1. Health Information
Associates of Texas
EIGHT T HINGS THAT WILL MAKE
YOUR EMR WORK FOR YOU –
INSTEAD OF THE OTHER WAY
AROUND
By: Ed Taylor
Health Information Associates of Texas
Austin, Texas
512-964-1934
ed.taylor@healthinfotexas.com
PURPOSE
Do we all get it now that purchasing an electronic medical record (EMR) system is
probably one of the most important decisions a practice will make? The systems
require major investments of time and money, and they bring fundamental change to
the practice’s clinical and business processes. Automation has a significant impact on
all aspects of a practice; it literally alters the way healthcare services are delivered.
This paper looks at eight practical suggestions which can help ensure a successful and
satisfactory shift from paper medical records to digital medical records.
5114 Balcones Woods Road
Suite 307 #417
Austin, TX 78759
1-888-391-3964
www.healthinfotexas.com
ed.taylor@healthinfotexas.com

2. Table of Contents
Purpose......................................................................................................................................... 1
Introduction ................................................................................................................................. 3
EMR or EHR ? ............................................................................................................................ 3
Controlling Your EMR Implementation Process .................................................................... 3
Step One: Create a Positive, Forward Looking Attitude ........................................................ 4
Step Two: Set Goals and Expectations...................................................................................... 4
Step Three: Get Buy-In From Your Entire Team ................................................................... 4
Step Four: Document Your Workflow and Identify Where Changes Will Need to be
Made in Your Way of Doing Things ......................................................................................... 5
Step Five: Understand the Technology Involved ..................................................................... 6
Hosting Model ......................................................................................................................... 6
Interfaces.................................................................................................................................. 7
Input Devices ........................................................................................................................... 8
Remote Access ......................................................................................................................... 8
Step Six: Determining the Features that Your Practice Needs............................................... 8
Support for your specialty or specialties............................................................................... 8
Stimulus reimbursement ........................................................................................................ 8
Template management ........................................................................................................... 8
Document management .......................................................................................................... 9
Patient education..................................................................................................................... 9
Prescription refill .................................................................................................................... 9
Ease of data entry and ease of access to H & P and notes................................................... 9
Voice recognition..................................................................................................................... 9
Interface with PMS, labs and imaging centers..................................................................... 9
Clinical decision support and evidence-based medicine...................................................... 9
Regulatory requirements that may be peculiar to your state ............................................. 9
Step Seven: Be in Charge!!!! ...................................................................................................... 9
Step Eight: Selecting the Right System ................................................................................... 10
Final Thoughts........................................................................................................................... 11
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3. INTRODUCTION
Yogi Berra purportedly said “If the world was perfect, it wouldn’t be.” Well, I
can’t see perfection coming any time soon. And speaking of perfection, has
anyone seen a “perfect” EMR system yet? A recent article posted at
HealthcareITNews.com ran a headline which indicated that EMRs are still a
“work in progress”. First of all, is that really the case? And – if so – should that
information change anything you are doing about acquiring an EMR?
Below are listed eight things which you need to consider when purchasing an
EMR. We know that following these eight principles will put your EMR to work for you!!!! Not the other way
around.
EMR OR EHR ?
Multiple terms have been used to define electronic patient care records, with overlapping definitions. Both
electronic health record (EHR) and electronic medical record (EMR) have gained widespread use, with some
health informatics users assigning the term EHR to a global concept and EMR to a discrete localized record.
For our purposes in this paper, the term EMR will be used.
CONTROLLING YOUR EMR IMPLEMENTATION PROCESS
Powerful prescription medications can be a great blessing. However, in order to
bring about the desired effects, the correct medication must be selected and then it
must be administered in the correct dosage and administered in the proper
manner and at the correct time intervals. Deviate from the correct path and
disaster can occur. Guess what? The same thing can happen with an EMR
system that is not correctly selected, installed and used for its intended purpose.
The financial impact can be significant. But just as troublesome and frustrating
is the time and energy that can be expended fighting the losing battle of trying to
make something work that was doomed from the start.
This paper will present eight strategic concepts which are designed to help you succeed in your EMR
implementation. Please note that this is NOT a step by step presentation on all the features you should look for
in an EMR or which EMR you should purchase. Rather, it is designed to help you create a positive structure or
framework in which the decision making process can take place. The goal is for your practice to use the
transition to electronic medical records as an opportunity to improve the operation of your practice and
provide quality patient care in an efficient manner.
To help in your selection process, we have attached a document from the AMA entitled “15 QUESTIONS TO ASK
BEFORE SIGNING AN ELECTRONIC MEDICAL RECORD OR ELECTRONIC HEALTH RECORD AGREEMENT”.
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4. STEP ONE: CREATE A POSITIVE, FORWARD LOOKING ATTITUDE
Following the fifth game of this year’s NBA Finals, ESPN interviewed some of the Laker players and asked
them what it would take for them to win the next game. The answers were very informative – and helpful.
What they said – to a man – was “If we go out there with the right team attitude, we will win the series”. They
did NOT include details of how the next game should be played, they did not talk about technique or ball
control, or how they needed to get the ball to Kobe more often (or less often). They knew that the key to
success was their attitude. Turns out they were right. Boston could have won the title but the Lakers wanted it
more.
Too many practices fail in their EMR implementation because that infectious disease known as a “negative
attitude” was introduced early on in the process. It will infect everyone in the practice. It will infect the vendor
you select, it will infect your patients, and, before you know it, everyone is talking about what a bad selection
you made.
Start this process with an attitude that is positive = “Yes, this will improve our practice”, “Yes, we will make
this process positive”, “Yes, we will improve our patient care and our own work environment”. Rather than
focusing on how this going to be such a big change, develop a forward-looking attitude. Embrace the change.
Look forward to the journey.
STEP TWO: SET GOALS AND EXPECTATIONS
Knowing where you want to go and what you want to accomplish is essential to a successful EMR
implementation strategy.
In setting your goals, you should consider the following:
1. am I interested only in an EMR
2. do I want to consider changing the practice management/billing software also
3. do I want to use this as an opportunity to review the entire operation of my practice
Think of a sliding scale. Where on that sliding scale do you want to be?
EMR Only EMR and PMS Review Entire Practice
This hopefully illustrates the real need for you – UP FRONT – to decide what you want to accomplish.
STEP THREE: GET BUY­IN FROM YOUR ENTIRE TEAM
Solicit input from your ENTIRE team/staff. Ask for their advice and input. Encourage discussion. Convey to
them your positive and forward-looking attitude we discussed above. Make sure that they know and
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5. understand what your goals are. Set their expectations Set up a process in order to allow them to express
themselves during the implementation phase.
STEP FOUR: DOCUMENT YOUR WORKFLOW AND IDENTIFY
WHERE CHANGES WILL NEED TO BE MADE IN YOUR WAY OF
DOING THINGS
You and your staff have certain ways of doing things. They are called habits. Habits can be good things – they
allow us to do things without thinking about them or without having to recreate a procedure every time a task
needs to get accomplished. However, hanging onto habits that are outdated or counter productive is not a good
thing.
One of the well-known “best practices” in regard to EMR implementation calls for a review and
documentation of your current procedures, policies and processes in order to help you understand how having
an EMR might change those processes.
Some of the key business processes you should document include scheduling, triaging, patient registration,
referral management, documentation of the patient encounter, orders, result management, protocols, treatment
plans, clinical decision support, copayment capture, claims processing, and billing. Good workflow mapping
will help you identify areas that need improvement in your office and consequently create specifications for
the EMR system you select.
Schedule time with your team to document how the above items are carried out in your office. Get a floor plan
of your practice and outline the flow of office staff and patients during a patient visit. This will help you
visualize the changes that may come with the acquisition of an EMR.
Focus on the value-added activities; that is, activities that directly affect the patient or the quality of care the
patient receives or which have an impact on the profitability of your organization.
Understand how an EMR will impact them and make plans for the necessary changes that will need to be
made. Pay attention in particular to the following:
• How the work gets done
• Identify who does the work
• Identify your critical practice processes
• Understand how the patient moves through your processes
• Identify the triggers that move the patients from process to process or from one part of the process to
another
Require everyone in your practice to consider the role they play and consider how this might be impacted by
moving to an electronic medical record as opposed to a paper-based record. Emphasize that you are not
looking to reduce staff – only to understand how to best utilize the personnel that you have.
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6. STEP FIVE: UNDERSTAND THE TECHNOLOGY INVOLVED
If you think you do not need to worry about or concern yourself with the technology involved and the choices
you have, you are almost assuredly dooming yourself to failure. The key decision points are as follows and
will be discussed in more detail below:
1. hosting model - client-server or ASP (application service provider)
2. interfaces between EMR and other software applications (practice management system, labs, patient
portal, etc).
3. input devices (desk tops, tablet PC, PDAs, etc.)
4. ability to access key components of system remotely (prescription refills, schedules, patient notes, etc).
Hosting Model
Where and how your system is hosted or resides is important and you should understand the distinctions. In
the client-server model, the software is installed on a server located in your practice. In the ASP or data-center
model, the software is installed on a remote server in a data center.
The table on the following page summarizes the main differences between the a client-server based model and
an ASP or hosted model.
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7. Client-Server vs. Application Service Provider (ASP) Models
Client-Server ASP Model
Costs Higher up-front costs because Lower up-front costs but there
hardware must be purchased are monthly fees because you
and dedicated to one are, in effect, leasing or
application. Practice owns renting the equipment on
equipment and must maintain which your application is
and upgrade. running.
Location of software and In physician’s office on In a remote location – most
data server. commonly in a secure data
center.
Data backup and recovery Usually the responsibility of Data backup and disaster
the practice or office where recovery are usually part of
data is located. the services provided under an
ASP model. Make sure you
know.
Maintenance of server Since you own it, it is usually The vendor or data-center
your responsibility to hosting the software usually
maintain the server. If it takes care of the equipment
crashes, there may be little the and will provide equipment
vendor can do. upgrades periodically as part
of the hosting agreement.
Remote Access to Data If the internet connection to Usually, data centers have a
office is down, you will not “larger data pipeline” and a
be able to access system more robust and secure
remotely. connection to the internet.
This is not a given so you will
need to check this out.
Interfaces
You will want your practice management system (PMS) to integrate or interface with your EMR whether you
acquire a new PMS system or whether you keep your existing system. Some vendors offer systems that are
already “internally” integrated. That is, you do not need to worry about how the data moves from one to the
other. However, if you keep your existing PMS system or go with a “best-of-breed” approach, you will
definitely need an interface.
Are you going to want to interface with laboratory or radiology imaging systems? If so, you need an interface.
The same applies to sharing data with a Patient Portal or health information exchange (HIE). You will need to
interface to move the data from one system to the other.
Interfaces are usually not put into place and tested until the implementation phase. By that time, it is too late to
learn that you may not be able to connect the systems that you thought you would be able to. You cannot
assume that an EMR will communicate with every other electronic system that you have. This must be
carefully analyzed and documented with the EMR vendor and PUT IN WRITING during the contract
negotiation phase. You may want to consider legal advice to put you in a stronger position.
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8. Input Devices
While we are all enamored with the latest technology (iPad,
Android, Black Berry, etc), you may have people in your practice that
just need to access the system from the plain ole desktop
computer. On the other hand, if you have a technology driven
practice, you will want to check out the latest “apps” your vendor has
for these other devices. From the physician and nurses’
standpoint, they will probably want a light-weight tablet PC that
they can carry around the office with them and enter data as they are
visiting with the patient.
Remote Access
One of the advantages of having patient data in an electronic format is that it is potentially easier to access.
And “easier to access” usually means via the internet – from home, from another office location, while on
vacation, while traveling, etc.
Think about what is important to you. Do you write a lot of prescriptions? If so, prescription refills may be a
headache that the proper EMR can alleviate. Do you want to access your patient schedule remotely? Do you
want the ability to communicate with internal staff quickly and easily through your EMR (sending notes,
documents, etc)?
Make sure that you determine in advance which of these features are important to your practice and then
prioritize them.
STEP SIX: DETERMINING THE FEATURES THAT YOUR PRACTICE
NEEDS
Speaking of features, now is the time to go to work and make that list of features that are important to your
practice. Some of the high lights of that list might include:
Support for your specialty or specialties - It matters not how great the system looks or how many
technological innovations it has, if it doesn’t have the specialty specific features that you need, it will be
literally worthless. You know better than anyone what your specific needs are. List them to ensure that the
vendors are able to demonstrate exactly what you are looking for.
Stimulus reimbursement – if this is important to you, get in writing from your selected vendor that they
will meet the “meaningful use” criteria or that the vendor will pay you the amount you would have gotten from
the federal government. Legal advice will put “teeth” in the promise.
Template management – Since most systems are based on templates which specify the medical content
you will see, it is imperative that you understand how the vendor’s template system works. Can you modify
the templates yourself? If not, can the vendor modify them? What does it take to do so?
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9. Document management – If your practice has a lot of documents to handle, you will want to look closing
at how well the various systems can handle both the scanning in of documents and the retrieval of documents.
Patient education – if easy-to-print and up-to-date patient educational material is important to you, the
vendor should be able to tell you where the material originates and how often it is updated.
Prescription refill – As noted earlier, if this is important to you, bear down on this with the vendor. This is
something that you will live with every day. Make sure it is what you need.
Ease of data entry and ease of access to H & P and notes – The more patients you see each day, the
more important it will be to you that you are able to enter and retrieve the necessary information quickly and
easily.
Voice recognition – You can save a ton on transcription costs if you currently do a lot of dictation. Dragon
Medical voice recognition software will work well with most EMRs. If this is important to you, ask the
vendors to demo it to you.
Interface with PMS, labs and imaging centers – See the discussion above regarding interfaces.
Clinical decision support and evidence-based medicine – If you are ready to embrace these
concepts in your EMR, get detailed information from the vendors. This can be a critical component of your
software.
Regulatory requirements that may be peculiar to your state – Do you need to print prescriptions on
specialized paper? Do you need to report child immunizations electronically to the state? Make sure you
understand what these needs are and how the vendors propose to meet them.
STEP SEVEN: BE IN CHARGE!!!!
Your attitude and your willingness to take charge will determine whether your profits increase or decrease
during and subsequent to your transition from paper to electronic charts. That does not mean you have to do
everything yourself. But remember – no one has a vested interest in this like you do. Don’t be afraid to ask a
question if it comes to mind. Every question is important and needs to be answered fully and to your
satisfaction.
Let the vendors know what you expect to get out of this process. Your leadership will drive the process to a
profitable conclusion.
Working with a consultant may be the key to “being in charge”. A consultant can document workflow and
processes, help gather and analyze staff suggestions and comments, help establish the proper selection criteria
and facilitate communication with vendors to your advantage.
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10. STEP EIGHT: SELECTING THE RIGHT SYSTEM
Now that you have created a positive, forward looking attitude, have set goals and expectations properly, have
gotten buy-in from your entire team, have documented your workflow and how an EMR may effect your
practice, learned about the technology involved, determined the features that your practices needs and have
made a commitment to “be in charge”, you are ready to select a vendor.
You should talk to five or six vendors (as a minimum) before you even start scheduling demonstrations. How
do you select the vendors with which to talk? There are a number of places to start as follows:
• Talk to peers (same specialty) that have an EMR already. Ask if they are willing to talk to you about
their experience in some depth. Ask them to evaluate the system they are using. Ask if you can visit
their office to see their system in action. Ask if you can talk with the office manager. Don’t just accept
a quick response such as “Yeah, we like our system”. Get more details.
• Check with your specialty/professional organization or medical society or association. Some of them
have recommendations or forums where you can get information from others in your specialty.
• Look for ads in your professional magazines and other publications. Look specifically for EMR
vendors that state they serve your specialty.
• If you attend a professional or specialty conference, ask around for recommendations. Talk to vendors
that might be there as exhibitors. If a vendor is an exhibitor at a specialty conference, you can assume
that they can handle the needs of that specialty. However, you will really want to put them to the test.
• Do a Google search for your specialty plus EMR/EHR. For example, “Pediatrics EMR”.
Once your list is complete, Google search the company name and look for blogs and forums where EMRs are
discussed. That may help balance all the positive things that vendors are saying about themselves on their own
website.
When you have done all of this, you are ready to contact the vendors. Check out their website. Then call and
ask to speak to a sales representative. Review your goals with them and the features you are interested in
before you schedule a demo. Ask the tough questions now. Ask for the number of installations they have in
your specialty. Ask for references in the same specialty as yours.
Now you can finally schedule a demo. Schedule the demos when you have plenty of time.
Narrow your potential vendors down to the top three and ask them to come on-site. As part of the on-site
demo, present them with scenarios or complaints based on what you see in your practice. Ask them how they
would handle those situations. As the demo is proceeding, keep a list of questions and/or concerns. Be sure
that they are satisfactorily resolved before you make a decision.
As a final step, you should consider an on-site visit to a practice that is similar to yours that is using the
system(s) you are interested in.
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11. FINAL THOUGHTS
Hopefully, at this point, you feel comfortable that you have done everything you can to select the EMR that
will be just right for your practice. Now you are ready for the contract. Look at the attached document from
the AMA for guidance in some of the issues you should consider. Using an attorney may be helpful at this
point. Better now than after the contract is signed and the system has been installed.
This is an exciting time for your practice. Stay positive and stay focused. As with any software application,
there will be glitches and rough spots. Those are part of the process. Work with your vendor in order to make
the product better - better for your practice, better for your patients and better for those that purchase the same
product after you.
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