Managing Your Practice

Small Practices Selecting EHR


When Dr. Maggie Blackburn decided to move in 2000 from a hospital clinic to a new solo practice in Stanford, a rural upstate New York town, she had a strong adversity to lining the walls of her already cramped office with paper charts. After test-driving several systems, she spent an estimated $23,000 on software and hardware, and her practice was up and running with a staff of two (a nurse and a front desk assistant). Although the options in electronic medical record systems are a lot different today than they were 7 years ago, Dr. Blackburn's advice still is sage straight talk from a family physician who didn't know what a network server was when she started. In this month's column, she shares her insights about the choices and compromises she made in making an EHR system work for her.

If you're in a small or solo practice and you're looking for an electronic health record system, congratulations. Although you may not have much capital, there are fewer people to please, which makes defining your priorities a lot easier. That said, anyone looking to invest in an EHR system should know two things: First, don't expect the system to run smoothly all the time—it will break down and there will be glitches. And second, it won't pay for itself.

Like buying a house, the financial outlay is ongoing (service contracts for tech support cost me $4,000-$5,000 annually and then there are hardware upgrades). But the investment will pay for itself in terms of enhancing your quality of life. The time you save by not having to do repetitive tasks and the workflow enhancements are priceless, especially to someone who would rather head home at the end of the day than be chained to an office desk finishing chart notes.

There are conveniences that feel like windfalls: When Vioxx was taken off the market in 2004, we had a letter written and addressed to all of our patients who were taking the cyclooxygenase-2 within 15 minutes to advise them about the matter.

And then there is the undeniable ease with which one can participate in clinical trials. Identifying all diabetes patients and tracking HbA1c levels, or any other quality measure, is almost effortless.

However, selecting the most appropriate system for your practice takes thoughtful research. Prioritize your wish list and then realize that it's likely to change. When I set out to purchase a system, options such as messaging and customizable fields didn't seem very important, but in retrospect, they have made a huge difference. The messaging component has enhanced interoffice communication in unanticipated ways, and having customizable fields has helped make the system interface feel comfortable.

Most physicians want their system to work smoothly right out of the box. But that's not realistic. A common complaint among physicians with new systems is that entering patient information takes more time with EHR than it does with a paper chart. Being able to customize templates myself—and change data entry options as I used the system—has made it much easier to iron out kinks.

The system I ended up with allowed me to finish my chart notes by the time the patient left the exam room and to have a script on the front desk awaiting my signature. My goal was to not have patient charts to catch up on at the end of the day, and having a system I could easily customize myself made that goal attainable.

Another component, having lab interface, has been a tremendous bonus. It eliminates the errors that occur when lab results need to be transcribed by hand. All lab results are downloaded from the lab directly into patient charts, and abnormal values are flagged for my review. A lab requisition component, which I added later, makes it infinitely easier to track what has been ordered and whether results are back.

When I started, I wanted the princess tech support plan, the one that allows the person who knows virtually nothing about computers to call and whine. It costs significantly more, but it's been well worth it. Tech support is an area you definitely do not want to skimp on, and good plans will require a hefty annual fee. Just make sure you check out the company claims regarding tech support by speaking with current users of the system.

Before you buy anything, shop around. Test products yourself. Sales representatives will be able to move around the system a lot faster than you can. Be explicit about needing to be able to use the system yourself. Review the templates; ask yourself if you can live with them as they are and whether the interface meets your needs. How easily can you add components later? Consider visiting a comparable medical office site that uses the software you are planning to buy.


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