Data Driven

Choosing an electronic health records (EHR) program for your practice is a daunting and risky task. Providers stand liable for major losses if they bet on the wrong company during this tumultuous time. To provide guidance for physicians in need of a new vendor, Endocrine News has distilled the advice of two EHR specialists into five crucial steps.

Step 1: Assess your needs

Samuel Ross, clinical implementation manager at the Chicago Health Information Technology Regional Extension Center (CHITREC), offers daily guidance to transitioning practices. As part of the American Recovery and Reinvestment Act, CHITREC has supported nearly 1,500 providers in Chicago on their path to meaningful use with EHR.

Ross encourages practitioners to think long term about needs. “There will be upgrades, maintenance, training of new staff, connecting with entities such as laboratories or the state immunization registry, and more ongoing tasks that demand a foundation of trust not only with your finances and employee satisfaction, but the well-being of your patients.”

An examination of office workflow will help identify the important functions for a digital system to fulfill, in addition to areas for improvement. Every physician operates a bit differently, and finding an EHR program that fits into or even improves day-to-day operations will make for a smoother transition. The staff’s input should be taken seriously in this regard.

“Physicians have to see this as enhancing patient care, not an obstacle to it,” according to Donna Vanderpool, MBA, JD, vice president of risk management at Professional Risk Management Services. As an expert on HIPAA and forensic liability, she knows the legal and regulatory needs that physicians must keep in mind when picking an EHR. First, any certified EHR must be able to meet the meaningful use criteria set forth by the federal government. The system should capture and share data, advance clinical process, and improve patient outcomes — as laid out in detail on

She says to avoid programs that display too much information and erroneous alerts. If irrelevant warnings pop up frequently, physicians and staff may develop “alert fatigue” and accidentally skip over a real issue. In the same vein, the EHR should have room for “free text,” such as notes, which can prove both clinically and legally important.

Vanderpool encountered one case where an EHR automatically updated all historical visits when new information was added. A patient came into a hospital and stated she had no known allergies. When she reacted to a medication prescribed during the visit, the physician entered it into the EHR as an allergy, and the system automatically revised her entire medical history. The patient sued and the record made it appear as though the physician had negligently prescribed a medication on the patient’s known allergy list.

These unexpected liabilities are a small sampling of the larger concerns surrounding digital records. The security of patient information often ends up entirely in the EHR vendor’s hands.

Step 2: Decide between a local or remote system

Perhaps the biggest choice for physicians and administrators to make is whether to host patient data locally or remotely. Vanderpool thinks that physicians need to focus on two aspects: cost and control of patient data.

“Of course, there is an inverse relationship with these two factors — it will cost physicians more to retain control of the data themselves than to have a cloud vendor control the data,” she explains.

With a locally hosted system, the physician stores and controls all of the data, but must purchase all hardware and software, and is responsible for system maintenance, security, and backup. On a remotely hosted system, the physician’s EHR data is stored by another entity that controls and manages the data.

There are three types of remote systems: 1) a subsidized system where another entity, such as a hospital or insurance provider, controls the EHR data; 2) a dedicated hosted system where the data is stored on the EHR vendor’s computers; 3) a cloud-based system, whereby information is stored on the Internet and records are accessed through the vendor’s website.

Each type of EHR has its pitfalls. A subsidized system risks potential violations of antitrust laws and, if the company goes under or the practice decides to switch programs, compatibility of the data will likely be an issue. The same problem applies to dedicated hosting systems, but without the risk of antitrust violations.

While there is a physical location of the data for the first two types of remote hosting, the same is not the case for cloud-based systems. The cloud has no permanent, physical place. These systems are often very inexpensive, and some are even free. However, Vanderpool warns that every EHR must generate income somehow. Physicians must investigate how the vendor will access and use their patients’ data.

Step 3: Research certified EHR vendors

Although it can be difficult to discern, a trustworthy EHR vendor is an absolute necessity. “If you feel comfortable with both the people and technology you’re partnering with and believe in their long-term vision, the odds of finding ‘the one’ are much more in your favor,” Ross explains.

When the EHR Incentive Program first appeared, the industry grew from a small pool of competitors to an onslaught of companies battling for market share. It is consequently “a matter of economic fact,” as Ross puts it, that many companies will be acquired or dissolved. This means that vendors’ business plans and prospects are as important as their technology.

He recommends talking to peers who have already gone through the EHR transition. “They know the process, pitfalls, and positives better than anyone and won’t have any reason to tell you anything but the truth,” he says.

An EHR is more likely to fit your practice if it has a number of clients within the same specialty on its customer list. “If you’re the only endocrinologist on the roster, it stands to reason they won’t put as many resources into meeting the needs that make you different,” Ross continues.

For other references, he describes the KLAS rankings and Black Book as trusted resources. The American EHR Partners offers free reviews that are managed in part by the American College of Physicians, which provides a more clinical point of view.

Currently, Epic is the leading EHR vendor in numbers of successful meaningful users. But, Athena Health recently displaced them atop the “Best in KLAS” rankings for overall software vendor in the EHR space. Ross has noticed that the free software Practice Fusion has become popular among CHITREC members. “They’ve positioned themselves as disruptive technology during a volatile time for the industry,” Ross says.

Step 4: Review contracts closely

Vanderpool has seen an uptick in lawsuits against EHR vendors for alleged non-adherence to contracts. Red flags early on can indicate future problems, such as an unwillingness to negotiate terms, failure to provide existing customers as references, service free-of-charge, and the lack of a Business Associate Agreement.

Some providers have been surprised with unexpected annual maintenance requirements and fees. Vanderpool has also encountered scenarios where the physician wanted to terminate the contract and was informed by the company that they would have to pay an enormous sum of cash to get their patients’ data back. Certain vendors will only provide EHR data in an unreadable format when a client indicates their intent to end a contract, citing “intellectual property rights.”

“Physicians need to be careful about the ‘click and agree’ online agreements where there is no negotiation of terms,” she says. These agreements may contain indemnification provisions that contractually obligate the physician to terms not approved by their malpractice insurance.

Step 5: Implementation

After due diligence, one has to take the leap and commit to an EHR. No matter the program of choice, Vanderpool recommends caution in execution. For example, accessing EHR data on mobile devices, which may easily be lost or stolen, can result in a breach of patient information. She also warns against using “cut and paste” functions in EHR programs due to questions of fraud. “The federal government is watching this issue closely,” she says.

Despite the many risks, a quality EHR can bring great rewards in years to come. The surviving programs will soon make referrals, labs, imaging, and patient access much more efficient. Ross encourages physicians to consider what is next. “It’s easy to get caught up in immediate goals, but extremely advantageous to take a long view,” he explains.

— Mapes is a Washington, D.C.-based freelance writer. She wrote about obesity and dementia in the February issue.

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