EMRs: An Electronic Solution to a Paper-Based Chart System

An analysis by Trevor Johnson

September 2009
Johnson September 2009

What is an Electronic Medical Record (EMR)?

According to the National Center for Health Statistics (NCHS), in 2003 an EMR was defined as a system
for e-documentation on patient condition and treatment. In 2005 this definition was revised to include
four main features that the NCHS determined all EMRs should possess. This compliments the definition
of 2003. The four main features are: computerized orders for prescriptions, computerized orders for
tests, reporting test results (such as labs and imaging) and clinical notes (both from the physician and
nurse practitioner) (Burt).

The Certification Commission for Healthcare Information Technology (CCHIT) is the largest certifying
entity of Electronic Health Records (EHR) as well as for EMRs. The CCHIT criteria must be met 100% to be
certified as a Qualified HER. The 2011 standards will be ratified and released in December of 2009 and
will include both 2009 and 2011 content (Concise).

EMR/EHR Acceptance Statistics

Beginning in 2011, $19 billion in net incentives will be distributed to physicians who are in meaningful
use of an EMR. The term meaningful use has not yet been defined. Incentives will be paid in the form
of increased Medicare and Medicaid payments distributed over a five-year period and not to exceed
$40,000 to $44,000 per provider, according to SK&A Healthcare Information Solutions.

In the United States approximately 80% of physicians belong to practices employing 1-9 physicians.
Conversely, practices with fewer than 10 physicians have a significantly lower acceptance rate of EMRs
compared to those with more than 10 physicians (Burt). As a general rule, larger physician groups are
able to implement complementary charges more easily that smaller groups due largely to stronger
organizational resources such as management expertise (Miller). There are a number of other barriers in
the way of broad EMR acceptance which will be discussed later in this document.

Table 1

# of Physicians % Using EMR 2003 % Using EMR 2006 Estimated % Using

EMR 2009*

1 13.0 24.0 35.6

2-4 16.2 28.0 39.6

5-9 19.9 30.9 42.5

10-above 33.8 46.5 58.1

*Approximate change in 3 years +11.6%

The statistics for physician acceptance of EMR by size of practices show the disparity between small and
larger practices. Solo physician practices compose 38.5% of all U.S. physicians according to the NCHS
2005 study of EMR Acceptance, yet they have the lowest adoption rate of EMR/EHR technologies. Large

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practices of 10 or more physicians compose the smallest segment of U.S. physicians with 9.7%. The
majority of U.S. physicians work in either a solo practice or a practice with 3-5 physicians.

The NCHS has conducted this study twice once in 2003 and again in 2006. If we extrapolate the growth
rate of EMR acceptance among these sectors we can create a meaningful estimate of EMR acceptance as
of 2009. According to our estimated 2009 statistics, solo practices still trail large practices of 10 or more
physicians by 12.5% adoption (Burt).

Table 2

EMR Acceptance by Scope of Service

Service % of U.S. % Using EMR

Solo and Single Specialty 78.6 21.8

Multispecialty 20.0 34.2

This is again reflected if we analyze physician adoption rates compared to the proliferation of specialties
at a given practice. Solo practices with a single specialty which again make up the vast majority of U.S.
physicians has a much lower acceptance rate then multi-specialty practices by a margin of 12.4% (Burt).

Barriers in the Broad Acceptance of EMR/EHR Technologies

In order to find the reasoning for the disparity in adoption of EMR/EHR technologies, we will discuss the
barriers in three categories: the financial barriers, the technical barriers and finally the stigmatic barriers.

According to the Washington State Health Information Infrastructure Advisory Board (WASHIIAB) study
of 2008, the main financial barriers were determined to be:

Table 3

Barriers Benefits

Lack of capital investment Reduced transcription costs

Maintenance costs Reduces staff expenses

Complex contracts Improved charge capture

Lack of time Increased revenue

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A study by the New York State Ophthalmological Society (NYSOS) found that the biggest obstacle in the
way of EMR adoption is the start-up cost. The study's survey indicated that for 33.1% of
ophthalmologists, start-up cost alone stood in the way of progress (EMR survey).

The average acquisitioned costs per physician for an EMR is $42,485.50. That is the average cost just to
acquire and begin using the system, not taking into account annual maintenance and upgrade costs. It
does, however, include the costs for acquiring new hardware to run the system including servers and
tablet PCs. The same study estimated the costs of annual maintenance to be $8,412 per year to maintain
the software and replace hardware including the labor for outside contractors to perform this service
(Burke-Bebee).

This is not the whole picture; time spent by personnel pulling charts can take five minutes per patient, or
five minutes a practitioner is away from the patient. For a solo practice that might see an estimated 35
patients per day, even if only half of these patients are returning patients, that amounts to 17 chart pulls
a day. If the practice remains open during all but the eight bank holidays a year (or 357 days), that comes
to 6,069 chart pulls annually. At 5 minutes a pull, 6,069 chart pulls a year becomes slightly more than
505 hours annually. According the Bureau of Labor Statistics the average income of a registered nurse is
$58,780 this compares to $28.26 per hour (Nurse). This equates to approximately $14,292 spent every
year on labor associated with chart pulls alone. This figure is is only an estimate but comes close to the
figure the WASHIIAB arrived at of $12,988 on chart-pull savings associated with an EMR (Burke-Bebee).
This, of course, fails to take into account the cost of the paper the charts are printed on, the cost of ink
and electricity required to print them, or the spatial cost of storing these charts.

Another aspect that should be taken into account is the cost of a medical transcriptionist, who can be
replaced with modern speech recognition software such as Dragon Naturally Speaking. According to the
WASHIIAB this equates to a net savings of $11,690 spent on transcription annually (Burke-Bebee).

This cost may further be mitigated by the announced federal stimulus for the adoption of EMR/EHR
technologies, which is scheduled to begin in 2011 (67%).

Table 4

Barriers

Lack of training

Migration

Fragmented EMR solutions

Lack of standards

Barriers associated with technical aspects of an EMR constitute individual problems for each vendor,
especially lack of training and fragmented solutions, by which we mean the lack of a total system that is

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capable of following a patient from scheduling, physical examination, labs, prescriptions, and billing
(Burke-Bebee).

The CCHIT has created a certification for qualified electronic health records and is currently the largest
entity providing such a certification. The NCHS definition of what constitutes an EMR and the federal
governments official standards of HIPPA are a move toward a formal list of standard features that all
EMRs should possess. This creates a sense of consumer confidence that a product meets these
requirements and overcomes this barrier.

To the larger issue of migration, two common solutions have been proposed. The first is a from-this-
point-on approach, which means all existing medical records are left in paper form and only new
records are entered into the system. One of the most serious drawbacks of this method is that it does
not actually eliminate the costs associated with chart pulls; however, for practices that focus on new
business such as walk-in clinics, this solution may be adequate because few patients revisit. For the rest
of small practices and family doctors, this may not be a viable solution because their business model is
built upon return visits.

For these establishments the second solution is the only real option. That solution is of course a back-
dated solution, which means entering all past data into the system. This can be a long and expensive
process that frightens away many physicians who fear losing productivity to this project. Modern
technologies like optical character recognition (OCR) software makes it possible to simply scan
documents in and have the computer process them into a digital format. Of course there is a stigma
associated with utilizing computer software to process text as is the case with speech recognition
software as well. This has stemmed from early version of these products which lacked the power to
perform the tasks as accurately as a human. In recent years this gap has grown significantly small to the
point where errors are negligible (Easiest).

Table 5

Barriers Benefits

Concerns over privacy Improved decision making

Dont see value Access to information

Difficult building a strong business case Improved workflow

Eliminate chart pulls

These constitute stigmatic barriers or problems perceived by the physician. Privacy concerns are of great
importance when it comes to medical records and must be treated with the utmost respect. Of the two
main solutions to data storage (on-site and off-site), there will always be a danger in sending patient data
to another location as is the case with off-site data storage. Modern security measures and federal

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regulations as to how this sensitive data is communicated has made some inroads as to assuaging the
fears of privacy beeches. The HIPPA security policies advise the use of a two-factor authentication
method, a role oriented clearance procedure and session timeouts when it comes to accessing the
system internally. When accessing the system externally all data should be transmitted using some form
of encryption such as SSL, S/MIME, SET, PEM or PGP to ensure that messages are not intercepted or
modified (HIPPA).

Nonetheless, on-site data storage is still the most popular solution as shown by the NYSOS EMR survey,
which found that 69% of EMR solutions are hosted locally in the physicians office as opposed to only
31% hosted remotely (NYSOS). This is genuinely due to the belief that on-site data storage is more
securing that off-site. This is due to physical security being seen as more secure then electronic security,
which is simply not the case. Most data breeches in recent years have not been a result of electronic
security failures. For example in 2008, the Jackson-Madison county school district leaked the social
security numbers of 200 students. This happened when a backup disc containing this information was
stolen from the principals car (Cheshier).

Who is using an EMR?

We have discussed already the acceptance rates for EMR technologies, but now lets take a moment to
look at what kind of physicians are actually jumping on the band wagon, and by extension, what the
market is for current EMR vendors.

Table 6

EMR Acceptance by Physician Age

Physician Age % of U.S. % Using EMR

Under 35 3.9 44.0

35-44 27.2 26.8

45-54 34.5 25.1

55-64 24.5 18.1

65 and older 9.9 18.4

The majority of physicians in the U.S., approximately 86.2%, are between the ages of 35-64; however,
only 23.3% (on average) of these physicians utilize an EMR. This is very disproportionate compared to
the 3.9% of physicians under 35, of whom 44.0% use an EMR. This reinforces the belief that older
physicians are unwilling to learn new technologies and change their ways. It also means that this is the
largest unconverted market for future EMR growth.

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Table 7

EMR Acceptance by Region

Region % of U.S. % Using EMR

Northeast 20.9 14.4

Midwest 21.4 26.9

West 22.7 33.4

South 34.9 21.7

We can gather from this dataset that the Northeast region of the U.S. is far behind the curve in adopting
EMR technologies at 14.4% compared to a national average of 24.4%. The West was way ahead of the
curve with a 33.4% adoption rate. The Midwest and the South were around center at 26.9% and 21.7%
respectively. This makes the Northeast the largest untapped market for EMR technologies. It also means
that they are the most uncommitted market. For an EMR to be successful in this region, the reasons
behind this sluggish adoption must be determined and overcome (Burt).

Features of an EMR

As mentioned earlier, the 4 main features that, according to the NCHS, constitute an EMR are
computerized orders for prescriptions, computerized orders for tests, reporting test results (such as labs
and imaging) and clinical notes (both from the physician and nurse practitioner). According to the
CCHHIT there are quite a few more and in fact, according to the federal government and the Health
Insurance Portability and Accountability Act (HIPPA), there are several. HIPPA states that the
documentation for each patient encounter should include:

The Chief Complaint

Relevant history

Findings of the physical exam

Prior diagnostic test results

Assessment, clinical impressions or diagnosis

A plan for care

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And the date and verifiable legible identity of the service provider

The benefits of following the HIPPA standards are the ability to file claims online using electronic data
interchange (EDI) which has the added benefit of people processed in 14 days and using electronic funds
transfer. Meaning the physician gets paid much quicker than traditional methods (HIPPA).

Most also consider the use of speech recognition as a fundamental feature for an EMR thus as to
eliminate the use of a medical transcriptionist. The most popular speech recognition software is Dragon
Naturally Speaking. Many physicians familiar with earlier attempts to digitally parse human speech will
remember with a certain degree of volatility as their words were translated in gibberish. This is a stigma
that must be overcome. In recent studies, speech recognition software suites such as Dragon Naturally
Speaking Medical have scored 99% accuracy except in the rare cases of physicians with strong accents.
Compare this to the accepted accuracy rate of 98% for the typical medical transcriptionist and it
becomes easy to see the advantages (Fishman).

The question now becomes: How do existing EMR technologies stack up to this list of features?

Table 8

Physicians Reporting Selected EMR Feature

Selected Feature % of U.S. % Using EMR

Patient demographics 21.4 91.5

Physician clinical notes 17.7 82.2

Laboratory results 17.2 80.9

Nurse clinical notes 14.0 72.6

Computerized orders for prescriptions 13.4 73.5

Computerized orders for tests 12.7 67.6

Clinical reminders 10.7 57.9

Public health reporting 5.4 34.2

In the NCHS survey of those with EMR technologies in place found that there is a rather clear gradient in
the importance of these features. Features such as computerized orders for tests and clinical reminders
is trailing behind (<70%) but the only feature which seems to be truly neglected is public health
reporting which was only features in 34.2% of EMR used (Burt).

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Most popular EMR Systems

The American Academy of Family Physicians (AAFP) conducted a survey in 2008 regarding the adoption
of EMRs in an effort to determine which systems were being used the most. The survey returned 422
usable responses regarding 61 separate EMRs most of which were reported by fewer than 3
respondents. In the end, 13 systems accounted for 80% of all responses. Of the 422 physicians
responding, 70% were in single-specialty family medicine practices, 80% of which had been using the
system for between 0.5 and 5 years (Edsall).

Table 9

13 Most common EMR systems (alphabetical order)

Amazing Charts

Centricity*

Cerner PowerChart

Office*

eClinicial Works EMR

e-MDs Chart*

EpicCare*

HealthMatics EMR*

Misys EMR*

NextGen EMR*

Practice Partner Patient Records*

Praxis EMR*

SOAPware

TouchWorks*

*CCHIT certified.

10 of 13 top EMR systems were CCHIT certified meaning they met 100% of CCHIT certification criteria. In
addition to aforementioned features the survey took into consideration a few special features involving
security. The AAFP found that 98% of the top 13 systems utilized password protection and that 90% used
different levels of access to secure information. Finally 74% of the top 13 systems used an audit trail to
track changes made in the system.

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When asked to assess overall satisfaction with the systems they had chosen, 83% of respondents
selected that they would chose the same system again and the vast majority of respondents preferred
their EMR system to a paper-based system.

When asked if they would ever go back to a paper-based system the users of one system indicated that
without a doubt they indicated 100% that they would not ever go back. That system was Praxis EMR
which also scored highest when its users were asked if the system cost more than it was worth with 92%
indicating the contrary (Edsall).

Now lets take a moment to discuss each of the top 13 in a better attempt to understand what makes
them the best.

Praxis EMR

Praxis EMR doesnt use pre-installed templates instead it dynamically learns from the physicians
treatments. That means it fills in the blanks with the physicians own words, albeit from another patient
with similar or identical complaint. By monitoring frequency of symptoms and complaints Praxis is able
to best match a new patient with an existing learned behavior thus reducing charting time (How
Praxis).

Amazing Charts

Amazing Charts is a low cost alternative to other bulky expensive systems. It utilizes templates and is
focused on speed and simplicity of chart entry. The patients charts loads on one page to quicken the
process of charting. Family history and past medical history are automatically filled in as these fields tend
to be static from visit to visit (Amazing Charts).

e-MDs Chart

e-MDs Chart is another template-based system which speeds up data entry for familiar visits. It also offer
the ability to customize flow sheets designs for better capturing, trending and graphing clinical data thus
making it easier to digest. It can obtain this data through integrations with popular lob software such as
Quest and Labcorp (e-MDs).

HealthMatics EMR, Misys EMR and TouchWorks EMR

Healthmatics EMR has since been swallowed up into the Allscripts collection of EMR technologies along
with Misys EMR and TouchWorks EMR which is now known as Allscripts Enterprise.

eClincalWorks EMR

eClinicalWorks is a template-based system that comes preconfigured to run with 40 specialties and is
fully hosted on eClincialWorks servers(eClinicalWorks). This makes eClincalWorks the first on our list
for web based EMR solutions and probably the best looking of the commercial EMRs.

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SOAPware

SOAPware sets itself apart with advanced tools for data mining and trending; however, what these tools
are is not mentioned. SOAPware is another template-based system (SOAPware).

EpicCare

EpicCare EMR has support for 40 specialties using another customizable template-based approach to
chart entry (Core.

Practice Partner EMR

Introduced in 1987 McKessons Practice Partner Patient Records or Practice Partner EMR has been a
mainstay. It features 200 clinical templates and 700 prescription templates providing a vast range of
supported specialties. It boast the ability to automatically flag abnormal data and comes with a built in
web browser (Patient Record).

NextGen EMR

NextGen EMR is yet another template-based system this time equipped to handle 25 specialties. It does
set itself apart with a mechanism for image management which means forms from other hospitals or
clinics can simply be scanned into a patient record (Electronic).

Centricity

Centricity by GE Healthcare is another template-based system. This system was formerly known as IDX
GroupCast until was acquired by GE.

Cerner PowerCharts Office

The only that can be said about Cerner PowerCharts to discern it from the rest is that like eClinicalWorks
it is web-based providing a physician with access to his or her chart anywhere and anytime. Included out
of the box is support for 27 specialties that can be further customized to fit an individual practice
(EMR).

Open Source EMRs

One last thing to discuss, we have already mentioned how an EMR solution saves versus a paper-bases
system and that the leading reason physician do not switch to an EMR is capital expense to begin using
it. What if there was a solution in which all the physician had to pay for was the hardware to run the
system? This is of course the open source approach and it is not without its pros and cons.

The pros are obvious; cost, cost, cost, and cost. With an open source system a practice no longer has that
very large payment to software manufactures instead all they need to supple is the hardware to run the
system. This can be a significant reduction as we saw earlier the average acquisitioned cost of an EMR
was $42,485.50 of this only $12,525 accounts for hardware (Burke-Bebee).

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The cons to using an open source solution are a little more difficult to get around. The primarily stem
from the fact that the organization that produced the software may not exist tomorrow and thus support
may not be available. But really this is no different than any other solution. As we saw when going over
the top 13 that 3 of them had ceased to exist and become part of another companies product.

There is one pro that not mentioned earlier and that is what separates open source from commercial
products. More than the cost which for most is or is near free (in the case of ClearHealth they charge
$250 for their product which is still quite a bit lower than $42,485.50) is that a physician is given the
ability to change the system in a profound manor (Burke-Bebee). Even to the extent of creating their
own system using an existing code base which can dramatically reduce development time.

Three major open source EMRs are ClearHealth, OpenEMR, and HealthForge. All three use a web-based
approach. HealthForge is based off the powerful .NET web programming (Functionallity). And
ClearHealth utilizes ASP web programming (ClearHealth). HealthForge and ClearHealth are both CCHIT
certified. None of these products; however, are market ready. They are in fact perfectly suited for
building on top of.

Summary

The fact is EMRs will be taking over the way physicians practice medicine and it will be happening in the
next couple of years. There are many existing solutions each with their own sets of advantages and
drawbacks. There is also the option for creating ones own EMR either from scratch or using a preexisting
code base to save development time and effort.

According to recent studies around 67% of physicians currently do not use some kind of EMR solution
that means that available market for such a product is incredibly large especially taking into
consideration federal policies to encourage physicians to adopt this new technology. The time to strike is
before 2011, when most physicians will posses such a system or face federal penalties in the form of
Medicare and Medicaid payment reductions for not implementing a meaningful use EMR (67%).

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Burke-Bebee, Suzie Assessing EMR Adoption & Implementation in Physician Small Office Settings.
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Burt, Catharine W. et al. Electronic Medical Record Use by Office-Based Physicians: United States,
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