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How to Compare EMR Vendors

After you compare multiple EMR vendors, you begin to realize that most of the vendors have the same set of features. The difference between each EMR vendor is the method in which these features are implemented in their system. This article will attempt to break down the functional grouping of benefits in an EMR system and then detail the differences in each of these features.

Appointment Scheduling

The majority of EMR’s in the market today provide some capability to schedule a patient. This feature may come from the built in appointment scheduler or one that the EMR vendor has interfaced with through another Practice Management Software vendor. Typically, the most basic features found in the appointment scheduler are providing multiple views of the schedule. This may be by the doctor, location, resource or a combination of the three. The views also allow the practice to see the schedule by day, week, and month.

Other basic feature most commonly found are assignment of appointment types which allows an office manager or physician to view their appointments of the day with a glance and have a pretty good idea of what their day is going to consist of. Some EMR’s also allow for appointment pop up’s to occur which can inform the front desk specific information about the patient. The more advanced appointment schedulers have features such as Rules Based Scheduling. This allows the physician to create a schedule based on the type of appointment and when they want to see that type of appointment. This application will then help the practice manage the patients and the types of visits they may be presenting with. Another advanced feature is the ability to drag and drop appointment changes. This prevents the user from having to click on the appointment, choose the day to move to and then click ok to move the appointment. If your office tracks no shows, many of the advanced EMR systems will help your practice track those patients.

Patient Flow Tracking

Most EMR systems will give you some way to track your patients as they move through your office. Patient flow tracking typically comes in three different styles. Some vendors give you a visual representation of the rooms and then display the patient in the room along with the procedures being done to the patient. Other systems provide a list of patients denoting their location, time spent in room, and who is currently treating them. The third style that is used is similar to a spreadsheet that is color coded with the patient exam rooms and the times turning colors as thresholds have been exceeded for the amount of wait time for the patient. All three styles are easy to use and seem to help make your office more efficient especially when someone has been designated to keep an eye on the tracking screen.

Documentation of an Encounter

Documenting a clinical encounter is the core function for every EMR in the market. The speed and functionality of this feature is usually the one feature that will either make or break the deal. What EMR vendors need to realize is that the speed in which an encounter can be completed is the one factor that makes a physician feel comfortable about the system. The biggest fear for physicians is that by switching to an EMR system will slow down their process and there by decrease the number of patients they can see in a day. If this occurs, ultimately the physician will return to paper and not use the system and consequently the implementation is deemed a failure. With that said, this one feature alone should be scrutinized with critical detail.

Templates: Clinical documentation screens can be broken down into three methods of data collection. The first method of data collection is context based templates. These templates are paragraphs of text that are created by the physicians, which address a specific diagnosis, procedure or treatment. As the physician performs the History of Present Illness and Review of Systems for the patient, the physician is selecting the context-based paragraph that best meets the ailment that the patient is being seen for. Upon completion of the note, most of these systems allow the physician to type additional text or use Dragon Naturally Speaking to modify the end result of the note. The benefit of this type of system is the speed in which a note can be created. A note can typically be created as quick as the doctor may dictate or make documentation in the patients chart.

Tab Based Templates: Tab based forms are the next type of data collection. Tabs based on the SOAP note procedure usually group these screens. Some systems will give the physician the ability to define the tabs in a custom workflow. For example, a nurse may only need to see the Vitals, Past Family History and Social History. This feature can be nice because it allows for an uncluttered desktop for the nurse and does not overwhelm them with information they are not concerned with. This feature also keeps HIPAA in check by only showing information to users on a need to know basis.

Past Family and Social History, Allergies, Immunizations, Medications: The next set of tabs across the top of the screen is usually Past Family and Social History, Allergies, Immunizations, and Medications. The vendors EMR application should allow the ability to add any fields the physician may need to these screens. Typically, the vendor already has a prebuilt template, but the template should be modifiable by someone in the physician’s office. In some states, such as Texas, a centralized database has been established to retrieve Immunization data from. Typically, this is done using HL7. If you are Pediatrician, this can significantly improve your patient’s care by having the ability to download the patient’s immunizations to your system. When you compare the EMR vendors, verify who has this capability and who does not. Also, request the cost of the interface for this feature. When it comes to collecting information about patient medications, the system should have the ability to denote the difference between medications prescribed by a physician and over the counter medications.

HPI (History of Present Illness): The next tab is generally the History of Present Illness tab. As stated previously, the vendor may already have templates pre-built, but the ability should exist for the office to custom design this screen. On each of these screens, a free text field should always be available in case the patient has something that you have not accounted for in your template.

ROS (Review of Systems): After the HPI tab, the Review of System tab usually follows. This screen is probably one of the most complex screens to create for your office. Most vendors will tell you that they have templates for your specialty but you will find that their templates probably only represent about 10% of what you actually need. Due to this, it is critically important that the EMR vendor show you how difficult it is to create a custom defined Review of System screen. Remember, during the demonstration, the vendor is going to demonstrate what they want you to see…not what you need to see. This is one of those areas. Tell the vendor ahead of time that you will want to see how a Review of System template can be custom defined. I will say it again; this is critical that you see this in your demonstration. When you hear it takes 6 months, 9 months, 12 months 18 months to get up and running on an EMR system…. this is why.

Orders – lab / diagnostic
After the Review of System, typically you will see a tab for Lab and Diagnostic Imaging. One thing to consider about these two tabs is the workflow for these screens. When the patient presents in your office, were labs or diagnostic imaging already performed. If so, these tabs need the necessary clinical elements to document these results. The system needs to understand that this labs/imaging was previously done and not to be billed by the system. At this time you are only documenting the information about the result. The second type of workflow is when you need to order labs/diagnostic imaging for the patient. The EMR application needs to understand when the order process needs to take place.

The Lab and Diagnostic Orders: module of the EMR application is probably the second most important feature of the EMR application. You will find that much of your time for you and your staff will be spent in these modules. For this reason, pay very close attention in the demonstration to how these modules are accessed, where they are accessed from, where the module will leave you when you complete the process, and how to follow-up on data that was entered into these modules. Some vendors will allow you to make an order request electronically via a HL7 interface with the vendor. When it comes to labs, most labs will pay for the interface if you do enough volume with the lab. It is also possible to have interfaces with multiple labs at one time. Verify the EMR vendor has the capability.

Voice, Dictation, and Dragon Naturally Speaking

Almost all EMR vendors allow some mechanism to capture voice into their EMR system. The majority of vendors have chosen to partner with Dragon Naturally Speaking. The EMR vendor usually provides some kind of text box within their application that accepts the input from Dragon Naturally Speaking. This is critical when you have already been using Dragon Naturally Speaking. If you already have the application and the EMR vendor does not support Dragon, I would not purchase the vendors EMR system. You are already comfortable with the speed in which a note can be captured. You will only become more frustrated with the system due to the speed in which you can capture all the necessary data. As you will see, you will have two choices in a template-based system. You either create a template that includes ever bit of detail you could want about a problem or create a simple template that is enough to document the encounter. Most physicians choose the latter and accept the fact that end result note is not what they have been accustomed to viewing in the past.

SOAP Note

Then final result of the note should be one that is easily modifiable. Many vendors will allow you to click on certain clinical elements in the note and then hyperlink back to the exact clinical element selection. You can then either delete or change your finding. Some vendors allow you to add free text directly to your note after it has been completed. Lastly, the groupings on the clinical note should be user modifiable. This means if you do not like where the Review of Systems or Assessment appears in the note, you should be able to change the order of the grouping.

A feature that allows for the quick documentation of an encounter is the ability to bring forward the past visit the patient was seen for. Many times, little has changed since you have last seen the patient. Therefore, it makes it quick and easy to pull forward the last visit’s documentation and then chart by exception. Chart by exception is another feature in EMR and system that allows the physician to either give a positive or negative result to a clinical element. For example, the patient either presented with fever or did not present with fever.

Another feature in the building of the SOAP note is real-time building of the SOAP note. In some EMR applications, the physician can make the clinical selections on one half of the screen and watch the note being built on the right side of the screen. This can be very helpful to know what the end result is looking like as you document the clinical encounter.

Most EMR vendors have the ability to append to a note. The question you need to ask the vendor during the demonstration is how you append new information to a clinical encounter that has already been posted for billing purposes. As you already know, a physicians day can be filled with interruptions and sometimes you inadvertently close encounters by mistake or sometimes you close the encounter just to get it done and over to billing so you can move on to your next task at hand. Sometimes that is ok and the billing department can make the necessary changes that need to be made but other times you made need to go back and make modifications to the clinical documentation.

Electronic signatures on encounter notes are a feature by many EMR vendors. Typically, you can use a tablet pc and its pen to sign your name digitally. The EMR vendor will then take this signature and then save it with each encounter.

Medications

The medications module is another module you will find that you spend a great deal of time with. Consequently, this is a feature you want to pay close attention to during the demonstration. The prescribing of medications should be quick, easy, and flexible. When prescribing medications you will want the system to check for drug-to-drug interactions along with any drug to allergy interactions. Some EMR systems will even check interactions if the patient is pregnant or breast-feeding. The biggest difference between the EMR systems is the ability to check interactions against prior medications. Some systems will only check the drugs that were prescribed during the encounter. Other EMR systems will check past medications and medications that have been prescribed by other physicians if they were entered in to the system. Most EMR systems will give the ability to do Pediatric Dosing. If you are a pediatric physician, make sure this feature is available. Other features in the medications module deal with creating the printed/electronic prescription. Some systems only have the ability to print the prescriptions. A printing feature found on some EMR systems will give you the ability to designate a “prescription printer” so you do not have to choose which printer the prescription is printed to. Another feature is the ability to fax the prescription to the pharmacy. Patients typically like this option because the prescription can be ready by the time they arrive at the pharmacy. Lastly, some systems can use EDI (electronic data interchange) to send the prescription to the pharmacy. This feature allows you to place the prescription directly into the pharmacist computer without any data entry on their side.

Anatomical Documentation

Most all EMR vendors will tell you they have the ability to document anatomical drawings. Typically, this means they give the physician the ability to use a pen and draw pictures that can be saved as an attachment to the patient note. What differentiate the EMR vendors are the clinical pictures that come with the EMR systems. Some vendors will give you a database of clinical artwork that you can then annotate on top of. Most of the vendors will tell you to scan an image in and then you and annotate on top of the image. If this feature is important to you, select a vendor that has a database of anatomical drawings.

In this article, we have attempted to cover some of the basic features to watch for during the EMR demonstration.

Defining the EMR Selection Process

In most situations, a physician will decide to purchase an EMR and then call other physicians they know that are currently running an EMR system. After determining which vendors are being used, the physician may call the particular EMR vendors and request a demonstration.

The selection process begins way before a vendor is called for a demonstration. Remember, the EMR system should make your office more efficient. With that said, the very first task that should be completed is a detailed workflow analysis of your practice. This analysis should start with the patient’s first step in your practice. For example, if the patient is a new patient, what forms are given to them by the front desk to fill out? If the patient is a worker’s comp patient, are there additional forms that need to be completed? Take each and every one of these forms and place them in a binder and label them “New Patient” documents. At this point, you have already identified a potential way to make your office more efficient. How long does your staff spend keying this data into your system or attaching it to a paper chart? Many EMR vendors provide the ability for a patient to key in data either online or in a Kiosk type environment. Most of the time, the data keyed by the patient is demographic related but some vendors take the process to the next step by collecting past family social history and history of present illness. Some may argue that patients would not be willing to complete these forms or enter the information, but in Kiosk environments where elderly patients had no problem-using Kiosk.

Phase two of the EMR selection process, a list of questions of capabilities needs to be created in which each vendor will answer either yes or no to as to the existence of that capability in their EMR application. Each capability needs to be weighted as to the necessity to your practice. An example of this is the ability to directly interface to an external PACS server. This feature may be extremely important to an orthopedic surgeon but have no importance to a pediatric physician. As such, the score for the same EMR vendor for one specialty may be completely different for another specialty.

Phase three in the selection process is to search for EMR vendors that you would like to see a demonstration from. This first place to start is the list of vendors who are CCHIT certified. Each of these vendors has gone through a process that truly puts their applications through scenarios that probably occur in your office on a daily basis. As you will see, there are over 50 vendors already on this list. At least this narrows the process down from 300+ vendors to 50+ vendors. Next, call other physicians that are in the same specialty who are currently using an EMR system. Determine if any of these EMR systems are on the CCHIT certified list and start with the demonstration of these vendors.

Phase four is the actual demonstration process. This is probably the most important phase of the entire selection process. What you will soon find out is that EMR vendors will take you down a demonstration path that is “their” own path. Some will attempt to show you a sampling of patients that may show up in your practice and others will show you just a basic demonstration of a patient being processed through their system. In either situation, it is the EMR demonstrator who controls the demonstration. This means the vendor’s attempts to show you what you want to see, not what you may need to actually see. For example, most presenters will walk you through a review of system on a patient. Notice that the presenter will only select what is on the screen. This kind of presentation does not show how you will handle a patient that presents with something that does not show up on the screen. This is where you need to as the physician take the presenter off the beaten path. Ask the presenter to choose options that do not necessarily appear in the screen. Attempt to pick something that may not even exist in the system.

Phase five begins with the analyzation of your demonstration documentation. The easiest way to score each vendor is to add up the total features / questions for the vendor and divide it by the total questions / features asked. You should now be able to see how well each vendor did as compared to the other vendors. What is important to notes is the way the questions are divided. When evaluating an EMR system that has an integrated PMS system, the questions should be divided between the two systems.

Phase six is where your office needs to narrow the EMR vendor selection down to two or three vendors. The best way to handle this process is create three different patient scenarios. Type the scenarios just like the patient were to walk into your office and you would go through the process manually. Next, call the three vendors and tell them you would like to schedule a final demo with them based on three patient scenarios. The vendor will want you to fax the scenarios to them so they can setup the templates in the system. Try to schedule all three demos within a day of each other. If you can see them all in one day, it makes it much easier to see the differences between the vendors. We also suggest that during these demonstrations that you might have a fourth scenario that you put together and not fax to the vendor.

Phase seven is the step in which you call references and make site visits. When you call the EMR vendor, ask for references that are very similar to your practice and your needs requirements. For example, if you have a need to connect with a hospital with a Meditech HIS system, it would greatly benefit you if you could see an actual practice who has accomplished that type of interface. Another example would be an interface to an external PACS vendor. How does the vendor EXACTLY interface to the PACS vendor? Is it as seamless as the vendor tells you it is? Or, is it even worth paying for the interface because it does not add a real value to your system. Next, make sure the reference that the vendor is sending you to come from your specialty. While you may be able to see the system in use, it does little good if the patient’s problems have no similarity to the patient problems you may see. The most important point to understand about this phase is not to skip this phase.

The last phase deals with signing off for the system and making payment. The most important part of this step is there must be a contract between you and the vendor. Do not sign a proposal for any dollar amount. This leaves no legal recourse if there are any problems with the software or vendor. Make sure the contract includes the specifications you have verbally discussed with the vendor.

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