A Step-by-Step Process for Selecting and Implementing an Electronic Health Record System

Most health and wellness services, especially of larger size or those billing insurance, employ an electronic appointment and billing system, plus a health record. Selecting a system that will work best for an organization and implementing the system is challenging. The resource commitment and potential disruption to current processes can be quite intimidating. Following a systematic selection process can help anticipate and address problems and reduce the stress of such an impactful decision.

1. Conduct a health information readiness assessment.

Conducting a Health Information Readiness Assessment can help anticipate barriers and identify steps that should be taken in your organization before selecting and implementing an electronic health record system. A tool for assessment is available from Healthit.gov: Assess Your Organization’s Readiness.

Using the available assessment tools can help target the areas in your organization needing additional groundwork or resources. 

2. Construct a project team.

A project team should adequately represent stakeholders yet remain small and flexible enough to set and meet timelines and efficiently determine and delegate essential tasks. Generally, the team members should be practical and organized thinkers, with good listening, communication, and problem-solving skills. An ideal size is somewhere between 5 and 12 individuals. Either the ultimate decision maker should be on the team or an effective mechanism for continual update and input should be structured before starting the process. The Project Team should engage the staff, at all levels, to help define the overall goals of the system, priorities for selection of a system, and the key elements of the implementation process.

3. Identify the overall goals/realistic expectations of the EHR system. 

Why is the organization implementing an electronic health system? What is the organization hoping to achieve that cannot be done within the current operational system? Setting realistic goals will help manage expectations and provide a road map for prioritization. When possible, it helps to keep the emphasis on improved patient care, as most health and wellness care personnel share this goal. It is very easy to drift toward a staff-centered model, as adequate student user representation is usually difficult to maintain through the selection and implementation process. 

4. Set priorities for system selection.

Priorities can be categorized into those system characteristics that are essential to any system purchased, those that are highly desirable, and those that would be nice to have but are not essential. As the priorities are identified, questions regarding the capabilities of the system can be generated and used for the request for Proposal (RFP). Establishing expectations/priorities will help to avoid placing undue emphasis on the bells and whistles of the system, without complete consideration of the basic capabilities.

Most health and wellness services will need to work closely with their college purchasing or procurement departments and must abide by bid process guidelines. It is best to involve key individuals in this area to fully understand any requirements, and recommendations. Some procurement departments also have evaluation tools available to facilitate the selection process. 

It is helpful to map significant workflow processes in the clinic and identify processes that you expect to be simplified and those you expect to increase in complexity or required resources. Again, desired system characteristics and priorities can be identified and will help with selecting a system that will best accomplish desired process improvements and efficiencies. 

Discussing and setting clinic-wide priorities for the system is well worth the time spent upfront. For example, if a system you are considering has great reporting capabilities but takes two extra steps for appointment scheduling, your priorities should be able to help determine how much weight you place on each during the selection and implementation process. Will the goal be to reduce practitioner time spent searching for codes/coding or will the goal be to reduce the number of coders or clerical staff needed to maintain efficient databases or perform coding tasks? Will the goal be to have patients make follow-up appointments in the exam room, return to a central area to make an appointment, or make appointments online?

5. Identify changes and gaps in user skills needed to maintain new processes.

Some of the skills valued in the current system may be very different after adoption of an electronic system. For example, memory for record location and quick file placement and retrieval may be valued when records are paper charts. The ability to maintain an accurate, clean database and build templates and knowledge of search engines may be valued characteristics in personnel after implementation of an electronic medical record. 

6. Identify barriers to implementation and create plans for reducing or overcoming the barriers.

Common barriers to implementation may include physical layout of the clinic or exam room space, inadequate staff to manage patients during the expected productivity decline, and general staff resistance to changing existing processes. Identifying the barriers specific to your health or wellness service and discussing ways to effectively address the barriers will reduce unanticipated problems and improve general communication among the staff before the implementation process begins. 

7. Define criteria for selection and weight the system according to your agreed upon priorities.

Cost of the System:
First, it is important to consider how much weight the cost of the system will have. Everyone may say ease of use is the main goal, but if the system costs three times as much, is the organization willing to spend the extra resources for the system?

Correctly identifying costs involved in purchasing and implementing the system helps reduce the frustration of incomplete implementation and poor match with expectations. For example, if the expectation for the use of an immunization compliance module has been set through a proposal or vendor demonstration, but the additional costs prohibit implementation of the module, personnel disappointment and frustration with the capabilities of the system is more likely. 

Some costs to consider when evaluating proposals:

  • Hardware and software initial costs: do not underestimate the importance of response time and speed to users. Slow systems create major frustrations for users and can significantly impact productivity/labor costs. 
  • Data storage: on-site or web-based
  • Ongoing maintenance/add-ons and upgrade costs
  • Labor costs: training, productivity impact, IT or other additional support staff
  • Conversion of current records
  • Licensing
  • Interface availability and costs (bursar, lab, radiology, pharmacy, mental health/counseling services)
  • Upgrades
  • Customer support

Other Parameters to Consider

  • Quality and quantity of training offered: super users and ongoing training
  • Ease of customization to meet practice needs
    • Ease of template building
    • Automatic alerts available
    • Bursar interface
    • Tiered access/security capabilities
  • Availability of online student portal: online appointments, ability to send test results, ease of student use, pre-appointment paperwork, upload of records
  • Response time to solve problems/issues
  • Ease of navigation through a patient visit
  • Ease of importing data into the EHR
  • Reporting capabilities
  • Ease of report customization
  • Card swipe or fingerprint sign-in capabilities.

8. Determine an evaluation process.

The weighted scoring system that you use determines the top systems to consider and identifies areas requiring additional information to clarify system capabilities. Some of the additional information gathering can be done during vendor visits to demonstrate the product. Representatives demonstrating the product are usually very skilled in presenting patient situations that display the best characteristics of the system, using templates that are pre-built and easy to use. Ask vendors to move through a new patient visit with unusual complexities and without pre-built templates.

It can be very helpful to visit similar size institutions currently using the system you are considering. Prepare a list of questions regarding system capabilities and include questions about how the system improved or facilitated patient care, how the system has impeded patient care delivery, and the satisfaction with response time to issues. 

Check the references provided by the vendor, preparing a list of questions regarding vendor availability, response to problems and expertise of their training and trouble-shooting teams. Also check with other similar sized schools that use the system but are not on the vendor reference list.

A compilation of all the information you have gathered during the selection process should successfully guide you toward the purchase and implementation of a system that best meets your organizational needs.