Family Practice management: Electronic Health Records
Transcription
Family Practice management: Electronic Health Records
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 Kenneth G. Adler, MD, MMM 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? David C. Kibbe, MD, MBA 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 Amazing Charts (N = 109) 1 1 4 8 17 eClinicalWorks (N = 165) 5 6 7 5 8 10 9 8 3 4 Praxis (N = 30) EpicCare Ambulatory (N = 242) 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 Practice Partner (N = 113) 6 7 5 15 12 4 6 3 5 7 11 8 Allscripts Professional EHR (N = 90) 9 10 6 6 3 10 10 4 10 10 8 10 Aprima (iMedica) (N = 18) 7 8 11 11 2 11 9 11 11 9 5 11 Centricity (N = 231) 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 NextGen EHR (N = 156) 15 13 19 10 10 8 8 15 14 12 13 13 Allscripts Enterprise EHR (N = 132) 14 15 16 12 5 16 17 13 13 13 16 16 CareRevolution (N = 13) 16 14 14 13 15 13 12 14 16 16 14 15 MediNotes e (N = 21) 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 PowerChart/PowerWorks (N = 75) 19 19 17 17 16 19 15 17 18 18 18 17 MedInformatix (N = 19) 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 Sage Intergy (N = 37) 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.’ Amazing Charts (N = 109) e-MDs (N = 98) SOAPware (N = 54) MEDENT (N = 23) eClinicalWorks (N = 165) Practice Partner (N = 113) Aprima (iMedica) (N = 18) Praxis (N = 30) Allscripts Professional EHR (N = 90) EpicCare Ambulatory (N = 242) Centricity (N = 231) All Respondents (N = 2,012) MediNotes e (N = 21) Sage Intergy (N = 37) Allscripts Enterprise EHR (N = 132) NextGen EHR (N = 156) CareRevolution (N = 13) MedInformatix (N = 19) AHLTA (N = 42) PowerChart/PowerWorks (N = 75) 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) Amazing Charts (N = 109) Aprima (iMedica) (N = 18) SOAPware (N = 54) EpicCare Ambulatory (N = 242) Allscripts Professional EHR (N = 90) eClinicalWorks (N = 165) All Respondents (N = 2,012) Sage Intergy (N = 37) Practice Partner (N = 113) MediNotes e (N = 21) NextGen EHR (N = 156) CareRevolution (N = 13) Centricity (N = 231) Allscripts Enterprise EHR (N = 132) AHLTA (N = 42) PowerChart/PowerWorks (N = 75) MedInformatix (N = 19) 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) Amazing Charts (N = 109) MEDENT (N = 23) Practice Partner (N = 113) eClinicalWorks (N = 165) EpicCare Ambulatory (N = 242) SOAPware (N = 54) Centricity (N = 231) Allscripts Professional EHR (N = 90) All Respondents (N = 2,012) Aprima (iMedica) (N = 18) Sage Intergy (N = 37) Allscripts Enterprise EHR (N = 132) NextGen EHR (N = 156) MedInformatix (N = 19) CareRevolution (N = 13) MediNotes e (N = 21) PowerChart/PowerWorks (N = 75) AHLTA (N = 42) MPM Suite (N = 31) 100% Blank Neutral 80% 60% 40% Strongly Disagree 20% 0% Disagree 20% Agree 40% 60% 80% 100% 80% 100% Strongly Agree Response spectrum: ‘This EHR is worth the expense.’ Amazing Charts (N = 109) Praxis (N = 30) MEDENT (N = 23) SOAPware (N = 54) e-MDs (N = 98) eClinicalWorks (N = 165) Practice Partner (N = 113) EpicCare Ambulatory (N = 242) Aprima (iMedica) (N = 18) Allscripts Professional EHR (N = 90) All Respondents (N = 2,012) Centricity (N = 231) NextGen EHR (N = 156) Allscripts Enterprise EHR (N = 132) MediNotes e (N = 21) Sage Intergy (N = 37) CareRevolution (N = 13) MedInformatix (N = 19) PowerChart/PowerWorks (N = 75) AHLTA (N = 42) MPM Suite (N = 31) 100% Blank Neutral 80% 60% 40% Strongly Disagree 20% 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.’ Amazing Charts (N = 109) e-MDs (N = 98) MEDENT (N = 23) Praxis (N = 30) eClinicalWorks (N = 165) SOAPware (N = 54) EpicCare Ambulatory (N = 242) Practice Partner (N = 113) Centricity (N = 231) Allscripts Professional EHR (N = 90) All Respondents (N = 2,012) Aprima (iMedica) (N = 18) Sage Intergy (N = 37) NextGen EHR (N = 156) MediNotes e (N = 21) CareRevolution (N = 13) Allscripts Enterprise EHR (N = 132) PowerChart/PowerWorks (N = 75) MedInformatix (N = 19) 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 David C. Kibbe, MD, MBA 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. Send comments to [email protected]. 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. Kenneth G. Adler, MD, MMM 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 All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. ■ ■ ■ 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. FA M I LY P R A C T I C E M A N A G E M E N T ■ 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, 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 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 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 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 ■ 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 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. Send comments to [email protected]. 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 Copyright © 2010 American Academy of Family Physicians. For the private, noncommercial one the All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. ■ ■ ■ 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 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 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 ■ FA M I LY P R A C T I C E M A N A G E M E N T ■ 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. 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 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. Send comments to [email protected]. 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. Copyright © 2010 American Academy of Family Physicians. For 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 All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. ■ ■ ■ 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 ■ 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 ■ 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 ■ FA M I LY P R A C T I C E M A N A G E M E N T ■ 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- 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 ■ 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. Send comments to [email protected]. 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 2007 | www.aafp.org/fpm FAMILY PRACTICE Copyright © 2010 American Academy of Family Physicians. For the private, noncommercial use of one| individual user ofMANAGEMENT the Web site.| 27 All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. 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. 28 | FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | July/August 2007 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. 30 | FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | July/August 2007 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 Send comments to [email protected]. 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. July/August 2007 | www.aafp.org/fpm | FAMILY PRACTICE MANAGEMENT | 31 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 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. 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 March 2007 | www.aafp.org/fpm | FAMILY PRACTICE MANAGEMENT | 35 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 36 | FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | March 2007 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. Send comments to [email protected]. 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 2006 | www.aafp.org/fpm FAMILY PRACTICE Copyright © 2010 American Academy of Family Physicians. For the private, use of one| individual user ofMANAGEMENT the Web site.| 37 All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. 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. 38 | FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | March 2006 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 Send comments to [email protected]. 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. March 2006 | www.aafp.org/fpm | FAMILY PRACTICE MANAGEMENT | 39 How to Successfully Navigate Your EHR Implementation These clues can help you avoid the pitfalls you’ll encounter on your EHR journey. Kenneth G. Adler, MD, MMM 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. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. 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 42 | FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | February 2007 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 February 2007 | www.aafp.org/fpm | FAMILY PRACTICE MANAGEMENT | 43 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 44 | FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | February 2007 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. February 2007 | www.aafp.org/fpm | FAMILY PRACTICE MANAGEMENT | 45 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 46 | FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | February 2007 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 Send comments to [email protected]. 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. Send comments to [email protected]. 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? David C. Kibbe, MD, MBA 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 of Family Physicians. For the private, noncommercial use of one individual user of the Web site. 52 |Copyright FAMILY PRACTICE 2010 All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. 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. Send comments to [email protected]. 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 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. 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 July/August 2009 | www.aafp.org/fpm | FAMILY PRACTICE MANAGEMENT | 55 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 56 | FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | July/August 2009 $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. July/August 2009 | www.aafp.org/fpm | FAMILY PRACTICE MANAGEMENT | 57 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. Send comments to [email protected]. 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. 58 | FAMILY PRACTICE MANAGEMENT | www.aafp.org/fpm | July/August 2009