Web EMR Selection is Hard?

I fully understand and know how hard it can be, given that Web-based EMR is not just another way of ‘clinical note taking’ as some people call it, but it is a paradigm shift for practices. I call it a paradigm shift because it changes almost everything that you do in your practice. It affects not only you but the entire staff.
There are several things that I urge Physicians to do.
  • Don’t make a decision in isolation, involve your staff, get their full buy-in and commitment, and not just because the ‘boss’ wants it.
  • Look at the impact on the entire practice – the workflow, productivity (loss or gain), and also the impact over time. How does the ‘curve’ look? How long will you ‘hurt’ before it starts yielding the benefits?
  • Don’t just look at the ‘features’ – I know. Most good systems have all the features. It is about the implementation, the support, the productivity.
Before I show the system, I try to understand your practice, and your workflow and then try to ‘map’ it to see how it may work in your practice. If it is not a good fit, I will tell you upfront. It would not make sense to ‘fit a square peg in a round hole’.

Simplicity of EHR

Must the EHR operating instructions be so complicated?


Segmenting and dissecting implementation and product operating instructions in isolation is not appropriate. It all starts with product design, which you alluded to in the beginning. The easier and simpler the product, the more difficult it is to design and build on the backend. Ask any engineer and software designer. Ask Apple. But, once you design a truly simple product, simplicity in operating instruction and therefore implementation is an extension of that philosophy.

Stage 2 Meaningful Use – Most Asked Question

The most confusing element of the Stage 2 Meaningful Use Final Rule has to do with a ‘mandatory’ requirement for patients to access their records online.
In stage 1, the objective was the following:

Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, and medication allergies), upon request.

The key here is ‘upon request’. In my experience, I have not a single instance where patients have requested an electronic copy of their health information.

Stage 2 objective now states the following:

Provide patients the ability to view online, download, and transmit their health information within four business days of the information being
available to the EP.

If you notice here, the words ‘upon request’ have been eliminated. Let’s examine and dissect what the Stage 2 Measure states. The measure is split into two parts:

  1. More than 50% of all unique patients seen by the EP during the EHR reporting period are provided timely (available to the patient within 4 business days after the information is available to the EP) online access to their health information.
  2. More than 5% of all unique patients seen by the EP during the EHR reporting period (or their authorized 4 representatives) view, download, or transmit to a third party their health information.

This Measure will be left to individual interpretation by both the certifying authority as well as the EHR Vendor. Every vendor has a unique way of presenting information and the implementation will vary. It will be easiest for vendors that have an integrated Patient Portal system. This way, the entire measure can be ‘automated’ without requiring the provider to do anything at all.

The second part of this measure will be tricky. How do you require and ensure that at least 5% of patients view, download, or transmit to a third-party their health information? What if your patient population does not have online access? Who can be defined as a ‘third party’?

The first bit of clarification may come from the certifying authorities. In any case, seek clarification from your vendor.

Solo Physician Practice is Dead? Web EMR Inquiries are Up! Go Figure

I just read this headline today “Recruiting Firm Says Solo Physician Practice is Dead”. I’m not sure if I agree. Read this article here.
The reason why I don’t agree is very simple.

  1. Inquiries from Solo Physician Practices looking for Web-based EMR systems are up. If what this report says is true, why would solo practices want to invest in new technologies?
  2. Inquiries from Physicians starting New Practices and looking for Web-based EMR are also up.

I was actually surprised when I analyzed some data of incoming inquiries for web-based EMR systems and tried to figure out how many of them were from solo practices and how many were actually starting new solo practices. It has actually been up in the last two years.

While I think there may be a trend, American Entrepreneurship is not dead, in spite of what is going on in the healthcare world.

EHR Meaningful Use Audits

CMS has hired a CPA Company, Figliozzi & Company out of Garden City, NY, to perform audits of providers that have attested to having achieved EHR meaningful use under ARRA.
Those providers ‘chosen’ for audit will receive a letter from the contractor. The letter will have the CMS logo on the letterhead.

CMS has posted audit guidelines on its website.

Who can be audited? I don’t think there is a way to determine who may be audited. There is no legacy data or history to come up with a pattern. If you receive an audit letter, there are just a few things you may need to provide.

  1. You would be asked to provide proof that you have purchased and are still in possession of (or access to, in the case of a web-based EHR) an ONC-certified EHR system.
  2. Second, prove that the data you reported for core and menu set measures were generated from this system. So, in other words, you really used the certified EHR system to generate data for reports, and therefore you used the system in a ‘meaningful way’. This should be easy to do if your system generates the report for you. You should also be able to generate the same report again if required by plugging in the attestation time period you originally selected.
  3. There were some items that were a yes/no attestation, based on what the EHR system is capable of, for example, ‘implement drug-drug and drug-allergy interaction checks, or ‘Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities’, i.e. Security risk analysis. I am not sure if you will be required to submit proof of this, because this capability is something that is intrinsic to the Certified EHR system you selected. So, even if asked, you would have to get the auditors in touch with the vendor.
  4. Finally, will they do site visits? I honestly doubt it. I think since Attestation was an honor system, they are probably just looking for major defaulters, or identify general failures with some key requirements.

I would like to hear from anyone who has received such a letter.

Upside Down Evaluation of EMR

Three questions a physician asked me yesterday.

  1. How can I save money?
  2. What can I do to NOT slow down?
  3. Yellow Pages is now Dead. What should I do So that patients find me?

All of this was in the context of EMR. What caught my attention immediately was that he was not focusing on ‘features’ and ‘tech’ talk but on real issues related to running the business of medical practice. If you look at these questions again, it tells you one major thing. Focus!

  1. Address the main Business issues and concerns first. Not just your business afflictions or ‘pain points’ but also your ‘Aspirations’. This includes all the questions the doctor asked me that may be applicable to your situation, and more.
  2. Only after You’ve written your questions and business concerns, then you start drilling down to level-2 questions such as -what technology?
  3. Level-2 questions would include – Web-based EMR? Cloud EMR? Client Server? Windows or Apple? Mobile?
  4. Finally, the features, user interface, accessibility, and so on.

As you start making a list of each of these four levels, make sure it Connects with the level above.
Unfortunately, most providers (and even vendors) start in the reverse order and try to ‘retrofit’. This is a recipe for disaster and failure. This is why by various estimates 70-80% of EMR implementations fail.
In another blog, hopefully, soon, I will try to list out sample questions for each of these 4 Focus levels.


Why are you a Physician?
Most of the doctors don’t think of this question anymore unless you just graduated. You don’t think about why you chose the medical profession. It has probably been your life for a long time, but if you had to think about it, I would venture to guess that it had to do with joining (as a human being) a unique profession which is given by our society great responsibilities and challenges at the same time. You have been entrusted lives of others in your own hands.

You are different from an airline pilot that is also responsible for the lives of many but that also includes their own. When you save a life it is not because doing so saves your own life.

There is more to being a doctor than society’s approval. There is a genuine good feeling from doing good. There is a sense of fulfillment.

Then of course, there is the comfort in doing all this that you are being financially well compensated and assuming you have the time to enjoy the fruits of your labor, you can ‘own’ the best things that the material world has to offer.

If your motive was altruistic, that’s fantastic, but then WHY are you in your OWN Practice? WHY not just work for a hospital or large group?

Your human need to be helpful to society is fulfilled, and you start looking at the financial side of things. You start looking at who you are as a person. You enjoy the freedom; both personal and financial, of being in charge of your own destiny. You like being your own boss. Being in your own Practice, and being in your own Business affords you all of that, and hopefully more.

Time flies, and you quickly find out grass is not as green as it looked. Being in business has its own set of challenges. Ranging from managing human resources, paying bills, and balancing books to decreasing reimbursements from payors. Compound that with the fact that you seem to have ‘lost’ your life. Look at the first WHY – Why you chose the medical profession. You are probably still dedicated to your patients, but then you have sacrificed something along the way. You no longer have a ‘life’ or freedom to pursue your other dreams, your hobbies, and spend quality time with your family.

You embark on a Mission to Save Yourself.


You’ve worked hard to become a Doctor. You’ve worked hard to establish yourself in the community and sharpen your skills. Your patients like you, and your peers respect you. Employees adore you (hopefully!). Your family respects you, but you need their love, not respect. You need time for yourself, and your family and do things that you promised yourself you’d do someday.

In the meantime, the world of Healthcare is turning upside down. CMS is pressuring you to go ‘digital’.


The general consensus is that it will, over time, improve patient care, reduce costs, and make healthcare more affordable for the overall population. But what about you – the Provider? They didn’t ask you, did they? Anyway, you decide to jump onto the bandwagon.


Because if you don’t, you’ll be outdated, your reimbursements will be cut and you will miss out on the attractive ‘EHR Incentives’ that CMS is giving out – a nifty $44,000 worth (for Medicare). Then you convince yourself, we’re being forced to do it, so hey, why not take advantage of it?

Wait a minute – the WHY became WHY NOT.

Along the way, you lost something. You lost the purpose. You lost the vision. Go back and read the first two WHYs. Do you see what I am saying? Honestly, it is okay to go Digital. But for God’s sake, don’t do it for the wrong reason. Don’t do it as WHY NOT. Do it for the real reason.

“Do it because you want to reclaim your life.”


EHR or EMR or whatever the hotshot consultants decide to call it needs to be recognized for what it is; just a tool. Before you buy or acquire anything, don’t forget to ask WHY. Then connect that WHY to the first WHY and the second WHY.

WHY should I buy an EMR? Will it improve my quality of life? Will it give me myself back? Will it put quality into my life again? If not, don’t get it. Because by getting it, you’re just going to make things worse. It will be one more ‘master’ to which you have to answer and bow down every day.

Seek out tools, technologies, and widgets, that give you the Real answer to your WHY. Is there such a thing or are we dreaming of Utopia?

I believe there is. It is perhaps disguised under a cloak of some lame name. Perhaps there is an ‘Apple’ out there. Even Apple has to call their cool stuff – guess what – computers, and smartphones. But, it is not ‘just’ a computer, is it? So, there are such hidden gems out there that will give you your life back. They may be hiding behind the ‘EMR’ curtain. Seek them out.


When you ask for a ‘demonstration’, seek to answer the WHYs. Your WHYs. Don’t fall for the trap of Can it do this, can it do that?

Let’s seek out these hidden WHY-Busters together.

Fear and Risk of EMR Implementation

This is another story of a conversation I had yesterday with a two-provider clinic that is considering a web-based EMR (Cloud EMR or SaaS EMR, whatever you want to call it).
The Providers are all excited, and gung-ho about getting started. They’ve done their homework. Started off with an on-site demonstration, and talked to some of the vendor’s clients in detail, probing them with everything from ‘Are you happy’ down to the nitty gritty. They even visited the Vendor company to get a feel for who’s behind the company and talked to the CEO as well as their support and training personnel. Finally sat down to negotiate the price.

Oh, by the way, they did the right thing. Initially, they did not ask, ‘How much’? They wanted to know if the solution was within their range and affordable, rather than asking for a full quote upfront. That’s the way it should be. You are not buying candy or commodities. This is a complex solution that will change the way a Medical Practice does business forever. How can you just buy on price? If so, why not just have ‘shopping carts’ for EMR – one of this and one of that? Pardon my anger and frustration, but some providers just don’t get it.

Anyway, I digress…

In a casual conversation with their staff, initially, no one spoke in front of one of the owner providers. Someone casually mentioned – ‘Dr. is excited, I’m not sure about us’. That broke the ice.

We had a very candid conversation to bring out what the fear really was about. Everyone had their concerns, and as I listened, it became clear that this was not unusual at all. I think this kind of fear exists everywhere, it is just that most people don’t express it. Here’s what I heard in a nutshell –

  •  Biller – I’m just afraid about the entire migration. Will something get dropped in the process? I will have to work with two systems in parallel for a long time, I don’t know how long… when do I know when to transition entirely?
  • Office Administrator – What do I do with paper charts? Doc is not very tech-savvy, I am afraid this will just create chaos. Something will be on paper, some on the computer, and will we scramble to find what is where?
  • Front desk and other staff – Just the usual fear of the unknown.

It was interesting that at the end of the meeting, everyone was looking forward to going electronic.


It is always the fear of the unknown. Bringing out the issues and fears in the open, addressing them head-on, is half the battle won.

The key is for all Practices, their EHR / EMR champions to hold such meetings and bring out issues in the open. Hold these meetings with vendors, and consultants so that it does not appear one-sided.

It is extremely crucial to have a complete buy-in from all involved, otherwise, you will not have a great implementation.

In summary, EMR Implementation success is about communication more than anything else.

What’s Wrong with This Cloud EMR Picture?

I spent half an hour with a Physician last evening who is starting a brand new practice. At his previous ‘group’ practice, they used eClinicalworks. He was quite happy with it in the sense that he knew it inside out, he had been using it for many years, and so was his new staff.
eCW had even offered him a very reasonable price for his new practice.

But, he was ‘EMR Shopping’- why?

The answer kind of stumped me.  Here’s what he said:

He wanted a web-based EMR because he did not want to invest in servers etc. Fair. But why not eClinicalworks? He wanted a good certified system that could get him started ASAP. At the very minimum, give him access to the system so that his staff can start scheduling patients for the practice that will open in the next two weeks.

That’s it – plain and simple.

So, vendors, I know you all are busy raking up sales, but gear up, shape up, or lose sales.

Definitions of Web-Based EMR

Definitions of “Web-Based EMR”
  • SaaS EMR – Software as a Service electronic medical record (EMR).  EMR product deployed in a practice in which server(s) are owned by the service provider and hosted remotely (off-site).  The only requirement for accessing clinical data stored on the off-site server(s) is an internet connection/internet browser, regardless of the computer’s location.  The service is a multi-tenant offering.  The vendor installs EMR updates/upgrades at once and these are immediately available to all SaaS EMR vendor clients.
  • ASP EMR – EMR data is stored on the server(s) which is hosted remotely.  The clinical data stored on the server(s) is accessed through the internet browser and additional remote access software (i.e. Citrix).  Only those computers with Citrix or some other type of remote desktop/terminal service software installed can access the clinical data on remote server(s).  Data on these EMR products are not to be included in this report.  There exists the “Hybrid” EMR (a mix of both remotely-hosted and client/server EMR models) which is not to be included in this report.
  • Client/Server EMR – EMR data is stored on a server(s) that is housed and located within the walls of the physician practice.  System maintenance and updates are conducted in the office.  Data on these EMR products are not to be included in this report.