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Kenneth G. Adler, MD, MMM 
Fam Pract Manag.  2005; 12 (2): 55-62.  ©2005 American Academy of Family Physicians

Introduction
This article is designed to help you develop that plan. By adhering to a logical and systematic selection process, you'll be able to make a high-quality decision about which EHR to choose. The process described below is based on my experience and research as an EHR committee chair for an 86-physician group. Although my group is large, I work in an office of three physicians, and I believe the following steps will apply to practices of all sizes.

Step 1: Identify Your Decision Makers
If you're in solo practice, this is easy. You're it. In a large group, a carefully selected committee will be more appropriate. Unlike, perhaps, selecting practice management software, this should be a physician-led effort, not one you delegate to your office manager or management team. Many selection efforts have been led by a "physician champion," someone absolutely committed to learning about EHRs and promoting the idea to his or her colleagues. This individual has to be willing to put in a lot of extra, typically uncompensated, hours doing research and management tasks. Since you're reading this article, perhaps that's you.

EHRs are often met with great skepticism and resistance. To avoid an aborted or seriously delayed selection process or a failed implementation, make sure that some of your practice's most influential people are on the selection committee. You will need at least one manager to help you implement this system, so make sure your practice manager or his or her trusted delegate is on the committee. If you have a key nurse or receptionist whom the others tend to follow, invite him or her aboard. If you have a partner who could easily derail this process, consider inviting him or her to participate as well. And remember, the most influential people are not always the ones with the titles.

Step 2: Clarify Your Goals
What inefficiencies or limitations do you have in your practice currently, and what do you hope to accomplish with an EHR? Do you waste a lot of time looking for charts? Do you play phone tag with patients because you don't have ready access to needed information? Do lab reports take forever to get into the chart? Are provider notes hard to read? Are you interested in electronic prescribing? Do you want to be able to print appropriate patient education materials with the push of a button? Do decision support tools matter to you? Is patient e-mail or Web access to your practice in your plan?

The list of EHR functionalities that appears in Table 1 may be a useful tool as you begin to prioritize your needs.

Step 3: Write a Request for Proposal
This is a tedious but necessary step. A request for proposal (RFP) will tell the prospective vendor about your practice, its resources and your priorities in terms of EHR functionality. The vendors' responses will allow side-by-side comparisons of products. Responding to a well-prepared RFP will take a fair amount of effort on the vendor's part, so invite only serious contenders to participate. For a sample RFP outline see Table 2 . A downloadable, modifiable RFP is available at http://www.orchardsoft.com/choosing/rfp/samplerfp.html. It is an RFP for a laboratory information system, but the basic structure and questions will work for an EHR.

Step 4: Selecting the RFP Recipients
How do you go from more than 200 products to a dozen without seeing any products? I suggest you use three defining criteria to winnow the products: 1) Does the software have a history of interfacing with your practice management system (PMS)? 2) Is the EHR typically marketed to practices of your size? and 3) Does the EHR have favorable published ratings?

PMS Interface
To avoid double entry of data such as patient demographics and diagnoses, your PMS and EHR must be able to share data. This is typically done through a software interface. To build and maintain an interface requires the cooperation of personnel from both the PMS and EHR companies. Each time the EHR software is upgraded (and most good EHR products promise at least one upgrade per year), any interfaces have to be updated. Many EHR developers will say that they can interface with any system, but frankly I wouldn't want to be their first. To determine which EHR companies have created interfaces with your PMS, ask your PMS company. This criterion alone may dramatically narrow the field.

If you aren't happy with your current PMS or anticipate outgrowing it soon, it may be a good idea to consider selecting a new one before you buy an EHR. Ideally, the PMS and EHR company would be one and the same, but your PMS company may not offer an EHR product, or if it does, it may not offer the functionality or service that you feel you need. As more physicians buy EHRs, the trend of the future will likely be integrated EHR-PMS products that don't require interfaces.

Practice Size
Most EHR vendors market their products to smaller practices (one to 15 providers), medium-sized practices (10 to 99 providers) or large practices (greater than 100 providers,) although a few market to all sizes. Picking RFP recipients on this basis will help you avoid having a "large practice EHR" declining to respond to your RFP because you're "too small." And it will prevent you from wasting time reviewing an RFP response from a vendor whose product turns out to be ill suited for a practice of your size. You can obtain information on who markets to whom in a useful free white paper by Mark Anderson entitled "2004 EMR Functionality Survey Results," which is available at http://www.acgroup.org/pages/396843/index.htm.

EHR Ratings
Several excellent sources for EHR ratings are available. In 2003, the American College of Rheumatology, in conjunction with the Aurora Consulting Group, evaluated EHRs in small practices. Go to http://www.rheumatology.org/products/coding/03emr_ack.asp to download their 50-page paper. Other ratings sources include the Health Information Management Systems Society (http://www.himss.org) and a Web site developed by Kirk G. Voelker, MD, at http://www.elmr-electronic-medical-records-emr.com. And if you want to go to one place where more than 150 vendors show their wares, consider the annual conference known as TEPR (Toward an Electronic Patient Record). Information on this can be found at http://www.medrecinst.com/conferences/tepr/index.asp. Finally, go to the AAFP's Center for Health Information Technology, http://www.centerforhit.org, for information on EHR vendors that have agreed to the center's principles of affordability, compatibility, interoperability and data stewardship. AAFP members can get discounts on several well-known systems, and the AAFP has arranged for purchases to be made on a subscription basis, with monthly payments.

Step 5: Review the RFPs and Narrow the Field
So you've narrowed the field, sent out the RFPs and received your responses. Now it's time to review the responses. Your goal is to pick the top contenders to visit you and give a demonstration of their system. These are typically two- to three-hour affairs in the evening with some health food - such as pizza. Everyone on the selection committee should attend every demo in order to make fair comparisons. This is a huge time commitment, and your group's willingness to spend evenings away from their families will determine how many demos you can tolerate. Our group chose five from an original field of eight. Of those that were eliminated, one vendor decided not to respond, one vendor didn't meet our training and service needs, and one didn't meet our deadline.

Step 6: Attend Vendor Demonstrations
Next, it's show time. Vendors will typically arrive for the demo with two to four people - one to two sales personnel, a skilled software presenter and perhaps a physician who is paid by the company. They'll be prepared to do a canned presentation that shows their software in the best light. For each of these presentations, you should do four things:

• Present them with one or two standard patient-visit scenarios to document, keeping the scenarios consistent from vendor to vendor;
• Try not to interrupt their demonstration every two minutes (my group was notorious for this);
• Don't focus solely on ease of note creation. Instead, pay attention to how the EHR enables users to find information, view labs, manage health maintenance reminders, write prescriptions, etc. These functions can be more important than how easily the EHR creates a patient note;
• Prepare a rating form in advance and ask every committee member to complete it at the end of each demo. You can then tabulate average or median results for each vendor. See the sample rating form in Table 3.

Step 7: Check References
Check at least three references for every vendor that is still in the running. Ideally, references should include one or more physician users, an information technology (IT) person and a senior management person. The vendor will provide you with a list of references - likely the vendor's happiest customers, who may be financially rewarded for talking to you (e.g., discounts on service fees or individual rewards), so be skeptical. Nonetheless, these folks can be very informative and honest, in my experience. If you know a person or group not on the vendor's reference list that uses or has used their product, call them too. Have a prepared list of questions for these phone calls. A sample, structured interview is shown in Table 4.

Another way to find references is to post a message on the AAFP-sponsored e-mail discussion list for EHRs. AAFP members can subscribe at http://www.aafp.org. From the AAFP home page, click on e-mail discussion lists, under the Membership heading.

Step 8: Rank the Vendors
Now that you've reviewed the RFPs, seen the demos and done the reference checks, it's time to rank the vendors and narrow the field to two or three vendors for site visits. Given the time and resources involved, doing more than three visits is impractical. Even one visit could be a challenge for a busy solo physician.

Before you rank the vendors, you should formally weigh your priorities in the following areas:

• Functionality. How well does the product perform your desired functions?
• Total cost. How much will the product cost, including hardware, software, support, etc.?
• Vendor characteristics. Does the vendor offer excellent service, training and implementation support, and are they financially secure?

Most physicians tend to put too much emphasis on functionality and cost while ignoring the critical nature of service, training, implementation support and the long-term viability of the vendor and product. If the system is not effectively implemented or maintained, it will not achieve its desired potential. And it will be more than a small inconvenience if the vendor you know and love goes bankrupt. We put a 40-percent emphasis on vendor characteristics, 40 percent on functionality and 20 percent on cost. The sample vendor rating tool in Table 5 breaks the selection criteria into these same three categories. (For another example, go to http://www.chcf.org/topics/view.cfm?itemID=21520).

Cost estimates can be tricky. Vendors tend to present these in a way that makes side-by-side comparisons difficult, and they focus only on software costs. Be sure to do a comparative spreadsheet that captures all associated costs over the first five years including new hardware costs, new IT personnel, network upgrades, extra licenses and annual service and maintenance. [One such spreadsheet can be downloaded from the FPM Web site at http://www.aafp.org/fpm/20020400/57howm.html#1.] When we did this for our top four choices, we found the costs to be surprisingly similar.

Step 9: Conduct Site Visits
Once you've selected your final contenders, plan site visits to see how the systems perform. Go to practices that are similar in size and configuration to yours. If possible, go to one that is using the same PMS that you are using. Bring at least one physician and the most senior management person that will be responsible for the EHR purchase. Plan to visit with physicians and observe them with patients. Also talk to back-office personnel, relevant management and the practice's key IT personnel. Take notes. Use the visit to confirm or contradict your expectations of the product based on what you learned through the RFP, demo and references.

Step 10: Select a Finalist
After each site visit, go back to your vendor ranking and see if it still holds. Select your top contender and a runner-up. If negotiations don't go well with your number one choice, you may want to fall back on number two. Also, having a serious back-up choice will give you more leverage in the negotiation process.

Step 11: Solidify Organizational Commitment
Now that you have picked the vendor you'd like to do business with, it's time to make sure the rest of the practice is with you. If you're in a small practice, hopefully you've involved all the key decision makers in the process to this point. If so, you can skip this step.

If you're in a larger practice, or one that has some potential naysayers, discuss your selection committee's recommendations with all the relevant stakeholders. Be prepared to "sell" your group on the EHR concept and this particular vendor. Invite the vendor to give another demo to the practice as a whole and be prepared to address a slew of questions and concerns. If significant concerns come to light that your committee didn't address previously (if you did your homework, that's unlikely), be prepared to drop back to step seven and repeat any steps necessary to solidify your practice's commitment to the EHR.

Step 12: Negotiate a Contract
Typical EHR contracts span from 10 years to lifetime. If the contract is to terminate in 10 years, be sure you know what happens after that. Current and future costs should be spelled out, as should the role the vendor will play and the amount of time the vendor will commit to the implementation process. Be sure to consider the possibility that the vendor could go out of business before you do. Request that the vendor's source code be put into escrow, and clarify the circumstances under which you could get access to it. Have a lawyer experienced in software contracts help with this step.

Final Note
The EHR selection process is time consuming, but for a decision as important as this one, it's necessary. You can't afford to purchase an EHR impulsively, and you want to make sure your practice is with you. The entire process can take from six months to two years. Our group took 13 months, which I suspect is about average. If your selection process is methodical, critical and inquisitive, you will undoubtedly be happy with your final EHR choice. Good luck on your quest.

Send comments to fpmedit@aafp.org

CME Information
The print version of this article was originally certified for CME credit. For accreditation details, contact the publisher. American Academy of Family Physicians, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672.

Table 1. 

Table 2. 

Table 3.  

Table 4.  

Table 5. 

Sidebar: Key Points

• To reduce your list of potential vendors to a manageable length, consider only those systems that have already developed interfaces with the practice management software you use, that are marketed to practices the same size as yours and that are well rated in published surveys.
• How the EHR enables users to create and complete tasks, find information, view labs, manage health maintenance reminders and write prescriptions can be more important than how easily it creates a patient note.

Dr. Adler is a family physician in full-time clinical practice in Tucson, Ariz. He has a Master of Medical Management degree from Tulane University and a Certificate in Healthcare Information Technology from the University of Connecticut.

Conflicts of Interest: none reported.