Experts and physician users offer advice on better electronic health records system selection, implementation and operation. Learn more about the costs and the process of going paperless.

"It's like somebody trying to give you a really good excuse to keep smoking--there just isn't one, there just isn't," says David Baron, MD, about some physicians' reluctance to switch to electronic health records.

As a solo family practitioner in Malibu and chief of staff at Santa Monica-UCLA Medical Center, Dr. Baron sees the benefits of EHR systems extending from electronic prescribing, to privacy protection, to simple legibility. "Every change is difficult," he says, "but the pros are going to outweigh the cons. The long-term benefits to the patient and to the practice almost certainly favor [records] going electronic."

From the beginning of his transition until now, Dr. Baron's experience with his EHR system has been a reasonably good one. Not everything has gone perfectly. But along with office management software, the EHR application runs his practice and his staff members operate it proficiently. And when the software slips up or bogs down, he has a company he trusts to help him resolve problems.

As it so happens, the path Dr. Baron took while shopping for an EHR system, implementing it and maintaining it follows closely to the route advised by EHR consultants. "I took advantage of a transition in my career," he explains. In 2003, he started a solo practice with two staff members. He researched the EHR field by studying the annual vendor survey printed in Family Practice Management, a magazine of the American Academy of Family Physicians. From there, Dr. Baron started cutting vendors and products from his list by deciding which features he needed.

Then, Dr. Baron asked for demonstrations. He remembers: "Some companies were anxious to send someone to your office to demo the program, some companies want you to [do] an online meeting where they demo it on the phone, and some companies didn't return the phone call, which was a good sign of their customer service."

With a decent idea of which EHR product he liked--ChartWare's eponymous product--Dr. Baron chose to go with separate systems for medical records and office management, and his staff tracked down a business software package compatible with the ChartWare application.

Implementation was a relative breeze, since Dr. Baron's practice was small and brand new. "I'd say it took me about 90 days  to get comfortable, efficient and productive," he says. He declined to say how much he paid for ChartWare, but estimated reasonable startup costs of $25,000 for a small practice needing both hardware and software. "We brought it in for a solo practice way under that," he says.

With a survey by the American Academy of Family Physicians finding that EHR adoption among its members had jumped to 37 percent this year from as little as 10 percent in 2003, more doctors are going electronic. For those colleagues, Dr. Baron's advice is to work with a vendor that is sensitive to practice needs, which in his case meant vendor responsiveness and easily accessible records and archives. He is even happy with the firm's technical support.

Read on for additional tips and insights from experts and other physicians. There's no excuse why your transition to EHR can't be as positive as Dr. Baron's.

Shopping Around
Buying an EHR system is not like dashing into the grocery for a gallon of milk. It should be a slow, studied process to ensure you get the best product for your needs from a reliable business partner.

"It's not 'I decided I want an [EHR] for our practice ... the guy down the street says vendor A is good for him, so let's go and buy vendor A on Friday, and on Monday morning we'll come in and we'll be using it,'" says Steven Waldren, MD, director of the AAFP Center for Health Information Technology in Leawood, Kan. "It just doesn't work that way. You really do have to spend a lot of time and energy to get this to work."

When it comes to settling on an EHR application, first figure out what you need it to do and then get the practice to "buy in," Dr. Waldren says. Many EHR systems were developed mainly to deal with documentation and to improve efficiency, and might lack support for pay-for-performance and quality reporting, he says. Make sure that not only are the physicians onboard, but so are the front office staff, the back office staff, and any owners or operators, he adds.

As president of Seattle-based Maxwell IT, Tracy Maxwell helps doctors become better EHR shoppers. Her firm has presented several local seminars focused on guiding the selection of systems, sponsored by the Southern California medical associations. Her best pearl of advice: Get an accurate accounting of the impact. "A lot of these EHRs fail, and the biggest reasons they fail are that physicians weren't given a total picture of what the systems cost and ... the time they take to implement," she says. "The break-even on investment with these systems takes a couple of years."

Maxwell advises practices to focus on the total cost of adopting a system. Over the course of about five years, it's generally cheaper to go with an "integrated" EHR system that handles medical records and business records, and communicates easily with medical devices, Maxwell says. But in some cases, such as in cardiology and ophthalmology practices, it's cheaper to look at separate systems, she adds.

When evaluating a vendor's likely longevity, look at profitability, organizational structure and leadership, Maxwell says. "You should be able to have a financial discussion with the vendor, and if they're not able to provide some sort of financial review, that's a red flag," she says. "You can guesstimate if a company is profitable by looking at its burn rate and staff size," she says. "Usually the average cost for a staff person in a software company is about $100,000 a year--that's their salary times 1.25." If the company's revenue is lower than its estimated burn rate, ask where it is getting capital and what the plan for the future is, Maxwell says. Based on Maxwell IT's review of about 40 percent of the market, only about one in 10 vendors is both viable and sells an integrated EHR, she adds.

When shopping, examine the company structure of potential vendors, especially the balance of people in support versus marketing and product development, Maxwell says. While a 100-person company is generally more stable than a 20-person company, that's not always the case, she says. Ask whether the leadership has experience building and sustaining a technology company. "Is the company missing key roles in the leadership, such as a CFO?" she asks. "If you don't see that breadth of experience, it would give me pause."

Most of all, talk to your peers, advises Dr. Waldren. The AAFP runs an internal e-mail listserv-style forum involving about 1,100 physicians. Using special software, the organization also pairs up doctors for discussion who have similar situations, he says. Vendor rating lists, such as those found on the AAFP Web site at www.centerforhit.org, are good resources. "Doctors rank their systems on a five-star system on things like productivity, changes in quality in their practice, usability, support, and an overall value rating," he says.

Implementing a System
"[Installing a system] is not a sort of plug-and-play type of thing, like you and I putting in Microsoft Word," says Bruce Kleaveland, president of Kleaveland Consulting in Seattle. He counsels that a successful implementation requires several deliberate steps: Choosing a reliable hardware service provider; taking staff training seriously; lightening the work schedule when the practice goes live; forcing all physicians in the practice to switch to the EHR; and investing adequate time in the implementation process.

It generally takes about a year to get a new EHR system up and running, depending on the size of the practice and the choice of vendor, Dr. Waldren says. He recommends incremental adoption: "Really try to figure out some early, easy wins for the practice, to get comfortable using the technology and get some efficiencies in the practice." One example is intraoffice messaging, where staff members communicate by electronic messages linked to a patient's chart, he says. Another quick benefit is using a SureScript-certified system to issue new prescriptions and renewals online, Dr. Waldren adds.

Instead of scanning all the old charts into the EHR system, "try to incrementally get rid of the paper-based records," Dr. Waldren says. This involves doctors abstracting important patient-history elements onto charts destined for electronic records, he explains. In about six months, most patients will have visited, and most electronic records will have the same important information found in the paper charts, he adds.

That's how Ruby Cecilio, MD, a family physician at a four-doctor practice in Whittier, approached the process. "About four years ago, when paperwork was really, really getting on our nerves, we decided to get into electronic medical records," she says. Already equipped with electronic billing, the practice selected Sage's Intergy, now WebMD's product, for its clinical needs. "Because it was so time-consuming to scan all the records, we scanned the records as the patients made appointments," she says. As another benefit, the practice has been able to free up some office space by getting rid of some paper records after entering them into Intergy.

Dr. Cecilio figures that it took about a year for her practice to convert from paper to using Intergy as its core record system. "We did it by module--first was checking patients in and out, then patient information, then imaging of the chart, then the doctors became more confident about inputting encounters," she says. Still, one of her main complaints about EHR systems is that the practice can never really be 100-percent electronic, because other offices they do business with still use paper, or their incompatible electronic systems require a paper intermediary.

Putting an EHR in Practice
Now that your EHR system is up and running, make the most of it. Don't let helpful functions simply go unused. "What [the AAFP is] really looking at now is the fact that just because you have an [EHR], it doesn't mean you're delivering a higher quality of care," Dr. Waldren says. Some advanced functions that doctors use less often include e-prescribing, messaging with patients, advanced decision support, population-based statistic reporting and management, and electronic or virtual visits, he says.

While there are things that Marcy Zwelling-Aamot, MD, a concierge physician in Los Alamitos, likes about her EHR system, such as legibility, remote access to records and some data-tracking features, it has limitations. Her critique draws on decades of frustration with software's limited ability to accept, process and display medical data in a useful format. "To this day, the electronic medical record is an event-driven machine," she says. "If I want to document my patient's high blood pressure from the age of 50 to 73, so that I can figure out what the next step might be, I would want a system where I could graph over time," using, for example, age, intervening events, medications and weight gain. "There's nothing available in the EHR marketplace that will allow me to take better care of my patients."

Dr. Zwelling-Aamot also decries the industry's slow progress on interoperability. "In terms of data exchange, EHRs stink," she says. They are often not able to crunch numbers in records received from outside sources, whether scanned in or not, she says. "If there's laboratory work that I have to follow over time, I have to physically enter it; if there's an EKG, I have to scan that separately," she says. "And depending on how [another physician's] system works, I have to document that [the physician] did an echocardiogram and what the results were. Every bit of data that comes in, I have to enter it somehow."

Similarly, Dr. Waldren notes that several EHR systems on the market serve to document things quickly and perform business functions, rather than answer the question, "How can this help me take care of my patients better, with more quality and more safety?" Still, newer systems are being developed to focus more on the clinical aspects. "Almost all [EHRs] have some type of graphing functionality--the question is, what can they graph and how robust is their graphing functionality?" Dr. Waldren says. "Can I graph the height and weight, or is it that I can actually graph that with some of the lab data?" Extra functions and customizability usually come with a higher price, or at the expense of other functions, he adds.

One of Dr. Cecilio's favorite features is her EHR system's ability to identify a set of patients, such as diabetics with certain complications, and regularly alert the staff when follow-up is necessary. "Also, we can customize our windows so that we can see the whole summary on a patient, like the past medical records and history, problems the patient has, allergies to medication, immunizations that are due ... it's easier to navigate through those rather than flipping through charts," she says. Dr. Cecilio's system also automatically checks patient insurance eligibility, which takes a lot of burden off the staff.

Her advice on getting to know your EHR system is an old chestnut in the computer field: Garbage in, garbage out. "Systems will produce what you put in," she says. "Vendors can promise you the moon and the stars, but if you're not going to make good use of the system, it's not going to happen."


TWO FEATURE ARTICLE SIDEBARS

Naming Names
The terms electronic medical record and electronic health record are used interchangeably by most physicians to refer to computer-based records or the software dealing with them, as long as the records include medical data and are used in a healthcare setting. Some experts distinguish between the two.

In the May 2003 issue of Healthcare Informatics, Peter Waegemann, CEO of the Medical Records Institute, defines EMR as an "electronic record with full interoperability within an enterprise," such as a hospital or a clinic. An EHR, he writes, is a "generic term for all electronic patient care systems." Unless otherwise noted, this article uses only EHR in the generic sense.


An Implementation Checklist
When implementing an electronic health records system, your project manager will have to carry out the following tasks--and probably a few more. Adapted from "EHR Implementation in Ambulatory Care," a 2007 white paper from the Healthcare Information and Management Systems Society, this list is intended to give practices a better idea of how to allocate staff and whether to hire a project manager temporarily.

1. Develop an implementation plan. Establish the plan, which might include having the most computer-savvy physicians "go live" until the EHR's idiosyncrasies are identified and resolved, and then adding the remaining physicians.

2. Develop a scanning and abstracting policy. Convert paper records to electronic format. This might include having physicians review charts and select files important to patient care for scanning into the EHR.

3. Analyze workflow. With input from the practice's whole staff and help from the vendor, map how the practice's work will flow using electronic records. Use the study to train the entire practice.

4. Facilitate third-party interfaces. Set up the EHR system to communicate with several devices and entities, including: labs, hospitals and pharmacies; picture archiving and communication systems; diagnostic devices; and practice management systems. Consider paving the way for e-prescribing, patient e-mail and patient portal access.

5. Develop templates. Get input from all physicians on the template for physician note entry. Typically, these "electronic charts" are modified vendor templates or are designed by the practice.

6. Conduct training. Develop training material for all existing and future staff. In a sample workflow system from the HIMSS paper, medical assistants enter simple patient history and vitals directly into the EHR, and physicians enter data from a patient worksheet into exam-room EHR terminals.