Twelve Questions to Ask Before Buying a Clinical Information System

Selecting a clinical information system is one of the most important decisions an ED manager can make. "Sound business practices of selecting capital equipment should be applied in this situation," says Todd Taylor, MD, FACEP, an emergency physician at Good Samaritan Regional Medical Center and Phoenix Children’s Hospital in Arizona and a former chair of ACEP’s section on computers in emergency medicine.

Here are a dozen questions ED managers need to answer before signing on the dotted line:

1. Will this system meet our specific needs? "This is where people probably make the biggest mistake," says Taylor. "Instead of identifying their true needs, they identify their hopes, dreams, and aspirations. As a result, they either overbuy a system or they buy a system that has no possibility of meeting their needs."

Avoid speaking to vendors without a clear sense of the ED’s needs. "Looking at vendors without detailed requirements is like listening to the siren’s song," says Marshall Ruffin, Jr., MD, MPH, MBA, FACPE, President of the Informatics Institute in Falls Church, VA. "You forget your mission, forget your key requirements, and find yourself seduced by an attractive interface."

2. Will this solve today’s problems? Instead of buying with future goals in mind, focus on your immediate needs. "The system should resolve some issues you are currently grappling with," says Taylor. "Otherwise, it will fail and people won’t use it."

In the fast-changing world of computers, buying a system can be like hitting a moving target. It’s important to stay focused on short-term goals. "If you buy for the future, you’ll end up not meeting your needs for the present," says Taylor. "As a result, the system will fail."

A system bought today will probably have a three- to five-year lifespan. "Don’t imagine you’re going to be able to buy something that will last you 15 years," says Taylor. "In the computer world, you’re lucky if you get three years of good use out of a system."

3. Are other EDs happy with this system? It’s crucial to select a system that has proven itself. "We wouldn’t even consider a system that wasn’t already run at a major hospital similar to us," says Kevin Moore, Associate Chief of Operations for Duke University Hospital in Durham, NC.

Talking with other ED personnel about their experiences can offer protection against less reputable vendors. "Talk to other people who bought the system away from the sales rep, and say, ‘Did it really cost what they said it would cost? When it broke did they come to fix it or were there developmental things that they ended up trying to sell you as soon as you bought the system?’" says Moore. "As much as it sounds like these guys are wearing masks and waiting in the bushes as you ride down the road, these things are not uncommon in the software industry."

After narrowing their search to four systems, Duke administrators visited hospitals that had recently installed those systems. "We got the brass together and let them speak with their counterparts where the systems were installed," says Moore. "If the CEO of the hospital never heard of it and doesn’t know about any problems, it’s a good system. The absence of knowledge at higher levels in the organization is a positive aspect."

4. Is the vendor in stable financial condition? The longevity of computer companies can be difficult to gauge. "At this juncture in time, it’s a little difficult to predict the future," says Taylor. "We’ve begun to see some vendors join forces and consolidate, while others are going out of business, and some new players are buying up existing companies. Don’t be scared off, but go in with your eyes wide open."

When Duke University’s ED was shopping for a system, administrators examined the vendors’ financial data. "We needed to make sure it wasn’t something that was going to evaporate as a company before we could get the system installed," says Moore. "We asked for confidentiality agreements so we could take a look at their books and see whether they were going to be around for the long term."

5. Is it in the ED’s best interest to buy a single module instead of an entire new system? "If all you need is triage tracking, that’s probably all you should buy," says Taylor. "If it works out, you can continue to expand your system as times goes on. Hopefully the company will still be in business at that time."

6. What mistakes should I avoid? Learn from others’ errors. "A friend of mine is now on the third system in seven years after spending well over $2,000,000," says Taylor. "There are pioneers who made the mistakes the rest of us can learn from, and if you don’t take advantage of those [lessons], you may make the same mistakes."

7. How can I avoid problems by planning for the new system during redesign? If the ED is undergoing construction, make sure future systems are accommodated. "The cost is inconsequential compared to retrofitting something later," says Taylor. "Run a wire to every place you might ever possibly want a terminal. That would probably include one in each room, and multiple ones in various stations."

8. What kind of hardware do we need? It’s probably best to choose a system with flexible hardware to accommodate the ED’s changing needs. "It’s not realistic that everything is going to be a CRT monitor system," says Taylor. "At a patient’s bedside, perhaps a wallmounted LCD monitor touch screen would be most appropriate, or a wireless remote with basic CRTs for the text inputting parts of the process."

9. What other departments should be involved in this decision? The purchasing process should be a collaborative effort. "Any system purchase should involve the information services department, as well as the purchasing department for contracts," says William H. Cordell, MD, FACEP, Director of Emergency Medicine Research and Informatics at Methodist Hospital in Indianapolis.

On the other hand, don’t buy into a system on the information system department’s say-so. "The IS people are dealing with the pharmacy, labs, the ICU, and everybody else, and may not address the particular needs of the ED," says Taylor. "They may say, ‘Go with this system, we’ll make it work, and we’ll be available 24 hours a day,’ but that may not be realistic."

10. Can I get this in writing? Promises made by vendors or hospital IS staff aren’t always honored. "They’ll promise they can do something, but once they get your money many of them will go by the wayside. You need definite contractual agreements," says Taylor.

11. Will the vendor be there for support and maintenance? Make sure that you’re not left on your own after you sign on the dotted line. "Some of these companies have more people on the sales force than they do in support and maintenance, that means there’s a lot of people out there selling it, and very few to help their existing customers," says Moore. "It pays to obtain a ratio of their staff in this regard."

12. Will the new system be compatible with other hospital systems? Interfacing allows downloading and uploading of data between the hospital and ED clinical information systems, and prevents duplication of data entry. The ED’s system must integrate with numerous, if not all, hospital information systems. "Interfacing and standardization are key design features," says Cordell. Instead of "going it alone," seek advice from the hospital’s information system staff on the issue, he advises, adding, "Most ED managers don’t have the level of technical expertise to address these issues on their own."

[Editor’s Note: A publication titled, Informatics Manual guides ED managers in selecting and implementing a clinical information system. To order, contact the Emergency Nurses Association at 216 Higgins Road, Park Ridge, IL 60068. Telephone: (800) 243-8362. FAX: (847) 698-9406. Also, the Pennsylvania chapter of ACEP holds an annual informatics conference designed for ED managers shopping for a system. For more information, call ACEP at (800) 798-1822.]