Section 3.3 Select

EHR and HIE Vendor Selection and Understanding the Marketplace

This document provides a picture of the marketplace for electronic health record (EHR) and health information exchange (HIE), including the products that are available, how to navigate the marketplace, and buyer beware tips, as well as information on product certification.

Time needed: 2 hoursSuggested other tools: 2.4 Visioning, Goal Setting and Strategic Planning for EHR and HIE

How to Use Review and understand the information in this tool before starting your vendor selection process.

What Are You Buying?The first question you should ask in the process of acquiring an EHR and/or the services of an HIE Service Provider (HISP) is: What are we buying? This may seem like a strange question, but you may set out to acquire an EHR and find great variation—including everything from a document imaging system to a product that supports documentation in structured format, alerting functions, and HIE. In between, there are many “cool gadgets” that may or may not be useful. You may find that the range of HIE offerings are more limited than EHR offerings:

Within your geographic area there may be a state-based HIE Service Provider. However, there also may be other, private HISPs to explore, including regional, specialty or vendor-based opportunities.

The Minnesota Department of Health certifies HIE service providers:

Minnesota’s approach to health information exchange is to support a market-based strategy for secure HIE that allows for private sector innovation and initiative, yet uses government oversight to ensure fair practices and compliance with state privacy protections. One role the Minnesota Department of Health (MDH) specifically has in supporting HIE is facilitating the development of technical infrastructure called shared services, which provide the services and functionality to support and promote the seamless connections between health and health care providers. These services will include provider directory solutions, consumer preference and consent repositories and record locator services. More information will be provided as these services are developed.

Another role the Minnesota Department of Health has is to certify HIE Service Providers operating in Minnesota (providing clinical meaningful use HIE transactions or services). The certification process is intended to also promote seamless connections - providers or provider organizations using any of the State-Certified HIE Service Providers could exchange health information because the certification process requires the HIE Service Provider comply with specific requirements such as: ENHAC certification; establish data sharing agreements between the State-Certified HIE Service Providers, and compliance with national standards for exchange. The statewide shared services described above will

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also support the secure exchange of health information and interoperability between the State-Certified HIE Service Providers1.

A list of MN Certified HIE service providers can be found here: http://www.health.state.mn.us/divs/hpsc/ohit/certified.html

There are also national HIOs, such as Surescripts, providing e-prescribing exchange, that are often offered as part of an EHR.

There may also be alternatives to participating in a formal HIO. It is important to consider the functionality desired and then determine who or what offers the support you need. For example, you do not need to belong to a formal HIO to use the Direct protocol for secure exchange of email (see Section 4.10 Using Direct for HIE).

EHR CertificationCertification of EHR products for behavioral health facilities is currently provided by two, somewhat overlapping, resources. The first is a voluntary certification provided by the Certification Commission for Health Information Technology (CCHIT). CCHIT established a behavioral health work group and criteria specific to behavioral health EHRs. See https://www.cchit.org/behavioral-health-ehr.

CCHIT also works with other companies to certify EHRs with respect to the federal incentive program for meaningful use (MU) of EHR. The Office of the National Coordinator for Health Information Technology (ONC) supplies the standards EHRs must meet for users to earn the MU incentives under the Centers for Medicare & Medicaid Services (CMS). Two sets of criteria have been used to conduct this certification. The initial set of 2011 criteria reflects the requirements for Stage 1 of the incentive program. The second set of 2014 criteria reflects the requirements for Stage 2. The program does not distinguish between health care specialties. Currently, approximately 30 behavioral health vendors are certified for the 2011 criteria; none have been certified for the 2014 criteria. It is important to check the list regularly to determine whether a vendor of interest is certified. See http://oncchpl.force.com/ehrcert to access the list of all certified products. To learn more about how EHR technology may serve healthcare providers ineligible for Medicare or Medicaid incentive programs, see: http://www.healthit.gov/sites/default/files/generalcertexchangeguidance_final_9-9-13.pdf. To monitor the ONC certification program and to access a list of certified EHR products, visit http://www.healthit.gov/policy-researchers-implementers/certification-programs-policy.

Another resource for identifying vendors is the trade publication Behavioral Healthcare, which publishes an annual IT Vendor Survey. See http://www.behavioral.net/article/2013-information-technology-vendor-survey for the latest survey available.

Most of these certified products include more functionality than you typically need for behavioral health facilities, and some functionality you do need will not be present. Any EP participating in the MU program needs to determine if any of the objectives or measures (where an exclusion does not exist) lie outside the scope of practice, thereby disallowing achievement of MU.

In Minnesota, if a provider does not have a certified EHR available for their setting, then the provider must have a “qualified EHR.” The “Minnesota 2015 Interoperable EHR Mandate” defines this as an electronic record of health-related information on an individual that includes patient demographic and clinical health information, and has the capacity to:

provide clinical decision support; support physician order entry; capture and query information relevant to health care quality; and exchange electronic health information with, and integrate such information from, other sources.

1 http://www.health.state.mn.us/divs/hpsc/ohit/hieguidance/planunderstand.html

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Minnesota providers are also encouraged to have an EHR with the capacity to securely: incorporate clinical lab test results as structured data; support transitions of care, population health and quality improvement; and allow patients or their representatives access to view online, download and transmit their health

information.The EHR marketplace is very dynamic with vendors that come and go. Some take more time than others to become certified. For a list of all certified products, visit http://oncchpl.force.com/ehrcert.

CCHIT Voluntary EHR Certification vs. ONC Certification of EHRThe CCHIT voluntary EHR certification criteria are very comprehensive and detailed, while the ONC certification standards focus exclusively and what is required for the incentive program. This is not to suggest that the ONC certification is easier to meet, but the CCHIT certification covers more functionality areas. CCHIT certification includes coverage of record maintenance/destruction, provider management, caseload, and other functions not addressed by the ONC certification. Neither of the certifications addresses practice management from the perspective of eligibility verification, charge capture, billing, appointment scheduling, etc. These are not considered part of what is commonly considered the “health record.”

HIE/HIO CertificationCertification of HIOs is new. Some state departments of health are certifying HIOs or HIE capabilities in vendors. There currently is no national certification program for HIOs, although the CCHIT has criteria, has certified HIOs in the past, and is currently establishing an HIE testing process. (See: https://www.cchit.org/cchit-2009-health-information-exchange.) As with the CCHIT criteria for behavioral health EHR vendors, the certification criteria for HIE may be more than what you need, but provides a good picture of what is possible.

Minnesota has an “HIE Oversight Process”. Under this law, an entity providing health information exchange services for clinical meaningful use transactions must apply for a certificate of authority to conduct business in Minnesota as an HISP. In Minnesota, to meet the 2015 Interoperable EHR Mandate providers must use a State-Certified HIE Service Provider. More information about Minnesota’s “HIE Oversight Process” and the 2015 Interoperable EHR mandate can be found at the links provided at the bottom of this document.

The MarketplaceThe marketplace for EHRs in behavioral health include products designed for private behavioral health practices, community mental health centers, crisis centers, methadone programs, outpatient clinics within an integrated delivery system, inpatient facilities, residential facilities, justice systems, employee assistance programs, and others. In addition to focused products, a number of general ambulatory EHR vendors provide behavioral health templates, workflows, and other tools to address behavioral health specialty functions.

The marketplace for HIOs and other forms of HIE vendor support is generally more state-specific, although there are some regional HIOs, some that span multiple states across the country. To determine what is available in your state, visit the State HIE Program at: http://statehieresources.org/state-plans. Links within this web site will lead you to additional information for each state or territory. The State HIE Program connects you to the following Web site that describes the HIOs in Minnesota: http://www.health.state.mn.us/divs/hpsc/ohit/hiemn.html

Price RangesVery little information is publicly available concerning the price of EHR products for any market. A few generic cautions apply:

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Very inexpensive EHR products may be based on Microsoft Office products—such as Word, Excel, or Access—and have minimal clinical decision support or workflow capability. Similarly, there are inexpensive products that only scan paper documents and make them accessible. These are typically referred to as scanning systems.

The next tier of EHR products are somewhat more robust in their functionality, do not have all the sophisticated clinical decision support or other functionality of a top tier product, do not interface well with other systems, and often are not very customizable. This tier of products may also include electronic document management systems (EDMS) that provide scanning and indexing of paper documents and other information already in digital form (such as transcribed documents electronically fed from a transcription system into a database, voice files, or PDFs sent through an HIE process). Being “digital” or “paperless” does not mean that you have structured data that can be processed into useful information.

Another tier of products have substantial functionality but are lower cost because they are offered in an application service provider (ASP) or software as a service (SaaS) mode. These products provide a source of financing and reduce the costs of maintaining servers and internal IT staffing needs. These products may suit an organization very well unless extensive customization or implementation support is desired.

A final, and generally more expensive, tier of products includes those that are highly customizable and may have more specialty functionality. The vendor spends considerable money on research and development to continuously provide new functionality. The level of interoperability within these product suites, with other vendors’ products, and within an HIE is variable. Vendors are making concerted efforts to become more interoperable. Service levels, implementation support (including attention to workflow and process support, testing, and training), and customer service responsiveness are generally stronger in this tier of products.

Product InteroperabilityInteroperability means that two or more systems or components are able to exchange information and to use exchanged information accurately, securely and verifiably. To end users and many in the industry, interoperability means every product works together seamlessly. Unfortunately, this is an expectation that not even the most highly integrated suite of product components fully achieves.

Interoperability can be achieved in various ways. When components are integrated, they generally are built by the same group that did the original development and programming, have similar design characteristics and components that are able to exchange most data. In general, the components in highly integrated suites of products work well together, but will not work with any other vendor’s product without specialized interfacing. Interfaces are software programs that help two disparate systems or components interoperate. The interfaces rely upon the fact that the software in both systems and components has been written to conform to interoperability standards.

An important indicator of interoperability is the ability to send and receive a Summary of Care record for transitions of care. Sending the Summary of Care record is a requirement for Stage 2 of Meaningful Use for Eligible Hospitals, Critical Access Hospitals, and Eligible Professionals. In order to be Certified EHR Techology (CEHRT), the EHR must be able to produce the Summary of Care record and transmit it electronically using the Consolidated Clinical Document Architecture (C-CDA) standards.

A summary of care record must include the following elements if available: Patient name. Referring or transitioning provider's name and office contact information (EP only). Procedures. Encounter diagnosis Immunizations.

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Laboratory test results. Vital signs (height, weight, blood pressure, BMI). Smoking status. Functional status, including activities of daily living, cognitive and disability status Demographic information (preferred language, sex, race, ethnicity, date of birth). Care plan field, including goals and instructions. Care team including the primary care provider of record and any additional known care team

members beyond the referring or transitioning provider and the receiving provider. Reason for referral Current problem list (EPs may also include historical problems at their discretion). Current medication list, and Current medication allergy list.

Behavioral health facilities may seek product components from a single vendor. This saves considerable money in managing interfaces and can be a very good strategy. However, you may find that attempting to interoperate with a hospital, physician practice, commercial laboratory, local public health, or other provider with an EHR from a different vendor is more challenging. In these cases, the options are:

Attempt to interface with other organizations for exchange of minimum essential information. Health care organizations that want to interface directly with another organization should also consider whether this is necessary, or only desirable. The volume and type of data that actually needs to be exchanged between some organizations may not warrant full interfacing or integration. For example, if you want to be able to trend lab values, it is necessary to have lab results in structured data format that can be processed by a computer. However, if you merely need the ability to gain access to view or retrieve lab results (or other information), it may not be necessary to have an interface.

Use a secure portal to gain access to view information and, in some cases, to use one or more of the other provider’s applications directly. A psychiatrist, for example, may be monitoring a patient in a general hospital and have access via a portal to the patient’s health record, and be able to remotely access the computerized provider order entry system to enter orders to adjust a medication.

Participate in an HIO, which is a service that supports secure electronic sending and receiving of health information in ways that can be understood by both the sender and the receiver.

For additional information on interoperability, HIE, and exchanging clinical summaries and other health information using the Consolidated-Clinical Document Architecture (C-CDA), see the following tools in this Toolkit:

Interoperabiity for EHR and HIE

HIE Technology Readiness Inventory

Using Direct for HIE

Using CONNECT for HIE

Exchange of Clinical Summaries and Other Health Information (CCR – CCD – C-CDA)

Clinical IntegrationOne other caveat should be mentioned regarding vendor selection. Vendors that have primarily sold PMS (practice management system) may have little clinical experience to design a robust EHR. But the market is changing and many such vendors are now developing EHRs that are so tightly integrated with the PMS systems that they are almost impossible to tell apart. In fact, some organizations are finding little

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incentive to stick with an old financial/administrative system when such an offering is available from their EHR vendor.

HIE in MinnesotaMore information about HIE in Minnesota can be found at:

A Practical Guide to Understanding HIE, Assessing Your Readiness and Selecting HIE Options in Minnesota, at: http://www.health.state.mn.us/divs/hpsc/ohit/hieguidance/index.html

Minnesota's 2015 Interoperable Electronic Health Record Mandate can be found at http://www.health.state.mn.us/e-health/hitimp.

Copyright © 2014 Stratis Health. Updated 06-24-14

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