EMR & EHR Blog for Physicians

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The world of healthcare is changing especially so in the light of an estimated 30 million new patients that will be added to the healthcare system. Most of them will be tended to by Family Doctors (including internists and pediatricians). Primary care practices typically measure productivity according to the number of visits, which also drives payment (which is less than half the money earned by specialists).

Besides the low salaries, there is tons of work that does not involve a visit from a patient, is invisible to those who support and purchase primary care and is therefore uncompensated.

In a recent study documented, each internist handled 18 visits per day in addition to the following unpaid tasks:

• 24 telephone calls (80% handled directly by Physicians; 28% resulted in writing of prescription and 8% ended in ordering of new tests)
• 12 prescription refills processed
• 20 laboratory reports read - they frequently trigger a review or adjustment of a medication, which requires access to accurate, current medication lists with doses.
• 14 consultation reports from specialists examined
• 11 X-ray and other imaging reports reviewed which may require updating problem lists or further referrals
• 17 e-mail messages including interpreting test results (59%) or responding to patients (22%)

The above numbers reveal phenomenal quantum of uncompensated work that is performed by primary care providers. If the metrics used for compensating these providers is not changed quickly, then it is easy to predict that the shortage of family doctors will increase at a rapid pace and the complete primary healthcare ecosystem will start crumbling.

The same study also dealt with implementation of Electronic Health Records and the changes in practice design that this brought forth in a Primary Care setting. Primary Care Physicians play a number of roles in the course of discharging their daily duties - from making diagnoses and providing treatment to ordering tests and filling out forms. How and by whom the work is done is dependent on both the skills of available support (non-physician) staff and the extent of information-technology support.

When EHR Software is implemented in a Primary Care Clinic, roles played by Clinic personnel often change. In this documented case study, the following changes were recorded:

1. The job profile of the registered nurse changed significantly after implementation of Electronic Health Records. While the nurse's work could be handled by personnel without any nursing skills, new duties of the nurse included doing "information triage" of incoming laboratory reports, telephone calls, and consultation notes.
2. Additional front-desk staff and medical assistants were hired to handle the increased tasks associated with the comprehensive management of chronic diseases like diabetes, etc.
3. Productivity metrics of the Physicians were changed from just using total charges (or number of visits) to including telephone calls and e-mails handled.
4. Doctors now rely on availability of comprehensive, contemporaneous structured data when responding to telephonic calls and lab results.
   
5. The purpose of documentation has shifted from billing to ongoing clinical care, and the EHR is now used more for 'information management' and 'active support of clinical-practice activities' (rather than mere progress note generation).

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RevenueXL Inc. assists medical practices in the assessment, selection and implementation of Medical Software including EMR Software (also called EHR Software), Patient Portal, and Practice Management or Medical Billing software. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.

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I cam across an interesting article on a very important topic that is very relevant in the light of recent discussion and legislation on 'meaningful use' of Electronic Medical Records (aka Electronic Health Records).

It was a survey that involved sixty respondents, including 52 physicians or staff from 26 practices with commercial ambulatory care EMRs in place for at least 2 years, chief medical officers at four EMR vendors, and four national thought leaders. There were 6 major findings:

1. EMRs facilitate within-office care coordination, chiefly by providing access to data during patient encounters and through electronic messaging;
2. EMRs are less able to support coordination between clinicians and settings, in part due to their design and a lack of standardization of key data elements required for information exchange;
3. Managing information overflow from EMRs is a challenge for clinicians;
4. Clinicians believe current EMRs cannot adequately capture the medical decision-making process and future care plans to support coordination;
5. Realizing EMRs' potential for facilitating coordination requires evolution of practice operational processes;
6. Current fee-for-service reimbursement encourages EMR use for documentation of billable events (office visits, procedures) and not of care coordination (which is not a billable activity).

The third goal of 'meaningful use' focuses on improving care coordination by enabling exchange of meaningful clinical information among professional health care team by requiring the EHR to possess the following capabilities and functions:

1. Capability to exchange key clinical information (for example, problem list, medication list, allergies, and diagnostic test results), among providers of care and patient authorized entities electronically.
2. Perform medication reconciliation at relevant encounters and each transition of care.
3. Provide summary care record for each transition of care or referral.

Given the survey findings listed in the earlier part of this blog, I am personally skeptical how many of the current versions of EHR Software solutions can pass the three capability tests (as above). The jury is out and we will better know which EMR / EHR Solutions will effectively meet the goal as far as co-ordination of care is concerned in the next few months.

If any EMR / EHR vendors or current users of EMR / EHR solutions would like to share their understanding, knowledge or perspective on this topic, please feel free to leave a comment.

We will continue exploring different aspects of 'meaningful use' over the next several weeks.

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RevenueXL Inc. assists medical practices in the assessment, selection and implementation of Medical Software including EMR Software (also called EHR Software), Patient Portal, and Practice Management or Medical Billing software. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.

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1. List of "meaningful use" criteria that healthcare providers must meet to qualify for federal IT subsidies based on how they use their electronic health records. 
2. The standards and certification criteria that those EHRs must meet for their users to collect the money.

Phased Approach to Meaningful Use

What has been proposed is a phased approach that encompasses reasonable criteria for meaningful use based on currently available technology capabilities and provider practice experience, and builds up to a more robust definition of meaningful use, based on anticipated technology and capabilities development.

Under this phased approach to meaningful use, the criteria of meaningful use would get updated through future rulemaking. The initial meaningful use criteria have been referred to as "Stage 1."

(Stage 2 criteria are expected to be proposed by the end of 2011 and the Stage 3 definition may be proposed by the end of 2013.)

Stage 1 Meaningful Use Criteria

The Stage 1 meaningful use criteria focuses on electronically capturing health information in a coded format; using that information to track key clinical conditions and communicating that information for care coordination purposes (whether that information is structured or unstructured, but in structured format whenever feasible); consistent with other provisions of Medicare and Medicaid law, implementing clinical decision support tools to facilitate disease and medication management; and reporting clinical quality measures and public health information.

Stage 2 and Stage 3 Meaningful Use Criteria

Stage 2 meaningful use criteria shall expand upon the Stage 1 criteria to encourage the use of health IT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible, such as the electronic transmission of orders entered using computerized provider order entry (CPOE) and the electronic transmission of diagnostic test results (such as blood tests, microbiology, urinalysis, pathology tests, radiology, cardiac imaging, nuclear medicine tests, pulmonary function tests and other such data needed to diagnose and treat disease).

Stage 3 meaningful use criteria shall focus on promoting improvements in quality, safety and efficiency, focusing on decision support for national high priority conditions, patient access to self management tools, access to comprehensive patient data and improving population health.

Stage 1 Meaningful Use Defined in Detail

Goal 1: To further the care goal of improving quality, safety, efficiency and reducing health disparities.

1. Use CPOE (which entails the provider's use of computer assistance to directly enter medical orders (for example, medications, consultations with other providers, laboratory services, imaging studies, and other auxiliary services) from a computer or mobile device. The order is also documented or captured in a digital, structured, and computable format for use in improving safety and organization. For Stage 1 criteria, it will not include the electronic transmittal of that order to the pharmacy, laboratory, or diagnostic imaging center)
2. Implement drug-drug, drug-allergy, drug-formulary checks.
3. Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT®. It also includes past diagnoses relevant to the current care of the patient.
4. Generate and transmit permissible prescriptions electronically (eRx).
5. Maintain active medication list.
6. Maintain active medication allergy list.
7. Record the following demographics: preferred language, insurance type, gender, race and ethnicity, and date of birth.
8. Record and chart changes in the following vital signs: height, weight and blood pressure and calculate and display body mass index (BMI) for ages 2 and over; plot and display growth charts for children 2 - 20 years, including BMI.
9. Record smoking status for patients 13 years old or older.
10. Incorporate clinical lab-test results into EHR as structured data.
11. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach.
12. Report ambulatory quality measures to CMS (or, for EPs seeking the Medicaid incentive payment, the States).
13. Send reminders to patients per patient preference for preventive/follow-up care. Patient preference refers to the patient's choice of delivery method between internet based delivery or delivery not requiring internet access.
14. Implement five clinical decision support rules relevant to specialty or high clinical priority, including for diagnostic test ordering, along with the ability to track compliance with those rules.
15. Check insurance eligibility electronically from public and private payers.
16. 16. Submit claims electronically to public and private payers.

Goal 2: Provide patients and families with timely access to data, knowledge, and tools to make informed decisions and to manage their health

1. Provide patients with an electronic copy of their health information (including diagnostics test results, problem list, medication lists, allergies) upon request. Electronic copies may be provided through a number of secure electronic methods (for example, personal health record (PHR), patient portal, CD, USB drive).
2. Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies) within 96 hours of the information being available to the EP. Electronic access may be provided by a number of secure electronic methods (for example, PHR, patient portal, CD, USB drive). Timely is defined as within 96 hours of the information being available to the EP either through the receipt of final lab results or a patient interaction that updates the EP's knowledge of the patient's health. 
3. Provide clinical summaries for patients for each office visit.

Goal 3: To improve care coordination by enabling exchange of meaningful clinical information among professional health care team.

1. Capability to exchange key clinical information (for example, problem list, medication list, allergies, and diagnostic test results), among providers of care and patient authorized entities electronically.
2. Perform medication reconciliation at relevant encounters and each transition of care.
3. Provide summary care record for each transition of care or referral.

Goal 4: To improve population and public health by having the patient's health care team communicate with public health agencies.

1. Capability to submit electronic data to immunization registries and actual submission where possible and accepted.
2. Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice.

Goal 5: To ensure adequate privacy and security protections for confidential information through operating policies, procedures, and technologies and compliance with applicable law and provide transparency of data sharing to patient.

1. Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities.

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RevenueXL Inc. assists medical practices in the assessment, selection and implementation of Medical Software including EMR Software (also called EHR Software), Patient Portal, and Practice Management or Medical Billing software. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.

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RevenueXL Inc. assists medical practices in the assessment, selection and implementation of Medical Software including EMR Software (also called EHR Software), Patient Portal, and Practice Management or Medical Billing software. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.

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Medicare payments to physicians not qualified as “meaningful users” of Certified Electronic Medical Record software will be reduced by 1% in 2015, then 2% in 2016, 3% in 2017, 4% in 2018, and by as much as 95% in subsequent years.

To avoid this situation your timing is critical. Experts predict that by mid-to-late 2010, the demand for Electronic Medical Record Systems may far exceed the number of qualified sales and support staff that companies with Certified Electronic Medical Record software will have to meet the last minute rush of physicians suddenly realizing their forthcoming financial misfortune. Therefore, now is the time to take action and give serious attention to the 2 to 4 months of lead-time required for planning and selection, set-up and training, implementation and “go live”. Then, add an additional 6 to 8 months to ensure physicians and staff are proficiently up and running as “meaningful EHR users”, so that each physician in your practice is eligible for the up to $44,000.00 in Medicare Incentive Payments beginning in January 2011.

Late adopters can surely expect huge delays or worse, being placed on a waiting list (at least by the best and most popular EMR software vendors).  In this case, your options may become very limited, and prices may even increase.  So, instead of receiving Bonus Payments, you may wind up being penalized through reduced payments.  Don’t be surprised if you find yourself on a “hotchpotch” path of trying to force-fit poorly matched EMR and Practice Management software together from different vendors. This predicament will cost you a lot of time, frustration, and money.

There are over 300 EMR vendors on the market, and only a few are CCHIT Certified and qualified take on the question, “Which EMR has the smoothest transition and implementation that meets the requirements of your practice and, ensures each physician in your practice receives the maximum Medicare Incentive payments?” The answer, find a good Independent Consultant who, at no cost to you, can help you find the best-fit Certified Electronic Medical Record software, which has all the answers “built-in”.   

It’s not everyday the government imposes new laws, regulations, costs, and penalties upon your business and then, turns around and pays you, to become compliant and avoid being penalized. Now is the time to start positioning each provider in your practice to leverage every Bonus Incentive dollar available. After all, the right-fit Electronic Medical Record software will make running your practice easier, more profitable, boost morale, improve patient care and, enhance your quality of life and that of your patients.  Everyone will “feel” the difference.

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RevenueXL Inc. assists medical practices in the assessment, selection and implementation of Medical Software including EMR Software (also called EHR Software), Patient Portal, and Practice Management or Medical Billing software. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.

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The American Recovery and Reinvestment Act of 2009 (ARRA) provides $17.2 billion in Medicare and Medicaid incentives designed to facilitate widespread implementation of certified Electronic Health Record (EHR) systems in physician practices and hospitals. Physicians, facilities, and other providers will receive money through Medicare or Medicaid programs for their "meaningful use" of EHR Software.

What constitutes "meaningful use" still hasn't been precisely defined. And there's still a lot of uncertainly. However, this hasn't prevented EHR vendors from aggressively marketing their EMR / EHR solutions to physicians and medical clinics, small and large.

What are these vendors doing to overcome physician hesitancy to implement EMR? They are guaranteeing that their EMR products will exceed, or at least meet, the requirements imposed by CMS. These warranties aim to lower one of the highest barriers to early EMR adoption: uncertainty about future standards.

Here's a sampling of the current vendor guarantees:

• ChartLogic Inc. says: "I guarantee that ChartLogic EMR users will be able to meet the "meaningful use" requirements needed to receive the stimulus money."
• eClinicalWorks similarly commits to supporting its customers' ability to meet the HITECH Act's "meaningful use" standards. In its license agreement, it warrants that its software will support the "meaningful use" criteria of the American Recovery and Reinvestment Act (ARRP).
• Athenahealth Inc. guarantees that its her users will receive Medicare meaningful use incentive payments authorized under the HITECH Act within the economic stimulus law. Athenahealth states:

"For each month for which you don't receive your qualified HITECH Act Federal Stimulus reimbursement dollars during the first year of funding, we will credit our monthly service payments, for up to six months. This offer applies to HITECH Act reimbursement payments only. Additional terms, conditions and limitations apply."

Note that the guarantee does not cover Medicaid incentive payments because of variations at the state level.

• Praxis EMR guarantees qualification under the ARRA's meaningful use guidelines within 90 days of publication, or your money back.
• Practice Fusion guarantees that physicians using its EHR will qualify for meaningful use before HITECH payments begin in January 2011.

A careful reading of these warranties reveals that every vendor pretty much guarantees that its EHR Software will qualify for "meaningful use" under the ARRA. However, the burden of proof that the qualified EHR is being used in a manner that proves "meaningful use" still lies with the physician.

Today, many physician organizations are expressing strong views about what they would like a working definition of "meaningful use" to include.

For example, the MGMA recently recommended that the federal government conduct a small pilot project among vendors and physician practices, to ensure that the process of demonstrating meaningful use will be achievable and practical. And they want the feds to complete the pilot program before any incentive programs for meaningful use of electronic health records begin. Additionally, the MGMA wants attestation and/or survey instruments to serve as primary methods for demonstration, instead of imposing arbitrary reporting thresholds on physicians. (Read more about MGMA's perspective on meaningful use of EHRs.)

According to recommendations submitted by HIMSS in April, it wants the following:

1. To ensure continuity, recognize CCHIT as the certifying body of EHRs.
2. To achieve incremental maturation of "meaningful use," adopt metrics that can be reasonably captured and reported beginning in FY11/2011, and then made increasingly stringent using intervals of not less than two years. HIMSS' definitions include specific metrics to enact, in phases, over a multi-year period.
3. To bridge existing gaps in interoperability of health information, coordinate with HITSP and IHE to create new harmonized standards and implementation guides.
4. Reconcile the gap between "certified EHR technologies," "best of breed," and "open source" technologies.

• Read the HIMSS definition for meaningful use of technology in hospitals
• Read the HIMSS definition for meaningful users of EHR technology
• Read the HIMSS letter sent to ONC and CMS
 

But where are we on the definition of meaningful use of an EHR?

HHS hasn't released a formal proposal for the final rules for meaningful use of EMRs. However, there are hints of what it might wind up including. National health IT coordinator Dr. David Blumenthal, speaking at the American Medical Informatics Association's annual symposium, said, "The meaningful use framework will be about the goals of care, not the technology." That's fairly vague, and Dr. Blumenthal didn't elaborate on the specifics.

My personal perspective on 'Meaningful Use'

Physicians should be aware that simply buying and installing an EHR doesn't always bring efficiencies to a medical clinic, or even prove meaningful use of an EHR. EMR software (also called EHR software) is only a piece of the complicated puzzle - it's only an enabler. Physicians would be well advised to do their homework to determine whether the promised ROI of the selected EHR system will actually be realized. And they should also recognize that the ball will be in their court when it comes to proving "meaningful use" of the EHR.

Contact us for a free 'no-obligation' Consulting Session to address any questions that you may have with regard to 'Qualified EHR', 'Meaningful Use', EMR Costs, etc.

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RevenueXL Inc. assists medical practices in the assessment, selection and implementation of Medical Software including EMR Software (also called EHR Software), Patient Portal, and Practice Management or Medical Billing software. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.

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Stories abound about botched EHR System implementations and providers uninstalling EHR Systems in Arizona. But at the same time, there are many case studies which prove that achieving ROI with EMR or EHR is very much possible, provided there is right focus on training, transition and implementation.

Computation of ROI with EMR Software is a complicated business, based on many assumptions and unquantifiable and intangible benefits. I personally like the definition: ROI = Increase in Revenues - Decrease in costs. I recently come across another definition: ROI = EMR - FTE based on the consensus that automated systems alleviate support staff needs. You can choose whatever definition appeals to you most.

According to "The formula for EMR: ROI=TCO?", if the average physician needs 4 assistants, implementation of an EMR can reduced that number by one or more. In a fast growing practice in New York State, which implemented an EMR, it was able to grow from 20 to 120 doctors in just two years because they only had to hire two or three FTEs per doctor instead of four or five.

In a recent case study published by HIMSS, Glynn Medical Associates, comprising of four internists, two rheumatologists and a physician's assistant, which implemented an integrated EMR/PM system with every provider using the system as of the first day, experienced savings conservatively estimated at $200,000 per year. But the ROI did not come easy. The first three months of going paperless were stressful. Also, one physician in the practice was seeing 33 percent more patients daily with use of the EMR system helping to increase patient satisfaction.

Some of the quantitative benefits included:

• Reduction in transcription costs.
• Reduction in medical records personnel
• Reduction in billing department personnel
• Possible downsizing of facility

In another case study, according to Wellesley, Mass.-based Nuclear Research, a 76-bed hospital in Bolivar, Mo achieved a 1,321 percent ROI in its first year after implementing an EHR Software solution, besides reaping other intangible benefits. Over three years, the hospital's ROI came in at 2,912 percent.

Here are two EMR Calculators that you can use:

1. Physicians Practice EMR ROI Calculator
2. HIMSS EMR ROI Calculator 

Experts say that an EHR implementation project is not a sprint but a marathon. Moreover, the race does not finish on the go-live date. You will see reduced productivity during period immedialtely followng post-activation followed by "stabilization" and then "optimization".  If everything goes right, you can achieve stabilization within 90 days. After that, the financial benefits will materialize gradually as staff increasingly utilizes the EHR Software and associated workflows. 

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There are many opportunities for revenue enhancement as well as cost reduction which will yield Return on Investment. Download our free article on 'Does EMR increase Revenues?'.

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RevenueXL Inc. assists medical practices in the assessment, selection and implementation of Medical Software including EMR Software (also called EHR Software), Patient Portal, and Practice Management or Medical Billing software. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.

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What is the difference between an EMR and EHR? Aren't they essentially the same?

It is easy get confused by the inconsistent way these terms are bandied about in the industry.

• Nextgen mentions both EMR and EHR in its home page title, but the product is called Electronic Health Records.
• GE Healthcare calls its product as Centricity EMR.
• Greenway characterizes its PrimeSuite product as an EHR.
• Aprima's PRM product was initially labeled EMR but is now described as EHR.
• eClinicalWorks continues to refer to its product as an EMR.
• Allscripts mentions both ‘Electronic Medical Records (EMR)' as well as ‘Electronic Health Records (EHR)' in the title of its home page, but their solution is called ‘Electronic Health Records'.
• CCHIT certifies EHR (Electronic Health Records) products, but the list of CCHIT-certified EHR products includes a number of ‘EMR' products.

As is clear from the above, vendors have been using the two terms - Electronic Medical Records (EMR) and Electronic Health Records (EHR) - interchangeably in their communication even though these two terms are technically different with different sets of features and capabilities.

Chris Hobson in a article published in ‘Advance for Health Information Executives' says that the difference between the two terms more than semantic and is crucial for health IT decision-makers to understand the difference.

So what is the difference between EMR and EHR? Let us review the distinction portrayed by three authorities in their own rights:

1. Chris Hobson:

The essential difference between EMR and EHR lies in how the (electronic) data will be used or shared - within the confines of a single office or practitioner or will it be shared across a wide range of different providers, such as specialists' offices, labs, insurance providers and government agencies?

Chris relies on the definition advanced by HIMSS and accordingly, an EMR is a set of applications and workflow tools that digitizes the creation, collection, storage and management of patient information "within the confines of a single organization". It may touch clinical data repositories, lab applications and patient information management systems, among others -- but all within the reach of a single organization.

EHR, on the other hand, is a longitudinal, complete and unified view of electronic record of patient health information produced by clinical assessments in one or more care settings drawn from across a wide region corresponding to all the providers who are seeing the patient -- the totality of his/her personal data, state of health and delivered care.

According to Chris, while both EMRs and EHRs provide some similar benefits -- cost savings through improved workflow and paper reduction, improved delivery of care accuracy -- EMRs provide those benefits only within a single organization. EHRs, because they are shared across the irrelevant geographic or otherwise defined region, increase the efficiency of patient care and improve patient outcomes, disseminate information rapidly between care providers, help with research efforts, and cut costs throughout the entire system more promptly and reliably.

2. National Alliance for Health Information Technology (NAHIT):

NAHIT while offering the following definitions, generally supports a similar distinction between EMR and EHR:

EMR (Electronic Medical Records) is an Electronic Record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one healthcare organization.

EHR (Electronic Health Records) is an Electronic Record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.

3. Healthcare Informatics:

EMR is a computerized legal clinical record created in Care Delivery Organizations (CDOs), such as hospitals and physician offices, and used and owned by the CDO. It becomes an EHR (Electronic Health Record) when:

• Reports and histories (labs, pharmacy, radiology, consults, etc) are electronically added;
• Items in the record are electronically exchanged with other providers, and
• There is a personal health record (PHR/PMR) component which allows patients to participate in documenting and creating their medical history and communicate with their provider.

EHRs represent the ability to easily share medical information among stakeholders and to allow it to follow the patient through various modalities of care from different CDOs. Thus EHR offers a holistic approach to patient care where continuity of care is emphasized.

EMR vs. EHR - What does it mean to you?

Regardless of whether vendors call their products EMR or EHR, what should your first priority be?

When selecting an EMR or EHR, ask your vendor to explain how its solution will support your vision for interoperability and rapid exchange of data between care providers, in order to provide a holistic perspective on delivering health to your patients. It's that simple. You can safely make this your criterion for choosing a system, and forget about what the vendor calls its product. For your purposes - providing efficient, effective care - the name is totally irrelevant.

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Read our related blog on Top 12 EMR Software Selection mistakes often committed by Physicians.

Contact Us for free no-obligation EMR / EHR Selection Consulting and Demo.

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RevenueXL Inc. assists medical practices in the assessment, selection and implementation of Medical Software including EMR Software (also called EHR Software), Patient Portal, and Practice Management or Medical Billing software. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.

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Web-based EMRs have been touted as a nice way to implement EMR solution with low initial investment. Web-based and client/server EMR systems have unique advantages and disadvantages. Which model you should choose for your practice will depend on your special requirements.

Despite the obvious advantages of web-based EMR (access from anywhere, remote hosting, etc.), there are some important points you should consider when deciding whether to implement a web-based system:

1. Don't imagine that a "high-speed" Internet connection is all you need to run a Web-based EMR. It's important to find out if you'll actually have the bandwidth required to send, receive, and exchange data efficiently. Consult the EMR vendor about its requirements, and talk to your Internet service provider about its available bandwidth options.

How much bandwidth you need will depend on the number of users and the volume of data flowing between your practice and the hosted Web- based EMR. If the data increases, you may need additional bandwidth, and you'll need to be prepared. Carefully review the EMR vendor's recommendations before you sign up for a bandwidth plan.

2. How reliable is your Internet connection? This is critical - and also, your upload and download speeds may vary depending on the time of day and how much bandwidth is being used by nearby businesses. You'll want to plan for extra bandwidth to avoid slow-downs in charting your patient encounters.

If you share an Internet pipe with other businesses in the same complex, your data transfer speeds may fluctuate dramatically, depending on how the others businesses are using the connection. We recommend asking your Internet service provider for documented evidence of the uptime you can expect. Depending on the answers, you may want to consider getting a dedicated pipe for your clinic. Work with the EMR provider to develop a backup system for charting on paper if the system goes down, and develop your office processes accordingly

3. What if your EMR vendor folds its tent? Will you be able to retrieve your data from the vendor's servers? Will the data be in a format that you can use/convert/transfer?

After deciding on a web-based EMR vendor, treat the vendor as your partner. You should be able to discuss every possible scenario with the vendor's sales reps. Better yet, work with an experienced EMR consulting company who'll help you communicate with the EMR vendor. Consider asking the vendor to provide data-backup files on a regular schedule.

4. Unlike a client/server environment, where you have local control over the server and EMR software, a web-based EMR makes you dependent on the vendor's customer support. Will your vendor reliably and promptly support you and your staff by phone, IM, email, or chat? Will the vendor be available to quickly help you solve urgent or critical issues? Talk to the vendor about its support structure, especially outside normal working hours.

5. What will happen if you someday decide to move from a web-based to a server-based EMR? Does your vendor offer that flexibility? If so, how seamless will the migration be? How much will it cost? Even if you don't believe it will ever happen, it's in your best interest to discuss it with the vendor today, and get an in-depth understanding of the process.

We've seen many successful web-based EMR systems. They do work well for most physicians. By understanding the handful of caveats we've outlined above, and preparing accordingly, you'll stand a better chance of implementing a successful web-based EMR system for your practice.

Learn about the top 10 EMR Software features that you should be looking for. Download our free article on Top 10 Electronic Medical Records features for every physician.

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RevenueXL Inc. assists medical practices in the assessment, selection and implementation of Medical Software including EMR Software (also called EHR Software), Patient Portal, and Practice Management or Medical Billing software. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.

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Here's a multiple-choice quiz with an answer that may surprise you:

What's the most expensive cost element when you implement new Electronic Medical Records?

a. EMR Software
b. Workstations and monitors
c. Training and Change Management
d. Customizing templates

If you answered "EMR software" - sorry, no cigar. While EMR / EHR software isn't cheap, it's a one-time expense.

If you chose "Workstations and monitors" you're still on the wrong track. Workstations and monitors with more than enough power for EMR cost under $1000.

If you answered "Training and Change Management," you may select the kewpie doll of your choice - you're absolutely right. This cost component is perennial and has no end!

Why is that true?

1. We've discovered that new staff usually needs to be trained not only on the EMR application, but also on basic computer skills like Windows, use of mouse, printing, creating folders, moving files, logging on and off, etc. If your staff is not comfortable with using computers with GUI (Graphical User Interface) for day to day operations, they will surely need training on that.
2. Implementation of Electronic Medical Records would involve use of devices like scanners, fax servers, etc. If the Clinic does not use such devices currently, staff will need to be trained on using these devices.
3. EMR software is a major application, thus most users will need to learn multiple new software functions. This takes time - learning a complex application requires lots of repetition until the new skills become second nature.
4. Initial training is often conducted in a tight time frame where the schedule is dictated by the EMR vendor and clinics find that they need additional training.

Here's another quiz question: what's the leading cause of failure for new EMR implementations? Studies show the failures are primarily related to inadequate training.

Clients often want to know the quickest, most cost-effective way to train their staff on EMR software. By avoiding the following 8 Cardinal Sins of EMR Training, you'll significantly slash your training costs, and improve your return on investment.

1. Big time gap between training and 'go live'

We've seen cases where the EMR vendor rushed ahead and trained staff on using EMR, even though the provider enrollment with various payers was far from complete. Big mistake! The training vendor went through the motions of training, collected a nice check, and went away. When the enrollment process was finally completed, 8-10 weeks later, and the clinic began using the EMR system - you guessed it, the provider and staff had forgotten how to use the application and were forced to purchase additional training days.

Here's our recommendation: insist on starting training after the setup process is complete, including all interfaces (lab interface, eRx, etc.).

2. Training everyone on everything

In a larger clinic (including multiple locations), clinic staff often play widely different roles, and therefore need to know very different parts of the EMR application. Training every staff member on every feature of the EMR won't optimize their skills on the parts that are most relevant to them. For example, only a few staff members will have access to the sensitive areas of the EMR (e.g., security administration).

Training plan must be based on roles. A better approach is to have the EMR vendor train a set of super-users ("Train the Trainer") who will have the responsibility to train and support the rest of the staff. They are the ‘go to' people when users have issues with using EMR (before someone makes a call to the Customer Support operations of the EMR vendor).

3. Assuming that training ends after implementation

Training doesn't end when the EMR system is up and running. Staff roles and responsibilities can change over time, and new employees will need training on the EMR software. Training never ends - but it's a lot cheaper to have one or more super-users on the staff who can train than others, than to bring back the training vendor each time. (See #2 above.)

4. Having the EMR vendor train staff in basic computer skills

Having the EMR vendor teach basic computer skills is a huge waste of money. If your staff members can't teach each other these simple skills, find an adult-education course, or hire a computer science student who'll do the job for a fraction of what the EMR vendor would charge. Plan to have the hardware installed well in advance, so that staff can be trained on basic skills before the EMR system arrives.

5. Assuming that training can be imparted remotely and effectively over Webex or other web conference media

Many EMR vendors offer remote training using remote Webex or GoToMeeting sessions over the Internet, without any on-site support during go-live. Remote training costs less but is never as effective as face-to-face training. Choose on-site setting, even if it means spending extra money. Also, insist on having an expert on-site during go-live.

6. Not insisting on formal training material or not using desktop recording software to record the training session

Insist that the vendor provide formal training materials that can be used to train new staff. Ideally, the training materials will be tailored to your practice requirements. If no formal training material is available, have your staff capture snapshots and create a training binder for future reference. Better still, use a desktop recording software to record the video and audio (if possible).

7. Assuming that the training provided by EMR vendor will encompass all elements that are relevant to your medical practice.

Most of the time, the EMR Vendor may adopt a ‘one size fits all' approach as far as EMR training is concerned. It is in your interest to work with the vendor in designing the training sessions customized to your specific requirements. You may find that some portions are not covered at all while some easy functionality hogs valuable training time.

8. Not validating the credentials of the trainer provided by the EMR vendor in the medical specialty of your Clinic.

We recommend confirming the trainer's credentials before he/she comes on-site. It's very important that the trainer understand the unique requirements of your medical specialty, so the trainer can offer relevant tips to help your staff optimize their use of the EMR system.

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We would like to keep revising this list for the benefit of our future readers. Hence if you believe that there are other training sins that you want included on this list, please do leave your comments. We will have an updated list avaialble for free download soon.

Check out our downloadable spreadsheet on EMR Implementation Costs - an organized approach for getting a good EMR RFP or price quote and select the right-fit EMR Software for you Practice. Don't forget to contact us for a no-obligation 'Free' Selection consulting available to all bonafide buyers.

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RevenueXL Inc. assists medical practices in the assessment, selection and implementation of Medical Software including EMR Software (also called EHR Software), Patient Portal, and Practice Management or Medical Billing software. RevenueXL offers a free consultation session to review your current challenges and answer open questions revolving around EMR and revenue cycle.