Choosing an electronic medical records (EMR) system is a critical purchasing decision for medical practices. EMR systems replace paper patient charts with computer records: they store physicians' notes, x-rays, prescriptions, and any other medical information usually found in paper records in electronic form. This makes searching and retrieving data easier, improves efficiency and accuracy, and allows doctors to access patients' information remotely.

Electronic medical records systems also provide benefits such as reduced mistakes caused by bad handwriting, drug interaction precautions, and improved billing and insurance handling.

There are hundreds of EMR systems available today, targeted at every type and size of practice. This BuyerZone.com Buyer's Guide will help you ask the right questions to evaluate both the software and the vendor so you can choose the best solution for your practice.

Running an EMR software evaluation

Conducting an evaluation of EMR software can be a real challenge: it's one of the most significant purchases you can make for your practice, and there are hundreds — maybe thousands — of different packages to choose from.

One reason there are so many different EMR software packages out there is that many are targeted towards specific types of practices: small family practices have considerably different needs than large hospital staffs, as do orthopedic practices and dentists. Try to find software that matches your specialty and office size.

The next step in this tactic is to see what practices like yours are choosing. Find offices similar to yours and visit their offices to see the software in action. Just seeing the system isn't enough, though: trying the software for yourself is an essential part of any EMR software evaluation. Many vendors allow you to log in to a sample account or will send you a sample CD to let you use the software — take advantage of these opportunities. Have all the interested parties from your practice go through their most common activities to get a sense of how easy the software is to use — watching "canned" demos does not give you the same in-depth look at the products.

Be sure to look for HIPAA compliance as part of your evaluation. The far-reaching Health Insurance Portability and Accountability Act has more impact on billing and insurance matters, which are usually handled by a practice management system instead of an EMR system. However, there are strict security rules that apply to any patient data. Most EMR software will meet HIPAA requirements, but you should still make the vendor provide details on how it does so.

Entering data into your EMR

The central focus of EMR software is on medical records: creating, updating, searching, and displaying the entire contents of patients' charts. As you compare different systems, try to stay focused on these essential features. Get answers to questions like these:

• Does the system recognize all the procedure and diagnosis codes your practice uses?
• Can the system handle multiple offices and several doctors?
• Does it support the style of charting your practice prefers?
• Are there multiple ways to organize and view patient data?
• Are labs, x-rays, and other types of information easy to manage and access?

One of the biggest decisions to make when switching to EMR is how you will enter patient data. There are two aspects to this question: what method you'll use to enter information, and what equipment you'll enter it on. Popular data entry methods include:

• Keyboard and mouse combinations — some doctors may be comfortable typing notes, while less technology-inclined physicians may prefer to select from lists of exam codes and diagnoses.
• Touch screen applications are very quick to use for standard procedures and codes, but can be very inefficient when the information you want to enter doesn't fit the template neatly.
• Speech recognition is very fast, but some doctors may not be comfortable with dictating notes while the patient is in the room. (Keep in mind that you may also want to simply record doctors' notes for later transcription.)
• Handwriting recognition lets doctors continue to work in a familiar style, but can balk at the messiest handwriting.

Your hardware options are basically several different sized computers:

• You can install desktop computers in each exam room, or purchase laptop computers for each physician. This may increase your initial expense, but it can reduce the time doctors spend entering information. They're also familiar to many users and can be used for more than just EMR.
• Tablet PCs are specialized, clipboard-shaped touch screen computers designed specifically for EMR applications. Doctors can easily use them while meeting with patients.
• PDAs are even smaller than tablets. They can be cheaper and more portable, but may be less efficient to operate than full-size computers or tablet PCs.

One of the best ways to proceed is to choose an EMR system that supports multiple data entry methods. This lets you start with one method and later switch to another, or support multiple modes for different doctors.

Whichever method you choose, be prepared for a slowdown in productivity when you first implement the new system. Once users get used to the new system, productivity will gradually increase.

You'll also have to consider how your existing paper charts will be incorporated into the EMR system. Some practices choose a "day forward" technique, in which records are scanned and converted into the system only as they're accessed — for example, when the patient comes in for a visit. This turns a daunting project into a more manageable ongoing task. You can also opt for a total conversion, hiring a document conversion company that can provide high-speed scanners. Generally, it's not worth the added expense to take this path.

Electronic medical record software features

Aside from how they handle patient records, there are many other features offered by electronic medical record software. Consider which are important to you:

• Allowing multiple users to access a record at the same time lets your administrative staff update insurance and billing information while the doctor meets with the patient.
• Remote access lets doctors access patient records from outside the office.
• Prescription handling can automate cross-checking for harmful drug interactions, as well as automatically transmit prescriptions to the pharmacy.
• Built in reporting can let you see statistics and trends across all patients: treatments ordered, visit times, total costs, and more.
• Any medical software should use SSL (secure sockets layer), the standard for secure communication — it's a HIPAA requirement as well as a good idea to protect sensitive patient data.
• Connecting to practice management systems is important — read more on this topic in Integrating with medical practice management software.

Once you know which features you want, you'll be able to narrow down your list of options. However, comparing these features across multiple packages can be difficult: you'll often see similar features going by slightly different names or with slightly different options. This is where you should fall back on your initial research: make sure you pay the most attention to the features your staff considers important.

It helps to be a bit of a cynic, too. If you can avoid letting yourself be "wowed" by bells and whistles that you are unlikely to use, you will be able to stay focused on evaluating the features that are important to you.

Don't just depend on a feature checklist, either. Getting your doctors and staff to adopt new electronic medical record software can be difficult, so it's important that the system be easy to use.

Of course, every salesperson will tell you their electronic medical record software is easy to use. You need to decide for yourself what "easy to use" means, but here are some examples.

• Is entering information intuitive? Can you skip sections or include non-standard information?
• How much is automated for you?
• Can you easily find specific information about a patient?
• Are the various screens easy to understand?
• Consider real-life situations: what happens when a doctor is in the middle of editing a record and gets a phone call? Does the system allow for quick jumps from one spot to another, outside the typical flow of work?

Users will always have questions. How much contextual help is included? Are there pop-up "tool tips" to explain various buttons? Is the "F1" help system … helpful?

You are likely to hear quite a bit from salespeople about how much they can customize their electronic medical record software for you. This is another instance where you should be skeptical. Unless you are buying for a hospital with very intricate reporting and functionality needs, the software you choose should already include all the basic features you need.

Integrating with medical practice management software

Another essential software purchase for a medical office is medical practice management (MPM) software, which allows staffers to track patient demographics, visits, and diagnoses; collect, transmit, and track billing information and insurance payments; manage appointment scheduling; and generate a variety of reports. MPM software can improve the efficiency of an entire practice, from physicians and nurses to clerks and billing specialists.

Both MPM and EMR are major purchasing decisions costing many thousands of dollars. Because of the magnitude and expense, it is usually advisable to purchase and install one at a time. However, to get the most out of both systems, it is important that they work well together.

The industry-standard HL7 protocol allows health care applications to share data with each other, so make sure both your EMR and MPM software use it. For truly seamless integration, you should not have to export batches of data from one and import them into the other — they should communicate in real time.

Many software vendors offer both types of software or even one software package that combines the functions of both. They also share many characteristics, so it often makes sense to look into both at the same time. Of course, the easiest way to ensure seamless integration is to buy both systems from the same vendor. However, you may find that the provider with the MPM that is ideal for your business does not offer the best EMR.

Both systems are critical to the day-to-day functioning of your office, so be sure to choose them based on your specific needs, not solely on convenience.

Users will always have questions. How much contextual help is included? Are there pop-up "tool tips" to explain various buttons? Is the "F1" help system … helpful?

Read the MPM software Buyer's Guide for more information.

ASP v. client-server

An important decision to make when choosing an EMR system is where you want the software hosted. If you run it in-house, the solution is usually referred to as a client-server system; vendor-run applications are referred to as application service provider (ASP) solutions. Both options provide distinct advantages: consider which are more important to you.

Client-server solutions
Most software used today is locally hosted — the program runs on your computer and stores the data either on your hard drive or on a network server in your office. This familiar setup gives you the greatest control over every aspect of your EMR system. Client-server solutions also tend to offer more comprehensive feature sets.

However, installing and maintaining the necessary SSL security and firewalls requires technical expertise and effort. In addition, keeping the data in-house gives you the responsibility of making regular backups — preferably daily — in case of a system crash.

Client-server proponents point out that EMR applications are generally quite stable and require little maintenance. And you can create scheduled backups that copy your data to off-site computers fairly easily. (Interested in remote backup services? Get a free quote today)

If you choose the client-server route, you'll pay a lump sum upfront to buy and set up the system, including software and servers.

ASP solutions
In an ASP solution, both the application and data reside on the vendor's servers, and your staff accesses them via the Internet, through a web browser or specialized client software.

The main advantage of ASP solutions is that they are maintained by IT professionals at the vendor's office. Multiple layers of firewalls and security, uninterruptible power supplies, fail-over (instant switching from one computer to another in case of a crash), and reliable backups are all standard operating procedures for these vendors. They combine to virtually guarantee that your application and data will always be secure and available.

The biggest risk of online solutions is that they require a broadband Internet connection at all times. Since no Internet connection works 100% of the time — your internal network may fail, your ISP may experience an outage, or an Internet worm may cause congestion — you may not always be able to access the system. These types of outages are rare but possible.

With online providers, payment is based on a smaller setup fee and ongoing monthly payments based on usage.

Which is right for you?
Client-server software is a much more familiar setup to most users, and it makes up the vast majority of currently installed systems. However, the ASP model is gaining popularity, particularly among smaller practices. Here are some areas you should consider:

• Can your employees handle it? If you have in-house staffers with computer expertise, a client-server solution may be your best option — but make sure you involve them in the purchasing decision. Smaller practices with little to no computer expertise are probably better off choosing an ASP solution.
• Do you need extensive customization? ASPs can easily make basic changes in appearance and functionality, in effect giving you more control over the application than you would get from an internal IT team. However, if you need extensive customization, client-server can provide more flexibility. If long-term integration with other systems is your ultimate goal, client-server solutions are probably the way to go.

Since both options provide secure, reliable options, a final way to make the choice is to consider which of the potential downsides you fear more: being unable to access your system while your Internet connection is down, or losing data and time because your server crashes.

You can also start off with a hosted service, then move to an in-house solution: ASPs should offer a seamless migration path that will allow you to easily export your data. If you're unsure of which direction you should go, this can be an easy way to get started without committing fully to either direction.

Electronic medical records vendors

In addition to selecting the electronic medical records software, you are choosing a new partner for your practice. The application you choose will be part of your operations for years to come, so it is important that you go with a vendor who will be around to support it.

One way to help assess the stability of your provider is to choose a product with a large installed base. This ensures that the vendor will continue to upgrade and improve the product, and demonstrates that the company has an ongoing revenue stream to keep them in business.

Electronic medical records training and support
Training and installation is critical. Getting started with a new electronic medical records system is an inconvenience even in the best case, so ask how the vendor plans to minimize disruption during installation.

The vendor should also provide training for everyone who will be using the system. Ask if the vendor provides different types of training for doctors and support staff — and find out how long it takes to get training set up once you sign a contract.

Many practices prefer having a trainer come to their office, but that is not always possible: web-based training can also be effective, if done properly. Regardless of the type of training, it should take users through the basics of setting up, operating, and troubleshooting the system.

As with any software, you should expect occasional problems or outages. While "guaranteed 99.5% uptime" and other vendor assurances are fine, more important is how they react when something does go wrong.

Inquire about their support policies: do they have live support staff on the phone during business hours only or? Do they guarantee a specific response time? Depending on the specific needs of your practice, the answers to these questions can make or break an electronic medical records decision.

Do a site visit
You can learn a lot by visiting one of the vendor's current customers. Ask to be put in touch with a local practice similar to yours so you can bring your team for a visit. If you can set up a visit with the other practice by yourself, all the better — you are more likely to get honest answers without a vendor representative looking over your shoulder. During your visit, have these questions ready:

• How responsive is the vendor when you have problems?
• Does the software do everything they said it would do?
• Did the vendor provide adequate training?
• How much downtime have you experienced in the last year?
• If you were starting over, would you work with the same vendor again?
• What do you like least about the program?

EMR pricing

Vendors use different standards to determine exact pricing: the number of physicians, concurrent users, or computers that will have the software installed, for example. A thorough needs assessment before you start shopping — who will use the system, and how — can make for smoother negotiation.

Desktop EMR pricing starts at $2,000 to $3,000 and range up to $10,000 or $15,000 per user. A medium sized practice can easily spend $50,000 on the hardware and software to install a comprehensive EMR system including PDAs or tablet PCs. Many vendors can set up leases or extended payment schedules, turning a hefty purchase into a more palatable monthly fee.

Online or ASP software pricing usually includes setup fees of less than $1,000 and monthly fees ranging from $50 to $300 or more. Some ASPs charge for actual usage: $0.50 per updated chart, $0.80 for each new record, etc. Often, they have monthly minimums no matter how little you actually use the software. Note that these usage-based pricing arrangements are generally fair — typically totaling $60 to $200 per month in fees for a small practice — but they require you to estimate your average usage before you can compute the total cost.

There are a large number of additional fees to be aware of for both types of systems. Some providers may include these as part of their monthly fees, and some may bill each item separately. As long as you know exactly what fees you will be expected to pay, you will be able to compare vendors accurately.

• Data transfer fees — when you import existing data, vendors will often charge you for an extra step of cleaning, de-duping, and preparing the data for the new system.
• Exit fees — when you leave the service, this fee covers the expense of exporting your data so you can move it to a new system.
• Support fees — basic support is often included for six months or a year with the purchase of a desktop system and is usually included in an ASP's monthly fee. However, you may encounter long hold times on the phone unless you upgrade to the "gold" or "premier" support package, which will cost extra.
• Training — As with support, basic training is often included, although it's usually computer-based training. If you need extra administrator training, or on-site classroom training, you can expect to pay extra for those as well.

Upgrade pricing can also vary. ASPs will usually upgrade their software without charge to you, but desktop vendors may charge an upgrade fee because they have to help install the new software. Check your contract to see how often upgrades will occur and how much they will cost.

EMR buying tips

• Build a test plan. Create a script that walks through your most common office tasks, both simple and more complex. Use it when you try out each solution, and you'll get a balanced comparison of how easy each package is to use.
• Portability of data.If you leave, how easy is it to export your records to take them to new system? Remember that the patient data is yours, not the vendors: they need to be able to provide you with usable information if you decide to stop using their software.
• Agree on your charts. Multiple physicians in the same practice often have different charting styles. Make sure you have a standard chart worked out before you start evaluating EMR software.
• Go for the standards. Make sure any software you choose for your practice uses both SSL (for security) and HL7 (for seamless data exchange). These industry standards ensure that your system is dependable and built for the long haul