Choosing an EHR is a significant investment in time, resources, and staff goodwill. When advising clients, we typically suggest building an EHR project around a six sigma model for clarity and control of outcomes.
This article won’t go into the details of project management, but if your organization is inexperienced in this area, we highly recommend bringing in an outside consultant to reduce the risk of project failure or cost overruns. As with any project, choosing the project team, identifying the appropriate project manager and sponsor, and clearly chartering the project are all front-end requisites to success.
The EHR project should specifically include a post-implementation or “go-live” phase, which is oftentimes skipped or marginalized by EHR vendors. This post-implementation phase should include measurement of progress towards goals, user adoption and satisfaction testing, and initial ROI calculations. After all, you hopefully are designing for adoption, not just implementation.
Organization Review and Goals
To begin, you need to adequately define your current state (assess IT infrastructure, map workflows, measure staff engagement and readiness, quantify funding sources). The following websites have some great resources for beginning this process:
Stratis Health (a QIO based in MN): http://www.stratishealth.org/expertise/healthit/nursinghomes/
LeadingAge CAST EHR Selection Tool: http://www.leadingage.org/ehr/search.aspx
You should also explicitly define goals for the EHR system: what do you want it to do? What areas of performance do you expect to improve? Be specific and measurable in selecting goals. Vendors are never happier than when they are explaining how their solution will save time, money, lives, etc, oftentimes with very little commitment to helping you actually achieve these efficiencies.
EHR Vendor Considerations
Hosted vs. Local Installation
Most EHRs offer a hosted version of their service (either through purchase or as a Software as a Services (SaaS) option, and some allow for software to be installed locally. Each option has advantages and challenges:
Hosted Solutions:
- Vendor managed storage, reliability, upgrades and security reduces infrastructure and capital needs. Most vendors offer uptime guarantees and automatic upgrades to the latest version. In addition, vendors typically conduct ongoing, comprehensive security and penetration testing, meaning, somewhat counterintuitively, the data is typically more secure than with local installations.
- Usually offered on a monthly contract or service charge basis, which can lower initial deployment costs substantially.
- The ownership of data varies, and it’s important to clarify at the onset. When a vendor owns the data, migrating to another solution in the future can prove to be an expensive proposition.
- Usage of the software is dependent on internet access, and reliability at the community site, thus, is crucial. Most organizations are not able to afford redundant solutions or direct internet pipelines, which can lead to some risk of downtime. Many EHRs have ways to mitigate the risks and challenges of internet disruption, such as local backups for time sensitive items like resident facesheets and MARs.
Local Installations:
- Software is oftentimes more customizable for a particular organization’s needs.
- Though it requires a higher up-front investment, purchased solutions may be less expensive over time, especially for organizations with already expansive IT capabilities.
- Less reliance on internet connectivity, which may be crucial for locations with intermittent or unreliable access to the internet.
- In addition to software, hardware investments and ongoing IT staff costs may be significant.
Platform/ Browser Dependence
Some EHR solutions are dependent on Microsoft Windows and/ or Internet Explorer. Additionally, EHR vendors are beginning to develop mobile applications, which may be only available on either iOS (Apple) or Android platforms. In general, dependence on a particular platform or browser is not recommended, though many otherwise good LTPAC EHR vendors are designed in such a fashion. Unfortunately, this practice can raise the cost of hardware, particular if using specific mobile or tablet technology. Software that is only capable of running on a desktop environment is not recommended, as the technology is quickly being surpassed by tablet technology with lowers costs and more person-centered design options.
Reporting Features
EHRs capture a tremendous amount of data. Using this data in a meaningful way, however, is a very different proposition. It’s important to review report writing capabilities of EHR systems thoroughly, as this area has been significantly overlooked in the vendors’ rush to capture market share. Specifically, you want to understand:
- How does reporting work in the EHR? What reports are standard? How are options controlled? What export formats are available?
- What options are available for customized report writing? Can the data be segmented and can multiple data fields be included in report writing?
Person-Centered Practices and Assisted Living Environments
Most EHRs were initially designed as revenue cycle management platforms. Accordingly, the software and databases are well-attuned to catching and reporting MDS data at the expense of resident outcomes. As you explore vendors, consider how the user experience allows (or hinders) access to the data that is important in day-to-day operations. Are nurses able to easily manage resident health issues? Are care plan templates designed to allow for flexibility in display and reporting to suit different user needs (e.g., LN vs. CNA vs. family member)? Are point of care portals intuitive and easy to use?
On this note, if your community has an assisted living component, carefully examine any AL-specific modules. Does it reflect your needs and workflows? Does the system focus on the whole resident rather than just the medical record and ADL capture? Most EHR vendors took SNF modules and repackaged them for ALFs, which has led to unnecessary medicalization of these community-based-care environments.
Vendor Contracts and Post-Selection
We’ve seen countless organizations trust vendors to ensure a smooth transition only to struggle as customization takes longer than expected, costs run over budget, and the final product offers less than what was expected. An important way to protect your organization is to make the vendor contract contingent on project milestones and based on project outcomes, not hours involved. We also recommend adding contract language that allows an organization to refuse payment for any vendor-controlled cost overruns. (Vendor-supplied agreements typically promise only an “estimate” of implementation costs based on vendor-recorded hours, while calling for fees of up to $125 per hour for overruns– even when caused by the vendor!) Timeliness penalties are also becoming more common, and can help ensure a vendor keeps to the established timeline.
During the post-selection phase, it’s important to maintain open and honest communication with the vendor. If you run into issues or challenges, don’t be afraid to speak up. It’s also sometimes useful to keep 2nd and 3rd choice vendors engaged, as it’s never too late to change direction based on outcomes of the implementation process. While switching mid-stream may seem expensive or wasteful, it’s far worse to end up with a vendor not committed to your success.
Final Thoughts
Current EHR systems on the market are valuable tools to manage data more effectively and streamline some of the labor-intensive parts of LTPAC operations. At the same time, they are not perfect solutions, and unfortunately reflect too much history as revenue cycle agents and not enough experience in day-to-day operations. Worse, all complete EHR systems currently on the market suffer from a deep bias of chartopomorphism, or paper-centric thinking, which hampers the ability of much of the healthcare industry to leverage technology in the same way that other industries have done (think Apple, Amazon, Google, and Netflix). This means that we likely will see tremendous innovation moving forward, and some of the giants today will struggle or fall away in the near future. Staying on top of technology solutions, rather than clinging tight to a trusted vendor, will require LTPAC organizations to think differently than they have in the past and embrace change much more quickly and lightheartedly.