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Large behavioral health group practices are caught between two worlds: that of the relatively mature market for EHR’s for general medical practices and the relatively immature world of EHR’s for behavioral health care practices. The products pitched to them from the large EHR vendors that focus primarily on primary care are way beyond their budgets, lack functionality (such as integrated scheduling and billing, behavioral healthcare-specific templates and treatment plans, etc.), and are cluttered with features that have no value in day-to-day psychiatric practice. Current EHR vendors that are focused on behavioral healthcare frequently have some of the desired functionality and lack the clutter, but they rarely offer a complete product that provides for all of the practice management needs of the mental health practice. In addition, the relative immaturity of the vendors and market makes the viability of the vendor a concern. So, there is no perfect answer. Yet large practices have known for a long time that their paper systems are inadequate and that the meaningful use incentive train is leaving the station. What are they to do?

I propose that the key is to set out clear expectations in a number of different areas and to set up a process for finding the vendor that will meet this threshold. Smaller practices are more likely to simply buy a product that they like. Large practices enter into partnerships. The quality and nature of the vendor are as important as the state of the product.

Vendor Viability does not equal Program Viability

Large EHR vendors usually pass the vendor viability test. No one thinks that GE or All-Scripts are going to go out of business any time soon. However, it might be wise to doubt their commitment to the needs of your practice. I call this “Program Viability”. The truth is that these larger vendors have dabbled in behavioral health care but have failed to create products designed for large behavioral health care practices. If they do come out with such products, there is still a real chance that they could abandon programs quickly if they believe that they could get larger returns on investment by returning their focus to other products or specialties. While Google has not been in the EHR space, its decision to drop its PHR program is a great example of a viable enterprise dropping a big program. Large behavioral health care practices are vulnerable when they team up with large vendors whose bread is buttered in other markets. Ask yourself if you believe that this vendor will be there for you after the meaningful use incentives are long gone? Will they come directly to you to help them gather requirements for future releases of their products? As a leader within your specialty by virtue of having achieved a large scale, you should expect and will need that kind of attention from your EHR vendor.

Vendors that are focused on behavioral health care tend to be smaller by virtue of their more narrow focus and because of the relative immaturity of the market. So how can you be assured of their viability? While there is no absolute answer, you can reassure yourself by doing some due diligence. Spend some time with different key employees in their organization. You usually can and should have access to leadership in sales, support, and on the product team. In most cases, this should include the CEO of the company. And you should make sure to ask the following questions to give you an overall feeling for the company.

  • How long have you been in business?

This is a general marker of sustainability. The failure rate for a new business is highest in the first 3 years of operation. It might be comforting to know that they have crossed that threshold. It means that they have probably survived a few crises and have improved their processes. This makes them more immune to future problems.

  • Do you have a complete product including a practice management system with medical billing and financial reporting, a clinical documentation system, and e-prescribing?

This shows the ability to get work done. Also, the vendor will need a complete solution to compete and stay viable in any EHR market, including behavioral health care. Company’s that do not have these basic capabilities are simply too late.

  • Are you certified for meaningful use?

This is a minimum benchmark for any EHR vendor, whether or not your providers are eligible for incentives

  • How many providers are using your system?

Successfully operating for years with hundreds of providers signifies that a company has processes in place that will allow it to successfully scale as the market heats up in 2012 and beyond.

  • Tell me what key milestones you have achieved such as financing, product releases, and hiring?

This gives you a general feel for the ability of the company to meet its cash requirements and execute in key areas such as financing, software development, and human resources. Successful financing, multiple product releases, and headcounts >= 20 are reassuring signs.

  • Tell me about your management team.

Even better is to meet the management team so that you can gauge your confidence in the company leadership and the leadership’s commitment to your practice

Balance between Usability and Power

EHR’s are not consumer products. Good business-to-business software usually provides a number of different ways to achieve a solution so that a business can customize to it is workflow. Yet if there are too many choices, the individual user can feel overwhelmed and might have difficulty getting started. This has been an enormous problem throughout the history of health IT. The solution is not to dumb down the product, but to work closely with the customer to find a balance between the power that a serious health care practice needs to do its complex work and usability. Customer support is the bridge that can make a powerful product optimally usable, which I cover below.


Clinical Documentation: Make sure that the product has behavioral health-specific templates, customizable templates, and that it handles structured data, such as vital signs and outcomes measures. Also, use it to make sure that it satisfies your requirements for efficiency.

Scheduler: Large group practices usually need centralized scheduling with the ability to view multiple providers’ schedules on one screen. Behavioral healthcare practices should expect the ability to create patient transactions out of the scheduler if they wish to.

E-prescribing: Certification for meaningful use will ensure that the product has the required functionality such as formulary checking and drug-drug interaction checking. But make sure that it enables the workflow you want in your practice. This might include the ability for an agent to enter prescription information for you that you can later send and sign. Also, check on the vendor’s progress towards implementing electronic prescribing of controlled substances.

Medical Billing: In 2011, there is no reason not to have an integrated system. But do make sure that your medical billers have an adequate chance to see the practice management portion of the product and that they, and you, are convinced that it will meet your needs.

Reports: It’s not enough that you see a report or two. Large practices usually have unique reporting requirements. You need to know that you can get customized reports if you need them, without breaking the bank.


I include training and ongoing support under this heading. Any complete system with adequate power to handle a psychiatric practice, let alone a large group practice such as yours, will require significant training and ongoing support. As I implied above, great support is a necessary element of great usability. Ask about the training and support processes. Whatever processes are in place, do insist on having a dedicated account manager that your internal point person can reach directly. It’s very important to check with other large practice customers about their experience with support.

Professional Services

This is most unique to large practices. There is no product on the market that perfectly meets the need of the large psychiatric practice. Behavioral health care-focused vendors should have the ability to customize tailored solutions. While this won’t be free, you should have a clear agreement about cost and confidence that the arrangement will be fair and sustainable.

Total Cost of Ownership (TCO), Return on Investment (ROI), and Price

Large practices are businesses and need to stay within budgets. It is tempting to compare products based on price quotes with a goal of staying within budget. However, price is not always reflective of the total cost of ownership (TCO). There are expected or known costs, as well as soft or unknown costs. Calculable costs include the price of software, implementation fees, hardware needs, maintenance and tech support, staffing requirements and professional development. Unexpected costs can include disruption and loss of efficiency during migration, time spent on research, staff frustration and resistance to change, as well as the opportunity costs that come with products that do not adequately address your specific needs. Here’s a great snapshot of what TCO can look like. Also remember that a great EMR should provide a return on investment by helping a practice to capture more revenue and practice more efficiently. I do think that price is useful as a predictor of how well an EHR company will meet the need of your practice. Products designed for large medical groups are invariably priced outside of the budget of large behavioral health care practices. But this is only part of the reason to run away. This large price is only the tip of the iceberg of your TCO. What’s more, you are unlikely to get the ROI that you desire because the product has not been designed with your needs in mind and with the participation of large behavioral health practices like yours. A price that is fair and sustainable might be a sign that you are working with a vendor that understands you and can work with you to keep TCO low and improve your ROI.

Product Roadmap

It is important to determine if you and the vendor are heading in the same direction. What are the plans for the product? Will future versions meet your needs? For example, do they have plans to include a patient portal that includes forms and surveys relevant to psychiatry? Will they build a product that works on smartphones and tablets? Are they building care management and clinical decision support tools for behavioral health?

Just some additional considerations for the large behavioral healthcare practice in the purchase of an electronic health record.