Written by Omar L. Gallaga

That's how long it took for TRMC to choose a new electronic medical records vendor. "We were exhausted by the process and the vendors were, too," said Scoggin. "Over the year, you get to know each member of the sales teams on a personal and professional level. It is hard to tell someone who has dedicated almost a year to the process that they are not the partner of choice for our health system.”

But that full year, which started with six vendors, then four vendors, then two, then one, Epic Systems Corp., was necessary. "I'm an impatient guy," Scoggin said. "I will tell you, the amount of effort it took was worth every minute. We had a formal process and it paid off immensely. What we're able to bring to the community through our new EMR is unquestionably an exciting opportunity."

TRMC did a few things that some smaller hospitals might not: it brought on a third-party contractor, Leidos, to help with the proposal process and contract negotiations. "Leidos was able to provide guidance around understanding contract language and identifying potential concessions that TRMC could not do alone. By utilizing a firm that specializes in EMR contracting, we were able to go through the contracting phase more efficiently and get to signature in relatively short order,” said Pugsley

The process of picking the vendor of choice involved a diverse selection committee, a requirement that no software be brought to the table that wasn't generally available publicly, and, ultimately, the team went through the process of doing full contracts from two vendors, Epic and Cerner Corp, even though only one was chosen.

"By dual contracting, we were able to really keep the leverage with TRMC through execution of contracts," Pugsley said.

TRMC is just one example of a hospital organization finding itself, more than 10 years into the digital records shift, deciding whether it can continue to live with its current system. Some organizations that rushed to meet meaningful use standards with EMR vendors years ago may be re-evaluating upgrades with a current vendor, adding on software layers to improve processes, or considering switching vendors and systems entirely.

"There is a lot of switching going on," said Sarah Churchill Llamas, a health care and health IT attorney and partner at Winstead PC in Austin. "You get disillusioned with the model that you're using. The grass is always greener to a certain extent, and after using a system clinically, people better understand the limitations of those systems and realize other EMRs might be more accommodating to their practice."

Llamas said that when hospitals change EMR vendors, they often bring in consultants to map out the specifics they need and recommend the product, but they don't always get enough help with the contract. "A lot of people accept the standard contract terms that the EMR (vendors) give them. That is generally a mistake," she said.

Interoperability is Key

Michael Reno, chief operating officer at Hill Country Memorial Hospital in Fredericksburg, said it made more sense to bring two disparate EMR systems, one on the hospital side and the other in Hill Country's medical group, closer in line.

"One of the key features of any EMR is interoperability," Reno said. When the systems don't talk to each other, delays in patient care and coordination happen and the staff workarounds are even worse. "It's fraught with human error because (staff) have to rely on manual processes.

They just absolutely kill productivity on both clinics' staff sides and the provider side."

Hill Country decided to stick with its EMR provider Meditech and migrate to a newer platform called Expanse. Reno said the move was deliberate and long-term. "If we're going to go through the effort and financial expense, we want to be on the most current platform so we can get five, seven, 12 years before we have to do another significant upgrade," Reno said.

Reno said he had very specific criteria for how the EMR upgrade would need to optimize revenue, improve care, reduce costs and enhance staff and provider satisfaction. These are all factors that should be made specific in as plain a language as possible in the vendor contract, said Cesar Lopez, J.D., associate general counsel at the Texas Hospital Association. "Those needs can’t be left up to a handshake deal. Contracts should clearly address the hospital’s specific needs, to avoid bitter disputes that can occur when a contract lacks clarity on issues that matter to the hospital. If it’s in a valid contract, it’s enforceable," he said.

That might involve getting multiple EMR vendors, such as an existing vendor and one providing a new layer of technology, to play together, "even if it's a separate letter signed by everyone," he said.

Price always will be a pressure point, but there are options, especially for hospitals that might feel more pressure than other institutions. "Smaller hospitals are going to be looking at the bottom line at the end of the day and asking, 'Can you provide a financial incentive?'" said Lopez. Benchmarks for performance and cost savings can be worked into an EMR contract, as well as specifics on how widely software will be implemented, what happens if a vendor is acquired and the contract is reassigned and what guarantees a hospital can expect from a vendor.

And, of course, one of the most important clauses in an EMR contract is whether there's a way to get out of an agreement if things go badly

Fernando Martinez, Ph.D., chief digital officer at THA, said that not having a good contract can lead to a bad understanding of how an EMR implementation or migration is actually going to go.

"Quite honestly, in every one I've examined, it's about a lack of project management, a lack of structured approach. Hospitals can underestimate how complicated it is to implement," Martinez said

For instance, if the amount of training required to get staff up to speed is not specified in writing, or the hospital doesn't take training seriously enough to follow through, it can cause disaster

"Training is incredibly, incredibly important," Martinez said, so spelling out clear terms for training staff to familiarize and maximize their use of the EMR tool is important. "In fact, it's so important that the vendors often insist on putting that into the contract. If hospitals don't invest in training, implementation goes south and hospitals blame the vendor."

As far as actually choosing what hospitals want in a vendor and an EMR contract, Martinez said interviewing existing and former customers is an often-overlooked opportunity. Health IT conferences are a good place to start, he said. "The best way to get information is to talk to people using vendors. Ask them, 'Why did you leave, what went wrong?' "

For Scoggin and Pugsley at Titus Regional, their biggest success was realizing that they were not going to be able to navigate the technical legal language of an EMR contract on their own and accepting that it was going to be a long, tough process to get right.

"I was against using a third party for total cost ownership and contracting in the beginning," Scoggin said. "I didn't understand the value of the service. Our CIO and another health system recommended using contracting experts like Leidos Health and I am now such a believer in the process and understand the true value of this expertise."