Electronic Medical Records for the Physician s Office. American College of Rheumatology Committee on Rheumatologic Care 2003 Report

Transcription

1 Electronic Medical Records for the Physician s Office American College of Rheumatology Committee on Rheumatologic Care 2003 Report

2 Acknowledgements The American College of Rheumatology s Committee on Rheumatologic Care (CORC) initiated this project in the fall of Members of the CORC Practice Management Subcommittee provided additional assistance in reviewing material and testing products throughout the project. Mark R. Anderson, CPHIMS, FHIMSS, a private consultant and president of AC Group, Inc., managed and conducted the survey process, provided analysis and with Mark L. Robbins, MD, MPH, former ACR, Committee on Rheumatologic Care Chair, drafted the final report. All funding was provided by the ACR. Participants wish to thank the ACR Board of Directors for supporting these efforts. We also wish to thank the participating electronic medical record companies who spent a great deal of time completing our questionnaire and demonstrating their products capabilities. Committee on Rheumatologic Care (2003) Cody Wasner, MD (Chair) Helen Bateman, MD Gary Bryant, MD William Docken, MD Christopher Morris, MD Daniel Ricciardi, MD Michael Schweitz, MD V. Michael Holers, MD (Board liaison) Kathleen Schiaffino, PhD (ARHP liaison) Members of CORC in 2002 Mark Robbins, MD, MPH (Chair) Chad Deal, MD Paul Katz, MD (Board liaison) CORC Practice Management Subcommittee Herbert Baraf, MD Neal Birnbaum, MD David Cooley, MD Joseph Flood, MD John Goldman, MD Robert Valente, MD Staff Steve Blevins Teresa Fitzgerald Ogden, CAE Christopher Welch, MBA, CPC

3

4 Table of Contents Page Executive Summary A. Introduction 3 B. Conclusion 5 I. Background A. Adoption Rates of PMS and EMR 7 B. Components of an EMR 8 C. EMR Platforms 9 1. PCs 2. PDAs (Personal Digital Assistant) 3. ASPs (Application Service Provider) D. Mobile Healthcare PDA 2. Tablet PC E. Consolidation of Vendors 12 II. Methodology and Project Findings A. Methodology 13 B. Composite Ratings of 18 EMR Applications 15 C. Total EMR Functionality 16 D. Desktop, Remote and Wireless Functionality 18 E. Ranking of PDA Functionality Alone 19 F. Ranking Based on Future Functionality 20 G. Vendor Rating by Market Demographics 21 H. Overall Functionality by Subcategory 22 I. Performance Testing 23 1) Methodology 24 2) Performance Models 25 3) On-Site Performance Ratings 26 4) Overall Vendor Rating by Category 27 5) Best Features 27 a) Documentation b) Order Entry c) Messaging d) Results Viewing e) Charge Capture and Level of Service Coding f) Organization and Graphics III. EMR Pricing Models 31 A. Pricing 31 B. Costing Model Assumptions 31 C. 10- and 5-Provider Models 32 Page 1

5 Table of Contents Page IV. AC Group Comparative Study 35 V. EMR Conclusion 37 Appendices Appendix A. Components of an EMR 41 Appendix B. The Business Case for an EMR 43 Appendix C. Can a Physician Office Really Go Paperless? 47 Appendix D. EMR Vendor Contact Information 49 Unless otherwise noted, statistics provided and the results of research conducted are attributed to Mark Anderson and/or AC Group, Inc. throughout this document. Page 2

6 Executive Summary A. Introduction In 2002, the American College of Rheumatology, Committee on Rheumatologic Care (CORC) conducted a year-long study of Electronic Medical Record (EMR) products suitable for a small office practice, both with and without hand-held solutions. Selected CORC subcommittee members attended healthcare IT conferences and numerous vendor demonstrations and, for some products, conducted performance testing. The purpose of these activities was to: 1. Provide ACR members with an independent, unbiased review of off-the-shelf EMR products currently available for contracting or purchase 2. Serve as an educational tool for the ACR and its members on what types of functions, services and performance features represent a good EMR 3. Explore the current and future role of hand-held and other portable devices in physician office practices The CORC team found evaluation of the EMR marketplace a daunting task. According to a survey by Healthcare Informatics, the number of vendors selling EMRs to small- to mid-size physician practices varies between 48 and 228, depending on their classification of an EMR (1). Adding to the complexity of an already unwieldy number of vendors was the rapid turnover in this vendor population due to either financial insolvency or frequent industry-wide mergers and acquisitions. Finally, the continued and rapid evolution of new products, features and technologies in this sector makes it extremely difficult to keep abreast of the latest developments. For the average physician purchasing an EMR, the question is not simply who provides the technology, but rather who provides the product with the best functionality for that particular practice environment at a price that is affordable. Although many of the EMRs reviewed are applicable for larger, multi-specialty clinics, we focused on systems that were practical and potentially affordable for the small office practice (1 10 physicians). A subcommittee of CORC, led by Dr. Mark Robbins, CORC Chair ( ) and consultant Mark Anderson, CEO Healthcare IT Futurist with the AC Group, Inc. (AC Group), created a comprehensive, 33- page questionnaire, which included a series of 2,626 functional questions divided into 20 categories and four methods of operation. The 20 categories of functionality were: Basic Functional Overview Reporting EMR Functionality Security Documentation Integration and Interfacing Patient Education Provider/User Interface Electronic Prescriptions Patient Self-Management Dictation PDA Functionality Laboratory Data Patient Tracking Document Management Charge Capture and Coding Alerts and Decision Support Orders and Results Specialty Functionality System Architecture 1 - Healthcare Informatics Magazine, May 2002, p. 41 Page 3

7 Executive Summary The four methods of operation evaluated were: Desktop capability (626 questions) Wireless capability (626 questions) Remote access capability (654 questions) PDA and Mobile capability (620 questions) The complete results of this study are presented in Section II Methodology and Project Findings. Reviewers also wanted to provide basic cost estimates for the implementation and maintenance of a comprehensive EMR, which are described in Section III EMR Pricing Models. The highlights of our findings are as follows: There are a few top-of-the-line products offering between 85 percent and 95 percent of EMR functionality. Most systems designed for desktop (PC) operation also offer complete functionality in their wireless and remote applications. In contrast, only a few companies offer full functionality on portable devices. However, this is rapidly changing as companies add portable devices to their EMR and as new technologies (notepads) revolutionize the definition and functions of a portable device. The EMR marketplace (particularly those vendors that offer products suitable for small office practice), is particularly volatile with frequent turnover of companies and products. Only a few of the companies that relied heavily on stand alone PDAs or web-based medical records are still in business today. Therefore, it is equally important for the purchaser to consider the track record and financial viability of the vendor as well as the performance of the product carefully. Documentation of the clinical encounter is time consuming. The best products offer providers multiple options and innovative short cuts for accomplishing this task. This includes free text entry (via typing, transcribed dictation, voice recognition, and copying and editing prior encounters), structured template data entry and pre-fabricated smart phrases, paragraphs and data lists for importation. Some of the most innovative features include: Automated pick list ordering clinician s most common selections automatically elevated to the top. Rx ordering Single keystroke or click and drag option allows simultaneous refill of multiple medications. Patient and insurer-specific formulary information including preferred medications, copayments and pre-authorization requirements are displayed. Intelligent charge capture counts documentation data elements, suggests level of service coding, displays missing elements for the next level of service, and offers alerts for orders not justified by diagnostic codes. Design and display of the provider s home base and its link to ordering, messaging and data review are among the most innovative and important pages of the EMR. Cost and vendor viability should be considered. Although functionality is important, physicians must also evaluate product costs, company financial viability and suitability for the small physician office (less than 10 physicians). Since some vendors market only to medium and large practices (over 10 physicians), physicians should compare functionality and pricing from only those vendors that market to their size. When it comes to company financial viability, measurement is very difficult since many of the vendors are privately held and do not release any financial information. Additionally, even the larger vendors are sold and purchased by other vendors each year. Therefore, size does not indicate long-term viability. To reduce risks, physicians should request information from each vendor regarding company viability. For a list of financial viability questions, visit Page 4

8 Executive Summary B. Conclusion Electronic medical records (EMR) and provider order entry systems (POE) hold enormous promise for improvement in the flow of information, reduction in medical errors, improved coding and charge capture, and lower transcription and chart storage costs. Further, EMR use assists in meeting burdensome payor requirements for increased documentation, thus supporting LOS coding and offering the potential for improved revenues. An EMR does require significant initial costs to the practice in training, workflow disruption, and capital and recurrent costs. Also time-consuming physician data entry can lower productivity during the transition period or even permanently. However, the time spent in documentation may be well offset by improved coding and charge capture, more rapid and efficient billing, and a reduction in the resources that were devoted to medical record storage, retrieval and claims submissions. Page 5

9 Page 6

10 Section I Background A. Adoption Rates of PMS and EMR For the past 20 years, physicians have been automating portions of their practices. From the 1980s through the 1990s, physicians selected and installed Practice Management Systems (PMS). Although these applications were designed fundamentally to track patient demographic, insurance and payment information, their real benefit was the electronic printing and subsequent electronic transmission of patient claims to insurers. In 1990, Medicare created new incentives accelerating the adoption of PMS through its policy of reimbursing electronic submissions ahead of paper claims. From 1985 to 2002, the number of physicians using PMS increased from 10 percent to almost 95 percent. (2) Starting in the late 1990s, physicians searched for additional systems designed to improve the management of their practices. New applications called Electronic Medical Records (EMR), Document Management, Lab Interfaces, Electronic Dictations and Physician Internet Access were reviewed and adopted, albeit at a slower pace than PMS. Among these applications, EMR appeared to hold the most promise as a breakthrough technology that might improve practice efficiency. Occurring simultaneously with the increasing sophistication of EMR function was the health care industry s growing emphasis on medical error reduction, improved clinical documentation and level of service coding. EMR s ability to facilitate a typewritten, legible, well-formatted note available to all providers within a healthcare system promised to make patient care easier and more efficient. During this early era, affordable office-based EMRs had a broad range of functionality. At one end of the spectrum were systems that offered little more than a typewritten chart. All the information was presented as free "text" with little structure and capacity for searching or sorting clinical information. Free text could be entered by scanning existing documents, routine dictation or, in some cases, using voice-recognition to capture the information. The main advantages of this system were the speed of data entry, limited disruption of existing provider documentation practices and workflow, and lower cost. In contrast, at the other end of the spectrum, were a number of EMRs that required clinical encounter data entry through a series of structured pick lists or templates. Although more time consuming in terms of data entry, this integration of information into a structured database facilitated subsequent queries and report writing. In 1995, healthcare IT experts had optimistically predicted that more than 50 percent of physicians would purchase an Electronic Medical Record for their practices by the end of (3) However, by 2000, the combination of technology challenges, reimbursement issues and the difficulty of justifying EMR capital costs based on return on investment (ROI) had left the estimated percentage of physician users at only 6 percent across all practice environments. (4) Furthermore, this low average figure concealed a marked discrepancy between EMR users in large institutions and those in a small office practice. According to one study, by the summer of 2002, 38 percent of all university and staff-model (Kaiser, Mayo, etc.) physicians were using an EMR as compared to less than 1 percent of community-based physicians. (5) It is likely that experts missed their projections primarily by underestimating how significantly EMR adoption changes the way a physician works. In addition, they were overly optimistic about the performance and speed of introduction of the so-called killer applications (voice recognition, intelligent charge capture, pharmacy formulary management, etc.) that were critical to the EMR s streamlining of workflow and ROI TEPR Report Conducted by the Medical Records Institute Annual Survey of Physician Adoption Rates by AC Group, Inc. (2,523 physician practices) TEPR Survey Conducted by the Medical Records Institute Presentation of EMR Usage, TEPR conference, Seattle WA, May 10, 2002 Page 7

11 Section I Background Physicians are far more likely to adopt changes that either improve their financial income, practice efficiency or enhance the quality of patient care. Accordingly, automation of the physician practice is mostly likely to occur if the following principles are a central part of the implementation strategy: 1. The EMR is part of an incremental approach towards office automation. 2. The EMR integrates with minimal disruption of existing work flow. 3. The EMR improves efficiency or reduces costs. B. Components of an EMR (see Appendix A for more detail) The EMR may have a dramatically different look and feel depending on the vendor and their particular product. Based on the ACR research, the majority of the EMR vendors provide functionality in the following categories: Access to Local and Remote Information Alerts and Decision Support Authorized User Access Automated History and Physical Basic Functional Overview Billing, Charge Capture and Correct Coding Charge Capture and Coding Clinical Data Dictionary Clinical Data Repository Clinical Reasoning and Rationale Documentation Confidentiality, Privacy and Audit Trails Guarantees Cost Measuring/Quality Assurance Dictations Direct Entry by Physicians Document Management Documentation Drug Reference E\M Compliance Check and Required Documentation Electronic Prescription Writing Electronic Prescriptions EMR Functionality Ergonomic Presentation Existing/Evolving Clinical Specialty Needs Facilitation of Clinical Problem Solving Health Status and Functional Levels Icon Generated Text Input Mechanisms Integration and Interfacing Intelligent Supports Delivery of Care Internet Access Lab Data Review Laboratory Data Links with Other Patient Records Longitudinal and Timely Linkages with Other Pertinent Records Medications Multimedia/Image Data Storage Multiple Controlled Vocabularies and Coding Structures Multiple Formulary Lists Multiple PMS/EDI Financial Links Orders and Results Other Patient Education Patient Information Tracking Patient Self-Management Patient Tracking Point-of-Care Facility Prescriptions Renewals Problem Lists Procedure Notes Progress Notes Provider User Interface and Administrative Tools Receiving of Alerts Reporting Security Simple Organizational Tasks Simultaneous User Views Specialty Functionality System Architecture Page 8

12 Section I Background C. EMR Platforms Initially, EMR products were designed to operate on the Internet, as stand-alone portable devices or on the desktop. This led to a hotly-contested debate over which approach would be the trend of future. Today, however, with the rapid evolution of these technologies and their diffusion through the marketplace, newer companies are building their EMRs to operate on all three platforms, matching the optimal technology with the functional requirements. 1) PCs For many years, the PC was the primary platform for EMRs, with only a few companies focusing on portable devices and web-based applications. The desktop offers the advantages of larger screen real estate for easier review of the medical record and a full-size keyboard suited for data entry. The obvious disadvantage has been the lack of portability, disruption of eye contact with the patient and the cost of hardware upgrades every few years. 2) PDAs (Personal Digital Assistant) The initial excitement over PDAs was tempered by their limited screen size, restricted battery life, limited potential for data entry and for viable voice recognition, and, often, by their lack of integration with full EMR and PM systems. However, improvements in integration, battery life, storage memory, wireless connectivity, touch screen technology and, now, enhanced screen size has greatly expanded the potential for portable device use in medical practice. The smaller hand-held devices are best suited for storing and viewing basic patient profiles (problem, medication, allergy lists and demographics), order entry of prescriptions and testing, and charge capture. The voice chip can be used to capture medical dictation and, then, either relayed or plugged in to transcription or voice recognition systems. The addition of the notepad may dramatically alter the landscape and definition of portable devices. The larger screen size, wireless function, touch screen keyboard for data entry and slim laptop profile which facilitates continued eye contact with patients may greatly expand the role of a portable device in the office and on rounds. EMR Adoption Rates Percentage of Physicians using EMRs 50% 40% 30% 20% 10% 0% Exhibit 1 Page 1 Page 9

13 Section I Background 3) ASPs (Application Service Provider) The future of the ASP or web-based EMR is in transition. The majority of vendors originally offering EMRs only as an ASP have failed. In a recent survey (6) of the 56 vendors that met the basic functionality of the Institute of Medicine, 82 percent will offer their EMR applications in an ASP model. In contrast, only 18 percent of these vendors are restricting their EMRs to ASP models. The ASP model is certainly well suited for a provider s remote EMR use, patient-centered applications (self-scheduling, patient generated health/medical profiles), large data files, decision support and graphics. ASPs also allow IT spending to take place in increments rather than one large capital investment, offering some economies of scale. Therefore, ASP-based EMRs allow smaller clients to access sophisticated applications and systems support that otherwise might be either too costly or simply unavailable. Despite these advantages a few cautions are in order. The new purchaser in this arena must be vigilant for new vendors promising of features and performances that may still be operationally immature or still in development. In addition, there is likely to be extensive consolidation in the ASP sector in the next two to three years that can be disruptive to particular products and services. Finally, despite its appeal for major investment savings in computer hardware, many practices want to maintain control over patient records on their own office-based servers, not on off-site, vendorowned databases. The recent discontinuation of a prominent web-based EMR product with resulting controversies over who owned the data and who was responsible for the cost of its transfer to a new EMR highlights the complexity and relevance of this issue. (7) 6 The 2002 AC Group Study on EMR Group Applications 7 Wipeout: Lessons on Protecting Web-based EMR Data by Bob Cook, amednews.com, August 19, 2002 Page 10

14 Section I Background D. Mobile Healthcare 1) PDA During the 1990s, Palm devices dominated the market landscape. However, in late 2001, Compaq (now HP) released a new PC Pocket IPAQ. With that launch, the healthcare industry jumped from Palm to IPAQ almost overnight. The main reasons were power, performance and the ability to capture digital dictation at the point of care. As a result, the IPAQ increased healthcare market share from 1 percent in 1999 to 30 percent in Based on projections from a variety of healthcare solution vendors, it is estimated that the IPAQ market share will exceed that of PALM by year-end 2003 with a 47.1 percent share. In fact, the IPAQ could capture as much as 70 percent of the healthcare marketplace by Why is IPAQ capturing the healthcare marketplace? Mostly because the top 40 healthcare IT applications vendors have already switched their development plans to the Microsoft PC Pocket applications and 90 percent of these top healthcare application vendors have selected IPAQ as the device of choice. Today, vendors are developing multiple applications that can run on a PDA. The main applications are: Charge Capture Correct Coding Dictation Electronic Prescription Writing Internet Access Patient Tracking Simple Organizational Tasks Specialized Calculators Store Reference Material One of the most valuable applications in the market today is Intelligent Charge Capture. Unlike traditional charge capture systems that allow a physician to record daily charges, intelligent charge capture provides the physician with updated knowledge on what individual health plans require for proper coding and charge reimbursement. Companies like MedAptus and Allscripts are leading the development and deployment of intelligent charge capture systems. 2) Tablet PC Windows XP Tablet PC Edition the newest Microsoft operating system offers the most flexibility and functionality of any portable device. The mobility of the Tablet PC, combined with ink and speech tools, allows physicians to use their PCs in many more places and ways. The Tablet PC lets users run Windows XP compatible applications like Microsoft Office XP that offer a variety of added capabilities to: Control the Tablet PC using a digital pen Create and save handwritten documents (text and drawings) on the Tablet PC Save, search and review handwritten documents Convert handwritten notes into typed text for use in other applications Annotate documents imported from other applications Dictate text or control the computer via voice Page 11

15 Section I Background Specially designed for mobile computer users who rely on a combination of notebook PCs, planners, spiral notebooks, hand-held devices and sticky notes to complete their work, Tablet PC is one of the most powerful tools for productivity away from the desktop. The market experts predict that one out of every three physicians will be using a Tablet PC by the end of E. Consolidation of Vendors In the past 20 years, over 1,000 companies have offered technologies to physician practices. (8) Currently the AC Group tracks over 130 product categories unique to healthcare, over 2,500 information technologies selling in the healthcare market and more than 10,000 different applications from which to choose. The majority of these companies have remained relatively small (less than $1M in annual revenues) or have been purchased by national vendors such as McKesson, Siemens, GE Medical, EPIC, Meditech, Cerner, IDX, WebMd/Medical Manager, Misys, Allscripts Healthcare Solutions and NextGen. Companies like IDX, Misys and WebMd/Medical Manager still dominate the Practice Management application marketplace. However, in the EMR marketplace, NO vendor has a majority share. There are no large providers of EMR technology. Even companies like Medicalogic (purchased by GE Medical in 2002), which was one of the dominant EMR vendors back in with approximately 4 percent of the market, has lost market share since 2000, partially due to an influx of new products in the past four years. New and upcoming vendors include NextGen, eclinicalworks, Hamilton Scientific, imedica, Allscripts, PMSI, a4healthcare, WebMD and others. Given the number of vendors, industry leaders project that over 40 percent of existing companies will be consolidated or closed within the next three years. (9) This trend highlights the importance of choosing an EMR based not only on its functions and performance, but also on the long-term track record of the parent company and its prospects for financial viability. A number of the larger vendors that have launched and maintained successful EMR products have priced and marketed their products primarily to larger medical groups. This further narrows the field of potentially sustainable vendors with products suitable for the small office practice. In the past two to three years, with the downturn in the economy, collapse of the.com industry and tightening of available venture capital funds, many of the stand-alone hand-held companies, as well as those promoting primarily application service provider (ASP) models of EMRs, have closed their doors or gone dormant until additional funding is available. 8 Presentations by Mark Anderson and Vince Hudson during the TEPR 2002 Conference in Seattle, May META Group Study, 2001 Page 12

16 Section II Methodology and Project Findings A. Methodology In 2002, the American College of Rheumatology, Committee on Rheumatologic Care (CORC) conducted a year-long study of EMR products suitable for the small office practice both with and without hand-held solutions. Led by Dr. Mark Robbins, CORC chair ( ) and consultant Mark Anderson, CEO Healthcare IT Futurist with AC Group, a subcommittee of CORC created a comprehensive 33-page questionnaire, which included a series of 2,626 functional questions divided into 20 Categories and four methods of operation. The four methods of operation included: 1. Desktop Capability (626 questions) 2. Wireless Capability (626 questions) 3. Remote Access Capability (654 questions) 4. PDA and Mobile Capability (620 questions) The 20 functional categories included sections on the Institute of Medicine s (IOM) requirements for a Computerized Patient Record (CPR), along with functional questions relating to operational areas including prescriptions, charge capture, dictation, interface with laboratories, provider order entry, decision support and alerts, security, reporting and documentation. The ACR awarded a weighted point value to each of the 2,626 question based on the following criteria: The current product DOES NOT offer this functionality. The current product DOES provide the functionality for an additional cost. The current product DOES provide the functionality from a third party. A future product enhancement WILL provide the functionality. The current product DOES provide the functionality. The ACR reviewed the membership database and determined that over 70 percent of ARC members worked in offices with less than 10 physicians. As a result, it was decided to limit the evaluation to vendors that targeted their EMR applications to physician groups of 10 or less. Further, it was felt that small office practices were more likely to be selecting their own EMRs than larger institutions where a Chief Information System Officer (CIO) was often responsible for final decision. Therefore, large institutional vendors of enterprise systems like IDX, EPIC, Cerner and McKesson who do not typically market to the 1-10 physician practice group were not included in the ACR EMR survey. A similar study (10) of 56 EMR vendor applications conducted by the AC Group included the same top vendors that participated in the ACR review. (See Section IV: AC Group Comparative Study.) In April of 2002, the ACR sent out the 33-page survey to 102 vendors that stated they provided EMR software to small- to mid-size practices. Of the 102, 17 EMR vendors completed the entire survey. During the year-long process of evaluation, one of the vendors that released new versions completed the survey for both their initial and updated software products. The detailed methodology and results of the 18 completed surveys are included in this report. Important caveats to keep in mind while reviewing the results follow: 1. Literally hundreds of products are identified as EMRs. While a good faith effort was made to contact as many vendors as possible, some may have been inadvertently overlooked. Many of those contacted chose not to respond. 2. The survey portion of this study is based on what vendors said about their own products. 10 EMR Functionality Study Based on the IOM Requirements, published October 2002 by AC Group, Inc. Page 13

17 Section II Methodology and Project Findings 3. Of the vendors ranking in the top 10 for self-reported functionality, only five underwent performance testing. The remaining vendors either completed the self-reported testing in the second round of submissions, and therefore weren t invited to participate in performance testing, or declined to participate. When evaluating functionality by different methods of input, the ACR team determined that today s technology allows end-users the same functionality no matter where they are located. In 95 percent of the cases, the vendor s application functioned the same from a desktop, remote location and wireless PC device. Therefore, the ACR team was able to consolidate Desktop, Remote and Wireless functionality into one rating. Because the only major difference was the functionality on a PDA device given the limited screen size, the ACR team created a separate rating for PDA devices. Simply stated, a number of the vendors that were highly ranked for the triad of desktop, remote and wireless, either did not offer a portable device or had one with limited functionality. When their overall performance ranking included low or nil scores for PDA, their ranking dropped precipitously. Therefore, the review team decided to split the rankings into the desktop triad and rank the vendors separately by PDA performance. The vendors that completed the detailed functional comparison included: 1) A4 Health Systems (A4) 2) Allscripts Healthcare Solutions (Allscripts) 3) Alteer Healthcare (Alteer) 4) Cliniflow (Monarch) 5) Companion Technologies Corp Medicware (CTC) 6) eclinicalworks (ecw 4.0 and 5.0) 7) e-mds 8) GE Medical Logic 9) Hamilton Associates (mypatient) Charts 10) Imedica 11) JMJ 12) MDAnywhere 13) Medical Manager (WebMD) 14) NextGen Healthcare Information Systems, Inc. (NextGen) 15) Noteworthy 16) Physician Micro Systems, Inc. (PMSI) 17) WebMD (Intergy) B. Composite Ratings of 18 EMR Applications The 18 products evaluated were rated on their ability to provide the required functionality. Each of the 2,426 questions was assigned a weighted value point based on importance to a practice. For ease of viewing, a one to five star summary rating system was developed based on the following criteria: Rating * * * * * * * * * * * * ** * Description The vendor s product has more than 90 percent of the important functionality available today. The vendor s product has more than 80 percent but less than 90 percent of the important functionality available today. The vendor s product has more than 70 percent but less than 80 percent of the important functionality available today. The vendor s product has more than 60 percent but less than 70 percent of the important functionality available today. The vendor s product has less than 60 percent of the important functionality available today. Page 14

18 Section II Methodology and Project Findings Overall Vendor and Product Ranking The following table (Exhibit 2) displays the overall rating of the 18 vendors by mode of display; Total Points Desk Top Remote Wireless PDA Total Total w/o PDA NextGen 94% 94% 93% 78% 90% 94% Allscripts 91% 91% 91% 73% 87% 91% Hamilton 91% 91% 87% 0% 67% 89% PMSI 88% 88% 87% 92% 89% 88% A4 Health Systems 86% 86% 85% 0% 65% 86% eclinicalworks % 86% 86% 83% 85% 86% Imedica 82% 79% 81% 0% 61% 81% CTC 79% 79% 78% 72% 77% 79% Noteworty 77% 0% 0% 0% 19% 25% e-mds 75% 75% 0% 0% 37% 49% eclinicalworks % 74% 72% 68% 72% 73% Cliniflow (Monarch) 71% 71% 70% 19% 58% 71% Medical Manager 71% 70% 68% 52% 65% 69% Web MD Intergy 70% 51% 68% 50% 60% 63% GE Medical 68% 0% 0% 0% 17% 22% JMJ 62% 62% 62% 65% 63% 62% Alteer 53% 53% 53% 21% 45% 53% MDAnywhere 50% 50% 50% 24% 44% 50% Exhibit 2 Page 15

19 Section II Methodology and Project Findings C. Total EMR Functionality The review team first looked at vendor applications that met all of the 2,646 functional questions, including PDA functionality. Vendor applications that did not provide PDA functionality rated lower in overall performance. In particular, companies like a4healthcare and imedica that ranked Four Stars in desktop functionality dropped to a Two Star rating for overall functionality because they do not offer a PDA solution at this time. The lower rating does not mean that the product does not meet the majority of the functional requirements, only that the vendor does not offer a PDA device for recording and viewing of EMR data. We also ranked the vendors excluding the PDA function scoring in fairness to those vendors who do not offer PDA solutions and for those physician offices where mobile PDA is not a priority. In overall points, the ACR study indicated that the top four EMR application vendors were NextGen, Allscripts Healthcare Solutions, Physician Micro System, Inc. and eclinicalworks. NextGen was the only vendor that rated above 90 percent in total functionality available today and, therefore, received Five Stars. However, Allscripts Healthcare Solutions, eclinicalworks and PMSI all meet over 85 percent of the required functionality. When evaluating the functionality that is available today, NextGen received Five Stars, Allscripts Healthcare Solutions, PMSI and eclinicalworks v 5.0, received Four Stars and CTC (Medicware) and eclinicalworks v4.0 received Three Stars. Four additional EMR application vendors received Two Stars since they provided between 60 percent and 70 percent of the required functionality (see Exhibit 3). 5 Top 10 EMR Products Ranking from 1 to 5 Total Functionality Available Today Rating g Total NextGen PMSI Allscripts ecw 5.0 CTC ecw 4.0 Hamilton Web MD A4 JMJ Based on 2,626 Functional Questions Divided Between 26 Functional Categories Exhibit 3 Page 2 Page 16

20 Section II Methodology and Project Findings The ACR team also looked at actual points received based on the weighted value of importance. As shown in Exhibit 4, this did not change the vendor rating by percent of total functionality, but does offer a clearer look at the mix of answers. It is important to look at the functionality of these applications as well as the financial viability of the company offering the product, the cost of the product and the suitability of that product for size and scale of the practice. In doing so, four vendors dominate the small practice market. In fact, as indicated below, these vendor ratings were very tightly clustered, then application ratings drop off precipitously. Keep in mind, some of the vendors who rated strong in desktop, wireless and remote functionality did not provide a PDA application. Therefore, their overall rating was reduced as in the case of Hamilton Associates mypatient Chart which rated in the top four in overall desktop functionality, but only seventh overall due to a lack of PDA functionality. Top 10 EMR Products Based on Total % of positive responses Total Functionality Available Today Rating 90% 85% 80% 75% 70% 65% NextGen PMSI Allscripts ecw 5.0 CTC ecw 4.0 Hamilton Web MD A4 JMJ 60% Based on 2,646 Functional Questions Divided Between 26 Categories Exhibit 4 Page 3 Page 17