Family Practice management: Electronic Health Records

Transcription

electronic health records
Selecting an EHR
2 The 2009 EHR User Satisfaction Survey:
Responses From 2,012 Family Physicians
Robert L. Edsall and Kenneth G. Adler, MD, MMM
If you’re shopping for an EHR system, you might
appreciate this advice from a couple of thousand
colleagues.
9 Toward a Modular EHR
David C. Kibbe, MD, MBA
Imagine being able to buy just the parts of an EHR
system that you need.
11 How to Select an EHR System
Kenneth G. Adler, MD, MMM
These 12 steps will help make the selection process
easier and lead you to the EHR that’s right for your
practice.
19 Purchasing an Affordable EHR
Louis Spikol, MD
An economy model may provide all the functionality
your practice needs.
23 Why I Love My EMR
William D. Soper, MD, MBA
Two years after he took his practice digital, the author
addresses the concerns of others who contemplate
leaving paper records behind.
Implementing an EHR
27 Improving Care With an Automated
Patient History
John Bachman, MD
The best way to fill your EHR with patient data
might be to let your patients do it themselves.
32 EHRs Fix Everything – and Nine Other
Myths
David E. Trachtenbarg, MD
Realistic expectations can help your conversion to
electronic health records succeed.
37 EHRs in the Exam Room: Tips on PatientCentered Care
William Ventres, MD, MA, Sarah Kooienga, FNP, and Ryan Marlin, MD, MPH
With a thoughtful approach, you can maintain your
focus on the patient.
40 How to Successfully Navigate
Your EHR Implementation
These clues can help you avoid the pitfalls you’ll
encounter on your EHR journey.
EHR Incentives & Meaningful Use
47 A Physician’s Guide to the Medicare
and Medicaid EHR Incentive Programs:
The Basics
David C. Kibbe, MD
With the changes made in the final rule, earning the
EHR incentive is still not easy, but at least it’s easier.
52 Should Doctors Reject the Government’s
EHR Incentive Plan?
It’s a big hill to climb for a carrot that may not be
there when you reach the top.
54 “Will the Feds Really Buy Me an EHR?”
and Other Commonly Asked Questions
About the HITECH Act
Steven Waldren, MD, David C. Kibbe, MD, MBA, and Jason Mitchell, MD
The economic stimulus package offers $19 billion in
health IT incentives, but it also creates new penalties.
Here’s what you need to know.
These articles, all previously published in FPM, are
included in the EHR Article Collection on the FPM
web site. View this and 20 other collections on topics such as coding, HIPAA, and quality and safety,
at http://www.aafp.org/fpm/collections.
www.aafp.org/fpm | FAMILY PRACTICE MANAGEMENT | The 2009 EHR User
Satisfaction Survey
Responses From 2,012 Family Physicians
Robert L. Edsall and Kenneth G. Adler, MD, MMM
If you’re shopping for an EHR system, you might appreciate
this advice from a couple of thousand colleagues.
G
This is a corrected version of the article originally published.
iven the growing number of family medicine practices moving to electronic health
record systems (EHRs), the prospect of
government incentives for the purchase of
EHRs, and the speed with which technology changes
these days, we thought it important to repeat the FPM
survey of EHR users that was last conducted in 2007.1
As in 2007, we published the survey instrument in
an issue of FPM and made an online version available
through the FPM web site.2 However, this year, in an
effort to maximize responses, we shortened the survey
significantly and offered incentives for usable responses
(one Apple iPod Touch and 10 one-year subscriptions to
FPM, which were awarded to randomly selected respondents). We also followed up publication of the survey
with reminders in FPM e-mail newsletters and sent one
e-mail reminder to all AAFP members.
Our intent was not to survey a random sample of
AAFP members but to collect as many responses as we
could from EHR users. Consequently, as with our previous surveys, the results should not be considered a statistically accurate picture of EHR use among AAFP members
but a more informal collection of responses from several
hundred colleagues. Given the wide availability of the
survey instrument, we accepted responses only from
AAFP members as a way of avoiding frivolous responses,
multiple responses per individual and other such potential sources of bias.
We were able to collect a total of 2,556 responses,
far more than in previous surveys. Of those, 477 were
excluded because the respondents said they did not use
EHR systems; 48 were excluded because they either did
not name the system they use, named a practice management system rather than an EHR system, or named
something that we could not verify to be an EHR system;
finally, 19 were excluded because they indicated that they
had a significant financial interest in or affiliation with a
manufacturer or vendor of an EHR program and either
did not explain the disclosure further or described what
amounted to a major stake in the success of an EHR system (e.g., an ownership interest, a sizable stock purchase
or involvement in development of the software). That left
2,012 responses for analysis.
Respondents reported a total of 142 identifiable EHR
systems, 120 of which were reported by 12 or fewer
respondents. The remaining 22 systems were reported
About the Authors
Robert Edsall is editor-in-chief and editorial director of Family Practice Management. Dr. Adler is a family physician in full-time
clinical practice in Tucson, Ariz., and a member of the FPM Board of Editors. He has a Master of Medical Management degree from
Tulane University and a Certificate in Healthcare Information Technology from the University of Connecticut. Author disclosure:
nothing to disclose.
| www.aafp.org/fpm
| November/December
| FAMILY
PRACTICE
MANAGEMENT
2009
Copyright
© 2010
American Academy
of Family Physicians.
For the private,
noncommercial use of one individual user of the Web site.
All other rights reserved. Contact [email protected] for copyright questions and/or permission requests.
Distribution of survey respondents by practice size for 20 EHR systems
Amazing Charts (N = 109)
e-MDs (N = 98)
Praxis (N = 30)
SOAPware (N = 54)
MediNotes e (N = 21)
eClinicalWorks (N = 165)
CareRevolution (N = 13)
Aprima (iMedica) (N = 18)
MEDENT (N = 23)
Practice Partner (N = 113)
Allscripts Professional EHR (N = 90)
Sage Intergy (N = 37)
All Respondents (N = 2,012)
MedInformatix (N = 19)
NextGen EHR (N = 156)
MPM Suite (N = 31)
Centricity (N = 231)
PowerChart/PowerWorks (N = 75)
Allscripts Enterprise EHR (N = 132)
EpicCare Ambulatory (N = 242)
AHLTA (N = 42)
0%
10%
Number of physicians in the practice: 20%
30%
1 by 13 or more respondents, and these were the systems
we set out to provide system-specific results for, using the
average of all 2,012 responses as a point of comparison.
Unfortunately, the survey instrument design apparently
led an unknown number of users of one system (Misys
EMR) to indicate that they used another (Misys MyWay,
now Allscripts MyWay). Consequently, data for these
two systems have been omitted from the system-specific
results reported in this corrected version of the report.
The remaining 20 systems accounted for 84 percent of
respondents (1,699). We chose to focus on these 20 systems because we believed that we had enough responses
for each to represent a reasonable spread of opinions on
the system. The 20 systems in question are shown on the
chart above. (A more detailed list is available in an appendix to the online version of this article at http://www.aafp.
org/fpm/20091100/10the2.html.) One of the systems,
AHLTA, is the U.S. Department of Defense system used
in the Military Health System and not commercially available. We kept it in the results nevertheless as a useful point
2 40%
3-5 50%
6-10 60%
70%
11-20 80%
21-50 90%
100%
>50
of comparison, at least for systems designed primarily for
large practices.
And large practices (large, at least, by family medicine
standards) were well represented in the data, with 20
percent of respondents (404) coming from practices of
more than 50 physicians. Still, 52 percent of respondents
(1,047) came from relatively small practices of 10 or
fewer physicians, with 16 percent (320) coming from
solo practices. As we expected, certain EHR systems were
reported more commonly in small practices and others
more commonly in large ones. The practice-size distribution of the 20 analyzed systems is shown above.
Respondents reported experience with their EHR systems ranging from a couple of weeks to 17 years, but the
majority (57 percent, or 1,142) said they had from two to
six years of experience with the system they reported on.
Asked to estimate their skill in using their EHR systems,
most respondents said they considered themselves average
users (33 percent, or 657) or above average but not expert
users of their EHR systems (41 percent, or 816). ➤
Article Web Address: http://www.aafp.org/fpm/20091100/10the2.html
November/December 2009 | www.aafp.org/fpm | FAMILY PRACTICE MANAGEMENT | To determine users’ satisfaction with various aspects
of their EHR systems, we asked respondents to indicate
their level of agreement or disagreement with each of the
following 13 statements, using the scale Strongly Agree,
Agree, Neutral, Disagree and Strongly Disagree.
1. Overall this EHR is easy and intuitive to use.
2. Documenting care is easy and effective with this EHR.
3. Finding and reviewing information is easy with
this EHR.
4. Ordering lab tests, referrals and imaging studies is
easy with this EHR.
5. E-prescribing is fast and easy with this EHR.
6. This EHR provides useful tools for health mainte-
nance (for instance, prompts, alerts and flow sheets).
7. This EHR provides useful tools for disease management (for instance, disease-specific prompts, alerts, flow
sheets and patient lists).
8. E-messaging and tasking within the office is easy
with this EHR.
9. This EHR enables me to practice higher quality
medicine than I could with paper charts.
10. I have a good idea how much this EHR system
is costing my practice.
11. This EHR is worth the expense.
12. Our EHR vendor provides excellent training
and support.
13. I am highly satisfied with this EHR system.
Survey overview: 20 EHR systems ranked
2
1
1
1
8
4
3
7
13
1
1
4
8
17
5
6
7
5
8
10
9
8
3
4
Praxis (N = 30)
2
7
4
8
1
13
2
7
5
5
9
2
5
4
1
1
12
7
6
13. Highly satisfied
4
MEDENT (N = 23)
1
2
12. Training and support
6
11. Worth the expense
4
9. Practice higher quality
5. e-Prescribing
2
8. e-Messaging
4. Ordering tests, etc.
3
7. Disease management
3. Finding information
2
EHR systems
e-MDs (N = 98)
6. Health maintenance
2. Documenting
Abbreviated survey statements
1. Easy and intuitive
The rankings in this table are based on
the percentage of respondents for each
system who agree or strongly agree with
the survey statements represented in
brief form across the top, with statement
10 excluded. For each statement, rankings run from 1 (best) to 20 (worst). The
four best and four worst rankings are
color coded for each statement.
5
3
2
3
2
3
2
1
4
3
1
4
1
6
6
9
5
7
8
7
7
6
7
5
15
12
4
6
3
5
7
11
8
9
10
6
6
3
10
10
4
10
10
8
10
7
8
11
11
2
11
9
11
11
9
5
11
11
11
10
9
11
3
3
6
9
11
15
9
SOAPware (N = 54)
3
5
9
18
14
9
14
18
8
4
6
6
13
12
12
14
9
14
11
10
12
15
10
12
15
13
19
10
10
8
8
15
14
12
13
13
14
15
16
12
5
16
17
13
13
13
16
16
16
14
14
13
15
13
12
14
16
16
14
15
12
17
13
20
19
15
16
12
17
14
12
14
AHLTA (N = 42)
18
18
15
2
7
20
19
20
19
19
17
19
19
19
17
17
16
19
15
17
18
18
18
17
17
16
18
16
20
18
20
16
15
17
19
18
MPM Suite (N = 31)
20
20
20
19
18
17
18
19
20
20
20
20
Note: Systems are listed by the sum of their rankings.
| FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | November/December 2009
ehr survey
Response spectrum: ‘Overall this EHR is easy and intuitive to use.’
e-MDs (N = 98)
SOAPware (N = 54)
MEDENT (N = 23)
Praxis (N = 30)
AHLTA (N = 42)
MPM Suite (N = 31)
100%
Blank Neutral 80%
60%
40%
Strongly Disagree For a rough, preliminary sense of the survey results, we
ranked the 20 systems by the percentage of respondents
who indicated that they agreed or strongly agreed with
12 of the 13 statements. (Statement 10, “I have a good
idea how much this EHR system is costing my practice”
played a different role in the survey; more on that
below.) The results are shown in “Survey overview: 20
EHR systems ranked,” on page 12. To help make sense
of the array of numbers, the highest four rankings for
each statement are tinted green and the lowest four are
tinted orange. The systems are listed by the sum of their
ranks; that’s why e-MDs is listed ahead of MEDENT
even though e-MDs had only one individual first-place
ranking (for e-Messaging) while MEDENT had three
and Praxis and Amazing Charts, the next two in the table,
had four each. The sum of e-MDs rankings, at 34, was
slightly better than MEDENT’s 37.
While this is a fairly crude ranking, it does offer some
useful insights. First, the high and low rankings do tend
to cluster in certain systems, as the areas of green and
orange on the chart suggest. Second, three of the four topranked systems are the ones most commonly reported by
physicians in small practices – e-MDs, Praxis and Amazing Charts – while two of the four lowest ranked systems
– AHLTA and Cerner Millennium PowerChart/PowerWorks – are among the four most commonly reported in
large practices. While we have reason to believe that physicians in smaller practices are more likely to be satisfied
20%
0%
Disagree 20%
Agree 40%
60%
80%
100%
Strongly Agree
with their systems than physicians in larger practices if
for no other reason than that they were involved in selecting the system, it’s interesting to note that two systems
commonly reported in small practices rank in the middle
of the pack (SOAPware) and toward the bottom (MediNotes e). This may suggest that one of the top-ranked
systems mentioned above might be a better bet for small
practices. Conversely, two systems commonly reported
in large practices rank somewhat higher (Allscripts Enterprise) and considerably higher (EpicCare Ambulatory)
than AHLTA and PowerChart/PowerWorks, the other
systems most common in large practices.
The ranking table does obscure the details of responses
for each statement. To better visualize the full range of
responses, we turn to charts like “Response spectrum:
‘Overall this EHR is easy and intuitive to use,’” above.
Each bar in a response spectrum chart represents 100
percent of responses for a given system (or for all systems
reported, in the case of the “All Respondents” bar), so all
bars on the chart have the same overall length. The number of responses represented by the bar is given in parenthesis after the system name. The bars are divided into
sections representing, from left to right, Blank (respondents who left the item blank, if any), Neutral, Strongly
Disagree, Disagree, Agree, and Strongly Agree.
Bar segments for Blank and Neutral are positioned
to the left and given only light tints to help highlight
the segments representing active agreement or disagree-
November/December 2009 | www.aafp.org/fpm | FAMILY PRACTICE MANAGEMENT | ment. Keep in mind, however, that these segments do
not represent negative responses and could as easily have
been placed on the far right end of the bars. The bars are
positioned so the dividing line between agreement and
disagreement falls on a midline, so bars that fall mostly
to the right of the midline represent a predominance
of agreement with the statement, while those that fall
mostly to the left indicate a predominance of disagreement. Bars are ordered by the sum of Agree and Strongly
Agree responses so that the systems with the most positive
responses appear toward the top of the chart. To interpret
the chart, though, you need to look at individual bar segments, not just the order of the bars. For instance, while
Praxis shows up in eighth place on the list, it received a
particularly high percentage of Strongly Agree responses –
53 percent. The only system with a higher percentage was
Amazing Charts, which had 71 percent Strongly Agree
responses in addition to 28 percent Agree, for a remarkable 99 percent positive response. At the other end of the
range was MPM Suite, with 16 percent of users agreeing that it is easy and intuitive to use and only 3 percent
strongly agreeing.
While we have room to display only a few response
spectrum charts in the following pages, an appendix available for download from the online version of this article
(http://www.aafp.org/fpm/20091100/10the2.html) does
provide all 13. The charts we’ve selected to include here
display results for four qualities that seem particularly
likely to be important to anyone selecting a system – vendor support (below), the system’s contribution to quality
of care (see page 15), value for investment (see page 15)
and overall satisfaction (see page 16). The same systems
tend to show up at or near the top and at or near the bottom of all four charts, as you’d expect from the ranking
table, but the charts show more. For instance, you’ll note
that, on the “training and support” chart, the whole block
of 21 bars seems to fall a little farther to the left than on
some other charts. Apparently even users of the highest
rated systems are not as enthusiastic about the training
and support as they are about other aspects. Also, of
course, the charts show variations in the relative strength
of agreement and disagreement for the 20 systems –
although here it’s particularly important to pay attention
to the N for a given system. For instance, CareRevolution
shows up on the “training and support” chart as having
respondents who strongly agree, strongly disagree or are
neutral, but none who just agree or disagree. While that
may be the expression of strong feelings, it may also be an
artifact of the low number of responses.
The chart of responses to the statement “This EHR
Response spectrum: ‘Our EHR vendor provides excellent training and support.’
Praxis (N = 30)
MEDENT (N = 23)
e-MDs (N = 98)
SOAPware (N = 54)
AHLTA (N = 42)
MPM Suite (N = 31)
100%
Blank Neutral 80%
60%
40%
Strongly Disagree 20%
0%
Disagree | FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | November/December 2009
20%
Agree 40%
60%
Strongly Agree
80%
100%
ehr survey
Response spectrum: ‘This EHR enables me to practice higher quality medicine than I could with paper charts.’
Praxis (N = 30)
e-MDs (N = 98)
MEDENT (N = 23)
SOAPware (N = 54)
AHLTA (N = 42)
MPM Suite (N = 31)
100%
Blank Neutral 80%
60%
40%
0%
Disagree 20%
Agree 40%
60%
80%
100%
80%
100%
Strongly Agree
Response spectrum: ‘This EHR is worth the expense.’
Praxis (N = 30)
MEDENT (N = 23)
SOAPware (N = 54)
e-MDs (N = 98)
AHLTA (N = 42)
MPM Suite (N = 31)
100%
Blank Neutral 80%
60%
40%
Disagree 0%
20%
Agree 40%
60%
Strongly Agree
November/December 2009 | www.aafp.org/fpm | FAMILY PRACTICE MANAGEMENT | Response spectrum: ‘I am highly satisfied with this EHR system.’
e-MDs (N = 98)
MEDENT (N = 23)
Praxis (N = 30)
SOAPware (N = 54)
AHLTA (N = 42)
MPM Suite (N = 31)
100%
Blank Neutral 80%
60%
40%
Strongly Disagree is worth the expense” needs special qualification. Our
previous surveys have given us strong indications that
many physicians have only vague notions of the cost of
their EHR systems, and probably fewer still have actually
measured the worth of their systems, so it is dangerous to
assume that respondents do in fact know whether their
systems are worth the expense. The best way to regard
the results on this chart may be as gut-level responses.
We included statement 10 (“I have a good idea how
much this EHR system is costing my practice”) in the
survey as an attempt to get a better picture of the cost/
benefit ratio. Even though that item asks for yet another
subjective response, we hoped that it would allow us to
get a better picture of cost and benefit by giving us the
ability to limit the analysis of worth to those respondents
who strongly agreed that they had a good sense of the
cost of their EHR. It turns out, however, that of the 358
respondents who strongly agree that they know the cost
of their systems, 90 percent (321) also had a hand in
selecting those systems – and in this survey, like our earlier ones, physicians who help choose an EHR system are
much more likely to be satisfied with it and to consider it
worth its cost than those who had no voice in the selection. Hence, we didn’t have enough respondents who
agreed strongly that they knew the cost of the system and
did not have a hand in selecting it to control for the effect
20%
Disagree 0%
20%
Agree 40%
60%
80%
100%
Strongly Agree
of having helped select the system.
As in past surveys, our goal was not to pick clear “winners” in terms of user satisfaction. The system characteristics covered in the survey may have different weights for
different practices, and we are conscious of several limitations of the survey. That respondents were self-selected
may mean that the survey attracted EHR enthusiasts, or at
least physicians with particularly strong feelings about their
EHRs, positive or negative. Moreover, cell size is a problem in two senses. By considering only systems for which
we had 13 or more respondents, we necessarily omitted
numerous systems; on the other hand, by including systems for which we had as few as 13 respondents, we risked
additional bias. As we said to begin with, it’s probably best
to consider the survey results as input you’d get from a
few hundred colleagues who volunteered to report on their
EHR experience. That said, we believe that the results presented in this article and its online appendix can help any
family medicine practice considering the purchase of an
EHR system. We hope you find them useful.
Send comments to [email protected].
1. Edsall RL, Adler KG. User satisfaction with EHRs: report of a survey of
422 family physicians. Fam Pract Manag. February 2008:25-32.
2. Adler KG, Edsall RL. The third FPM survey of user satisfaction with
EHR systems. Fam Pract Manag. May/June 2009:12-14.
| FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | November/December 2009
opinion
Toward a Modular EHR
Imagine being able to buy just the parts
of an EHR system that you need.
T
he remarkable report “Initial Lessons From the
First National Demonstration Project on Practice
Transformation to a Patient-Centered Medical
Home,” in the May/June Annals of Family Medicine,1
makes this point about the state of primary care information technology (IT): “Technology needed for the
PCMH [patient-centered medical home] is not plug
and play. … The hodgepodge of information technology
marketed to primary care practices resembles more a
pile of jigsaw pieces than components of an integrated
and interoperable system.”
Surprise! Well, actually, no surprise. We all recognize
that health IT implementation in family medicine
electronic health record (EHR) from a single vendor is
a noteworthy recognition of how our changing business
models in primary care intersect with a major shift in
the health IT market of products and services aimed at
primary care practices. It also signals that it’s time for the
AAFP to reconsider its recommendation that members
adopt comprehensive EHRs.
Modularization of the EHR
The shift from a vendor-centric approach to one that
is platform-centric and modular has been described at
length in the business and computing literature. Clayton M. Christensen, PhD, the noted Harvard Business
School professor and author of several books on innovation, has described this evolution at length, even coining
a “law of the conservation of modularity.”
EHR users are screaming for the features they need but getting
a lot they don’t need, at prices that seem like extortion.
practices, even under the best conditions and with the best
of planning, is difficult and can be an ongoing challenge.
What is surprising to me, however, is this comment in
the recommendations section of the article (which I’ll call
the Nutting Report, after lead author Paul Nutting, MD,
MSPH): “…[I]t is possible and sometimes preferable to
implement e-prescribing, local hospital system connections, evidence at the point of care, disease registries, and
interactive patient Web portals without an EMR.”
This is real wisdom, borne of collective experience
placed under the microscope by a study of PCMH
demonstration practices. The idea that it is “possible
and sometimes preferable” to implement components
or modular applications instead of a comprehensive
About the Author
Dr. Kibbe is senior advisor to the AAFP’s Center for Health Information Technology, chair of the ASTM International E31Technical Committee on Healthcare Informatics, and principal of The
Kibbe Group, LLC. Author disclosure: nothing to disclose.
Christensen explains that in some industries, when the
products are relatively new and not very good in terms
of performance, the early entrants must provide all of
the parts of the product by themselves. For example, if
you wanted to be in the computer industry in 1982, you
needed to manufacture the computer’s operating system,
the application software, the peripheral devices, the processors, etc. Even the cases housing the various components
came from a single producer. The product was “vertically
integrated.” IBM, Digital Equipment, Unisys and Wang
were all companies from whom customers had to buy the
entire package, including consulting. But over time, as the
performance of the product improves, the vertically integrated, highly proprietary companies whose approach was
what do you think?
The opinions expressed here do not necessarily represent
those of FPM or our publisher, the AAFP. Please send your
comments to FPM at [email protected].
| FAMILY PRACTICE
2009 | www.aafp.org/fpm
MANAGEMENT
Copyright © 2010 American Academy of Family Physicians. For theJuly/August
private, noncommercial
use of one individual
user of the
Web site. | All other rights reserved. Contact [email protected] for copyright questions and/or permission requests.
opinion
strongest during the early phases of the industry’s development give way to non-integrated and horizontally stratified companies whose products are capable of integrating
through standards, not by virtue of a single company’s
owning all the components. Christensen says this “looks
like the industry got pushed through a bologna slicer.”2
This happens because the basis of competition changes.
Customers become less willing to reward further slow
improvements in functionality (for example, adding a
registry on to an existing EHR, as described in the Nutting Report) by paying premium prices. Companies that
get better at giving customers exactly what they want (for
example, e-prescribing or a registry) when they want it and
at an affordable price earn attractive profit margins. And
they take business away from the vertically integrated firms.
Modularity, in effect, enables the dis-integration of
the industry. This is exactly what happened in the computer industry. By 2002, virtually every part of a PC was
modular and substitutable – and many of the leading
computer manufacturers of 1982, including three mentioned earlier, had gone out of business. During the same
period, Dell grew to dominate the industry without manufacturing anything, simply purchasing microprocessors,
memory, hard disks, etc., and assembling them according
to the wants and needs of the customer.
What’s happening in today’s EHR industry is analogous. Vertically integrated, top-tier companies such as
Allscripts, GE Centricity and NextGen would like to continue to sell comprehensive EHRs to their best customers, who will pay their highest prices at maximum profit
margins, often greater than 50 percent. But they are
struggling to add value fast enough and at a price individual practices can afford. The proof is seen in examples
throughout the Nutting Report and in countless practices
across the country as users try to get vertically integrated
vendors to respond quickly to their functionality needs
but find the workarounds and awkward installations
maddeningly frustrating. EHR users are screaming for
the features they need but getting a lot they don’t need,
at prices that seem like extortion.
In brief, we doctors have arrived at a next stage of
value addition for EHR technology, one at which faster
response, greater agility, convenience and lower pricing
have become as important as or more important than a
very long list of features and functions that are no longer
as useful or desirable as they once were perceived to be.
Transition and instability
Let’s repeat the Nutting quotation, seeing it now as a new
value statement: “...[I]t is possible and sometimes preferable to implement e-prescribing, local hospital system
connections, evidence at the point of care, disease registries,
and interactive patient Web portals without an EMR.”
10 | FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | July/August 2009
This is an explicit recognition of a sharpening focus on the
capabilities most important for primary care IT, and a call
for us all to recognize that circumstances have changed.
Implied by this new value statement is that these components ought to be plug and play. Makes perfect sense.
Modularize and integrate through standard interfaces.
Emulate the iPhone applications and Google Health. Drs.
Ken Mandl and Isaac Kohane recently described in the
New England Journal of Medicine3 the potential virtues
of an “interoperable and substitutable” platform for EHR
components, so the idea certainly has other adherents.
And yet right now, most of these components are not
plug and play. The market is in a state of transition, but
not yet stable. In fact, it’s worse than unstable. Top-tier
vendors like Allscripts and GE Centricity are digging
in and fighting the shift to plug-and-play modularity.
They’re doing this primarily through the Healthcare
Information and Management Systems Society, which is
lobbying hard to lock in federal policy that will discriminate against new entrants into the EHR market.
As reported in the Washington Post, they want the
Office of the National Coordinator for Health Information Technology to mandate that incentive payments
under the Health Information Technology for Economic and Clinical Health (HITECH) Act can go only
to EHRs certified by the Certification Commission for
Healthcare Information Technology (CCHIT) – that is,
comprehensive applications from single vendors.4
The AAFP is caught in the middle, supporting CCHIT
but also encouraging the government to open the door to
innovation by allowing physicians to qualify for incentive
payments if they adopt components of EHR technology –
precisely the ones mentioned in the Nutting Report. It
may, however, be time for the AAFP to take a more deliberate approach, one that recognizes the experience reflected
in the Nutting Report and tries to accelerate the rate at
which modular and component EHR technology becomes
interoperable and substitutable, i.e., plug and play.
How the transition to plug-and-play technology will
work out, only time will tell. A transition seems both
inevitable and likely to make life easier for practices of all
sizes. In the meantime, the health care IT marketplace will
continue to be an uncomfortable place for everyone.
1. Nutting PA, Miller WL, Crabtree BF, Jaen CR, Stewart EE, Stange KC.
Initial lessons from the first national demonstration project on practice
transformation to a patient-centered medical home. Ann Fam Med.
2009;7:254-260.
2. Christensen CM, Raynor ME. Innovator’s solution: creating and sustaining successful growth. Boston: Harvard Business Press; 2003.
3. Mandl KD, Kohane IS. No small change for the health information
economy. N Engl J Med. 2009;360:1278-1281.
4. O’Harrow R. Group seeks sway over e-records system. The Washington
Post. May 21, 2009.
How to Select an
S
o you’ve decided to purchase an
electronic health record (EHR)
system, and your initial research
reveals that more than 200 companies claim to make an EHR. You’ve barely
started looking, and already you feel overwhelmed. A natural tendency might be to
call a few vendors that you’ve read or heard
about and ask them for a demo. Stop. Unless
you want the vendors to control the selection process, you need a plan. Remember,
the EHR will have a huge impact on your
practice, going to the very heart of how you
practice medicine. A rushed or ill-informed
decision could make your life miserable.
This article is designed to help you develop that plan. By adhering to a logical and
systematic selection process, you’ll be able to
make a high-quality decision about which
EHR to choose. The process described
below is based on my experience and
research as an EHR committee chair for an
86-physician group. Although my group is
large, I work in an office of three physicians,
and I believe the following steps will apply
to practices of all sizes.
Electronic Health
Record System
These 12 steps will help make the selection
process easier and lead you to the EHR
that’s right for your practice.
i l l u s t r at i o n b y c u r t i s pa r k e r
Step 1: Identify your decision makers
If you’re in solo practice, this is easy. You’re
it. In a large group, a carefully selected committee will be more appropriate. Unlike,
perhaps, selecting practice management software, this should be a physician-led effort,
not one you delegate to your office manager
or management team. Many selection efforts
have been led by a “physician champion,”
someone absolutely committed to learning
about EHRs and promoting the idea to his
or her colleagues. This individual has to
be willing to put in a lot of extra, typically
Dr. Adler is a family physician in full-time clinical practice
in Tucson, Ariz. He has a Master of Medical Management
degree from Tulane University and a Certificate in Healthcare Information Technology from the University of Connecticut. Conflicts of interest: none reported.
February
2005 www.aafp.org
/fpmuse Fof
AM
I L Yindividual
P R A C T I Cuser
E Mof
AN
A GWeb
E M E site.
NT
11
Copyright © 2010 American Academy of Family Physicians. For
the private,
noncommercial
one
the
■
■
■
SPEEDBAR ®
➤➤
Form a physician-led
election committee
early in the selection
process.
➤➤
Be sure to include
your office manager
or practice administrator, since he or she
will have to be heavily involved in implementing the EHR your
group chooses.
➤➤
Before you start looking at specific systems, determine what
you hope to accomplish with an EHR and
identify the functionality you’ll need to
meet those goals.
uncompensated, hours doing research and
management tasks. Since you’re reading this
article, perhaps that’s you.
EHRs are often met with great skepticism and resistance. To avoid an aborted or
seriously delayed selection process or a failed
implementation, make sure that some of
your practice’s most influential people are
on the selection committee. You will need
at least one manager to help you implement
this system, so make sure your practice manager or his or her trusted delegate is on the
committee. If you have a key nurse or receptionist whom the others tend to follow, invite
him or her aboard. If you have a partner
who could easily derail this process, consider
inviting him or her to participate as well.
And remember, the most influential people
are not always the ones with the titles.
Step 2: Clarify your goals
What inefficiencies or limitations do you
have in your practice currently, and what do
you hope to accomplish with an EHR? Do
you waste a lot of time looking for charts?
Do you play phone tag with patients because
you don’t have ready access to needed information? Do lab reports take forever to get
into the chart? Are provider notes hard to
Key points
• To reduce your list of potential vendors to a
manageable length, consider only those systems
that have already developed interfaces with the
practice management software you use, that are
marketed to practices the same size as yours and
that are well rated in published surveys.
• How the EHR enables users to create and complete tasks, find information, view labs, manage
health maintenance reminders and write prescriptions can be more important than how easily it
creates a patient note.
read? Are you interested in electronic prescribing? Do you want to be able to print
appropriate patient education materials with
the push of a button? Do decision support
tools matter to you? Is patient e-mail or
Web access to your practice in your plan?
The list of EHR functionalities that
appears below may be a useful tool as you
begin to prioritize your needs.
Step 3: Write a request for proposal
This is a tedious but necessary step. A request
for proposal (RFP) will tell the prospective
vendor about your practice, its resources and
EHR functionality
This list, which includes most of the capabilities of EHRs, is designed to help you organize your priorities. As you
clarify your goals, you may want to rank each of these functionalities in order of need or divide the functions into
three groups: must-have, want-to-have and not critical.
external e-mail for patients
n Results reporting (lab, radiology, other)
n Secure
Web portal
n Order entry (lab, radiology, other)
n Patient
note creation options (templates, macros, diceducation
n Multiple
n Patient
tation, voice recognition, hand writing recognition)
n Scanning
E/M coding adviser
n Automated
Automated
chart documentation (problem lists,
n
medication lists, vital signs, health maintenance)
interfaces with internal and outside labs
n Software
writer and database (with online
charge entry
n Prescription
n Automated
formularies and drug-interaction checking)
reports (downloadable)
n Inpatient
Flow
charting
(labs,
vital
signs,
n growth
fax reports (dictation, lab, radiology)
n Electronic
parameters)
to outside specialists
access
n Remote
follow-up/health-maintenance
n Patient
deficiency alerts
ordering and tracking
n Referral
registration information
population analysis tools
n Patient
n Practice
(master patient index)
support tools
n Decision
message documentation and tasking
n Telephone
(audit trails, user access hierarchy, passwords)
n Security
e-mail
n Internal
12
■
FA M I LY P R A C T I C E M A N A G E M E N T
■
www.aafp.org /fpm
■
February 2005
pic k ing an ehr
your priorities in terms of EHR functionality.
The vendors’ responses will allow side-by-side
comparisons of products. Responding to a
well-prepared RFP will take a fair amount of
effort on the vendor’s part, so invite only serious contenders to participate. For a sample
RFP outline see below. A downloadable,
modifiable RFP is available at http://www.
orchardsoft.com/choosing/rfp/samplerfp.
html. It is an RFP for a laboratory information system, but the basic structure and questions will work for an EHR.
winnow the products: 1) Does the software
have a history of interfacing with your practice management system (PMS)? 2) Is the
EHR typically marketed to practices of your
size? and 3) Does the EHR have favorable
published ratings?
PMS interface. To avoid double entry
of data such as patient demographics and
diagnoses, your PMS and EHR must be able
to share data. This is typically done through
a software interface. To build and maintain an interface requires the cooperation
of personnel from both the PMS and EHR
Step 4: Selecting the RFP recipients
companies. Each time the EHR software is
How do you go from more than 200 produpgraded (and most good EHR products
ucts to a dozen without seeing any products? promise at least one upgrade per year), any
I suggest you use three defining criteria to
interfaces have to be updated. Many EHR
developers will say that they
can interface with any system,
request for proposal (RFP) outline
but frankly I wouldn’t want
to be their first. To determine
A request for proposal that follows an outline like the one below
which EHR companies have
will tell prospective vendors what they need to know about your
created interfaces with your
practice to provide you with useful information about their products,
PMS, ask your PMS company.
and it will help to ensure that the responses you receive can be more
This criterion alone may draeasily compared.
matically narrow the field.
I.Cover letter
If you aren’t happy with
II.Introduction and selection process
your
current PMS or anticipate
III.Background information about your practice
outgrowing
it soon, it may be
a.Size and location
a
good
idea
to
consider select
b.Current practice management system and any EHRs
ing a new one before you buy
c.Current computer hardware
an EHR. Ideally, the PMS and
d.Current network information
EHR company would be one
IV.Your practice’s desired EHR functionality (prioritized)
and the same, but your PMS
V.Vendor information
a.Company history
company may not offer an
b.Number of employees (separate numbers for sales, support,
EHR product, or if it does, it
research and development, and management)
may not offer the functional
c.Financial statements
ity or service that you feel
d.History of their EHR product
you need. As more physicians
e.List of all current EHR users and list of users similar to
buy EHRs, the trend of the
your practice in size and type (including how long they’ve
future will likely be integrated
been using the software and, ideally, what version they’re
EHR-PMS products that don’t
using currently)
require interfaces.
VI.Product description
Practice size. Most EHR
a.How it performs the functions described in section IV
vendors market their products
b.Other functions it performs
to smaller practices (one to
c.Product brochures, etc.
15 providers), medium-sized
d.Software versions and release dates
practices (10 to 99 providers)
VII.Hardware and network requirements
or large practices (greater than
VIII.Customer maintenance and support
100 providers,) although a few
IX.Vendor training
market to all sizes. Picking
X.Implementation plan
RFP recipients on this basis
XI.Interface history and capabilities
will help you avoid having a
XII.Proposed costs and payment schedule
“large practice EHR” declinXIII.Warranties
ing to respond to your RFP
XIV.Sample contract
because you’re “too small.” ➤
February 2005
■
www.aafp.org /fpm
■
SPEEDBAR ®
➤➤
Developing a request
for proposal (RFP)
will take significant
effort, but it will
impose some order on
the responses you’ll
receive from vendors
and make comparisons easier.
➤➤
To shorten the list of
vendors you’ll send
RFPs to, consider
whether the vendor
has already developed
an interface with your
practice management
software, whether it
markets its product
to practices like yours
and how it performs in
published ratings.
➤➤
If you are dissatisfied
with your practice
management software, it would be a
good idea to replace
it before you select
an EHR.
■
13
SPEEDBAR ®
➤➤
Published ratings of
EHRs from organizations like Aurora
Consulting Group, the
annual TEPR conference and the AAFP’s
Center for Health
Information Technology can be valuable
resources to your
selection committee.
➤➤
You should narrow the
field before scheduling vendor demonstrations to ensure that
you won’t have an
impractical number of
sessions to attend.
➤➤
During vendor presentations, be prepared
to present the vendor
representatives with
patient-visit scenarios
to document so that
you’ll see more than a
canned presentation.
➤➤
Develop a rating form
and be sure that each
committee member
fills it out at the end
of the demo.
14
■
And it will prevent you from wasting time
reviewing an RFP response from a vendor
whose product turns out to be ill suited for
a practice of your size. You can obtain information on who markets to whom in a useful
free white paper by Mark Anderson entitled
“2004 EMR Functionality Survey Results,”
which is available at http://www.acgroup.
org/pages/396843/index.htm.
EHR ratings. Several excellent sources
for EHR ratings are available. In 2003, the
American College of Rheumatology, in conjunction with the Aurora Consulting Group,
evaluated EHRs in small practices. Go to
http://www.rheumatology.org/products/
coding/03emr_ack.asp to download their
50-page paper. Other ratings sources include
the Health Information Management Systems Society (http://www.himss.org) and
a Web site developed by Kirk G. Voelker,
MD, at http://www.elmr-electronic-medical-records-emr.com. And if you want to
go to one place where more than 150 vendors show their wares, consider the annual
conference known as TEPR (Toward an
Electronic Patient Record). Information on
this can be found at http://www.medrecinst.
com/conferences/tepr/index.asp.
Finally, go to the AAFP’s Center for
Health Information Technology, http://
www.centerforhit.org, for information on
EHR vendors that have agreed to the center’s principles of affordability, compatibility,
interoperability and data stewardship. AAFP
members can get discounts on several wellknown systems, and the AAFP has arranged
for purchases to be made on a subscription
basis, with monthly payments.
Step 5: Review the RFPs and
narrow the field
So you’ve narrowed the field, sent out the
RFPs and received your responses. Now it’s
time to review the responses. Your goal is
to pick the top contenders to visit you and
give a demonstration of their system. These
are typically two- to three-hour affairs in
the evening with some health food – such as
pizza. Everyone on the selection committee
should attend every demo in order to make
fair comparisons. This is a huge time commitment, and your group’s willingness to
spend evenings away from their families will
determine how many demos you can tolerate. Our group chose five from an original
field of eight. Of those that were eliminated,
■
www.aafp.org /fpm
■
February 2005
one vendor decided not to respond, one
vendor didn’t meet our training and service
needs, and one didn’t meet our deadline.
Step 6: Attend vendor demonstrations
Next, it’s show time. Vendors will typically
arrive for the demo with two to four people
– one to two sales personnel, a skilled software presenter and perhaps a physician who
is paid by the company. They’ll be prepared
to do a canned presentation that shows their
software in the best light. For each of these
presentations, you should do four things:
• Present them with one or two standard
patient-visit scenarios to document, keeping
the scenarios consistent from vendor
to vendor;
• Try not to interrupt their demonstration every two minutes (my group was notorious for this);
• Don’t focus solely on ease of note creation. Instead, pay attention to how the
EHR enables users to find information, view
labs, manage health maintenance reminders, write prescriptions, etc. These functions
can be more important than how easily the
EHR creates a patient note;
• Prepare a rating form in advance and
ask every committee member to complete
it at the end of each demo. You can then
tabulate average or median results for each
vendor. See the sample rating form on the
opposite page.
Step 7: Check references
Check at least three references for every
vendor that is still in the running. Ideally,
references should include one or more physician users, an information technology (IT)
person and a senior management person.
The vendor will provide you with a list of
references – likely the vendor’s happiest
customers, who may be financially rewarded
for talking to you (e.g., discounts on service
fees or individual rewards), so be skeptical.
Nonetheless, these folks can be very informative and honest, in my experience. If you
know a person or group not on the vendor’s
reference list that uses or has used their
product, call them too. Have a prepared list
of questions for these phone calls. A sample,
structured interview is shown on page 60.
Another way to find references is to post a
message on the AAFP-sponsored e-mail discussion list for EHRs. AAFP members can
subscribe at http://www.aafp.org. From the
EHR DEMONSTRATION RATING FORM
-----------------------------------------------------------------------------------------------------
Each person who observes vendor demonstrations should complete a form like the one below. The form you use should list the functionality that
your selection group decided was most important to your practice. To analyze the results, assign 1 point to strongly disagree, 2 to disagree, 3 to
unsure, 4 to agree, and 5 to strongly agree. Calculate average scores for each function and print a summary score sheet for each vendor.
PRODUCT:__________________________________________________________________
DATE:_______________________________________________________________________
EVALUATOR:________________________________________________________________
Please evaluate the product based on all the information you have available at this time. If you need more information, please note that in your comments.
I. FUNCTIONALITY: This product performs the following functions with little user effort:
Strongly disagree
Disagree
Unsure
Agree
Strongly agree
Results reporting (lab/X-ray)
Progress/consult notes
E/M coding
Telephone message documentation and tasking
Chart documentation (problem list, medication list,
allergies, vital signs, health maintenance, trending
lab values, etc.)
Order entry (lab/X-ray)
Prescription writer
Formularies
E-fax to outside physicians
Remote access (e.g., to off-site transcription or
physician’s home)
Referral management
Charge capture without manual entry
E-mail (encrypted)
Health maintenance alerts
Medical decision support tools
Patient education materials
Security (passwords, audit trails)
Comments:____________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
II. OVERALL EASE OF USE AND FLEXIBILITY
Strongly disagree
Disagree
Unsure
Agree
Strongly agree
This product allows individual user-specific customization
This product minimizes user data input
This product offers multiple note creation options
Comments:____________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Developed by Kenneth G. Adler, MD, MMM. Copyright © 2005 American Academy of Family Physicians. Physicians may photocoopy or
adapt for use in their own practices; all other rights reserved. “How to Select an Electronic Health Record System.” Adler KG. Family Practice
Management. Feb 2005:55-62; http://www.aafp.org/fpm/20050200/55howt.html.
SPEEDBAR ®
➤➤
Check several references for each EHR
you’re considering,
and go beyond the list
of references the vendor provides you.
Questions to ask EHR references
A
list of questions like this one will help you to make the most of your opportunities to talk with other practices
about their experience with the EHRs you’re considering purchasing.
Background
Training & support
• How many physicians/nurse practitioners/physician
assistants are in your group?
• How long does it take a physician to become fully
trained/efficient in using the EHR?
• How many office sites do you have?
• How long does it take a medical assistant to
be trained?
• What year did you go live?
• What practice management software do you use?
• Do you own your own lab?
Does the EHR interface with your lab?
➤➤
A vendor rating tool
can help you narrow
your list of contender
to two or three, which
will be the focus of
your site visits.
➤➤
Your rankings should
be weighted to reflect
the relative importance to your group of
functionality, cost and
vendor characteristics.
• How many interfaces do you have with the EHR?
Provider usage
• What percent of your providers use the EHR?
• What kind of support system did you set up for
the EHR? How many full-time support people
are required?
• Have you been happy with the upgrades and support?
• Do you have an EHR committee? An IT medical
director? Are physician “champions” involved in the
maintenance, training and upgrading of your EHR?
• What functions do most/all of your providers use?
Implementation & hardware
• Do your providers still dictate?
•D
id the implementation go smoothly?
How long did it take?
• What has been the most frustrating thing about
the EHR for the providers?
• What has been the best thing?
•D
o you have a wide area network (WAN)?
How much bandwidth is used?
• How much individual physician customization
is there?
• Was the EHR preloaded with CPT and ICD-9 codes?
Was it preloaded with formularies?
• Are you happy with the templates? Were they
pre-loaded? How do they get modified?
• What hardware do the physicians use?
What hardware do the medical assistants use?
• Have you saved money? Have you broken even?
• If you are using a wireless network, how well
does it work?
• Does electronic prescribing work?
• Does e-faxing work?
• How have patients responded to the system?
• Can your physicians access the system from home?
How do they do this?
• How much of the paper chart did you scan or input
into the EHR? How did you do it?
• Do you still use paper?
If paperless, how long did that take?
Satisfaction
• Would you buy this system again?
• What would you do differently?
➤➤
Don’t underestimate
the importance of service, training, implementation support
and the long-term
viability of the vendor
and the product.
16
■
AAFP home page, click on e-mail discussion
lists, under the Membership heading.
Step 8: Rank the vendors
Now that you’ve reviewed the RFPs, seen
the demos and done the reference checks,
it’s time to rank the vendors and narrow the
field to two or three vendors for site visits.
Given the time and resources involved,
doing more than three visits is impractical.
Even one visit could be a challenge for a
busy solo physician.
Before you rank the vendors, you should
formally weigh your priorities in the following areas:
• Functionality. How well does the
product perform your desired functions?
• Total cost. How much will the
■
www.aafp.org /fpm
■
February 2005
product cost, including hardware, software,
support, etc.?
• Vendor characteristics. Does the
vendor offer excellent service, training and
implementation support, and are they financially secure?
Most physicians tend to put too much
emphasis on functionality and cost while
ignoring the critical nature of service, training, implementation support and the longterm viability of the vendor and product. If
the system is not effectively implemented or
maintained, it will not achieve its desired
potential. And it will be more than a small
inconvenience if the vendor you know and
love goes bankrupt. We put a 40-percent
emphasis on vendor characteristics, 40 percent on functionality and 20 percent on
vendor rating tool
-----------------------------------------------------------------------------------------------------
For each EHR product you are considering, assign a ranking from 1 to 5 (with 5 being best) for each of the criteria listed in the functionality and
vendor characteristics categories below. Total the rankings for each vendor to determine a combined score for each category, then assign an overall
ranking. For the cost section, supply a dollar amount for each criteria listed and then rank each vendor based on your assessment of its total initial
and total annual costs. Next, consider the relative importance of the three categories and assign a percentage to each (e.g., functionality = 40 percent,
cost = 20 percent and vendor characteristics = 40 percent). Finally, use these percentages to calculate the weighted scores for each vendor.
Functionality
Vendor 1
Vendor 2
Vendor 3
Vendor 4
Vendor 5
Vendor 1
Vendor 2
Vendor 3
Vendor 4
Vendor 5
Vendor 1
Vendor 2
Vendor 3
Vendor 4
Vendor 5
Vendor 1
Vendor 2
Vendor 3
Vendor 4
Vendor 5
Quality/presence of features we prioritized (see demo rating summaries)
Ease of use (e.g., minimizes typing, is intuitive, simple layout)
Speed (network/hardware configuration, minimizes keystrokes)
Individual user flexibility
• Multiple note creation options (transcribe, voice, template)
• Provider can modify/create own templates
• Provider can create own macros
Preloaded templates and patient education
Combined functionality score (total the rankings for each vendor)
A Overall functionality ranking
COST
Initial hardware and network upgrades
Initial interfaces
Initial software
Total initial cost
Annual software maintenance (includes upgrades and support)
Annual interface upgrades
Total annual cost (excludes initial costs)
B Overall cost ranking
vendor characteristics
Training
Support
Implementation
Software upgrades
Company stability
Combined vendor characteristics score (total the rankings for each vendor)
C Overall vendor characteristics ranking
D Functionality
%
E Cost
%
F Vendor characteristics
%
should total 100%
overall ranking
G Weighted functionality score ((A 3 D) ÷ 100)
H Weighted cost score ((B 3 E) ÷ 100)
I Weighted vendor characteristics score ((C 3 F) ÷ 100)
Weighted overall score (G + H + I)
Final Ranking
Developed by Kenneth G. Adler, MD, MMM. Copyright © 2005 American Academy of Family Physicians. Physicians may photocopy
or adapt for use in their own practices; all other rights reserved. “How to Select an Electronic Health Record System.” Adler KG.
Family Practice Management. Feb 2005;55-62; http://www.aafp.org/fpm/20050200/55howt.html.
SPEEDBAR ®
➤➤
A thorough analysis of
each vendor’s costs is
critical; a spreadsheet
can help sort out the
costs and facilitate
comparisons.
cost. The sample vendor rating tool on page
61 breaks the selection criteria into these
same three categories. (For another example,
go to http://www.chcf.org/topics/view.
cfm?itemID=21520.)
Cost estimates can be tricky. Vendors tend
to present these in a way that makes side-byside comparisons difficult, and they focus only
on software costs. Be sure to do a comparative
spreadsheet that captures all associated costs
over the first five years including new hardware
costs, new IT personnel, network upgrades,
extra licenses and annual service and maintenance. [One such spreadsheet can be down-
the rest of the practice is with you. If you’re in
a small practice, hopefully you’ve involved all
the key decision makers in the process to this
point. If so, you can skip this step.
If you’re in a larger practice, or one that
has some potential naysayers, discuss your
selection committee’s recommendations with
all the relevant stakeholders. Be prepared to
“sell” your group on the EHR concept and
this particular vendor. Invite the vendor to
give another demo to the practice as a whole
and be prepared to address a slew of questions
and concerns. If significant concerns come
to light that your committee didn’t address
➤➤
When planning site
visits, target practices
that are similar to
yours in size and, if
possible, ones that
use the same practice
management software
that you use.
➤➤
Select your winner
and a runner-up; having a good second
choice will give you
more negotiating
leverage.
➤➤
Negotiate a contract
only after shoring up
the support of all the
stakeholders in your
practice.
Vendors tend to present their costs in a way that makes side-by-side
comparisons difficult, and they focus only on software costs.
loaded from the FPM Web site at http://www.
aafp.org/fpm/20020400/57howm.html#1.]
When we did this for our top four choices, we
found the costs to be surprisingly similar.
previously (if you did your homework, that’s
unlikely), be prepared to drop back to step
seven and repeat any steps necessary to solidify your practice’s commitment to the EHR.
Step 9: Conduct site visits
Once you’ve selected your final contenders,
plan site visits to see how the systems perform. Go to practices that are similar in size
and configuration to yours. If possible, go to
one that is using the same PMS that you are
using. Bring at least one physician and the
most senior management person that will be
responsible for the EHR purchase. Plan to
visit with physicians and observe them with
patients. Also talk to back-office personnel, relevant management and the practice’s
key IT personnel. Take notes. Use the visit
to confirm or contradict your expectations
of the product based on what you learned
through the RFP, demo and references.
Step 12: Negotiate a contract
Typical EHR contracts span from 10 years
to lifetime. If the contract is to terminate in
10 years, be sure you know what happens
after that. Current and future costs should
be spelled out, as should the role the vendor
will play and the amount of time the vendor
will commit to the implementation process.
Be sure to consider the possibility that the
vendor could go out of business before you
do. Request that the vendor’s source code
be put into escrow, and clarify the circumstances under which you could get access
to it. Have a lawyer experienced in software
contracts help with this step.
Step 10: Select a finalist
After each site visit, go back to your vendor
ranking and see if it still holds. Select your
top contender and a runner-up. If negotiations don’t go well with your number
one choice, you may want to fall back on
number two. Also, having a serious back-up
choice will give you more leverage in the
negotiation process.
Step 11: Solidify organizational
commitment
Now that you have picked the vendor you’d
like to do business with, it’s time to make sure
18
■
■
www.aafp.org /fpm
■
February 2005
Final note
The EHR selection process is time consuming, but for a decision as important as this
one, it’s necessary. You can’t afford to purchase an EHR impulsively, and you want
to make sure your practice is with you. The
entire process can take from six months
to two years. Our group took 13 months,
which I suspect is about average. If your
selection process is methodical, critical and
inquisitive, you will undoubtedly be happy
with your final EHR choice. Good luck on
your quest.
Purchasing an
Affordable
Electronic Health Record
An economy model may provide all the
functionality your practice needs.
Louis Spikol, MD
I
i l l u s t r at i o n b y r i c h l i l l a s h
have a secret for you. In the world of electronic
health records (EHRs), especially EHRs in small
family medicine practices, bargains may await you.
I’ve driven both the luxury and economy models of
EHRs, and so far, relative to what you get for
your money, the economy models are
winning. The economical EHR offers
70 to 80 percent of the functionality of the luxury EHR at a fraction of the price. Some of the
software available was even
developed by family physician
entrepreneurs, either out of
desperation or as a labor of
love within their own practices. Thanks to their sweat and
compulsion, you can find complete, reliable, reasonably priced
software for your practice today.
EHR, which I define as less than $3,000 for the software
alone, should have the capability, either independently or
with inexpensive paper management software, to achieve
an office with no paper charts. This is essential, as the
What should
your EHR do for you?
The trick to finding the right software at the right price is to know
what your practice needs – and
what it doesn’t. Many of the bells
and whistles that come with the
more expensive, luxury models may
be superfluous to the typical family medicine practice. An inexpensive
Dr. Spikol uses an EHR for his full-time office practice, which is part of Lehigh Valley Physician Group in Allentown, Pa. Conflicts of interest: none reported.
February
2005 www.aafp.org
/fpmuse Fof
AM
I L Yindividual
P R A C T I Cuser
E Mof
AN
A GWeb
E M E site.
NT
19
the private,
noncommercial
one
the
■
■
■
SPEEDBAR ®
➤➤
Inexpensive electronic health records
(EHRs) offer many of
the same features as
expensive EHRs at a
fraction of the price.
➤➤
If you know what EHR
features your practice
needs, you will be in a
better position to shop
for an inexpensive
EHR.
➤➤
Many of the bells and
whistles that come
with expensive EHRs
are unnecessary for
small family medicine
practices.
➤➤
For features like basic
interface appearance
and integration with
practice management
software, an inexpensive model can
be easier to use and
just as effective as a
pricier model.
20
■
return on investment in an electronic record
depends heavily on the elimination of paper
charts. However, I’m convinced that there
are four costly EHR features small family
medicine groups can live without:
• Expandability. The ability to transfer
the record from one physician to hundreds,
encompassing practices separated by location.
• Granularity. The ability to limit access
of various groups of physicians, secretaries and
nursing staff to specific areas of the chart.
• Customization. The ability to set up
the record (usually for an added cost) to
satisfy specific needs.
• Cross-specialty functionality. The
ability to use the record with multiple specialties across a medical enterprise.
These four features can add a substantial
sum to the cost of your EHR. Although
large medical groups may find them beneficial, it is likely that you don’t need them. If
you aren’t convinced your practice will use
them, don’t waste your money.
Basic EHR functions
Among the vast array of EHR functions
currently available, there are some basic
features you should look for. Some of the
more expensive models do offer enhanced
versions of these features, as I explain
when applicable, but the key to finding
an affordable EHR is to evaluate each
feature’s importance to your practice’s
daily operations. As you read through
the features, keep in mind your practice’s
needs so you can distinguish what is
necessary from what is not.
Key points
• Even small practices can afford an electronic
health record system that contains all the features they need, including note creation, integration with practice management and billing
software, and electronic prescribing.
• Some EHRs cost less than $3,000 and have the
ability to support a paperless office.
• E xpensive EHRs often contain features that are
unnecessary for a small office and may detract
from the EHR’s overall usefulness.
by features that will add more complexity
and time.
Note creation. This aspect of the EHR
is usually at the forefront of doctors’ minds.
Price does seem to have some bearing on
how this feature is implemented, so this
may be the place to splurge. Usually, but
not always, more expensive products have
sophisticated macros consisting of text
expanders or documentation dialog boxes.
Text expanders are small groups of words
that, when selected, expand into full text
for documentation. I tend to prefer them to
dialog boxes as they allow the physician to
work in one continuous window.
On more expensive EHRs, you can add
templates and macros to streamline documentation for common visits in your practice. However, inexpensive EHRs created
by physician programmers are more likely
to offer you the ability to reuse previous
dictations and other information, which
is a helpful feature.
I’m convinced that there are four costly EHR features
small family medicine groups can live without.
Basic interface appearance and functionality. Many of the less expensive products have simpler, well-laid-out screens with
minimal switching between screens and
minimal pop-up screens. The primary interface is often a tab-top menu, which is fairly
intuitive, much like paper charts. Some of
the more expensive products have features
such as pop-up calendars and hyperlinks,
which, although nice, can add undue complexity. Make sure you take a good look at
the basic interface and do not be influenced
■
www.aafp.org /fpm
■
February 2005
Scanning and paper management. This
is a key feature if your office intends to eliminate paper charts and electronically store all
patient information (including consultant’s
notes, lab reports, X-rays, etc.). Less expensive EHRs may not include the ability to
scan documents at all, but you can add this
function by purchasing a third-party product. Look for more expensive EHR solutions
to be able to scan multiple-page documents
directly into the patient’s chart.
Integration with practice management
aff o r d a b le ehr
SPEEDBAR ®
Do not be influenced by features
that will add more complexity and time.
and billing software. These features are
available on products of all prices. The less
expensive products are generally fine for
smaller practices since the more expensive
products are meant to be expandable over a
larger and more varied physician population.
Database structure. Inexpensive EHRs
generally function with simpler, less expensive databases. This usually puts an upper
limit on the number of users of such records,
so make sure you understand the limitations and abilities of the underlying database
before you buy.
Prescribing module. Inexpensive and
expensive electronic records offer the same
core functions: printing legible prescriptions, renewing prescriptions, compiling
favorite prescription lists, printing one or
multiple prescriptions at a time, and keeping
track of expired prescriptions and medica-
➤➤
tions that did not work. Luxury features
found in higher-priced products might
include allergy checking, drug interactions,
prescription plan cross-checking and clinical decision-support with medication names
and dosages in a list.
Problem list. The functionality and style
of the problem list varies between products
and seems to have no relationship to price.
I have not found a problem list in an EHR
that I considered particularly complete or
user-friendly. You should look for problem
lists that answer the following questions to
your satisfaction:
• Are you able to link a problem with the
ICD-9 code?
• Does the electronic record force you
to use an ICD-9 code and prevent free text
entry?
• Does the problem list allow you to filter
Scanning and paper
management is a key
feature for an EHR if
you intend to eliminate paper charts from
your office, which
should be your ultimate goal.
➤➤
Many affordable EHRs
offer free downloads
from their Web sites
so you can try them
before you buy.
Inexpensive EHR Options
B
efore you invest in an electronic health record (EHR), experiment with several products, such as those listed here. Some programs can be downloaded from the Internet for a trial run, or for a few hundred dollars, you can purchase one and test it out. Many EHRs are modular in nature, which
means you can buy the initial product for a reasonable price and add modules as desired.
Price
Highlights
Imaging
Trial
Developer
SOAPware
http://www.docs.com
$300-$3,999,
basic module
$300
Ability to link to practice
management software;
modular software and large
number of primary care
templates available; large
user base; network capable.
Optical character recognition
(OCR) and
imaging modules available.
No; Web
demo or demo
CD available.
Randall Oates, MD
(family physician)
Amazing Charts
http://www.amazingcharts.com
$500
Integrated practice management and billing; network
capable.
Version 2 beta
has imaging.
Yes; download
from the Web.
Jonathan Bertman, MD
(family physician)
SpringCharts
http://www.springcharts.com
$700 (single
computer),
$2,600 (three
computer
network)
Practice management and
EHR; Java enabled; will work
on PC, Macintosh and Linux
platforms; network capable.
Single page
jpeg.
Yes; download
from the Web.
A team of physicians
and technology
professionals
Cottage_Med
http://mtdata.com/~drred/
Free but requires
FileMaker Pro
Customizable; will work on PC,
Linux or Macintosh platforms.
Multi page.
Download
FileMaker Pro
demo from the
Web.
Stefan Topolski, MD
ComChart
http://www.comchart.com
$500 for single
user version
(one computer)
Will work on PC and Macintosh platforms; runs with
included version of FileMaker
Pro; network capable.
OCR.
Yes; download
from the Web.
Hayward Zwerling, MD
February 2005
■
www.aafp.org /fpm
■
■
21
SPEEDBAR ®
➤➤
Regardless of how
much you spend, your
office must work
together to make
implementation
successful.
➤➤
An affordable EHR
implemented carefully
will save you just as
much time and money
in the long run as an
expensive EHR.
22
■
active and inactive problems as well as different types of problems?
• Does the problem list link in some way
to the assessment and plan so you can easily complete the encounter note and bill for
your services?
Reminders and communication. Many
of the less expensive EHR programs have
simple methods for facilitating communication among small numbers of physicians
and staff and for generating care reminders. Expensive EHR products usually allow
a large number of physicians and ancillary
staff to communicate, as well as attach pertinent areas of the electronic chart to the
communication. Some of the more expensive
products have fairly mature reminder systems, which can track studies, such as mammograms and anticoagulation treatments,
from the initial order to the final result.
Health maintenance. Both less expensive and more expensive EHRs can have
health maintenance sections. Look for the
product’s ability to incorporate guidelines,
and, in more expensive products, the flexibility to set the guidelines yourself.
■
www.aafp.org /fpm
■
February 2005
Motivation, perspiration
and implementation
Learning which features you need and which
are expendable is a crucial first step to purchasing an EHR. Remember, success with
your EHR system will depend not on how
much money you invest but on how much
time you invest in research and implementation. When all the factors are weighed, no
matter which EHR system you choose or how
much you spend, it is vitally important that
your office work as a team to make implementation successful. A less expensive, modestly-featured product implemented carefully
is better than a more expensive, fully featured
product implemented in a shoddy fashion.
With this in mind, you can achieve the
twin goals of eliminating paper records and
completing your charting in real-time during the patient visit, regardless of the price
of your EHR. The payoff will be an EHR
that meets your practice’s expectations, saves
you time and money, and helps you provide
better patient care.
Why I Love My EMR
William D. Soper, MD, MBA
illustratio n s by jen s bon nke
I
Two years after he took his practice digital, the author
addresses the concerns of others who contemplate leaving
paper records behind.
f you’re like a lot of family doctors – at least those who
Since there are no longer charts to shelve, we no longer
aren’t thinking about retirement in the next few years – need a file clerk. Medical offices generally require one file
you’ve probably thought about buying an electronic
clerk per three physicians. Switching to an EMR saves
medical record (EMR) system. Although EMRs offer
one-third of a file clerk’s salary and benefits for each physipotential long-term savings, you may be worried about
cian in the practice.
the start-up cost or daunted by the implementation
Not having paper charts also means not having to rent as
process. You may also fear, consciously or subconsciously,
large an office space. If you’re like I used to be, you’ve probthat the learning curve may be too steep. All of these are
ably never really thought about the amount of physical
pretty good reasons to postpone going digital.
space paper charts occupy. But consider this: If your charts
I had these same apprehensions and experienced the
take up 200 sq. ft. of space and you’re paying $15 per sq. ft.
same inclination to hang onto my paper-based ways.
in rent, that’s $3,000 a year out of your pocket. And, since
Then, a couple of years ago, I opened a new office, did
our EMR system, like virtually all EMR systems, integrates
the math and decided that I
ICD-9, CPT and HCPCS
couldn’t afford not to install
codes into the record automati
A couple of years ago, I opened a new cally, we no longer need a codan EMR. The process wasn’t
exactly easy, and it was initially
office, did the math and decided that I ing clerk. We also save staff
time. Our nursing assistants
more expensive than I’d anticicouldn’t afford not to install an EMR.
estimate that using an EMR
pated, yet it was one of the best
saves them each two hours a
decisions I ever made. Now, I’d
day in requisitioning, obtaining, reviewing and dispensing
never consider going back to paper charts.
charts needed for phone calls, refills, etc.
Because of my experience, I often talk to colleagues
Not only does my EMR reduce expenses; it has also
who are considering taking the EMR plunge. Since I
enhanced revenue. Reimbursement improved because the
suspect many of their concerns are similar to yours, let
billing staff has immediate access to our records, minimizing
me address those I frequently encounter here.
the time and effort needed to substantiate a claim or to challenge a denial. My per-visit income has increased because I
An EMR is too expensive
am confident my record adequately supThere’s no question about it. Buying and installing an
ports more aggressive coding. In
EMR system represents a significant capital investment.
I spent about $60,000 for software, hardware, installation addition, the system
helps me determine
and training for my three-physician practice. Yet my systhe level of
tem completely paid for itself within a year of buying it.
It substantially lowered my overhead by reducing my transcription costs. At 11 to 15 cents per line for transcription, the cost savings add up quickly. (To determine
your potential savings, use the calculator available
online at www.aafp.org/fpm/20021000/
35whyi.html or see the box on page 37.)
EMRs also reduce overhead costs in other ways.
For example, by not having to make paper charts,
we save $3 to $6 in raw materials per new patient.
That may not sound like much, but if your practice
sees 100 new patients per month, using paper charts
can reduce your annual gross income by $7,000.
---------------------------------- - Soper is in private practice in Kansas City, Mo., and is a member of the FPM Board of Editors. Conflicts of interest: none reported.
Dr.
the private,
noncommercial
one
site.
October
2002 www.aafp.org
/fpmuseFof
AM
I L Yindividual
P R A C T I Cuser
E Mof
A Nthe
A GWeb
EMEN
T
23
■
■
■
SPEEDBAR ®
➤➤
Buying an EMR system
requires a significant
capital investment,
but the overhead costs
associated with paper
charts can also be
substantial.
➤➤
For example, paper
charts require more
physical office space,
a file clerk and the
use of transcription
services.
➤➤
The author finds using
an EMR helps him
better care for his
patients.
➤➤
It allows him to print
complete and legible
prescriptions and get
information at the
point of care when he
needs help with any
thing from a dosage to
a diagnosis.
evaluation and management (E/M) coding justified by the documented services. And associated charges such as surgical trays, injection
fees and drawing charges are automatically
added to the charge list.
I don’t need an EMR to be a good doctor
Very true. An EMR isn’t going to replace
knowledge, hard work and human compassion, but I’ve found that I do a better job caring for my patients and am less stressed when I
use one. Templates in the program remind me
of questions I might not think to ask a patient.
The medication and problem lists automatically warn me if I enter a prescription for a drug
my patient is allergic to or one that interacts
with another drug the patient is taking. And
when I’m unsure of a dosage or contraindication, or when I need help determining a differ
ential diagnosis, I can get the information I
need in a couple of mouse clicks.
Like most good systems, my EMR has hundreds of patient education files I can print out
and modify to fit my patients’ needs. I often
print out a copy of the record for the patient to
take home. I’ve found this written documentation to be a good motivator for patients who
need to change their lifestyles, and a help for
those who don’t retain everything we’ve discussed. The EMR also allows me to print legible
and complete prescriptions. Since it “remem
bers” prescription-related instructions once I’ve
entered them, I can provide much more comprehensive information to patients and pharmacies
in less time, reducing the likelihood for errors.
Is it safe to keep
my records on a computer?
Records on my EMR are backed up twice a day
and are invulnerable to crashes because every
keystroke is saved. When I was using paper
records, I had two occasions where someone
stole a chart. And, we lost charts – at least temporarily – more often than I care to admit. The
office also caught on fire once. Fortunately, it
was quickly contained and didn’t reach the area
where records were stored. Had the fire started
when no one was in the office, it would have
been a different story. Today my backup tapes
are stored off-site in three different locations.
What if the electricity goes off?
If the electricity went off, my uninterruptible
power source (i.e., a battery that keeps the system operating for 10 to 30 minutes) would signal the server to start shutting down the system
24
■
■
www.aafp.org /fpm
■
October 2002
key points
• The process of choosing an EMR system and
getting it up and running can be so overwhelming
that some physicians avoid purchasing one.
• The author was initially apprehensive but now
calls purchasing an EMR “one of the best decisions
I ever made.”
• EMRs can help increase reimbursement, reduce
overhead costs, decrease errors and save staff time.
in an orderly way rather than letting it crash.
We would have to stop seeing patients, but this
is something we had to do when we used paper
records and didn’t have light to read by.
And if you’re wondering about losing data
in hard-disk crashes, we have mirrored dual
hard drives – that is, two hard disks that both
store the same data simultaneously – to keep
all our data safe even if one disk crashes.
What about patient confidentiality?
Some patients are concerned that computer
records could be susceptible to “hacking.”
When I explain that the records reside on a
server physically located in the office, that each
person in the office has to access the system by
a password, and that the system has nothing to
do with the Internet, they stop worrying.
Initially, we were concerned with how safe
it was to leave a patient unattended in an exam
room with an EMR workstation. In nearly two
years, we’ve yet to encounter a patient trying to
hack into our system, nor have we encountered
children playing with keyboards or getting into
wiring. Also, once a physician signs off on a
patient record, it cannot be altered in any way.
What about HIPAA?
Reputable EMR vendors have already programmed or are in the process of programming their systems to meet the security
regulations of the Health Insurance Portability
and Accountability Act (HIPAA). Although
these rules have not been finalized, they are
expected to require rigid access control and
audit trails to protect personally identifiable
health information [see “A Problem-Oriented
Approach to the HIPAA Security Standards,”
FPM, July/August 2001, page 37].
Where do I find time
to learn a new system?
I don’t have a good reply for this. There were
times the first couple of weeks when I was
emr s y s tem s
strongly tempted to give up and go back to
dictation and paper. I had to keep reminding myself that the long-term results were
worth the short-term pain.
How physicians and staff learn to use an
EMR will vary by learning style and by individual experience and comfort with computers. It will help if you are already reasonably
computer literate. We found learning the system was not nearly as challenging as we’d
feared. Since our office staff was familiar with
computers and used Windows for other appli
cations, we learned the system by reading the
training manual, using training disks and
“playing” with a training database. We then
held several staff sessions to teach one another
what we had learned. As a result, we used the
EMR with all our patients the first day we
went “live.” Most of us were reasonably comfortable with the system within a week and
quite comfortable with it after about a month.
Others may prefer more didactic approaches. Many EMR vendors offer training sessions
on site or at their facilities, CD-ROMs or
Internet-based training sessions. On-site
training can be very expensive, so find out
what alternatives the vendor can provide you.
How can I convince doctors
who are dragging their feet?
There’s no need. It’s OK if some physicians
want to continue to dictate their notes. The
transcriptionist simply enters the data into
the EMR rather than a word processing program. Often as doctors become more comfortable, they’ll gradually do more and more
direct entry and eventually become full EMR
users. Unfortunately your practice will still
incur transcription expenses, but it will get
the other benefits of the EMR.
A solution for some practices is to implement an EMR in stages, with the “early
adapters” going first. You may want to give
doctors using the EMR a bonus in return for
the cost savings their activities produce. This
may also motivate the physicians who are dragging their feet. Their transition can be eased by
the support and advice of the early adapters.
Some doctors are intimidated because of
weak keyboarding skills and unfamiliarity
with point-and-click entry. Most will pick up
these skills naturally the more they use them,
SPEEDBAR ®
➤➤
Admittedly, learning a
new system does
require effort and a fair
amount of time, and
the learning curve for
some EMRs is steeper
than for others.
➤➤
The best way to intro
duce an EMR to physi
cians who are reticent
about using one may
be to do it in stages,
with those more com
fortable going first.
How much will you save with an EMR?
To determine how much you can save switching from paper records to
an electronic medical record (EMR) system, you’ll first need to figure out
how much you’re currently spending on transcription costs. If you don’t
have the information from an annual report, you can estimate it easily. To
do this, check several patient records to determine the average number of
lines transcribed per patient encounter. Also, determine the average num
ber of patients you see per day. Locate these numbers in the first two
columns in the chart and the amount you pay per line in the third column.
Following the row across will show you what you currently pay for tran
scription services – which is how much your gross income would rise once
you’ve paid off your EMR.
You can also determine your cost savings using our interactive
calculator, available via a link from the online version of this article, at
www.aafp.org/fpm/20021000/35whyi.html.
Medical transcription costs per provider
Dictation lines per Patients per patient (avg.) day (avg.)
Cost per line Cost
per day
Days per month
Cost per month
Annual
cost
15
15
15
15
30
25
30
25
0.14
0.14
0.12
0.12
63.00
52.50
54.00
45.00
20
20
20
20
1,260
1,050
1,080
900
15,120
12,600
12,960
10,800
20
20
20
20
30
25
30
25
0.14
0.14
0.12
0.12
84.00
70.00
72.00
60.00
20
20
20
20
1,680
1,400
1,440
1,200
20,160
16,800
17,280
14,400
25
25
25
25
30
25
30
25
0.14
0.14
0.12
0.12
105.00
87.50
90.00
75.00
20
20
20
20
2,100
1,750
1,800
1,500
25,200
21,000
21,600
18,000
Note: If you do your transcription in-house you may be saving as much as 20 percent on per-line charges, but keep
in mind the cost of providing equipment, space and benefits for your staff transcriptionists.
October 2002
■
www.aafp.org /fpm
■
■
25
SPEEDBAR ®
➤➤
The author estimates
that using an EMR adds
about three minutes to
each patient encounter,
but the chart is com
plete when the patient
leaves the room.
➤➤
He enters his own data
but still sees the same
number of patients per
day as he did when he
was dictating.
➤➤
When purchasing an
EMR, “play” around
with it and talk with
other practices current
ly using the system.
Don’t base a decision
on the sales rep’s demo.
➤➤
The price of EMR soft
ware has remained
fairly constant and
hardware costs have
fallen dramatically in
recent years.
26
■
and you can use a keyboard training software
program for those who don’t. Just in case,
you will want to make sure the system you
choose accommodates voice entry (most do).
I’ve worked with voice entry but have found
it slows me down. Others have had different
experiences, so if voice entry works for you,
use it.
How do I find time to see patients
and enter my own data?
I see 30 to 40 patients per day, just as I did
when I was dictating my notes. I estimate
that the EMR adds about three minutes to
each patient encounter; the same three minutes I used to spend searching through charts
and signing off on them at the end of the
day. And virtually every chart is complete
when the patient leaves the room.
What do I do with my old records?
There are several workable approaches. Most
physicians keep old paper records in the office
for six to 12 months after converting to an
EMR and then send them out to long-term
storage. Some offices wait to scan the charts
into the EMR until after a patient makes an
appointment. Others wait until after the first
office visit post-conversion so the doctor has
the patient’s paper record and can make additions or modifications to it prior to scanning.
I simply had a file clerk scan into the
EMR my paper records for the last two
years, plus medication lists, problem lists
and the most recent ECG and lab reports. I
found initially I needed information that
hadn’t been scanned into the EMR system
less than a few times per month.
How do I decide which system to buy?
Some doctors are so confused by the process of
choosing an EMR that they never get around
to buying one. Or, they pick the wrong system
and give up after an unsuccessful experience.
This almost happened to me. The first system
I purchased wasn’t a good fit for our practice. I
chose it based on what I then thought were
logical criteria – the company had been in
business for 15 years and its application was
being used nationally and by many family
practice residency programs. It just didn’t work
as well as we had expected it to.
We bit the bullet and converted to an entirely new system six weeks later. Fortunately, it has
proven to be the perfect EMR for our practice.
And, after we told the first vendor how mislead-
■
www.aafp.org /fpm
■
October 2002
ing the sales presentation had been, we received
a refund for most of our purchase price.
I’m not going to give the name of either
system here; my purpose is to talk about the
value of EMRs, not specific systems. Besides,
what works for my practice may not work for
yours. If you are interested in a given system,
my best advice is to insist on “playing” with
it yourself. Don’t base your decision on a
slick demo by a sales rep. Talk to and visit
others who use the system. Take some of
your staff with you and talk to everyone there
who is using it. If you can, visit the compa
ny’s headquarters to get a feel for the commitment and enthusiasm among the
management and the programmers.
Won’t technology improve
and prices go down?
There’s no doubt. EMRs will certainly continue to improve. But I think the better systems currently on the market are already way
ahead of the old paper technology. And if you
choose your vendor carefully, you will reap
the benefits of improvements as they happen.
The price of EMR software has remained
fairly constant for the last several years. Aside
from one or two really expensive programs, it’s
unlikely that prices will fall. On the other hand,
hardware costs have fallen dramatically over the
past few years – fallen to the point where most
people in the industry feel they’re now pretty
much as low they will go. In fact, the price of
computer memory has gone up a bit recently.
What you will need to keep in mind is the
ongoing cost associated with maintaining
an EMR. For help comparing the long-term
costs of the EMR systems you are considering, see “How Much Will That EMR System
Really Cost?” FPM, April 2002, page 57.
What’s the bottom line?
EMRs aren’t for everyone. Going digital is
costly. The conversion process isn’t easy, and
acquiring new skills is frustrating, hard work.
However, I’ve found that transitioning to an
EMR system has been worth every frustration and every penny. It has made me a better doctor, reduced my overhead, made my
staff happy and pleased my patients. I can’t
convince you to let go of your paper records.
That’s for you to decide. But I am willing to
bet that if you do, you’ll get the same results
I did.
O
ne of the biggest challenges of using
an electronic health record (EHR)
system is how to fill it with patient
data. What data should be entered,
who should enter it, and when should it be
done? I’ve seen many strategies tried, and in my
experience the ideal solution is to have patients
enter as much data as possible themselves before
beginning a patient visit. This saves physicians
time and can even lead to higher-quality data.
After all, the patient is the person most interested in providing a thorough history.
This article is intended to help you decide
whether you want to have your patients enter
their own histories and, if the answer is yes, to
settle on the best approach. It is based on both
my experience and literally thousands of studies
done during the past 40 years. Patient-entered
histories have proven to be effective, and the
time a patient-entered history can save leaves
you time to do an unhurried assessment and
plan. Better yet, some vendors have now moved
to the Web, so patients can do their histories
easily at home.
Improving Care
With an
Automated Patient History
Alternative histories
The best way to fill
your EHR with patient
data might be to let
your patients do it
themselves.
r o b i n ja r e a u x
John Bachman, MD
There are bound to be advantages and disadvantages to
whatever method you choose for collecting patient data
and getting it into an EHR. Here’s a rundown of the
most common strategies:
Electronic templates filled in by physicians or
nurses. This strategy involves creating electronic tem-
plates for the EHR that list questions to be posed to
patients in the exam room, with their answers entered
into the computer by a nurse or a physician.
The obvious disadvantage of this method is lost
productivity, but the disadvantages go beyond that.
Although family physicians are good at multitasking, they
should avoid trying to fill in templates during a patient
visit. That time should be spent talking with and treating the patient. Using templates interferes with both the
normal flow of open-ended questions and the physician’s
focus on the patient’s reactions and mannerisms. Patients
would like physicians to look at them, not at a computer
July/August
FAMILY PRACTICE
Copyright © 2010 American Academy of Family Physicians. For the
private, noncommercial
use of one| individual
user ofMANAGEMENT
the Web site.| 27
Despite physicians’ reservations,
90 percent of patients in most practices
can use this sort of system.
screen, when they are telling their stories.
Moreover, most templates use yes/no questions that patients could easily do themselves
if they were allowed.
Paper templates filled in by patients.
Patients can
enter data about
themselves into
electronic health
records using interactive computer
interviews in the
waiting room or at
home on the Web.
In computerized
interviews, patients’
answers to questions at one point
in the interview
determine which
questions will be
asked later.
Studies show that
physicians receive
more data using
computerized
patient interviews
than they do from
conventional
patient histories.
With the paper method, the patient fills out
a paper questionnaire, which is then scanned
to populate some of the EHR’s fields with the
patient’s responses.
The method has a handful of advantages:
• It is familiar.
• It is simple.
• It saves the time it would take to ask
the questions.
However, its limitations might outweigh
those advantages:
• Some patients will fail to fill out forms
completely. When that happens, the physician
or the practice’s staff members will have to
use valuable time updating and filling out the
incomplete forms electronically.
• You will need to process the paper questionnaires with a scanner, which you’ll need
to buy. Afterward, the forms will need to be
shredded and discarded. These steps insert
inefficiency into your practice.
• It might be difficult to quickly revise a
paper questionnaire whenever a new question
is needed (e.g., during a bird flu epidemic).
• Paper questionnaires tend to provide a
high number of false-positive responses. A
patient might mention a symptom without
defining the severity. At the Mayo Clinic, it
was determined that, even after giving three
sets of paper questionnaires, each one based
on the preceding one, there were still many
false-positive responses.1-3
Interactive computerized interviews
filled in by patients. This method, in my
opinion, is the ideal solution. Because the
interview is computerized, the patient’s
About the Author
Dr. Bachman, a family physician, is the Saunders Professor of Primary Care at the Mayo Foundation, Rochester, Minn. Author disclosure: nothing to disclose.
answers to questions at one point in the
interview can determine the questions asked
later; this ability to follow any of a number of
designed-in branches of inquiry is one of the
most important distinctions between these
computerized interviews and paper questionnaires. Using one of the systems now on the
market, the patient can do his or her part on
a Web-based portal from home or in the waiting room before an office visit (see “Currently
available systems” on page 41). The physician can then edit the patient’s work, rather
than doing all the data input. A few editorial
changes might be needed, but the bulk of the
work can be done before the patient encounter starts. Reviewing a structured history that
the patient has provided can be done quickly
and efficiently.
The advantages of using patient-entered
data are numerous:
• Physicians receive more data than they
would from a conventional history.4 Computer programs generally provide more information than physicians document. Examples
include interviews related to infertility (2.9
times as much data) and general gynecology
(1.6 times as much data).5 One study found
35 percent more information in histories
gathered by computers,6 while another study
found 56 percent more information in such
histories.7 Yet another study discovered a program on life events that revealed 40 percent
more important new information, and this
information led to improved communication
with 22 percent of patients.8
• Patients like it. Despite physicians’ reservations, 90 percent of patients in most
practices can use this sort of system.9 Elderly
patients are slower but more accurate than
young people.10
• Interpreters can be put to better use. One
of the available systems offers a Spanish-language version that allows a comprehensive
history to be taken without an interpreter and
then outputs the responses in English. Another
has 30 different languages available. These
programs allow you to spend more time with
automated patient history
the interpreter on assessment and planning.
• Patients are better organized after completing the computer questionnaire.8,11
• Patients are more likely to reveal social
secrets to a computer than to a physician as
shown in studies on a number of subjects,
including suicide,12 psychiatric evaluation13
and adolescent drug use,14 to name a few.
• The programs can produce scales that
help measure the severity of illnesses (e.g., the
Epworth sleepiness scale) or the likelihood of
a problem (e.g., the Woman Abuse Screening
Tool or the Zung scale assessments for depressive symptoms).
• The information is provided in a format
that can easily be read before the patient visit
(see the sample output on page 42). This lets
the physician start the exam focused on problems identified by the patient. For example, if
the patient has chest pain, then the physician
talks with the patient about the nature of this
pain. If the patient says he or she hasn’t had
surgery to remove gallstones, then it’s highly
unlikely that the patient has had surgery to
remove gallstones. The physician can usually
ignore this sort of negative response because
patients can enter data into an EHR with an
accuracy rate of 94 percent to 97 percent.15
• The physician can adjust the number of
questions the patient is asked on a particular
subject and, of course, can determine during
the visit how many of the patient’s answers to
review and where to ask for additional information. For example, an ear, nose and throat
specialist can set the program to ask for a
high level of detail on questions related to ear,
nose and throat, and a low level of detail on
everything else. A family physician could set
the program for a medium level of detail on
all subjects. And if the patient has a litany of
complaints, having the interview means that
the physician is more likely to have all the
relevant history at the outset of the visit, and
the patient is less likely to have an “Oh, by
the way” complaint at the end. The physician
is better situated to decide whether to deal
with a few medically significant issues on the
current occasion and postpone others to a follow-up visit.
• The interview provides data that are discrete and structured. While physician-completed templates are very appropriate for other
parts of the clinical examination, especially the
physical examination, and for documentation
of procedures, computerized patient interviews
make them less necessary in the history.
• The interview has no real-time constraint
because no staff labor costs are involved.
• If the patient is able to complete a previsit interview before the office visit, then
the office visit is streamlined even more. The
Cedar Rapids Family Practice Residency in
Cedar Rapids, Iowa, provides an excellent
example. If a patient calls for a pregnancy
test, she is asked to come in that same day.
When she arrives, she completes an automated patient history, then receives prenatal
vitamins and education. She returns later for
a physician visit. Their unpublished work
shows that patients are happier, the clinic’s
no-show rate for doctor visits is dramatically
reduced and the clinic’s qualifications for
metrics are 100 percent.16
• Branching computerized
interviews solve the problem
Currently available systems
of false positives because a
Here are some of the systems that allow patients to enter
patient is not given the choice
their own history.
of not answering a question.
EncounterSuite’s TurboHX
They just keep going.
(http://www.medicalnetsystems.com)
There are disadvantages to
the
electronic interview, too:
This program, which currently is in beta testing, is used in
•
The
patient might not be
numerous EHR systems and patient portals.
able to read the materials. If
Instant Medical History (http://www.medicalhistory.com)
this is the case, other options
will be needed.
This program can interface with several EHR brands.
• About 10 percent of the
Medisolve (http://www.medisolve.ca)
population chooses not to do
The company furnishes a computer kiosk, and the program
their histories on computers.
includes 30 languages.
• Physicians sometimes
try to confirm all the answers
About 90 percent
of patients are
capable of using
computerized
patient histories.
Elderly patients
are slower but
more accurate with
computerized interviews than younger
patients.
Physicians can
adjust the number
of questions
patients are asked
on a particular
subject.
July/August 2007 | www.aafp.org/fpm | FAMILY PRACTICE MANAGEMENT | 29
Patients can enter data into an EHR with
an accuracy rate of 94 percent to 97 percent.
to the questions – try to duplicate the work
of the computer – with obvious ill effects
on efficiency.
The workflow
With a Web-based computerized interview
system, patients log on to the system, either
at home or in the waiting room or office, and
enter information according to your instructions. The electronic interviews typically start
by offering the patient a list of complaints.
The patient selects one, and the interview
proceeds in a series of simple questions and
answers. At the end of the interview, the
patient is asked if there are other complaints
Sample output
This is an example of what your EHR would produce using Instant
Medical History if it were set up to exclude negatives.
Chief Complaint
K.J. is a 23 year old female. Her reason for visit is “cough.”
History of Present Illness
She reported: Wheezing sometimes.
Severity: She reported: Continuous cough.
Duration: She reported: Cough 7 to 10 days.
Timing: She reported: Nocturnal cough.
Context: She reported: Paroxysmal cough. Nonproductive cough.
Modifying Factors: She reported: Cough worse recumbent.
Associated Signs and Symptoms: She reported: Recent coryza
improved then worsened.
Past, Family and Social History
Past Medical History
History of Sinusitis. Esophageal disease.
Social History
Activities for Daily Living
History of: 3 days in bed in last 2 weeks due to illness or injury.
Tobacco Use
History of: Smokes cigarettes every day now. Smoking cigarettes.
Currently uses tobacco.
Review of Systems
Constitutional
She reported: Exhaustion and fatigue.
and may enter those. When all the preliminary
interviewing is done, the patient’s history is
submitted directly to the history portion of the
EHR. The electronic interview of the patient
usually takes 10 to 30 minutes.
If you are already using an EHR, you
should check whether it includes a system
for doing patient entry. Instant Medical History is used by a number of EHR systems,
including Cerner, eClinicalWorks, NextGen,
Practice Partner and SOAPware. It is used
in major online portals such as Medfusion.
Although Instant Medical History, which
costs about $50 per month, occupies more
than 95 percent of the market, there are other
niche players in this arena, as indicated in
“Currently available systems” on page 41.
If you do not have an EHR, the patient’s
responses to the questionnaire can be placed
on a dictation template or just printed and
added to their chart.
In my practice, a simplified version of the
output is printed for the patient, using language that the patient will understand. When
I enter the exam room, I have reviewed the
simplified version and can give the patient a
copy to review. While the patient is looking
at this summary, I call up the first page of the
medically sophisticated version of the history
in my EHR.
At this point, we are both ready and I
begin the interview. My total focus is on the
patient, and it’s unusual for me to need to
look at the computer. When we finish, we
often review the history together and make
any changes that need to be made. We also
review other pertinent information such as
prevention, ongoing treatment and other
chronic problems.
More efficient, better outcomes
The desirability of this workflow seems obvious:
Physicians should not do what nurses or medical assistants can do, and none of them should
do what patients can and are willing to do.
Time studies show that history taking in this
manner is more efficient than the traditional
automated patient history
method and allows more time for discussing
the assessment and plan.4 Best of all, it is also
associated with better clinical outcomes.4
1. Mayne JG, Martin MJ, Morrow GW Jr, Turner RM, Hisey
BL. A health questionnaire based on paper-and-pencil
medium individualized and produced by computer. I.
Technique. JAMA. 1969;208:2060-2063.
2. Martin MJ, Mayne JG, Taylor WF, Swenson MN. A
health questionnaire based on paper-and-pencil medium
individualized and produced by computer. II. Testing and
evaluation. JAMA. 1969;208:2064-2068.
3. Mayne JG, Martin MJ, Taylor WF, O’Brien PC, Fleming
PJ. A health questionnaire based on paper-and-pencil
medium, individualized and produced by computer. 3.
Usefulness and acceptability to physicians. Ann Intern
Med. 1972;76:923-930.
4. Bachman JW. The patient-computer interview: a
neglected tool that can aid the clinician. Mayo Clin Proc.
2003;78:67-78.
5. Bingham P, Lilford RJ, Chard T. Strengths and weaknesses of direct patient interviewing by a microcomputer
system in specialist gynaecological practice. Eur J Obstet
Gynecol Reprod Biol. 1984;18:43-56.
6. Simmons EM Jr, Miller OW. Automated patient historytaking. Hospitals. 1971;45(21):56-59.
7. Quaak MJ, Westerman RF, Schouten JA, Hasman A,
van Bemmel JH. Computerization of the patient history
– patient answers compared with medical records. Methods Inf Med. 1986;25:222-228.
8. Schuman SH, Curry HB, Braunstein ML, et al. A computer-administered interview on life events: improving patientdoctor communication. J Fam Pract. 1975;2:263-269.
9. Slack WV, Leviton A, Bennett SE, Fleischmann KH, Lawrence RS. Relation between age, education, and time to
respond to questions in a computer-based medical interview. Comput Biomed Res. 1988;21:78-84.
10. Herzog AR, Rodgers WL. Age and response rates to
interview sample surveys. J Gerontol. 1988;43:S200-S205.
11. Mayne JG, Weksel W, Sholtz PN. Toward automating
the medical history. Mayo Clin Proc. 1968;43:1-25.
12. Greist JH, Gustafson DH, Stauss FF, Rowse GL,
Laughren TP, Chiles JA. A computer interview for suiciderisk prediction. Am J Psychiatry. 1973;130:1327-1332.
13. Carr AC, Ghosh A, Ancill RJ. Can a computer take a
psychiatric history? Psychol Med. 1983;13:151-158.
14. Paperny DM, Aono JY, Lehman RM, Hammar SL, Risser
J. Computer-assisted detection and intervention in adolescent high-risk health behaviors. J Pediatr. 1990;116:456-462.
15. Porter SC, Silvia MT, Fleisher GR, Kohane IS, Homer
CJ, Mandl KD. Parents as direct contributors to the medical record: validation of their electronic input. Ann Emerg
Med. 2000;35:346-352.
By having patients
enter their histories
before the exam,
physicians can
spend more time
in the exam room
talking to and treating patients.
In addition to
increasing efficiency, computerized patient
interviews have
been associated
with better clinical
outcomes.
16. Zelnick C. Instant Medical History entered directly
into Medical Logic. Presented at: Towards the Electronic
Patient Record Conference, Seattle, Wash; May 14, 2002.
Realistic expectations can help your conversion to electronic
EHRs Fix Everything
and Nine Other Myths
David E. Trachtenbarg, MD
T
wo physician groups implement the same
electronic health record (EHR) system. One
improves quality of care and productivity and
saves thousands of dollars. The other reports more
errors, loses efficiency and teeters toward bankruptcy.
What’s the difference, and how can other EHR users
achieve the results of the more successful group?
Having realistic expectations about what EHRs will
do for your practice and how they’ll work is a key to
effectively selecting and implementing an EHR system,
but too many groups set themselves up for failure by
beginning without a clear sense of what they will achieve.
This article offers suggestions for dealing with 10 common misconceptions that lead physicians off course on
the EHR journey. It is based on my experience purchasing and implementing an EHR system for a 120-provider,
30-site group, as well as my discussions with physicians
from more than 50 organizations about their potential
EHR purchases. It includes a few references to EHR
studies, but, like the authors of one literature review, I
found that information on EHR use in primary care was
a “descriptive feast but an evaluative famine.”1
Myth 1
A new EHR system will fix everything
Some groups want to purchase an EHR system to
help transform their organization and take it to the
next level, but they may be expecting too much. In the
book Good to Great, author Jim Collins observed that
technology works as an “accelerator of momentum, not
as a creator.”2
An EHR will not fix organizational problems, and
it does not guarantee improved efficiency and quality.
In fact, installing software is just one part of a journey
toward improved efficiency and quality.
Fact: An EHR system is not a panacea. The transition
will create new problems in addition to solving old problems. Think carefully about whether your organization is
stable enough to handle the challenges.
Myth 2
Brand A is the best
I’ve met physicians who would never seek out an expert
on hypertension to ask, “What is the best drug for hypertension?” yet they search high and low for tech experts
to ask, “What is the best EHR software?” Just as it is for
hypertensive drugs, the correct answer for EHR software
is, “It depends.”
Fact: There is no perfect software. You should expect
your EHR software to do some things well, some things
so-so and other things not at all, and what works well
for one group may not work for another. The following
three considerations will help guide you:
1. Determine your vision. Is it that better documentation will enable you to maximize billing or achieve outstanding disease management or something else? When
my group was thinking about which software to buy, we
summarized our vision for the EHR system in the phrase
“Networked physicians, shared care.” Starting from that
vision, we tried to purchase software with features that
could promote communication with other physicians and
integration with other hospital systems.
| www.aafp.org/fpm
| March 2007
32 |Copyright
FAMILY PRACTICE
© 2010MANAGEMENT
American Academy
For the private, noncommercial use of one individual user of the Web site.
health records succeed.
2. Determine the scope of
the project. For example, are
you a solo physician in a single office, or will the project
involve many physicians located at multiple sites? Some systems are better for small practices, others for larger groups.
3. Determine what other systems need connections
to the EHR. Consult with information technology
professionals to make sure the software you choose will
work well with your other systems.
Myth 3
Our software needs to work
the way we currently work
After one consultant advised my group to produce the
best paper record possible and then convert it into an electronic record, one of our physicians commented, “So we
should make the best horse and buggy possible and then
use it to create an automobile?” We passed on the consultant’s system, though the exchange raised an important
point: To maximize the benefits of an EHR system, you
ehr SATISFACTION SURVEY
greg cl arke
Get the facts about family physicians’ satisfaction with
their EHRs in FPM’s user satisfaction survey. We published the results of our last survey in October 2005,
and we will field an updated survey beginning this
spring. Look for it in an upcoming issue of FPM.
need to take advantage of its
positive aspects by changing
your workflow to accommodate them. It will not be
possible to continue doing business as usual.
Fact: An electronic record is not a paper record on the
computer, and you will maximize your efficiency only by
making significant changes in your workflow. Expect to
work differently to make the most of the EHR system’s
advantages as well as overcome its disadvantages compared to paper (yes, you will find some).
Myth 4
Software will eliminate errors
I’ve found that this misconception often surfaces after
software is installed. For example, I’ve had more than
one frustrated physician say to me, “I thought that
installing an EHR was supposed to eliminate drug errors.”
Unfortunately, intelligence in software is no substitute
for knowledgeable users. As the old adage says, “It is
impossible to make anything foolproof because fools
are so ingenious.”
My group found that EHR software reduced drug
errors but did not eliminate them. In addition, we
encountered new types of errors that we never had to
think about with a paper record, such as accidentally
selecting a liquid preparation instead of a capsule when
making choices from a preset list.
Fact: There is no such thing as an error-proof system.
You will need to be vigilant as ever and alert to the
possibility of new types of errors related to EHR use. ➤
March 2007 | www.aafp.org/fpm | FAMILY PRACTICE MANAGEMENT | 33
Expect your EHR software to do some things well,
Myth 5
Discrete data is always best
Discrete data entry (also called structured data
entry) in EHR systems forces users to document an encounter by making choices from
preset lists. For example, by being allowed to
select only “No” or “Yes” in the discrete data
input below, the clinician will clearly indicate
whether eye pain is present:
EHR projects
can be derailed
by common
misconceptions.
Many physicians
unrealistically
expect an EHR system to be a cure-all
for their problems.
You should expect
to work differently
once the EHR is
installed to maximize its advantages
over paper.
N
Y
Visual disturbances
N
Y
Eye itching
N
Y
Eye pain
If you plan to extract data from an EHR
system, it’s best to store information for reporting as discrete data. Unfortunately, there are
several drawbacks to collecting discrete data.
First, clicking or typing text multiple times
is generally slower than dictating.3 Consider,
for example, the time it takes to document
a thorough history of a patient’s back pain.
Using discrete data, it took me 95 seconds to
complete 17 clicks for yes-or-no questions,
five text boxes that required typing and two
drop-down lists. In contrast, it took me 41
seconds to document the same history using
dictation. (Of course, the cost of transcription
needs to be considered as well.)
Discrete data also produces less readable
output than dictation/typing. Physicians have
a tendency to avoid discrete data entry whenever possible and instead type (if they are good
typists) or dictate (if it is an option). When
About the Author
Dr. Trachtenbarg is medical director for information
technology at Methodist Medical Center Family
Practice in Peoria, Ill., and clinical professor of family medicine at the University of Illinois College of
Medicine at Peoria. Author disclosure: Dr. Trachtenbarg discloses that he spoke about electronic
health records at meetings where his expenses
were paid by McKesson Corp.
34 | FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | March 2007
this happens, your organization can no longer
use discrete data fields to generate accurate
reports. Finally, discrete data may not catch
the nuances of patient variability.
You need to strike a balance between your
organization’s needs to collect discrete data
for quality improvement and pay-for-performance initiatives and your end users’ needs for
efficiency. We’ve done this in my organization
by requiring discrete data entry for selected
exam elements, such as foot exams for patients
with diabetes, and allowing dictation or typing for other parts of the exam.
Fact: Both discrete data and free text have
their downsides. Consider using discrete data
selectively rather than trying to use it for everything, and establish and continually update
discrete data standards for your practice.
Myth 6
The more templates, the better
When my group was looking for an EHR system, we asked every vendor how many templates their system included. Our assumption
was that more was better. However, when we
started using our EHR system, we found that
most physicians preferred to use relatively
few templates. We also found that many
physicians preferred to use a point-and-click
method to document normal findings and to
type or dictate abnormal findings.
Each new template takes time to learn.
It is faster for the average physician to use a
smaller number of templates he or she is very
familiar with. In other settings, physicians
have also been found to forgo templates if
they take extra time to complete.4 Fortunately,
a template that primarily documents normal findings rarely needs to be changed. An
organizational problem with disease-oriented
templates is the need for frequent review and
updating.
Fact: Less is more where templates are
concerned. Physicians tend to use relatively
few, and maintaining them is time-consuming.
Make sure that people in your group realize
10 ehr myths
some things so-so and other things not at all.
the true costs of developing and maintaining a
template, try to be reasonable about the number of templates you’ll need and be clear about
who is responsible for updating them.
Myth 7
Electronic records are
more legible than paper records
Many people assume that notes generated by
EHR systems are easier to read than a physician’s hand-written documentation. The truth,
however, is that although the words are easier
to read, the documents are often harder to
read. The reason for this is usually a low/poor
signal-to-noise ratio, meaning the amount of
useful information (the signal) is less than the
amount of irrelevant data (the noise).
An example of a high/good signal-to-noise
ratio that I have encountered came out of an
older physician’s patient database, which was
composed of 3x5 index cards. Each index
card contained a patient’s first and last name
with one-word descriptions of any diagnoses
and recommended treatments. For example,
“Susan Jones, pharyngitis, penicillin” would be
written on a typical index card. These records
were almost all signal.
The other extreme I once came across
outside my organization was an EHR-generated three-page report for the same diagnosis.
Although most physicians would agree that it
contained more than four words of good signal, they also would complain that the report
contained much bad noise, making it harder
to read.
Fact: EHRs can capture lots of unnecessary
data, which can make patient records difficult
to read. Before purchasing an EHR system,
determine what parts of the record require
discrete data entry and what parts allow dictation or typing, and assess the readability of
the discrete data portions. Look for an EHR
system that flags key data for you. During
implementation, consider how to format
your templates for maximum readability. For
example, you could arrange the template with
the assessment and plan first and the supporting documentation following.
Myth 8
Mobile is best
Most of my physician colleagues love the concept of mobile computing. It is appealing to
be able to carry an electronic “chart” that can
be positioned to make good eye contact with
the patient.
However, as with most other information
technology ideas, there is a gap between the
idealized concept and reality. When lightweight tablet computers were given to the
physicians at my institution, about 70 percent
said they didn’t want to carry them around,
due primarily to their size and weight. Among
the roughly 30 percent who weren’t fazed
by the tablet computer’s weight, some lost
interest due to the three-hour battery life and
smaller screen size (which necessitates more
scrolling) and the fact that the tablet computers are relatively slow and expensive when
compared with desktop computers.
Of course, many organizations are successfully using tablet computers and other new
technologies. That’s because they understand
the weak points in the technology and how to
get around them.
Fact: Mobile is worth considering, but you
shouldn’t purchase new technology based on
an attractive concept. Try the technology by
piloting it first. If possible, offer a range of
data input options that accommodate multiple preferences. You’ll get more buy-in from
users this way.
Errors won’t disappear when you start
using an EHR; in
fact, you’ll need to
watch out for new
types of mistakes.
Patient records
produced by EHRs
can contain lots of
unnecessary data,
making them hard
to read.
Mobile computing
isn’t always as
great as it sounds;
try using a tablet
computer before
you buy them for
your group.
Myth 9
You must have a detailed plan,
and stick to it
With proper planning, you can anticipate
problems and avoid many bumps along the
road of implementation, but you can also
spend too much time planning. Until you
start working with a software program, it is
You should start preparing for a replacement EHR
system before you implement your first.
You need to remain
flexible during
the implementation and be willing
to alter plans as
needed.
It’s a good idea to
start planning for
your second EHR
system before you
buy your first one.
Every EHR implementation is different; distinguishing
facts from myths
will help you to be
successful.
not possible to understand the fine points
needed to do detailed, productive planning.
For example, in my office we developed
an elaborate scheme for creating groups to
handle physician messages. Unfortunately,
our EHR program created groups in a different way than we envisioned, and the planning had to be completely redone. It is often
helpful to plan a basic “direction” and fill
in the details later when you understand the
product better.
Some believe that the project needs to stick
to the scope of its original planning and not
deviate. However, new, beneficial features of
the software will likely become apparent during implementation. If you rigidly stick to
your original plan, you will miss out on the
advantages of these features. You may also
find that some of the things you planned to
do will not work as well as you had hoped
once you start using the software.
Fact: The best-laid plans may need to be
revised. Start with planning to move the project in the direction of your vision. Then take
advantage of the understanding that comes
with implementation to use other features
of the software and make modifications as
needed.
Myth 10
You can stop planning
Unfortunately, all systems have a finite life
cycle. With that in mind, you should consider
how easy it will be to transfer information
from the EHR system you’re about to buy to
another system in the future. You should also
do yourself a favor and delay the inevitable
replacement by selecting a system that will
be supported for as long as possible before it
needs to be replaced.
Most EHR vendors that I’ve encountered
take one of two approaches to life-cycle management. One approach is to eventually stop
supporting what you have purchased and try
to sell you an entirely new product that uses
new technology for about the same or higher
cost than you originally paid. The second
approach is to “upgrade” the original product
as part of the normal software maintenance
cost. In most cases, you will want a vendor
who takes this approach.
Fact: You should start planning for a
replacement EHR system before you implement your first one. Purchase systems from a
vendor with a history of continuous improvement and upgrades, and be ready for the
inevitable replacement. Monitor the cycle of
your system to anticipate when it will need
to be replaced. One way to do this is to ask
your vendor what it is developing for its next
generation system and when it is expected to
be available. Another method is to check for
software and hardware used to build the EHR
that your IT experts may consider obsolete.
A clear path to success
Every EHR implementation is unique.
Not every organization will encounter every
misconception discussed in this article. By
being aware of the myths that can sidetrack or
derail your implementation, you will be more
likely to reach your destination. I wish you a
smooth and successful trip.
1. Mitchell E, Sullivan F. A descriptive feast but an evaluative famine: systematic review of published articles
on primary care computing during 1980-97. BMJ.
2001;322(7281):279-282.
2. Collins J. Good to Great: Why Some Companies
Make the Leap … and Others Don’t. New York, NY:
HarperCollins Publishers Inc.; 2001.
3. Waegemann CP, Tessier C, Barbash A, et al, for the
Consensus Workgroup on Health Information Capture and
Report Generation. Healthcare documentation: a report
on information capture and report generation. Boston,
Mass: Medical Records Institute; June 2002. Available at:
http://www.medrecinst.com/pages/libArticle.asp?id=39.
Accessed Feb. 1, 2007.
4. Tai SS, Nazareth I, Donegan C, Haines A. Evaluation
of general practice computer templates: lessons from
a pilot randomised controlled trial. Methods Inf Med.
1999;38:177-181.
With a thoughtful approach, you can maintain your focus on the patient.
EHRs in the Exam Room:
Tips on Patient-Centered Care
E
marie l afr ance
lectronic health records
(EHRs) are clearly part
of family medicine’s future.
However, the information available
on EHRs to date has focused on the practicalities of
buying and implementing a system. Minimal attention
has been paid to understanding how family physicians
use EHRs with patients in the examination room.
In our work both as clinicians practicing with EHR
systems and as researchers studying the communication
patterns of physicians using EHRs with patients, we have
observed how EHR use in examination rooms can inhibit
physicians from focusing on their patients.1,2 Even skilled
physicians commonly use troubling
behaviors such as looking predominantly
at the computer monitor during office visits,
typing while patients are talking about intimate
concerns, reading silently from the monitor while patients sit
idly, using templates to lead interviewing rather than listening to patient narratives, and turning their backs to patients
in spite of the availability of mobile computer monitors.
These behaviors need not be the norm. In fact, EHRs
have the potential to enhance in-office communication with
patients. To accomplish this, however, physicians will need
to bring the best of both EHRs and patient-centered interviewing to the examination room.
William Ventres, MD, MA, Sarah Kooienga, FNP, and Ryan Marlin, MD, MPH
Marchnoncommercial
FAMILY PRACTICE
Copyright © 2010 American Academy of Family Physicians. For the private,
use of one| individual
user ofMANAGEMENT
the Web site.| 37
EHRs have the potential to enhance
Ten tips for EHR-enhanced exams
As family physicians
get into the habit
of using computers
during exams, it’s
important to develop a routine that
keeps the focus on
the patient.
It can be difficult,
even for veteran
EHR users, to avoid
typing or looking at
the monitor while
a patient is sharing
intimate concerns.
A monitor that can
be moved easily
into a more patientcentered position
can quickly improve
an exam’s dynamic.
closed-ended question-and-answer format
allows little room for patients’ narratives to
evolve, a key task in patient-centered care.
Based on our research and in hopes of improving
doctor-patient communication using EHRs, we
offer physicians the following tips. All of the recommendations come from either study subjects
or our observations as investigators.
Use mobile computer monitors. Large,
fixed monitors located in the corner of the
examination room make EHR use almost
incompatible with patient-centered interviewing. We recommend investing in either
flat-screen monitors on mobile arms, tablet
computers or laptop computers. The ability
to rearrange the monitor’s position can
so change the dynamic of encounters that
mobility is worth the extra cost.
Learn to type. This recommendation
seems obvious, and it is. Until voice recognition improves dramatically, cost concerns
will demand that physicians type their notes
or enter them through templates. Other
computer skills such as managing Windowsbased programs, searching the Internet and
manipulating a mouse are also necessities for
physicians using EHRs.
Unless a physician reviews EHR notes at the
beginning of the day or at a hallway work
station before entering the exam room, there
may be little chance to focus attention on
the presenting patient until after entering
the examination room. Rather than walking
straight to the monitor following only a brief
greeting, consider listening to the patient’s
concerns before opening the screen to review
the last visit’s notes.
Integrate typing around your patients’
needs. Regardless of your note-taking style –
Tell your patients what you are doing –
as you’re doing it. If you sit silently looking
whether you type during the visit, immediately afterward in the exam room or later in your
office – it is important to know when to push
the computer screen away. Use of EHRs may
require a heightened recognition of sensitive
psychosocial concerns.
for information on the computer – opening
and closing windows or scrolling though text –
you risk confusing your patients. Instead,
try to keep talking as you go about the work
of both searching for and entering data into
the EHR.
Point to the screen. Patients may not
share physicians’ understanding of the intricacies of the computer screen and its visual
contents. Even computer savvy patients may
find that their emotions override their ability
to quickly grasp where to look. Use a finger,
pen or cursor to guide the patient’s gaze when
discussing data viewed on the monitor.
Reserve templates for documentation.
Templates are an excellent way to structure
notes but can be disastrous when used to
structure interviews with patients. Their
About the Authors
Dr. Ventres is a family physician with the Multnomah County Health Department in Portland,
Ore. Sarah Kooienga is a family nurse practitioner
and instructor at the Oregon Health and Science
University in Portland. Dr. Marlin is a first-year family medicine resident at the North Colorado Family
Medicine Residency Program in Greeley, Colo.
Conflicts of interest: none reported.
Separate some routine data entry and
health-care maintenance issues from your
patient encounters. Until patients are able to
complete forms online in your waiting room
or at home, consider having office nurses or
medical assistants enter basic information
before you walk into the exam room. In addition, ancillary staff members can track whether
patients are up-to-date on preventive services,
noncontemporaneous with visits, freeing exam
time for you to explore your patients’ concerns.
Start with your patients’ concerns.
Encourage patients’ participation in
building their charts. Consider using the
“nothing about me without me” philosophy
about information. Saying things like “Would
you mind if I typed a few notes into your
chart?” or “May I show you what I’m doing?”
when using an EHR may promote rather than
in-office communication with patients.
hinder the physician-patient relationship.
Look at your patients. This may seem
patently obvious, but the reality is that even
with the availability of mobile screens, many
experienced clinicians persistently stare at the
computer monitor. Remember that while the
EHR becomes much like a third party to a
conversation, it is an inanimate party that represents, at least, a repository of information and,
at best, a tool to enhance our care for patients.
Patients deserve our primary attention.
with EHRs in examination rooms. Although
there might be other ways of accomplishing
the same goal, we believe being mindful of
these hints will help you develop patientcentered habits as you integrate EHRs into
daily practice.
EHRs in the examination room are quickly
becoming a reality. Reflecting on how we
integrate our clinical styles with the use of this
technology will ensure that EHRs are used
in ways that best fit the social, emotional and
medical needs of our patients.
Adapt EHR use to your style
Everyone has a unique style of interacting
with patients. The above recommendations
are not meant to be dogmatic rules that every
family physician should follow, but rather
helpful hints to consider when practicing
1. Ventres W, Kooienga S, Marlin R, Vuckovic N, Stewart V.
Clinician style and examination room computers: A video
ethnography. Fam Med. 2005;37(4):276-81.
2. Ventres W, Kooienga S, Vuckovic N, Marlin R, Nygren P,
Stewart V. Physicians, patients, and the electronic health
record: an ethnographic analysis. Ann Fam Med. In press.
Involve your patients
by starting with their
concerns, telling
them what you’re
doing and encouraging them to help
build their charts.
Your unique
approach to patient
encounters can be
improved with EHR
use if you are mindful of patientcentered habits.
How to Successfully
Navigate Your
EHR Implementation
These clues can help you avoid the pitfalls you’ll encounter on your EHR journey.
The three T’s
Team. Tactics. Technology. I have organized
the key dos and don’ts of implementation into
these three categories. Team refers to people and
organizational issues, tactics to specific techniques
and choices made in design and setup, and
technology to the software, hardware and network
choices you will make. Many implementation
issues are common to large and small practices
alike. Yet large practices, perhaps due to their
complexity, tend to suffer more from team issues,
and small practices, perhaps due to their more
limited resources and experience, tend to falter when it
comes to technology issues. Any size practice can crash
and burn when it comes to tactics.
Team
Everyone in your
practice will
play some role in
the success or failure of your EHR implementation. Some roles will be bigger than
others, but they all need to be acknowledged and understood from the start.
Three types of leaders. Study after study
on EHR implementations reports the same
thing: People are key, and leadership is one of
the biggest issues. An EHR project needs three
kinds of leaders: a physician champion (or two
or three), a CEO and a skilled project manager.
In a small practice, the physician champion and
CEO may be the same person. That should help
the implementation’s chance for success.
The physician champion should be a respected
clinician who is a good communicator and a tireless supporter of the project. He or she should be
the engine that motivates others. Physician champions are so important that one report stated, “Identify an EMR champion – or don’t implement.”1
The CEO and the rest of your practice’s senior
management team should fully back the project through thick and thin and help provide the
needed resources. They should help clear the
track of obstacles. ➤
Copyright © 2010 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site.
40 | FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | February 2007
christine schneider
S
ome electronic health record (EHR) implementations proceed on schedule with full involvement of their participants and achieve their
goals. Others flounder, stall or
struggle, experiencing only
partial success or, in
extreme cases, no
success at all.
What accounts
for the difference? Is it
a problem with the people, the
process or the EHR product? How
are large-practice implementations different than small-practice ones? How can you
fortify yourself against failure and plan for
success? Keep reading for some answers based
on my review of available literature on the
topic as well as my personal experience. (See a
list of Dr. Adler’s prior FPM articles on EHR
systems on page 37.)
Learning how to use an EHR is a lot like
learning a musical instrument. You don’t just
pick it up the first day and expect to be a virtuoso.
The project manager should not be just any
available manager. Rather, he or she should
be someone who is trained, skilled and experienced in managing complex information
technology (IT) projects with overlapping
timelines and multiple stakeholders. Ideally, the project manager will have managed
an EHR implementation before. He or she
will be the engineer that keeps the train on
track and anticipates the stops ahead. Large
practices will need to hire a full-time manager,
while small practices will likely partner their
office manager with an implementation manager assigned by the EHR vendor.
Change management. Not only does an
EHR project need good management, but it also
needs broad stakeholder involvement, a motivated implementation team and an excellent
communication plan. Unfortunately, installing
an EHR is not like installing a new program on
your home computer. You cannot simply load
it, learn how its features work and go on your
merry way. EHRs are much more complex.
You will need to understand your EHR’s
capabilities and determine how it can be used
to streamline and improve current paper-based
office processes. Using an EHR will require
you to change the way you do many things
and who does what. EHRs offer an opportunity for you to improve your office efficiency
and service level, but that isn’t automatic.
This means change, and change is a dirty
word to many people. It inspires fear, resistance and sabotage. Understanding and utilizing a good change management process will
About the Author
Dr. Adler is a family physician and medical director
of information technology for Arizona Community
Physicians in Tucson, Ariz. His medical group has
49 physicians, and 20 nurse practitioners and physician assistants, in 15 offices successfully using an
electronic health record system. He has a Master
of Medical Management degree from Tulane University and a certificate in health care information
technology from the University of Connecticut.
Author disclosure: nothing to disclose.
help. An excellent book about this is Leading
Change by John Kotter.2
Expectations and goals. If you buy an
EHR expecting it to make you loads of money
without any extra work, then you’re on your
way toward what you’ll perceive as a failed
implementation. You need to start out with
realistic expectations. EHRs do require extra
work for most users during the first year, and
financial break-evens typically don’t occur until
two to three years from your go-live date.3
Setting specific, measurable goals for what
you want to accomplish with the EHR will
also help you define what constitutes success
or failure. For example, you might decide that
all six of your practice’s physicians need to be
fully utilizing all seven modules of your EHR
by a target date. Or you might decide to shoot
for a 70-percent reduction in transcription
usage practice-wide by a certain date. Goals
like these should be determined early in the
planning, if not before purchasing your EHR,
then certainly before implementing it. Again,
be realistic. This is a long-term project. That
isn’t to say you shouldn’t set high expectations.
Establishing goals that are ambitious, but
achievable, can be motivating. Yet it’s important to understand your users’ needs, and
to make sure they understand and share the
stated goals. Otherwise, they might not play
along, destroying your implementation plans.
Finally, it’s wise to monitor and communicate your progress in terms of achieving your
goals. There are many ways to do this, but one
easy tactic would be to display an implementation timeline poster in a break room where all
staff can see it. This poster should show past and
future key implementation dates and accomplishments. This will help keep things on course.
Functional organizations. If your practice
is broken, you need to fix it before you try
to bring an EHR on board. Dysfunctional
organizations are likely to have dysfunctional
implementations. Excellent communication,
clear lines of authority and an explicit decision-making process promote success.
An implementation team composed of key
Your EHR implementation has a
better chance
for success if you
organize it into
three categories:
team, tactics and
technology.
Studies have found
that a practice’s
employees are key
to an EHR implementation’s outcome, with project
managers playing a
critical role.
Everyone involved
with the new EHR
will need to be
open-minded
about changing the
way the practice
operates.
February 2007 | www.aafp.org/fpm | FAMILY PRACTICE MANAGEMENT | 41
If your EHR implementation team is
given unrealistic
goals, the project
is likely to end as a
perceived failure.
When it comes to
your implementation tactics, spend
as much time as
possible planning,
which should cut
down on surprises
as the project
proceeds.
Your strategy for
scanning paper
charts should balance your physicians’ need for
easily searchable
data with how much
staff time you’re
willing to spend on
scanning.
stakeholders should design and monitor the
implementation process, but one individual
alone, the project manager, should direct the
actual implementation. Of course, the project manager should do so in a collaborative,
rather than a dictatorial, fashion.
Tactics
New questions will pop up almost every day
while you’re doing an EHR implementation.
With the right tactics in place from the beginning, you’ll have answers ready – for most
of them.
Plan, plan, plan. It can’t be said enough.
Much of an EHR implementation’s eventual
outcome depends on the planning you do
long before you go live. Write the plan down.
Use project management software. Talk to
experts and other users. Visit other implemented sites. Do not wing it.
Workflow redesign. A key piece of planning frequently mentioned by EHR implementation experts is “workflow redesign.” As
mentioned above, an EHR implementation
offers you an opportunity to improve some of
your less efficient processes through automation and fewer steps.
Ideally, for each major office process, you
should review the current paper process, analyze
its steps and record them on a flow diagram.
You can then determine if the process can be
improved by comparing it to a flow diagram
you create of an EHR process that accomplishes
the same thing. Office processes that you should
examine include medication refilling, telephone
messaging, appointment requesting, lab reviewing, other test reviewing, prescription writing,
patient check-in, health maintenance tracking,
referral making, lab and test ordering, communicating test results to patients, interoffice messaging and note charting.
Not all EHR processes will be quicker
and more efficient. You shouldn’t insist that
people switch from an efficient paper process
to a less efficient EHR process just for the
sake of automation.
Sometimes, though, a slower EHR process
can pay off in other ways, making it worthwhile.
For example, progress note documentation with
an EHR is typically slower than using dictation
or even a paper check-box form. However, by
documenting directly in an EHR you immediately gain easily readable notes at the end of the
visit. Notes can then be shared with patients or
consultants, or the notes can be used for immediate review of those patient-care questions that
arise before a dictation would normally return.
Direct EHR note entry also commonly allows
you to record diagnoses and populate problem
lists simultaneously. These computerized problem lists facilitate a wealth of disease management and quality improvement efforts that can
only be dreamed of in the paper world.
Scanning strategy. How much of an old
paper chart should you scan in when you initiate your EHR, and when should you do it? This
is a topic of some debate in the EHR world,
and no single answer will suit all users. The
strategy my three-physician office chose was
to scan in records of patients with scheduled
appointments just before they came in. Eventually, as our volume of first EHR visits decreased,
we started scanning in charts for any patients
that made phone contact with the office.
Another strategy would be to spend six months
before your go-live date trying to intensively
scan in all your charts. This would likely require
extra personnel and more than one scanner.
That answers “when,” but what about
“how much”? One possibility is to scan in
as much as possible into one electronic file.
For example, with a high-speed scanner that
handles 90 pages per minute, you can scan a
200-page record into one file in just over two
minutes. But that isn’t terribly useful, because
to find anything in the old paper record would
involve browsing through that entire electronic
file. Another possibility is to divide those same
200 scanned pages into subfiles using easily
ehr success
retrievable categories such as “urology consult,”
“ECG,” “echo,” “brain MRI,” “chest CT,”
“progress note” and “comprehensive exam.”
This could conceivably require filing 200 pages
in 100 categories, and that isn’t tenable either.
It might take a staff member much longer than
an hour to scan one chart. At that rate, your
staff will quickly fall behind.
The right answer involves a compromise
somewhere between these two approaches.
You’ll find your answer by balancing your physicians’ need to minimize the time they spend
searching for scanned data in an EHR with
how much staff time (read: money) you’re
willing to spend on scanning. Remember, of
course, that physician time spent unproductively also equates to money.
I’ve talked to many EHR users who feel that
you shouldn’t try to scan in the whole old chart.
I agree with this – but only to a point. In my
view, the goal should be to scan in enough of
the chart so that you won’t need to pull paper
charts for appointments. Your records staff will
be busy scanning and filing documents. It’s not
reasonable to expect them to continue doing
the old process of pulling charts, too.
We found it worked well to discretely scan
in the key data we thought we’d need 90 percent of the time and to bulk scan the rest. We
then shredded our charts. We ended up with
more room in our office and were able to get
many old charts out of storage. In some offices,
depending on design, old chart rooms can even
be converted to productive exam room space.
Data entry. To get value out of an
EHR, it’s critical to maintain problem lists,
medication lists and allergy lists. But who
enters that data and when? Again this is an
issue you’ll need to decide during implementation. In our office, medical assistants entered
medications and allergies from the old chart,
and physicians entered the problem lists. This
was done just before an upcoming appointment, and then the chart went to scanning.
That meant that the first time we saw the
patient after going live, we had a completely
functional electronic chart and no longer
needed the paper one. Some offices hire registered nurses to help with problem entry. Others never get around to completing the data
entry and thus have less than fully functional
EHR systems.
Whatever you do, it’s critical that you have
a plan and be consistent. By sticking with
our approach, we were able to have about 80
percent of our active patients’ records scanned
into our system within a year.
Electronic interfaces. Generally the more
options you have to get information into the
EHR electronically, the better. A practice management interface is essential if you have a standalone EHR product. Otherwise you will have to
do double entry of all patient demographics.
Lab interfaces should be a high priority.
With them, you will have a much easier time
finding the specific lab result you’re looking for
than you would if you were using paper, and
you might even be able to flowchart or graph
trends in specific lab values, like all of a patient’s
A1C rates for the last several years. Without a
lab interface, you will have to scan in lab reports
and be no farther ahead than you were with
paper reports, or you or your staff will manually
enter lab values, a labor-intensive process.
Radiology and hospital interfaces are nice
but not as essential. Electronic interfaces will
allow you to reduce how much you scan in
and will speed your access to information.
The problem is that interfaces can break, and
they can have errors. They require skilled IT
personnel to manage them. Don’t implement
one if you can’t skillfully manage it. A broken
interface is worse than no interface at all.
Big bang vs. phased implementation.
It’s critical that you
maintain a consistent policy on who
will handle data
entry and which
data they will enter.
Among optional
EHR interfaces, lab
interfaces should
be a high priority,
while radiology and
hospital interfaces
are nice but not
as essential.
Ideally, all physicians
in one office should
begin working with
the EHR system at
the same time.
Should all physicians go on the system at once?
Should you start all functions at once? Ideally, all
physicians in one office should go on the EHR
together. Otherwise, the office staff will need
to run at least two different sets of processes for
paper-based physicians vs. EHR physicians. Not
OTHER FPM articles by Dr. adler
“An EHR User-Satisfaction Survey: Advice from 408 Family Physicians.”
October 2005:29-35.
“How to Select an Electronic Health Record System.” February
2005:55-62.
“Why It’s Time to Purchase an Electronic Health Record System.”
November/December 2004:43-46.
Training on the EHR
system is best done
within two weeks
of going live so that
new skills are not
forgotten.
You’re likely to get
more doctors using
the EHR system if
they’re given some
leeway to customize note templates.
When you’re ready
to “go live” with
your EHR, try to
avoid starting on
a Monday, which
is already your
busiest day.
only is that confusing, but it also is inefficient.
However, if your practice has more than one
office, there is no overriding reason that all practices have to go on the EHR at one time. In fact,
depending on your practice’s resources, you
might be wiser to roll out one office at a time.
A few practices have successfully implemented all functions of an EHR at once. This
can be called “big bang.” The consensus, however, is that success is more likely if you implement functions sequentially in what is known as
“phased implementation.” Typically you start by
introducing less interactive functions first, like
scanning and result reviewing, and then move
on to more interactive functions, like interoffice
messaging, prescription writing and note documentation. A lot of variability exists in this area,
partly perhaps due to variation in EHR software. With regard to specific phased implementation strategies, you should pay close attention
to your EHR vendor’s recommendations.
Training. Many implementations use a
train-the-trainer approach, in which a core
group of people are trained directly by the
vendor. This group in turn trains the rest of
the users at their site(s).
Training for end users is best done within
two weeks of going live so that new skills
aren’t quickly forgotten. One initial training
session may not be enough. Teaching complex
skills, like efficient note documentation for
physicians, can be started with the initial training and then advanced with briefer updates.
While some EHR skills apply to all users,
distinct user groups, such as receptionists,
records personnel, medical assistants/nurses
and physicians, will benefit from customized
training relevant to them.
Training can be done classroom style, via
the Web or one-on-one, depending on your
resources and inclinations. Initial training
time will vary depending on your software
and implementation plan. Our clinic’s initial
training commitment ranged from four hours
for receptionists to 16 hours for physicians.
Note design. Vendors will often supply
some standard note templates for your use that
their other customers have used. Given the variation in how physicians practice medicine, you
will most likely decide to customize these templates to suit your practice style. Some practices
develop dozens, even hundreds, of templates for
use in a wide variety of clinical situations.
You’ll need to consider how much leeway
each physician should have on customized
templates. For example, should your practice
design one common template for the medical
group on diabetes? Or would it work better if
you allowed each physician or practice site to
create a customized variation? If you are using
a template for the purpose of disease management, then it makes sense to standardize.
Otherwise, allowing individual variations will
likely promote higher EHR utilization and
efficiency among your physicians.
After you’ve decided on a template policy,
you still need to offer your physicians other
ways to document their patient encounters.
I’ve found that if you try to force everyone to
use the same method of note documentation,
then you won’t be able to get everyone to use
the system. Choosing an EHR product that
allows a variety of ways to document notes
will lead to fuller EHR utilization. In addition
to templates, other documentation options
include free text typing, voice recognition,
partial- or full-note dictation using voice files,
macro use and handwriting recognition. In
some cases, a combination of these can be
used to create a note most efficiently.
Going live. If you’ve prepared well, turning
your system on, or “going live,” should be
uneventful. Given that Mondays are your busiest days, they are a bad choice for a “go live”
day. Pick any other day. Make sure your
physicians have lighter-than-normal schedules –
ideally about a 50-percent workload. Our
practice did that for the first two weeks and
then resumed our normal schedules. This will
vary depending on your implementation’s
design. Ask your vendor what has worked
best for other customers.
It’s common to underestimate how long it
will take staff and physicians to get up to speed
on the EHR. Remember, learning how to use
an EHR is a lot like learning a musical instrument. You don’t just pick it up the first day
ehr success
and expect to be a virtuoso. Depending on the
complexity of the product, basic competency
can easily take six months. That’s why phased
implementations are typically recommended.
Support. Adequate vendor support is
essential for success. If your vendor fails to
respond to your calls for help or responds too
slowly, your implementation can be sabotaged.
This speaks to the importance of thoroughly
investigating your vendor and the product
before you sign the contract.
A common tip for success is to create one
or more “power users” at each clinical site.
These will be employees to whom the rest of
your staff can turn first for immediate advice
on many issues. If the issue is beyond a power
user’s knowledge, then it is passed up to your
internal IT staff or your EHR vendor.
Technology
Many EHR experts say that people problems, or what I call “team” issues, rather than
technology problems, lead to nearly all EHR
failures or partial implementations. Their
favorite examples always involve one practice
that succeeded and one practice that failed,
even though they bought the same EHR
system and used the same hardware. My
experience and conversations with other users
has led me to the perspective that technology
matters, too.
Need for speed and high network availability. Although I agree that people issues are
critical, I believe that technological problems
can torpedo an implementation, too. Poorly
written software that requires numerous clicks
to accomplish a process, compared to an alternate product that does the same thing with one
click, makes it harder for EHR users to succeed.
Inadequate server memory or processing power
or poor network design can slow down common EHR tasks to the point of crippling them.
Our group’s implementation came perilously close to failing when we ran into problems with our network. All of our EHR sites,
and two in particular, had problems with speed.
Screen changes often took several seconds. This
caused enough consternation among our physicians that some wanted to get their money back
and return to paper. After much investigation,
we learned that the primary issue was a lack of
bandwidth. It would have broken our budget
to increase bandwidth enough to solve the
problem. Fortunately, we found an affordable
solution using network compression hardware.
Large medical groups and hospitals typically have a sophisticated IT infrastructure
and more resources to invest in hardware than
smaller practices. Thus, they are less likely to
suffer from network or server problems. Small
practices should be sure to have excellent IT
support or consider an application service provider (ASP) model. With an ASP, an outside
Many practices
designate in-house
EHR “power users”
to whom other
employees can turn
first for advice and
support.
Technological
problems, such as
poorly written software or inadequate
server memory,
can cripple an EHR
implementation.
the three t’s of a successful EHR Implementation
Team
Tactics
Technology
• Identify one or more
EHR champions or don’t
implement.
• Make sure your organization’s
senior executive fully
supports the EHR.
• Use an experienced, skilled
project manager.
• Utilize sound change
management principles.
• Have clear, measurable goals.
• Make sure users share your
goals.
• Establish realistic
expectations.
• Don’t try to implement
an EHR in a dysfunctional
organization.
• Plan, plan, plan.
• Redesign your workflow.
• Don’t automate processes just because you can; make sure
the automation improves something.
• Design a balanced scanning strategy.
• Consistently enter key data into your new EHR charts.
• Get data into the EHR electronically when possible.
• Utilize a phased implementation.
• Train, train, train.
• Be flexible in your documentation strategy and allow
individual differences in style.
• Don’t “go live” on a Monday.
• Lighten your workload when you “go live” and for a short
period afterward.
• Don’t underestimate how much time and work is involved in
becoming “expert” with an EHR.
• Pick a vendor with an excellent reputation for support.
• Utilize “power users” at each site.
• Don’t scrimp on your IT
infrastructure.
• If you’re a small practice,
consider an application
service provider (ASP) model.
• Make sure that your IT
personnel do adequate
testing.
• Utilize expert IT advice when
it comes to servers and
networks.
• Make sure your servers and
interfaces are maintained on
a daily basis.
• Back up your database at
least daily.
• Have a disaster recovery plan
and test it.
screens to change while you are in the middle of
a busy day practicing medicine is not acceptable.
Disaster recovery. You will invest heavily
in hardware, software and training. You will
reap many rewards for your efforts. Yet there
is one more investment you must make that
will have no obvious return. You need to back
up your data daily and have a working disaster
recovery plan. Think of this as an insurance
policy. You should test your back-ups and
make sure they work. You also should build
redundancy into your system to maintain
high availability of the EHR. Get some expert
IT advice here.
Line up expert IT
support and maintenance, or suffer
the consequences.
Your data should be
backed up daily.
With careful
planning and good
advice, your EHR
project will succeed.
entity maintains the servers and backs up your
data. You just provide desktops and a broadband Internet connection.
Testing. If you are running your own servers, you should have a “test” environment to
mirror your “live” environment. All new software products, upgrades and patches should
be thoroughly tested before unleashing them
in the live environment. Otherwise, something
as simple as installing a new patch could cause
your EHR to malfunction during the middle of
a busy workday. After that happens a few times,
your users will be eager to go back to paper.
Be aware that your IT personnel should
perform different types of testing with names
like “smoke testing,” “end-to-end testing” and
“volume testing” before a new implementation.
Although a detailed description of testing
techniques is beyond this article’s scope, you
should get a list of all the recommended types
of testing from your EHR vendor and then
ensure that this is done by whoever will be
responsible for it in your implementation.
IT support and maintenance. The more
complex your server and network environment,
the more support and maintenance you will
need. Get expert help here or suffer the
consequences.
Server and network hardware can be expensive. Because EHR software is also expensive and
EHR vendors want to promote sales, they have
a stake in quoting you the minimal hardware
configurations that will work with their product. Consider getting independent verification
on their specifications if possible. Ask for a list
of the hardware choices some of their other clients made. Also, don’t go with the minimums.
Performance will be enhanced if you have a
buffer. Remember, from the end-user’s point of
view, speed is everything. Having to wait for the
The journey ahead
I’ve put my key points in the list on page 38
(see “The three T’s of a successful EHR implementation”). Undoubtedly, looking at that list
and thinking about your EHR implementation is daunting. There’s so much to learn,
and so many things can go wrong.
Take it step by step. Plan carefully. Get
good advice. Be patient. You will succeed.
But remember, implementing an EHR is
not a destination but a journey. As one EHR
expert put it, “Successful implementations
never end – only failures.”4
1. Miller RH, Sim I, Newman J. Electronic medical
records: lessons from small physician practices. Available at: http://www.chcf.org/topics/chronicdisease/index.
cfm?itemID=21521. Accessed Oct. 11, 2006.
2. Kotter JP. Leading Change. Boston, Mass: Harvard Business School Press; 1996.
3. Miller RH, West C, Brown TM, Sim I, Ganchoff C. The
value of electronic health records in solo or small group
practices. Health Affairs. 2005;24:1127-1137.
4. Carter JH. EHR implementation successes and failures:
what have we learned? Available at: http://www.amia.org/
noind/meetings/spring05/jcarter.ppt. Accessed
Oct. 12, 2006.
coming soon:
ehr user-satisfaction survey
An upcoming issue of FPM will include our
EHR user-satisfaction survey. Two years
have passed since our last survey, and
we’re interested to learn and to share how
our readers are faring with their EHRs.
With the changes made in the final rule, earning
the EHR incentive is still not easy, but at least it’s easier.
A Physician’s Guide
This is a corrected
version of the article
that appeared in print.
to the Medicare and Medicaid
EHR Incentive Programs:
The Basics
N
ew laws introduced by Congress and the
Obama Administration will greatly change
the way most of the health care industry
approaches electronic health record (EHR)
technology. Their objective is sweeping reform of health
care delivery and payment.
The most important elements of the federal health IT
agenda are the Medicare and Medicaid EHR incentive
programs, the result of passage of the HITECH portion
of the American Recovery and Reinvestment Act (ARRA),
the economic stimulus bill of 2009. The act gave the
Centers for Medicare & Medicaid Services (CMS) and
the ONC a broad charter and an original budget of about
$19 billion (now reported to be up to $27 billion).
This has culminated in the issuance of a complex set of
rules and regulations that govern how physicians and hospitals may start to receive incentive payments beginning
in 2011 for the “meaningful use of certified EHR technology.” The programs are voluntary, but the incentives
for participation and the penalties for non-participation
warrant a close look by all doctors regardless of practice
size, location, specialty or payer mix.
This “physician’s guide” is intended to help you learn
about the incentive programs. It provides essential information, commentary you may find useful, and references
to additional sources of information.
The basics: eligibility, incentives, requirements
and the application process
The EHR incentive programs don’t provide cash for
physicians to buy EHR software. Instead, physicians
can collect a year’s payments only by demonstrating the
David C. Kibbe, MD
meaningful use of certified EHR technology for the full
reporting year. (The exceptions are that, in the first year
they demonstrate meaningful use, participants in either
program need only prove 90 consecutive days of meaningful use starting as late as Oct. 1, and that Medicaid participants don’t need to demonstrate meaningful use until
the second year, as long as in the first year they adopt or
upgrade certified EHR technology.)
Physicians who can demonstrate meaningful use of
certified EHR technology and who submit claims to
Medicare are eligible for the Medicare incentive. Physicians are eligible for the Medicaid incentive if their caseload includes at least 30 percent Medicaid patients (at
least 20 percent for pediatricians). Physicians may switch
once from one program to the other during the five years
the programs run but can’t claim both incentives at once.
Under Medicare, the incentive is 75 percent of the
physician’s Medicare allowed charges for the year, up to
the year’s maximum incentive. Under Medicaid, it is 85
percent of the physician’s Medicaid allowed charges up
to a different maximum. Payments for the Medicare program are spread out over five years and for the Medicaid
program over six, with diminishing amounts available to
those who start in later years. The tables on page 19 indicate how the maximum incentive payments are to be paid
out. For providers in federally designated health professional shortage areas, payments will be 10 percent greater.
Medicare incentive checks will go to individual physicians; physicians who work in group practices or hospitals
may assign their payments to their employers. For the Medicaid program, each separate state Medicaid agency will process the incentive payments to physicians or their practices.
Unlike the Medicaid incentive program, the Medicare
Copyright © 2010 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site.
| www.aafp.org/fpm
| FAMILY PRACTICE
All other rights reserved. Contact [email protected]
for copyright
and/or permission
requests.MANAGEMENT | 47
September/October
2010 questions
The incentives for participation and the penalties
for non-participation warrant a close look.
Physicians who are
“meaningful users of
certified EHR technology” can earn
CMS bonuses over
several years.
For the incentive programs,
meaningful use is
defined in terms
of EHR-derived
data that must be
reported to CMS.
The EHR technology used must be
certified as capable
of collecting,
manipulating and
reporting the data
required by specified objectives and
measures.
program includes penalties. The Medicare fee
schedule will decrease by 1 percent in 2015, by
2 percent in 2016 and by 3 percent in 2017
for physicians who aren’t “meaningful users.”
Every physician must have a National
Provider Identifier (NPI) and be enrolled in
the CMS Provider Enrollment, Chain and
Ownership System (PECOS) to participate in
the Medicare incentive program. Most physicians also need to have an active user account
in the National Plan and Provider Enumeration System (NPPES). The Medicaid program
is offered and administered voluntarily by
states and territories. States can start offering
incentives as early as 2011 or as late as 2016.
Registration for both programs is expected to
open in January 2011. Details of the application process will posted on the CMS web site
at http://www.cms.gov/ehrincentiveprograms.
(That is, by the way, an excellent source of
information about the programs in general.)
The meaning of ‘meaningful use’
Meaningful use requires using the EHR for
structured data collection, e-prescribing,
health information exchange, clinical decision support, patient engagement, security
assurance and quality reporting. The data elements that must be collected in coded format
include demographics, vital signs, problems
and diagnoses, immunizations, laboratory
results, medications, etc.
CMS specifies a “core set” of 15 objectives
and measures that must be met to qualify for
meaningful use, along with a “menu set” from
which the physician must select five for Stage 1
About the Author
Dr. Kibbe is a senior adviser to the AAFP’s Center
for Health IT (CHIT), in Leawood, Kan., chair of the
ASTM International E31 Technical Committee on
Healthcare Informatics, and principal of The Kibbe
Group, LLC. Author disclosure: nothing to disclose.
(see “Meaningful use objectives and measures,”
page 20). Meeting the targets for meaningful
use requires clear understanding of the new
practice workflows needed and the right equipment to report the results of meaningful use.
For 2011, participants will be asked to provide aggregate data for numerators, denominators and exclusions, and to attest that these
numbers were arrived at using certified EHR
technology. In 2012, CMS will continue
accepting attestation for most objectives but
plans to require electronic submission of the
clinical quality measures and to develop audit
systems to protect against fraud. Similarly,
state Medicaid programs will support attestation initially and then move to electronic submission of clinical quality measures.
At bottom, “meaningful use” requires physicians to collect a designated set of data about
patients and encounters, to store those data in a
computer database and to perform a number of
computations with those data. As the stages of
the incentive programs progress, the required
operations become more complex. In Stages 2
and 3, the plan is to require additional capabilities and more sophisticated uses of the data for
decision support and population reporting.
Why “EHR technology”
is not the same as an EHR
Physicians need to grasp the difference
between certified EHR technology as used in
these incentive programs and terms such as
electronic medical record (EMR) and electronic
health record (EHR). The new regulations
define certified EHR technology with specific
reference to the capabilities needed for meaningful use, and they also subdivide EHR technology into two new categories:
1) A complete EHR is one that equips
a physician to attain all of the objectives of
meaningful use.
2) An EHR module is defined as any EHR
technology that equips a physician to attain at
Article Web Address: http://www.aafp.org/fpm/2010/0900/p17
48 | FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | September/October 2010
Meaningful Use
Maximum incentive payment amounts
Physicians who use a qualified EHR could receive up to $44,000 over five years from the Centers for
Medicare & Medicaid Services, assuming they have at least $24,000 in Medicare allowed charges per
year and use the qualified EHR from 2011 or 2012 on. The incentive amount is based on 75 percent of
the physician’s Medicare allowed charges, up to the year’s maximum incentive amount.
Alternatively, a physician may choose the Medicaid incentive, which pays up to $21,250 in year one
(85 percent of a maximum of $25,000 in Medicaid allowed charges) for health information technology adoption and implementation and up to $8,500 over the next four years (85 percent of a $10,000
maximum) for operation and maintenance. To qualify for the Medicaid incentives a physician’s caseload must include at least 30 percent Medicaid patients.
Physicians may not receive both Medicaid and Medicare incentives. For providers in federally designated health professional shortage areas, incentive payments will be 10 percent greater.
Medicare incentive maximum per year:
Year EHR use is
first demonstrated
2011
2012
2013
2014
2015
$18,000
$12,000
$8,000
$4,000
$2,000
$18,000
$12,000
$8,000
$4,000
$2,000
$44,000
$15,000
$12,000
$8,000
$4,000
$39,000
$12,000
$8,000
$4,000
$24,000
$0
$0
$0
2012
2013
2014
2015
2016
Total maximum
incentive
2011
$44,000
Medicaid incentive maximum per year:
Year 1
(no later
than 2016)
$21,250
Year 2
$8,500
Year 3
$8,500
least one of the objectives.
An e-prescribing application, for example,
is an EHR module that could meet several
meaningful use objectives. E-prescribing integrated with other modules – a patient registry,
a module for providing patients with clinical
summaries, etc. – might meet all of the criteria of meaningful use. Modular EHRs, opensource and home-grown software programs
are specifically cited in the regulations as
being allowable EHR technologies provided,
of course, that they undergo certification.
The important notion here is that EHR
products now on the market may not qualify
as certified EHR technology even if they were
certified by the Certification Commission for
Health Information Technology (CCHIT).
For example, most legacy EHR systems are
not equipped to report out specific quality
measures or to offer patients a clinical summary in electronic form, which are capabilities
Year 4
$8,500
Year 5
$8,500
Year 6
$8,500
Total
maximum
incentive
$63,750
included in the meaningful use criteria.
At the same time, many legacy EHR
products have functions that lie outside the
definition of meaningful use. Automated calculation of evaluation and management (E/M)
codes to justify billing levels is a staple of
many legacy EHRs, for instance, but not one
of the meaningful use criteria.
As you evaluate products with an EHR
incentive program in mind, you will want to
be sure you buy neither too little to qualify for
the incentive nor too much for the needs of
your practice. Mistakes could be costly.
Previously certified EHR systems
will need to be
recertified under
new rules to qualify
as certified for
meaningful use,
and most will likely
require upgrade.
Medicare-associated incentives
can be as much as
$44,000, and Medicaid-associated
incentives as much
as $63,750.
To qualify for incentive payments, a
physician must
meet 15 specified
objectives plus five
the physician can
choose from a list
of 10.
The new rules regarding certification
An important aspect of the incentive programs
is the requirement that only certified EHR
technology may be used to qualify for meaningful use incentives. Under the new rules, the
ONC will accredit “testing and certifying bodSeptember/October 2010 | www.aafp.org/fpm | FAMILY PRACTICE MANAGEMENT | 49
ies” starting in early fall 2010. There is to be no grandfathering in of either certification bodies such as CCHIT
or of products certified by them. Legacy EHR technology
must go through the new certification process along with
newer technology. To receive incentive payments, most
users of older EHRs will need to upgrade their systems to
versions that have met the new certification criteria.
The first products certified under the new system will
reach the market in late 2010 or early 2011. CMS and
ONC will maintain a web site for products and services
that have been tested and certified.
Quality reporting requirements
All physicians seeking incentive payments will have to
report data on three core quality measures in 2011 and
2012: blood-pressure level, tobacco status and adult weight
screening and follow-up, or alternates if these do not apply.
Alternates include influenza immunizations for patients
older than 50, weight assessment and counseling for children and adolescents, and childhood immunizations. Physicians must also report three more clinical quality measures
chosen from 44 familiar National Quality Forum and/or
Physician Quality Reporting Initiative (PQRI) measures. A
complete list is available through the online version of this
article at http://www.aafp.org/fpm/2010/0900/p17.
According to recent announcements from ONC and
CMS, the PQRI program may be consolidated with the
Medicare EHR incentive program to avoid redundant
reporting requirements. And by 2012, CMS intends to
create a single reporting infrastructure for electronic submission of clinical quality data.
To qualify for Medicare’s 2011 meaningful use incentive,
participating physicians must send CMS summary clinical
quality data gathered from all patients, not just Medicare
beneficiaries. After 2012, Medicare assumes that it will
Meaningful use objectives and measures
Core Set
Stage 1 Objectives
Stage 1 Measures
Use computerized physician order entry
(CPOE) for medication orders.
> 30 percent of patients with at least one medication in their medication list
have at least one medication order entered using CPOE.
Implement drug-drug and drug-allergy
interaction checks.
Enable this functionality for the entire reporting period.
Use e-prescribing.
> 40 percent of all permissible prescriptions are transmitted electronically.
Record patient demographics.
> 50 percent of patients have demographics recorded as structured data.
Maintain an up-to-date problem list.
> 80 percent of patients have at least one entry, or an indication that no
problems are known for the patient, recorded as structured data.
Maintain an active medication list.
> 80 percent of patients have at least one entry recorded as structured data.
Maintain an active medication allergy list.
> 80 percent of patients have at least one entry recorded as structured data.
Record and chart changes in vital signs.
> 50 percent of patients age 2 or older have height, weight and blood
pressure recorded as structured data.
Record smoking status for patients 13 years
old or older.
> 50 percent of patients age 13 or older have smoking status recorded as
structured data.
Implement one clinical-decision-support rule.
Implement one clinical-decision-support rule.
Report ambulatory clinical quality measures
to CMS or the states.
For 2011, provide aggregate numerator, denominator and exclusions
through attestation.
For 2012, submit the clinical quality measures electronically.
Give patients an electronic copy of their
health information upon request.
> 50 percent of patients who request an electronic copy of their health
information get it within 3 business days.
Provide clinical summaries for patients for
each office visit.
Provide clinical summaries to patients for > 50 percent of all office visits
within three business days.
Be able to exchange key clinical information
with other providers and patient-authorized
entities electronically.
Conduct at least one test of the EHR’s ability to exchange key clinical
information electronically.
Protect electronic health information
created or maintained by the certified
EHR technology.
Conduct or review a security risk analysis, implement security updates as
necessary and correct identified security deficiencies.
50 | FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | September/October 2010
Meaningful Use
CMS specifies a “core set” of 15 objectives
and measures along with a “menu set”
from which a physician must select five.
be able to receive the raw, de-identified data
directly from EHR technologies via electronic
data formats not yet specified. The states will be
able to decide their own methodology for Medicaid data collection starting in 2012, although
they must validate this with CMS.
Getting help: RECs and other resources
A provision in ARRA/HITECH establishes
a set of regional health IT extension centers
(RECs) modeled after the agricultural extension programs of the 1930s. The RECs are
intended to help eligible professionals earn the
meaningful use incentives. They are to give
priority to primary care professionals in small
and rural practices. Each must assist at least
1,000 such professionals in the next two years
to retain funding. About 60 RECs are funded
as of August 2010, with most being state-level
organizations. For more information and to
locate the REC in your region, consult the
ONC web site at http://bit.ly/REC_program.
To stay up-to-date on all aspects of meaningful use, visit the AAFP’s Center for Health
IT (CHIT) web site at http://www.centerforhit.org/meaningfuluse and follow the new
FPM blog, “Making Health IT Meaningful,”
written by the staff of CHIT. You’ll find it at
http://blogs.aafp.org/fpm/healthit.
To begin with,
participants need
only attest that the
results they report
were derived from
EHR technology.
Regional health IT
extension centers
are being set up
to help physicians
achieve the objectives specified
by the incentive
programs.
MENU SET
Stage 1 Objectives
Stage 1 Measures
Implement drug-formulary checks.
Implement this functionality and have access to at least one drug formulary
for the entire reporting period.
Incorporate test results as structured data.
> 40 percent of all lab test results reported in a positive/negative or
numerical format are incorporated in the EHR as structured data.
Generate lists of patients by specific
conditions.
Generate at least one report listing patients with a specific condition.
Send reminders to patients per patient
preference for preventive/follow-up care.
> 20 percent of all patients 65 or older or 5 or younger were sent an
appropriate reminder during the reporting period.
Give patients timely electronic access to
their health information.
> 10 percent of all patients seen are provided electronic access to their
health information within four business days of its updating in the EHR,
subject to the physician’s discretion to withhold certain information.
Provide patient-specific education resources Use the EHR to give > 10 percent of all patients seen patient-specific
to the patient as appropriate.
education resources.
Perform medication reconciliation whenever
appropriate.
Perform medication reconciliation for > 50 percent of patients arriving from
another setting.
Provide summary-of-care records.
Provide a summary-of-care record more than half the time when referring
patients to other providers or settings of care.
Be able to submit electronic data to
immunization registries or immunization
information systems.
Perform at least one test of the EHR’s ability to submit electronic data
to immunization registries and make a follow-up submission if the test is
successful (if the registries to which the physician submits such information
can receive it electronically).
Be able to submit electronic syndromic
surveillance data to public health agencies.
Perform at least one test of the EHR’s ability to provide electronic syndromic
surveillance data to public health agencies and make a follow-up submission
if the test is successful (if the agencies to which the physician submits such
information can receive it electronically).
September/October 2010 | www.aafp.org/fpm | FAMILY PRACTICE MANAGEMENT | 51
opinion
Should Doctors Reject the
Government’s EHR Incentive Plan?
It’s a big hill to climb for a carrot that may
not be there when you reach the top.
I
s health information technology (IT) being set up to
fail? Might we be facing a lost generation of health IT
investment? Will Kaiser Permanente and Mayo Clinic
get windfall profits while small practices receive nothing
but hassles? It’s beginning to seem that way.
I’m sure you already know the broad outlines of the
government’s plan to pay physicians roughly $44,000
each (a national investment of $20 billion or more), over a
five-year period starting next year, for “meaningful use of
certified electronic health record technologies.” (If not, see
“‘Will the Feds Really Buy Me an EHR?’ and Other Commonly Asked Questions About the HITECH Act,” FPM,
July/August 2009; http://www.aafp.org/fpm/2009/0700/
p19.html.) While we now have the U.S. Department of
Health and Human Services (HHS) proposed rule for
defining meaningful use and the “interim final rule” for
EHR certification criteria, we won’t know until later this
year precisely what meaningful use means, how doctors
can apply for the payments, what technologies will be
certified, or when the payments will start. But it’s not too
early to begin asking some hard questions.
How can we decide whether to buy an EHR when
the future is so uncertain? Federal Reserve Chairman Ben
Bernanke is said to have made this comment more than 30
years ago: “If you as a business were considering buying a
new boiler, and if you knew the price of energy was going
to be high, you would buy one kind of boiler. If you knew
the price of energy was going to be low, you’d buy another
kind of boiler. If you didn’t know what the price of energy
was going to be, but you thought you would know a year
from now, you wouldn’t buy any boiler at all.”
Similarly, physicians will not be able to judge the costs
of EHR technology easily for at least the next year given
that a certification process yet to be implemented may force
vendors to modify their products in as-yet unforeseeable but
potentially costly ways, and given that we don’t know what
it will cost physicians to use the technology “meaningfully.”
More, physicians face uncertainty regarding their future
revenues – the revenues that will determine how much
they can spend on EHRs. While the health care reform
bill passed by the U.S. House of Representatives includes
a modest increase in Medicare fees for primary care physicians, the fate of that bill and of health care reform in general is more uncertain than ever now that the Republicans
have 41 seats in the Senate. And while the threatened 21percent cut in Medicare rates seems unlikely now, it’s not
completely out of the picture. If the massive cut is averted,
who knows what will replace it – a short-term preservation
of the status quo, perhaps, to be followed by … what?
One hopeful but still unsettling prospect: With HHS’s
replacement of criteria for certification developed by the
Certification Commission for Health Information Technology (CCHIT) and what may be the replacement of
CCHIT as certifying body, the current crop of EHR vendors may have diminished influence over market offerings
in the future. This could open the door to innovative and
affordable web-based EHR technologies.
Also, content in the new regulations suggests that the
Office of the National Coordinator for Health Information Technology (ONC) and HHS are now favorably disposed to EHR technologies that are modular and able to
be assembled from components – what I and others have
called “clinical groupware.” These changes suggest that
HHS-certified EHRs could be less expensive to own and
operate than the monolithic, single-vendor products that
what do you think?
About the Author
Dr. Kibbe is a senior adviser to the American Academy of Family
Physicians, chair of the ASTM International E31 Technical Committee on Healthcare Informatics, and principal of The Kibbe
Group, LLC. Author disclosure: nothing to disclose.
The opinions expressed here do not necessarily represent
those of FPM or our publisher, the AAFP. We encourage
you to share your views on the issues discussed. Please
send your comments to FPM at [email protected].
| www.aafp.org/fpm
| March/April
© 2010MANAGEMENT
American Academy
For the
private, noncommercial use of one individual user of the Web site.
52 |Copyright
FAMILY PRACTICE
2010
CCHIT certified through mid-2009. (To learn more about
the advantages of a modular approach to EHR technology,
see “Toward a Modular EHR,” FPM, July/August 2009;
http://www.aafp.org/fpm/2009/0700/p8.html.) If this is
the case, then physicians who don’t yet have EHRs might
be wise to wait until at least late this year to make any decision about a purchase.
Physicians who already own EHRs are in their own
limbo. Even regularly upgraded systems will still need to
go through the new HHS certification process before they
can be considered platforms for meaningful use – and the
upgrades or patches needed to enable existing software to
meet the new standards could be expensive.
About the only physicians who have certainty in this
environment are those working for large provider organiza-
This is a question that physicians understand almost
instinctively. Quality and performance data reporting is
highly specific to practice context and fraught with technical problems. Now, along comes a requirement to use
an untested set of EHR technologies, possibly involving
hundreds of different vendors’ products, most rarely if ever
used for the submission of these clinical data, paired with a
so-far nonexistent infrastructure intended to collect, aggregate and analyze these data. And this is supposed to work?
It’s hard to believe that ONC/HHS/CMS can put all of
these pieces together in a matter of 12 to 18 months, let
alone ask physicians to accept the risk that this will eventually validate their claim of meaningful use. And what
happens if the Republicans take back the White House in
2012 and scuttle the whole program?
Small- and medium-size medical practices may feel the risk
much more profoundly than larger groups.
tions. These salaried physicians can expect their administrations to upgrade their EHRs for certification, regardless of
cost, with the incentive payments flowing to the enterprises.
Can we trust the government to run this program
any better than the Physician Quality Reporting Initiative (PQRI)? Physician confidence in the government is at
an all-time low. Many I speak with openly challenge the
ability of the Centers for Medicare & Medicaid Services
(CMS) to pay physicians who fulfill the meaningful-use
requirements. They cite the administrative nightmare of
PQRI, which David Brailer, MD, PhD, the first national
health information technology coordinator and predecessor
to David Blumenthal, MD, MPP, recently called a “mangled set of incentives” that “turned into a massively complex bureaucracy of forms and applications,” and “failed to
do what it promised physicians it would do.”
To many physicians, meaningful-use qualification looks
like more of the same: a maze of bureaucracy, attestation
forms and applications, and new outlays for software, hardware and consulting services, with a very uncertain chance
of receiving a check from Medicare or Medicaid when all
is said and done. It is a lot of risk, so far without a lot of
assurance of return. Small- and medium-size medical practices may feel the risk much more profoundly than larger
groups, because they lack the administrative apparatus to
smooth the transition and assure that payment is received.
What if CMS isn’t able to handle the data? The
proposed rule defining meaningful use includes a core
mandate for physicians to use certified EHR technology to
submit quality and performance data to CMS. What confidence can we have that the government will be technologically competent to handle this massive amount of raw data?
Will Congress really penalize doctors who don’t
comply? Meaningful-use implementation could prove
onerous and overly complicated for doctors in small- and
medium-size practices, costing them much more in dollars
and productivity than they would gain in incentive payments. Given that, will Congress have the will to punish
physicians who chose to forego the program, paying them
at a lower Medicare fee schedule starting in 2016 as the
plan calls for? What would such a penalty accomplish,
other than to drive even more primary care physicians into
retirement or large groups, where they are generally the
lowest paid and least respected members of the organization? What would be the political backlash from physician
organizations and patient advocacy groups?
The Congressional Budget Office has opined that physicians are unlikely to respond to financial incentives in
large numbers and that it will take a penalty to get them to
comply with mandates for EHR use, but physicians know
that Congress has never been willing to punish them for
any behavior. The threat of a penalty may be empty, or at
least worth risking.
I’m not yet at the point where I would recommend that
doctors reject the incentive program. But it’s hard for me to
recommend participating, given the degree of uncertainty
and risk. I’d like to see evidence that the feds understand
the complexity of community-based medical practices and
can refine and simplify their meaningful-use criteria. And
I worry a great deal that big organizations will get windfall
profits out of this deal, while most family medicine practices will only get new hassles and unfunded mandates.
March/April 2010 | www.aafp.org/fpm | FAMILY PRACTICE MANAGEMENT | 53
Steven Waldren, MD, David C. Kibbe, MD, MBA, and Jason Mitchell, MD
This is a corrected version of the article that
appeared in print.
“Will the Feds Really
Buy Me an EHR?”
and Other
Commonly Asked
Questions About
the HITECH Act
The economic stimulus package offers $19 billion in health IT incentives,
but it also creates new penalties. Here’s what you need to know.
changes to the information privacy and security rules
established under the Health Insurance Portability and
Accountability Act, or HIPAA.
To help physicians make sense of the new regulations,
this article offers answers to commonly asked questions.
How much money is available
to physician practices?
The health IT portion of the stimulus package contains
$2 billion for the Office of the National Coordinator for
Health Information Technology to use to promote health
IT adoption and health information exchange, primarily through grants or loans that will be made available
through state governments. Grants or loans may be avail-
| www.aafp.org/fpm
| July/August
54 |Copyright
FAMILY PRACTICE
2009
© 2010MANAGEMENT
American Academy
For the
private, noncommercial use of one individual user of the Web site.
To m F ot y
T
he recent promise of $19 billion in federal
aid for the adoption of health information
technology such as electronic health records
(EHRs) has piqued the interest of many physicians – from early adopters, who are eager to recoup their
investments, to EHR skeptics, who are still deciding
whether to make the leap. This unprecedented level of
funding was established by the Health Information Technology for Economic and Clinical Health (HITECH)
Act, which was signed into law on Feb. 17 as part of the
American Recovery and Reinvestment Act (ARRA), commonly referred to as the economic stimulus package. The
legislation relies on a combination of incentives and penalties to encourage providers to adopt health information
technology. It also makes some potentially cumbersome
HIT incentives
The other $17 billion goes to CMS for
incentive payments to physicians –
up to $44,000 over five years.
able to physician practices to help purchase
EHRs; however, we will not know for sure
until such programs are put in place.
The other $17 billion in the health IT portion of the stimulus package goes to the Centers for Medicare & Medicaid Services (CMS)
for incentive payments to physicians.
Any physician who participates in the
Medicare Part-B program and “meaningfully”
uses a “qualified” EHR system will be eligible
to receive the incentive payments. Payments
will be sent to the individual physician, not
to the practice. To qualify for the Medicaid
incentives, a physician’s caseload must be
made up of at least 30 percent Medicaid
patients. Physicians may not receive both
Medicaid and Medicare incentives.
Hospital-based physicians are not eligible
to participate in either incentive program,
although hospitals can. For more on incentive
amounts, see the table on page 21.
Will physicians get money
up front to help purchase EHRs?
In general, there will not be up-front money to
help physicians purchase EHRs. As noted above,
grants may be distributed to the states to help
with EHR adoption and health information
exchange. It is likely that rural and underserved
areas will be given priority.
When can I receive the incentive
payments from CMS?
Medicare incentive payments will be made
between 2011 and 2016. Incentive amounts
will depend on when you begin meaningfully
using a qualified system. (See the table on
page 21.) Scheduling of Medicaid incentive
programs will be left up to the states, with the
stipulation that programs must begin by 2016.
If I already have an EHR,
can I qualify for the incentives?
As long as your EHR meets the standards that
are to be announced by Dec. 31, 2009, you
can qualify for the incentives. Although those
standards are not currently defined, the legislation does require functionalities such as the
following:
• Decision support,
• Physician order entry,
• Health information exchange,
• Quality reporting.
It’s possible that some EHR products
that are currently certified by the Certification Commission for Healthcare Information Technology (CCHIT) may not qualify
for the incentives, as CCHIT criteria do not
fully encompass the potential requirements
for a “qualified system.” Who will be certifying EHRs for the incentive program is still
unknown.
What do I have to do
to qualify for the incentives?
You must use a “qualified system” and demonstrate “meaningful use” of that system,
according to the legislation. However, these
terms still need to be defined by the Secretary
of Health and Human Services.
The AAFP and more than 70 other organizations recently signed onto a consensus
statement drafted by the Markle Foundation’s
Connecting for Health collaborative, which
proposes the following definition for meaningful use of health IT systems: “Demonstrates
that the provider makes use of, and the patient
has access to, clinically relevant electronic information about the patient to improve patient
outcomes and health status, improve the delivery of care, and control the growth of costs.”
The economic
stimulus package
set aside $19 billion
to encourage the
adoption of health
care information
technology, such as
EHRs.
Physicians who
“meaningfully use” a
“qualified EHR system” could receive
up to $44,000 from
Medicare.
The money will not
be available up
front but will be
issued between
2011 and 2015.
Article Web Address: http://www.aafp.org/fpm/20090700/19will.html
The consensus statement proposes the use
of a more lenient definition from 2011 to
2012: “Demonstrates that the provider makes
use of, and the patient has access to, clinically
relevant electronic information about the
patient to improve medication management
and coordination of care.”
It’s likely that the definition of meaningful
use will expand over time to encompass more
ambitious health improvement aims.
after the agriculture extension program).
Regional extension offices will help
physician practices and others to adopt,
implement and effectively use health
information technology.
Are there any penalties
if we don’t adopt an EHR?
Yes. Penalties for not adopting an EHR are
scheduled to begin in 2015 with a 1 percent
reduction in Medicare payments. Penalties
will increase to 2 percent in 2016 and 3 percent in 2017. The Secretary of Health and
Human Services has the option of extending
these penalties beyond 2017 and increasing
the amount to a maximum of 5 percent if
fewer than 75 percent of physicians are using
EHRs by that time. ➤
Will there be any money to help
with implementation?
Definitions of a
“qualified system”
and “meaningful
use” have yet to
be released by
the Secretary of
Health and Human
Services.
To help with implementation, a health
information technology extension
program is being
funded.
Yes. Part of the $2 billion allocated to the
Office of the National Coordinator for
Health Information Technology must go
toward establishing a health information technology extension program (modeled
Maximum incentive Payment amounts
Physicians who begin using a qualified EHR by 2011 or 2012 could receive up to $44,000 over five
years from the Centers for Medicare & Medicaid Services, assuming they have at least $24,000 in
Medicare allowed charges per year. Under Medicare, the incentive amount is 75 percent of the physician’s Medicare allowed charges for the year, up to the year’s maximum incentive amount.
Alternatively, a physician may choose the Medicaid incentive, which pays up to $21,250 in year one
(85 percent of a $25,000 maximum) for health information technology adoption and implementation and up to $8,500 over the next four years (85 percent of a $10,000 maximum) for operation and
maintenance. To qualify for the Medicaid incentives a physician’s case load must include at least 30
percent Medicaid patients.
Physicians may not receive both Medicaid and Medicare incentives.
Penalties for not
adopting an EHR
will begin in 2015
with a 1 percent
reduction in Medicare payments.
Note: For providers in federally designated health professional shortage areas, incentive payments
will be 10 percent greater.
Medicare incentive maximum per year:
Year EHR use is
first demonstrated
2011
2012
2013
2014
2015
$18,000
$12,000
$8,000
$4,000
$2,000
$18,000
$12,000
$8,000
$4,000
$2,000
$44,000
$15,000
$12,000
$8,000
$4,000
$39,000
$12,000
$8,000
$4,000
$24,000
$0
$0
$0
2012
2013
2014
2015 or beyond
2016
Total maximum
incentive
2011
$44,000
Medicaid incentive maximum per year:
Year 1
(no later
than 2016)
$21,250
Year 2
Year 3
$8,500
$8,500
Year 4
$8,500
Year 5
$8,500
Year 6
$8,500
Total
maximum
incentive
$63,750
HIT incentives
Will the government incentives
cover the full cost of an EHR?
The government funds are intended to offset
the costs of health information technology,
not to cover them fully. A recent report from
PriceWaterhouseCoopers estimated that a
three-physician practice could spend from
$173,750 to $296,000 for an EHR package
complete with software, implementation,
training and software maintenance.1
What should a practice do if
it is currently in the process of
buying an EHR?
If you’re well into the process and have
already selected a system, proceed with the
purchase but make sure your vendor will support future requirements related to the government incentives. If you’re not far along in
choosing and buying a system, you may want
to wait a few months until the final details of
the regulations are released.
Existing users may have to upgrade their
systems and buy additional products and services to meet the federal requirements.
How will the HIPAA amendments
affect medical practices?
Family physicians who use EHRs will need to
consult with their vendors about the security
of their patient data and the EHR’s ability
to produce the disclosure reports that will
now be required. Physicians will also need to
implement safeguards, such as data encryption
and secure passwords, and should make sure
that their staff – particularly new staff – are
up-to-date on privacy policies and procedures.
Physicians’ business associates (clearinghouses, accountants, etc.) will now be
required to comply fully with the HIPAA privacy and security rules as well.
Is it true that practices will have
to track every time they disclose a
patient’s medical information even if
the disclosure is for payment purposes?
Yes. The HITECH Act requires covered entities with EHRs to produce, upon an individual’s request, an accounting of all disclosures of
the individual’s protected health information
(PHI), including disclosures made for treatment, payment and health care operations,
over a three-year period. This expands current
law, which requires accounting of non-routine
disclosures only, such as those for research.
Many EHR systems will need to be updated
to be able to track all types of disclosures.
The Secretary of Health and Human
Services is required to issue regulations that
specify what information should be included
about each disclosure, taking into consideration patients’ interests in learning about how
their PHI is disclosed as well as the administrative burden of accounting for disclosures.
Once the regulations are final, practices may
need to modify their HIPAA forms.
When do the new HIPAA regulations
go into effect?
The regulations don’t kick in for current EHR
users until Jan. 1, 2014; however, at that time,
patients are expected to be able to request an
accounting of disclosures of their electronic
PHI dating back three years.
The government
incentive payments
will offset the cost
of an EHR but will
not cover it fully in
most cases.
The stimulus package also made
several changes
to the HIPAA
requirements.
Do practices have to follow these
regulations if they don’t use an EHR?
No, the new disclosure provisions apply only
to covered entities that have an EHR.
What else do the HIPAA
amendments require?
In the event of a breach of patients’ privacy
(e.g., the theft of a laptop computer containing patient information from your office), the
practice must notify the affected individuals
in writing by first-class mail or by electronic
mail if specified as a preference by the individual. If 10 or more individuals’ contact
information is out-of-date, a conspicuous
posting on the practice’s home page or notice
in major print or broadcast media may serve
as a substitute form of notice. If the breach
has affected the unsecured PHI of more than
500 patients, notice must also be provided to
prominent media outlets. Further, the practice must notify Health and Human Services
of a breach; notice must be immediate if it
affects 500 or more individuals. HHS will
post these notices on its web site.
Practices with EHRs
will be required
to produce, at the
patient’s request, a
list of all disclosures
of the individual’s
personal health
information, including disclosures
made for treatment and payment
purposes.
Despite these serious obstacles, an investment
in our nation’s health IT infrastructure is
much needed and long overdue.
Are there fines for breach
of patient privacy?
If patients’ personal
health information is breached,
the practice must
notify the affected
individuals, and
in some cases
the media and
Health and Human
Services.
Penalties for violating the HIPAA
requirements have
been expanded.
This significant
investment in
health information
technology is a positive development
overall, despite
some legitimate
concerns.
Yes. The HITECH Act expands the penalties
for violating HIPAA requirements. In place of
the current penalty of $100 per violation, the
HITECH Act adds a new tiered-penalty structure based on the practice’s level of knowledge
of the violation:
• In circumstances in which the entity did
not know (and would not have known despite
reasonable diligence) that it violated these provisions, the entity will be subject to a penalty
of at least $100 per violation, not to exceed
$25,000 per calendar year for all violations of
an identical requirement or prohibition.
• If a violation is due to reasonable cause
and not to willful neglect, the entity will be
subject to a penalty of at least $1,000 per violation, not to exceed $100,000 per calendar
year for all violations of an identical requirement or prohibition.
• If a violation is due to willful neglect but
the failure to comply is corrected within 30
days of when the entity knew or should have
known that the failure to comply occurred,
the entity is subject to a penalty of $10,000
per violation, not to exceed $250,000 per
calendar year for all violations of an identical
requirement or prohibition.
• If a violation is due to willful neglect and
is not corrected within 30 days, the entity is
subject to a penalty of at least $50,000 per
violation, not to exceed $1.5 million per calendar year for all violations of an identical
requirement or prohibition.
The HITECH Act also allows state attorneys general to seek damages on behalf of state
residents in an amount equal to $100 per violation (for a maximum of $25,000 per year).
Commentary
While this unprecedented investment in health
information technology is seen as a positive
development overall, there are some cautions.
First, widespread adoption of EHRs over the
next five years could stress physician practices
and cause short-term declines in productivity.
Second, the emphasis on EHRs could hinder
the adoption of equally beneficial health information technologies that have fewer implementation hassles, such as e-prescribing or e-visits.
(Read the related opinion piece on page 8.)
Third, the “free money” for health information
technology could essentially reward EHR vendors without the market requiring them to first
improve their products. Finally, physicians may
be hesitant to participate in yet another government incentive program, given the recent
difficulties many of them have faced with the
Physician Quality Reporting Initiative.
Despite these serious obstacles, an investment in our nation’s health information
technology infrastructure is much needed and
long overdue. The complexities of modern
medical practice will increasingly require the
use of electronic records, which will enable
physicians to track their patients’ health in
new and exciting ways.
1. Health Research Institute. Rock and a Hard Place: An
Analysis of the $36 billion Impact From Health IT Stimulus
Funding. New York: PriceWaterhouseCoopers; April 2009.
About the Authors
Dr. Waldren is director of the AAFP’s Center for Health Information Technology (CHIT) in Leawood, Kan.
Dr. Kibbe is a senior adviser to the CHIT, chair of the ASTM International E31Technical Committee on
Healthcare Informatics, and principal of The Kibbe Group, LLC. Dr. Mitchell is the assistant director of the
CHIT. Author disclosure: nothing to disclose.

Family Practice management: Electronic Health Records

Transcription

Similar documents

Diabe-DS - HL7 Wiki

April 2011

iKnowMed EHR: Support for Successful Participation in Clinical Trials

HARVARD VANGUARD MEDICAL ASSOCIATES Major Systems

Complete Behavioral Health EHR and Practice

THE ESSENTIAL ELEMENT of a SuccESSfuL LAborATory

Lytec 2014 Overview