As healthcare moves further into the digital realm, having a competent electronic medical records (EMR) system becomes a necessity and not just a high-tech toy. This author discusses key attributes to look for in an EMR system, how these systems can streamline the practice and how to decide upon a particular system.
As physicians, we are not fully schooled in how to implement a process of evaluating electronic medical record (EMR) systems to make our businesses run effectively and efficiently. As computerized systems have been developed over the years, I have seen some highly effective products come into vogue and then drift into obscurity because they really did not help a DPM run a business.
With healthcare reform at our doorstep, we are all looking for that one system that will cure all of our difficulties. Accordingly, let us take a closer look at what an ideal system should provide and how to decide which system works best for you and your staff. I do not believe the perfect system exists yet. While there are systems that have many of the desired attributes, other systems have some of these attributes and charge extra for the add-ins.
The EMR system should have an intuitive interface that does not require years of cryptology training to understand. The menus should be concise and clearly direct the users to the function they need. There should be drag and drop capability for inputting and changing information. 
The system should offer preloaded information such as drop-down zip codes so one does not have to enter the city. Staff should not have to continuously re-enter all of the same information as “cut and paste” or “drag and drop” must be available for all fields. Physician names/addresses, physical therapy and radiology labs all should be preloaded to eliminate inputting repetitive information.
Optical character recognition (OCR) is helpful to process insurance cards and driver’s licenses. The system should have an OCR engine that can pull the information into the proper fields. Then the staff only needs to proof the information and store scanned images and patient photos.
The EMR program should have the ability to access a central server of health information such as Google Health or any number of online services that are developing to maintain patient health information. Having this capability will potentially provide a bonus percentage from CMS. (Greenway or Noteworthy software have this capability).
The system should have the capability of inputting information by typing, writing, speech or even by scanning in a written note. Each doctor has his or her preference and a setup that allows this type of flexibility is very important.
One should be able to allow macros, pre-written paragraphs that one can call up by key combination or certain speech commands. The system should also have templates, whole notes pre-written with spaces one can fill in to personalize the note.
The charting system needs to be intuitive as well. One must be able to create a solid note that fulfills all of the legal and insurance requirements. This means that you fully document all of the aspects of an encounter to cover requirements of evaluation and management (E&M) coding. A solid charting system also ensures that you have covered all aspects of consent and documentation when it comes to discussing potential risks and complications.
The EMR program should permit the physician or staff to review past medical history with each encounter. This way, you can easily see past diagnostic testing and treatments as well as what you might be considering for the next visit.
You should be able to visualize medications and allergies easily. The EMR system should track the progress or lack of progress of your treatment plan. The ability to link seamlessly from your note to labs and imaging is a significant plus as is the ability to order imaging and lab tests directly from your note. 
When it comes to writing a prescription, the system should include drop-down menus or auto-completing boxes. As you type the generic or trade name of medications, the computer displays the choices with dosing alternatives as well as drug interactions. Staff should also not have to re-enter pharmacy information. The computer will electronically submit the prescription to the pharmacy that the patient identified at check-in.
When one prescribes physical therapy, the system prompts for input regarding frequency, duration, goals and prescribed modalities.
When prescribing durable medical equipment (DME), the system prompts for all requirements to fulfill insurance documentation. It also prompts for invoices or a scanned copy of the invoice.
Another key is the availability of an online portal for patients. This allows patients to:
• input their past medical history, chief complaint and medications;
• pay their bills;
• message the office;
• change their appointments; and
• request prescription refills.
Home instructions are available on the online portal and a link is printed on the instructions that patients receive at the check-out desk.
The recall system is available to run at specified intervals so the staff can call, write or e-mail patient reminders to come in or follow up. A to-do reminder system for doctors and staff can help track at-risk patients, post-op patients and orthotic follow-up.
This system should be capable of sending birthday and holiday cards if you are so inclined to send them. The system can also send out newsletters to patients and integrate with the telephone or postcard reminder system.
With the EMR program, one can send a referral letter to the patient’s primary care and referring physician with a cover letter via e-mail or fax.
The system integrates with other entities including imaging centers, hospitals and labs that you work with. This integration should be bi-directional, meaning one can place orders to the system and receive reports back once the testing is complete.
The CPT, ICD-9 codes or descriptions should open as you start to type the code or description. It is important to have drop-down CPT coding while you are documenting your treatment plan and ICD-9 diagnostic codes as you complete your assessment. This coding automatically goes into the billing portion of the EMR for claims to be automatically transmitted electronically.
The system should provide a suggestion for appropriate modifiers if necessary to avoid rejected claims. It should also suggest appropriate bullet points to fulfill the needs of E&M and/or procedure codes. For example, if one notes an ulcer debridement code in the chart, the system should prompt for the dimensions of ulcer, drainage, odor and wound type classification.
The reporting portion of the program should be able to provide reports based on CPT codes or ICD-9 diagnosis to evaluate treatment outcomes and provide documentation for credentialing. The system should be upgradeable to the new ICD-10 codes with a tentative implementation date of October 2010. The system needs to be certified by the Certification Commission for Healthcare Information Technology (CCHIT) or other agency deemed to be qualified by the Centers for Medicare and Medicaid Services (CMS) to qualify for incentive pay and reimbursement.
The system needs to have full integration with the medical record portion in order to facilitate the coding captured during the patient encounter. This will facilitate immediate submission to the clearinghouse and speed up payment for your services. It is helpful if the EMR automatically adds the G code to billing so the practice gets credit for electronic submission and receives the 2 percent Medicare bonus.
When the practice submits billing claims to an insurance company, the EMR set-up should be able to receive an electronic remittance and automatically post payments to the patients’ accounts. This only requires the staff to review that the system has posted the payments correctly and the practice has received correct payment. Staff should have the ability to pull up a patient account and send out statements.
Electronic medical records should automatically check that payments occur according to the established fee schedule and the practice receives correct payment. If not, the system should flag the transaction for staff to investigate the under- or overpayment. The system should also prompt and automatically electronically bill any secondary payors listed on the patient’s account.
The frequency of billing should be flexible with the capability of sending out bills daily or weekly. The more frequently you send out bills, the better your cash flow. Each day, invoices go out for any patients who came in and did not pay the co-pay or have an outstanding balance.
The system should allow billing notes on each patient, when staff submitted and resubmitted the claim, and any additional documentation included. It should keep track of when the practice contacted the patient about the outstanding balance, when staff called the insurance company and to whom the staff person spoke. Document the outcome of the conversation and the date of the next follow-up.
The system should send collection letters to the patient with different letters based on how long the balance is outstanding. A better method would be automated reminders to staff via internal messaging.
The computer should allow one to send or fax notes electronically, including scanned documents to requestors such as insurance carriers, workers compensation reviewers and attorneys. The system should record the time and date that staff sent the notes, who requested the notes and to whom the staff sent the notes.
The system should allow scanning on non-electronic explanation of benefits (EOB) to each patient’s record. The goal is to improve the ability to retrieve and send out EOBs if requested, and also to eliminate clutter in the office.
The EMR program’s business reports should include a daily report on office production, charges and income, as well as a daily bank deposit report. The daily “dashboard” report should show accounts receivable totals for all insurance companies and patients for 30, 60 and 90 days. This report should track the number of both new and follow-up patients tracked per day, per week, per month and per year. The dashboard report should also list average income and charges calculated per patient per day.
Monthly reports are very similar to dashboard reports with additional details. These reports can be sorted by doctor and location. The report should list accounts receivable by insurance company and patient. The system should also keep monthly tabs on income averages and charges per patient.
Presenting the above information in a graphical format is very important. It gives the doctors a quick overview of the health of the practice. If data is present for a comparison of previous years, the system should generate reports to evaluate the year over year production of the practice.
Bring your staff into the process of choosing a system. First, figure out what you can afford. (At this stage, do not necessarily add into the equation the potential revenue that the system could save or generate.) Set an amount that is comfortable for you. Just like buying a car, buy what you can afford but consider the potential of improving the efficiency of your practice by automating many of your repetitive tasks.
As far as the type of EMR server, consider the two models available: application service provider (ASP) or an on-site server.
ASP model. With this model, the practice pays the software company a monthly fee. The software company maintains the server at a distant location to which the practice connects via the Internet. The practice needs to have a fast Internet connection such as T1 line, fiber optic, cable or digital subscriber line (DSL).
With this type of setup, the advantages include: a low entry cost (typically one month upfront); training cost for your staff; and any terminals/laptops you will need for the treatment rooms and front desk. The system is offsite and offers a secure backup. This keeps the records safe should there be a disaster at your office. There is typically no maintenance fee or upgrade fees. You can access the system anywhere in the world that has an Internet connection.
You may be able to negotiate a long-term contract to ensure the stability of the monthly cost. If you opt to switch to another EMR company, it is possible to convert data to a new system. However, this usually proves to be a very difficult and expensive process. You can get a copy of your data but it may be useless if you do not have the software to read it.
There are some disadvantages with the ASP model. If the Internet connection goes down, your server access in many cases will not work. In these situations, some systems, such as eClinical Works, will allow your staff to continue to work but with limited functionality. For example, you can write a note or make a tentative appointment but none will be confirmed until the system reconnects with the server. The monthly fee for ASP type set-ups ranges from $400 to $800 per month per doctor.
On-site server. For larger practices, an on-site server may make more sense. For several smaller practices that want to share a server and use the same software, this may be a great option.
Upfront costs are higher. Maintenance is required for equipment, the server software and the server operating system. Maintenance includes ensuring backups, virus protection, licensing the software and yearly maintenance of the software. These all have recurring costs plus the time to do the maintenance and upgrades. You can rent space at a server farm such as Rack Space. That way, the server is offsite and for a monthly fee, professional technicians maintain the server and provide protected backups.
The choice is personal. Some practitioners prefer having total control and being able to know the server and data are in their possession. Personally, I am in favor of the ASP model for safety and lower upfront expenses for the small solo practitioner or small group. For larger groups, the cost may be spread out and it may make more sense to bring everything in house.
After deciding on the type of server, first make sure the prospective EMR model is certified by the CCHIT or another agency deemed appropriate by CMS. Then ask a successful, well managed practice what system that practice is using. Ask the staff if they are happy with the system. Ask if they would change the setup if they could and which setup they would switch to.
Seek out online product reviews and read the blogs about each product. Check out customer service complaints and ask for references in your specialty. Ask for the names of practices that may have abandoned their product if that information is available. Look for testimonials and call the people giving testimonials to ask if they still feel the same way and what they would do differently.
Go see the product in use at a local practice. Send your staff to talk with that practice’s staff. Usually you will find out from staff if there are any problems, which the doctors may not share as easily.
Go to a Web site such as www.ehrscope.com  to see a listing of most EMR systems available. There are several hundred of these systems.
Personally, I like the idea of going with a market leader. For example, a podiatry specific system is Dox EMR (Dox Podiatry). More generic systems are Medisoft and Medinotes, just to name a couple. For specialty non-specific programs, look at Centricity (General Electric Healthcare), eClinicalWorks and MedInformatix (DavLong Business Solutions), Noteworthy and/or Greenway. These are just a few well-known market leaders. Additionally, there are several low cost systems available such as Amazing Charts or even free systems.
The process I have used to make my decision is first to ask for references. I then ask the hospital medical staff office if the hospital system is sponsoring any EMR systems as they may be offering a large group discount. Check with your state medical society or state tech consult as they also may have one or two systems that they are sponsoring or offering at a lower cost.
Then draw up a list of eight systems that you have heard about that the hospital or state tech council has offered you. Review one or two products every week and have each staff member write down the pros and cons of each system.
After reviewing all eight systems, narrow it down to the best three systems and have a demo day for the three remaining systems. Again write down the pros and cons of each system. Call each vendor and ask about your concerns. Talk to more references and ask for a final quote with the bells and whistles that you will use — the ones you really need. Make sure the vendor provides all of the costs of training, setup conversion and implementation schedule.
Review the essential features and features that would be on your wish list. Do not accept any features that may be coming in a few months. Consider those to be “vaporware” (nonexistent until implemented).
Now make the decision based on budget, the service provided, a demonstration of systems, reviewing the references and an impression of the onsite visit. Check the company’s financials. Is the company solvent? Will it be in business in five to 10 years? How many installations does the company have? Check that the company is really certified. Talk with your staff and make sure they are comfortable with your decision. Most importantly, take your time as it is a big investment so make sure you are going to be happy with this system for at least five years.
When implementing the system, should you attempt to convert present systems into new system? I do not advise this. It is costly and it is better to run the old system down and start the new system from scratch as there is less chance of errors or picking up corrupt data.
If you know when your patient flow is the slowest, that is the time I recommend implementing the new system. I have found the best way to keep up production and minimize disruption is to take your schedule one day at a time. Hire data entry people and have them enter all the data for the next day’s work. If the system does have OCR, tell patients to come in 20 minutes earlier so you can gather their information. If the system has an online portal and it allows the patients to enter their own data, invite the patients to enter their information into your new high-tech system.
It is possible that your production may be off by 20 to 30 percent in the first few weeks but the price will be worthwhile in the long run of increased efficiency and hopefully improved cash collections and lower accounts receivable.
Dr. Werber is in private practice in Mesa, Ariz. He is the Director of Clinical Education at Midwestern University in Glendale, Ariz. Dr. Werber is a Fellow and Past President of the American College of Foot and Ankle Surgeons.