1 e l e c t r o n i c h e a lt h r e c o r d s 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 Patient- Centered 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 FAMILY PRACTICE MANAGEMENT
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. This is a corrected version of the article originally published. Given 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 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 newsletters and sent one 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. FAMILY Copyright PRACTICE 2010 MANAGEMENT American Academy of Family Physicians. November/December For the private, 2009 noncommercial use of one individual user of the Web site. All other rights reserved. Contact for copyright questions and/or permission requests.
3 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% 20% 30% 40% 50% 60% 70% 80% 90% 100% Number of physicians in the practice: >50 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 org/fpm/ /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 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: November/December FAMILY PRACTICE MANAGEMENT
4 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 maintenance (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 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. EHR systems 1. Easy and intuitive 2. Documenting 3. Finding information 4. Ordering tests, etc. Abbreviated survey statements e-mds (N = 98) MEDENT (N = 23) Praxis (N = 30) Amazing Charts (N = 109) eclinicalworks (N = 165) EpicCare Ambulatory (N = 242) Practice Partner (N = 113) Allscripts Professional EHR (N = 90) Aprima (imedica) (N = 18) Centricity (N = 231) SOAPware (N = 54) Sage Intergy (N = 37) NextGen EHR (N = 156) Allscripts Enterprise EHR (N = 132) CareRevolution (N = 13) MediNotes e (N = 21) AHLTA (N = 42) PowerChart/PowerWorks (N = 75) MedInformatix (N = 19) MPM Suite (N = 31) Note: Systems are listed by the sum of their rankings. 5. e-prescribing 6. Health maintenance 7. Disease management 8. e-messaging 9. Practice higher quality 11. Worth the expense 12. Training and support 13. Highly satisfied FAMILY PRACTICE MANAGEMENT November/December 2009
5 Response spectrum: Overall this EHR is easy and intuitive to use. ehr survey 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% 80% 60% 40% 20% 0% 20% 40% 60% 80% 100% Blank Neutral Strongly Disagree Disagree Agree Strongly Agree 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/Power- Works 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 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 (Medi- Notes 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 FAMILY PRACTICE MANAGEMENT
6 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/ /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% 80% 60% 40% 20% 0% 20% 40% 60% 80% 100% Blank Neutral Strongly Disagree Disagree Agree Strongly Agree FAMILY PRACTICE MANAGEMENT November/December 2009
7 Response spectrum: This EHR enables me to practice higher quality medicine than I could with paper charts. ehr survey 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% 80% 60% 40% 20% 0% 20% 40% 60% 80% 100% Blank Neutral Strongly Disagree Disagree Agree 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% 80% 60% 40% 20% 0% 20% 40% 60% 80% 100% Blank Neutral Strongly Disagree Disagree Agree Strongly Agree November/December FAMILY PRACTICE MANAGEMENT
9 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 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 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. 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 Copyright 2010 American Academy of Family Physicians. For the July/August private, noncommercial use of one individual FAMILY PRACTICE user of the MANAGEMENT Web site. All other rights reserved. Contact for copyright questions and/or permission requests.
10 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. 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 Medicine 3 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 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: Christensen CM, Raynor ME. Innovator s solution: creating and sustaining successful growth. Boston: Harvard Business Press; Mandl KD, Kohane IS. No small change for the health information economy. N Engl J Med. 2009;360: O Harrow R. Group seeks sway over e-records system. The Washington Post. May 21, FAMILY PRACTICE MANAGEMENT July/August 2009
11 Kenneth G. Adler, MD, MMM How to Select an So 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. 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 illustration by curtis parker 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 /fpm F A M I L Y P R A C T I C E M A N A G E M E N T 11 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 for copyright questions and/or permission requests.
12 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 EHR functionality 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 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 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. n n n n n n n n n n n n Results reporting (lab, radiology, other) Order entry (lab, radiology, other) Multiple note creation options (templates, macros, dictation, voice recognition, hand writing recognition) Automated E/M coding adviser Software interfaces with internal and outside labs Prescription writer and database (with online formularies and drug-interaction checking) Flow charting (labs, vital signs, growth parameters) Remote access Referral ordering and tracking Patient registration information (master patient index) Telephone message documentation and tasking Internal n n n n n n n n n n n Secure external for patients Patient Web portal Patient education n Scanning Automated chart documentation (problem lists, medication lists, vital signs, health maintenance) Automated charge entry Inpatient reports (downloadable) Electronic fax reports (dictation, lab, radiology) to outside specialists Patient follow-up/health-maintenance deficiency alerts Practice population analysis tools Decision support tools Security (audit trails, user access hierarchy, passwords) 12 F A M I L Y P R A C T I C E M A N A G E M E N T /fpm February 2005
13 p i c k i n g a n e h r 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 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. Step 4: Selecting the Rfp recipients How do you go from more than 200 products to a dozen without seeing any products? I suggest you use three defining criteria to request for proposal (RFP) outline A request for proposal that follows an outline like the one below will tell prospective vendors what they need to know about your practice to provide you with useful information about their products, and it will help to ensure that the responses you receive can be more easily compared. i. Cover letter II. Introduction and selection process III. Background information about your practice a. Size and location b. Current practice management system and any EHRs c. Current computer hardware d. Current network information IV. Your practice s desired EHR functionality (prioritized) V. Vendor information a. Company history b. number of employees (separate numbers for sales, support, research and development, and management) c. Financial statements d. History of their EHR product e. list of all current EHR users and list of users similar to your practice in size and type (including how long they ve been using the software and, ideally, what version they re using currently) VI. product description a. How it performs the functions described in section IV b. Other functions it performs c. Product brochures, etc. d. Software versions and release dates VII. Hardware and network requirements VIII. Customer maintenance and support IX. Vendor training X. Implementation plan XI. Interface history and capabilities XII. Proposed costs and payment schedule XIII. Warranties XIV. Sample contract 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 companies. Each time the EHR software is upgraded (and most good EHR products promise at least one upgrade per year), any interfaces have to be updated. Many EHR developers will say that they can interface with any system, but frankly I wouldn t want to be their first. To determine which EHR companies have created interfaces with your PMS, ask your PMS company. This criterion alone may dramatically narrow the field. If you aren t happy with your current PMS or anticipate outgrowing it soon, it may be a good idea to consider selecting a new one before you buy an EHR. Ideally, the PMS and EHR company would be one and the same, but your PMS company may not offer an EHR product, or if it does, it may not offer the functionality or service that you feel you need. As more physicians buy EHRs, the trend of the future will likely be integrated EHR-PMS products that don t require interfaces. Practice size. Most EHR vendors market their products to smaller practices (one to 15 providers), medium-sized practices (10 to 99 providers) or large practices (greater than 100 providers,) although a few market to all sizes. Picking RFP recipients on this basis will help you avoid having a large practice EHR declining to respond to your RFP because you re too small. 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. February /fpm F A M I L Y P R A C T I C E M A N A G E M E N T 13
14 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. 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 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 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 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 com/conferences/tepr/index.asp. Finally, go to the AAFP s Center for Health Information Technology, 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, 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 discussion list for EHRs. AAFP members can subscribe at From the 14 F A M I L Y P R A C T I C E M A N A G E M E N T /fpm February 2005
15 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: 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 (encrypted) Health maintenance alerts Medical decision support tools Patient education materials Security (passwords, audit trails) Strongly disagree Disagree Unsure Agree Strongly agree Comments: II. OVERALL EASE OF USE AND FLEXIBILITY This product allows individual user-specific customization This product minimizes user data input This product offers multiple note creation options Strongly disagree Disagree Unsure Agree Strongly agree 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;
16 SPEEDBAR Questions to ask EHR references Check several references for each EHR you re considering, and go beyond the list of references the vendor provides you. 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. 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 How many physicians/nurse practitioners/physician assistants are in your group? How many office sites do you have? 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? How many interfaces do you have with the EHR? Provider usage What percent of your providers use the EHR? What functions do most/all of your providers use? Do your providers still dictate? What has been the most frustrating thing about the EHR for the providers? What has been the best thing? How much individual physician customization is there? Aare you happy with the templates? Were they pre-loaded? How do they get modified? Have you saved money? Have you broken even? 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? Training & support How long does it take a physician to become fully trained/efficient in using the EHR? How long does it take a medical assistant to be trained? 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? Implementation & hardware Did the implementation go smoothly? How long did it take? Do you have a wide area network (WAN)? How much bandwidth is used? Was the EHR preloaded with CPT and ICD-9 codes? Was it preloaded with formularies? What hardware do the physicians use? What hardware do the medical assistants use? Iif you are using a wireless network, how well does it work? 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? Don t underestimate the importance of service, training, implementation support and the long-term viability of the vendor and the product. AAFP home page, click on 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 Satisfaction Would you buy this system again? What would you do differently? 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 16 F A M I L Y P R A C T I C E M A N A G E M E N T /fpm February 2005
17 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 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 Vendor 1 Vendor 2 Vendor 3 Vendor 4 Vendor 5 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 Vendor 1 Vendor 2 Vendor 3 Vendor 4 Vendor 5 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 Vendor 1 Vendor 2 Vendor 3 Vendor 4 Vendor 5 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;
18 SPEEDBAR A thorough analysis of each vendor s costs is critical; a spreadsheet can help sort out the costs and facilitate comparisons. 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. cost. The sample vendor rating tool on page 61 breaks the selection criteria into these same three categories. (For another example, go to 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 downloaded from the FPM Web site at aafp.org/fpm/ /57howm.html#1.] When we did this for our top four choices, we found the costs to be surprisingly similar. 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 Vendors tend to present their costs in a way that makes side-by-side comparisons difficult, and they focus only on software costs. 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. 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. 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 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 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. 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 18 F A M I L Y P R A C T I C E M A N A G E M E N T /fpm February 2005
19 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 /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 for copyright questions and/or permission requests.
20 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. 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. 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 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. Ssome EHRs cost less than $3,000 and have the ability to support a paperless office. Expensive 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. 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 20 F A M I L Y P R A C T I C E M A N A G E M E N T /fpm February 2005