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Managed electronic health record systems are not all created equal

Not all Software as a Service, managed or hosted electronic health record systems will suit every practice. Here’s what you need to know to sort them out.

Atlanta South Gastroenterology PC realized it needed an electronic health record (EHR) system about five years ago, when it decided to open a second office. “Physicians needed to be able to access patient records from either office, because we never knew which one a patient would go to,” said Dr. David Martin, president of the three-physician practice. They also wanted to be able to access records from a hospital or their homes.


Other needs were pushing the group to an electronic health record system: Paper-based charts often got misplaced or misfiled. Combining information from two charts was difficult. Doctors had trouble dictating charts to a transcriber, and often wound up writing them out by hand. “We figured that with an EMR [electronic medical record] system, if doctors could input data with approximately the same ease and speed it took to write it out, we would have a clear advantage because it would be more legible, more complete and could be accessed from both locations,” Martin said.


After evaluating several commercial electronic health record softwares, the clinic went with Integrimed Inc., an Atlanta-based company that hosted eClinicalWorks’ EHR Software as a Service (SaaS) offering. One reason the clinic went with SaaS was to minimize up-front costs, Martin said. Money was tight: In addition to the new second office, the group was opening an endoscopy center.


Atlanta South Gastroenterology is way ahead of most small to medium-sized medical practices, according to Wes Rishel, a vice president at research firm Gartner Inc. “The vast majority of outpatient medicine is provided by practices of five physicians or less, less than 10% of which have EHR systems.”


According to a survey of 1,000 physicians published in June by speech recognition vendor Nuance Communications Inc., 23% of respondents had no electronic health record system, and of those, 44% did not know when they would deploy one.


In addition, 78% of respondents to the Nuance study were either concerned or very concerned about the cost of implementing electronic health records; 90% concerned or very concerned about usability of such systems; and 78% had concerns about the learning curve.


A hosted EHR service is a viable option for small to medium-sized practices that can’t afford the up-front capital costs and have no in-house IT department, said Gartner’s Rishel. Many smaller practices “don’t even have a doctor who understands bread-and-butter things like getting backups done,” he added. With an application service provider (ASP), “Your likelihood of getting operations right is greatly enhanced, because most of the IT stuff is off your plate.”


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Health care technical decision makers should bear in mind, however, that SaaS-based EHR solutions aren’t necessarily cheaper than in-house systems over the long haul, and that cost models vary widely. Just ask Jody Newman, EMR coordinator at Dream Center Clinic (DCC).


Based in North Charleston, S.C., DCC is an all-volunteer clinic offering free, nonemergency medical care to uninsured, poverty-level patients. It has almost 400 volunteers, including 28 doctors, 521 nurses, 12 Hispanic interpreters and 20 data entry specialists. Doctors come in when they can, which means a patient rarely sees the same doctor twice in succession. “And all the doctors have bad handwriting,” Newman said.


The clinic, which opened in January, needed an electronic health record software that would enable medical practitioners to have full and immediate access to a patient’s profile, treatment history and Subjective-Objective Assessment Plan notes that other physicians had made on previous visits, Newman said.


Having determined that a Software as a Service model would work best for the clinic’s needs and budget, Newton went shopping -- only to discover that several providers’ cost models were budget breakers.


EClinicalWorks’ software was “robust, full-featured and visually appealing,” Newman said. However, the vendor charged $750 per day for mandatory on-site, 10-day training and installation. AdvancedMD Software Inc.’s offering, based on Microsoft Office, also seemed robust, but the company wanted a $2,000-plus setup fee, plus a $685 monthly charge per computer: “And we have 12 computers,” Newton said.


Newman’s ultimate choice, Practice Fusion, is free, funded by advertising. “There’s no licensing, hosting or maintenance fees, and nothing to install,” she said. Companies can opt to skip the ads and pay a $100 per-month charge.


Most importantly, Practice Fusion has met all of the clinic’s electronic health record needs, and then some. Since it was installed at Dream Center Clinic early this year, Practice Fusion has logged 1,603 active patients and 3,657 patient visits, with no significant problems, Newman said. “We would have gone with them even if they’d charged us.”


Among the basic criteria that health care providers should consider when shopping for an electronic health record software provider are the following:


         Application portfolio: SaaS providers like eClinicalWorks and Practice Fusion manage electronic health records as part of an integrated suite that also includes practice management and back office functions like billing, prescription management and insurance claim management.


         Flexibility: The vendor should provide templates and data entry forms that can be customized to the needs and specifications of different medical specialties, as well as to the preferences and routines of a given organization. Dream Center Clinic now has four custom schedules: a primary one for the overall clinic, one for pediatrics, one for chiropractics and one for emergency medical technicians.


         Certification: Does the provider guarantee that physicians using its EHR software will qualify for Meaningful Use before the government starts handing out HITECH incentives in January 2011?


         Usability: Is the user interface intuitive? Are login and data entry procedures simple and fast? Can physicians with minimal technical training get up to speed quickly? How much up-front training is required, and how much does it cost?


         Infrastructure: Is the provider’s data center infrastructure sufficiently reliable, regularly backed up and secured according to HIPAA regulations? Is the hardware and software regularly upgraded to the latest versions?


         Security: How granular is access control? Can the provider incorporate patient preferences as to who gets to see which records? To prevent fraud and for identification, Newman insisted that a photo of the patient be included on the initial profile screen.


         Support: Does the vendor’s help desk answer calls 24/7/365? When response time deteriorates, does the vendor work with you or say, “That’s your problem?” Typically, a service provider will take care of running and maintaining the actual EHR system, database and infrastructure, while the customer remains responsible for all the on-site business computing equipment and software, as well as the high-speed connection to the ASP’s data center.


For a small clinic in which doctors and personnel have neither the expertise nor the time to keep up with technology, this generally means hiring an independent IT contractor.


Atlanta South Gastroenterology pays Mike Danford, president of SereniTech Business Systems, to come in two to five hours a week. Danford does a lot more than just maintain office equipment and make sure everything is running smoothly. He initially rewired the clinic’s network and replaced some switches to deal with response time problems. He also suggested moving the clinic to a different eClinicalWorks data center that had less traffic. He has helped the clinic fine tune its forms and templates, and also acts as a tech-savvy liaison communicating the clinic’s needs to the ASP, “ensuring the practice leverages all of the service’s capabilities,” he said.


Dream Center Clinic found a volunteer with IT experience to handle day-to-day maintenance of in-house systems and the network connection to Practice Fusion’s host, Newman said.


         Up-front and ongoing costs. Does the provider charge a monthly fee by computer, by “provider” (which could be an office or a specialty) or something else?


One unavoidable cost is a high-speed DSL connection that can handle high-volume, often graphics-intensive traffic traveling to and from the ASP’s data center. Ensuring adequate and consistent response time requires a 768 Kbps, business-class DSL line at a minimum, said Girish Kumar Navani, CEO of eClinicalWorks, which offers both SaaS and on-premise solutions. For smaller clinics, that can be a heavy cost burden.


Indeed, health care decision makers should be aware that the SaaS model isn’t necessarily a cost saver compared with hosting an EHR system in-house, especially over the long run. While the initial outlay for an ASP service is significantly lower, the monthly charges tend to add up. The break-even point with internally hosted software is typically three to four years, said Navani.


Cost-justifying electronic health records can be difficult, given that many health care practitioners are still uncertain of its ultimate paybacks. Sixty-four percent of respondents to the Nuance survey agreed or strongly agreed that electronic health records improve the quality of their patient notes. However, only 34% agreed or strongly agreed that it improves the speed of documenting a patient encounter; 48% of respondents agreed or strongly agreed that EHR improves quality of care, and 27% were neutral.


Still, by lowering the initial entry cost barrier, SaaS offerings can help push “even the smallest practices to do some kind of EHR, or at least electronic document management,” Gartner’s Rishel said. This is important, given that EHR looks like it will become less an option than a mandate during the next few years. Not only the Obama administration, but also hospitals and regional health networks are providing financial incentives to get medical practitioners on board with EHR. And over the long term, there will be penalties for organizations that fail to comply, Rishel said.


It will still be a slow process: Gartner expects 20% of physicians in small practices will be using EHR by 2013. This is a long way from President Barack Obama’s prediction that 100% of physicians will be using EHR by 2014, Rishel said. “But there’s a tipping point with any trend like this, and at least we’ll be 20% closer.”


Elisabeth Horwitt is a contributing writer based in Waban, Mass. Write to her at

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