From initial research into available options to submitting proposal requests to signing on the dotted line, negotiating and signing a new contract for an electronic health record (EHR) can be a long, involved, and often stressful process. Whether you choose to stay with your current vendor or not, the information presented here will help you make an informed decision that best serves the interests of your facility, your residents, and your staff.
In this article, you will learn how to:
- Assess your current EHR, and decide if it is time to move on
- Evaluate your processes, and determine what precisely needs to be moved from paper to electronic documentation
- Ask the right questions before, during, and after demos
- Get your entire team – clinical, financials, and IT – onboard
- Identify red flags in your contract
- Gain clarity regarding pricing
- Negotiate your contract successfully
Explore All of Your EHR Options
In order to give yourself the opportunity to find the EHR that is best for your facility, you will first need to be on top of your current contract’s termination date and renewal stipulations. EHR providers will usually require that you notify them of your intent to terminate a contract 60 days before it comes to an end. If they do not hear from you, they will likely renew it for another year or three years – depending on the module – automatically. You, thus, are the one responsible for knowing the end date of your contract. It should also be noted that many vendors offer a grace period during which clients can either negotiate new terms for an ongoing relationship or transition to a new vendor.
As EHR contracts are usually for three years, facility owners may feel that they are stuck and decide not to shop around until after their current contract has expired. That, though, is a mistake that will put you and your facility in a tough spot. Experts say 1it takes at least one to two months of research for a long-term care facility to find a vendor that may be a good fit. An LTC team will then need to complete its requests for proposal, look into pricing, and get demos of various EHR systems. Finally, there is a lengthy transition period to consider. It will take about four months to migrate data from one system to another.
The most common time for long-term care facilities to start considering their software options is six to twelve months before their current contract is up.
It is, in fact, worth investigating your options up to 18 months in advance of the termination of your current contract. That will allow you ample time to ask for renewal contracts at a lower rate before you begin to look for alternatives. Regardless of the outcome of the conversation with your current vendor, it is wise to utilize this time to explore other options, as you may find a better value, a more ideal system for your facility, or both. The window of opportunity for most facilities only comes around every few years and is determined by the stipulations of your current contract.
Make a Decision About Your Current EHR Vendor
Take into account the factors and numbers related to either renewing your contract or terminating it and moving on to another EHR provider. Vendors will generally provide incentives for renewing your contract. If you approve of the terms they propose and the features they offer, then you can continue with them. There is one major advantage to continuing with your current vendor, even if you are not entirely content with their service: avoiding the cost of data migration.
Data migration requires an enormous amount of money, sometimes millions of dollars.
It will usually be necessary to pay a third party to create a custom program that allows it to handle the burdensome task of transferring data. That means you will have to pay a significant fee for migration in addition to the fees associated with linking your data together. There is also the issue of retraining your staff and teaching them an entirely new EHR, which is both time-consuming and costly. Thus, it may be wiser to learn to adapt to the shortcomings of your current provider than to move to a new EHR if the cost and time involved in data migration are too great.
If, however, an LTC provider is not heavily invested in its EHR, moving to another system is not nearly as complicated. Some facilities only utilize the minimum data set (MDS) and billing parts of their EHRs. It is not particularly difficult to import that information into a new EHR software.
Even if the trouble data migration creates is significant, you may still decide to move on.
The features and price that another vendor offers might be too good to resist. If you determine that you want to terminate your relationship with your current EHR vendor at the end of your contract, notify the vendor in writing well before the termination date. Most vendors do not require this termination notice to be signed by the person who signed the original contract. Nonetheless, you should check to make sure that is the case for your vendor.
Evaluate Your Current EHR
As your current contract nears its end, you should be assessing how well the software – and the company behind it – is serving your organization.
Here are questions you will want to include in your evaluation:
- Is the software configurable and comprehensive enough to meet your needs?
The right EHR should be able to adjust quickly to meet all of the operational needs of your team.
- Are there features your team needs that your current system does not include?
Talk to your team members who use the software on a daily basis to see if there is anything that would allow them to work more efficiently. You may find that your EHR is creating duplicative work or that your staff relies on spreadsheets or other tools outside the EHR to accomplish their jobs.
- Does your current software help your team easily identify and monitor your facility’s current key performance indicators (KPIs)?
If you cannot easily find important data points, your software could be hindering your facility’s financial and clinical outcome success.
- How does the EHR’s usability compare to its utility?
An EHR may be easy to use, but that will not matter much if it does not meet the needs of your staff. If it does not produce equal participation across providers, nursing, the care plan team, therapy, aides, and billing, then it may not be the right EHR for you. For example, some EHRs will place physicians in one system, nurses in another, and therapists in yet another. This makes it difficult for these groups to communicate and complicates billing.
- Does your vendor have A+ customer support?
The EHR that you choose should engage clients to help you fully utilize the product. Experience Care stands out from the competition because it provides a monthly open forum, the Cantata Clinical User Group, in which users share their experiences and frustrations with the software. Issues are addressed by Gina Barrett, the Director of Operations, Charles Oliver, the Director of Customer Success, and even Jason Long, the CEO of Experience Care. Your suggestions then find their way into Cantata Health’s Beta program, which gives users the exciting experience of seeing their ideas enter the pipeline.
EHR providers might offer low-cost customer support, but that usually translates to low-quality customer support as well. In the long run, that will place a greater financial burden on a facility.
Point Click Care, for instance, does have a system, IdeaGlow, by which users can suggest enhancements. However, for an idea to get recognized, it must receive a certain amount of support through a user voting system. And since they do not sufficiently engage their users and ideas do not receive enough votes, suggestions fall on deaf ears.
- What is the roadmap of your EHR provider? Your EHR vendor should have a plan for further making further progress. It is important to know whether they plan on branching out to serve other industries or tailoring their product for facilities like yours. The history and sustainability of their business model should also be considered.
Look into Other EHR Options
Comparing EHRs is a complicated process that requires some technical knowledge of how they operate. While conducting such research may be time-consuming, it can pay big dividends in the long run.
If you are an LTC facility decision-maker, plan on spending about 20 hours a week for one to two months on the process of researching EHRs. You will then request a price, schedule demos, request proposals, and go through demos.
Take these five steps to determine which EHR is best for your facility:
- Research – Before the demo stage, the initial research that you conduct should tell you the following about the long-term care EHR vendors you are considering:
- The markets they serve
- The features they include
- The other software that they provide in addition to an EHR system
- The other systems with which they integrate
- The complaints and problems users of each software have shared online
You will also want to consider the customer relationship management (CRM) system that vendors use. Some EHR providers offer integration with Salesforce. Others, like Experience Care, have their own CRM.
Other things to look for are:
- Electronic signatures for admission paperwork and physician orders
- Dictation software for physicians
- Encrypted text (like TigerConnect)
- Available options offered through an application programming interface (API) – This is how some software programs, like Experience Care’s, talk to a third-party vendor. Having that connection broadens the usability of a software.
- Integration with hospital systems for admissions – This means using an API to transfer medical records to an EHR, thus reducing the manual task of pouring over a resident’s medical record.
- Request Pricing – Vendors should be able to give you an estimate based on the size of your facility and your case mix index (CMI).
- Schedule Demos – Your first demo will likely be with a sales representative and last an hour. The second demo, if necessary, will be with someone on the clinical side and also last an hour. The sales representative, though, should also be well-versed in the industry and be able to answer questions and address concerns.
- Send requests for proposal (RFPs) – Make sure to mention in your requests the systems with which you will need your software to integrate, like systems for wounds and labs and the hardware you use at your facility.
- Test out the EHRs – In most cases, two demos are needed for each system. Most facilities demo three or four different EHR systems before making a decision. This is an opportunity to understand each product, its benefits, and its limitations. During the demo, you can let your previous research guide your questions and concerns. You should bring up the features that you are looking for as well as the type of training and support that you expect. Lastly, you should mention the complaints and problems that other users have had and demand clear and direct answers. Do not settle for vague replies or things like “I’ll get back to you on that” or “I’ll have to ask my supervisor.” Put pressure on the representative and demand an immediate answer. That is how you get to the bottom of the matter.
Check to See if the EHR will Work at Your Facility
After the initial research period and the trial stage, you must then look into the details of the software you will be getting. That means learning more about the features they offer, their customer support system, customer satisfaction, and whether or not the software will serve the needs of your organization.
Of course, the easiest way to figure out whether the EHR in question is right for you is to actually get in there and use it. That is entirely possible. You just have to request to access a test database. If the vendor makes excuses, mention other providers who find a way to make it happen.
The entire process of finding the right EHR can be quite overwhelming when you do not know what to expect. Setting aside enough time is critical to making the right decision and negotiating the best possible terms. As you evaluate an EHR, you will want to ask if a facility has the hardware and infrastructure to support the software, how each system interfaces with other vendors using an API, and whether accessing historical data will be cumbersome.
While one person might assume the role of lead negotiator, it is important to make sure that input from clinical, accounting, legal, and management is considered throughout the entire decision-making process. Before obtaining input from your team, though, you must first ensure that the software is going to work for your organization’s needs. That is why you should start with IT and ask if the product can be run and supported on your current hardware. Tablet use is becoming increasingly prevalent in LTC. CNAs will generally use tablets to conduct their daily charting. Problems occur when a particular EHR, like Point Click Care, is only certified on iPads, and your staff uses Android tablets. Any issue that occurs will be blamed on your device, as it is not certifiable from the perspective of the software provider. That means that service will end there. And switching an entire facility to new tablets is rather costly. Other issues arise from scanners that may not work with the new software.
After it has been concluded that your hardware can run the EHR you have in mind, you can then invite billing or payroll to see if the product is financially feasible for your facility. Finally, include the DON and physician staff in the conversation to obtain buy-in from the clinical staff, whose concerns will include:
Quick data entry and reduced clicks – Experience Care has modified its software to minimize the number of screens physicians and DONs need to view and help them access the information they need with far fewer clicks than are required by other EHRs, like Point Click Care.
The EHR that you choose should minimize the need to create spreadsheets, keep paper lists, and utilize other systems, like interfaces for labs, wounds, or dietary matters. Experience Care has a wound interface that is integrated with its software, which means its users can move the documentation of wounds from paper and spreadsheet to their EHRs. That is a big time-saver. Further, Experience Care has recently enabled communication with the food service provider for a client and is looking to make greater progress in enhancing dietary communication. That means that all of the details about the kitchen and tray cards in the system of the food provider will be integrated with your EHR. So now, instead of having to key in a request for soft food in the food provider’s software, it will be in the same system, which will help avoid putting your residents at risk.
Report functionality – Meeting the demands of state surveyors and reporting to the CMS annually require that you have ad hoc reporting right there in your EHR. This is because the clinical staff will run a variety of reports and then combine them to produce an acceptable report for a surveyor.
Ease of data entry – Security is important, but too many security restrictions can produce the opposite of the intended purpose. Busy care providers will not always be able to enter long passwords when prompted, which may force them to select short and easy ones, like “1234.” This is likely to occur when a nurse is required to enter a passport for every entry, like medication, blood pressure, weight, etc. Unfortunately, some EHRs, like Point Click Care, have not addressed this issue. Experience Care, meanwhile, allows a user to log in once per session and enter items without having to reenter his or her password.
Intuitiveness – Nurses are excellent at caring for the sick and vulnerable. They are not, however, always the best with computers. They might be savvy with their iPhones, but sometimes even learning to right-click can be a challenge. It is, thus, of utmost significance that the EHR you choose is intuitive so that it makes the lives of your staff less, and not more, complicated.
Offsite access – Doctors may need to access the information in your EHR from their homes or another location. While they could give a verbal order, it is much safer for them to enter orders in the system. Further, they could need to look at charts before their next opportunity to come to your facility. Thus, they need to have offsite access. Because Experience Care hosts your system itself, it has the ability to whitelist a particular IP address so that your clinical staff can have remote access. Other EHRs might require you to purchase this feature or to manage your own virtual private network.
Don’t Overpay for Your EHR
There is no other way of saying it: EHRs are expensive. This is in part due to the nature of the business; EHRs vendors must keep up with the standards imposed by the Centers for Medicare and Medicaid Services (CMS) and adjust their software constantly. State regulations may change as well, creating further work for developers. And there is a significant amount of work that is put into customizing the software for your facility, as there is no EHR that will work for every state and every nursing home. During the course of your contract, you might find that you need other kinds of assessments or start taking on residents that require different interfaces. Still, like any service provided, there is always room to narrow the profit margin. Whether you are negotiating a renewal contract with your vendor or an initial contract with a new vendor, you must be aware of the terms of the deal.
Pay Attention to Hidden Costs
Hidden costs are the biggest culprit in driving up EHR prices. “They nickel and dime you,” Trevis Cleary, the Director of Informatics at Care Centers Management Consulting, said of Point Click Care. “After your software is up and running, you come to realize that it lacks a lot of the functions you would expect. Some of those [optional] modules are exponentially better than manual entry and far more essential than you may have originally imagined. But they also drastically raise your monthly rate.” Thus, throughout the negotiation process, it is imperative to receive clarity from the vendor regarding costs like:
- Interface setups – This is needed for connecting with other systems, and it can be rather expensive. You will need your system to connect with multiple interfaces for labs, pharmacies, and medical imaging centers. That can get complicated when, for instance, you must use a VA lab for veterans and a different lab for non-veterans. So you must know in advance what interfaces you will need and ensure that they are included in your initial quote.
- Initial online training – While Point Click Care offers online training, it comes at an additional cost that is charged for each individual trained. With the high turnover rate of nurses, that could mean training new members of the staff every six months or so, which comes out to a pretty penny. Experience Care, meanwhile, has developed an elaborate online training program, LevelUp, that is absolutely free of charge to its users. Experience Care also provides PowerPoint presentations that are individually designed for doctors, nurses, and other members of the team and their specific duties.
- Additional training hours – If your facility requires in-person training after the initial phase, you will have to calculate how many two-hour sessions you will need based on the size of your staff. Ideally, you will have a financial lead and clinical lead or director of informatics receive training and then be able to teach the system to the rest of the staff as needed. Smaller facilities, though, do not always have someone who can become the system expert, meaning training can take more time and require additional support.
- On-site travel expenses and training, per diems, lodging, and car rentals – You may prefer onsite training at your facility or you might find that your staff is struggling to grasp the training process and requires further guidance. That means you will have to pay thousands of dollars to bring out a representative of the vendor. If you want to avoid this cost, ask your vendor if it is possible to receive offsite training instead.
- Recurring costs to maintain or upgrade software – These expenses are the result of changes in survey requirements, regulations, or reimbursement.
- Ownership of the actual data and cost to access it later – Most vendors do not allow you possession of your own data. It may cost a pretty penny to gain control of it.
- After-hours support – Though your facility operates 24 hours a day, that is not the case for these vendors. They will usually be open more than eight hours, to account for the different time zones in the U.S., but do not expect them to be available late at night. Unless, of course, you are willing to pay a couple of hundred bucks per hour for support. Larger organizations will often have a director of informatics or another expert who is qualified to provide assistance, thus avoiding such expenses.
- System configuration assistance – After a system is up and running, you may find that you need to change the settings of a particular room that was made private or add a new time code for getting medications into the system. In cases like these, you will have to contact your EHR vendor for support.
- Customization of a package – You may be charged change fees or penalties when you initially commit to a particular module only to later modify it. So make sure to spell out the customization that you need from the start. Experience Care’s software offers a great deal of flexibility for configurations, and the support will provide an official assessment before your contract begins. You can then review the modules included and change them on the front end as needed. If you later decide to make adjustments, you can either contact Experience Care for help or ask someone in your facility to change your configurations as necessary.
How To Avoid Hidden EHR Costs
The best way to mitigate the risk of hidden costs is to hold detailed meetings about implementation, installation, technical services and support, and training. This must be done before signing your contract. The terms should be clear for all and then put in writing and reviewed by both parties. Also, make sure to ask about the possibility of fee increases. Many vendors increase various fees on an annual basis. If this is the case with your vendor, you need to know about it upfront and define the fee limits.
Don’t Settle in Your EHR Contract Negotiations
You could save upwards of tens of thousands of dollars a year with some good contract-negotiating skills. These tactics can be used not only for EHR contracts but for other long-term care software contracts that you may encounter as well. One such software program is myABILITY, which offers valuable features for LTC facilities, like psycho management, insurance verification, and Medicare billing. Allscripts, meanwhile, facilitates communication between LTC facilities and hospitals through admissions and marketing strategies. These are just some of the other software programs you may need to pair with your EHR. Use the guidelines below to get the most of your money from any of these software providers.
Simply ask for discounts
Many facilities do not recognize that there is always flexibility in the prices that EHR vendors charge. So do not be too shy to ask for price adjustments. Remember, there is no harm in asking. But make the focal point of your conversation the services attached – some of which will be overpriced or unnecessary – and not the price of the software itself.
You can start negotiations with an advantage if you appoint as lead negotiator someone who does not have the authority to sign off on just any deal. In other words, you can have your director of informatics speak with the vendor and say that he or she could not convince the owner of the facility to spend more than a certain amount. That will force the EHR provider to enter into a serious discussion about price.
If you are looking to move to a new EHR because of its more advanced software or added features, you might be able to get more for the same price (or less than) you were paying before. Vendors are eager to earn your business and do not want to be outdone by competitors. At the very least, you can get them to throw in modules for free to make their deal far more appealing than your previous provider. This tactic will be especially effective if you arrange your negotiation for the end of the month, when the sales team will be eager to close their pipeline.
Once you have chosen a strategic date and decided what you do and do not need, it is time to push for the best rates possible. There are three key areas in which you, the buyer, have the advantage in negotiating:
Annual rates – While EHR contracts are usually for three years, you will be able to get a discount if you decide to make the deal for five years instead.
Recurring costs – EHR vendors charge these throughout the life of the contract. Examples include the maintenance of hardware and software. These charges may occur at regular intervals, or they might be contingent on a particular event taking place. Generally, long-term care facilities allow a significant amount of room for negotiating recurring costs because vendors do not incur large expenses for the items being provided.
Price per bed per day – EHRs know that, when you have fewer beds, you are using fewer features and using the software less frequently overall. They also know that there are always competitors out there who are willing to work on a cost-based analysis, meaning, they will drop the price when your census drops.
When the number of your residents drops, it will become much more difficult to pay your bills. At that point, you will not want to pay the same amount for your EHR as you were paying when at full capacity. Because of your facility’s economic considerations, an EHR provider may drop the price per bed per day in order to retain you or outdo the competition.
Also, you may not be making as much as other facilities per bed due to a low CMI. If you only have twenty residents who are generally at a lower complexity, you likely have a lower reimbursement rate than a facility with a great number of residents who require severe therapy or had tracheostomies in the past. This is another economic factor that EHR providers must take into consideration when determining a reasonable price to charge you per bed per day.
It is, thus, always wise to ask about the details, like whether you will be charged for beds that are not occupied and if the price you pay will vary should the total number of beds at your facility increase or decrease.
Request additional products for your LTC facility
If the vendor will not budge on price, you can still get them to add value by throwing in free training hours, a complimentary audit from the director of customer success, or by including other modules free of charge. If you tell your vendor that you would like a free trial period, they are likely to oblige, knowing it may result in further business. If they cannot offer a module for free, they should, at the least, be willing to provide a significant discount as a form of encouraging you to invest further in them.
Read the Fine Print of your EHR Contract
Though you may have already agreed on a price, the wording of your contract can have a huge impact on how well your EHR software serves your needs. Ensuring that your contract includes exactly what you want – and excludes what you do not need – can save your team time, money, and frustration for years to come.
Some of the conditions to keep an eye out for are:
Termination Clauses – If something unexpected happens, and a facility or a company has to terminate their EHR contract early, they may have to pay a fee. Make sure you know how much that is as well as the terms. Sometimes the terms of voiding your contract may deter you from signing a contract.
Your vendor may offer an out clause or a 30-day grace period. After such periods have passed, you will find yourself on the hook for the remaining value of the contract. Even then, though, there is still the possibility that you can get a discount on the remaining payout.
Retaining the rights to your data – Whenever you decide to part ways with your vendor, you may or may not be given access to your own information as part of your base plan. Some EHR providers, like Point Click Care, require you to pay more, like $150 per month per facility, to retain your data. They do this because they house everything on central databases and do not have their own offsite hosting service. Thus, they must use a file transfer protocol (FTP) hosting service, or, a third-party data warehouse.
Furthermore, as briefly mentioned above, there is a fee for migrating that data from the primary tables at certain timed intervals, spinning up the server to house the data, licensing the encrypted data, and then decrypting the data with special software. The licensing fee for unlocking the data alone can cost $3,000 annually. Furthermore, it is upon the client to maintain the server and access the appropriate tables using management software. Experience Care, meanwhile, does have its own offsite hosting service that is included in its base package, which means you can keep your own data at no extra cost.
The option to cancel individual items – If there are any problems, and a product or portion of the product does not work out for you, you could be eligible to cancel just that module and receive a refund. Of course, that process may include certain fees, such as paying half of the contract value if you cancel within 90 days. You want to ensure that you have this option so that you do not get stuck paying for something you never use.
Red Flags to Watch for in EHR Contracts
In addition to the particular conditions of your contract, you will want to pay close attention to the language that is used. Terms should be clear and specific to your facility. If not, you may want to reconsider entering into an agreement. Here are some examples of red flags:
Generic, template-style language – If your contract looks like it was a massive copy/paste, you should be on high alert. Any vendor should be considering your organization’s particular needs and customize your contract accordingly.
Vague terminology – A lack of precise and explicit language is concerning. Be on the lookout for any vague wording of hidden costs, the ownership of data, and access to data, especially in relation to audits. EHRs are often limited in their capacity of creating turnkey reports for every possible scenario that could occur during an audit. This is further complicated by varying state regulations.
When an EHR provider, like Experience Care, has outright access to the raw data of each facility, its director of informatics can take that data and apply it as necessary to potential situations during an audit. The facility would not then be bound by the limited options in the software and can be better prepared for whatever occurs during an audit. But if an EHR software provider does not have this ability, the facility will have to pay a fee and wait weeks to receive that data.
Fees increase periods – Fee increase periods or the possibility of increased costs over time must be stated clearly, especially if they were not discussed or agreed upon by your team in advance. While you will agree with your vendor on a three-year contract, that is only for basic access. Certain portions of the software may only be agreed upon for one or two years. For instance, access to a document manager may be on an annual or even monthly basis.
Furthermore, fees may go up when a promotion ends. At the start of a contract, the vendor might give access to certain features for a limited amount of time either free of charge or at a reduced rate. If that promotion ends before your deal does, then you will be charged additional fees. Thus, you must note promotional rates and their end dates.
Keep Your Residents and Outcomes in Mind, and Win Your Negotiation
There are no shortcuts to negotiating your EHR contract. It is common for three to five versions of the contract to go between each party’s legal counsel before a deal is finalized and approved. The process includes redlining the document, hammering out terms and conditions, and making counteroffers.
Knowing what the negotiation process involves and planning ahead will help reduce the strain on your team and facilitate the best possible outcome. Bypassing your window of opportunity, meanwhile, can get your team stuck in a less-than-ideal situation, both financially and operationally, for years to come.
Your EHR is a big investment, one that impacts the health and well-being of residents, staff performance, and your facility’s bottom line. When your organization runs more efficiently, your staff will have more time to spend with residents, receive better salaries, and, in turn, be more content with their jobs, which means less turnover. As a result, you will earn a strong reputation in the industry, receive more referrals, and turn greater profits.
The information provided above tells you what to expect when shopping for a new EHR or re-upping with your current provider. Knowing what features you will need and where EHRs have flexibility in price will give you a great advantage heading into negotiations. Still, each facility is different, so you must use your own business acumen to come to terms that work for you. Though it is often a lengthy and confusing process, negotiating your next EHR contract can be far more productive with sufficient preparation and careful planning. As a result of following the guidelines above, you will get excellent value for a software product that significantly elevates the standard of care at your facility.