CorrectCare

All Systems Go? How to Select an EHR That Meets Your Needs

by Madison L. Gates, MS

Electronic health records are often pitched as a tool that will enhance health professionals’ capability to provide and manage care, while also facilitating patients’ ability to understand and participate in the management of their care. The U.S. Department of Health and Human Services, as well as primary care organizations such as the American Academy of Family Physicians, strongly advocate for EHRs as necessary if physicians are to improve the way they manage care and health outcomes. Many advocates also propose that EHRs will decrease health expenditures by making patient charts more integrated, shareable and secure, and making them less timely and labor intensive to manage.

These are compelling arguments, and if they hold true in the private sectors, then they are just as true in correctional health care systems, which face the additional complications of limited budgets, a patient population with few resources and the need to balance security and health care. While it’s not the panacea for all of these problems, implementing a correctional electronic health record system often is proposed as a way to simultaneously control rising costs and improve outcomes.

Despite the many reasons why health professionals may want EHRs, the decision to adopt a system is difficult. And, once that decision is made, the selection of a specific EHR system is just as difficult. In fact, the success of the project ultimately is determined by the specific EHR that is chosen.

This article is based on a case study of a system successfully implemented and managed throughout the Kentucky Department of Corrections. The intent is to provide guidance for other DOCs interested in selecting an EHR that best meets their clinical, administrative and institutional needs. To make an informed selection, it is critical to understand what you mean by EHR, your institutional needs, the type of system that best fits your organization and the type of service you expect.

Defining EHRs
The first generations of EHRs are vastly different from the systems being implemented today. For example, some early EHRs were more document repositories than comprehensive tools to manage health and support clinical decision making. Today, EHRs come in many varieties. Thus, the first and most important question that any organization should ask is, “What do we mean by EHR?” The answer to this seemingly simple question establishes the criteria for evaluating prospective systems.

While organizations can begin to learn what an EHR is or can be via product demonstrations, the caveat to this approach is that not all EHRs are the same and different systems define the technology differently. Starting with a definition is advantageous even if you later must amend it.

Broadly defined, an EHR is an integrated data system to document, analyze, manage and support clinical information and decision making, as well as a resource for patients to understand and participate in the management of their health. Using this definition, the essential components of an EHR can be categorized into four capabilities: documentation, order management, reporting and analysis, and communication. These capabilities should be seamlessly integrated and interrelated, which is to say that all features and functions should be accessible from every aspect of the system. The documentation function should support recording clinical encounters, making amendments, documenting in a structured manner, and relating and linking information to other aspects of health information, such as problems, procedures and medications.

Integrated within documentation, order management should support initiating, transmitting and managing orders, such as medications, labs, diagnostic tests, patient care, administrative and other directives. Structured data is preferable and should be used when possible. The key aspect of order management is the ability to track what has been requested, when the task has been completed, and who initiated, performed and reviewed the order. This capability also should minimize the potential for orders to “fall through the cracks” by not being completed or reviewed. An alert system and automatic messaging is fundamental to this function.

A system capable of documentation and order management is incomplete without a reporting and analysis component. Structured data for documentation and order management is critical to an effective and flexible reporting and analysis feature where the underlying information largely comes from databases. “Structured data” does not mean that there are no options for write-in text or that users must adapt the art of their practice to prearranged forms. However, structured data provides consistency for reporting and analyzing data.

The function common throughout any system should be communication, which is more than sending, receiving and managing messages like e-mail. Communication is the function that binds documentation, order management and reporting into a seamless system. This includes system-to-user and user-to-user communication, as well as alerts.

These four capabilities—documentation, order management, reporting and communication—broadly represent what an EHR system should be capable of doing and are important factors to consider in the selection process. Starting with a definition of an EHR and its components, an organization can evaluate realistically what is possible compared to what it wants. The next step of the selection process is to identify and evaluate its institutional needs.

Workflow and Operational Analysis
Identifying an organization’s needs is important because not all EHRs are the same or appropriate for all types of institutions. But it is a difficult process and entails more than an evaluation of policies, procedures and guidelines. In a multiclinic organization, policies, procedures and guidelines often can be interpreted differently based on the particular clinic’s culture, staffing mix and size, patient population and many other factors. Thus, too much reliance on these formal documents may not fully capture what is actually occurring.

This aspect of the EHR selection process entails examining how clinics operate, identifying the different types of encounters and evaluating the effectiveness of your paper system. You must define with some specificity what the EHR needs to do in order to build on your current workflow or to reorganize operations altogether.

When documenting workflow, no detail is too minor. For example, what are the many ways for a patient to get to clinic? What happens when the patient gets to clinic? What happens during the clinical encounter? What happens when the patient leaves the clinic? The best way to document these events is to follow a live example.

This analysis should produce a list of needs that can be ranked as either critical or as wants. The critical features and functions of an EHR are those essential to your clinic operations, such as the ability to document clinical encounters; everything else is a want. Of course, the rankings can be granulated further, but what you want to learn from this activity is what your EHR must be capable of doing. A primary reason for transitioning to an EHR is to improve the existing system, not to replicate it. An EHR that does not add value is not the right system for your organization.

Build or Buy?
Some organizations believe that the system most suitable for their operations is one they build. Regardless of whether you want to build or buy, you need to know what an EHR is and what is necessary to operate clinics. I propose that most organizations will, and should, want to buy. While there may not be a perfect system that meets all of your needs, building one is unlikely to meet your expectations, either. Also, building an EHR requires time, expertise and resources.

One way to think about the “build or buy” decision is that most organizations do not debate whether they should develop their own word processor, spreadsheet, presentation or database programs; they rely on companies with expertise in this type of software development. And these programs are far less complicated than a full EHR.

Medical informatics, the underlying discipline for most EHR systems, is not just a combination of medicine, information and technology, but a distinct field. Medicine, nursing, pharmacy, other health professions, computer science and project management are only some of the disciplines involved in the development of an EHR. Most EHR vendors specialize in developing these systems and devote the time and resources to the product.

My advice is to buy a system developed by experts. The remainder of this article assumes that your organization will make that decision.

Vendor Service
The range of EHR vendors is as diverse as the systems themselves. In the selection process, the services that the vendor provides is a critical factor.

Some vendors are moving toward a hosted Web-based solution. There is much debate over whether such a system is better than a software-based one. Web-based systems are typically accessible anywhere with Internet access. Software-based systems can be housed on a server and be accessible remotely via a virtual private network. While there are advantages to Web-based systems—such as graphical user interface, lower learning curve and a smaller and less expensive technology footprint (hosted systems do not require an investment in servers)—the two types of systems can offer the same or similar features and functions. The primary difference is location. The hosted Web-based solution is often housed by the vendor, whereas the software-based solution tends to be housed internally.

Where the system is housed raises other issues and concerns, mostly related to service, with hosted solutions tending to provide more service. The extent of service your organization will require depends on the extent to which you want to invest time, expertise and resources to manage the system.

One of the most important services a vendor can provide is disaster recovery. It’s not enough for a vendor to simply state that it has a disaster recovery plan. You should receive detailed and specific information about this service. Disaster recovery plans minimally should describe in detail how a vendor will secure, protect, backup and recover data. Disaster recovery should entail periodic backups, on-site and off-site storage, Internet service redundancy, mirrored servers in different locations and an estimated time for recovery. An organization that does not require a policy risks disaster without recovery.

Service also includes a range of options that will either enhance or impede the implementation, use and management of a system. Before selecting an EHR, you will want to know how the vendor will facilitate the transition from paper to electronic. Regardless of the type of system, service should include project management, training, support after implementation, technology and infrastructure guidance, and product enhancement. Although a good on-staff project manager can guide the EHR project to successful implementation, a vendor should have expertise in managing the adoption of its product and should provide the service.

There are many service questions that should be asked and discussed prior to selection. Who will train and support users? What is the product enhancement cycle? This is sometimes overlooked, but no technology is static, especially EHRs. No matter how carefully an organization evaluates its needs and how diligently a vendor develops its system, there likely will be a need for change. How often is the system updated and enhanced with new features? Are innovations included in the pricing model? What is the vendor’s history in interfacing with other systems? How flexible is the system and vendor?

An organization can request a product enhancement history. Be cautious of too many enhancements in a short period of time, which may suggest a faulty system, and of too few innovations, which may indicate inattention to the product. Of course, many enhancements may mean that a vendor is highly motivated and active, and few innovations may suggest that the system was well-developed. The type and number of enhancements can be informative and may indicate the level of service that you can expect.

Flexibility vs. the ‘Ideal’
In addition to the considerations discussed above, cost is a major deciding factor in selecting an EHR. Also, a vendor should be willing to provide an online demonstration site or environment to explore the product, or to facilitate a visit with an existing client. Both options demonstrate the vendor’s level of comfort with its product.

— About the author: Madison L. Gates, MS, is a data research analyst in the Department of Family and Community Medicine, University of Kentucky, Lexington. To reach him, e-mail  mgates@email.uky.edu.

[This article first appeared in the Winter 2009 issue of CorrectCare.]