Implementing electronic health records (EHR) in your practice, whether transitioning from paper charting or from another system, can be a daunting task. The medical record (along with the practice management [PM] system — see “The EHR and PM system relationship”) is the lifeblood of a practice, and making a change entails a significant investment of money, time and resources. Furthermore, navigating the vast sea of vendors and packages to ensure that the product selected is the best fit for your practice can be difficult (and stressful).

In this article, I’ll discuss the key variables that should be considered when choosing and implementing a new EHR system.

DETERMINE IF YOU NEED AN EHR SYSTEM

While it may seem intuitive and even obvious to most, the first step in this process is to determine whether a change is necessary. The phrase, “If it ain’t broke, don’t fix it” is often uttered by providers who have grown accustomed to, or even mastered, their current documentation method. Practices must carefully determine whether making this substantial investment will yield a positive return. Moving from paper to EHR can require overcoming a significant amount of inertia.

What will transitioning to an EHR achieve? Increased clinical efficiency, better documentation to improve patient care/outcomes, improved ability to achieve merit-based incentive payment system, or MIPS, bonuses, and improved charge capturing for billing are all potential advantages to an EHR that may warrant the effort necessary to make this change. EHRs also offer significant advantages in terms of accuracy and validity of the medical record (time stamping, tracking changes/amendments), and prevents/avoids transcription errors and handwriting illegibility issues as well. These advantages often outweigh the cost (financial and otherwise) of transitioning, which is why the movement to EHRs continues to gain momentum.

When transitioning from one EHR to another, these advantages may be much more incremental. Taking all these factors into account will help determine whether “the juice is worth the squeeze.”

FIND A SYSTEM THAT SUITS YOUR PRACTICE

Once the decision has been made to pursue a new EHR system, the following factors must be analyzed to determine the system that will best suit a practice.

1. Specialty-specific functionality

While every medical subspecialty possesses its own nuances, ophthalmology is especially unique in terms of its terminology and workflow. Because of this reality, while most large EHR system providers have ophthalmology-specific modules, some providers have emerged as “eye-care specialists” (see page 37).

Generally speaking, the larger players in this space are commonly present in major health systems, because they provide cross-specialty functionality that can be generalized across the entire health system. This flexibility also means that these systems tend to be orders of magnitude more expensive than the more boutique eye-care specialized providers. The combination of eye-care specific functionality and affordability of these systems explains their prevalence in independent practices.

2. A user-friendly interface

The importance of the variables discussed in this article will ultimately vary from practice to practice and provider to provider; however, the user interface is one of, if not the most, important factor to consider. The interface is the “face” of the system that physicians, technicians, front-desk staff and opticians (also known as “end users”) must interact with day-in and day-out. The goal of an EHR is to enhance the ability of providers to deliver care and limit the administrative burden of doing so.

Ensuring that the key end users are involved in the evaluation process and are comfortable with the user interface can dramatically improve the ease and ultimate success of an implementation.

A good EHR service should not balk at the idea of providing multiple demonstrations to various user groups and separately highlighting the relevant features to each group. While it may seem tedious to spend additional hours pursuing demonstrations of various systems, this small additional investment can be a make-or-break factor in the ultimate success of the implementation.

User interface preference is just that — a preference. The look and feel of a user interface is heavily influenced by taste. Below the surface, however, the user interface determines how a provider goes about completing a chart. The presence or absence of smart phrases, the amount of data that needs to be “free texted” vs “templated,” the way in which exam findings are populated, and the way billing is completed are all key components of the user interface that go beyond form and points toward function. Making sure that providers pay close attention to these specifics (ie, go beyond the cosmetic appearance of the software) can be challenging. Yet, ultimately, it is this feedback that is much more relevant to the decision-making process.

3. Integration capabilities

To provide an efficient service, the EHR must communicate efficiently with other information technology components present in the practice. Assuming your practice has a PM solution that is working effectively (and assuming the decision has been made to keep the current PM), it is vitally important to ensure that the integration between the new EHR and the existing PM is seamless. While purchasing both EHR and PM systems from one provider has its advantages, the decision to do so is individually complex and outside the scope of this discussion.

Beyond the PM, it is important to ensure that the EHR system can communicate effectively with the practice’s existing imaging equipment. Image handling, whether using a DICOM solution to transfer raw image data or exporting PDF/JPEG files of the image, can be a bottleneck for practice flow. Therefore, the compatibility of equipment and the ease of the image transferring process is a significant factor to evaluate.

4. Cloud-based vs server-based data storage

Data generated by EHR systems can be stored in one of two ways: on a local server or in the “cloud.” Organizations that choose to use servers to store data must house physical server units in-house and maintain them routinely. Servers have an average life cycle of 5-10 years and must be backed up regularly to ensure data is not lost when a server reaches the end of its life cycle. The advantage of server-based data storage, however, is direct ownership of the data. Since the data is written onto a physical server, that data is available unless the server itself becomes non-functional.

Conversely, cloud storage of data allows for easy remote access to the EHR platform and data from any computer with a web browser. Cloud systems also have much larger data storage capacities, so larger practices may choose cloud storage to avoid having to house and maintain multiple servers. Financially, cloud storage may be more expensive than server storage for smaller entities that would need fewer servers, but it can be more cost effective at a larger scale. Cloud systems are, however, more susceptible to service interruption due to loss of internet connectivity (weather, for example) or central cloud server interruptions. While rare (and usually short-lived), these interruptions can be crippling to the workflow of the practice as there is no ability to access data until the issue is resolved.

5. Implementation and training

The implementation phase of a new EHR system can be especially taxing for the entirety of the practice. Prior to “going live,” it is imperative that every individual who will come into contact with the new system is adequately trained on user-specific tasks and workflow.

When evaluating EHR platforms, it is important to discuss the timing, amount and quality of training opportunities they will be providing with the vendor. Training often starts remotely — both asynchronously with learning modules and synchronously with a live trainer over webcam. Many companies will offer training in terms of sessions or hours, with additional training resources being available for fees beyond what the initial contract covers.

6. Data transfer/conversion

If transitioning from one EHR system to another, you must establish the method of migrating previous data to the new system. Discrete data transfer involves migrating data from a previous system directly into the new system in the appropriate field within the new system. For example, a discrete data transfer would transfer refraction data from an exam in the old system directly into the refraction field in the new system, as if the data had been created originally in the new system. Conversely, data can be transferred non-discretely, meaning that prior exams are transferred in image or PDF form without the data migrating to its appropriate field.

Discrete data transfer is essential to ensure that prior exam data can be efficiently used going forward without requiring manual review. Prior data transfer (especially discrete data transfer) often comes with a separate fee; however, it is likely well worth the additional investment.

7. Cost

Ultimately, the selection of a new EHR system may distil down to one primary factor: cost. EHR implementation costs fall into two broad categories: initial set-up costs and ongoing subscription charges. The initial set-up cost can be quite steep, exceeding five-figures in most cases.

While the set-up cost can be the most striking figure on the contract, the month-to-month cost is a much bigger determinant of overall return-on-investment. Monthly charges can vary widely depending on the number of users, number of locations and amount of à la carte services that are required. Regardless of the specific amount, however, the aggregate of month-to-month service fees will invariably far exceed the initial set-up cost (likely significantly) over time. “Shopping around,” aggressive negotiation and trimming non-essential additional services are all important strategies that can be used to reduce the month-over-month cost of an EHR system.

CONCLUSION

Selecting and implementing a new EHR system can be a challenging and stressful endeavor for a practice. While the above list is not exhausting, the topics covered in this article can serve as a starting point to help organize thoughts early in the process. Ultimately, the relative weight of each factor will vary from practice to practice, yet being organized and consistent when evaluating across platforms will make the selection process more efficient. OM

NEEL S. VAIDYA, MD, MPH, joined Chicago Cornea Consultants in Highland Park, Ill., in 2021 after completing advanced training in cornea, external diseases and refractive surgery during his fellowship there. Dr. Vaidya also completed his MPH degree and is pursuing his MBA at Northwestern University Kellogg School of Management. Find him on LinkedIn at https://bit.ly/3PMEuO3 , on Twitter @neel_vaidya and on Instagram @neel_vaidya and @chicornea. Dr. Vaidya reports no relevant disclosures.