Difference between revisions of "Vendor Selection Criteria"

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=== Clinical Process Assessment and Improvement ===
=== Clinical Process Assessment and Improvement ===
*The EMR vendor, in response to requirements defined in the [[Request for Proposal|request for proposal (RFP)]], should describe a plan for evaluation and assessment of the as-is clinical processes and workflows, identification of needed improvements and a proposal for implementing workflow optimizations necessary to launch the EMR. <ref name=”McDowell2003”>McDowell, S. W., Wahl, R., & Michelson, J. (2003). Herding cats: the challenges of EMR vendor selection. Journal of healthcare information management, 17(3), 63-71.</ref>
*The EMR vendor, in response to requirements defined in the [[Request for Proposal|request for proposal (RFP)]], should describe a plan for evaluation and assessment of the as-is clinical processes and workflows, identification of needed improvements and a proposal for implementing workflow optimizations necessary to launch the EMR. <ref name=”McDowell2003”>McDowell, S. W., Wahl, R., & Michelson, J. (2003). Herding cats: the challenges of EMR vendor selection. Journal of healthcare information management, 17(3), 63-71.</ref>
== 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 [[Health Insurance Portability and Accountability Act (HIPAA)|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 [[Data security|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|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? <ref name="mit cybersecurity">MIT Geospactial Data Center: Protecting EMR Data (1 of 2) http://cybersecurity.mit.edu/2012/11/protecting-emr-data-1-of-2/</ref>
* 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. <ref name="Ensuring Security of High Risk Information in EHRs">http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_039956.hcsp?dDocName=bok1_039956</ref>
* Are all messaging capabilities within the EMR encrypted? <ref name="Electronic Health Records: Privacy, Confidentiality, and Security">http://journalofethics.ama-assn.org/2012/09/stas1-1209.html </ref>
* Does the system have the ability to audit / monitor user activity if needed?<ref name="Electronic Health Records: Privacy, Confidentiality, and Security">http://journalofethics.ama-assn.org/2012/09/stas1-1209.html </ref>
* Does the system have time-stamp functionality (name, date, & time)? <ref name="Security Risk Analysis Tipsheet: Protecting Patients’ Health Information">http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/SecurityRiskAssessment_FactSheet_Updated20131122.pdf</ref>
* 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?<ref name="FAQs About the Disposal of PHI">http://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/disposalfaqs.pdf</ref>
* 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?<ref name="information security">Information security policy template. (2011). Retrieved from http://www.healthit.gov/sites/default/files/info_security_policy_template_v1_0.docx.</ref>
=== 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. <ref name="results Mgt"> Carter, J. A New Look at Results Management. 2012. http://www.americanehr.com/blog/2012/07/a-new-look-at-results-management/ </ref>
* 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?<ref>Patient Results. https://www.labcorp.com/wps/portal/patient/results</ref>
** Will the system suggest follow up test depending of test done and results obtained?
* LOINC Codes
** Will the EHR accept LOINC-mapped electronic lab results if available from the source lab <ref name="functional"></ref>?
*Radiology Results
** Will the system  accept radiology results and reports electronically from imaging centers or through the HIE? <ref name="functional"></ref>
** Does the EHR support the direct viewing of DICOM medical images without having to log into the separate PACS system?<ref>Radiology Today. http://www.radiologytoday.net/archive/rt0513p18.shtml </ref>
** 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?<ref name=“ IT REference Guide for the Practicing Radiologist “> 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</ref>
* Reminder of next test due
** Will the system set a reminder for recommended time frame for next lab test <ref name="functional"></ref>?
===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.<ref>http://www.acog.org/About-ACOG/ACOG-Departments/Health-Information-Technology/EMR-Vendor-Selection-Process</ref>
===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.
* '''Graphing Capabilities''' - With continuous fluctuations in vital signs, the ability to graph these allows the care provider to quickly and easily view changes over time and  treat any issue immediately and appropriately.
* '''Medication Pump Integration''' -Anesthetic gases, such as sevoflurane and isoflurane, and pain medications, such as remifentanyl, are given continuously in some surgical cases, and with the interoperability of the EMR with these pumps, allows for accurate recording of quantities and doses administered to the patient as well as time-sensitive recordings.
* '''Unique user sign-ons''' -With the capability of having unique user sign-ons, it allows the ability to track all anesthetic personnel associated with the record and who administered the medications or completed an activity.
* '''Narrative Capability''' - By allowing the ability to also include narratives, in addition to automatically sync information, it allows the clinician to provide as much detail as deemed appropriate regarding a situation or case.
=== 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 [http://www.hopkinsguides.com/ 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?<ref name="KDHE 2008">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</ref>.
* 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 [[PHR|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-
#at the user interface level (for example, separate inpatient and outpatient applications, minimal data sharing with separate databases, viewable in same shell)
#at the database level (such as having two separate applications and one database, with the ability to manually transfer data between applications)
#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.<ref name="Continuity of Care">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</ref>
#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. <ref name="Cerner">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/</ref>
=== Management and Reporting Requirements ===
The [[Request for Proposal|request for proposal (RFP)]] should include requirement of a risk management plan which includes risk identification, risk analysis and risk mitigation.  Status of the risk management plan should be included in project status reports. <ref name=”CMTP”> Texas Comptroller of Public Accounts (2014). Texas government project management. Contract Management Training and Certification. http://www.comptroller.texas.gov/procurement/prog/training-cert/cmt/</ref>
==New Non Traditional Approach Overview==
==New Non Traditional Approach Overview==

Revision as of 19:45, 18 September 2015

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]

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 [3]
    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.

Core clinical features

Vendor Selection Criteria: Core clinical features

IT and technical requirements

Vendor Selection Criteria: IT and technical requirements

Regional Selection Center EHR Selection Criteria

The Regional Selection Center suggests that medical practices compare EHR vendors using the following criteria before selecting a specific product. [4]

  • Will the vendor’s product accomplish key practice goals?
  • Clarify EHR system start-up prices before selecting a vendor including costs associated with hardware, software, maintenance and upgrades, phase payment options, lab and pharmacy interfaces, connection to health information exchange, and customized quality reports.
  • What implementation support does the vendor offer?
  • What are the costs, roles, and responsibilities associate with the data migration strategy?
  • What are your sever options?
  • What is the products ability to integrate with other products?
  • What are the privacy and security capabilities of the product and what is the back-up plan?
  • How does the product link payments with EHR incentive rewards, which are necessary to meet the practices EHR implementation goals and milestones?
  • What is the vendor’s stability and market presence?
  • What is the cost to link the product to HIE?
  • What are the costs associated with legal counsel for contract review versus open sources through medical associations?

Basic EHR Criteria

  • ONC‐ATCB certification (Six certifying bodies ) [1]
  • HIPAA privacy and security compliant [2]
  • Meaningful use reporting
    • Stage 1 (2011-2012) Data Capture and Sharing
    • Stage 2 (2014) Advance Clinical Processes
    • Stage 3 (2016) Improved Outcomes
  • Ability to generate county, state, and federal reports
  • Support HL7 messaging standard [3]
  • Support Secure Sockets (SSL) digital certificate
  • Audit trail capabilities[5]

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

Go live support

Vendor Selection Criteria: Go live support

Vendor Assessment

Most vendors typically fall into one of the three categories:

  1. Vendors that develop their own software organically on a single source code, one database, single instance.
  2. Vendors that may operate under one name, but offer several acquired products, including some custom programs.
  3. Vendors that have been acquired/sold/merged as a means to stay more competitive.

The first category of vendor is less likely to run into major market conflicts to keep its software modern and compliant with regulations. Vendors that operate on a single source code have far less difficultly staying current and/or responding to rapid changes in the market and mandated IT standards.[6]

  • Vendor viability must be checked. Will the vendor be around in nine years (the average life span of a significant IT investment)? If not, can the organisation live without them? Evaluations by neutral third-party analysts like Gartner, Chilmark, KLAS, and The Advisory Board must be considered to see what these analysts are saying about the vendor’s prospects in the market. Questions about vendors viability must be considered such as: Is the vendor in solid financial shape? What’s their monthly burn rate vs. income? How many days cash-on-hand do they maintain? What does their sales pipeline look like? Does the vendor’s executive leadership team have a track record for jumping from one company to another or do they have a track record of longevity and success? How much is the vendor spending on sales staff in comparison to engineering and product development staff? The best products are supported by a very lean sales staff. That’s because great products sell themselves.[7]
  • EHR Goals must be set. Goals should be specific, measurable, attainable, relevant, and time bound.[8]
  • Key Decisions should be made by making a list of potential deal-breakers such as deciding whether EHR data should reside in-office, a vendor server, or in web-based storage (“cloud storage”). To help form a list of potential deal-breakers, vendor websites should be researched. Making key decisions up-front will enable a practice to effectively narrow the field..[8]
  • Asking about product experiences and user experiences are crucial before selecting a vendor. [9]
  • An EHR evaluation tool should be utilized before selecting a vendor. EHR evaluation tools can be obtained from medical societies. [9]
  • 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 [10]
  • Requesting a demo from the vendor keeps a potential buyer informed on prospective features an EHR possesses. [9]
  • Asking if the vendor is committed to training the institution's in house staff. [3]
  • 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. [11]
  • Will the EHR meet present and future requirements? How user friendly is the EHR? [12]
  • 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 ?[13] 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.
  • Percentage of research and development reinvested into the company.[14]
  • Life cycle state or maturity of EHR system products should be asked(i.e., the occurrence of software obsolescence)..[14]
  • Frequency of software product updates..[14]
  • Customer support availability..[14]
  • Certification status of the EHR..[14]
  • Setting goals before selecting an EHR. The goals should be specific, measureable, attainable, relevant, and time bound. Having these goals will guarantee that your organization benefits from the EHR. [14]
  • Make a rundown of potential issues and choose where you wish to have your EHR data to reside. Whether you need your EHR information to reside in a live in-office, a vendor server, or web-based storage. Making this list before selecting an EHR will help your practice to narrow the field. [14]
  • Plan site visits. Ask vendors for a list of practices that have successfully implemented the EHR. At site visits it is important to have a list of questions for the practice during, before, and after implementation of the EHR. [14]
  • No vendor can offer all possible services and products. Therefore, it is important to assess if an ecosystem of partners exist for the selected vendor. Is there active developer program? Does the vendor use an open strategy or single a source strategy? [15]
  • A good vendor should have a healthy management team that keeps it growing and improving. Does the vendor have stable, visionary and efficient management team?
  • We certainly do not wish to select a vendor that may bankrupt in the near future. Does the vendor have resources to compete in the market and likely to win in the future?

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". [16]
  • 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?[17]
  • 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.[17]

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 [13]
  • 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

Clinical Process Assessment and Improvement

  • The EMR vendor, in response to requirements defined in the request for proposal (RFP), should describe a plan for evaluation and assessment of the as-is clinical processes and workflows, identification of needed improvements and a proposal for implementing workflow optimizations necessary to launch the EMR. [18]

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. [19] 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.[20] 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. [20]

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.[20]

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.[20]

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.[20] 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.[20]

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? [21]
    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.[22]
  4. Ease of access and usability of EHR for nursing administration and clinical documentation for nurses. [23]
  5. Clinical decision support and risk assessment tools for issues related to nurse care delivery, such as falls, medication delivery, skin ulcers etc. [24]

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.[25]

  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. [17]
  • 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? [26]
  • 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? [27]
  • Does EMR system provide functionality to contact potential candidates and notify the patient’s providers of potential study eligibility? [27]
  • Does EMR system provide capability to systematically captured study specific data and electronically exports deidentified study data to clinical trial electronic data capture system? [27]
  • 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. [28] 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

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. [29]

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). [30]

Vendor Financin g

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. [31]

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. [32]

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? [33]
  • 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?[34]

Extensive Testing of EMR Software Prior to Implementation

Vendors should be able to demonstrate the conduction of rigorous testing of their EMR, such as: [35]

  • 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 [35]
  • 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. [36]
  • 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 [35]
  • 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 [35]
  • 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 [35]
  • Usability Testing - Realization of EMR benefits depends largely upon usability. Usability testing with representative end users validates “the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency and satisfaction in a specified context of use” (p. 331). [37]

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.[38]

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.[38]

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.[38]

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. [38]

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.[38]
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. [39] 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 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 [17]
  • Since users may have varied experiences according to Kannry, Mukani, and Myers (2006, p. 89)[17] 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. [17]

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. [40]
  • 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.


  • 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?
  • Is the vendor stable and does it has presence in the region where the system will be implemented?[41]
  • Is the system capable of integrating with other product such as billing systems, practice management software and public health interfaces?[41]
  • 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. [42]
  • 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?[43]
  • 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?[44]
  • 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?[45]
  • Does the system offers privacy and security capabilities?[41]


Contracts are as much a business tool as they are a purchasing agreement. [46]

  • Project Payments
  • Contract Terms [4]
  • 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. [47] 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). [48]
  • 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.[49]

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. [50]
  • 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.) [51] [52]

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.[38] 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.[38] 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. [53]

  • 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.


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. [54]

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) [55]
  • Is the vendor active in national EMR leadership task forces, such as the Electronic Health Records Vendors Association [56]
  • 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? [57]
  • 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? [10]
  • 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.[58]

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. [59] A gap analysis can be performed:

Meaningful Use Gap Analysis

  • Is it ONC Certified? [5]
  • 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? [60]
  • Is the ONC certification current or does the product require inherited certification/ gap certification?[61]

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. [62] 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] [63] 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 [64].

    EHR Evaluation Resources

    • American Academy of Family Physicians Vendor Rating Tool
    • American Academy Of Family Physicians HR Demonstration Rating Form EHR Demonstration Rating Form [6]
    • American Academy of Family Physicians vendor's references verification form [7]
    • American College of Physicians EHR Feature Checklist
    • Bureau of Primary Health Care. BPHC Electronic Medical Record Resources page. [8]
    • 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. [65]
    • California Health Care Foundation, EMR Evaluation Tool and User Guide - A Guide for Small Physician Practices: [9]
    • American Medical Association - 15 questions to ask before signing an EMR/EHR agreement [51]
    • Health Resources and Services Administration How to Select a Certified EHR [10]
    • Select or upgrade to a certified electronic health record vendor [10]


    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. 3.0 3.1 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
    4. Selecting or Upgrading to a Certified EHR. http://www.healthit.gov/providers-professionals/ehr-implementation-steps/step-3-select-or-upgrade-certified-ehr
    5. HITECLA.Org Selecting the Right EHR. http://www.hitecla.org/ehr_selection_tips
    6. Types of vendors http://www.greenwayhealth.com/wp-content/uploads/2013/03/Replacing_an_EHR-Coker_Greenway_white_paper.pdf
    7. vendor viability https://www.healthcatalyst.com/How-to-Evaluate-a-Clinical-Analytics-Vendor/2/
    8. 8.0 8.1 Vendor Assessment http://www.healthit.gov/providers-professionals/faqs/how-do-i-select-vendor
    9. 9.0 9.1 9.2 - Vendor Assessment http://www.healthit.gov/providers-professionals/faqs/how-do-i-select-vendor
    10. 10.0 10.1 10.2 - 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
    11. 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
    12. ‘’Practice Fusion Blog”, 4 questions to ask when selecting an EHR, July 7, 2014
    13. 13.0 13.1 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
    14. 14.0 14.1 14.2 14.3 14.4 14.5 14.6 14.7 Vendor Selection http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047961.hcsp?dDocName=bok1_047961
    15. Enterprise EHR Vendor Evaluation https://www.advisory.com/Research/Health-Care-IT-Advisor/ATC/research-notes/2013/enterprise-ehr-vendor-evaluation
    16. EHR/HIE: Interoperability http://interopwg.org/certification.html/
    17. 17.0 17.1 17.2 17.3 17.4 17.5 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
    18. McDowell, S. W., Wahl, R., & Michelson, J. (2003). Herding cats: the challenges of EMR vendor selection. Journal of healthcare information management, 17(3), 63-71.
    19. The Christ Hospital http://www.thechristhospital.com/
    20. 20.0 20.1 20.2 20.3 20.4 20.5 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/
    21. http://www.healthsecure-emr.com/jail-emr-emar
    22. 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
    23. 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
    24. 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
    25. 10 Popular Pharmacy Information Systems".http://www.informationweek.com/healthcare/clinical-information-systems/10-popular-pharmacy-information-systems/d/d-id/1104805?
    26. Jain, V. (2010). Evaluating EHR systems. Health Management Technology, 31(8), 22-24
    27. 27.0 27.1 27.2 Integrating Electronic Health Records and Clinical Trials http://www.esi-bethesda.com/ncrrworkshops/clinicalresearch/pdf/MichaelKahnPaper.pdf .
    28. 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
    29. McCarthy, K. 5 important considerations when choosing EHR. 2014. http://www.nuemd.com/news/2014/10/28/5-important-considerations-when-choosing-ehr-systems
    30. 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
    31. 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
    32. 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
    33. How Much Will That EMR System Really Cost? http://www.aafp.org/fpm/2002/0400/p57.html.
    34. 35.0 35.1 35.2 35.3 35.4 Valacich, J. S., George, J. F., & Hoffer, J. A. (2012). Essentials of systems analysis and design (5th ed.)
    35. Proposing Regulatory-Driven Automated Test Suites http://ieeexplore.ieee.org.ezproxyhost.library.tmc.edu/stamp/stamp.jsp?tp=&arnumber=6612874
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    37. 38.0 38.1 38.2 38.3 38.4 38.5 38.6 http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_031357.hcsp?dDocName=bok1_031357
    38. How to Select an Electronic Health Record System. http://www.aafp.org/fpm/2005/0200/p55.html
    39. AHIMA http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047959.hcsp?dDocName=bok1_047959
    40. 41.0 41.1 41.2 Upgrade to a Certified EHR http://www.healthit.gov/providers-professionals/ehr-implementation-steps/step-3-select-or-upgrade-certified-ehr
    41. (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
    42. Transmitting Data Using the Direct Protocol. (2013, February 4). Retrieved February 3, 2015, from http://bluebuttonplus.org/transmit-using-direct.html
    43. 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
    44. 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
    45. Carolyn Hartley - signing an EHR contract http://physiciansehr.org/signing-an-ehr-contract-25-tips-to-control-costs.aspx
    46. Finding an EHR vendor: Mistakes are costly, and questions about confidentiality linger. (2011). Alcoholism & Drug Abuse Weekly, 23 (42), 1-4.
    47. Signing an EHR contract. Tips to control costs. http://physiciansehr.org/signing-an-ehr-contract-25-tips-to-control-costs.aspx
    48. http://www.himss.org/files/HIMSSorg/content/files/Code%2093_15%20questions%20to%20ask%20before%20signing%20an%20EMR-EHR%20agreement_AMA.pdf
    49. 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/
    50. 51.0 51.1
    51. Selecting An EHR, Now What? ftp://ftp.hrsa.gov/ruralhealth/jan082008tacall.pdf
    52. MetaStar https://www.metastar.com/web/professional/docs/DOQ-IT/Vendor/Tools/SiteVisitingTips.doc
    53. EHR Contracts: Key Contract Terms for Users to Understand. http://www.healthit.gov/sites/default/files/ehr_contracting_terms_final_508_compliant.pdf
    54. Certified Health IT Product List (CHPL) list of EMRs. http://oncchpl.force.com/ehrcert
    55. HIMSS Electronic Health Record Association http://www.himssehra.org/ASP/index.asp
    56. Better Patient Safety is Goal of Confidential EHR Error Reports http://www.amednews.com/article/20130724/profession/130729986/8/ .
    57. HEY, WHO DID THIS? Note: there needs to be something here
    58. Meaningful Use Definition and Objectives http://www.healthit.gov/providers-professionals/meaningful-use-definition-objectives
    59. http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html
    60. http://healthit.gov/sites/default/files/final2015certedfactsheet.022114.pdf
    61. Hospital Inpatient Quality Reporting Program. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalRHQDAPU.html/
    62. Physician Quality Reporting System http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/PQRS/
    63. 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
    64. The National Learning Consortium Vendor Evaluation Matrix Tool. http://www.healthit.gov/providers-professionals/implementation-resources/vendor-evaluation-matrix-tool