Introduction to EMRs (very basic information) Barriers to Adoption: Some Problems with Data Accessibility and Care Processes

EMRs for Clinical Research EMRs and HIPAA Security No Nonsense Guide to Selecting an EMR Examples of EMRs
Lessons Learned
OpenSource Commercial

Why do we need Electronic Medical Records (EMRs)? Many problems with the current healthcare system (underuse and overuse)
30% of children receive excessive antibiotics for otitis 20-50% of surgical procedures are not necessary 50% of back pain x-rays not necessary 50% of elderly patients dont get a pneumovax

Why do we need EMRs?

Clinical practice is a data intensive operation a Inadequate data communication causes medical errors Human cognition is good at pattern recognition but not at remembering lists or evaluating multiple business rules.

Available 24 x 7 Can be viewed by more than one user at a time Is available from remote locations
Data can nearly always be found Is legible
To covering MDs Others with appropriate needs

Enhances Communication:
Between providers--clinical messaging Can tag EMR location with message Referrals
Half of specialists didnt know what main question was A third of the time no information came back to PCP

Cost Savings:
Dictation cost savings
$170/FTE/month

Chart pull savings

$217/FTE/month

Savings accrue to practice, apply to all payers

Assist with Decision Support:

Many domainscost and selection of: Drugs
18% reduction found by Overhage

Lab tests
10-15% reduction in cost for charges, last result, probability of abnormal

Radiological studies

Decision Support: In inpatients, computerizing ordering decreased

EMR can help by
Alerting about
Serious medication errors by 55% All medication errors by 81% Structuring medication orders
Allergies Duplicate medications Many other issues

34% error rate with paper vs. 6% with electronic

Do EMRs make a difference?

UNEQUIVOCALLY YES, BUT AT A COST! In multiple studies, EMRs have been shown to:

Most benefits come from Decision Support.

Shorten Length of Stay in a Hospital setting Decrease Adverse Drug Events (ADEs) Improve Readability, Consistency and Content of the medical record Improve Continuity of Care Reduce practice variation

Even though the US Health Care system is the costliest in the world, its performance ranks 37th in the world according to the WHO! Only 5% of US primary care providers use EMRs (Bates et. Al., JAMIA 2003), 7% of all physicians (Wang, Bates, et. Al., American Journal of Medicine, April 2003)

Use PCs Use EMR Australia 90% 53% Denmark 95% 62% Netherlands 95% 88% Sweden 95% 90% United Kingdom 95% 58% (c) 2001 Harris Interactive

Use EMR Of Those:

Australia 90%
100% Unknown Unknown 15% (ICPC) Unknown

UK 99%
80% 45% 70% 100% (Read) 45%

Prescrip Notes Reminders Clin Vocab Paperless

$2B initiative by UK to get all physicians online

At their heart, EMRs are just a database This database hold many kinds of information

(coded and not coded)

This database is organized by date, time, pat ID and contains:

Patient registration data (name, contact info, DOB, SSN, etc.) Test results (laboratory, radiology, nuc med etc.) Medications (active, inactive) and Allergies Current list of diagnoses and problems Appointment Data Clinical Notes Billing Information

So if an EMR is just a database, how is it different from other databases, and why is it so useful? Value Added:
How do clinical concepts work together Ex: Digoxin toxicity can occur with hypokalemia

A Clinical Knowledge Heirarchy (term dictionary) A List of Current Clinical Recommendations A List of Appropriate Medication Indications, Doses, Adverse Effects and Interactions and Cost Estimates Costs, Indications and Utility of Tests

What are some typical EMR Components: Lab System: Contains all lab tests ordered and their results and stored as coded results (LOINC etc.) in many systems Radiology System: Stores test reports Pharmacy System:List of current medications, inactive meds and when they were last dispensed or ordered Billing System : A list of diagnostic codes used for billing (ICD9, CPT, etc.) Registration System: Names, Contact Info, Personal Info, etc. for patients

Additionally, many EMRs have:

An Order Entry System (where physicians enter orders, prescriptions, notes etc. online) A Decision Support System

Often linked to the order entry system to provide guidance at the point of care Contains databases for clinical knowledge, guidelines, list of medication indications, doses etc.

The spectrum of EMRs

EMRs target specific user bases, from solo officebased practices to large, multispecialty tertiary care centers Many features are thus directed at managing workflows specifically to these user bases

For example, large commercial EMRs unbundle services such as clinical documentation, results display etc. while office systems typically integrate all of these under the same interface.

Patients REGISTRATION SYSTEM LAB SYSTEM Nursing Staff PHARMACY SYSTEM Physicians RADIOLOGY SYSTEM Coding Staff

Clerks

BILLING SYSTEM

Insurance Co. Order Entry/Results Reporting

EMRs dont necessarily need to be expensive and complicated or require that a computer be used to enter data Can have hybrid computer/paper based approaches

Ex: In the CHICA System, paper is used to interact with an electronic data repository Standardized paper forms are printed and then scanned Characters are recognized and the electronic data so generated interacts with the data repository

At Indiana University, pediatric clinics use this system:

A data repository was developed using Microsoft SQL Server A clinical guideline system was written in Arden Syntax An optical character recognition system called Cardiff Teleforms is used to process handwritten numerical data on preprinted scanned forms The data so generated is stored in the database and dynamic reminders are generated for the physician These are printed on the clinic computer The entire operation takes < 2-3 minutes!

The Mosoriot Medical Record System

Indiana University has an HIV Effort in Kenya A Simple MS Access based database holds all patient records (3 years worth!) Provides forms for data entry, standard term dictionary, medication listings, registration system, clinical documentation system etc. Created by 1 programmer over 2-3 weeks! Highly effective, easy to maintain, inexpensive!

So how can EMRs populate their databases? Data can come from many many sources:
Admission/Discharge/Billing Anesthesia Systems Cytology Systems Diagnostic Imaging Management Systems EKG Carts Endoscopy Systems ER Systems

More Data Sources:

Home Care Systems ICU Monitoring Systems IV Fluid Infusion Control Systems Laboratory Systems Nurse Triage Order Entry Systems Pharmacy Systems (Inpatient/Outpatient) Pulmonary Function Systems

More Data Sources

Radiology systems Risk Management systems Registration Systems Scheduling and Clinic Charge Systems Transcription Systems Unit Dose Dispensing machines Ventilator Management systems

So if there are so many data sources available and so many people are interested in using EMRs, why are they not more prevalent?

For the last 30 years the medical informatics community has struggled with how to architect the vessel that will hold patient data Problem is that they have focused on the wrong problem! We dont just want to create a system that permits entry of data electronically, we want to create a system that can acquire this data

automatically from other electronic data repositories and make it available at the time of service.

Too many repositories or islands of systems

Difficult to bridge and combine in useful ways Contain different data at different levels of granularity Each uses a different code to identify the same information. Many institutions do not capture all of the data of interest to clinicians. Labs are sent to external reference laboratories Patients fill their scripts at community pharmacies As a result many implementations do not lead to satisfactory achievement of the intended quality assurance goals

Another problem is that there are many many care providing sites in the United States: Hospitals 5000+ Nursing Homes 19000+ Pharmacies 59722+ Physician offices 200000+ Laboratories 63000 Emergency Rooms 4856 Hospice Care 2800 Home Care agencies 4258 All of these sites generate data that are not necessarily compatible.

Thus, the problem is not one of creating database fields de novo, it is one of merging existing fields from many different sources in meaningful ways
When commercial and other EMR vendors create proprietary, closed, systems, with custom database architectures, they often worsen the problem and make it harder to populate the database with useful information, inexpensively

Fortunately, most of the informatics community has realized that the solution to the problem of merging data lies in the implementation of Standards for Data Communication.
These standards permit data to be easily translated from one database system to another

There are many many standards, each for a different purpose

Lab Data Communication General Clinical Messaging Radiology Image Transmittals Diagnostic Coding Procedure Coding

Need to distinguish between coding standards and messaging standards.

HL7 (Health Level 7)

Most widely used standard General clinical messaging standard Communicates structured data Fields for:
Diagnostic Results Notes Referrals Scheduling Information Nursing Notes Problems Clinical Trials data

Health Level 7

2000 hospitals, the CDC and most referral labs. Also used in Canada, Australia, New Zealand, Japan and extensively in Europe Bridges many systems, including laboratory, dictation, pharmacy, electronic patient records, performance databases, data repositories (cancer registries) etc. Web Site:

http://www.mcis.duke.edu/standards/HL7/ h17.htm

LOINC

Logical Observations and Indicators Names and Codes A coding standard that is used for LAB data Used for representing laboratory observations and common clinical measurements At least 5 large commercial labs (Corning, MetPath, LabCorp, ARUP Labs and Life Chem) have adopted LOINC

DICOM

Another messaging standard Standard of choice for transmitting diagnostic images Closely supported by all of the imaging vendors and is working with the HL7 group Web site:

http://www.xray.hmc.psu.edu/dicom/dic om_home.html

ICD9/10 Used to code diagnoses CPT Used to code procedure data ISO+ - Used to code units of measure UMDNS Device classification standard NDC Drug entities classification SNOMED organism names, topologies, symptoms and pathology HOI Outcomes variables UMLS Metathesaurus for clinical nomenclature Arden Syntax Clinical knowledge

How do we ensure that the information belongs to the correct person?

Patients move and change addresses/tel#s Patients change names or use aliases Patients sometimes have multiple SSNs There are differences in patient, provider and place of service identifiers among data sources

Solutions to this problem do exist but at a local institutional level at the moment Our institution uses a combination of mothers maiden name, SSN and DOB to uniquely identify the patient
The Kassebaum-Kennedy Bill (PL 104-191) will make this into a national effort and standardize patient and provider identifiers

The ultimate EMR promises to capture whatever data is needed to perform any EMR task outcomes analysis, utilization review, profiling and cost estimation.
This prospect excites many CEOs and CIOs However, much of the data needed for such functionalities comes from physicians (disease severity and clinical findings) and most of this data is recorded as un-coded free text.

In order for physician generated data to be useful it needs to be in coded form so that algorithmic assertions can be made
The problem of coding free text data is of paramount importance and information systems designers have struggled with this as long as the field of medical informatics has been in existence

One approach we could take would be to translate existing free text dictations into coded, computer readable information, but:

Or the physician could code the data themselves by entering structured notes but:

Human coding is error prone and expensive and is at too high a level of granularity to be useful Decades of research into computer based coding has still not yielded satisfactory results

This is costly in terms of time as it requires the user to map the terms into computer understandable words at a level of granularity which is useful

Commercial EMR vendors bypass the problem and provide every mode of data entry possible:
Direct keyboard entry Dictation with human transcription Voice Recognition Structured Data Entry Paper based data collection Web/PDA/Mobile devices

Problem is that we dont know which one is the most efficient so users have to think with their feet

We did a study at Indiana University comparing voice recognition with typing and dictation/transcription and found that (at least for 1 user): Voice recognition almost doubled the note size as compared with typing It took longer to use voice recognition by 1.3 min as compared with typed notes Voice recognition was 30 fold less accurate than dictation/transcription During proofreading, the user missed 30% of errors 1.2% of errors changed the intended meaning Dictated note turnaround time was from 2-5 days!

Managers and quality analysts want data that is often never captured And we dont even know how much of this kind of information is needed?
For some disorders (angiography and knee surgery) data sets have been developed but we do not know the operating characteristics or predictive value of the data elements? How do we define and collect the soft data elements? Formal functional status Detailed Guideline criteria

We do have some instruments for some disorders (CAGE, Hamilton Scale, SF12/36 etc.)
But we lack them for many other clinical entities and for much of specialty clinical care And checklist based symptom questionnaires as opposed to validated instruments elicit many more symptoms than open ended questions, so which of these are really

important?

Coding of all medical information is unnecessary

So where do we draw the line?
(how much should be coded and how much can be stored as free text) in order to maximize the utility of the information.

The other issue is with longevity of clinical notes.

How often do you use a note from 2 years ago? How long do we need to keep the EMR data?

Cost is perhaps the biggest barrier to implementation Unfortunately there are few studies that have looked at the long term ROI with EMRs Most existing studies have been done by the system vendors and so the data should be examined with a cautious note However, the data that is available suggests that the ROI is excellent!

Several studies are worth mentioning

(1) Renner et. Al. looked at implementing an EMR in 1996 in 40 primary care practices
Its net present value (1996 dollars) was about $280,000 based on a 5-year model They found that reducing the cost of medications and preventing ADEs was of the greatest benefit in primary care

(2) Wang, Bates et. Al. looked at the cost of implementing a full EMR in primary care as compared with paper based chart systems Primary outcome was the cost benefit per provider over a 5-year period Used average statistics from their institution (Partners Healthcare, Boston), expert opinion and national data to estimate costs

System Costs ($13,100 initial, $3100 each year + HW) Induced Costs ($11,200 in year 1)

(2) Wang, Bates et al.

Benefits resulted from costs averted ($/year)

All benefits finally being realized in year 4

Transcription savings ($2700) Reduction in need for chart pulls ($5/chart pulled) Drug cost savings and prevention of ADEs ($2200) Laboratory and Radiology cost savings ($10,700) Charge capture improvement ($7700) Decrease in Billing Errors ($7600)

(2) Wang, Bates et. Al.

Resulted in present value of net benefit (2002 dollars) to be $86,400/provider in year 5 Breaking down by EMR feature they got:
Light EMR (net loss of $18,200/doc in year 5)
Online patient charts only Adds an Electronic Prescribing Module

Medium EMR (net benefit of $44,600/doc in year 5) Full EMR (net benefit of $86,400/doc in year 5)
Adds Lab, Radiology and Charge Capture systems

(2) Wang, Bates et. Al.

Conclusions: An Ambulatory EMR

Resulted in net benefits across a range of assumptions, which increase as more features are added and as the time horizon lengthens Most benefit was derived from reductions in drug expenditures, improved test utilization, improved charge capture and reduced billing errors The greater the portion of capitated patients the greater the return, although benefits also accrue for fee-for-service patients (but mostly to payers and not health care institutions) Limitation: Did not consider malpractice reduction, increased provider productivity or decreased staffing requirements. Intangible benefits: Improved Quality and Decreased Errors

(1) Physician reluctance and fear that their productivity may decline (which it does) (2) Unreliability of EMR Vendors in a volatile IT economy. Lack of adequate IT support from the vendors (3) Concerns over data security

Too many data sources, no simple way to coordinate and connect them except to use standards which are still evolving Unique patient identification still a problem esp in large tertiary care centers Physician data capture inefficient and expensive

Startup costs can be prohibitive but long term benefits are clearly evident form pilot studies Physician reluctance a major barrier to use Concerns over security still an issue, eg: HIPAA System vendors are transient and fail to provide adequate support

So what EMR functions do we need in order to effectively do clinical research? Answer: Depends on what you want to do However, to be able to ask questions of your practice, you need:

Registration data (Registration system) Diagnoses (Billing data) Medications (Pharmacy data) Labs and other Test Results (Lab/Radiology data)
AND

A system to query these databases intelligently

You dont necessarily need a decision support or order entry system but if you want to intervene, you may want to include these systems as well

Note that the registration, billing, pharmacy and lab/radiology data usually (but not always) exists, outside of the context of any specific EMR system
These are just data repositories which need to be tapped into and queried So you need a system to access and query these databases, independent of any electronic medical record system.

Alternatively, you could build a master repository which acquires and stores this information and permits intelligent queries to be performed
This is exactly what we did in Kenya in the Mosoriot Medical Record System, although data is still hand-entered. Eventually it will be downloaded using HL7 messages.

An example of an EMR that is inexpensive and functional and supports both clinical care and research in rural Kenya Built in 2-3 weeks by 1 programmer using Microsoft Access Consists of: Data dictionary tables which define test names, medications, diagnoses etc. Forms which are used for data entry Has tables for registration data, billing data, medication lists, lab and test results Currently running on Tablet PC devices in Kenya

REGISTRATION SYSTEM LAB SYSTEM PHARMACY SYSTEM RADIOLOGY SYSTEM BILLING SYSTEM

Eligibility Data Acquisition

DATA ANALYSIS

INTERVENTION

Reliance on Standards (HL7, LOINC, ICD9, CPT) Easy access to data repository, i.e. database structure is well documented Built-in Practice Profile Management systems Built-in decision support and order entry functionality Able to export data in a standard format (CSV, MDB etc.)

HIPAA = Heath Information Portability and Accountability Act Final Security Rule Published in the Federal Register on February 20, 2003 (effective 60 days)
Designation: 45 CFR 160, 162, 164 Compliance Dates: April 20, 2005

http://www.cms.hhs.gov/hipaa/hipaa2/regulatio ns/security/default.asp Covered Entities: 24 months after effective date Small Health Plans: 36 months after effective date

Some excellent links:

http://privacy.med.miami.edu/glossary/gt_securit y_rule.htm http://www.hipaadvisory.com/tech/wireless.htm http://www.hipaadvisory.com/regs/securityovervie w.htm

Security should not be confused with Privacy or Confidentiality

Privacy: The rights of an individual to control his/her personal information without risk of divulging or misuse by others against his or her wishes Confidentiality only becomes an issue when the

a means of protecting this information Security refers to the spectrum of physical, technical and administrative safeguards used for this protection

individuals personal information has been received by another entity. Confidentiality is then

Addresses 3 tiers of protection:

Administrative Safeguards Physical Safeguards Technical Safeguards

Institutional level

Develop security management process where potential threats to PHI are determined Provide training to all employees about HIPAA Provides appropriate level of authorization based on a protocol for granting access Violations should be clearly documented and investigated A disaster recovery plan should be in place

Applies to 3 elements of the PHI data storage infrastruture:

Facility where PHI data is stored Workstations on which it is stored Media on which it is stored

Require that the facility have access control Contingency plans need to be in place in case an intruder gains access Workstation security measures be in place
Automatic logoff Screen is placed away from potential viewers PDAs should be password protected

Devices and media should be appropriately disposed of in case they are no longer needed and data should be erased properly

Applies to how information is stored, verified, accessed and transmitted/received Access and audit controls Emergency access to information when needed Automatic logoff is enforced Data is encrypted and decrypted during transmission Verify integrity of the storage and transmission (digital signatures)

Questions to ask yourself and your institution

1. Was a security audit done and if so what are the results? 2. Did I get the appropriate HIPAA training and do I have a certificate to prove this? 3. Are there procedures in place to grant access to PHI to authorized users? 4. What are the procedures in place in case of disaster, data loss or data theft? Are Backups made frequently?

1. What are the procedures in place to safeguard the facility from intruders? Are there contingency plans for dealing with intruders, data theft or other event?
2. How do protect the safety of workstations? Are they password protected? 3. Can bystanders view the screens on which PHI may potentially be displayed?

4. Is an automatic logoff mechanism enforced? What time limits are provided before this occurs? 5. What types of data are stored on PDA devices and if PHI is stored is it password protected or encrypted? 6. What procedures are used when disposing of, reusing or archiving data on hard disks, CDs, floppys and Zip disks? Are PHI data erased properly if the disks are to be disposed of or reused?

1. Are there audit mechanisms for checking who is accessing the PHI data and is this done on a regular basis by authorized personnel? 2. Are there procedures in place to grant emergency access to information if needed? 3. Is data integrity checked when the data is transmitted or received? (digital signatures, digital certificates, checksums etc.) 4. Is the data encrypted and decrypted during the transmission process?

Do I really need to be wireless of can I get by with a wired connection?

Is space limitation a problem? Is mobility absolutely necessary?

Do I have the permission of my institution to install wireless networks? Do I have adequate IT support to do this?

Wireless is inherently unsecure Many Many ways of hacking into wireless networks Technology base is there to make it secure Some simple steps can be taken to maximize the security of your wireless network

1. Change the default SSID (network name) on the router so that your name/location is kept secret 2. Disable the SSID broadcast, if your router supports it. This will prevent hackers from seeing you 3. Change the administrators password on your router.

4. Turn on the highest level of security supported by your hardware (i.e. Wireless Equivalent Privacy WEP, which is older or WPA which is the latest and most secure) 5. Make sure you have the latest firmware updates. Implement MAC (media access control), which specifies exactly which WLAN PC cards can access the network and excludes others

6. Place the Wireless Access Point (WAP) towards the middle of the building, keeping the zone of potential access within the building. 7. Do your own security audit. Use Network Stumbler (www.netstumbler.com) on your Tablet PC, laptop of PDA and walk around the perimeter of your building to see where and what a would-be hacker may see

8. If you have a limited number of wireless clients (Tablet PCs), provide them with static IP addresses, and disable DHCP on your router. This ensures that only authorized machines can see your network.

9. If we are in an enterprise setting, use VPNs (Virtual Private Networks). You can isolate your WLAN from the wired network using products such as the Netgear FVM318 or the SonicWall SOHO TZW. Then you can use the VPN to tunnel directly into the wired network securely

10. Avoid using public hotspots, areas that are insecure and open for general use. 11. Turn off file and print sharing on your Tablet PCs. Most devices do not prevent client-to-client traffic, so people sitting across the street from you can be looking at your shared directory remotely.

Award winning EMRs CPRI Davies Award Winners (1995-2000)

Emphasis on successful implementation, not on technology that is behind the design Functional Requirements:
Integrate data from multiple sources Provide decision support Used by caregivers as primary source of information Must enhance care, not just replace paper

So who are there award winners and what are their strategies for success?

1995

1996 1997

1998

1999 2000

Intermountain Healthcare System, Salt Lake City Columbia Presbyterian Medical Center Department of Veteran Affairs CPRS (now open-source) Brigham and Womens Hospital Kaiser Permanente, Cleveland OH Regenstrief Medical Record System North Mississippi Health Services Kaiser Permanente, Portland OR Northwest Memorial Hospital, Chicago Kaiser Permanente, Rocky Mtn. Region Harvard Vanguard System

Common Strategies and Attitudes towards implementing EMRs

Vision of healthcare as an information business Sustained leadership (5 years +) Run by project leaders and not CIOs
EMRs subjected not to a cost benefit ROI analysis but to an unremitting pressure to show value
Most projects had physician champions

Customer Service, Customer Service!

Frequent, sustained, end-user orientations and feedback with demonstrated responsiveness to feedback!

System developers were also the salespeople, troubleshooters, coaches and colleagues!

Weekly Regenstrief Pizza Meetings Kaiser physician focus groups Northwestern weekly feedback with supplements

Plans in place for system evaluation and change management All winners had to re-engineer some workflow process dont automate a manual process that occurs commonly but does not work! Incremental deployment dont rush things Each increment overcame a specific barrier

to care

Systems were viewed as tools to enable care process improvement and were not an end

to themselves

All resulted in a decreased reliance on paper-based sources of information Decision Support, Decision Support, Decision Support -> provides the largest value added compared to a paper system Focus on standards based data architecture rather than specific applications to do this or that FAST RESPONSE TIME! Flexible enough to adapt to organizational change

Depends on your size and your budget Solo practice -> yes, definitely Multispecialty group (2-100) -> probably (cost is around $4-20K per provider) Multispecialty, multisite groups maybe Tertiary care centers with scattered secondary care sites -> probably need to be brave and wealthy!

Do not start in product selection mode Begin by identifying the practice processes that you wish to improve first Then search for the functions you need:
Problem List Clinical Encounters Telephone Calls Preventive Care Medications Lab/Xray/Pathology Referrals Managed care

Anticipate primary and secondary users

Primary
Clinical decision making, Documentation Support for Billing Provider profiling and service utilization Quality report cards and outcomes analysis Regulatory reporting and justification for studies

Secondary

Again, think of using selected modules to enhance parts of your practice

Clinical Note Systems Prescription Writer

Use one or more of the OpenSource EMRs

Need some level of IT expertise to deploy No real support available from the developers

a. OpenEMR (http://www.synitech.com/openemr/ <http://www.idltechnology.com/products/openemr/index.php>) b. Care2002 (<http://sourceforge.net/projects/care2002/>) c. Open Infrastructure for Outcomes UCLA (<http://sourceforge.net/projects/open-outcomes/>) d. PatientRunner (<http://sourceforge.net/projects/patientrunner/>) mental health record system e. OpenSDE (<http://sourceforge.net/projects/opensde/>) structured note entry system f. MedSurvey (<http://sourceforge.net/projects/medsurvey/>) clinical information system for Windows PCs g. OpenEMed (<http://sourceforge.net/projects/openmed/>) Java based EMR h. Hardhats (VAs VISTA software) yes this IS open source now and available to EVERYONE (<http://www.hardhats.org/>), (<http://sourceforge.net/projects/hardhats/>)

Recent survey done by the journal Family Practice Management (2001) Surveyed 28 vendors Price structure highly variable Found that the market is highly volatile and some vendors went out of business or merged with others during the time of the survey

Five star systems:

ChartWare HealthProbe Patient Information Manager EpicCare

Four Star Systems

Logician NextGen Pearl Physician Practice Solutions PowerMed EMR Practice Partner Patient Records QD Clinical

Four Star Systems

SOAPWare Welford Chart Notes Clinical Works Module (ASP) NextGen (ASP) Physician Practice Solution (ASP) topsChart (ASP)

4+ physician practices:
ENTITY, Logician, NextGen, ClinicalWorks

10+ physician practices:

EpicCare, PEARL, Physician Practice Solution

All others can serve practices of any size

Most allow ICD9 and CPT codes Many allow access from the web Most allow multiple modes of data entry (keyboard, mouse, touch-screen, light-pen, voice recognition etc.) Most permit integration of hospital data with a primary care database

Some EMRs allow data access from PDAs and other handheld or laptop devices:
ChartWare DOCU*MENTOR ENTITY EpicCare MedicWare NextGen topsCHART - O-HEAP - Partner - PowerMed - SOAPWare - Welford ChartNotes - ClinicalWorks

HealthCare Informatics 2004 Resource Guide

Comprehensive listing of EMRs, features, costs, contact information etc. $50 per copy Order from:
http://www.healthcare-informatics.com

Well-designed renowned vendor products meet about 80% of your needs -> where will the other 20% come from? Poorly designed systems will be quickly abandoned by time-pressured end-users Caveat Emptor: Total Solution, Turnkey solution, esp if a proprietary black box

Clinical/Administrative information is inherently structured. Capturing it in unstructured ways (images) is a costly mistake Data acquisition costs may be more expensive than operational expense (I.e. keyboard entry time more costly than provider input)

Users will accept a tradeoff if there is a clear payback in functionality Attitudes towards computer use are not age dependent Be the 10th customer to a vendor, never the first! Beware of vendors who say we can do that what is it?

The most important information a vendor will give you is the address of 2-3 sites where their system is currently in use