15 things you should know before shopping for an EHR

1.     Alerts (required for meaningful use)


Alerts generated by an EHR system currently fall into two categories: prescription and clinical-decision support. Prescription alerts warn providers of possible drug interactions and possible allergic reactions. Clinical-decision alerts remind providers about screenings, tests, labs or other treatments and options that might be necessary or indicated. They also alert providers to available results for pending orders. An EHR system that lets you decide whether to turn various alerts on or off can help providers avoid “alert fatigue” which is the over-exposure of providers to constant alerts. Alert fatigue can lead to providers routinely ignoring some or all of the warning alerts they receive.

 2.     Appointments/Billing (practice management)

Practice Management software helps automate the workflow in a patient encounter eliminating duplicate or redundant processes. One area that shows big cost savings for Physicians is in missed appointments. Physicians who have adopted systems with built in appointment reminders for patients can experience a significant decrease in missed appointments. Finding a system that integrates the patient demographics with the scheduling process will help eliminate redundant data entry and help with up to date demographics and payer information. Physicians are particularly fond of systems that have eligibility verification built into the system’s process to help ensure claim payment.

 3.     Customized Templates and Notes

The number one area of physician frustration with EHR systems is in the charting section. If the system’s notes are too rigid, then providers are forced to change their behavior or processes. If the system’s notes are poorly defined then Providers can lose valuable time while charting. It is best to find a system that has existing templates or elements that are fully customizable to create specific encounter type note templates that can still be edited on the fly so that the result is a note that looks clean and reads like the provider naturally speaks. You should also be able to work in the patient history and demographics to update or research without having to close out the current note you are creating.

 4.     Clinical Decision Support (required for meaningful use)

Clinical Decision Support includes alerts as well as standard of care guidelines and evidence based solutions. Given the growing push towards “pay for performance”, Clinical Decision Support should be tightly linked with Clinical Quality Measures. Clinical Decision Support is showing early benefits in improved patient outcomes.

 5.     Document Management

Document management is at the core of EHR systems. While an EHR system is thought of primarily in regards to the creation of new electronic documents and information, it is important to remember those racks and racks of paper files that already exist. Going truly digital will require the scanning and importing of all those old paper files into your new EHR system so that they are available through the same medium at the same time that new information is being created. It is important to find out how your system would handle these files, while being imported, being reviewed, as well as the filing structure or folder options and the ability to customize them.

6.     Note Dictation

While note dictation is supported by many systems, one study found that “quality of care appeared significantly worse” when note dictation was used in an EHR compared to when notes were created using structured documentation or free text. The study published in the Journal of the American Medical Informatics Association, NextGov reports (Pulley, NextGov, 5/23) online at http://jamia.bmj.com/content/early/2012/05/19/amiajnl-2011-000788.short?g=w_jamia_ahead_tab concludes that; “EHR-assessed quality is necessarily documentation-dependent, but physicians who dictated their notes appeared to have worse quality of care than physicians who used structured EHR documentation.” The study suggests that details pertaining to health alerts or clinical decision support may be overlooked when dictation is used.

 7.     ePrescribing (required for meaningful use)

As a required component for all stages of Meaningful Use, ePrescribing should be something that is easy, straightforward and inclusive, especially in regards to refill requests from the patient as well as the pharmacy. All systems will require some type of interface to connect with an ePrescribing clearing house but not all systems will charge you for this interface. It is important to note that Medicare/Medicaid doctors are currently being penalized for non-compliance with ePrescribing and the penalties continue to go up for each year of non-compliance.

 8.     Health Maintenance (required for meaningful use)

In order to qualify for Stage 2 Meaningful Use, EHR systems must be able to use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care. In Stage 2 this is a Core requirement so all providers must comply. In Stage 1 this is a Menu requirement so a provider may or may not choose to comply with this. As a provider, you should make sure that this component is customizable and that alerts can be managed as to if, when and how alerts are delivered.

 9.     Secure Internal Messaging

Internal messaging systems may not seem that important to the smaller practice but if you have ever been stuck trying to figure out if someone was told to do something or not, or when they were told, an electronic “paper trail” is priceless. Internal messaging, with its electronic paper trail, is a great place to start in improving office communication and getting staff to take responsibility. So what should you look for in an internal messaging component? Of course ease of use is first; messages should be delivered organically, that is, without having to go look for them. A good system will have notices of new messages that are visible no matter which section of the EHR system the user is in. The second thing would be the tracking of messages; when were they read, who read them, etc. The third would be the ability to send different kinds of messages such as tasks, informatives, interrogatives and to send them with different priority levels and even ‘due by dates’ or times. The last would be the ability to communicate externally both securely and via email, to patients, labs etc., either through this same system or with a quick link from within the system to an outside email program. And last, but not least, would be the security of the messaging which should be inside the protections of your EHR.

 10.     Interfaces (required for meaningful use)

Interfaces should be included with any software you are looking at but be sure to ask if these are free of charge or if you will have to pay a monthly access fee. A lot of companies will quote you the price they are charging but fail to include the monthly access fees that you will pay to third parties for e-Prescribing, Labs, billing, etc. When comparing costs it is important that you look at all costs necessary for a system to be functional and for you to achieve Meaningful Use of an EHR.

 11.     Patient Portal (required for meaningful use)

Patient Portals are a requirement for Meaningful Use. A patient portal is the ability for patients to view their own information, exam results and medical records online without contacting the provider’s office. The big question is, “who is responsible for the setup and maintenance of the patient portal?” I believe that it is best to pick a system that has a third party responsible for this task so as to let the portal do what it was designed to do without extra work for the office staff.

 12.     Role-based Security

User access should be definable in order to limit or grant specific permissions to specific areas or data sets. A front office technician who primarily sets appointments may have the need to view a patient’s account for balances, charges or payments but may not need the ability to edit that information.

 13.     Platform

There are typically 3 choices when it comes to EHR platforms:
Client/Server – the traditional model (and typically the most expensive starting at around $20,000+ per year per physician), which includes purchasing, installing and maintaining the EHR system in-house. Ongoing maintenance, support and upgrades are the responsibility of the practice.
ASP – (less expensive as there is no server hardware to buy or maintain but still around $10,000+ per year per physician) you license the EHR software and access it from a remote server hosted by an application service provider (ASP) using broadband Internet connectivity. Upgrades are typically free.
SaaS – (least expensive, around $400 per month per physician) the system is hosted and maintained outside the practice and you pay monthly for its use. Access is through broadband internet. You will always have the latest version of the software at no additional cost.

 14.     Practice Specialty

Many systems often come with specialty specific content. Specialty specific templates, code sets and health maintenance alerts may prove helpful but only if the templates and/or elements are customizable. Given most doctors proclivity for tweaking things, any system with notes that are too rigid will not be well received. We find that most doctors end up creating their own notes, templates, lists, etc. even if their system came formatted for their specialty.

 15.     Intuitive Workflow

When picking an EHR, you should look for one that has logical, seamless transitions from one stage to the next. Especially useful are alerts, statuses, or queues that automatically alert the appropriate staff when a patient is ready for the next step. Look for systems that do not require duplicate entries of data in order to fit your current processes, such as getting diagnosis codes into your billing process. You should also identify current processes that may be adapted, changed or even eliminated to streamline functionality of the new system. You should also note any current redundancies that you would like to eliminate when bringing on a new system. By taking a close look at your current workflow, you will have a better idea of how a new system will fit and what its impact on your practice in general may be.


These are just some of the things to consider when picking an EHR, the best advice is to NOT settle for something that doesn’t feel right. For software that will be such an integral part of your daily practice, a “good fit” is mandatory or “chafing” will occur. And starting over is never fun.


You can download a pdf of this list here.

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