EMR Getting Started

Slow Adoption Rate of EMR

2008-08-23T04:36:00Z

This is a Getting Started resources discussing the Slow Adoption Rate of EMR.

This discussion between Robert Gleeman and Mark Anderson, CEO of the AC Group, Inc. discusses the slow adoption rate of EMR and delves into some of the reasons behind why Doctors are not using EMR as actively as they could. This interview is also provided as a written transcription below. Click the arrow to play:

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Robert Gleeman: This is Bob Gleeman with Mark Anderson from the AC group on Casual Friday. Mark, we had talked a little bit about why more people haven't adopted EMR. You had a study that you mentioned that said something like 4% of doctors are using EMR?

Mark: Correct, there was a study that just came out of the "New England Journal of Medicine" that actually went out and surveyed a number of physicians to find out what their EMR usage was.

They determined that about 17% of the doctors have purchased an EMR but only 4% of them were actually using the EMR in the full capacity, for actually recording, review systems, HPI, their evaluation, and actually generating a chart note out of it. 13% were using parts of the product.

After 20 years, we only got 4% of the doctors using an EMR, there's a big question out there about how valuable these systems are.

Robert: Well first of all, do you agree with that figure, does that jive with what you've been seeing in the field as a consultant?

Mark: Actually it does, we thought the number was closer to 7% of the doctors are actually using the full EMR. We do a lot of surveys and talk to a lot of reference sites when we're looking for vendors. A lot of references sites said: yes we had the EMR, we really like it, and our doctors are still dictating.

They classified that as a full EMR implementation. Which is OK, but the goal of all of this is to have a full EMR where the EMR generates the note, does the E &M coding. We're actually creating discrete data out of everything. We're finding reality is a lot of doctors not using all of that and not using the full capabilities of this EMRs. Now the question why are they not doing it?

Robert: Why do you think that is?

Mark: I think when you sit down with the physicians, we finished a new survey that shows that the average doctor spends 38 seconds charting on a returned patient. About two minutes on a new patient. The question always is, can the EMR product allow the physician to chart the complete note in 38 seconds?

The answer traditionally is "no." It's going to take a lot longer than that. The doctor are saying, if it takes me any longer, I don't want to use it. That 38 seconds goes by pretty fast when you're trying to click 500 different buttons on those EMR products today.

Robert: Yes, yes. Now how about as far as the quality of the documentation. I've had doctors whose medical records about me were completely worthless. They didn't know what I was taking, what was wrong with me. Barely remembered ever seeing me and the notes did not help.

I know was not a one to one comparison, but what do you think is the solution to this dilemma? What is the cause and what is the solution?

Mark: I think part of the cause still is that we have not tied financial incentives back to using the EMRs. I know Medicare CMS has a program where they're providing a little incentive for doctors using prescribing.

There's no incentive for doing all of the charting yet. I think if we can get a system... Like an EMR light product, where the doctor can at least know with what's wrong with you. They have your problem list, they have your diagnostic codes, your allergies, your lab results.

In other words, all of that important stuff about you in the chart, and they can review that. Then maybe still dictate or hand write out their note, or place all their orders on‑line. We're going to get 60% to 70% of all the business benefits that a physician needs, with a much simpler system to use today.

Therefore, allow the doctor to not become the data entry clerk for everything, maybe start walking before you run. Until someone mandates full EMRs or starts paying the Doctors for the full EMRs, then we got to come up with something that's going to work for them. Again, CMS has it, but they're only paying for e‑prescribing right now, not for the full EMR.

Robert: What can we do at EMRUpdate to spread the word? I know what we're doing with these interviews helps a lot of people and they're discussed for years afterwards. Is there anything else EMR Update can do to further the cause of EMR?

Mark: I think we have to get doctors and the vendors really communicating on the same level. Doctors have got to really tell people what do they really want today, versus what they may want some time in the future.

The EMR vendors have to find a way to start showing them how they can use the product today. Today may be as I need to do the whole review of systems, the HPI and everything else. Today I'd like to have information about the patient, review that information, and then have the dictated report, or the handwritten report available to me electronically. I don't have to put all of that data in.

That's got to be an option out there, and literally rarely do I ever see any vendors showing that. They spend 20 minutes show a physician can spend the next 10 minutes charting of all this information, which is nice to have. Do the doctors really want to spend the time charting all that, do they need all of that data as discrete data? Are they getting paid to do all that data entry work? Those are questions [inaudible 6:03].

Robert: So you really see that as the major problem that the entry of the data is being done by the doctor.

Mark: Correct.

Robert: Would it be better if the doctor had a person like a scribe to work with them and enter into the EMR?

Mark: Yes, if the doctor had a scribe, then they could spend more time one on one with the patient. People can enter the information in. The difference is that we're entering a lot of data in there, primarily so we can make sure that we have the right E&M code put together.

But some [inaudible 6:44] review of systems, it's kind of like everything is normal, except I have a cough, so we're going to listen to the heart.

Right now we spend maybe 30, 40, 50 seconds charting all the stuff about review of system, where it could be done in about five seconds. You can't go and say that everything is normal unless you actually looked at everything.

Again these EMRs are designed to record thousands of data elements, which is nice but most of the doctors are saying: I don't need all 12,000 of those data elements recorded. Because I don't used any of that afterwards. I'm not getting paid to do all that data entry work.

So if we can get people using I think EMR lights today. Then in 2009, 2010, 2012 progress more into full EMR capability. We got to move the number of doctors that are buying these systems from 17%, which is the estimate today, to 40, 50, 60% relatively quick. If we're going to have full EMR adoption by 2012 or 2014, we're not getting anywhere if we only 4% using it today and 17% that is bought.

Let's come up with a new model that really takes care of 80% of what the doctors need today. A product then that could meet those other 20% of the requirements sometime in the future. We all agree we need to have all this information, but right now it's not working because the doctors are not using it.

Robert: You say they're not using it because they are the ones burdened with the entry of the data primarily.

Mark: Well, there's a couple things that always come up. One is it's too costly, that's why I didn't purchase it. But all of the references we called that are using these vendors' products come back and say: Well yes, we liked the product but we realized the full charting took too long, so we're not using that anymore.

The interesting part is when you talk to the vendors they all say: Oh, all of our clients are using the product or 90% of our clients are fully using the product. If that was true then why are we only at 4%, based on "The New England Journal of Medicine" that are actually using it?

The reference checks we do, we find only about 7% of the total doctors are really using these systems. Especially during that first year, it takes a long time to get your templates built and do all these kind of things.

I think we need to step back now and yes, I agree we need to have the C chit stuff to determine what we're going to need in the future. But can we buy a very strong maybe C chit application that we know is going to meet the requirements of the future? Then use parts of that, in the beginning, to get physician adoption.

Let's don't give them everything. You know, make them use everything in the beginning; let's have them use certain things. Incremental approach to the EMR I think works.

Robert: The incremental approach you have mentioned before. I think this is appealing to a lot of doctors, to start small and work your way up to make a gradual transition. As medicine always says: do things gradually, don't shock the system.

As we talk in the EMR Update, this is one of the things that comes up quite often. As you know we are primarily pro EMR, but we have a few people that are very resistant to EMR. They claim they are pro doctor and they resist.

Mark: Right.

Robert: Do you think that these three or four people that we have, very vocal on EMR Update, have any influence at all on the adoption rates of EMR?

Mark: Well, I think that they are very vocal, like you say, and things. But I agree with them a lot of times, because is this really benefiting the physician themselves? We have to go back to this. This whole EMR is about the doctors using it are they getting the benefits out of it?

Most of the benefits people talk about are going to benefit the insurance companies, it may benefit the patients. In theory it's going to improve quality. But for this specific physician, is this EMR that's going to take longer for me to use, really going to benefit me enough.

I think they do, if you start with an incremental approach. Get messaging. Maybe have orders going through. But if you're going to sit there and spend five minutes recording review of systems, HPI, your full evaluation and you never use any of that data later on, does it really benefit the physician?

Or are we all doing all this data recording just so we can get the correct ENM coding, which is a financial reimbursement system. Are we really using all this data for any purpose except to just recording for some day we may need it.

I agree, orders, problem lists, basically the data that's in the CCR and now the CDA format is the biggest value. That's why I agree with a lot of the government agencies that are looking at: let's come up with a minimum data set of information that everybody can share. Why don't we just start with that?

Why don't we just start with a minimum data set that the government has set and record all of that information? But do we really need the other 98% of the data that we need to record today? We'll need it sometime in the future, but we need to get that implementation rates got to go from 17% to 50% in a short amount of time, if we're ever going to get to a full adoption rate.

At the rate we're going right now, I think we've, what, increased what 2% in the last three years? We're never going to get there growing at that rate of increase. People are selling, but not necessarily using it a lot.

Robert: One of the topics that this seems to relate to is granularity versus text. In other words, if you take the time to check off many different points of data and increase what they call granularity, then you can use this data later and call it back. Is this what is lengthening the data entry more so than a text note?

Mark: Yes, the text note, again a text note you can dictate a lot quicker than clicking all the buttons. Clicking all the buttons gives all this granule information. The question is what is anybody doing with all of this granule information?

Is anybody actually using that to determine anything? I think it's great to have a database with all that in, it but if you're never going to use it, what's the purpose?

Robert: Well Mark I think you've stimulated some more heated discussion that will occur around this talk so I thank you very much for being with us again on Casual Friday. Mark Anderson, AC Group, thanks again, Mark.

Mark: Thank you, bye, bye.

Robert: Bye, bye.

Thanks again to Mark Anderson, AC Group for supporting our Getting Started resources for Doctors Researching EMR solutions.

For more information about the subjects discussed here you can contact Mark Anderson at the details listed below.
See our other Getting Started resources here.

Mark R. Anderson CPHIMS, FHIMSS
CEO and Healthcare IT Futurist
AC Group, Inc.
118 Lyndsey Drive
Montgomery, TX 77316
(c) 281-413-5572
(f) 832-550-2338
email: mra@acgroup.org
web: www.acgroup.org

Insider Tips for Getting Quality EMR Vendor Support

2008-08-19T02:31:00Z

by Michael Uretz, Executive Director EHR Group

As I thought about my experience over the past few years negotiating contracts with Electronic Health Records and Electronic Medical Records vendors, I kept coming back to one of the top questions posed by frustrated providers and administrators attending my seminars and workshops... "How can we guarantee we'll get timely vendor support when we need it?" For some reason, Murphy's Law ("Anything that can go wrong, will go wrong"), seems to always kick in after the system is installed, the final payment is tendered, and the practice is now dependent on the new technology. After all, you're paying a substantial percentage of your license fee every year for your support and maintenance "rights". But still, in most cases, the onus is on you to protect your own interests. I have infrequently run across a vendor that voluntarily offers to penalize themselves for poor support or that guarantees and commits to exactly how you will be taken care of. You need to become the "squeaky wheel" when you need support and a "squeaky wheel" gets better traction if you have contractual "teeth" backing you up. Thus, the concept of support clauses in your contracts or separate Service Level Agreements (SLA's)...

These agreements outline various areas of vendor accountability in which the vendor is willing to make a commitment to service and support with associated penalties. I've worked with IT contracts for almost 30 years and for some reason many EHR and EMR vendor contracts have had very "lightweight" or weak contractual clauses when it comes to customer support assurances and guarantees. Some important areas to be aware of include the following.

Hours of support.

Don't just accept such terms as support during "standard business hours". You need to have a specified range of hours. And make sure the hours are satisfactory based on local time. I've seen support clauses where an East Coast Vendor specifies 8-6 EST and the client is on the West coast. That would put the ending of a normal support day at 3pm PST. Remember, any issues that are resolved outside of normal business hours typically have an additional charge.

Problem Escalation

Whether it be your phone company or bank, have you ever gotten frustrated by the lack of knowledge or problem resolution by the immediate support person, and have asked to speak to the "manager". This is what I'm talking about. In the case of your EHR contract make sure it's the levels of escalation are specified ahead of time. These are your rights. This can also include asking that the vendor's support person come on site if the issue can't be resolved by the normal means in a reasonable timeframe.

Response and Resolution Times

How long does it take a vendor to respond to you when you have a problem? How long will it take to actually fix the problem? If your system is completely down or if this is an issue that affects patient care, will you be expected to wait 24 hours or will you get taken care of immediately. Be aware that different functions of the system might warrant different response times. For example, clinical documentation problems might need immediate attention, while a problem with a patient education module might not be as urgent. Get a commitment as to how long the vendor will guarantee a response to you. This includes associated financial penalties if they fail to meet their commitments. That's a powerful "squeaky wheel"!

Upgrading to New Versions

What about new releases of your software as time goes on? By paying your support and maintenance fee you certainly have the right to receive new releases free of charge. But, I've seen contracts where a vendor has the right to expect you to upgrade in a short timeframe or support will be reduced or even dropped until you are compliant with the new system. From a vendor's perspective, this is great because they would only need to support the newest version. However, you might not want to install the newest version right away, as the time to test and install a new version is not trivial and can possibly impact your internal resources and the operation of your practice. Also, many times, new releases can have some initial kinks. You should always expect that, at the very least, a vendor will support the previous version(s) for a reasonable amount of time.

There are more items to address in an acceptable Support clause or Service level Agreement, but hopefully the above tips will help get you thinking and pave the way to greater comfort in this area. Remember, you can choose the right vendor and get a great deal, but the key to your ultimate success is in holding your vendor accountable for the service and support you expect and deserve.

For more information about the subjects discussed here you can contact Michael Uretz by email mikeu@ehrgroup.com or 1-888 5 GET EHR

See our other Getting Started resources here.

Contact information for Mike:

Michael Uretz, Executive Director
The EHR Group
700 NW Gilman Blvd. Suite E293
Issaquah, WA 98027
Tel: +1 (425) 434-7103

E-mail: sales@ehrgroup.com
Website: www.ehrgroup.com

The Community EHR of the Future

2008-08-15T13:45:00Z

This is a Getting Started resources discussing the The Community EHR of the Future.

The speakers are Mark Anderson CEO, AC Group, Inc. and our roving reporter Robert "Bob" Gleeman.
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These are my brief notes from Mark's interview in a Yellow Cab travelling from downtown Manhatten to JFK.

Challenges is that the patient in the hospital -- Doc has to use the Hospital System which he is completely unfamiliar with. CPOE Products. Every Hospital that the Doctor goes to, he has to learn a new product - none are similar to their office EMR.

What is the Community Health Record? A new approach. Have a system where the Doc uses their usual EMR system but when they go to the Hospotal their using the same system. The Doctor doesn't have to use different systems -- all the data goes into the same system. Create one system for the Physician and easier for the ER technician, the Nurse, the Health Worker using the same data.

Timescales? Working with a think-group asking how we can roll this out to small communities. A place where they're looking to trial this is a hospital, 32 Docs, which doesn't have an existing system. Try to establish a EHR for the whole community. A Patient centric EMR for the whole community.

Are there vendors already looking at doing this? There are vendors that talk about it. There's a company called EPIC but they're not really scaleable down to the smaller hospital.

In the past we've talked about the Hospital offering the Doctor the EMR software. Is this along the same lines? Yes. The hospitals are offering a stand-alone EMR product to their employed physicians and community physicians. This goes to the next level where instead of offering an Inpatient and an Ambulatory EMR and offering one community EHR.

Who pays? Today the person that pays is the hospital -- they pick up 85% of the costs. Why? For every 20,000 ER visits we can save 1/2 million dollars per year. If the ER doctor gets all the information in a familar format, this saves the uncompensated care in the Emergency Room. A great fit.

Reimbursement. EMRupdate has quite a few posts about Medicare Reimbursement. Will this have an impact on Medicare? It is all about improvement in the Health of the Patient.

Thanks again to Mark Anderson, AC Group for supporting our Getting Started resources for Doctors Researching EMR solutions.

For more information about the subjects discussed here you can contact Mark Anderson at the details listed below.
See our other Getting Started resources here.

Add-ons for EHR and EMR

2008-07-31T08:00:00Z

This is a Getting Started resources discussing the Add-ons for EHRs and EMRs; what Add-ons do you need, should you be paying for them and do you need every add-on? What should we know about Add-ons?

The speakers are Mark Anderson CEO, AC Group, Inc. and our roving reporter Robert "Bob" Gleeman.
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These are my notes from the interview:

There are a number of additional things you might want to add on. For example, have a scanner to scan in the Insurance Card. That can be really useful.
Some of the typical EMR Add-ons are:
Clinical knoweldege base
Zinks knowledge base.
Health & Maintenance alerts.
Clinical Protocols and National Requirements; Doctor doesn't need to research and enter all that data. It's already uploaded
Probably 30 categories of add-ons.
Would the vendor raise with the Doctor?
Talk to the Vendor -- each Vendor will bring up certain things. e-Prescribing. raise a drug-to-drug database and it's worth asking what is the source for that. Who is the company -- which database. Did they build or use from a Nationaly renowned company.
What shoujld the doc have in mind to ask about an add-on.
When the Vendor raises an Add-on, the Doctor has to ask "Is this part of the Product, or is this an add-on with an additional cost?"
A lot of vendors are charging maybe $25.00 a month for access to SureScripts or Rx Hubs. They may not mention that, but it is an added costs.
Some of the products can provide for the scanning of documents; is it their product or third-party -- and if third-party what is the cost for that.
InstantMedicalHistory -- an add-on that probably 30 of the top vendors have today which allows the patient to go on-line using a computeror through a kiosk to answer the Review of Systems, HPI, Social 7 family Hiostory -- but allows the patient to enter all of this data. Sometimes comes in as discrete data. Allows patient to be part of the data-entry form. Why not give the patient the Social Medical History and how you feel today.
Direct Link to Medical Test -- either a one-way of bi-directional interface. Any time you need data from an external source. I'm want those results back to the EMR. It could be a free or add-on costs. But the biggest issue is that I want the Lab Test to go to the correct Lab Company. Remember the HealthCare plans dictate where those labs can go. I want them to come back as discrete data. And is that a one-way or a two-way, bidirectional. What's the additional cost to get that data in.
Any add-on product should be part of the cost proposal. And you need to include within your contract how they are going to work today and in the future. The contract must state who will provide the two-way interface and if it doesn't work who is going to get it fixed. Is the Doctor going to call the Lab company or will the EMR vendor get it fixed.
So the EMR Vendor will support the EMR product, but you buy all these Add-ons and the EMR Vendor can say "not my problem", but you bought the Add-on from them. That's where the Contract needs to be looked at.
You need some experience as to What works with what. Unless you know and the vendor can prove that they've integrated a specific add-on, then you want pretty specific language in your contract to make sure they're going to follow through.
Would you recommend that a Doctor visit a reference site which has that EHR and that Add-On? We're always talking about the EMR product, we're not asking about the complete solution, if you like "The Digital Medical Office of the Future".
When does your Drug database get updated, it it online. Series of additional questions that need to be asked. Very rare today that you see an EMR being sold without Add-Ons because the EMR vendor will just not have that knowledge or expertise like the ones mentioned above.
One example; I want to have a card-scan so that when I scan in the Driving License, it automatically places the picture into the EMR or PM system but also takes off the address, date of birth, sex of the patient. Have they actually done this, not that they could build an interface in the future, because a lot of times the future never actually gets here.

Is that a real product -- MediCard allows the drivers licenses to be scanned in and to pull off whatever information is on the Driving License.
IntelliFinger - TEPR conference award. Also do the credit card to pay for your co-pay. So the patient arrives and scans their finger themself with the biometric device and they're already checked into for their appointment - including a request for payment collection now or later. All these things can be done in a kiosk like format.
There are some great little products out there that are really nice add-ons that help improve the customer-satisfaction and the efficiency of a practice.

... and Mickey says hello to everybody.

Thanks again to Mark Anderson, AC Group for supporting our Getting Started resources for Doctors Researching EMR solutions.

For more information about the subjects discussed here you can contact Mark Anderson at the details listed below.
See our other Getting Started resources here.

Side by Side Comparison of EMR Costs and Price Matrix

2008-07-16T14:11:00Z

This is a Getting Started resources discussing the Side-by-Side Comparison of EMR Costs; how to really compare EMR pricing from different vendors.

We're running this interview in parallel with our call to EMR vendors to participate with our Price Comparison Matrix - we're trying to give Doctors researching EMR solutions a good starting point to compare the price of different EMR products. We reason that everyone saves time and effort if they know what an EMR Vendor's ballpark prices are. This allows the Doctor to select EMR vendors that are likely to feature on their investigation list.

Price Comparison Matrix (Excel template)

Download this Vendor Price Matrix template; fill in pricing for 1, 2 and 5 doctors; and send it back to Nick or contact Robert for any assistance adding your content; Help us build and maintain a comprehensive pricing resource for Doctors who visit this site.

You can get a sneak preview of the (draft, subject to change, didn't say it was finished) Price Comparison Matrix here. Each Vendor's Product Price includes a Blog Post entry detailing additional notes and information about that line's items. The Price Comparison Matrix can be used to compare on-screen prices from any checked price-line. A useful tool for getting a good feel and ballpark for an EMR Vendors prices. He's a demo snapshot:

On with the interview! The speakers are Mark Anderson CEO, AC Group, Inc. and our roving reporter Robert "Bob" Gleeman.
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These are my notes from the interview:

All EMR Vendors have different pricing structures & methodologies.
Pricing can be different; by Physician, by part time Physician; some include or exclude third-party software (or not even tell you that you need that component).
How widespread are prices across EMR vendors? Working with a 3-doctor practice in Georgia, two quotations came within $1,000 of each other. However when adding support, implementation, training, over a 3 year period, there was a $60k difference per physician.
You have to try and get down to an apples-to-apples comparison.
Get everything you think you need included on your quotations and then start negotiating.
Are there some Price landmark features; such as bi-directional Lap Reports? There are major differences in interface costs with different philosophies; some hospitals may charge $10-$15k, some vendors only charge a $1k.
EMR Vendors might include things such as Personal Health Record, CPT or IC9 Codes, connection to AllScripts or Rx might be included. But if you don't need these things you're paying for things you don't need.
Document Imaging can be another big difference. With some vendors this is a completely separate third-party product not included in their quotation.
Some EMR Vendors may include or exclude things -- and sometimes your EMR salesman doesn't even know what's included.
The SQL relational database can also be anoother big issue; some vendors might only require the low-cost MySQL and we've seen some Vendors asking for an unlimited SQL Server License at $6,300.
emrupdate.com are providing a Price Matrix to give a good starting position on EMR prices.
The Doctor has to know exactly what is included in the core software price. List all the options and understand what these are. Let the Doctors check-off what they want and what is not needed.
GET A CONTRACT. DO NOT BUY an EMR without one. This is really is a case of buyer-beware. You should be changing the contract and/or adding clauses to guarantee your on-going support.

Thanks again to Mark Anderson, AC Group for supporting our Getting Started resources for Doctors Researching EMR solutions.

For more information about the subjects discussed here you can contact Mark Anderson at the details listed below.
See our other Getting Started resources here.

Who should enter the data (into the EHR)

2008-07-04T10:48:00Z

This is a Getting Started resources discussing Who should enter the data into the EHR. The speakers are Mark Anderson (with the suntan) CEO, AC Group, Inc. and our Robert Gleeman (without tan). Click the play button below to play this interview.

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I noted the following points from the discussion which might give you a feel for what the discussion gets into:

With EHR we're able to move some work to the patient, the MA or the nurse. Patient can enter their own data -- previously they would usually do this on a clipboard. These days they do this on the web, or use a kiosk like a tablet machine, or bubble-sheet (OMR).
Some are using web-based Insant Medical History, almost an HPI.
The advantage of using a portal or kiosk web-based application is that new questions can be asked depending upon how some questions are answered.
Some are allowing the nurse to do RoS and HPI. When Doctor walks in a lot of data is already ready. This can cut out about 60% of the data-entry. Setup a division of labor in the recording of patient data while still keeping your existing processes. Doctor should be reviewing the data and letting someone else do the majority of the data-entry.
This works really well with templates - and they need protocols established. The adoption of EHR really does touch everyone in the clinic. The Doctors that are doing all the data-entry work are sometimes giving up if they're being asked to do too much. The successful practices have moved a lot of the work down to the MA or the nurse.
Here at emrupdate.com we have a lot of discussion about what equipment or techniques the Doctor uses in adding their part of the data. We've talked about a tablet and pen-based data-entry.
It's really down to how they want to interact with the patient.
Goal has to be that we can collect the data the Doc needs (by the patient or the nurse). Doctors can then record just the data that they require; only the data that they can enter.

(stage-left a cleaning operative malfunctions)
The Tablet as the state of the art. Do you see people leaning towards the tablet? Most are using a desktop or notebook. Most practices are not entering data in the consultation but actually back in the office. Going forward you will see a lot more tablet use.
Do you see a reduction coming in the price of tablets? You always see hardware going down in price; not much reduction in tablets, but this will eventually happen.
What is the nurse going to use? And what happens when they drop it. Do you have a number of spares available in the office. The device you use to enter the data does make a big difference. In a Doctor office last week I saw a PC mounted on the wall, a monitor on a swivel arm with a printer combined into the setup. The Doctor could print the patient chart or educational material right there in the consultation.

Thanks again to Mark Anderson, AC Group for supporting our Getting Started resources for Doctors Researching EMR solutions.

For more information about the subjects discussed here you can contact Mark Anderson at the details listed below.
See our other Getting Started resources here.

Does CCHIT really matter for a Specialty Practice?

2008-06-26T13:35:00Z

This is a Getting Started resources discussing the relevance of CCHIT to a Specialty Practice today and in the future. The speakers are Mark Anderson (left in baseball-cap) CEO, AC Group, Inc. and our Robert Gleeman (sporting his new weekend look). Click the play button below to play this interview.

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I noted the following points from the discussion which might give you a feel for what the discussion gets into:

Mark Anderson describes (current) CCHIT as a general foundation or a minimum standard for what should be in an EMR. CCHIT doesn't yet get into the specifics that a speciality practice does on a day-to-day basis.
CCHIT have acknowledged that they need to start looking at specialities and have already identified the following Specialties: Child Health, Behavior Health, Personal Health Records, Cardiology and OBGYN.
CCHIT will start to identift the minimum requirments for these Specialities. Mark states that its good that a there will be a mimumum standard but will the Doctors pay that increased price for that CCHIT certified specialty product.
Robert asked how many CCHIT certs in 2008. Mark Anderson answered 45-50 for 2007. 18 in 2008. With interoperability built into the 2008 standard, maybe that answers why the reduced numbers planning certification.
Robert credits Dr. Al Borges as the "world leader" of the anti-CCHIT movement. Does Mark Anderson agree with Al? Lot of Doctors don't need CCHIT today -- but what about 2011, 2012? (This is the second mention for Al Borges MD in our Getting Started resources!)
What vision or forecast can Mark Anderson give for CCHIT in the next 5 years? Vendors are now adopting CCHIT -- not because their customers are requesting it -- because they are losing sales if they don't have it.
Mark touches on vendor demos - adding that he sees some 100-150 a year and many are not great.
Price cannot be the only factor. If the hospital is offering a product which doesn't meet your way of work, it may be better to walk-away and start with a lite-EMR and build up to an EHR over time.

Thanks again to Mark Anderson, AC Group for supporting our Getting Started resources for Doctors Researching EMR solutions.

For more information about the subjects discussed here you can contact Mark Anderson at the details listed below.
See our other Getting Started resources here.

Company Viability

2008-06-03T16:17:00Z

Today's Casual Friday discussion is talking about Company Viability.

Will the company and the product survive?
For how long should you need a product to be around?
Is one of our regulars Al Borges, MD right to check company Stock Prices?
How strong is the company? But what about Misys? Big Company?

Thanks to Mark Anderson and Robert Gleeman for a excellent thought provoking discussion.

(Please visit the site to view this media)

Folks -- "The Hawain look". I'm just about keeping up with the last minute wardrobe changes; unable to find a suitable summer shirt I had to fall back on the 10-gallon Texas Hat*. As always I'm in trepidation at what next I have to introduce.

* Canadian; Calgary Convention & Visitor bureau actually!

Nick

How to conduct EMR Vendor Demos

2008-05-30T08:18:00Z

We're unable to brush over the delay in posting this interview as we're looking at a tanned Mark Anderson fresh from the TEPR conference which completed last week May 22, 2008 in Fort Lauderdale, FL. An upgrade delayed our concentration on content.

The subject for today's Casual Friday discussion is How to conduct a vendor demo.

We're hoping for some feedback from any EMR Vendor sales representatives about the issues they have with Physician demonstrations. Be of interest to get their perspective.

Click the Play button below to watch our discussion.

(Please visit the site to view this media)

What tips can Mark Anderson offer.

Talk to the vendors -- they always want to present what they're used to presenting.
Mark recommends that the Doctors create some kind of documentation script around their workflow and have each of the vendors present that using the same workflow methodology

The sound of an in-bound Skype Chat Bubble at 1m 25s ... is probably me calling Bob. Oops.
Just looking for an EMR? Start with the Patient Check-in. How does the nurse know which patient to bring back to the office, then how the nurses would enter in vital signs, present illness, etc.
This also depends on the Physician Specialty. If orthodpedic, you would do x-rays first before having the patient back to the office.
Propose that you use some Sample Patients? Look at your types of workflow then pick a few patients. An existing Patient on their 2nd or 3rd repeat visit, and a New Patient and one with multiple complications.
Process is the same across all the demonstrations -- That is the Check-in / Check-out process should be the same. Have each vendor demonstrate that.
It is then easier for the practice to do side-by-side comparison between products if using the same scripted workflow.
Often a sales person may not be trained to do that sort of demonstration or they say "It doesn't help us to show how great our product is, if we follow your type of demo, because our product does more".
How many demos? One for each of their top-five? For PM and EMR. You may do separate demonstrations for each.
Get down to the top #2. Come back for a second or third demo with the same product.
Like watching a movie. You see different things the second or third time you watch the film.
How long should the demo be? Webcast should be 45 + questions. If the vendor is on site. 1 hour for demo, 1 hour on PM, 1 hour on EMR and 1/2 hour on viability and implementation.
What advice can offer the EMR vendor salesman? Know who your audience is. Know the size of the practice, know the Doctors Workflow. Does the product meet the physicians requirements, not that your is the best product. This is not about functionality or bells and whitles. The physician should have done all basic check before they get the vendor in for a serious demonstration.

Thanks again to Mark Anderson, AC Group for supporting our Getting Started resources for Doctors Researching EMR solutions.

For more information about the subjects discussed here you can contact Mark Anderson at the details listed below.
See our other Getting Started resources here.

How to select an ASP or Data Center and negotiate a contract for Hosting Services

2008-04-27T05:00:00Z

This is the transcript of Robert Gleeman's discussion with Mike Uretz talking about ASP and Data Centers and how to negotiate a contract for Hosting Services. You can listen to this interview by clicking the youTube play button a few paragraphs below.

Robert Gleeman: This is Robert Gleeman with EMR Update. I am talking today with Michael Uretz, Executive Director of the EHR Group. Michael's number is 425‑434‑7102. Thanks for being with us today, Michael. Good to have you here.

Mike Uretz: Hi, Bob. I certainly appreciate it.

Robert: Our topic today is, "How to select an ASP or data center and negotiate a contract for hosting services?" As you may know, this is one of the most frequently discussed subjects on EMR Update, to get the server or to go ASP.

Michael, let me ask you: why get an ASP or hosted solution instead of just hosting myself if I am a small office doctor with a practice?

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Mike: I think one of the big things I'm seeing as small to medium practices move towards adoption is because of the availability of ASP or data hosted solutions in terms of why you might go with that instead of hosting yourself.

When you think about hosting an application yourself, there are a number of things you have to think about. One is just the resources it takes. When we go into the world of EMR, now all of a sudden we are talking about 24/7. We are talking about folks being able to get to their records from home at 11 at night. The question you ask yourself is, can I as a group or practice have the resources available and the servers available to support that 24/7.

The second issue that folks really don't think about is when you think about leasing your own equipment, well on an average they say there is about a three year lifespan for equipment.

Robert: Right.

Mike: Probably in three years or so you will need newer equipment or updated equipment whereas many times an ASP solution or a data center hosted solution will provide under contracts the ability to upgrade equipment automatically every two to three years. You are kind of covered that way. It really depends on if you really want to devote your own resources or not.

Robert: What is the difference between an ASP and a data center hosted solution?

Mike: An ASP solution or Application Service Provider solution typically means that what you are going to be doing is you are getting both the software and servers and services as well from one company. You will be paying a monthly charge, almost like a rental fee, and what you will be getting out of that is you will be getting the application, the EMR application. You will be getting typically training and implementation services from that company as well as all the server equipment it takes to host it all.

The other option that folks look at is what's called a data center centric or data center hosted solution. Typically, the model of that is that you actually purchase the products, the EMR software, as well as training and implementation services. That comes directly from the EMR manufacturer.

Then, in turn, you look for a data center to host it up. In other words, when you look at a data center solution it is almost like as if you have your own IT department only it's at a different location. Does that kind of make sense?

Robert: I see; that does make sense.

Mike: There are pros and cons of either approach. You have to look at your particular situation. For example, when you look at an ASP solution you have a benefit, for example, of your cost. Instead of having to shell out money for all these upfront licenses you typically get some kind of monthly cost. In other words, you are renting the software out. Another potential benefit of an ASP is that they are more of a local support presence. Typically, ASPs many times are regional in nature.

A lot of times they will give you value added services. Some of these folks, for example, might offer some kind of billing service in addition to the EMR they offer. There are all kinds of services they can offer. The other benefit is that it is one point of support for everything.

On the other hand, what some folks choose to do when you go to the data center model is some people like to actually own their own licenses for whatever reason. Let's say you are planning on selling your practice a couple of years from now, and you want to transfer those licenses to somebody.

The other thing is with a data center model it's kind of a best‑of‑breed approach because you have a true IT data center that is providing all of the services to serve up the IT whereas you are working directly with the EMR vendor for anything having to do with their software. But, many times when you pay a monthly ASP charge that's rolled together when you look at your costs over time sometimes it can effectively be more of a cost for the actual software than if you had just purchased the licenses in the first place.

Robert: Michael, how do you choose an ASP or data center?

Mike: Well, there are a lot of variables in this. A lot of the vendors themselves, a lot of EMR vendors, seem to have partners more and more in the ASP and the data center realm. One of the things you can do if you choose an EMR system is you can go to that vendor and say, "Who have you used? Who is involved in your partnership program?" That's one way to, at least, get a short list.

The other thing you want to find out then is how many deals have these particular ASP or data center vendors done with the particular EMR system. Find out how many deals have they done. Also, find out do they specialize in a certain system; that's real important. Are they an ASP that actually has five EMRs that they resell, or do they sell one? Obviously, if they specialize in one they are going to be better at doing that.

The other thing then is you really have to look closely at the infrastructure and the resources these folks have. Talk to them. Find out how large their data centers are. What types of equipment? How long have they been around? Find out how many people? What kind of skill sets do they have? Do they have the types of skills that they can run those servers?

Another thing to look at are the service options. What can they really do in terms of services? Many times ASPs or data centers have all kinds of different services they can offer.

Then finally, Bob, really at the end of the day the most important thing is the reference checking because there has been many, many times that I have done reference checking on an ASP provider or a data center, and then people have shared with me all kinds of stories.

For example, the things that happened when things went wrong; the extra things that the person at the data center that stayed on the job until three in the morning to get something done. These stories are priceless. Make sure that you do very, very robust reference checking because things will shake out through that.

Robert: This is going to be mission critical for a doctor. How do you make sure that either way that you go that they live up to their commitments?

Mike: You really want to make sure that you have a good type service contract that covers many of the areas because it's the same old thing. Can you walk the walk and talk the talk? What happens when you finally purchase it? In terms of living up to the commitments, you can certainly get a good contract. Of course, the other thing is in the selection process you can do a lot of due diligence as well to see what the track record has been.

Robert: What are the components of a good contract, Michael? As a consultant, is this something you can help a doctor with?

Mike: Oh, sure. It's really interesting because I negotiate a lot of EMR practice management contracts. One of the things I encourage people to think about is that they look at, number one, the types of services they are getting because in many cases it can be like when you buy a car. You buy the car, but then you have everything around there. Do you get the satellite radio? Understand and define very distinctly what all the services are that they are claiming and you expect.

Another component that is extremely important is what is the expected performance. You understand what the expectations are in terms of performance, and you get that down in writing.

The same thing with response time for problems. Make sure that that's all covered. If there is a problem, how fast are they going to get to you? How fast are they going to take care of it?

Now, people can make commitments in a contract what they are going to do, but where's the teeth that makes them do it. Well, there needs to be financial penalties if they don't come through with performance, and these penalties typically are credits towards your monthly charge.

You need to have the right to terminate the agreement based on certain conditions. Again, you negotiate this with your vendor. What I would mention in relation to the termination is make sure that they will help you in transferring that data. Remember if they are doing an ASP or data center they have your data on their data center so you have to have certain rights with that termination to get that data in a format that you can use.

Robert: Now, what if I decide to host the solution myself later on?

Mike: That's a very, very important question because typically what happens is people grow where you might have an ASP solution or you might have a data center solution for a couple of years. Maybe, you will actually have your own server at some point. Maybe, you might want to change. You need to make sure that there is documentation at all times of how they do things, what they are doing. There are diagrams of how everything works.

If you ever get to the point where you are actually bringing all this in‑house, there needs to be that transference of knowledge. Make sure you always have good documentation from your vendor, and if your vendor doesn't want to supply that for you I wouldn't deal with that vendor.

Robert: Michael Uretz, Executive Director, EHR group. Thank you very much. Excellent information. Thanks again for being with us at emrupdate, Michael.

For more information about the subjects discussed here you can contact Michael Uretz at the details listed below.
See our other Getting Started resources here.

Contact information for Mike:

Michael Uretz, Executive Director
The EHR Group
700 NW Gilman Blvd. Suite E293
Issaquah, WA 98027
Tel: +1 (425) 434-7103

E-mail: sales@ehrgroup.com
Website: www.ehrgroup.com

What is an "EMR Lite"

2008-04-18T02:15:00Z

This is our casual Friday interview with Robert Gleeman and Mark Anderson of the AC Group, Inc. discussing What is an "EMR Lite". Mark Anderson can be reached at the email address and contact numbers detailed at the end of this interview.

In a departure from our usually impeccable presentation style -- as it's Friday -- we've ditched the suits, lost the ties and gone all casual. Robert and Mark discuss what sort of things go into the basics of a Lite EMR -- the EMR ingredients that do just enough to provide the basics for managing a Patient encounter.

Please click the Start button below to watch our interview.

(Please visit the site to view this media)

Thanks again to Mark Anderson, AC Group for supporting our Getting Started resources for Doctors Researching EMR solutions.

For more information about the subjects discussed here you can contact Mark Anderson at the details listed below.
See our other Getting Started resources here.

How to Select an IT Contractor and Negotiate a Contract for IT Services

2008-03-27T03:21:00Z

This is the transcription of my discussion with Michael Uretz, Executive Director of The EHR Group discussing "How to Select an IT Contractor & Negotiate a Contract for IT Services". You can listen to this interview by clicking on the YouTube play button below the first couple of paragraphs.

Robert Gleeman: This Robert Gleeman with EMR Update. We're talking today with Michael Uretz, Executive Director of the EHR Group, phone number (425) 434‑7102. Michael, thank you for being with us today.

Michael Uretz: Well thanks Bob, I appreciate it.

Robert: Our topic today is "How to Select an IT Contractor and Negotiate a Contract for IT Services."

Michael, can you tell me what type of consulting work you do over at EHR Group?

Michael: What I've been doing the last few years is EHR selection and contracting but also I like to help folks with the IT components; figuring out how to work with IT folks, how to do IT contracting, so I think that's something I bring to and I think it will play in our conversation we're going to have today.

Robert: Let's say I'm a doctor, maybe three to five doctor office. Michael, why would I want to contract out IT services instead of just hiring my own IT person?

Michael: Well, actually being an ex‑IT manager myself, I know how tough it is with experience in IT. Unless you are very technically inclined, you probably haven't a lot of experience with those folks. And actually my experience has been working with a lot of small groups doing EMR, that they actually would prefer not to have their hands full of getting somebody onboard, paying salaries and they'd rather contract it out.

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Robert: And what size company should I contract with?

Michael: Potential problem with a too small a group is that there is no backup, right? What happens if there's a proverbial he gets hit by a truck, right? And you're dependent on this IT resource.

So, if it's too small it might not be good. On the other hand though, my bad experience even as an IT manager, I'm hiring out work to contractors in very large companies and you just don't get the personal attention.

So, it's all individual, but I think there's a sweet spot of, you know, I'm just going to throw numbers out, maybe five, ten people, maybe 15 where it's small enough where you still get that personalized attention and people will take care of you when you come calling.

Robert: And what services can an IT contractor really offer to a doctor?

Michael: When you look at an IT contracting group you have to be all inclusive. And typically the types of things, at least with my clients, when I look for IT contractors for the EMR system, they've done things for example from soup‑to‑nuts from the beginning; they'll help evaluate the vendor infrastructure.

In other words, if you're going to get and EMR, you really want somebody in your corner to help evaluate how it's going to work on certain servers; what are the work stations; what kind of network do you need?

So that's one thing. They can help spec out hardware and even negotiate it for you so you can get a good deal because typically a good IT contractor will have relationships with many hardware distributors.

Then the next step would be they need the ability obviously to set the systems up with you so they work correctly. And then you kind of have a choice there: Can they do desktop support?

There are two things: you're going to have servers that are going to run the applications.

Robert: OK.

Michael: And then you're going to have the workstations and the tablets and all the things that the nurses and doctors and administrators use. Then the question is, "Do you want to have them be a support desk for those types of things, as well as the applications on the servers?"

So those are kind of the soup‑to‑nuts types of things. And of course really good experience networking because I've found that's where things fall down is not getting good networking infrastructure systems.

Robert: What should this cost me to get IT contractors in to help me as a doctor?

Michael: Pricing is across the board, but only plan on what is really important to look at. You're going to see two models of costs. One is an hourly charge. You have a problem and you call them up and they say, "OK, we'll come for an hourly charge of X dollars."

The other option, which I think is a better option, is actually to use them as truly an IT department and contract them on like a monthly basis. Really, it's a yearly type of contract with a monthly payment. And then they are really there for you.

Robert: And how do you choose an IT contractor? Is it all based on experience and if so what experience should they have?

Michael: What I've found is two things. Can they communicate? But secondly, really do your due diligence on how they work with other groups or practices. Make sure they can explain to you things in lay language. If you have questions, ask them. And then secondly, just do really, really good reference checks.

Robert: How do you make sure that they live up to their commitments, Michael?

Michael: That's why we have things called Contracts and Agreements. It's unfortunate that we need these things, but you need to be sure about their commitments. And that's why you want to make sure you have very, very strong contracts with these folks.

Robert: What are the components of a good contract?

Michael: What I'd like to do if we have a minute is kind of go over some of the more important components?

Robert: Sure.

Michael: And one is really the service that they're going to give you, the commitment of the service, what is typically called a Service Level, or a Service Level Agreement. And these things are; how are they going to be there when you call them? [laughs]

Are they going to guarantee that they are going to come in an hour, two hours? Three hours? What are they going to do? How are they going to do it? How are they going to escalate things? The process, what they guarantee. You want to get these in writing.

But a lot of people don't go far enough. If they say they are going to come in an hour and they don't come in an hour, or don't call you in an hour, or whatever you guys agreed to, there have to be financial penalties. They have to credit you X dollars of.

The fee per month or whatever you agree on. You know, it's funny. It doesn't matter if it's a cent or $100. The point of penalty is for accountability, really.

Other things you want to make sure, and this is really important, when I have clients in a health and EMR system we'll negotiate then we'll get an IT contractor. The benefit of having an IT contractor is, you put this in the contract, that they are your.

First point of contact. They might not understand the EMR application, but they are a point of contact for you to call if there's a problem.

The termination clause is extremely important! And really, put exclamation points on this. If they don't come up with the goods, if they don't give you good service, well, they should be out. So termination clauses, under certain situations; they haven't come three times in a row, or whatever you negotiate, that there needs to be some kind of termination clause. OK?

What's also extremely important is the definition of what they're going to be doing. Typically you want to have some kind of appendix or exhibit in there that says what they are going to do for you.

And finally, this is extremely important, is what I call transition services. They have to give you documentation of what they're doing and what they've done so if you need to basically pull the plug; you have a transition to another company. And that's really important!

So these are...there are many, many, many clauses, but these are some of the main things I'd like your folks to think about as they go through and talk to IT contractors.

Robert: What if I decide to have an in‑house IT later on? They are fulfilling their contract, but I just want to bring it in‑house and hire my own person?

Michael: Typically when you think about it you have a small practice. You're starting out you might not want to hire an IT.

But let's say you grow four years down the line and now you can afford an IT person or three staff or whatever. You don't want to be restricted.

I'm doing this right now. I'm working with a group of providers. There are about ten providers, they are large enough to have their own IT people, but they want to start out with a contractor's desk but yet they see two or three or four years down the line they might have their own staff.

So what we're doing is we're making sure that from day one whatever work that contractor does for us they're documenting that. And whatever the architecture is, whatever the processes are; how they do backups, when they do things; what the system looks like; because there will be a point in time where this practice that hired me will want an IT manager and that IT manager will step in and say, "OK, how does this work?"

And if we have the documentation where the IT contractor has been doing all the work for the last one, two, three years, than it's much, much easier to make that transition and that's very important for you to have.

Robert: As a final word to the 6,000 or 7,000 doctors that are members of the EMR Update, who may have been holding off on EMR because they're afraid of the IT aspects, what can you leave them with? What can you tell them to bolster their courage out there?

Michael: That's a great question. In fact it's funny because I do a presentation called "Barriers to Adoption." I found that it's just the fear of technology that holds people up.

But to answer, really, that's one of the reasons why I think I see people going towards, at least initially when they do this, they're not big enough to get their own folks, to hire it out.

Because that's quite a commitment to have to interview somebody, bring them on your staff, and have them be part of your business, OK. Much less of a fear if you get somebody from the outside with a good contract that lets you pull the plug at any time, and then you can slowly move into it.

Make sure, as I talked about before; get the person you hire to be very communicative with you. Do not be shy about getting somebody you can communicate with. There's something funny about communication, if you feel comfortable with that person it's going to overcome a lot.

Secondly, if you take away the fear of having this long‑term commitment of hiring somebody for your staff that will also take away the fear. You have to have an out. You have to have good contracts and you have to have really good commitments.

So if you have that I think those are some of the things I've found where people will make that jump and then do it.

Robert: Michael Uretz, EHR Group, thank you very much for being with us today, Michael.

Michael: Thanks Bob.

Thanks again to Michael Uretz, The EHR Group, for supporting our Getting Started resources for Doctors Researching EMR solutions.

For more information about the subjects discussed here you can contact Michael Uretz at the details listed below.
See our other Getting Started resources here.

Contact information for Mike:

Michael Uretz, Executive Director
The EHR Group
700 NW Gilman Blvd. Suite E293
Issaquah, WA 98027
Tel: +1 (425) 434-7103

E-mail: sales@ehrgroup.com
Website: www.ehrgroup.com

Getting Started: Contract Terms and Conditions to watch out for

2008-03-15T08:52:00Z

This is the transcription of my discussion with Mark Anderson, CEO of the A.C. Group, Inc, discussing "Contract Terms and Conditions. What to watch for". You can listen to this interview by clicking on the YouTube play button below the first couple of paragraphs.

Robert Gleeman: This is Robert Gleeman with EMR Update. We are talking today with Mark Anderson from the AC Group. Mark's cell phone number is 1‑281‑413‑5572 and our topic today for the Getting Started section is contract terms and conditions to watch out for.

So Mark, you've decided to sign on the dotted line and it's time to negotiate the contract. How much is negotiable?

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Mark Anderson: Well it's interesting because depending on the vendor and the size of the practice, there may be a lot of things you can negotiate, but that is part of the problem that most vendors are used to having physician offices sign their normal contracts.

They are not used to doctor's wanting to negotiate much with them, although we do a lot of negotiations on large medical device purchases, but we don't do enough negotiating on these technology contracts.

Robert: The license fees, is that ever negotiable?

Mark: The license fees are somewhat negotiable. There are a couple issues you have to think about. One issue in license fees is what is their definition of a provider. It may be a doctor with a P.A. and a nurse practitioner. Some vendors may count that as three different providers.

Robert: This is one of the things that you do a lot of, isn't it Mark?

Mark: Yeah, I would say the majority of our work really is the contract negotiation. Many of the physician offices will call us up and say, look I've picked this one vendor, we have heard you can help to negotiate a better contract for us.

About 40 different contract terms need to be either adjusted either as an addendum to the contract or actually go back and change the wording of the contract to better protect the practice.

Robert: Can you tell me, what is the most negotiable and what is the least negotiable?

Mark: Well I think there are a couple that you need to negotiate no matter what. In other words, if they are not willing to negotiate with you, you should walk away from the deal.

The highest ones really are all about support. The number one priority always has got to be, I've got to make sure this product is working effectively and if it is not working effectively, the vendor needs to make it so that it will work in my time frame, not their time frame.

That is probably the biggest area of negotiating, is negotiating the support contract and what happens if the vendor does not provide the adequate support that you were expecting. Those need to be negotiated right off the top.

Robert: Included in that part of the negotiation of the support, would you include in that how you will receive updates, new versions, patches, and etcetera?

Mark: Yes because it's very important that you stay as current as you can on the products because there is always new regulation coming out. There might be state or national requirements or just upgrades to the product.

The challenge you also run into is that most of the vendors, if you pay your support fee, they will provide you an upgrade, but what is the definition of an upgrade? They may add something new to it that they call a new product. So you really need to define what a new product is versus an upgrade. Then is there any testing of those upgrades.

Robert: Do you find the vendors are willing to state assurances and state what their escalation policies are and problem resolution policies? Are they willing to do it?

Mark: Some of the larger vendors are willing to do that if they have already established those escalation policies are out there. Many of the small vendors have never even heard of this kind of stuff.

Robert: If a vendor goes out of business or is acquired, is it reasonable in the contract to ask for some kind of a source code escrow clause?

Mark: Yes, well actually there are two ways. So another vendor buys out the software product, your contract should stay in effective for at least the next five to seven years. That needs to be a contract addendum in there. What you don't want to have happen is somebody buys out your EMR product and then they stop supporting it because they want you to switch to something else.

Same thing is if the company goes out of business, you want to have a clause in there that you can get access to the source code, which is called an escrow account. It's important too that if the practice gets sold, that you are able to transfer that license to the buying new company.

Robert: You've mentioned before, Mark, that some of these contracts are very one‑sided in favor of the vendor. Can you ever work it out with the vendor to have milestone payments at key phases?

Mark: We've done on every one of our contracts, no matter who the vendor is. You always pay something up front to buy it. You pay another percentage once the product is installed and somewhat usable. You pay another percentage once your staff is fully trained on how to use the product and typically you do not make the final payment until 30‑90 days after going live.

I want to make sure the system is working and go through all that; otherwise the vendor is not getting their final payment.

Robert: This seems like a long process. How long should you expect this to take?

Mark: Well if you've never negotiated a technology software contract with escalating clauses, it will take a physician a long time. I mean it can take you two or three weeks to negotiate all of the different points that are out there if you have never done one before.

A lot of practices will give the contract over to their lawyers. Lawyers are very good at going through this and looking at the periods and the commas to make sure that everything is legal. Most of them are not that strong on technology software contracts.

Robert: You told me once a while back how many of these contracts you have negotiated. Do you recall?

Mark: Well I would say since 2000, we've probably done about 600 contracts that is [xx] negotiation. Although we have done a lot more where the practice came to us afterwards and said, things are not working; can you help us get out of the contract?

After we go back and look at the contract and say this is a strong contract, you have no out clauses at all. One of the most important factors in a contract is making sure the product meets your requirements. Too many times the doctors will say, gee can your product do this, and the vendor says sure we can do it, some day for some cost, but it may not be in your cost proposal.

A lot of our clients have actually added additional functionality they want built into their product over the next 12 months. We've gotten the vendors to sign off that they will add additional functionality to their products within a period of time or the client (the physician practice) gets a rebate on the software.

Robert: Should a doctor request from a vendor to look at the contract before even making a decision to buy that software?

Mark: I think part of the selection process always is while you are looking at the software originally, you should be getting a copy of an estimated quote on the cost and then the actual contract wording to review. I've seen contracts come in where the doctor signs and they get hit with 50% more costs. Things that they didn't realize were there.

They were in the contract but they are in fine print or if this and this, or escalations of cost. They don't really realize how much more they might be paying for something they thought was going to be included in the actual software cost.

Robert: This can be one of the most important contracts a doctor ever negotiates, can't it?

Mark: It probably is the most important because when you think about electronic medical record, your billing system and everything it's the running of your business and if it goes bad and you are not able to generate the right notes or the right bills, you don't get paid.

Robert: Now one thing I know that you try to do is make your fee transparent. In other words, save the doctor enough money to cover your fee. Are you usually able to do that in helping to negotiate a contract?

Mark: We have found on average that depending on the size of the practice, you get an X times reduction in cost that more than over compensates for our cost. A sample would be that we have found practices with over 50 doctors having saved nine times our cost.

For one and two doctor practices there is not a lot of cost, not a lot you can negotiate, but we are still saving about three to four times our cost.

Robert: Is there a red flag that you should be looking for when you negotiate these contracts?

Mark: The biggest red flag would be is when they send you a purchase order with almost no terms and conditions built in. The small physician practice, the one, two and three doctor practice should be requiring the vendors to provide not only a purchase order or a contract fee, but true terms and conditions.

Terms and conditions will be a minimum of 8‑12 pages long, in small print too.

Robert: Any final warnings to the readers of EMR Update, Mark?

Mark: It's always buyer beware on all of these things. I think there are a number of vendors that participate in EMR Update that have very good contracts out there. A couple ones I have negotiated in the past. There are only two or three terms we need to have changed on there.

Other vendors we have added 20 or 30 pages of changes to their contracts. You don't want to make the wrong decision and sign the wrong contract.

Robert: We're talking with Mark Anderson from the AC Group. Thanks again Mark.

Mark: Thank you.

Thanks again to Mark Anderson, AC Group for supporting our Getting Started resources for Doctors Researching EMR solutions.

For more information about the subjects discussed here you can contact Mark Anderson at the details listed below.
See our other Getting Started resources here.

Links and Resources

2008-02-19T16:14:00Z

This is a collection of useful links and resources recommended by posters at emrupdate.com from the Getting Started Library.

To recommend a new resources for our Links and Resources section within the Getting Started library, please post your link for comment and peer-review within the main EMR forum. This helps Doctors researching EMR solutions get a feel for the value of that link with both good or alternative comments to the article linked.

Electronic Health Records: A primer for practicing physicians posted by Al Borges, MD, discussed on the forum here. Backup copy here.

Five things to do with your old paper medical records

2008-02-11T05:09:00Z

This is the transcription of my discussion with Mark Anderson, CEO of the A.C. Group, Inc, discussing "Five things to do with your old paper medical records". You can listen to this interview by clicking on the YouTube play button below the first couple of paragraphs.

Robert Gleeman: We're talking today with Mark Anderson from the AC Group. Mark Anderson's phone number, in case you want to give him a call, is 1‑281‑413‑5572.

Thanks for being with us again today, Mark.

Mark Anderson: Thank you for having me come and speak again.

Robert: Our subject today is "Five things to do with your old paper medical records" and I assumed that burning in a public bonfire is not one of them. Is that true?

Mark: That is one of the options but not one that we would recommend doing.

Robert: Well, why don't we go through these one by one and if you would, let's start out with number one.

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Mark: Well, if you'd look at most practices, like the average doctor has around 5,000 active charts, and what the vendors usually recommend option one is just scan everything in. It's amazing where a lot of vendors are telling people that you have all these medical records information and one of the ways of reducing cost is to give it over to your chartroom. Some doctors have actually gone back in and taken all their old charts, pulls them out and actually scan them directly in as a PDF file into the EMR.

The vendors recommend that once you go back and look at the cost taking all those charts, scanning them all in, and storing it in your EMR, there's heavy cost for the labor to scan everyone of those documents in. Yes you do free up that space, but if you're not going to use that space for revenue‑producing new activities, there's a lot of cost added in. So a lot of doctors think about scanning everything in, then they come back and say, "There must be a better option. Maybe I can just scan parts of the information in."

Robert: Does that lead us to number two?

Mark: Yes. I think what it does to make a little bit more sense is a partial scanning of your paper charts. A couple of things to remember, when you scan the document in, there is no data. You're basically looking at a piece of paper. So if you want to go back and say, "Give me all the patients that are on a certain medication or have a certain lab result", you're not going to have that by scanning the information in.

So what most practices are doing‑‑and this is one of the options that are out there under option two‑‑is that they're going in and saying "Any new patient that I have coming in today or the next week based on your appointment schedule, I'm going to have a clerk, pull that chart like they normally would do, then they go on and either scan the whole chart in based on that appointment or they will decide based on the specialty what pieces of information are important to my practice?"

A lot of times the doctors will say, "Give me the last three lab results, the last three office visit notes, and any other basic procedure that may go on and have that brought in as a scanned in document."

Robert: In the second scenario, what percentage of the charts would typically be scanned?

Mark: Obviously, it always depends on the specialty. If you go back and look at a typical family practice physician, there's a lot more of that chart that they want to have they classifies as clinically important. So in that case, you may see 40% or 50% of the chart maybe scanned in. If you go back to another specialist, maybe a dermatologist or let's call an orthopedic surgeon, you may only want to be scanning in relative information that taking care of the current injury that you're taking care of the patient for.

Robert: This leads us to scenario number three.

Mark: Well, I think these are looking at scenario number three. It's really going back and saying, "Can you find a way of summarizing the charts in a‑‑what lots of doctors are calling‑‑a patient's summary page?" A typical patient's summary page is a one or two‑page document that's usually on the very front of the chart that has on it information about the diagnosis of the patient, what labs that they've had, what medications that they're probably on. Then maybe you just scan in that one piece of paper or two pieces of paper about the patient. The value there is maybe the patient doesn't have an appointment to come in yet, but they call up about a medication refill.

With your typical EMR, until that patient's been seen, there's no data in the computer system at all. But in this case, where the patient's calling in and you scan in that one or two pages that summarize everything about the patient, the doctor can then pull up, see who the patient is, find out what active meds they're on, or when was the last time they've been seen?

Enough information where they can actually help the patient without having to tell the patient to call back later or have somebody run and go find the chart every single time. We found by having a summary page, you can cut out about 80% of the chart pulls that are necessary‑‑again, so many doctors established what they call as "clinically important information" and have that summarized in an analyzed form on the actual chart to start with.

Remember, you can always go back in‑‑if it's a very active page of multiple diagnosis issues‑‑you can always go back in and scan more pages in or the whole chart if you want. This is probably where the highest level of adoption is where the doctor has a summary sheet and then maybe they actually will highlight the last three lab reports you also want to have scanned in.

What you're doing is really limiting the amount of scanning that you want to do on active patients by having a one sheet or two sheets that really summarizes on maybe two or three pieces of paper that are clinically important that you really can't put on a summary sheet. We're saying about 80% of the doctors are embracing that kind of technology right now.

Robert: Interesting.

Mark: Option four is where the doctor sees the patient with the paper chart today. They see the patient, they put new things into the EMR, and then what they do is they go back to the old note and they may put a little sticky note on that chart stating that these are clinical important things that you need to have pulled and scanned in after the visit. They may go in and circle things on the chart, specific data elements that they want, maybe their nurse or a clerical person to enter in those discreet data. So we think option four is probably the best way to do it today.

Robert: And there is an option five. What is that?

Mark: Option five is an interesting approach because most doctors today are very busy in their practices and their staff doesn't have a lot of extra time to scan charts. Option five deals with hiring an outside firm that can come in and they really do two things. One is they review the chart and they can scan pieces of paper in for you. But a lot of these companies also can go to review the chart and do a lot of your data entry for you.

So they can actually be your interim nurse or MA who goes through, reviews all your active charts‑‑maybe patients are coming in the next week‑‑and they spend the time scanning the documents in and putting in discreet data into the EMR. Of course, there's a cost applied to that, but in most practices, again, we find that they do not have enough time to do their normal work, learn how to use the EMR, and scan the documents in especially during that first six months.

Robert: At what point can you actually get rid of the paper files and destroy them?

Mark: Well, we always say to always check you're state because each state has a little different requirements. What traditionally everybody looks at, you have to keep any patient that has been active in your practice for seven years over and above the age of 21. So anybody that's been in your practice‑‑maybe they were seen when they were five years old‑‑you have to keep that chart active until they're 21.

Robert: Mark, of the five options you've mentioned, which is the most cost‑effective?

Mark: I think the most cost‑effective method right now is that we talk about as far as option four, the one where the practice sees the patient with the paper chart, records what's important for them, maybe put a sticky note on the documents that they really need, and then the staff basically‑‑instead of refilling that chart later on‑‑they take that chart, scan in the specific data that's important and you may file it offsite.

You won't need it again for a while. That way the staff, instead of spending the time refilling the chart is basically scanning it in so there isn't a lot of additional cost for doing it that way. We think that's the most effective way of hauling the old paper records today.

Robert: Very interesting, thank you very much, Mark Anderson, AC Group. Thanks for being with us today.

Mark: Thank you.

Thanks again to Mark Anderson, AC Group for supporting our Getting Started resources for Doctors Researching EMR solutions.

For more information about the subjects discussed here you can contact Mark Anderson at the details listed below.
See our other Getting Started resources here.