EMR Contract Review Guide (Just Released)

How to Compare EMR Vendors

After you compare multiple EMR vendors, you begin to realize that most of the vendors have the same set of features.  The difference between each EMR vendor is the method in which these features are implemented in their system.  This article will attempt to break down the functional grouping of benefits in an EMR system and then detail the differences in each of these features.


Appointment Scheduling:


The majority of EMR’s in the market today provide some capability to schedule a patient.  This feature may come from the built in appointment scheduler or one that the EMR vendor has interfaced with through another Practice Management Software vendor.  Typically, the most basic features found in the appointment scheduler are providing multiple views of the schedule.  This may be by the doctor, location, resource or a combination of the three.  The views also allow the practice to see the schedule by day, week, and month.  Other basic feature most commonly found are assignment of appointment types which allows an office manager or physician to view their appointments of the day with a glance and have a pretty good idea of what their day is going to consist of.  Some EMR’s also allow for appointment pop up’s to occur which can inform the front desk specific information about the patient.  The more advanced appointment schedulers have features such as Rules Based Scheduling.  This allows the physician to create a schedule based on the type of appointment and when they want to see that type of appointment.  This application will then help the practice manage the patients and the types of visits they may be presenting with.  Another advanced feature is the ability to drag and drop appointment changes.  This prevents the user from having to click on the appointment, choose the day to move to and then click ok to move the appointment.  If your office tracks no shows, many of the advanced EMR systems will help your practice track those patients.  Recently, some of the newest features found in the EMR systems are the ability to check the insurance eligibility of the patient before they arrive in the office.  Some systems force you to check each patient individually and others allow you to process the batch of patients for the next appointment day.  The returned information of the patient eligibility is based on the insurance company that sends the information.  A few insurance companies will provide co-pay and deductable information but most will only state whether the patient is eligible or ineligible.  For the most part, most appointment schedulers have the same features, the key is to identify which one has an appointment scheduler that is the easiest to use and contains the specific features you need for your office.


Patient Flow Tracking:


Most EMR systems will give you some way to track your patients as they move through your office.  Patient flow tracking typically comes in three different styles.  Some vendors give you a visual representation of the rooms and then display the patient in the room along with the procedures being done to the patient.  Other systems provide a list of patients denoting their location, time spent in room, and who is currently treating them.  The third style that is used is similar to a spreadsheet that is color coded with the patient exam rooms and the times turning colors as thresholds have been exceeded for the amount of wait time for the patient.  All three styles are easy to use and seem to help make your office more efficient especially when someone has been designated to keep an eye on the tracking screen.


Documentation of an Encounter


Documenting a clinical encounter is the core function for every EMR in the market.  The speed and functionality of this feature is usually the one feature that will either make or break the deal.  What EMR vendors need to realize is that the speed in which an encounter can be completed is the one factor that makes a physician feel comfortable about the system.  The biggest fear for physicians is that by switching to an EMR system will slow down their process and there by decrease the number of patients they can see in a day.  If this occurs, ultimately the physician will return to paper and not use the system and consequently the implementation is deemed a failure.  With that said, this one feature alone should be scrutinized with critical detail.


The documentation of the encounter begins with the nurse collecting vitals, past family social history, and sometime the history of present illness.  In many EMR systems, nurses have special screens that gather this information only.  These screens are designed to allow for quick collection of data.  Some EMR vendors have chosen to interface to vital collection devices such as Welch Allen.  The data is collected from the machine and then stored in the patients chart as discrete data elements.



Clinical documentation screens can be broken down into three methods of data collection.  The first method of data collection is context based templates.  These templates are paragraphs of text that are created by the physicians which address a specific diagnosis, procedure or treatment.  As the physician performs the History of Present Illness and Review of Systems for the patient, the physician is selecting the context based paragraph that best meets the ailment that the patient is being seen for.  Upon completion of the note, most of these systems allow the physician to type additional text or use Dragon Naturally Speaking to modify the end result of the note.  The benefit of this type of system is the speed in which a note can be created.  A note can typically be created as quick as the doctor may dictate or make documentation in the patients chart.  The disadvantage of this type of data collection is the inability to allow the system to calculate the proper E&M code and furthermore the inability to provide granular reporting that may be necessary for pay for performance reporting in the future.


Tab Based Templates 


Tab based forms are the next type of data collection.  These screens are usually grouped by tabs based on the SOAP note procedure.  Some systems will give the physician the ability to define the tabs in a custom workflow.  For example, a nurse may only need to see the Vitals, Past Family History and Social History.  This feature can be nice because it allows for an uncluttered desktop for the nurse and does not overwhelm them with information they are not concerned with.  This feature also keeps HIPAA in check by only showing information to users on a need to know basis.


Typically the first or second tab is a Vitals Tab.  Most vendors capture all the standard vitals you would expect along with the Chief Complaint from the patient.  The chief complaint should be a text box that allows the nurse/physician to document the complaint in the patient’s own words.  When it comes to entering vitals into the system, some vendors make it easier than others.  You would think that all the EMR vendors would first assume that the vitals were being collected by the nurse on a tablet in the exam room.  The data entry feature that makes this easy on the nurse is to automatically pop up a numeric key pad with large keys to hit with the pen.  While it is true that all offices may not take a tablet to the exam room, if this was detected by the vendor’s software, it would make it really quick to enter data for the nurse.  If you are an EMR vendor that is reading this article, please remember it is about speed not just for the doctor but the nurse also.  Vitals can also be collected via automated devices from vendors like Welch Allen.  When you rate the EMR vendor, verify that this is an available feature by the EMR vendor.  Also, it is wise to request a list of vendors that they can interface with.  You will find that the cost of the interface will vary with some vendors.


Past Family and Social History, Allergies, Immunizations, Medications

The next set of tabs across the top of the screen is usually Past Family and Social History, Allergies, Immunizations, and Medications.  The vendors EMR application should allow the ability to add any fields the physician may need to these screens.  Typically, the vendor already has a prebuilt template, but the template should be modifiable by someone in the physician’s office.  In some states, such as Texas, a centralized database has been established to retrieve Immunization data from.  Typically, this is done using HL7.  If you are Pediatrician, this can significantly improve your patients care by having the ability to download the patient’s immunizations to your system.  When you compare the EMR vendors, verify who has this capability and who does not.  Also, request the cost of the interface for this feature.  When it comes to collecting information about patient medications, the system should have the ability to denote the difference between medications prescribed by a physician and over the counter medications.  Many EMR systems will perform drug to drug interactions which is a very helpful feature.  One feature to inquire about is does the EMR application check prior medications that have been prescribed to the patient by other physicians.  Most system do not do this, moreover, most systems only check the medications that are prescribed on a specific encounter not prior prescriptions prescribed by your office.


HPI (History of Present Illness)

The next tab is generally the History of Present Illness tab.  As stated previously, the vendor may already have templates pre-built, but the ability should exist for the office to custom design this screen.  On each of these screens, a free text field should always be available in case the patient has something that you have not accounted for in your template.


ROS (Review of Systems)

After the HPI tab, the Review of System tab usually follows.  This screen is probably one of the most complex screens to create for your office.  Most vendors will tell you that they have templates for your specialty but you will find that their templates probably only represent about 10% of what you actually need.  Due to this, it is critically important that the EMR vendor show you how difficult it is to create a custom defined Review of System screen.  Remember, during the demonstration, the vendor is going to demonstrate what they want you to see…not what you need to see.  This is one of those areas.  Tell the vendor ahead of time that you will want to see how a Review of System template can be custom defined.  I will say it again, this is critical that you see this in your demonstration.  When you here it takes 6 months, 9 months, 12 months 18 months to get up and running on an EMR system….this is why.  Some systems are easier than others to create custom templates.  In the opinion of HDS, this is one feature of the EMR application that could mean the success or failure of your EMR implementation.  A few things to look for in the template creation is first, the ability to create user defined elements and text.  Some EMR systems only let you place on the screen what has already been defined in their clinical element database.  This cripples the ability to create a screen just like you would like to see it.  Therefore, try to come up with a clinical element that you think may not exist in their database and watch how their system has to deal with that situation when designing the template.  Some systems will not allow you to create labels or text on the screen that you believe needs to appear in the note.  Other features to look for are the ability to create logic between the clinical elements you place on the screen.  This will give you the ability to use if/then statements or similar data structures to default other clinical elements on the screen to a specified value.  If your practice has to use modifiers often, verify if by selecting specific elements that default modifiers can be selected at the same time.  One example of this is the Right / Left modifier.  Code linking is another feature for template design.  Some vendors allow you to select an ICD9 code and then link specific procedures codes along with a plan.  While the work for this can be quite intensive on the front side, it significantly impacts the back office due to the fact the staff does not have to manually link the ICD9 code and billing code.  Also, improved payment efficiencies can occur due to the lack of mistakes that can be made on the back side of the billing system.


Orders – lab / diagnostic

After the Review of System, typically you will see a tab for Lab and Diagnostic Imaging.  One thing to consider about these two tabs is the workflow for these screens.  When the patient presents in your office, were labs or diagnostic imaging already performed.  If so, these tabs need the necessary clinical elements to document these results.  The system needs to understand that these labs/imaging were previously done and not to be billed by the system.  At this time you are only documenting the information about the result.  The second type of workflow is when you need to order labs/diagnostic imaging for the patient.  The EMR application needs to understand when the order process needs to take place.


The Lab and Diagnostic Orders module of the EMR application is probably the second most important feature of the EMR application.  You will find that much of your time for you and your staff will be spent in these modules.  For this reason, pay very close attention in the demonstration to how these modules are accessed, where they are accessed from, where the module will leave you when you complete the process, and how to follow-up on data that was entered into these modules.  Some vendors will allow you to make an order request electronically via a HL7 interface with the vendor.  When it comes to labs, most labs will pay for the interface if you do enough volume with the lab.  It is also possible to have interfaces with multiple labs at one time.  Verify the EMR vendor has the capability.


Voice, Dictation, and Dragon Naturally Speaking

Almost all EMR vendors allow some mechanism to capture voice into their EMR system.  The majority of vendors have chosen to partner with Dragon Naturally Speaking.  The EMR vendor usually provides some kind of text box within their application that accepts the input from Dragon Naturally Speaking.  This is critical when you have already been using Dragon Naturally Speaking.  If you already have the application and the EMR vendor does not support Dragon, I would not purchase the vendors EMR system.  You are already comfortable with the speed in which a note can be captured.  You will only become more frustrated with the system due to the speed in which you can capture all the necessary data.  As you will see, you will have two choices in a template based system.  You either create a template that includes ever bit of detail you could want about a problem or create a simple template that is enough to document the encounter.  Most physicians choose the latter and accept the fact that end result note is not what they have been accustomed to viewing in the past.  When you can combine the template based system with Dragon Naturally Speaking, you get the best of both worlds.  When viewing the EMR demonstration, make sure the vendor demonstrates the ability to use Dragon in the collection of clinical information.  The reason for this is it is very easy for the vendor to say “Yes, we support Dragon Naturally Speaking” and then find out that they only support it in the resulting of orders or some other location that does not impact the amount of time it takes to document a clinical encounter.


If the system does not support Dragon Naturally Speaking, the EMR vendor probably will allow for the capture of voice data which is then saved as an attachment on the patients encounter.  This can still be helpful if you allow an outside dictation service access to you system.  The service can then access the voice file and dictate your note into the system.



Then final result of the note should be one that is easily modifiable.  Many vendors will allow you to click on certain clinical elements in the note and then hyperlink back to the exact clinical element selection.  You can then either delete or change your finding.  Some vendors allow you to add free text directly to your note after it has been completed.  This is nice especially if you can use Dragon Naturally Speaking.  Lastly, the groupings on the clinical note should be user modifiable.  This means if you do not like where the Review of Systems or Assessment appears in the note, you should be able to change the order of the grouping.


A feature that allows for the quick documentation of an encounter is the ability to bring forward the past visit the patient was seen for.  Many times, little has changed since you have last seen the patient.  Therefore, it makes it quick and easy to pull forward the last visits documentation and then chart by exception.  Chart by exception is another feature in EMR systems that allows the physician to either give a positive or negative result to a clinical element.  For example, the patient either presented with fever or did not present with fever.


Another feature in the building of the SOAP note is real-time building of the SOAP note.  In some EMR applications, the physician can make the clinical selections on one half of the screen and watch the note being built on the right side of the screen.  This can be very helpful to know what the end result is looking like as you document the clinical encounter.


Most EMR vendors have the ability to append to a note.  The question you need to ask the vendor during the demonstration is how you append new information to a clinical encounter that has already been posted for billing purposes.  As you already know, a physicians day can be filled with interruptions and sometimes you inadvertently close encounters by mistake or sometimes you close the encounter just to get it done and over to billing so you can move on to your next task at hand.  Sometimes that is ok and the billing department can make the necessary changes that need to be made but other times you made need to go back and make modifications to the clinical documentation.  In many EMR systems, this process can be quite cumbersome.  If you believe that you may have to come back and make corrections to the encounter quite often, verify with the vendor how difficult the process is.


Electronic signatures on encounter notes are a feature by many EMR vendors.  Typically, you can use a tablet pc and its pen to sign your name digitally.  The EMR vendor will then take this signature and then save it with each encounter.  Other vendors simply put the words “This encounter has been digitally signed by Dr. Smith on 03/27/08”.  In order for the application to place this line in the encounter, the physician usually has to type some password for the system to stamp this into the encounter.


The medications module is another module you will find that you spend a great deal of time with.  Consequently, this is a feature you want to pay close attention to during the demonstration.  The prescribing of medications should be quick, easy, and flexible.  When prescribing medications you will want the system to check for drug to drug interactions along with any drug to allergy interactions.  Some EMR systems will even check interactions if the patient is pregnant or breast feeding.  The biggest difference between the EMR systems is the ability to check interactions against prior medications.  Some systems will only check the drugs that were prescribed during the encounter.  Other EMR systems will check past medications and medications that have been prescribed by other physicians if they were entered in to the system.  Most EMR systems will give the ability to do Pediatric Dosing.  If you are a pediatric physician, make sure this feature is available.  Other features in the medications module deal with creating the printed/electronic prescription.  Some systems only have the ability to print the prescriptions.  A printing feature found on some EMR systems will give you the ability to designate a “prescription printer” so you do not have to choose which printer the prescription is printed to.  Another feature is the ability to fax the prescription to the pharmacy.  Patients typically like this option because the prescription can be ready by the time they arrive at the pharmacy.  Lastly, some systems can use EDI (electronic data interchange) to send the prescription to the pharmacy.  This feature allows you to place the prescription directly into the pharmacist computer without any data entry on their side.  One additional feature you want to ask the EMR vendor is if when the prescription is prescribed is the medication documented in the clinical encounter SOAP note for that day.  There are some systems that do not do this and if it is important to you, verify the EMR vendor has the capability.


Anatomical Documentation

Most all EMR vendors will tell you they have the ability to document anatomical drawings.  Typically, this means they give the physician the ability to use a pen and draw pictures that can be saved as an attachment to the patient note.  What differentiates the EMR vendors is the clinical pictures that come with the EMR systems.  Some vendors will give you a database of clinical artwork that you can then annotate on top of.  Most of the vendors will tell you to scan an image in and then you and annotate on top of the image.  If this feature is important to you, select a vendor that has a database of anatomical drawings.


In this article, I have attempted to cover some of the basic features to watch for during the EMR demonstration.  What is most important to understand is determine what features are most important to your practice and make sure the vendor has these features.  When the decision is finally made, be sure to choose the system that seems to be the easiest to learn and provides a quick and efficient mechanism to document a clinical encounter.


As you will see, the EMR selection process can be a daunting process.  Hughes Data Systems has reviewed many EMR vendors and posses a significant amount of experience in the features that one system has over the other.  Our company would be happy to assist you in any consulting needs you may have when going through the EMR selection process.


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