, Android, etc.)
  • Is remote access cross platform? The use of open standards (e.g. HTML5, XML) allows users on any platform, including smartphones and tablets, to have equivocal access to the system.
  • Does the system support web-based working environment?
  • Does the system provide extension package or software for IT engineers or users?
  • Does the system comply with HIMMS standard?
  • Can the system be installed on Windows or IOS operating systems?
  • How does the system’s IT infrastructure requirement align with the institution’s current infrastructure and the institution’s infrastructure five-year strategic road map?
  • What hardware technology (Server) does the database support? And does the supported hardware provide built-in high availability?
  • Does the system’s application (not database) support virtual environments? Will it run on a virtual server?
  • Is your ticketing system capable of interfacing with [name of ITSM software utilized by your institution]?
  • Negotiate the terms and prices of the interface system: to/from PM system, scanner, fax machine, laboratory, health information exchange partners such as hospitals, ambulatory surgical centers, radiology, ePrescribing.
  • Can the system be hosted and supported remotely by the vendor?
  • How scalable is the IT infrastructure? Is there a peak limit on the number of concurrent users utilizing the system? (this comes in handy during mergers & acquisitions in which you may exponentially increase in size of user base)
  • Does the system support dictation function?
  • Does the system support speech recognition?
  • Does the system have a spell check tool for notes (progress notes, letters, and H&P notes)?
  • What are the data back up options available in case of natural calamity?
  • Is the EHR system compatible with other systems in the event of termination or vendor's insolvency? [50]
  • Are scanning capabilities available and if so, is there a particular scanner make and model required?
  • Are scanning licenses needed? How much are the scanning licenses and are they needed per user or per pc?

Legacy systems

  • How does the vendor compare in KLAS rankings of similar systems and applications?
  • How will legacy patient record data be integrated into the new system?
  • Does the vendor provide services to convert and transfer data from legacy systems into the new system, and if so, what is the cost?[51]
  • How does a legacy Practice Management System integrate with the EHR system? Is there a list of successful PM vendor integrations?
  • Make sure the vendors give accurate information for the Request for Proposal. So the stakeholders can make informed decisions on the comparison of vendors.

-Zoker 9/17/2011

  • What is the legacy Practice Management System conversion process for legacy data import into the EHR system? Time/cost and loose-ends? What reference clients are there for particular legacy PM systems?
  • Does the vendor have a List of Lessons Learned from previous implementations?
  • Does the vendor have a legal license to essential code sets, such as the AMA Current Procedural Terminology (CPT®) file? Will the vendor maintain this license annually as part of your service or maintenance agreement?American Medical Association
  • How does the vendor manage diagnosis documentation and coding? Does the system require specific coding terminology or does it allow provider synonyms for coding terms? How is that updated and maintained?
  • Does the vendor offer a “test environment” in which upgrades are loaded to allow you time to test and learn their functionality without affecting your live system? American Medical Association
  • What is the vendor's rate for on time & under budget implementations?
  • Are other consulting firms certified to implent the vendor's product? If so will the vendor provide system updates and customer service if system issues (not related to implementation) arise?
  • Check whether the vendors EMR products are certified Health IT products through the Office of the National Coordinator (ONC) for HIT. Previously CCHIT provided a list of certified EMR but as of late 2014 is no longer in operation.
  • What services does the EHR vendor offers for post-implementation optimization of the system with respect to training and system customization?
  • What is the company policy regarding data ownership for the ASP EHR?
  • The EHR product should be certified for the standards and certification criteria issued by the Office of the National Coordinator for Health Information Technology (ONC-HIT)? How many criteria does it satisfy?
  • How is documentation managed and preserved over time? How is documentation protected from being altered, in all parts of the system including the underlying databases?[52]
  • Does the vendor retain, ensure availability, and destroy health record information according to organizational standards? For instance, retaining all EHR data and clinical documents for the time period designated by policy or legal requirement; retaining inbound documents as originally received (unaltered); ensuring availability of information for the legally prescribed period of time; and provide the ability to destroy EHR data/records in a systematic way according to policy and after the legally prescribed retention period.[53]

Troubleshooting

  • Immediate trouble shooting ability
  • Once the problem is identified, the first step is to ascertain the scope[54]
  • If the scope of outage is large and the root cause is unknown, raise alarm bells early[54]
  • Bring visibility to the process by having hourly updates,and multiple eyes on the problem[54]
  • Over communicate with the users[54]
  • Do not let pride get in the way[54]
  • It is important to set deadlines in the response plan[54]
  • The simplest explanation is usually the correct one[54]
  • Regular connect with customers about their problems
  • The system shall include documentation that describes the patch (hot-fix) handling process the vendor will use for EHR, operating system and underlying tools (e.g. a specific web site for notification of new patches, an approved patch list, special instructions for installation, and post-installation test).
  • The system shall include documented procedures for product installation, start-up and/or connection.
  • What options does the EMR have for upfront abstraction and scanning? Are these costs included in the purchase of the EMR?
  • Can the vendor support the organization desired implementation strategy?
  • How can the quality of EHR technology be useful for electronic exchange of clinical health information among providers and patient authorized entities?

EHR Disaster Recovery

Either internal hardware problems or external sources (especially in EHR systems that store data in the cloud) may cause unexpected EHR system failures. The EHR may be unavailable for a few hours or for a week or more. Disaster recovery must always be considered when selecting a vendor to ensure that data is secure in these emergency situations. Questions to consider include:

  • Does the EHR use internal hosting or an ASP model? [55]
  • Is the EHR system adherent to the HIPAA Security Rule and provides both a contingency plan and secure data back-up reserves in case of system failure?
  • Has the EHR provided users with a detailed disaster plan during implementation of the EHR that includes how to cope with unexpected system failure?
  • Has the EHR provided training packets and educational materials for end users to study to prepare for unscheduled downtime of the EHR?
  • Will the EHR notify users immediately when system failure occurs and provide information about the breadth of the failure and the time anticipated before the EHR will be restored?
  • What happens when small private EHR vendors go out of business for any reason? Will you have a backup of the source code when that happens? Are we able to access that source code for our use?
  • Is off-site back-up and recovery supported in the event of a natural disaster or other catastrophic event?
  • Is training available for catastrophic event recovery?
  • What safeguards does the software have to warn users/administrator of an impending major failure?
  • Does the software monitor the hardware that it runs on?
  • Is there a technical relationship between the EHR/EMR vendor and hardware vendors?

Some of the criteria I will like to see in an EHR system in the event that it crashes or during downtime*****

1. What backup system does it have in place during such an event so that patient care continues without reverting to a paper system?

2. How is data updated into the system when it is back up and running again?

3. Where is the data stored so that in the event of a catastrophic crash historical data is not lost?

Health information exchange, connectivity, and standards

Because healthcare providers rarely use the same EHR system integration between providers in a state or region is being addressed by healthcare information exchange (HIEs). Patients will often see different providers from different groups. An exchange that provides one of more standards methods for integrating with it means that a provider needs to integrate just once, to the exchange, rather than dozens of times.[56]

  • Does it meet the following connectivity standards: HL7, HL7 CDA, CCR, HL7 CCD, ELINCS and Vendor software specifications? [57]
  • How flexible is there connection framework? Can it negotiate multiple standards?
  • How quickly can you build and implement an interface within the interface engine?
  • Can our facility support the space needed for the installation and implementation of an EHR?
  • Make sure wireless connection is accessible in all parts of the hospital is your facility is planning to use portable devices (tablets, computers on wheels, etc.) to access the system.
  • Is there a cost to connecting the EMR/EHR to an HIE? [58]
  • Does the vendor meet the certification requirements to allow patient data to go from different EHRs to meet Meaningful Use? [59]
  • Does the system support C-CDA? Can the system accept, parse, and integrate a CDA document as well as create and export a CDA document as specified in C-CDA?


Mobile Devices

One of the most logical reasons to have an EHR System linked up to a mobile device, such as a cell phone, is for the convenience aspect. “According to a 2012 Vitera Healthcare survey, a reported 91 percent of physicians are interested in a mobile EHR access, along with 66 percent of practice administrators.” [60]

Advantages: [60]

  • Accessibility is the greatest advantage derived from being able to view patient data. A physician can view necessary patient records whether he/she is at the clinic or at home.
  • Clinical documents can be virtually updated from anywhere, speeding up the healthcare process. Medical personnel will be able to avoid the necessity of having to fax or scan documents.
  • Patient perception of a physician speaking to him/her from a desktop has been identified as negative. With a mobile device, this barrier is dropped and the patient can feel more in control speaking face-to-face and viewing results on a screen.
  • The small size of a cell phone enables a physician or home health worker to avoid the bulkiness of carrying a tablet. The only necessary tool when walking into a consultation will be the mobile device. Hand written notes and large electronic devices will be a thing of the past.

Disadvantages: [60]

  • Sensitive nature of Patient Health Information
  • Providers will have to look into providing Mobile Device Management (MDM) in order to have data stored safely.
  • Lost or stolen devices will need to have the ability of having information completely wiped from a remote location
  • The durability of a mobile device is a concern for hospitals and clinics if they are going to issue out devices to employees. Many mobile devices are very fragile and tend to have an average life span of 2-3 years.

Cost and Budget

There are also long-term costs associated with EHRs that need to be considered. Certain systems require specific hardware, interfaces, networking, training and support resources that all add on to the price. Practices should take these additional services into account to get a comprehensive picture of what the technology will cost. [61]

Associated Costs – in addition to EHR licensing and maintenance, studies report expenses can be expected for; over 130 hrs./physician for system training, reduction in patient volume by as much as 50% during initial implementation, and significant expenses for additional IT infrastructure (e.g. approx. $10,000 for primary care practice). [62]

Vendor Financing

A 2010 Health management Technology article states, a number of healthcare technology vendors are now offering free financing for electronic health record (EHR) purchases, in an effort to increase adoption of electronic records. [63]

Cost is physicians' top concern when considering EHRs, according to a recent Ingenix survey of 1 ,000 physicians and physician-practice administrators. More than 80 percent ranked cost as one of the greatest risks to deploying technology in their practice. [64]

Hardware

Most physician practices will need to upgrade existing hardware (computers and servers) in order to run the EHR. Typically the vendor will give the organization a “shopping list” for hardware so that the organization will purchase equipment that is compatible with the EHR. [1]

  • Will the new hardware include tablets, laptops, desktops, servers, routers, printers, and scanners? [65]

Desktops

Advantages:[66]

  • Desktops are low-cost and available from a wide variety of vendors.
  • Because desktop PCs are standardized, it is relatively easy and inexpensive to find spare parts and support, or to replace a machine.
  • Desktops will run just about any software you need.
  • Additional devices such as microphones, speakers, and headsets are readily available at low cost.

Disadvantages:[66]

  • Because it's stationary, you need to buy a desktop PC for each room in which you need access to your EHR software.
  • Desktops typically take up more space than a laptop or tablet PC. While flat screen monitors and tower units save actual desktop space, the standard desktop computer requires more room than either a laptop or tablet PC.
  • You must purchase additional equipment to take full advantage of voice recognition and/or handwriting recognition programs.

Laptops

Advantages:[66]

  • A laptop has a smaller footprint and can easily be turned to allow patients to view information on the screen.
  • A laptop is less obtrusive during patient interviews.
  • Most have fairly long battery life and/or an A/C adaptor.
  • Laptops use standard PC inputs such as keyboard and mouse and/or touchpad.

Disadvantages:[66]

  • Although laptops are portable, they can be heavy to carry, typically weighing five to eight pounds.
  • Repairs and maintenance tend to be more expensive because laptops use non-standard or proprietary parts. You may have to send a laptop off-site for diagnosis and repair.

Tablet PCs

Advantages:[66]

  • Tablets are truly portable and lightweight, typically weighing three to four pounds.
  • It is as powerful as a PC, but it doesn't require a keyboard. Instead, you add information by writing on the screen with a digital pen or stylus, much like you do in a paper chart.
  • Handwriting recognition software developed for tablet PCs is excellent, even for very poor handwriting.
  • Tablet PCs have integrated dictation capability with voice recognition software that transcribes directly into the patient record.

Disadvantages:[66]

  • Writing with a stylus takes getting used to; there is a longer learning curve in adapting to a new way of using a computer.
  • Handwriting recognition dictionaries have not yet fully integrated medical terminology and acronyms, requiring more correction.
  • There is not as much standardized software yet available for tablets.
  • Screens are easily scratched and can become unusable without screen protectors purchased at additional cost.
  • Some EHRs/EMRs require a higher/lower resolution than others and won't work on a tablet. ex: Amazing Charts (AC) will not work on the Surface Pro 2 but will work on a Surface Pro 3.
  • Some EHRs/EMRs can work on a tablet but licenses/support will cost more. ex: To use Amazing Charts on an iPad will require the clinic to purchase their "Cloud Based" package. It is slightly more expensive since AC will host the data vs hosting the EMR on a server built by the clinic or hospital. Amazing charts charges $39 a month in addition to license and support fees, per user for their "cloud." When a clinic or hospital hosts AC on their own server, they only pay the license and annual support fees. [67]

Software

  • Identify and budget for required systems changes
    • Software changes
    • Increased system storage capacity
  • Know if the necessary upgrades are covered by current vendor contracts
  • Identify for what upgrade costs the practice will be responsible [68]

Professional Support

  • What kind of support is included in the initial purchase price of the EHR system?
  • How long will support be provided (e.g, on site, by telephone, or email)?
  • Will the vendor work with contractors to install the system or just be providing with a set of network, telecommunications and electrical specifications?
  • Will the vendor be working with the organization to customize software features such as the templates that will be used? [69]
  • Will the travel expenses of the vendor be included in the implementation estimate? Are the travel expenses fixed or a percentage of the implementation fees?[70]

Extensive Testing of EMR Software Prior to Implementation

Vendors should be able to demonstrate the conduction of rigorous testing of their EMR, such as: [71]

  • Unit Testing – testing of software codes and algorithm to detect errors which might lead to inaccuracies in patients’ medical records i.e., transposition of patient information, omission of diagnostic test results [71]
  • Regression Testing – Testing “end to end” functionality after the introduction of an additional ‘unit’ of functionality or a “bug fix” to confirm that the newly introduced change does not “break” related processes. [72]
  • Integration Testing – testing for integration and interface between different vendor modules i.e., faulty integration of CPOE and Pharmacy modules could result in physicians orders not being forwarded to the pharmacy department [71]
  • Systems Testing – testing of the EMR system’s ability to run on a multiple user environment, have optimal runtime availability, have an interface that is highly usable and intuitive, with strict adherence to information security regulations such as HIPAA [71]
  • User Acceptance Testing – testing by end users (physicians, nurses, administrative personnel) that validates whether all specified requirements and functionalities for the EMR have been met [71]

Implementation

  • Implementation Project Manager – A project manager is necessary to bring vendor experience and guidance to the implementation process and should hand off the implementation to your internal team within 12 to 15 months.
  • While vendors often assign resources designated as “project managers”, and this may be important for vendor-side work, it is in the best interest of the customer to obtain a project manager accountable to the executive sponsor for the success of the overall implementation (which often has a scope beyond that of the EHR itself).
  • Will the vendor be readily available to conduct training for all shift and service line?
  • Service Agreement - A service agreement identifies what the EMR vendor will do to maintain the software, including software maintenance, technical support, and upgrades.
  • IT Support Agreement - Hardware installations are your responsibility, not the EHR vendor. However, if you do not have onsite IT support, request an estimate for the following:
    • Installation charges for electrical requirements, cable and phone connections for the system
    • Monthly fees to provide access to patient data on a remote server
    • Networking design and administration charges related to the set-up and service of client's network
    • Hardware onsite installation and maintenance
    • Third-party software maintenance for products not provided by the vendor
    • Correcting errors that result from changes you or a third-party made to the software. This applies primarily to client-server agreements
    • Backup capabilities. This applies primarily to client-server agreements.
  • Terms and Conditions - Irrespective of the contract length, ask about penalties for withdrawing your data. Any vendor interested in preserving its reputation will provide you with data in a common format able to be transitioned to another system, but there is a withdrawal fee. [13]
  • How long is does it take for a typical install, troubleshooting and go-live of the EHR?
  • The significance of a multidisciplinary group with dedication to common aims and objectives for the task of EMR implementation cannot be overstated. [73]

Configuration

  • Does the vendor factor the number of users as part of their implementation cost?
  • Does the system provide pre built records or allow the import of pre built from a third party (i.e. Specialty order set, Medi-Span Medication records, SNOMED Clinical Terms)? Or do all of these records need to be built again[74]
  • Does the vendor provide their own hardware or use a third-party company for their hardware needs? Based on the practice size and niche, is a well-established vendor with all software and hardware in-house preferable?
  • If you have an existing system, what kind of difficulties will the vendor encounter? Will it be possible to transfer existing data to the new system?
  • In calculating the Total Cost of Ownership (TCO), the break out costs should include who pays for the additional costs due to delays in implementation, especially those due to the Vendor. In fairness, the Vendor's rate for successful, on-time and under-budget implementation should be discussed as well.

•Does the TCO include lifecycle costs that include milestone payment scheduling to back up promises made by EHR implementation? [75]

  • Does the system minimize or ease the data input, so that doctors spend more time with their patient?
  • Does the vendor qualify under the organization acquisition policies?
  • How will current policies and procedures change once implementation takes place?
  • Is there a dedicated support team?
  • If implementation of the system fails, what steps is the EHR willing to take to make it successful?
  • Will the license cost for updated versions of the EHR be borne solely by the purchasing institution or will there be cost sharing between the institution and the vendor for updates?
  • How often the possibility of system break out?
  • Does the fee include pre-training and post-training?
  • How long and including of the warranty of infrastructure and system? Do we pay for accident damage for system or hardware?
  • What system configurations are available? How does the vendor involve the client in the configuration of the system?

Face the Interfaces

One of an EHR’s most valuable assets is its potential to share information with other IT systems such as lab and diagnostic services. Interfaces allow the EHR system to communicate with other applications. These applications can reside outside the practice, such as lab applications, or can be another system within the practice, such as a billing system.[76]

Interface development is completed during the implementation phase; however, interface functions and costs must be a consideration during system selection. One cannot assume that a given EHR product will automatically communicate with other electronic functions such as appointment scheduling or billing. Vendors should be asked to address the issue of integrating lab and radiology results into the electronic record.[76]

Many vendors offer ancillary services such as automatic statement processing, billing services, consulting services, additional coding enhancements, and claim scrubbing. One may want to take advantage of these services later. These items are considered third-party or add-on applications.[76]

Many practices are considering the implementation of portals that offer patients a secure Internet connection to the practice. The portal allows patients to schedule appointments, complete paperwork, and access test results (or even their medical record), depending on the services the practice offers. These portals have the potential for increased practice production, increased revenues, and increased patient satisfaction. [76]

Interfaces can be a tricky piece of system selection and the implementation that follows. Red flags during the selection process include:

  • One-way or bidirectional interface not specified. The system may only accept demographic or appointment data from the practice management system but not feed data back to it.
  • Data format not specified. Data can be entered into EHRs in one of two formats--as free text (unstructured data) or as defined elements (structured data) such as forms and pick lists. Each practice must weigh the pros and cons for itself.1 However, ask vendors if their products support standard vocabularies such as SNOMED, Medcin, and LOINC.
  • Additional license costs not specified. Additional fees for third-party applications could apply, such as plug-ins for a drug database or CPT and ICD-9 coding, code scrubbing, database user seats, and anti-virus software.
  • Interface promised but not available. A vendor may say it can interface with your billing application or a lab system, but after the contract is signed it may advise you that the interface is not available. That can place a serious strain on the practice and require you to enter data twice.[76]
Interface History

One of the more efficient methods of determining a particular EMR's ability to handle interfaces is by reviewing the history of interfaces which have already been built and established. [77] The following questions should be answered in order to establish if the EMR being considered meets your organization's needs:

  • Which vendors (and which of their applications) have they interfaced with?
  • What type of information (patient demographics, order entry, laboratory results, billing, radiology findings, etc.) was interfaced?
  • How many interfaces were built, and what is the maximum the system can support?
  • What is the capacity of the interface; how many messages where sent and/or received per day; and what is the theoretical maximum amount allowed?
  • What, if any, additional costs were involved in creating, operating, and maintaining the interface?
    • Where there additional fees depending on the amount of data being sent/received?
    • Were there any costs to expand and/or modify the capabilities of the interface in the event the organization grows and requires additional functionality?

User Training

A significant predictor or implementation difficulty is lack of adequate end-user training and support. Depending on your organization and its staff, training may need to address the entire spectrum of computer usage from basic use of a mouse to specific use of that mouse to navigate your EHR.[78]

  • How many hours of initial training is provided for administrators? For users?
  • When is the initial training provided, during or after implementation?
  • How large a virtual environment will be required to provide training for staff, and how much time should be allocated.
  • What are the time requirements to train the trainers?
  • Is the initial training included in the costs of the tool?
  • If additional training is required post-implementation, how is it priced – lump sum or hourly rate?
  • How many hours of post-implementation support is included?* Will the vendor provide technical training to the IT Department of the purchasing institution to handle minor non-critical hardware problems?
  • How long is the training that is required for each subgroup to fully implement the system?
  • What are the training requirements for the vendor? For the clinic/hospital?
  • What is the vendor's track record for successfully training a new system for your clinic/hospital size?
  • What training manuals, user guides, on-line training assets, and any other training materials will be made available to the clinic/hospital?
  • What training mechanisms are used by the EHR Vendor? (http://www.americanehr.com/Home.aspx)
  • Does the vendor provides training instructors at beginning?
  • Are the training staff familiar with both the technical aspects of the product and the clinical needs of the department of interest? (i.e. subject matter specialist, clinical informatics specialist)
  • Does the vendor has well-organized and reliable training courses?
  • Training Contract - Training should be included in the licensing and service agreement, but some vendors provide separate online and onsite training contracts.
  • Does the EHR vendor provide a test version of EHR product for training and quality assurance (QA) purposes as well as the full production environment that is installed in the clinic? (The test version is a segmented area where users can make changes to templates or forms without it affecting the live environment) [6]
  • Are training materials provided by the vendor or is the organization responsible for producing in-house? If the training material will be developed in-house, does the vendor stipulate specific training requirements (i.e. classroom-based vs. web-based, mandatory competency examinations)?
  • What kind of on-going training and support will be provided after implementation? Is the cost of post-implementation training and support clearly specified?
  • What type of training is given for upgrades to the system. Does the vendor offer any online education material to assist?
  • If there are major updates to the system, will the vendor provide ample support and training for the users? And how much will this additional training cost?
  • Does the EHR/EMR vendor offer the option to have their staff available to be present at the hospital/clinic/facility during training and then "go-live" implementation? This would allow the EHR/EMR staff to offer hands-on support for any obstacles that come up during training and "go live" implementation.
  • Does the product have a functional academic version that can be used to train physicians and nursing staff , to allow them to adapt to the installed EHR quickly and easily?

* Spell out pricing before selecting and Electronic Medical Record (EMR/Electronic Health Record (EHR) system such as hardware, software, maintenance, upgrade costs, lab and pharmacies interfaces, customized quality reports, expenditure to connect to health information exchange (HIE)

References

<reference/>

User Satisfaction : User-Centric Selection

  • User satisfaction of the clinical staff plays a key role in vendor selection and can predict the success or failure of the EMR system implementation [18]
  • Since users may have varied experiences according to Kannry, Mukani, and Myers (2006, p. 89) it is important to include a multidisciplinary team from clinical, administrative and IT personnel as part of the vetting and selection process.
  • The creation and use of Scripted Scenarios representative of user workflow was helpful even when users had little technical knowledge of EMR systems. [18]


Future Relationships: Vendor Partnership

  • Talk to vendor's existing customers, making sure to also contact some vendor customers independently, as the vendors tend to only provide contacts to their most satisfied customers.
  • Research available EMR systems and vendors: determine if your jurisdiction has a "pre-approved" vendor list; develop checklists & questionnaires to assist with product comparison; and prepare a Request for Proposals (RFP).
  • Composing the RFP can be a daunting task. AHIMA has created a guidelines for a template that may be used to write the RFP. The guidelines are extensive and include several particular components that must be included. It can be found here. [79]
  • An important consideration is whether the vendor or any of its industry partners have done an analysis of processes in healthcare
  • Ensure there will be well-laid out contractual agreement regards the 'source code' that will satisfy/cover necessary conditions: "When does the company get the 'source code?, How does the company get the source code?"
  • If there are workflow changes within the organization, after the product is implemented, is the product flexible enough to allow for changes without major outages or disruptions to daily activity?
  • What are the vendors’ contingency plans if technical glitches occur, post implementation?
  • Is technical support offered by the vendor 24 hours per day/ 7 days a week?
  • In the event of need for support from the vendor, what is the approximate response time to calls that vendor the projects?
  • What is the cost of providing this technical support per hour?
  • What size, in terms of employees, is the EHR vendor? Do they have the staff to fully address the support needs of their current client base and, can they accommodate the added support load of your institution?
  • In terms of clinical decision support, how often are drug list and drug interaction list updated? Once updated, how long will it take for the changes to be accessible by the end users?
  • When code sets and medical vocabularies, ontologies, etc. are updated, how long after will the tool be updated?
  • In "EMR Vendor Selection" on Health Technology Review website, it states an old adage in the Software industry that consumers will buy a product based on features, but will leave the vendor based on a lack of support. Therefore, it is important to check references for the vendor related to post-implementation technical support satisfaction.
  • Aside from providing source code in the event the company undergoes changes, how and when can the organization acquire the "raw" data?
  • Will the source code be placed in escrow so that the system could be maintained and modified by internal IT staff in the event that the vendor ceases operation.
  • Does the vendor have local support personnel or will all issues be handled by a distant team?
  • What is an average time for installing and testing upgrades to the system? If an upgrade is missed or skipped, does the subsequent upgrade(s) have all prior changes included or just the current fix or feature for that version?
  • Is there going to be a vendor-institution confidentiality agreement or can the vendor share institutional information and dealings with other establishments?

* Does the vendor's produce meet our needs and goals for our practice? Carryout a test drive of our specific needs with the vendor's product and provide the vendor with patient and office scenarios or mock trial that they may use to customize their produce demonstration.

Upgrades

  • Does the vendor share the organization's vision for the EHR?
  • Does the product provided by the vendor has all the key functions needed to fulfill the vision of the organization?
  • Is the vendor utilizing the desired technology?
  • Compare retail broker workstation alternatives, including proprietary and third party packages, based on user requirements and technology/operational considerations. Project included EMR development and response evaluation
  • Does the vendor plan to offer interoperability options in the event of a nationally implemented CIS?
  • Upon the termination of a license or agreement, is there an orderly process for you to extract your data? This is applicable if you access the vendor’s software within an application service provider (ASP) model.American Medical Association
  • Ability to have HIE compatibility
  • Improved billing accuracy and charge capture
  • Electronic replacement for traditional reportable disease notifications to health departments, may become part of biosurveillance in the future.
  • Is it possible to virtualize or sandbox the system to test updates? This functionality would allow site specific testing of new features and systems with less risk of corruption of the current system. It would also allow testing of new features functionality and allow easy rollback if features end up being unwanted.
  • Does the system allow outreach/growth to affiliates as a "subset" of the existing clinical provider group? Does that outreach include full or limited functionality? How does that data interface with the existing clinical record?
  • How does the system scale? Is the vendor able to provide support and functionality as a practice grows or can they provide functionality to a small, regional branch?
  • Provision of EHR systems that support the capture of public health data from Clinical Information Systems.
  • Does the system can combine with EHR in long term health care area as a reminder of senior people?
  • Ensure that your vendor will be around when you need help. While specific vendor qualifications vary, generally information to be considered in the vendor vetting process, besides functional and technical details, includes vendor reputation, staff experience and qualifications, and financial solvency. (Chao, C., & Goldbort, J. (2012). Lessons Learned from Implementation of a Perinatal Documentation System. JOGNN: Journal Of Obstetric, Gynecologic & Neonatal Nursing, 41(5), 599-608. doi:10.1111/j.1552-6909.2012.01378.x)
  • Does the vendor allow discrete data capture and easy reporting of critical data that needs to be submitted for reimbursement by the national and state policies on healthcare?
  • Is the vendor at the forefront of research in healthcare and does the software offer clinical dashboards and predictive models for easy tracking and analysis of patient data and efficient decision making by clinicians.
  • Does the vendor require hiring of outside consultants for training?
  • Does the vendor, as part of their 18-24 month roadmap, include Direct-Trust (commonly referred to as Blue Button) to facilitate a more automated Provider to Provider data exchange as a replacement for FAX machine?[80]
  • Does the vendor, as part of their 18-24 month roadmap, include Fast Healthcare Interoperability Resource (FHIR) protocol as well as Human APIs implementation to facilitate bi-directional data exchange between Provider and Patient?[81]
  • Does the vendor, as part of their 18-24 month roadmap, include not only Member Eligibility data but History data, Formulary data as well as Drug Utilization Review (DUR) data in their ePrescription Hub?[82]

Contracts

Contracts are as much a business tool as they are a purchasing agreement. [83]

  • Project Payments
  • Contract Terms [7]
  • All costs, current and future, associated with the implementation

Details of the total cost incurred by the institution also called total cost of ownership (TCO) is an important consideration in the selection process. It helps to predict the longevity of the program. The request for proposal to vendors should include a request for information about vendor license and implementation costs. Vendors should deliniate the assumptions made when preparing the TCO so the decision committee is able to verify that they are parallel to the goals and objectives of the insitutions. If the same assumptions are encorporated in all request for proposals one can better compare the applications. [4] Institutions must also consider the intangible return on their investments such as reduced adverse events, decreased hospital stay, accurate and timely billing and improved management of supplies.

  • Does the vendor have any hidden fees?
  • Time commitment from vendor with regard to implementation and training
  • Penalties for delays in implementation
  • Code escrow - be sure code will be available if vendor goes out of business
  • Indemnification and hold harmless clauses
  • Confidentiality and nondisclosure agreements
  • Warranties and disclaimers
  • Limits on liability
  • Dispute resolution
  • Termination and wind down
  • Intellectual property disputes
  • IT support agreement
  • Training Contract
  • Applied area contract
  • User and vender liability
  • Disputation judgment
  • Attorney of vender and clients
  • User License - The person who has access to data using a user ID and password. Pricing structures vary according to the definition of user.
  • Consider variation of user licenses according to the needs: one price per MD, tiered price (MD, nurse or administrator), site license (25+ providers in the same facility), and enterprise license (multiple users in multiple departments). [84]
  • Interface - The EHR vendor's contract includes the cost of interfaces. These include interfaces such as those with your scanner or fax machine; and more complex interfaces such
  • Hardware Contract - Review the EHR vendor's hardware quote, but research may lower costs. Check the vendor's website for hardware specifications the vendor supports. Hardware includes servers, high-speed scanners, computers, handhelds, computer on wheels (COW), wall mounts, etc. Hardware installation to a wholesaler means assembling the server and software to make it work at their location prior to delivering it to you. It usually does NOT mean the installation at your location, a difference that will create a significant budget surprise. Clarify the term "installation" with any hardware wholesaler before making the purchase.
  • Third Party Software Contracts – Software includes encryption, speech-recognition, password management, Microsoft™ suite, anti-virus, golden image, bar-coding or webcams.
  • Business Associate Agreement - To be HIPAA-compliant you will need a business associate agreement with the vendor, and must ensure the vendor meets HIPAA security and privacy requirements.[85]

Check Vendor References

  • Each vendor being considered should provide minimal of three (3) references, to include a) physician users, b) IT person, and c) senior manager of the facility or practice.
  • Vendor provided references may be considered 'happy customers' with biased viewpoints.
  • Check several references on your own, outside of the provided references from the proposed vendor.
  • The chosen reference should be of a comparable size and structure
  • Have a prepared list of questions to ask.
  • Compare vendor satisfaction with current customers.
  • Ask supplied list of references how they acquired the EHR system, eg did they purchase the system or was it provided by the vendor?
  • Ask each reference to rate the vendor on a scale from 1 (very dissatisfied/strongly disagree) to 5 (very satisfied/strongly agree) for each criterion
  • Each vendor reference should provide reference on background information such as version of system currently being used, duration using current system, length of implementation, number of interfaces practice currently installed and estimated time to install, training provided on-site or remote.
  • Each vendor reference should provide reference on current system overview such as system reliability, satisfaction with vendor, and overall satisfaction with system.
  • Research references the vendor did not mention, visit facility to get an unbiased viewpoint
  • Must use listservs, internet searches and networking to identify other users to interview to get more objective viewpoint.
  • All interviewers should utilize the same questionnaire approved by the project manager or steering team.
  • Notes must be recorded by each interviewer for each customer interviewed.
  • These notes should be made part of the overall evaluation process, ideally kept by the project manager. [86]
  • Is the vendor currently involved in or have a history of any litigation with customers?
  • Does the vendor have a track record?
  • Has the vendor been in business for long?
  • Perform site visits to similar organizations that are currently implementing the vendor’s product and ask plenty of questions to all end users (physicians, administrative staff, nurses, etc.) [87] [88]

Site Visits

Once you have narrowed down your search to two vendors, you’ll want to visit a practice where the system has already been implemented. Ask the vendors for a client list and contact the references yourself. If there is no local client base, keep in mind that you won’t have the support of a local colleague, and that can be challenging. Only visit practices that are similar in size and specialty to yours; if they use different templates you may not get the full idea of how the system can be applied to your specialty.[76] During site visits, ask how engaged the vendor was in the implementation. For a truly successful implementation, you’ll need a close relationship with your vendor. Be sure that the vendor’s project manager provides face-to-face interaction with your staff. The project manager should also attend staff meetings and produce regular project updates as the implementation progresses.[76] Conducting site visits at other institutions that have already implemented the vendor’s system may provide additional and practical insight. Below is a list of criteria that should be observed on site visits. The following are criteria established by MetaStar and can be found here. [89]

  • Bring a diversity of positions from your committee.
    • At minimum bring a physician, IT specialist, and senior management person.
  • Observe during actual patient encounters.
  • Observe other departments such as billing and labs using the vendor.
  • Choose a site to visit based on your own research rather than one provided by the vendor.

Transparency

EHR vendors may enter contracts with confidentiality or non-disclosure terms that can prevent transparency. Examples include:

  • Disclosures required by law or regulation, sometimes with an obligation to give the other party advance notice and the opportunity to oppose the disclosure or seek confidential treatment.
  • Disclosure of information that has been independently developed by the disclosing party
  • Disclosure of information that is available to the general public or has been provided separately to the disclosing party without violation of an agreement.
  • Are there any hidden fees associated with training, support, consultant costs?

The definition of confidential information may be broad and could restrict your ability to share access to the EHR technology developer’s software in order to compare different EHR technology developer systems, provide access to researchers, or even address possible patient safety concerns. You should review the confidentiality and non-disclosure language carefully to make certain it does not inhibit your ability to conduct activities you value. [90]

Misc considerations

  • It is not uncommon for developers or implementers to impose lock-in features in order to protect their IP rights. How mature is the support community for the particular vendor and is there a marketplace for support and services to their product or is support limited to their own team?
  • A multidisciplinary team, usually a subset of the decision team consisting of a physician, IT personnel and a senior management must conduct a site visit to one of the vendor customer sites and vendor headquarters. Informal discussions at this level were quite informative as they bridged the gap between theory and practice for actual software implementation and usage.
  • An unstructured “drive-by” demonstration of the system must be arranged for, wherein the vendors conduct product demos, demonstrate product futures and distribute promotional materials for a majority of the employees to get the feel of the new systems. It facilitates building a comfort level and relationship with the vendor and the product offered.
  • Can the company demonstrate tangible ways that use of the product can increase hospital revenue? If yes, can you validate this/these claims?
  • Is the vendor willing to contract to go "at risk" for any part(s) of the contract?
  • What other services does the company offer (especially useful for rural or small hospitals or practices)? e.g. consultants to do special projects, data transmission/claims, billing
  • Can the record be accessed at home by clinicians and patients, or do they have to be on-site at the facility?
  • Is the vendor capable of adapting to emerging technology such as open source programming, cloud computing, "tablet" PCs/Macs, demand for smartphones (e.g. iPhone), and Web 2.0 technology?
  • Is the vendor capable of integrating its system with a personal health record and allowing more patient control?
  • Can the company provide return on investment analysis?
  • Vendors may not be chosen if the current managers have been convicted of or have had a civil judgment for the following: fraud, antitrust violations, embezzlement, theft, etc.
  • Reduced pharmaceutical costs derived from having information available at the time it is needed
  • How can this EHR be an asset for the solo practitioner who sees this technology primarily as a financial drain?
  • How much extra financial cost will it be to train outpatient clinics that are a subset of the system?
  • Does the vendor return loss money if their system can not complete established goal in scheduled time?
  • Can the company provide a multi-background consult team from doctors, nurses, IT engineer, to attorney?
  • Does the vendor qualify the organization's acquisition policies? Is the vendor CCHIT certified?
  • Certification can be verified at the Certified Health IT Product List (CHPL) [91]
  • Is the vendor active in national EMR leadership task forces, such as the Electronic Health Records Vendors Association [92]
  • Will the vendor be supporting the organization's desired implementation strategy?
  • Check the track record of vendor for operations and maintenance support?
  • Will the vendor sell or monetize of our clinical data for research or any other purposes?
  • Is Application Support provided by on-shore resources?
  • Clarify the roles, responsibilities and costs for data migration if desired. [2]
  • Does the Vendor demonstrate financial and management stability?
  • Does the vendor have experience with implementing the product in a similar type of organizations? How many?
  • Conduct a site visit [2]
  • Ensure that the site is similar to you - similar number of beds, acuity, rural/urban setting
  • Flexibility that allows for significant changes in product or order lines. Thus, this enables for businesses to modify orders, if necessary, without having to face a penalty from the vendor. Not always do things go as planned and if any modifications are needed, there should not be any consequences that inhibit this from occurring.
  • The ability to provide all the products/services required and/or the complete solution. This in turn can provide the whole picture in allowing for the consumer more transparency in terms of being able to distinguish between the products/services that a particular vendor is offering. As a result, this can save time and money in terms of a consumer being able to choose a certain business that can provide everything that is needed instead of wasting time and effort in purchasing products/services from individual vendors that have a small selection available.
  • The ability to have a consistent supply of products or services readily available for the business to purchase at all times. There is always a need for products and services to be provided on a regular basis; thus a business does not want to have a vendor that has supply issues. If a vendor is not reliable, then it can affect the business’s ability to in turn supply and provide for its customers, which can have a dramatic effect on the reputation and finances of the business.
  • Does vendor volunteering disclose adverse events or near misses data involving vendor’s EMR system to potential buyers? Are there protocol designed to notify federally designated patient safety organizations of IT related adverse events or near misses? [93]
  • Does the EHR have the ability to link payments and incentive rewards to the implementation of milestones and performance goals, as well as conduct data queries for support of quality improvement? [12]
  • Attend Demonstrations with a rating form this will help you write down the important parts of what you DID and DID NOT like and help you make the best EHR decision for your practice. Sales people are awesome and so are the demonstrators but it's important to stay focused on what will work for you.[94]

Dr. Sittig's Overview of EMR Vendor Selection

  1. Make The Plan
    1. Identify Decision makers
  2. Set Goals
    1. Make a Checklist of what should the EMR accomplish
    2. Map your Workflow
    3. Do a thorough Scan of your environment
  3. Prioritize needs
    1. Make EHR Functionality Checklist
  4. Develop a Request For Proposal (RFP)
  5. Select RFP recipients
    1. For example up to 5 vendors
  6. Narrow the field
    1. EHR Evaluation Form
  7. EHR Vendor Demonstrations
  8. Narrow the field
    1. For example up to 3 vendors
    2. Ask additional questions to vendors
  9. Check references
    1. Examples: consulting KLAS, Gartner etc
  10. Rank the vendors
    1. Functionality vs cost vs vendor characteristics
      1. functionality can be the institution's most important function
      2. cost can include the total amount from hardware, software, training, and support
      3. vendor characteristics can be important traits that are aligned with the institution's core values [13]
    2. Vendor selection tools
  11. Site visits
  12. Select a finalist (between the last 2 competitors)
  13. Verify Commitment
    1. Determine approval of selection committees and discuss choice will all the key stakeholders.
    2. If possible repeat the Demo to all the staffs
    3. For uncovered concerns, verify all the references and repeat verification steps if necessary
  14. Formal Contract Negotiation
    1. Ask vendors to spell out all the current as well as the future costs including the vendor time commitments for training and implementation
    2. Ask vendor to put source code in escrow just in case Vendor go out of business
    3. Before signing the software contracts,make sure you have familiar attorney to review
  15. Follow all the above process
    1. Know that the process takes time and do not rush because the end result can be expensive.
    2. Follow the process without skipping any steps.

Regulatory Compliance

Selecting an EMR is like buying a house where it needs thorough inspection/evaluation and making sure that every component is functional and meeting all the related requirements prior to approval and signing of contract. Based on experience, some of the significant criteria that must be considered during the selection process are the following:

Meaningful Use (MU)

Meaningful use is using certified electronic health record (EHR) technology to: Improve quality, safety, efficiency, and reduce health disparities. Engage patients and family. Improve care coordination, and population and public health. [95] A gap analysis can be performed:

Meaningful Use Gap Analysis

  • Is it ONC Certified? [8]
  • Does it meet all Meaningful Use objectives?
  • Does it provide automated MU & Clinical Quality Measure Reports?
  • Does the vendor provide MU Training Guides/Resources?
  • Does the system facilitate easy MU Data capture such as required data fields?
  • Does it provide audit logs, usage monitoring, etc?
  • Does it allow/include data migration from previous EMR?
  • Does it contain CDS Rules to improve performance on high priority health conditions?
  • Does it have capability to electronically submit Clinical Quality Measures to CMS?
  • Does it have Public/Cancer Registry Reporting Capabilities?
  • Does it provide 24/7 technical support?
  • Does it include Pt Portal, CCD Transmission & Direct Messaging with no extra/minimal cost? [96]
  • Is the ONC certification current or does the product require inherited certification/ gap certification?[97]

Hospital Inpatient Quality Reporting Program (IQR)

The Hospital Inpatient Quality Reporting (Hospital IQR) program was originally mandated by Section 501(b) of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. This section of the MMA authorized CMS to pay hospitals that successfully report designated quality measures a higher annual update to their payment rates. Initially, the MMA provided for a 0.4 percentage point reduction in the annual market basket (the measure of inflation in costs of goods and services used by hospitals in treating Medicare patients) update for hospitals that did not successfully report. The Deficit Reduction Act of 2005 increased that reduction to 2.0 percentage points.

In addition to giving hospitals a financial incentive to report the quality of their services, the hospital reporting program provides CMS with data to help consumers make more informed decisions about their health care. Some of the hospital quality of care information gathered through the program is available to consumers on the Hospital Compare Website. [98] It is important that the EMR supports the capability to capture all required elements for different Core Measure Conditions to help facilitate compliance.

Physician Quality Reporting System (PQRS)

PQRS is a reporting program that uses a combination of incentive payments and negative payment adjustments to promote reporting of quality information by eligible professionals (EPs). The program provides an incentive payment to practices with EPs (identified on claims by their individual National Provider Identifier [NPI] and Tax Identification Number [TIN]). EPs satisfactorily report data on quality measures for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare Secondary Payer).

Beginning in 2015, the program also applies a negative payment adjustment to EPs who do not satisfactorily report data on quality measures for covered professional services. This website serves as the primary and authoritative source for all publicly available information and CMS-supported educational and implementation support materials for PQRS. Stay informed for latest updates by subscribing to the [PQRS Listserv] [99] EMR should have PQRS data capture and reporting capability in order to meet PQRS and avoid related payment adjustments.

The measures CMS has selected for PQRS are developed and approved by organizations such as the National Quality Form (NQF). Some measures represent undesirable outcomes, while others represent desirable outcomes. New measures are added each year and measures from previous years can be updated or deleted. A list of the 267 measures for 2012 can be found here. The PQRS measures include both process quality measures and outcome measures, such as the patient’s blood pressure and HbA1c level. Examples include:

  • Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus. Developed by the NCQA. A patient aged 18 through 75 years with diabetes mellitus whose most recent hemoglobin A1c was greater than nine percent.
  • Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD. Developed by the American Medical Association-sponsored Physician Consortium on Performance Improvement. A patient aged 18 years and older with a diagnosis of CAD who was prescribed oral antiplatelet therapy.
  • Participation in PQRS is voluntary, but there are rewards and penalties associated with participation. Currently, providers earn an incentive payment simply for reporting PQRS measures [100].

    EHR Evaluation Resources

    • American Academy of Family Physicians Vendor Rating Tool
    • American Academy Of Family Physicians HR Demonstration Rating Form EHR Demonstration Rating Form [9]
    • American Academy of Family Physicians vendor's references verification form [10]
    • American College of Physicians EHR Feature Checklist
    • Bureau of Primary Health Care. BPHC Electronic Medical Record Resources page. [11]
    • Doctor's Office Quality - Information Technology Guidelines for Evaluating EHR Vendors
    • www.purchasing-procurement-center.com/selecting-a-vendor.html
    • The National Learning Consortium Vendor Evaluation Matrix Tool. [101]
    • California Health Care Foundation, EMR Evaluation Tool and User Guide - A Guide for Small Physician Practices: [12]
    • American Medical Association - 15 questions to ask before signing an EMR/EHR agreement[102]
    • Health Resources and Services Administration How to Select a Certified EHR [12]
    • Select or upgrade to a certified electronic health record vendor [13]

    References

    1. 1.0 1.1 Selecting the right EMR vendor. http://www.himss.org/files/HIMSSorg/content/files/selectingemr_flyer2.pdf
    2. 2.0 2.1 2.2 What factors should I consider when selecting a vendor? http://www.healthit.gov/providers-professionals/faqs/what-factors-should-i-consider-when-selecting-vendor
    3. HITECLA.Org Selecting the Right EHR. http://www.hitecla.org/ehr_selection_tips
    4. 4.0 4.1 Finding an EHR vendor: Mistakes are costly, and questions about confidentiality linger. (2011). Alcoholism & Drug Abuse Weekly, 23 (42), 1-4.
    5. 5.0 5.1 Johnson 2006: Selecting an electronic medical record system for the physician practice. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_035390.hcsp?dDocName=bok1_035390g
    6. 6.0 6.1 Jain, V. (2010). Evaluating EHR systems. Health Management Technology, 31(8), 22-24. Retrieved from http://ezproxyhost.library.tmc.edu/login?url=http://search.proquest.com/docview/747986471?accountid=7034
    7. 7.0 7.1 7.2 Selecting EHR http://www.healthit.gov/providers-professionals/ehr-implementation-steps/step-3-select-or-upgrade-certified-ehr
    8. American Medical Association. 15 questions to ask before signing an EMR/EHR agreement. http://www.himss.org/files/HIMSSorg/content/files/Code%2093_15%20questions%20to%20ask%20before%20signing%20an%20EMR-EHR%20agreement_AMA.pdf
    9. American Medical Association. 15 questions to ask before signing an EMR/EHR agreement. http://www.himss.org/files/HIMSSorg/content/files/Code%2093_15%20questions%20to%20ask%20before%20signing%20an%20EMR-EHR%20agreement_AMA.pdf
    10. American Medical Association. 15 questions to ask before signing an EMR/EHR agreement. http://www.himss.org/files/HIMSSorg/content/files/Code%2093_15%20questions%20to%20ask%20before%20signing%20an%20EMR-EHR%20agreement_AMA.pdf
    11. 11.0 11.1 11.2 - Vendor Assessment http://www.healthit.gov/providers-professionals/faqs/how-do-i-select-vendor
    12. 12.0 12.1 12.2 - http://search.hhs.gov/search?q=EHR+evaluation+form&site=hrsa&client=hrsa&proxystylesheet=hrsa&btnG=Search&lr=lang_en&output=xml_no_dtd&sort=date%3AD%3AL%3Ad1&ie=UTF-8&ud=1&oe=UTF-8
    13. 13.0 13.1 Weber, M. Selecting an EHR, now what???? [PDF document]. Retrieved from Lecture Notes Online Web site: https://moodle.sbmi.uth.tmc.edu/pluginfile.php/43545/mod_resource/content/1/Selecting_an_EHR_Vendor.pdf
    14. https://medicalmastermind.com/blog/emr-checklist-ten-product-questions-to-ask-the-vendor/ ‘’Medical Mastermind’’, EMR Vendor Checklist: Ten Important Product Questions to Ask the Vendor, July 31, 2012
    15. ‘’Practice Fusion Blog”, 4 questions to ask when selecting an EHR, July 7, 2014
    16. 16.0 16.1 Kenneth G. Adler, MD, MMM Fam Pract Manag. 2005 Feb;12(2):55-62How to Select an Electronic Health Record System http://www.aafp.org/fpm/2005/0200/p55.html
    17. EHR/HIE: Interoperability http://interopwg.org/certification.html/
    18. 18.0 18.1 18.2 18.3 - Kannry, J, Mukani, S & K Myers. Using an Evidence-based Approach for System Selection at a Large Academic Medical Center: Lessons Learned in Selecting an Ambulatory EMR at Mount Sinai Hospital, Journal of Healthcare Information Management — Vol. 20, No. 2
    19. MIT Geospactial Data Center: Protecting EMR Data (1 of 2) http://cybersecurity.mit.edu/2012/11/protecting-emr-data-1-of-2/
    20. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_039956.hcsp?dDocName=bok1_039956
    21. 21.0 21.1 http://journalofethics.ama-assn.org/2012/09/stas1-1209.html
    22. http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/SecurityRiskAssessment_FactSheet_Updated20131122.pdf
    23. http://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/disposalfaqs.pdf
    24. Information security policy template. (2011). Retrieved from http://www.healthit.gov/sites/default/files/info_security_policy_template_v1_0.docx.
    25. 25.0 25.1 25.2 HIMSS Computerized Provider Order Entry (CPOE) Wiki. https://himsscpoewiki.pbworks.com/w/page/26349065/Clinical%20Content
    26. 26.0 26.1 26.2 Kansas Department of Health and Environment 2008: Selecting an EHR, Now What??? http://krhis.kdhe.state.ks.us/olrh/Notices.nsf/bf25ab0f47ba5dd785256499006b15a4/720f6f7bfa876f0a862573c600595a2f/$FILE/EHR%20System%20Selection%20Process.pdf
    27. http://www.aafp.org/practice-management/health-it/product/features-functions.html
    28. http://www.aafp.org/practice-management/health-it/product/features-functions.html
    29. Requirements Analysis. http://www.stratishealth.org/documents/HITToolkitHospital/1.Adopt/1.3Select/1.3Requirements_Analysis.doc.
    30. EHR Checklist: Functional and Technical Essentials. http://www.poweryourpractice.com/electronic-health-records/ehr-checklist-functional-and-technical-essentials/.
    31. Boone,K.W. Clinical Documentation. 2011. http://www.springer.com/cda/content/document/cda_downloaddocument/9780857293350-c1.pdf?SGWID=0-0-45-1140144-p174097770.
    32. 32.0 32.1 32.2 32.3 32.4 32.5 32.6 32.7 32.8 EHR Functional Requirements. http://www.nyehealth.org/images/files/File_Repository16/pdf/Version_2_2_EHR_Functional_Requirements-16_Nov_09.pdf.
    33. Carter, J. A New Look at Results Management. 2012. http://www.americanehr.com/blog/2012/07/a-new-look-at-results-management/
    34. Patient Results. https://www.labcorp.com/wps/portal/patient/results
    35. Radiology Today. http://www.radiologytoday.net/archive/rt0513p18.shtml
    36. Kevin W. McEney MD. Radiology Information Systems and Electronic Medical Records http://www.acr.org/~/media/ACR/Documents/PDF/Advocacy/IT%20Reference%20Guide/IT%20Ref%20Guide%20RISEMR.pdf
    37. http://www.acog.org/About-ACOG/ACOG-Departments/Health-Information-Technology/EMR-Vendor-Selection-Process
    38. Using an evidence-based approach for system selection at a large academic medical center: lessons learned in selecting an ambulatory EMR at Mount Sinai Hospital. http://www.ncbi.nlm.nih.gov/pubmed/16669592
    39. Cerner Hospital Information System in Extended to Ambulatory Clinics in Three Ontario Hospitals. http://www.cerner.com/Cerner_Hospital_Information_System_is_Extended_to_Ambulatory_Clinics_in_Three_Ontario_Hospitals/
    40. The Christ Hospital http://www.thechristhospital.com/
    41. 41.0 41.1 41.2 41.3 41.4 41.5 Blake, R.T., Massey, A.P., Bala, H., Cummings,J., Zotos,A. (2010).Driving health IT implementation success: Insights from The Christ Hospital.53(2),131-138 http://www.sciencedirect.com/science/article/pii/S0007681309001530/
    42. http://www.healthsecure-emr.com/jail-emr-emar
    43. Carayon, P. Cartmill, R. Blosky, M. Brown, R. Hackenberg, M. Hoonakker, P. Hundt, A. Norfolk, E. Wetterneck, T. Walker, J. (2011).ICU nurses’ acceptance of electronic health records. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3197984/pdf/amiajnl-2010-000018.pdf
    44. Raasikh, . What the others haven't told you: lessons learned to avoid disputes and risks in EHR implementation.http://go.galegroup.com.ezproxyhost.library.tmc.edu/ps/i.do?action=interpret&id=GALE%7CA365889941&v=2.1&u=txshracd2509&it=r&p=HRCA&sw=w&authCount=1
    45. Dowding,D. Turley, M. and Garrido, T. (2012). The impact of an electronic health record on nurse sensitive patient outcomes: an interrupted time series analysis. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3384108/pdf/amiajnl-2011-000504.pdf
    46. 10 Popular Pharmacy Information Systems".http://www.informationweek.com/healthcare/clinical-information-systems/10-popular-pharmacy-information-systems/d/d-id/1104805?
    47. Kannry J 2006: Using an Evidence-based Approach for System Selection at a Large Academic Medical Center: Lessons Learned in Selecting an Ambulatory EMR at Mount Sinai Hospital. http://www.ncbi.nlm.nih.gov/pubmed/16669592
    48. 48.0 48.1 48.2 Integrating Electronic Health Records and Clinical Trials http://www.esi-bethesda.com/ncrrworkshops/clinicalresearch/pdf/MichaelKahnPaper.pdf .
    49. Using an evidence-based approach for system selection at a large academic medical center: lessons learned in selecting an ambulatory EMR at Mount Sinai Hospital. http://www.ncbi.nlm.nih.gov/pubmed/16669592
    50. Neal, D. (2011). Choosing an Electronic Health Records System: Professional Liability Considerations. Innovations in Clinical Neuroscience, 8(6), pg. 45.
    51. http://www.himss.org/files/HIMSSorg/content/files/Code%2093_15%20questions%20to%20ask%20before%20signing%20an%20EMR-EHR%20agreement_AMA.pdf
    52. Understanding Features & Functions of an EHR.http://www.aafp.org/practice-management/health-it/product/features-functions.html
    53. 54.0 54.1 54.2 54.3 54.4 54.5 54.6 http://www.kevinmd.com/blog/2010/09/10-tips-troubleshooting-complex-ehr-infrastructure-problems.html
    54. EHR and Disaster Recovery. http://www.himss.org/News/NewsDetail.aspx?ItemNumber=6469
    55. Healthcare Electronic Records Technology and Government Funding:Improving Patient Care.http://www.myemrstimulus.com/tag/ehr-application/
    56. What is Your EHR Connectivity Strategy? http://www.corepointhealth.com/sites/default/files/whitepapers/emr-connectivity-strategy-healthcare-interoperability.pdf
    57. How to implement EHRs? http://www.healthit.gov/providers-professionals/ehr-implementation-steps/step-3-select-or-upgrade-certified-ehr
    58. How to connect Health Information Exchange (HIE) with Electronic Medical Records.http://www.practicefusion.com/blog/how-to-connect-health-information/
    59. 60.0 60.1 60.2 Mobile EHR Access http://www.hitechanswers.net/mobile-ehr-access-healthcares-next-big-thing/
    60. McCarthy, K. 5 important considerations when choosing EHR. 2014. http://www.nuemd.com/news/2014/10/28/5-important-considerations-when-choosing-ehr-systems
    61. Understanding the True Costs of an EHR implementation http://go.galegroup.com.ezproxyhost.library.tmc.edu/ps/i.do?ty=as&v=2.1&u=txshracd2509&it=search&s=RELEVANCE&p=HRCA&st=T002&dblist=HRCA&qt=TI~Understanding+the+true+costs+of+an+EHR+implementation~~SP~52~~IU~14~~SN~00257206~~VO~89&sw=w&asid=a842cc467e789e3bde4b58ab9e5d0fab
    62. EHR financing offered. (2010). Health Management Technology, 31(2), 10. Retrieved from http://ezproxyhost.library.tmc.edu/login?url=http://search.proquest.com/docview/622031107?accountid=7034
    63. EHR financing offered. (2010). Health Management Technology, 31(2), 10. Retrieved from http://ezproxyhost.library.tmc.edu/login?url=http://search.proquest.com/docview/622031107?accountid=7034
    64. How do I plan for hardware purchases? http://www.healthit.gov/providers-professionals/faqs/EHR-infrastructure-investment.
    65. 66.0 66.1 66.2 66.3 66.4 66.5 www.aafp.org/practice-management/health-it/product/hardware.html
    66. No Servers to set up. No software to install. http://amazingcharts.com/products/web-based-ehr/
    67. Is your practice ready? 5010 and ICD-10 vendor questions and guidelines. 20143. http://www.mgma.com/government-affairs/issues-overview/health-information-technology/icd-10/5010-and-icd-10-vendor-questions-and-guidelines
    68. How Much Will That EMR System Really Cost? http://www.aafp.org/fpm/2002/0400/p57.html.
    69. Kannry, J., Mukani S., Myers K. Using an Evidence-based Approach for System Selection at a Large Academic Medical Center: Lessons Learned in Selecting an Ambulatory EMR at Mount Sinai Hospital. Journal of Healthcare Information Management. Vol. 20, No.2 pg.94
    70. 71.0 71.1 71.2 71.3 71.4 Valacich, J. S., George, J. F., & Hoffer, J. A. (2012). Essentials of systems analysis and design (5th ed.)
    71. Proposing Regulatory-Driven Automated Test Suites http://ieeexplore.ieee.org.ezproxyhost.library.tmc.edu/stamp/stamp.jsp?tp=&arnumber=6612874
    72. Holbrook, A., Keshavjee, K., Langton, K., Troyan, S., Millar, S., Olantunji, S., Pray, M., Tytus, R. & Ford, P.T. (2001). A critical pathway for electronic medical record selection. Proceedings of the AMIA Symposium; Pages 264–268. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2243608/
    73. Healthcare Standards. http://www.emrandehr.com/tag/healthcare-standards/
    74. Finding an EHR vendor: Mistakes are costly, and questions about confidentiality linger. (2011). Alcoholism & Drug Abuse Weekly, 23(42), 1-4.
    75. 76.0 76.1 76.2 76.3 76.4 76.5 76.6 http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_031357.hcsp?dDocName=bok1_031357
    76. How to Select an Electronic Health Record System. http://www.aafp.org/fpm/2005/0200/p55.html
    77. Planning Your EHR System:guidelines for Executive Management.http://www.satva.org/white-papers/MHCA-SATVA-PlanningYourEHRSystem.pdf
    78. AHIMA http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047959.hcsp?dDocName=bok1_047959
    79. Transmitting Data Using the Direct Protocol. (2013, February 4). Retrieved February 3, 2015, from http://bluebuttonplus.org/transmit-using-direct.html
    80. HL7 Fast Healthcare Interoperability Resources Specification (FHIR™), Release 1. (n.d.). Retrieved February 5, 2015, from http://www.hl7.org/implement/standards/product_brief.cfm?product_id=343
    81. Pennell, U. (2013, August 21). What is E-prescribing and What are the benefits? - EMRConsultant. Retrieved February 7, 2015, from http://www.emrconsultant.com/emr-education-center/emr-selection-and-implementation/what-is-e-prescribing-and-what-are-the-benefits/?s=dur
    82. Carolyn Hartley - signing an EHR contract http://physiciansehr.org/signing-an-ehr-contract-25-tips-to-control-costs.aspx
    83. Signing an EHR contract. Tips to control costs. http://physiciansehr.org/signing-an-ehr-contract-25-tips-to-control-costs.aspx
    84. http://www.himss.org/files/HIMSSorg/content/files/Code%2093_15%20questions%20to%20ask%20before%20signing%20an%20EMR-EHR%20agreement_AMA.pdf
    85. Murphy E., et. al. An Electronic Medical Records System for Clinical Research and the EMR–EDC Interface http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2361387/
    86. http://www.himss.org/files/HIMSSorg/content/files/Code%2093_15%20questions%20to%20ask%20before%20signing%20an%20EMR-EHR%20agreement_AMA.pdf
    87. Selecting An EHR, Now What? ftp://ftp.hrsa.gov/ruralhealth/jan082008tacall.pdf
    88. MetaStar https://www.metastar.com/web/professional/docs/DOQ-IT/Vendor/Tools/SiteVisitingTips.doc
    89. EHR Contracts: Key Contract Terms for Users to Understand. http://www.healthit.gov/sites/default/files/ehr_contracting_terms_final_508_compliant.pdf
    90. Certified Health IT Product List (CHPL) list of EMRs. http://oncchpl.force.com/ehrcert
    91. HIMSS Electronic Health Record Association http://www.himssehra.org/ASP/index.asp
    92. Better Patient Safety is Goal of Confidential EHR Error Reports http://www.amednews.com/article/20130724/profession/130729986/8/ .
    93. HEY, WHO DID THIS? Note: there needs to be something here
    94. Meaningful Use Definition and Objectives http://www.healthit.gov/providers-professionals/meaningful-use-definition-objectives
    95. http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html
    96. http://healthit.gov/sites/default/files/final2015certedfactsheet.022114.pdf
    97. Hospital Inpatient Quality Reporting Program. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalRHQDAPU.html/
    98. Physician Quality Reporting System http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/PQRS/
    99. Bryan Dowd, Chia-hsuan Li, Tami Swenson, Robert Coulam, and Jesse Levy. Medicare’s Physician Quality Reporting System (PQRS): Quality Measurement and Beneficiary Attribution. Medicare Medicaid Res Rev. 2014; 4(2): mmrr2014.004.02.a04
    100. The National Learning Consortium Vendor Evaluation Matrix Tool. http://www.healthit.gov/providers-professionals/implementation-resources/vendor-evaluation-matrix-tool
    101. http://www.himss.org/files/HIMSSorg/content/files/Code%2093_15%20questions%20to%20ask%20before%20signing%20an%20EMR-EHR%20agreement_AMA.pdf
    1. [Kannry, J., Mukani, S., & Myers, K. (2006). Using an evidence-based approach for system selection at a large academic medical center: lessons learned in selecting an ambulatory EMR at Mount Sinai Hospital. Journal of Healthcare Information Management: JHIM, 20(2), 84–99.]

    64. www.hrsa.gov

    1. McEney.(2013). Radiology Information Systems and Electronic Medical Records. IT Reference Guide for Practicing Radiologist. Retrieved from http://www.acr.org/~/media/ACR/Documents/PDF/Advocacy/IT%20Reference%20Guide/IT%20Ref%20Guide%20RISEMR.pdf