The EHR Selection Process: A 5-Step Vendor Evaluation Framework

Why EHR Selection Matters More Than You Think

Your EHR is the operating system of your practice. Every clinical encounter, every billing cycle, every patient communication, every quality report flows through it. Choose well, and the system fades into the background — a tool that makes your team more productive. Choose poorly, and you inherit years of friction: workarounds, lost revenue, clinician burnout, and eventually the enormous cost of switching.

The data paints a sobering picture of how often organizations get this wrong:

• 44% of practices that switched EHRs cited an unresponsive vendor as the primary driver (Black Book Research). They didn't leave because the software was broken — they left because the vendor stopped showing up.
• 60% of physicians either dislike or feel neutral about their EHR (Stanford Medicine/The Harris Poll). Only 4 in 10 are genuinely satisfied — a remarkably low bar for a tool they use 4+ hours daily.
• The average EHR earns a System Usability Scale score of 45.9 out of 100 — an "F" grade by standard benchmarking (AMA research). For comparison, an ATM scores around 80. EHR usability is measurably poor, which makes hands-on evaluation during selection even more critical.
• Switching EHRs costs 2-3x the original implementation when you factor in data migration, retraining, productivity loss, and the opportunity cost of the entire process. For a mid-size practice, that can mean $150,000-$500,000 in total switching costs.

The conclusion is straightforward: a disciplined selection process is not bureaucratic overhead — it is risk management. The 3-6 months you invest in evaluation saves you 3-5 years of regret. Here is how to do it right.

Step 1: Define Your Requirements

Before you look at a single vendor website, you need to define what you're looking for. This sounds obvious, but it's the step most organizations rush through — and it is the step where the most consequential mistakes happen. A vague requirements list leads to demo presentations that look impressive but tell you nothing about actual fit.

Build your requirements document across six categories:

Clinical Documentation Needs

This is the core of the EHR. Document exactly how your clinicians work today:

• Note types — What clinical note formats do you use? SOAP notes, H&P, progress notes, procedure notes, group therapy notes? Does the EHR support your specialty's documentation patterns natively, or will you need to build custom templates from scratch?
• Documentation workflow — Do providers type, dictate, use scribes, or rely on templates? The ideal EHR supports your preferred method. If you're interested in AI-powered ambient documentation, verify the vendor's roadmap.
• Order entry — Lab orders, prescription management (e-prescribing including EPCS for controlled substances), imaging orders, and referral management.
• Clinical decision support — Drug interaction alerts, allergy warnings, clinical guidelines, preventive care reminders. Are they configurable? Alert fatigue from poorly tuned CDS is a major clinician complaint.
• Specialty-specific features — Behavioral health practices need treatment plans, PHQ-9/GAD-7 tracking, and group note capabilities. Surgical practices need procedure logs. Pediatrics needs growth charts and immunization tracking. Generic EHRs often handle these poorly.

Billing & Revenue Cycle Management (RCM)

A significant percentage of EHR dissatisfaction traces back to billing dysfunction. Define:

• Integrated vs. separate billing — Do you want billing built into the EHR, or will you use a separate practice management system? Integrated platforms (athenahealth, AdvancedMD, eClinicalWorks) reduce data entry and claim errors. Separate systems give more flexibility but add interface complexity.
• Claims management — Electronic claim submission, ERA/EOB posting, denial management workflows, and secondary billing. What is the vendor's first-pass claim acceptance rate?
• Payer connectivity — Can the system connect to your specific payers? Verify real-time eligibility checking for your top 10 payers by volume.
• Reporting — Financial dashboards, A/R aging, collection rates, provider productivity. Can you generate these reports without paying for an add-on module?

Interoperability Requirements

Interoperability is no longer optional — it is a regulatory requirement and a practical necessity:

• FHIR R4 API support — Required under the 21st Century Cures Act. Verify the vendor has a certified, production-ready FHIR API — not just a roadmap item.
• TEFCA participation — The Trusted Exchange Framework and Common Agreement enables nationwide data exchange. Ask whether the vendor participates through Carequality, CommonWell, or another Qualified Health Information Network (QHIN).
• Health information exchange (HIE) — Can the system connect to your state or regional HIE? This matters for care coordination and is increasingly required for value-based contracts.
• Third-party integrations — Lab interfaces (Quest, LabCorp, local labs), pharmacy (Surescripts), imaging centers, patient engagement tools, and telehealth platforms. Count your current integrations and verify each one is supported.

Practice Size & Growth Plans

• Current size — Solo practice, small group (2-5), mid-size (6-25), large group (25-100), or enterprise/health system (100+)? Some vendors excel at specific practice sizes and are poorly suited for others.
• Growth trajectory — Are you adding providers, locations, or specialties in the next 3-5 years? A cloud EHR scales more naturally for growing organizations.
• Multi-site needs — If you operate multiple locations, does the system support centralized scheduling, cross-location patient records, and consolidated reporting?

Deployment Model Preference

Decide early whether you want cloud-based, on-premise, or hybrid. Our cloud vs. on-premise EHR comparison provides a detailed analysis. For most practices in 2026, cloud is the right default — but read the data before committing.

Regulatory & Reporting Requirements

• MIPS/APM participation — Does the EHR support your quality reporting programs? Can it calculate and submit MIPS scores automatically?
• Meaningful Use / Promoting Interoperability — Is the system ONC-certified (2015 Edition Cures Update)? Verify at the ONC CHPL database.
• State reporting — Immunization registries, PDMP reporting, cancer registries, syndromic surveillance. Requirements vary by state and specialty.

Step 2: Research & Shortlist

With your requirements document in hand, you now need to narrow the field. There are over 600 certified EHR products listed in the ONC CHPL database, but the practical universe is more like 50-60 actively marketed systems. Your goal is to get from that 50+ down to 3-5 finalists for full demonstration.

Research Sources Worth Your Time

KLAS Research

KLAS is the gold standard for EHR vendor performance data. They survey actual customers — not marketing claims — and rate vendors on implementation quality, functionality, support, value, and overall satisfaction. Key 2025 data points:

• Best in KLAS 2025 for Large Health Systems: Epic Systems
• Best in KLAS 2025 for Small/Independent Practices: athenahealth
• KLAS reports segment by practice size, specialty, and deployment model — so you can find data relevant to your specific situation.

KLAS reports range from free summaries to paid deep dives ($2,000-$5,000+). The free "Best in KLAS" annual report is a worthwhile starting point. For practices spending $100K+ on an EHR, the paid reports easily pay for themselves.

Black Book Research

Black Book conducts an annual EHR satisfaction survey of over 10,000 healthcare providers. Their data is particularly useful for understanding vendor responsiveness, switching patterns, and satisfaction by practice size. The stat that 44% of practices switch EHRs due to an unresponsive vendor comes from Black Book's annual survey. Their rankings also break down by specialty and organization size.

ONC CHPL Database

The ONC Certified Health IT Product List is the official registry of EHR systems certified under the 2015 Edition Cures Update criteria. Any EHR you consider must be listed here. This is not a rating — it is a compliance verification. If a system is not on CHPL, it cannot meet Promoting Interoperability requirements and you should eliminate it.

Peer Recommendations

Talk to colleagues in your specialty who have implemented an EHR in the last 2-3 years. Specifically ask:

• What do you wish you had known before you chose this vendor?
• How responsive is the vendor when you have a problem?
• What was the implementation experience actually like vs. what was promised?
• Would you choose the same system again?

Peer recommendations carry disproportionate weight because they reflect operational reality — not sales presentations. Medical societies, specialty associations, and state medical associations often maintain EHR recommendation lists or host vendor fairs.

Analyst Reports

Gartner, HIMSS Analytics (now part of Oracle), and Definitive Healthcare publish market share data and vendor assessments. These are useful for understanding the competitive landscape, financial stability of vendors, and market trends. Definitive Healthcare data is the most commonly cited source for market share figures.

How to Narrow from 50+ to 3-5

Apply filters in this order to reduce the list quickly:

1. Eliminate by practice size mismatch — Epic is superb for health systems but impractical for a 3-provider practice. DrChrono is great for small practices but won't scale to 200 providers. Remove any vendor that doesn't target your size category.
2. Eliminate by specialty gap — If you're a behavioral health practice, eliminate general-purpose EHRs that lack treatment plan management, group therapy notes, and outcome tracking. If you're a surgical practice, eliminate systems without procedure logging and surgical scheduling.
3. Eliminate by must-have gaps — Cross-reference your must-have list against each vendor's published feature set. A quick call to the vendor's sales team can verify ambiguous items. Any vendor missing a must-have is out.
4. Eliminate by deployment model — If you've decided on cloud deployment, remove vendors that only offer on-premise.
5. Eliminate by budget — Request preliminary pricing from remaining vendors. If a vendor's ballpark exceeds your budget by more than 30%, they're unlikely to close the gap during negotiation. See our EHR cost guide for benchmarks.

After these five filters, you should have 3-5 vendors. If you have more than 5, tighten your must-have criteria. If you have fewer than 3, revisit whether some requirements are truly must-haves vs. nice-to-haves.

Step 3: Vendor Demonstrations

This is where most selection processes go wrong. The standard approach — invite the vendor to present their system for 60-90 minutes to your leadership team — is almost useless. The vendor controls the narrative, shows pre-configured best-case scenarios, and glosses over weaknesses. You leave impressed but uninformed.

Here is how to structure demonstrations that actually tell you something:

Before the Demo

• Send your workflow scenarios in advance — Give the vendor 5-7 realistic clinical scenarios specific to your practice: a new patient intake, a follow-up with medication changes, a complex referral, a billing denial workflow, a group therapy session. Ask them to demonstrate the system handling these exact scenarios.
• Require the same scenarios across all vendors — This is critical. You cannot compare vendors if each one shows different features. Standardize the demonstration script.
• Include your end users — Physicians, nurses, medical assistants, front desk staff, billers. The people who will use the system daily should evaluate it. Leadership should observe, not dominate the conversation.
• Prepare a scoring form — Every evaluator should score each demo against the same criteria using the same scale. We provide a scorecard template in the scorecard section below.

During the Demo

• Block 2-3 hours minimum — A 60-minute demo is a sales pitch. You need at least 2 hours to see real workflows, ask questions, and let end users interact with the system.
• Request hands-on time — Ask the vendor to let your providers actually use the system. Type a note, enter an order, search for a patient. Nothing reveals usability issues faster than hands-on interaction. If the vendor resists this, consider it a red flag.
• Ask about workarounds — For any feature the vendor can't demonstrate natively, ask: "How do your current customers handle this?" A mature vendor will have workaround suggestions. An immature vendor will promise it's "on the roadmap."
• Watch for speed — How many clicks does it take to complete common tasks? Time the vendor completing your clinical scenarios. If a simple progress note takes 15+ clicks, multiply that by 30 patients per day and 250 days per year.
• Ask about reporting — Can they generate your top 5 most important reports on the spot? Custom reporting is one of the most common gaps between vendor promises and operational reality.

Red Flags During Demos

Scoring Methodology

After each demonstration, have every evaluator independently score the vendor on a 1-5 scale across your predefined criteria before any group discussion. Group discussion introduces anchoring bias — the most senior person's opinion disproportionately influences everyone else. Individual scores first, group discussion second.

Weight the criteria by importance. A vendor that scores 5/5 on "nice-to-have" features but 2/5 on clinical documentation is not your answer. Clinical workflow fit and usability should carry the highest weights.

Step 4: Due Diligence

Your demo scores have identified 1-2 frontrunners. Before entering contract negotiation, conduct due diligence on the finalist vendors. This step catches problems that demonstrations cannot reveal.

Reference Checks

Request 3-5 customer references from the vendor — then go find 2-3 more on your own. Vendor-supplied references are pre-screened for satisfaction; independent references give you a complete picture.

• Match your profile — References should be similar in practice size, specialty, and deployment model. A pediatric practice's experience tells you little about how the system works for an orthopedic group.
• Ask about implementation — Was it delivered on time and on budget? What were the biggest surprises? How long until the team felt proficient?
• Ask about support — How quickly does the vendor respond to support tickets? Is there a dedicated account manager or just a help desk queue? This is the #1 predictor of long-term satisfaction.
• Ask about updates — Are software updates smooth or disruptive? Does the vendor communicate changes in advance? Have they ever released an update that broke existing workflows?
• Ask the hard question — "If you could go back, would you choose this vendor again?" The answer — and the hesitation before the answer — tells you everything.

Data Portability Assessment

The 21st Century Cures Act prohibits information blocking, meaning your EHR vendor cannot make it unreasonably difficult to export your data. But "unreasonably difficult" is still being tested in enforcement. Verify:

• Export formats — Can you export patient records in C-CDA (clinical), FHIR bundles (structured data), and CSV (financial/operational)? All three matter.
• Bulk export capability — Can you export your entire database, not just individual patient records? Some vendors technically comply with Cures Act while making full database export impractical.
• Cost of export — Is data export included in your contract, or does the vendor charge per-record or per-export fees? These fees can be substantial and are a common form of soft lock-in.
• Document images and attachments — Scanned documents, uploaded images, and attachments are often the hardest data to extract. Confirm the export includes these, not just structured data.

Financial Stability

Your EHR vendor needs to be around for the next 5-10 years. Assess:

• Revenue and growth — Is the vendor growing, flat, or declining? Publicly traded companies (athenahealth was acquired by Hellman & Friedman; Oracle Health is part of Oracle Corporation) are easier to evaluate. Private vendors may be less transparent.
• Customer base trajectory — Is the vendor gaining or losing customers? Meaningful customer losses signal problems.
• Ownership and funding — PE-owned vendors may face pressure to cut costs (especially support staff) to boost short-term margins. VC-funded startups may not reach profitability. Neither is automatically disqualifying, but understand the incentives.
• Acquisition risk — If the vendor is acquired, your product could be sunset, deprioritized, or merged into a different platform. Contractual protections for this scenario are essential.

ONC Certification Verification

Verify the vendor's ONC certification status at chpl.healthit.gov. Specifically check:

• 2015 Edition Cures Update certification — This is the current standard. Systems with only the original 2015 Edition certification may not meet current requirements.
• Certification scope — Not all modules are certified. Verify that the specific modules you need (clinical, billing, patient portal, etc.) are included in the certification.
• Surveillance history — CHPL shows whether the product has been subject to ONC surveillance or corrective action. Past issues don't necessarily disqualify a vendor, but you should understand what happened and how it was resolved.
• Real World Testing results — ONC requires vendors to publish annual Real World Testing plans and results. Review these for evidence that the system performs as certified in production environments.

Security & Compliance Verification

• HIPAA compliance documentation — Request the vendor's HIPAA security risk assessment summary and Business Associate Agreement (BAA) template.
• SOC 2 Type II report — Request a copy. A vendor unwilling to share their SOC 2 report should be viewed with skepticism.
• HITRUST certification — The gold standard for healthcare security. Not all vendors have it, but those that do have undergone the most rigorous third-party security assessment available in healthcare.
• Breach history — Search the HHS Breach Portal for any incidents involving the vendor. Breaches don't automatically disqualify a vendor (they're unfortunately common), but the vendor's response and remediation matter.

Step 5: Contract Negotiation

You have selected your vendor. Now comes the step that protects you for the next 5-10 years: the contract. EHR contracts are long, dense, and heavily vendor-favorable by default. You need to negotiate specific protections.

If your organization does not have experience negotiating software contracts, consider engaging a healthcare IT attorney or consultant for this phase. The cost ($3,000-$10,000) is trivial compared to the risks of a poorly structured 7-figure contract.

Uptime & Service Level Agreements (SLAs)

• Minimum 99.9% uptime guarantee — This allows approximately 8.7 hours of downtime per year. For critical healthcare operations, 99.95% is better. Anything below 99.9% is unacceptable for a cloud-based EHR.
• Financial penalties for SLA breaches — The SLA is meaningless without teeth. Negotiate service credits (typically 5-10% of monthly fees per hour of unplanned downtime exceeding the SLA) or the right to terminate if uptime falls below a threshold for consecutive months.
• Planned maintenance windows — Specify that scheduled downtime must occur outside business hours and with at least 72 hours notice. Planned maintenance should not count against the uptime SLA.
• Support response times — Define severity levels (critical: system down; high: major feature unavailable; medium: workflow impact; low: cosmetic). Negotiate response times for each: critical within 1 hour, high within 4 hours, medium within 1 business day.

Data Export & Portability Clauses

• Right to export at any time — Your contract should explicitly state you can export all patient data in standard formats (C-CDA, FHIR, CSV) at any point during the contract, not only at termination.
• No export fees — Or at minimum, capped export fees that are reasonable and defined in advance.
• Data retention after termination — The vendor should retain your data for a minimum of 90 days after contract termination to allow for migration. 180 days is better.
• Data destruction certification — After the retention period and your confirmation of successful migration, the vendor should provide written certification that all your data has been destroyed from their systems, per HIPAA requirements.

Implementation Milestones

• Tie payments to deliverables, not dates — Structure implementation payments as milestone-based: X% at contract signing, Y% at configuration complete, Z% at successful go-live. This gives the vendor financial incentive to hit milestones. See our EHR implementation checklist for the phases to use as milestones.
• Define "go-live" clearly — What constitutes a successful go-live? All providers live on the system, all interfaces active, data migration verified, and a defined stabilization period (typically 30 days) without critical issues.
• Remedies for missed milestones — If the vendor misses a milestone by more than 30 days due to their actions, what are your remedies? At minimum, you should be able to defer payments. For significant delays, you may want the right to terminate.

Training Commitments

• Quantify training hours — "Training included" is meaningless. The contract should specify: number of training hours per user role (providers, nurses, front desk, billing), training format (on-site, virtual, recorded), and training materials (user guides, video library, sandbox environment).
• Ongoing training access — Staff turns over, features change. Does the contract include ongoing access to training materials and periodic refresher training, or is that an additional cost?
• Super-user program — Will the vendor train designated super-users who can handle day-to-day questions internally? How many hours of super-user training are included?

Cost Escalation Caps

• Annual price increase cap — Lock in a maximum annual increase. A cap of 3-5% is standard and reasonable. Without a cap, vendors can (and do) increase prices 10-15% annually after the initial contract term — effectively forcing you to accept or face the cost of switching.
• No hidden fees — Enumerate all potential fees in the contract: implementation, training, interfaces, data conversion, add-on modules, report development, API access, and support tiers. Anything not listed should be included at no additional cost.
• Volume discounts — If you're adding providers or locations, negotiate a per-provider pricing schedule that decreases as you scale.

Business Associate Agreement (BAA)

• Execute before data transfer — The BAA must be signed before any protected health information (PHI) is shared with the vendor, including during implementation.
• Breach notification — The BAA should require the vendor to notify you of any security breach within 24-48 hours of discovery — not the 60 days permitted by HIPAA, which is far too slow for operational response.
• Subcontractor chain — If the vendor uses subcontractors (hosting providers, clearinghouses, etc.), the BAA should require that all subcontractors are also bound by equivalent BAA terms.

EHR Evaluation Scorecard Template

Use this weighted scorecard during Step 3 (demonstrations) and update it through Step 4 (due diligence). Each evaluator should complete the scorecard independently, then aggregate scores for group discussion.

Scoring: 1 = Does not meet requirements, 2 = Partially meets requirements, 3 = Meets requirements, 4 = Exceeds requirements, 5 = Exceptional. Weighted score = (raw score / 5) x weight. Sum all weighted scores for the total.

EHR Market Data & Statistics for 2025-2026

Context matters when evaluating vendors. Here is the current state of the EHR market, drawn from the most reliable public data sources.

Market Share

• Epic Systems holds approximately 37-44% of the ambulatory EHR market and an estimated 96% of hospitals with 500+ beds (Definitive Healthcare, KLAS). Epic's dominance in health systems is unmatched, but they also serve mid-size and large physician groups.
• Oracle Health (formerly Cerner) is the second-largest hospital EHR and is actively migrating its platform to Oracle Cloud Infrastructure.
• MEDITECH holds strong in community hospitals, particularly in the 100-300 bed segment.
• athenahealth is the market leader for independent and small physician practices, with cloud-native architecture and strong RCM capabilities.
• eClinicalWorks serves 150,000+ providers, primarily in the ambulatory space, with a mixed cloud/client-server deployment model.
• NextGen Healthcare targets mid-size specialty and multi-specialty groups.

Adoption & Satisfaction

• 96% of non-federal acute care hospitals have adopted a certified EHR system (ONC, 2024). Adoption is essentially universal.
• ~80% of new EHR purchases are cloud-based, up from approximately 60% in 2020 (KLAS, Black Book).
• 60% of physicians are dissatisfied or neutral about their EHR (Stanford Medicine/Harris Poll). Satisfaction has improved slightly from historic lows but remains poor by software industry standards.
• Average EHR usability score: 45.9/100 on the System Usability Scale (AMA study). For context, the SUS benchmark for "acceptable" software is 68. Banking software averages 75+. EHRs have the worst usability of any major software category.

Switching Patterns

• 44% switched due to vendor unresponsiveness (Black Book) — the single largest driver of EHR replacement.
• 28% switched due to missing functionality — features that were either absent or did not work as expected.
• 18% switched due to cost concerns — typically driven by unexpected price increases after the initial contract term.
• Average EHR contract length: 5-7 years. Most organizations begin evaluating replacements 12-18 months before contract renewal.

The Global Market

The global EHR market is projected to reach approximately $47 billion by 2030, growing at a compound annual rate of 5-6% (Grand View Research). Growth is driven by cloud migration, AI integration, interoperability mandates, and expansion in emerging markets. For practices making a selection today, this growth means more vendor options, more innovation, but also more consolidation risk as larger vendors acquire smaller ones.

Frequently Asked Questions

Next Steps

Selecting an EHR is a high-stakes decision, but it does not have to be an overwhelming one. This 5-step framework — define requirements, research and shortlist, conduct structured demonstrations, perform due diligence, and negotiate a protective contract — provides a repeatable process that dramatically reduces the risk of choosing the wrong vendor.

The investment of 3-6 months in rigorous evaluation pays for itself many times over. The 44% of practices that switch EHRs due to vendor problems, the 60% who are dissatisfied — they overwhelmingly report that they rushed their original selection, relied too heavily on demos without due diligence, or failed to negotiate adequate contract protections.

Don't be that statistic. Follow the framework, involve your end users, and choose a partner — not just a software platform.