So, you’ve made the decision to implement an ePCR solution. Congratulations, that was a good decision, which, if implemented correctly, will pay big dividends to you and your stakeholders.

At the Montgomery County Hospital District (MCHD), we’re continuing our long-standing journey toward data-driven operations. As discussed in a previous JEMS article (“The Root of all Data,” January 2009, available at, we’re big believers that all aspects of our service can be enhanced by the appropriate capture, analysis and use of data. Over the years, our experience with implementing organization-wide information systems (including earlier, less functional solutions) has taught us a few things. As we moved forward with our ePCR program, we decided to capitalize on our acquired wisdom. We developed the following selection precepts to guide the process:

Involve the IT department in the very beginning. Make no mistake, an ePCR solution, by its very definition, involves hardware, software and the integration of complex information system components. These subjects are the domain of your IT department, and their substantive early input will go a long ways toward helping ensure an appropriate purchase decision followed by a successful implementation. Bringing them in late can cause setbacks or total project abandonment.

Ensure the new ePCR program works with, and does not require major modifications to, existing hardware and software. It’s important to involve not only IT experts but also those on your staff who are responsible for integrating information technologies into your clinical practice. No one wants to become involved with implementing an ePCR solution that necessitates costly purchases and/or modifications to existing hardware and software systems (e.g., field mobile computers).

Ensure the new ePCR program actually meets functional expectations and has a substantial enough existing feature set to meet current and future needs. All organizations will have different expectations of what they want their ePCR to do. You need to find a solution that closely fits your specific functional requirements. However, don’t underestimate the need for a system to grow, both in functionality and features. The world will change, and your system must be able to meet the demands of those changes.

Also, make sure that the ePCR you select has existing functionality and features that meet your needs. Even a well-intentioned vendor’s promise that their ePCR solution will “eventually” work with one of your existing subsystems (e.g., CAD or billing systems) must be viewed with some skepticism. Quite frankly, promises of future or planned features must be discounted in the “here and now” world in which we operate.

Ensure “users” are substantively involved in the ePCR selection process. It’s extremely important that the end users (field staff, analysts, etc.) have a say in the selection process. After all, they’ll actually have the hands-on experience with whatever program is selected. Overlooking their input could lead to a suboptimal decision and will make gaining their buy-in more difficult. (At MCHD, we have a Product Review Committee that participates in all our major systemic purchases.)

Make sure that the final cost of the ePCR program is rational and in line with the benefits to be experienced. Although it’s critical to keep the cost of purchasing, implementing and maintaining the ePCR system as reasonable as possible, seeking the “lowest cost” solution is not the goal. The decision should be driven by value.

Based on the above precepts, a team from our Facilities and Systems Technology (FaST) department developed a nine criteria matrix (see Figure 1) to guide our selection process. The criteria were initially used as a front-end screening tool. Any ePCR solution that could not pass all nine main criteria (and appropriate sub-criteria) was eliminated on the spot.

If your staff members are experts in database architecture (such as Microsoft’s SQL), there would be no need to consider solutions using another database platform; only a robust database would pass the second key criteria. Likewise, vendors not offering existing interfaces with CAD, ECG monitor and billing system did not pass the third key criteria.

For instance, solutions fell away if the software wasn’t Gold NEMSIS certified or if it didn’t have a CQI module, data validation capabilities or the ability to deal with multiple patient assessments.

The ePCR solutions that didn’t offer extensive reporting capabilities (including custom reports) were rejected, as were solutions that didn’t offer SSL authenticated Web access, the ability to select which specific computers and users would have access or that didn’t provide highly-detailed audit trails.

The eighth criterion was intended to screen out vendors that didn’t offer 24/7/365 North American user and technical support. It also favored vendors who provided reasonably priced upgrades that were easy to install and didn’t require every computer to be “touched.” Also favored were those vendors with an active program of soliciting and responding to customer input on operating issues, functionality and feature set.

Finally, the ninth key criterion was based on “usability” as assessed by our staff in conjunction with our Product Review Committee. Solutions that pass the first eight criteria can still be rejected if they’re deemed to be difficult to use, non-intuitive or time-consuming.

Once the initial screening was completed, staff performed an informal assessment intended to determine the relative strengths and weaknesses of each system that passed the initial screening. This assessment wasn’t intended as a ranking of vendors but as an attempt to develop a broader understanding of how each proposed solution matched up against the others.

Of course, MCHD is a governmental body and therefore must comply with a strict policy that requires major purchases be put out for bid. We are, after all, spending taxpayer money and, as discussed above, overall cost is a significant factor. However, we’re not required, nor would it be wise, to make such a major decision based solely on the lowest bidder. Our ePCR system is a core component of our records retention, billing, CQI and operations functions. The ePCR will also form the basis for our future Health Information Exchange system, and we look forward to that future.

Montgomery County is located just north of Houston. MCHD is an independent governmental entity that provides the entire county with indigent health-care services and 9-1-1 emergency medical services. MCHD also operates an 800-megahertz radio system that supports other governmental and emergency responders in the county.

Acknowledgement: Michael Lambert, president of the consultancy PaladinSG, contributed to this article.

Disclosure: The authors have reported no conflicts of interest with the sponsors of this supplement.