EHRs: Improving efficiency & maximizing potential

Surescripts sponsored E-Book by Medical Economics

EHRs: Improving efficiency & maximizing potential

1. e-book
Digital publication
Important information about EHRs
from the publishers of
Medical Economics
This E-Book is brought to you by
EHRs:
Improving efficiency & maximizing
potential

2. 2 MedicalEconomics.comMedical econoMics
Go to modernmedicine.com/
EHRbestpractices for more
practical tips and to access
Medical Economics’ content
related to the implementation
and use of EHRs.
07 Top 50 EHRs: EHR Capability Checklist
10 Top 50 EHRs: Top 50 EHRs
13 Top 50 EHRs: Scorecard
22 EHR 2.0: 4 ways vendors are building
better systems
26 EHRs: 5 ways to put data into action
30 How to optimize your patient portal
34 E-prescribing rates soar among
physicians
35 E-prescribing is benefi tting healthcare
system, but barriers to adoption remain
37 Ways to optimize EHR documentation at
your medical practice
41 Utilize your EHR system to boost
practice revenue
insiDe
About this ebook  The information contained in this e-book is an aggregation of published works from Medical Economics.
It was created to off er physicians a useful guide as it relates to implementation of technology in their practice. For more insights on this and other
topics, visit our Resource Center at: medicaleconomics.modernmedicine.com/EHRbestpractices.
EHRs: Improving ef  ciency & 
maximizing potential 
As the evolution of health information technology forges for-
ward, electronic health record (EHR) systems will continue
to transform the practice of medicine. Tomorrow’s practice
won’t be confi ned by four walls and 15-minute appointment
slots, but will have the ability to infl uence, guide and educate
patients in real-time at home or at work while changing the
way healthcare teams operate to achieve successful outcomes.
In this e-book, Medical Economics showcases recent cover-
age of important EHR topics to help you improve your effi cien-
cy and maximize the impact of technology on your practice.
Th is coverage includes the results of our exclusive national
physician survey providing usability ratings of the top EHR sys-
tems in fi ve key areas, including Meaningful Use attestation,
clinical support, technical support, impact on quality of care,
and patient portals. Th is also features the top 50 EHR compa-
nies displayed alphabetically to off er a predictive metric for a
company’s longevity in the market on as well as a capabilities
checklist to use when selecting (or changing) an EHR system.
Other key EHR topics include ways to maximize revenue, data,
documentation, and patient portal use.

3. 3 Medical EconomicsMedicalEconomics.com
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4. 4 MedicalEconomics.comMedical Economics
We believe healthcare will get better with improved information. As the nation’s
most comprehensive health information network, we integrate with existing
software systems to connect providers, health plans, pharmacies and healthcare
technology partners—helping improve the efficiency and effectiveness of
America’s healthcare system.
Copyright © 2014 by Surescripts, LLC. All rights reserved.
E-PRESCRIBING
Medication History
Immunization Reporting
Electronic Prior
Authorization
E-Prescribing of Controlled Substances
Unleashing
the Potential
of Healthcare.
Surescripts services are accessible to you
through your EHR vendor.

5. We believe healthcare will get better with improved information. As the nation’s
most comprehensive health information network, we integrate with existing
software systems to connect providers, health plans, pharmacies and healthcare
technology partners—helping improve the efficiency and effectiveness of
America’s healthcare system.
Copyright © 2014 by Surescripts, LLC. All rights reserved.
E-PRESCRIBING
Medication History
Immunization Reporting
Electronic Prior
Authorization
E-Prescribing of Controlled Substances
Unleashing
the Potential
of Healthcare.
Surescripts services are accessible to you
through your EHR vendor.

6. Introducing the Medical Economics app for
iPad and iTunes
The leading
business resource for physicians
is now available in an app!
Download it for free today at
www.MedicalEconomics.com/MedicalEconomicsApp

7. 7Medical econoMicsMedicalEconomics.com
e-book
Digital publication
Does your electronic health record (EHR) system have the functionality you need?
Choosing an EHR vendor that provides the services your practice requires is a
complicated endeavor, and purchasing the wrong system can cut into practice
fi nances and hamper workfl ow for years. Th is EHR Capability Checklist was designed
by Medical Economics editors to help physicians evaluate their current EHRs or shop
for a new one. Is your system up to snuff ? See the checklist below to fi nd out.
EHR capability
CHECKLIST
VENDOR SUPPORT AND TRAINING
Offers on-site training
Provides online resources for training
purposes, such as tutorials, online
chats and downloadable educational
materials
Ability to create customized templates that suit the needs of your practice
Responds quickly to technical problems associated with the EHR system
Provides guaranteed turnaround times for resolving technical issues
Offers fl exible and after-hours technical and staff support
Provides U.S.-based technical support call centers
PATIENT PORTAL
Offers a patient portal
Allows patient to view:
Lab results
Plan-of-care summary
X-ray reports
Other diagnostic testing

8. 8 MedicalEconomics.comMedical Economics
Consultant reports
Educational materials
Ability to communicate securely
through the patient portal
Enables patients to schedule and cancel appointments through the patient portal
Enables patients to request prescription refills through the patient portal
INTERFACES
Provides the following system interfaces:
Reference
Hospital
Imaging
Practice management (PM) system
Devices
EKG
Spirometry
Holter monitor
X-ray
Ultrasound
Provides customized interfaces to meet your needs
QUALITY CARE AND REPORTING
Produces quality data for Meaningful Use
Generates quality data for Physician Quality Reporting System
Enables providers to identify patients who are not meeting clinical guidelines for chronic conditions
Helps physicians improve quality metrics
Ability to implement at least five clinical decision support tools (such as drug interaction checkers)
POPULATION HEALTH MANAGEMENT
Generates reports on subgroups of patients (for example: women over 50 who are due for mammograms.)
Creates patient registries that track the preventative and chronic care services provided to patients
Ability to provide patient-care alerts
Capable of exchanging clinical summaries across the spectrum of care
Generates tailored educational materials for patients

9. 9 Medical EconomicsMedicalEconomics.com
26
%
of physicians are
very confident
their EHR system
will still be viable
in five years
38
%
of physicians are
doubtful or very
doubtful their EHR will
be viable in five years
67
%
of physicians are
dissatisfied with EHR
system functionality
35
%
of physicians believe
their EHR has
improved the quality
of patient care
69
%
of physicians say
their EHR system
has not improved
coordination of care
with hospitals
63
%
of physicians
would not
purchase the same
EHR system if they
had a chance to do
it over again
31
%
of primary care
physicians believe
their EHR system
has been worth the
effort, resources
and costs.
Physician E HR satisfaction
Source: 2014 EHR Survey; MPI Group/Medical Economics
FINANCIAL SUPPORT TOOLS
Offers a practice management system
or interface
Offers revenue cycle management services
Ability to track financial performance within the practice management system

10. MedicalEconomics.comMedical econoMics10
e-book
Digital publication
Top 50 EHRs
Medical Economics is unveiling this exclusive report on the top 50 electronic
health record (EHR) vendors in an eff ort to help physicians make purchasing
decisions. Companies are listed in alphabetical order.
Public
or PrivateCompany Annual Revenue EHR Annual Revenue WebsiteVendor System Name
4Medica 4medica iEHR Private $6,000,000 $2,000,000 www.4medica.com
AdvancedMD (ADP) AdvancedMD EHR Public $12,000,000,000 www.advancedmd.com
Advanced Data Systems
Corp.
MedicsDocAssistant EHR/EMRPrivate * www.adsc.com
Allscripts Healthcare
Solutions, Inc.
Touchworks EHR, Allscripts
Professional EHR
Public $1,400,000,000 $870,000,000 www.allscripts.com
Amazing Charts, LLC Amazing Charts Private ** www.amazingcharts.com
Aprima Medical SoftwareAprima EHR Private ** www.aprima.com
athenahealth athenaClinicals Public $595,000,000 www.athenahealth.com
Benchmark Systems, Inc.Benchmark Clinical Private $10,000,000 $3,000,000 www.benchmark-systems.com
Bizmatics, Inc. PrognoCIS EMR Private $6,000,000 $6,000,000 www.bizmaticsinc.com
CareCloud Corp. CareCloud Charts Private $11,000,000 $11,000,000 www.carecloud.com
Cerner Corp. PowerChart AmbulatoryPublic $2,900,000,000 www.cerner.com
CompuGroup Medical, Inc.
(CGM US)
CGM CLINICAL, CGM webEHR,
CGM ENTERPRISE EHR
Public $50,000,000 $40,000,000 www.cgmus.com
CPSI CPSI Medical Practice EMRPublic $200,860,000 www.cpsi.com
*Revenue estimates gathered from Hoover’s fi nancial reporting.
**Revenue withheld at company’s request

11. 11 Medical EconomicsMedicalEconomics.com
Public
or PrivateCompany Annual Revenue EHR Annual Revenue WebsiteVendor System Name
CureMD CureMD All-in-One EHRPrivate $91,800,000 $62,200,000 www.curemd.com
Cyfluent Cyfluent Private $5,000,000 $2,000,000www.cyfluent.com
DocuTAP, Inc. DocuTAP Private ** www.docutap.com
e-MDs , Inc. Solution Series,
Cloud Solutions
Private ** www.e-mds.com
eClinicalWorks eClinicalWorks Private $280,000,000 $252,000,000 www.eclinicalworks.com
Endosoft
(Utech Products, Inc.)
EndoVault Private * www.endosoft.com
Epic Systems Corp. EpicCare Ambulatory,
EpicCare Inpatient
Private $1,660,000,000 $1,660,000,000 www.epic.com
GE Healthcare (GE Corp.)Centricity Practice Solution /
Centricity EMR
Public $146,000,000,000 www.gehealthcare.com
Glenwood Systems, LLCGlaceEMR Private $7,500,000 $7,500,000 www.glenwoodsystems.com
Greenway Health, LLCPrimeSUITE, Intergy,
SuccessEHS
Private $350,000,000 www.greenwayhealth.com
HealthFusion, Inc. MediTouch Private $35,000,000 $35,000,000 www.healthfusion.com
Integrated Systems
Management, Inc.
Omni EHR Private * www.omnimd.com
iPatientCare, Inc. iPatientCare Private $39,000,000 $39,000,000 www.ipatientcare.com
Kareo, Inc. Kareo EHR Private $48,000,000 $48,000,000 www.kareo.com
MacPractice, Inc. MacPractice MD,
MacPractice 20/20,
MacPractice DC,
MacPractice DDS
Private $15,000,000 $15,000,000 www.macpractice.com
McKesson Specialty
Health (McKesson Corp.)
iKnowMed (SM) EHR, iKnowMed
(SM) Generation 2
Public $122,460,000,000 www.mckesson.com
MD On-Line, Inc. (MDOL)MDOL EMR Private ** www.mdon-line.com
MEDENT MEDENT Private $42,000,000 $30,000,000 www.medent.com
Medical Informatics
Engineering, Inc.
WebChart EHR Private * www.mieweb.com
MEDITECH MEDITECH Private $597,840,000 www.meditech.com
Meditab Software, Inc.IMS Clinical Private $35,000,000 $20,000,000 www.meditab.com
MicroFour, Inc. PracticeStudioX16 Private $13,650,000 $12,000,000 www.practicestudio.net
Modernizing
Medicine, Inc.
Electronic Medical Assistant (EMA)Private $17,300,000 $17,300,000 www.modmed.com
MTBC ChartsPro Public * www.mtbc.com
Nextech Nextech Private ** www.nextech.com
*Revenue estimates gathered from Hoover’s financial reporting.
**Revenue withheld at company’s request

12. 12 MedicalEconomics.comMedical Economics
Public
or PrivateCompany Annual Revenue EHR Annual Revenue WebsiteVendor System Name
NextGen Healthcare
Information Systems, LLC
NextGen Ambulatory EHRPublic $444,700,000 $335,000,000 www.nextgen.com
Optum, Inc.
(UnitedHealth Group)
Optum Physician
EMR
Public $37,000,000,000 www.optum.com
Platinum Systems
Specialists, Inc.
PlatinumEMR Private * www.platinumemr.com
Practice Fusion, Inc.Practice Fusion EHR Private * www.practicefusion.com
Practice Velocity, LLCVelociDoc Private $24,500,400 $12,800,000 www.practicevelocity.com
Praxis EMR
(Infor-Med Medical
Information Systems, Inc.)
Praxis EMR v5 Private $38,400,000 $38,400,000 www.praxisemr.com
Prime Clinical
Systems, Inc.
Patient Chart ManagerPrivate $10,000,000 www.primeclinical.com
Pulse Systems, Inc.
(Cegedim Group)
Pulse Complete EHR Public $1,200,000,000 $92,300,000 www.pulseinc.com
Quest Diagnostics Care360 EHR Public $7,100,000,000 www.medplus.com
RazorInsights, LLC ONE-Electronic Health RecordPrivate $7,000,000 $7,000,000 www.razorinsights.com
SOAPware, Inc. SOAPware, myHEALTHwarePrivate $5,600,000 $5,600,000 www.soapware.com
Viztek Opal-EHR, Exa Private $72,000,000 www.viztek.net
This Medical Economics
project started in spring
2014 and concluded on
August 28, 2014. Here is
how the editorial team
approached gathering
company data presented
in this report:
1  Companies offering complete,
ambulatory EHR systems were given the
opportunity to report company data by filling
out a
Medical Economics survey. Editors
evaluated companies based on survey
responses and other criteria.
2  When available, editors obtained
revenue for publicly traded companies from
published annual reports.
3  Editors used revenue estimates from
Hoover’s financial reporting if vendors
did not complete the survey and if other
information, such as published annual
reports, was not available. Hoover’s
estimates are denoted with an * in the
revenue field.
4  If editors obtained a revenue range,
the low end of the range was used.
5  Some survey participants
provided 
Medical Economics with revenue
data for our internal deliberations only.
Those vendors are marked with ** in the
revenue field.
6 The Top 50 is listed in alphabetical order.
7 Some companies provided annual EHR
revenue while others did not. That field was
left blank when not provided.
*Revenue estimates gathered from Hoover’s financial reporting.
**Revenue withheld at company’s request
Download Find the Top 50 list and other EHR reference materials at http://MedicalEconomics.com
How we got
our data

13. 13Medical econoMicsMedicalEconomics.com
e-book
Digital publication
EHR SCORECARD
by KE N TE R RY Contributing editor
Exclusive survey gathers physician usability ratings
of the top EHR systems in fi ve key areas
SATISFACTION
WITH

EHR SYSTEMS
GROWS AMONG PHYSICIANS
Considering the dissatisfaction that many
physicians have expressed about electronic
health records (EHRs), you might think that
most doctors hate these systems. But, ac-
cording to an exclusive Medical Economics
survey, 55% of physicians are fairly or very
satisfi ed with their EHRs, and 54% believe
they have helped improve the quality of care.
Forty-fi ve percent of respondents said
that EHRs have had a positive fi nancial im-
pact on their practices. Most of that is proba-
bly related to the Meaningful Use incentives
from the government, says Michelle Holmes,
MBA, a Seattle-based principal with ECG
Management Consultants. “I don’t think it’s
the norm for people to say the profi tability of
their practice is better after EHR implemen-
tation than before it, from a productivity and
cost perspective.”
About 80% of Medical Economics’ respon-
dents had EHRs, and only 11% of those said
they were planning to replace their system
within the next 12 months. On the other
hand, only 55% said they would recommend
their EHR to colleagues. Th e satisfaction of
physicians with particular aspects of their
EHRs varied a great deal, and the market
leaders were not necessarily the most popu-
lar among their customers.
Since the survey sample was skewed to-
ward small and medium-sized private prac-
tices, this doesn’t surprise Holmes. Th e phy-
sicians in these practices probably selected
the cheap and free products from smaller
vendors, she notes. “Th ey’re not using a
system that someone else selected on their
behalf.”
Internist Edward Gold, MD, an experi-

14. 14 MedicalEconomics.comMedical Economics
enced EHR user who practices in a 59-doc-
tor group based in Emerson, New Jersey,
says many physicians prefer the inexpensive
EHRs “because they’re simple, and they’re
meant to be easy to use. But they don’t ac-
complish all the things that need to be ac-
complished for Meaningful Use. They don’t
give you the reports you need for the medi-
cal home, the reports you need to belong to
an ACO. They don’t have the interoperability
or the connectivity that’s required. They’ll
do for keeping an office record, but they just
EHR
usabilit y
ratings
The performance of an
electronic health record
(EHR) system can mean
the difference between
a thriving practice and
a struggling one. These
systems impact every
aspect of medical care,
from the care physicians
provide to patients to the
practice’s ability to get
paid for the work it does.
For this exclusive
EHR Scorecard, Medical
Economics asked
thousands of physicians
to rate their systems, on a
scale of 0 to 10, in the key
areas that matter most to
them.
Demographic
information on the survey
respondents can be found
on page 34.
Quality of care
The effect your EHR has on the
quality of care your practice provides
An EHR system can either enhance or hinder the care a physician
provides to his or her patients. The promise of EHRs is that they
will help physicians and the healthcare system provide high-value
care, but that remains largely unfulfilled. Some systems are closer to
this ideal than others. The vendors that focus on helping physicians
navigate today’s healthcare challenges will thrive.
RankSystem BaseScore
1SOAPware 24
8.0
2MEDENT 67 7.2
3Healthfusion 29 6.9
4e-MDs 156 6.5
5Epic 986 6.3
6Amazing Charts 114 6.3
7Advanced MD 27 6.2
8Practice Fusion 255 6.1
9Modernizing Medicine 42 6.1
10athenahealth 221 6.0
11eClinicalWorks 540 5.8
12Aprima 48 5.7
13Care360 (Quest) 54 5.6
14McKesson [All systems} 105 5.2
15GE 256 5.1
16Greenway* 227 5.0
17Vitera* 108 5.0
18Nextech 23 4.9
19Cerner 211 4.6
20Allscripts [All systems] 552 4.5
*Greenway and Vitera merged in late 2013 to become Greenway Health.

15. 15 Medical EconomicsMedicalEconomics.com
provide the basics.”
This coverage highlights five EHR usabil-
ity areas important to physicians: Quality of
care, Meaningful Use, patient portals, tech-
nical support and clinical support. (See EHR
system scores on pages 25, 26, 28, 30 and 32.)
Attestation tools
Of the respondents who used EHRs, 78%
had attested to Meaningful Use in the past
year. Sixty-eight percent said the ability of
their EHR to enable them to attest to mean-
ingful use was “good” or “excellent.”
Internist Kenneth Kubitschek, MD, a
partner in North Carolina Internal Medicine
in Asheville, North Carolina, and Gold both
said their EHRs made it fairly easy to attest
in Meaningful Use stage 1. But like most
doctors, they’re having trouble with some
stage 2 requirements for reasons that have
little to do with the quality of their EHRs.
Their challenges include getting patients
to use patient portals and exchanging care
summaries at transitions of care in an en-
vironment where interoperability remains
limited.
One area in which EHRs seem to have
made progress is clinical decision support
(CDS). Sixty-eight percent of our respon-
dents had a positive opinion of their ability
to use their EHR to implement at least five
CDS support tools, which is required for
Meaningful Use stage 2.
Holmes notes that the CDS tools in cur-
rent EHRs go well beyond pop-up alerts in
electronic prescribers that warn doctors
about drug interactions, wrong dosages,
and so forth. CDS is built into the documen-
tation templates of many EHRs, she points
out. For example, there may be prompts
regarding out-of-range information on vital
signs.
Some of the prompts regarding practice
guidelines, such as initial medications sug-
gested for a patient with newly diagnosed
Meaningful Use
Percentage achieving Meaningful Use
The ability to attest to the federal government’s Meaningful Use
incentive program is the primary reason many physicians purchased
an EHR. But some systems have tools that make attesting easier
than others. Satisfaction with this function is key, especially for
meeting the challenges of stage 2.
RankSystem BaseMU%
1 Epic 986 87%
2 Allscripts [All systems] 552 87%
3 Nextech 23 87%
4 GE 256 85%
5 NextGen 399 83%
6 Cerner 211 83%
7 eClinicalWorks 540 82%
8 athenahealth 221 82%
9 MEDENT 67 81%
10 Vitera* 108 79%
11 McKesson [All systems] 105 79%
12 MEDITECH 102 79%
13 Greenway* 227 76%
14 Care360 (Quest) 54 76%
15 e-MDs 156 75%
16 Aprima 48 73%
17 Practice Fusion 255 68%
18 SOAPware 24 67%
19 Modernizing Medicine 42 60%
20 Healthfusion 29 60%
*Greenway and Vitera merged in late 2013 to become Greenway Health.
30%
of physicians rated their
EHR system as excellent
at making attesting to
meaningful use easy

16. 16 MedicalEconomics.comMedical Economics
diabetes, are quite helpful, Kubitschek says.
But many care planning prompts, such as
suggested recommendations to an over-
weight patient, are unnecessary, he adds.
Peter Basch, MD, medical director for
ambulatory health and health IT policy at
MedStar Health in Washington, D.C., ob-
serves that EHRs certified for Meaningful
Use must contain certain types of CDS tools.
These include reminder alerts, he says. But
he feels that vendors have much further to
go in this direction. For one thing, alerts that
are fired improperly can lead to alert fatigue.
Also, he notes, smart features could be de-
veloped to suggest diagnostic tests for a
particular problem and to find out whether
similar tests had been performed earlier.
Connecting with patients
About six in ten respondents gave a “good”
or “excellent” rating to the usability of their
patient portal and the ease of updating
EHR data on the portal. This is important to
many practices because of Meaningful Use
stage 2. The government incentive program
requires that eligible professionals provide
50% of patients with online access to their
records. They must also ensure that 5% of
their patients view, download or transmit
their health information online. And they
have to demonstrate that they can exchange
secure messages with patients.
The main barrier to achieving these goals
is not the technology, Holmes notes. “Most
portals aren’t difficult for the practice or the
patient to use. The hurdle is getting people
to use them.”
Aside from that, Kubitschek says, his
patient portal works very well. “When I do
my labs and other stuff, the information
Patient portal
Usability of the patient portal
from your EHR vendor
A functional and intuitive patient portal is key to lessening the administrative burdens faced by physicians and improving communication between providers and patients. It leads to more efficient workflow and boosts practice productivity. Studies have shown that patients who use a portal to communicate with their doctor are healthier and more satisfied.
RankSystem BaseScore
1MEDENT 67
8.1
2Epic 986 7.1
3athenahealth 221 7.1
4Practice Fusion 255 7.0
5SOAPware 24 6.7
6Healthfusion 29 6.6
7Amazing Charts 114 6.5
8Modernizing Medicine 42 6.3
9eClinicalWorks 540 6.2
10Advanced MD 27 6.1
11Nextech 23 5.8
12Aprima 48 5.7
13Greenway* 227 5.5
14McKesson [All systems] 105 5.5
15Vitera* 108 5.3
16GE 256 5.1
17Cerner 211 5.1
18e-MDs 156 5.0
19Care360 (Quest) 54 4.9
20NextGen 399 4.8
*Greenway and Vitera merged in late 2013 to become Greenway Health.
49%
Fewer than half of
physicians said their EHR
system is capable of
enabling them to identify
patients who are out
of bounds on specific
individual measures, such
as an elevated A1C.

17. 17 Medical EconomicsMedicalEconomics.com
uploads automatically as soon as I sign it.
And the patients are getting it, because we’re
talking to them. It has their problems, aller-
gies, medications, and immunizations. We
get messages back and forth from the pa-
tients. I’ve been pretty pleased with it.”
Another benefit, he adds, is that patient
messages come right into an EHR inbox,
and physicians can decide to whom those
should be directed. He has his nurse triage
the patient communications. He can then
reply directly to a patient message or send
it back to his nurse, and can choose whether
to save it to the chart.
Vendor customer service
About 60% of the respondents rated the
quality and amount of EHR training and the
vendor’s ability to solve technical problems
as “good” or “excellent.” Around the same
percentage gave a thumbs-up to the quality
of the interface between their EHR and prac-
tice management system (PMS), if they had
non-integrated systems.
On the other hand, many respondents
gave their vendors fair or poor scores for
their ability to solve technical problems
(30%), the level of support the practice re-
ceived in configuring the EHR (29%), the
quality and amount of training (28%), and
the ability to customize their EHR (36%).
Basch believes that increasing transpar-
ency and competition have induced vendors
to offer packages of software, training and
implementation that are better than they
70%
of physician respondents
who do not have an EHR
system have no plans to
purchase one.
Technical support
Vendor’s ability to resolve technical
problems with your EHR
Is your vendor there when you need them? Glitches and system
crashes can derail a physician’s day and harm a practice’s workflow,
not to mention the aggravation of waiting on the phone instead of
seeing patients. Technical support and training a vendor provides
is key when shopping for an EHR system. Nothing leads to buyer’s
remorse faster than poor customer support.
RankSystem BaseScore
1MEDENT 67
8.3
2Amazing Charts 114 7.7
3SOAPware 24 7.5
4Modernizing Medicine 42 7.4
5Practice Fusion 255 6.8
6Healthfusion 29 6.7
7athenahealth 221 6.6
8Care360 (Quest) 54 6.6
9Nextech 23 6.5
10Epic 986 6.4
11Advanced MD 27 6.4
12e-MDs 156 6.3
13Aprima 48 6.3
14eClinicalWorks 540 6.1
15Vitera* 108 5.7
16Greenway* 227 5.6
17McKesson [All systems] 105 5.2
18Cerner 211 4.9
19GE 256 4.8
20Allscripts [All systems] 552 4.7
*Greenway and Vitera merged in late 2013 to become Greenway Health.
53%
of physicians say they do
not use their EHR vendor
for billing or revenue
cycle management

18. 18 MedicalEconomics.comMedical Economics
were. Holmes, in contrast, speculates that
many physicians rate their vendors highly
because they don’t know how much of the
support work is being done by their organi-
zation’s IT staff or by “super-users” in their
own offices.
Gold and Kubitschek both give their ven-
dors fairly high marks for training and tech-
nical support. But Gold notes that training
varies greatly among EHR suppliers. “The
basic problem that most doctors have with
EHRs has to do with the inadequacy of train-
ing. The lower level EHR vendors will give
you six hours of training online. The more
training you get, the more it costs, and doc-
tors don’t like costs. Doctors never invest
enough in training,” he says.
His own group he adds, is big enough to
afford its own IT person, who trains new
staff and provides ongoing training to the
doctors and staff members. “It’s never once
and done,” he points out. “In a higher-end
system, there are so many bells and whistles
that people are unaware of that could make
their lives a lot easier. It’s a continuous pro-
cess of educating people.”
Quality reporting
Seventy-nine percent of EHR users said
their systems could generate quality reports.
That’s about the same percentage of respon-
dents who said they’d attested to Meaning-
ful Use, which requires quality measures.
But these statistics obscure the difficul-
ties that some users have in using their EHRs
to report on quality measures, Gold says. “In
some systems, it’s easy to generate reports,”
he notes. “Others require the involvement of
the vendor, which charges the physicians to
do this.” Moreover, if doctors and practice
staff aren’t specifically trained to produce re-
ports, it might be very challenging for them.
Gold himself finds it fairly simple, he adds,
because his system provides a dashboard for
this purpose.
30%
Number of physicians who
said they have had their
EHR system for more than 5
years.
Clinical support
Ability to implement at least five
clinical decision support tools
Most systems can provide alerts and other notifications to help
physicians provide better care to their patients, especially those
suffering from chronic conditions that require constant monitoring.
Intuitive clinical decision support—including alerts and reminders,
clinical guidelines, documentation templates, and focused patient data
reports—can help doctors improve care and meet quality measures.
RankSystem BaseScore
1MEDENT 67
8.4
2Amazing Charts 114 8.1
3Healthfusion 29 8.0
4athenahealth 221 7.7
5Modernizing Medicine 42 7.6
6Practice Fusion 255 7.5
7Aprima 48 7.5
8e-MDs 156 7.4
9Epic 986 7.3
10Care360 (Quest) 54 7.2
11Advanced MD 27 7.1
12eClinicalWorks 540 6.8
13SOAPware 24 6.8
14Vitera* 108 6.5
15Greenway* 227 6.3
16McKesson [All systems] 105 6.3
17GE 256 5.7
18NextGen 399 5.6
19Allscripts [All systems] 552 5.5
20Cerner 211 5.5
*Greenway and Vitera merged in late 2013 to become Greenway Health.

19. 19Medical econoMicsMedicalEconomics.com
More than 7,400 primary care physicians and specialists took part in this exclu-
sive Medical Economics survey, conducted by Readex Research. The charts
below provide a snapshot of the survey pool’s pertinent information, including
practice description, size, and affiliation, and electronic health record (EHR)
use and history.
aT a
glanCE
Years with current EHR system N=5755
<1 year 1-3 years 4-5 years >5 years
40%
30%
20%
10%
Practice description
N=7442
Family Medicine
Pediatrics
Internal Medicine/Other IM specialty
OB/GYN
Other
Surgical specialty
Multispecialty group
Cardiology
No answer
22%
19%
17%
12%
11%
8%
8%
2%
1%
Practice size

N=7442
25% 32% 15% 11%
5% 3% 8%
1 physician 2-5 physicians 6-10 physicians 11-25 physicians 26-50 physicians 51-100 physicians More than 100 physicians
Physician employment

N=7442
61% 28%
5% 4% 3%
Privately held Owned by a hospital/health system Part of a government system Other Not currently employed
EHR use
80%20%
NO YES
N=7240
Meaningful use attestation
in last 12 months
78%20%
2%
YESNO
No answer
N=5790
Planning to replace
current EHR system
11%
89%
YES
NO
N=5701
Top 10 ambulatory EHR systems,
by number of respondents
Epic
Allscripts
eClinicalWorks
NextGen
Practice Fusion
GE
Greenway
athenahealth
Cerner
e-MDs
1004
561
551
405
261
257
230
222
214
158
surVey respondents

20. 20 MedicalEconomics.comMedical Economics
Fairly high numbers of respondents said
their EHRs could generate clinical reports
on subgroups of patients (63%), identify pa-
tients who were out of bounds on specific
measures, such as diabetic patients with
elevated A1c levels (49%), and send alerts
to providers and care managers about pa-
tient care gaps (45%). Eighty-seven percent
of EHR users said their systems could do at
least one of these tasks.
Do many physicians use this data and
the related workflow features to improve
care and manage population health? Basch
doubts it. The business case for using health
IT to improve quality, he says, is still lacking
in most practices.
For Kubitschek and his colleagues, how-
ever, the challenge is much more immedi-
ate. They’re too busy attesting to Meaningful
Use stage 2 and getting all their quality re-
ports right to worry about using the data for
quality improvement, he says.
Usability
Nearly two-thirds of respondents gave
above-average scores to their EHRs on two
markers for usability: ease of ordering tests
and medications, and ease of moving be-
tween sections of EHRs. And 53% of respon-
dents rated their vendor’s ability to custom-
ize their EHRs as “good” or “excellent.”
Regarding customization, Holmes be-
lieves that most physicians can’t readily dis-
tinguish between what their own IT people
or other staffers do and what their vendor
does. But employed physicians have a more
difficult time getting things changed in their
EHR than do private practice doctors, she
says, because of the former’s need for orga-
nizational approval. So she thinks the us-
ability scores reflect “the amount of control
that physicians have over their systems in
smaller practices.”
That doesn’t explain the popularity of
cloud-based EHRs, which allow little cus-
tomization. Holmes thinks that practices
that choose those products see other ad-
vantages in them. Among other things, she
says, they’re generally simpler to implement,
learn and navigate than are more complex
client-server programs.
Basch gives credit to EHR vendors for
improving the usability of their products
in some ways. For example, he notes, phy-
sicians can order a test or a prescription
anywhere in the workflow in many systems,
rather than having to be at a certain point in
the process.
Kubitschek, says that the usability of
EHRs has vastly improved since he start-
ed using one in 1995. While the vendors
haven’t made much progress in the past
three years because of their focus on Mean-
ingful Use, he says, he’s recently seen some
innovations that have made his EHR more
user-friendly.
Practice management systems
Because finances are the lifeblood of prac-
tices, the practice management system
component of EHRs—or the standalone
PMS bolted to an EHR—is vitally impor-
tant. But just 61% of respondents gave good
or excellent scores to the ability of their
system to post electronic remittance advice
EHR usability report
Survey
methodology
The findings cited in this
report are based on a survey
conducted by Readex Research
and sponsored by Medical
Economics. Through the use of
an online survey, the purpose
of this research project was
to better understand use
and performance regarding
ambulatory electronic
health record (EHR) systems
currently available to medical
professionals.
Data was collected via
an online survey from June
10, 2014 to June 27, 2014.
The survey was closed
for tabulation with 7,442
responses. However, a
majority of the study’s results
are based upon the 5,790
employed respondents who
indicated their practice has an
ambulatory EHR system.
As with any research, the
results should be interpreted
with the potential of non-
response bias in mind. It is
unknown how those who
responded to the survey may
be different from those who
did not respond. In general,
the higher the response rate,
the lower the probability of
estimation errors due to non-
response and thus, the more
stable the results.
The margin of error for
percentages based on 5,790
responses is ±1.3 percentage
points at the 95% confidence
level. The margin of error for
percentages based on smaller
sample sizes will be larger.
54%
More than half
of physician
respondents say
their EHR has had
a positive impact
on the quality
of care they provide.
11%
Number of
physicians who
said they have had
their EHR system
for less than 1 year.
45%
of physicians
reported that
the overall
performance
of their EHR
system was
average to poor.

21. 21 Medical EconomicsMedicalEconomics.com
(ERA) correctly; 53% did the same for their
system’s ability to provide feedback on cod-
ing errors.
“I thought those numbers should be
higher,” Holmes says. “If you have a PMS that
can’t post an ERA correctly, you have a prob-
lem. That’s core functionality that’s been
there for years.”
Some practices are still clinging to old
billing systems that are no longer supported
by their vendors, she notes. In addition, a
substantial portion of the practice universe
isn’t even using ERA yet, according to a re-
cent report.
Optimization
The bulk of responses to questions about
the respondents’ EHRs ranged from neutral
to slightly positive. To Holmes, this indi-
cates that much more is buried beneath the
surface of the survey results. For example,
she says, she’d like to know how much IT
support the respondents had available to
them and how much of the EHR’s function-
ality they’re actually using.
Basch takes a more optimistic view.
Considering all of the difficulties doctors
encounter in learning how to use an EHR
and changing how they work, he says, “I’d
expect people to feel neutral to slightly
positive.”
The determining factor in how an indi-
vidual physician or a group feels about an
EHR—assuming it has decent functional-
ity—is the degree to which the doctors have
optimized their system so that it helps them
become more efficient and deliver better
care. Says Basch, “If you take a less than op-
timal tool and try to optimize it, you can get
better results.”

22. MedicalEconomics.comMedical Economics22
e-book
Digital publication
While vendors have focused most of their development efforts
on meaningful use and ICD-10 readiness, innovations are
on the way to improve system functionality for physicians
by Ken Terry Contributing editor
EHR 2.0:
4 ways vendors are
building better systems
Physicians continue to express dissatisfac-
tion with the usability and the workflow
features of electronic health records (EHRs),
yet these information systems don’t seem
to improve. One reason, experts say, is that
vendors have poured most of their research
and development budgets into meeting the
requirements for meaningful use (MU) and
the International Classification of Diseases-
10th revision (ICD-10).
“They have only so much of a devel-
opment budget, and anything that’s
required by government regulations
might take away from something else,”
says Doug Thompson, MBA, senior re-
search director for The Advisory Board
Company, a healthcare consulting firm.
The poor usability of ambulatory care
EHRs also can be attributed to shifts in
the marketplace, notes David Kibbe, MD,
president and chief executive officer of
DirectTrust, a trade association for secure
messaging networks. During the past few
years, he says, the big EHR vendors have
increasingly focused on hospital systems
at the expense of ambulatory EHRs, partly
because the bulk of MU incentive payments
have gone to hospitals.
At the same time, he points out, more and
more physicians have gone to work for hos-
pitals, and “the employed providers have be-
come disenfranchised in terms of their choice
of information technology. Their choices, par-
ticularly in primary care, count for very little
in the decisions made by those big corporate
entities with respect to EHRs.”
Thompson believes that EHR vendors
have improved their product designs over
time. But today’s EHRs are more complicated
because of their increased functionality, he
adds, and can be difficult to customize.
Small to medium-sized physician practic-
es may not be equipped to deal with the tech-
nical aspects of these systems. “They’re prob-
ably stuck with EHRs that are not customized
enough, that are not easy to use, and that they
don’t understand very well,” he says.
Despite all of this, however, some inno-
vations are starting to enhance the usability
of EHRs. These include refinements in natu-
ral language processing, advances in EHRs
designed for mobile devices, the addition of

23. 23 Medical EconomicsMedicalEconomics.com
context to clinical decision support (CDS),
and the spread of direct clinical messaging.
Read on to find out how these developments
could benefit you, either now or in the future.
1/ Natural language
processing
The biggest problem that physicians have
with EHRs is the way that these applications
force them to enter data.
Encounter documentation with point-
and-click templates can be excruciatingly
slow and difficult. Physicians don’t like to
type, and many doctors also have trouble
using speech recognition programs, Thomp-
son points out. Even if they can overcome
these barriers, free text does not create the
structured data that is required for MU and
quality improvement.
The ideal scenario for doctors would be
to speak to the computer and have it convert
their speech into structured data that would
automatically go into the proper fields in the
EHR. That technology, known as “natural
language processing” (NLP), has been under
development for years. The speech recogni-
tion engines used in transcription have be-
come fairly accurate, but the ability of com-
puters to “understand” medical terms in the
context of speech and categorize them is
still fairly limited.
Greenway Health, an ambulatory EHR
vendor, is making use of NLP in its Prime
Speech module, which it co-developed with
M*Modal, a vendor of speech recognition
software. Prime Speech allows physicians
to “dictate and place content into existing
custom clinical templates,” according to Gre-
enway’s website. But Jim Ingram, MD, chief
medical officer of Greenway, admits that
Prime Speech is not yet able to transform
speech into discrete data automatically.
Prime Speech can take information from
the Greenway EHR’s patient “face sheet”—
including medications, allergies, and prob-
lems—and export it into the “speech docu-
ment” that a doctor dictates into. The NLP
application can slot the past medical history
data into one of six categories that are part of
the visit note. As the physician dictates, he can
pull parts of the medical history into the ap-
propriate sections as he goes along.
“Vital signs go into the physical exam
section, for example, and the problem list
would go into the assessment section,” In-
gram says.
For now, Prime Speech cannot extract
newly entered data from the note and export
it back to the correct fields in the face sheet,
but Ingram says that’s where the technology
is heading. In the future, Prime Speech will
also assist evaluation and management cod-
ing and trigger clinical alerts.
Other vendors, including Allscripts and
eClinicalWorks, have integrated aspects of
NLP into their EHRs. But so far, none of these
companies has had a breakthrough that
would significantly improve EHR usability.
2/ Mobility
Most physicians now use smartphones and/
or computer tablets at work, and they would
like to be able to use their EHRs on these
mobile devices.
The leading vendors have accommodat-
ed them to some degree by allowing their
applications to run on an iPad or a smart-
phone, says Kenneth Kleinberg, MD, man-
aging director for health IT at The Advisory
Board. But more progress has been made in
ambulatory care than in acute care EHRs,
and there’s a significant difference between
iPad-native EHRs and mobile versions based
on EHRs designed for desktops and laptops.
One problem with trying to use the desk-
top model of an EHR on a mobile device is
that the latter’s screen is smaller, so some in-
formation may be cut off, Kleinberg notes. In
addition, if a clinician tries to use the pop-up
virtual keyboard on an iPad, it can cover up
essential information, including alerts.
Allscripts, Epic, and Cerner—along with
a number of smaller EHR vendors—have
all created native apps for iPads, Kleinberg
says. Allscripts’ approach is to pick the 20%
of functions that physicians use 80% of the
time and include that in its iPad-native
Wand EHR, “recognizing that they’ll prob-
ably have to return to the desktop to com-
plete their work.” Allscripts Wand gives
physicians the ability to review and add to
documentation, prescribe electronically,
and communicate with staff.
Not all vendors with mobile-native
EHRs have focused on the Apple iOS. Some,
like Meditech and Siemens, have used the
HTML5 browser approach to format their
EHRs to run on any platform, including
iOS, Android and Windows. But some parts
of the EHR functionality can get lost with
HTML5, Kleinberg says.
Some physicians have told Kibbe that
EHR vendors
have improved
their product
designs over
time. But
today’s EHRs
are more
complicated
because of
their increased
functionality,
and can be
difficult to
customize.

24. 24 MedicalEconomics.comMedical Economics
they prefer the touch screens on iPads to us-
ing a mouse to point and click on desktops
or laptops. Kleinberg acknowledges that
this can be an advantage, but points out
that typing is still much more difficult on an
iPad than on a desktop. That’s why speech
recognition is an important technology for
mobile devices, he says.
While NLP hasn’t yet achieved its mobile
use potential, Kleinberg believes it’s moving
in the right direction.
“When you talk to the device, it’s navigat-
ing to the right template. Some systems can
recognize the field you’re talking about just
from what you’re saying. You can go between
tabs using speech; you can do almost all of it
using speech,” Kleinburg says.
Noting that cloud storage of data files is
essential when using mobile devices, Klein-
burg adds: “I believe you can do everything
you need to do on an iPad, especially the
large ones they have now.”
3/ Clinical decision support
Ideally, EHR alerts and reminders can help
prevent harm to patients or remind physi-
cians to provide essential care. Other kinds
of CDS built into the EHR’s structure can
help doctors follow evidence-based guide-
lines.
The drawback of alerts and reminders—
the most visible form of CDS--is that they
can pop up unnecessarily or erroneously. “In
most systems, they’re at a very simple level,”
says Dean Sittig, Ph.D., a professor at the
University of Texas Health Sciences Center
in Houston. “Most doctors would say they’re
overly simplistic and are often wrong.”
Frequently, alerts are based on insuffi-
cient information. For example, the program
might tell the doctor that Valium should not
be prescribed to the elderly, although the
patient in question is not old. As a result of
such mistakes, Sittig says, physicians ignore
the vast majority of alerts in EHRs. “They
think they’re almost all wrong, or that they
don’t matter, or that they don’t apply.”
In some cases, he points out, the EHR
alerts create confusion because they don’t
include the context of why a physician made
a particular medical decision. For example,
perhaps the physician is prescribing a small
dose of Valium to an elderly patient to ease
his or her anxiety before an MRI test.
“A lot of the decision support we give is of
that type: It’s true and it’s right, but it doesn’t
pertain to this patient,” Sittig says. “To get
the decision support to pertain to the pa-
tient, you usually need more context about
that patient.”
Intermountain Healthcare, based in Salt
Lake City, Utah, has developed a context-
sensitive alerting system over many years,
Sittig notes. As a result, he says, “Its physi-
cians accept decision support more than
95% of the time.”
Intermountain is replacing its home-
grown EHR with a system from Cerner,
which plans to integrate Intermountain’s
context-sensitive alerts into its own EHR,
he says. But most other vendors aren’t mov-
ing in this direction because they haven’t
seen customer demand for it.
Meanwhile, researchers are seeking
Direct messaging
Find an accreditted DirectTrust network service provider
Accredited providers
Source: DirectTrust
❚ Axesson
❚ CareAccord
❚ Cerner Corp.
❚ Covisint
❚ Data Motion, Inc.
❚ digiCert, Inc.
❚ EMR Direct
❚ Healthcare Information Xchange of New
York, Inc.
❚ Infomedtrix, LLC
❚ Informatics Corp. of America
❚ Inpriva, Inc.
❚ Integrated Care Collaboration
❚ IOD, Inc.
❚ MaxMD
❚ MedAllies
❚ Medicity
❚ Michiana Health Information Network
❚ MRO Corp.
❚ NextGen/Mirth
❚ New Uork eHealth Collaborative
❚ Optum
❚ Relay Health
❚ Rochester RHIO
❚ Secure Exchange Solutions
❚ Surescripts
❚ Truven Health Analytics
❚ Updox
Candidates for accreditation
❚ Alere Accountable Care Solutions
❚ athenahealth
❚ Corepoint Health, LLC
❚ Cozeva (Applied Research Works, Inc.)
❚ DataMotion, Inc.
❚ eClinicalworks
❚ Glenwood Systems
❚ GlobalSign, Inc.
❚ Health Companion, Inc.
❚ HealtheConnections RHIO
❚ Healthunity Corp.
❚ iMedicor
❚ Nitor Group
❚ Orion Health
❚ Pulse Systems, Inc.
❚ Qsource
❚ Quest Diagnostics
❚ Safety Net Connect
❚ San Diego Regional Health Information
Exchange
❚ Shifox, LLC
❚ Siemens Medical Solutions USA, Inc.
❚ Simplicity Health Systems
❚ Utah Health Information Network
❚ Vitalz Technology, LLC

25. 25 Medical EconomicsMedicalEconomics.com
ways to improve alerts. A recent paper
that Sittig co-authored proposes a system
for improving CDS by using web-based
monitoring tools and an interactive dash-
board for evaluating alert and response
appropriateness.
To avoid alert fatigue, Thompson points
out, some vendors have designed their sys-
tems to present information to doctors
about medication safety and dosing at the
point of prescribing. Only if a prescribing de-
cision is truly dangerous would “the flashing
light go on,” he says.
4/ Interoperability
Despite billions of government dollars
poured into EHR incentives and health in-
formation exchanges, a recent Health Affairs
article notes, the amount of data exchanged
among providers is still very modest.
To jump-start these communications,
which are vital to care coordination, the
government joined with the private sector
a few years ago to create the Direct secure
messaging protocol. Direct is supposed to
be embedded in all EHRs that have been
certified for use in the second stage of the
MU program. It can be used to meet the
stage 2 requirement that providers ex-
change care summaries at transitions of
care.
The use of Direct is starting to grow and
is expected to increase rapidly in 2015, Kibbe
says. His own organization, DirectTrust, per-
forms an important function in this field. By
accrediting health information service pro-
viders (HISPs), which carry secure messages
between physicians with Direct addresses,
DirectTrust enables the HISPs to trust each
other enough to exchange secure messages.
As of the end of July, the two dozen HISPs
in the DirectTrust community were serving
13,000 healthcare organizations and had
provided over 400,000 Direct addresses, ac-
cording to Kibbe.
Direct messaging can increase the use-
fulness of EHRs by enabling physicians to
attach documents, such as care summaries,
notes, and lab results, to messages they ex-
change with their colleagues. Hospitals can
also use Direct to send discharge summaries
and notices of admission and discharge to
doctors.
From a workflow standpoint, having Di-
rect embedded in their EHRs is a boon to
physicians, because they don’t have to leave
the EHR to view or download information
from other providers.
But there are also disadvantages. For
example, Direct can’t be used to search for
information across the community. Sec-
ondly, it’s designed only for point-to-point
exchanges. Also, the data in the attached
documents can’t flow into the structured
fields of the receiving EHR.
Greenway has found that to be a problem
for ob/gyn customers, who want the EHR to
consume data attached to Direct messages,
and vice versa, notes Mark Janiszewski, the
company’s senior vice president of prod-
uct management. To make this happen, he
notes, Greenway has built limited interfaces
for medications, problems and allergies for
use with with EHRs from vendors such as
Epic, Cerner, McKesson, Meditech, and CPSI.
Works in progress
While the innovations described above are
all works in progress, they seem destined
to benefit physicians in the long run. In the
meantime, Thompson points out, there are
some significant differences among EHRs,
including ease of customization, whether
they allow physicians to move easily among
templates, and how many clicks are required
to accomplish a particular task.
If you’re shopping for your first EHR or
considering a switch, pay close attention
to what these systems can actually do, and
don’t depend on demonstrations by experi-
enced users. Try them out yourself and visit
other practices to see how specific EHRs are
being used.
Meanwhile, keep your eye on the innova-
tions that will eventually make EHRs more
usable. They may be arriving sooner than
you expect.
To avoid alert fatigue,
some vendors have
designed their systems
to present information to
doctors about medication
safety and dosing at the
point of prescribing.

26. MedicalEconomics.comMedical Economics26
e-book
Digital publication
Physicians share strategies to improve quality metrics,
chronic care
by Ken Terry Contributing editor
EHRs: 5 ways
to put data into action
Physician frustration over the functionality of
electronic health record (EHR) systems has
been escalating. While the source of physi-
cian unhappiness stems from the belief that
expensive technology should make their
work life easier, the reality is that this technol-
ogy requires greater physician involvement at
a time when many practices struggle to main-
tain adequate patient volumes and remain fi-
nancially solvent.
The disquiet over the current state of
technology was well documented in a recent
Medical Economics survey of nearly 1,000
physicians in which 45% of responding physi-
cians said patient care had grown worse since
they implemented an EHR system. Nearly a
quarter of internists said the quality of care
was significantly worse.
While the message came through loud
and clear in this survey, what can we learn
from the silent minority about using data in
their EHRs—including their Meaningful Use
quality reports—to improve the quality of
care they deliver?
Jennifer Brull, MD, a solo family practi-
tioner (FP) in Plainville, Kansas, shares of-
fice space, staff and services with four other
FPs, four midlevel practitioners, and a nurse
midwife. When she and her colleagues first
implemented an EHR in 2007, she screened
only 43% of her eligible patients for colorectal
cancer; in the next few years, with the help of
EHR reminders, she raised that rate to 90%.
She also used the EHR to increase her pa-
tients’ recommended mammography rate
from 65% to 99%.
Chronic care also benefited from her
practices’ EHR use. In 2012, Brull and her
colleagues were regularly testing only 14%
of their patients with diabetes for micro-
albumin. After educating their staff in the
process and turning on an alert in their EHR,
they raised that number to 95% within nine
months. In 2012, only 11% of their heart fail-
ure patients had received a recommended
echocardiogram within the previous two
years; by the end of 2013, the network had in-
creased that to 68%.
Most of the data you need to improve the
quality of care is in your EHR, says Rosemarie
Nelson, a Medical Group Management As-
sociation consultant based in Syracuse, New

27. 27 Medical EconomicsMedicalEconomics.com
York. “But in some cases, the tools to make
the data useful are not there,” she notes. Even
when those functions are present, she adds,
clinicians don’t necessarily use them.
If you find EHR documentation a bit over-
whelming and resent the time it takes away
from patient care, you might view the idea of
using your EHR for quality improvement as
a non sequitur. But some studies show that
EHRs also do improve patient care and safety.
Moreover, we’re entering a new era of value-
based reimbursement, in which part of your
income will be based on your quality scores.
So it’s worth considering how your EHR can
help you raise those scores.
EHR Challenges
EHRs were not originally designed for qual-
ity improvement, but rather for improving
efficiency and documentation so that doc-
tors could get a return on their investment.
But with the advent of Meaningful Use, ven-
dors had to rewrite their software to pro-
duce quality reports in order to get certified
for Meaningful Use. At the same time, physi-
cians started to pay more attention to qual-
ity improvement.
The Breakaway Group, a health informa-
tion technology consulting firm owned by
Xerox, surveyed physician practices with
EHRs in 2009 and found that fewer than
20% of them were trying to understand how
EHRs affected quality of care. Today, partly
because of Meaningful Use, “people are be-
ing forced to answer some of those ques-
tions,” says Heather Haugen, PhD, managing
director of the Breakaway Group.
EHR vendors are offering better tools for
quality reporting than they did a few years
ago, Nelson notes. But the quality of these
tools varies considerably, and some of them
must be purchased as add-ons, she says.
The leading EHRs include health main-
tenance alerts that remind physicians
about some of their patients’ preventive and
chronic care gaps when they see them. In
some systems, however, users have to build
their own alerts, Nelson says.
If an EHR includes prebuilt alerts, you
may be able to customize or add to them.
Brull says this is not a big chore in her EHR.
She has customized about 25% of the health
maintenance alerts—most of them in less
than five minutes each.
Certified EHRs must be able to extract
quality data for Meaningful Use. While the
clinical quality measures are very limited,
they can be used in quality improvement,
Nelson says. In some EHRs, for example,
you can get a list of diabetic patients with an
HbA1c >8 by clicking on the percentage of
patients in that category.
Unfortunately, Brull says, “That’s where
it stops in our EHR software. You can’t click
on the patient’s name and go to their chart,
which is the most actionable next step.”
The other problem with the reports in
Brull’s EHR, she says, is that they can’t be
customized. That is one reason why her
group has acquired web-based registry soft-
ware that interfaces with its EHR. This ap-
plication, which also has population health
management features, can generate a wide
range of custom reports.
“The ability to customize reports is some-
thing the EHR vendors are working on,” Hau-
gen says. “But it’s definitely not there. What
most practices do, if they want to get this
information, is hire people who can write
those custom reports.”
Of course, many practices can’t afford to
pay a technical expert to program these re-
ports, so it doesn’t get done, she adds.
Registry functions
Registries, which track the services provid-
ed to patients along with indicators of their
health status and due dates for recommend-
ed care, are not yet being widely used in
healthcare, Haugen says. But some vendors
have begun to incorporate registry func-
tions into their EHRs, according to Nelson.
Several vendors, for example, offer the
ability to query the database for a range of
dates, she says. For example, the EHR could
supply a list of patients with uncontrolled
hypertension who haven’t been seen in three
months and don’t have an appointment in
the next three months.
Brull’s EHR can’t do this, but her group
can use the web-based dashboard of its out-
side registry for that purpose. “If I have a pa-
tient with high blood pressure (BP) who fails
to come see me for a prolonged period of
time, they won’t show up on my EHR report,
but they will show up on my registry report
as a patient with hypertension who has not
had their BP checked in an interval of time,”
she says.
Making the data actionable
Seeking to capitalize on the new opportuni-
5 ways
to put data
into action
1. Use EHRs
as reminders
2. Customize health
maintenance alerts
3. Use registry
functionality
4. Share results with
the healthcare team
5. Maximize benefits
of structured data

28. 28 MedicalEconomics.comMedical Economics
ties for value-based reimbursement, a grow-
ing number of healthcare organizations are
using EHRs and other kinds of health IT
applications to identify patients who have
care gaps. But relatively few of them are able
to ensure that those gaps are filled, Haugen
says.
In large part, that’s because EHRs lack the
functionality to make the data actionable.
For example, even if the EHR has a built-in
registry, it may not be able to upload a list
of patients who need a specific service to
an automated messaging system or send a
message to those patients through the EHR’s
patient portal, Nelson says.
Brull agrees. There’s a “registry proces-
sor” function in her group’s EHR that lets the
practice email a list of patients who need
services, she says. But even if the network
could send such emails securely, she notes,
it’s not easy to construct the end-to-end pro-
cess with the outside registry. “All the pieces
are there, but they’re not ‘click here and do
this.’ You have to know what you’re doing,”
she says.
Instead, the group exports the registry
report data to an Excel file that includes pa-
tient demographic information, including
addresses and phone numbers. Since regu-
lar mail hasn’t proved to be effective, the
staff either calls patients or contacts them
via the patient portal, “but it’s not an auto-
mated process,” Brull notes.
The large group approach
In a large group practice the challenges are
somewhat different. The EHR usually oper-
ates on a central server, and the quality re-
ports are programmed by the organization’s
IT department. The organization may also
have a mechanism for contacting patients
who are not in compliance with their pro-
viders’ care plans.
Robert Segal, MD, works for Scottsdale
Healthcare in Scottsdale, Ariz. His ambu-
latory EHR is used by hundreds of physi-
cians that are employed by the healthcare
system. When the system decides that it
wants the doctors to focus on a particular
quality area, a report-writing team creates
the requisite reports, and data on individ-
ual doctors’ performance is sent to them
monthly.
In the near future, Segal says, the organi-
zation will begin giving the physicians com-
parative quality reports. He welcomes those
because they will show him where he stands
in relation to his peers and how he can im-
prove his quality scores.
While some healthcare organizations
use this approach, others don’t even share
the quality data with their doctors, Haugen
says. She cites the example of a large hospi-
tal group that was collecting quality data for
Meaningful Use but was not communicat-
ing it to the physicians. They told her, “We’d
like to see the data but no one is showing it
to us.”
Haugen comments, “In some respects,
small practices are doing this better because
their ability to affect the process is some-
times much more immediate.”
Structured data is key
Although doctors don’t like to hear it, their
ability to use their EHRs to improve qual-
ity depends on whether they enter key data
into the system in structured form. If the
data is not in codified fields, it doesn’t show
up in reports or health maintenance alerts.
❚ increase in staff productivity;
❚ increase of practice revenue and profit;
❚ reduction in costs outright or controlled cost increases;
❚ improved clinical decision-making;
❚ enhanced documentation;
❚ improved patient care; and
❚ reduced medical errors.
Measuring quality
Is your EHR up to the task?
Evaluating your current electronic health records
(EHR) system on its ability to deliver the data you
need is key to improving quality performance.
Look for the following specific benefits after
installation of your EHR system, and try to
quantify them:
Source: Shahid Shah

29. 29Medical econoMicsMedicalEconomics.com
Consequently, those reports and alerts may
not be reliable.
Haugen, a strong proponent of struc-
tured data entry, acknowledges that this is
a sore point for doctors. But not all data has
to be structured to improve quality, she says.
What practices need to do is fi nd “a happy
medium between what data must be struc-
tured and what can be unstructured,” she
notes. Vendors must also do their part to
make it easier for physicians and their staff s
to enter the data, she adds.
Nelson suggests that practices work on
improving clinical documentation if they
want to improve quality. Also, she says, the
physicians in a group should standardize
their EHR templates and enter data the
same way. If one doctor uses a template that
suits him or her, but nobody else uses it,
quality improvement will suff er.
In the end, you’ll get out of the EHR what
you put into it. If big chunks of data are miss-
ing, you can’t use the information to deliver
better care. Also, remember that the EHR is
only a tool; process improvement is up to
you and your staff .
“We can track the quality of care with the
EHR, but the EHR doesn’t change the care
we’re providing,” Haugen observes. “So we
have a big step to take beyond the EHR.”
QuEstIons to asK youR VEndoR
Uncover your EHR’s limitations
Q: Does the system give me a way to measure
my performance on quality measures and compare
it to that of my colleagues?
Q: Does the system notify me of abnormal
lab results when they’re received and provide
normal ranges?
Q: Can I create ad-hoc reports or am I limited
to reports provided off-the-shelf?
Can reports be customized?
Q: Can I query the EHR to identify certain
patients, such as those with particular
conditions or who use certain medications?
Q: Will my practice be able to generate queries,
such as “identify all male diabetic patients, aged 50
to 65, with A1c hemoglobin levels above seven”?
Q: Can the EHR system automatically generate
reminders for follow-up based on specifi ed criteria?Q: Does the system fl ag overdue health
maintenance items? How are these fl ags displayed?
Q: Does the EHR come with
preconfi gured health maintenance alerts?
Q: Can my practice confi gure health maintenance
templates without vendor support?
Q: If so, are there any limitations
to the templates we can build?
Q: Does the EHR have a built-in patient registry
that can be used for quality measure reporting?
Q: Is the registry standard or is there
an extra fee for the feature?

30. MedicalEconomics.comMedical Economics30
e-book
Digital publication
Getting patients to use the EHR patient portal is a key part of
meaningful use stage 2
by Andrea Downing Peck Contributing editor
How to optimize
your patient portal
If you are a physician looking to optimize the
use of your practice’s patient portal, you may
be the most effective marketing tool and an
important reason for the technology’s suc-
cess –or failure–to build practice efficiencies
and patient loyalty.
About 25% of physicians or their care
teams last year communicated with patients
using a portal, according to Manhattan Re-
search’s 2014 “Taking the Pulse” survey. That
number is likely to go higher as Medicare-el-
igible providers attesting for meaningful use
Stage 2 (MU2) use secure messaging to com-
municate “relevant health information” with
patients.
Launching a campaign to extol a portal’s
24/7 convenience and timesaving services
is essential for driving up patient adoption
numbers, but providers ultimately wield the
greatest influence when encouraging pa-
tients to register and use the technology.
When Jose Polanco, MD, joined Blackstone
Valley Community Health Care (BVCHC) in
Pawtucket, Rhode Island, as medical director
in 2012, physicians were beginning to pro-
mote the portal in the exam room, a formula
that helped push portal registration from
roughly 2,000 patients to today’s total above
3,300.
“It makes a huge difference because peo-
ple want to talk to their provider,” Polanco
says. “If your physician tells you, ‘You can
email directly with me,’ it’s very powerful.
People will walk out [of the exam room] and
do the registration.”
In addition to supplying providers with
small portal registration information cards to
give to patients, BVCHC trained a cross-sec-
tion of staff members ( front desk, medical as-
sistants and nurses) at each of its three clinics
in the portal registration procedure and hired
an engagement coordinator to do outreach
and targeted enrollment for the portal.
Minimizing portal pain
Patient engagement strategist Jan Olden-
burg, a senior manager for healthcare and
consumer advisory service at Ernst &Young
LLP, acknowledges that the portal has been
a problem for many practices, particularly if
the impact on workflow has not been con-
sidered from registration through ongoing
use.
“Getting portal use up should be thought

31. 31 Medical EconomicsMedicalEconomics.com
of as a team sport in the office,” Oldenburg
says. “It has to be embedded in the work-
flow and everybody in the office has a role
in making this happen. I recommend put-
ting in scripts for everyone—from the per-
son who does the registration to the person
who rooms the patient, for the nurse, the
doctor, phlebotomist. Everybody has a role
in getting a patient registered and giving
them permission to use the capabilities and
reminding them this is another way to make
the clinic accessible to them.”
Oldenburg says providers also should
find ways to make a portal rollout “fun” for
both patients and staff by marketing the por-
tal at community health fairs, offering prizes
to staff members who register the most pa-
tients or holding monthly prize drawings for
patients who sign up. An awareness cam-
paign also can include “theme” days such as
Hawaiian Fridays when staff show pa-
tients how to “surf ” their way to the portal.
“Stop thinking about the portal as drudg-
ery, but as something cool and innovative,”
she says. “Promote it as a part of how we do
business.”
Zachary Landman, MD, senior research-
er, Institute for Strategy and Competitive-
ness at Harvard Business School, says regis-
tering patients is only half the battle.
“In the beginning, a lot of physicians and
people who designed portals were under
the impression that if you build it, they will
come,” says Landman, former chief medical
officer at DoctorBase. “You can have initial
registration levels pretty high, but getting
people to log on, access and use the portals
has turned out to be a more difficult con-
cept.”
Landman offers a simple method for
transforming patients into active users. “It’s
quite easy,” Landman says. “As a clinician,
you just have to use it. The number one way
to engage your patients is to use the portal
to engage your patients. Reach out to them.
Encourage them to put more of their data
into the portal so it becomes not something
the patient checks one a year when they get
a lob, but a dynamic process and a relation-
ship building tool between not only the phy-
sician, whose time is constrained, but the
entire care team.”
BVCHC’s providers help drive traffic to
the portal by sending patients pre-formulat-
ed email messages that alert them if a pre-
scription refill has been sent to a pharmacy
or a lab has returned normal. In addition, at
the end of each office visit, they send a “Pa-
tient Plan” document to the patient’s por-
tal that includes a visit summary as well as
goals and educational information.
“By sending something to the portal,
we’re making it more meaningful for the pa-
tient to visit their account,” Polanco says.
Until recently, however, BVCHC’s Next-
Gen portal was available only in English,
effectively excluding the practice’s large
Spanish-speaking patient population from
the site.
“We were going up against a very strong
barrier for the first three to four years,” says
4 tips to market your patient portal
1
Get the entire staff involved
Everyone in the practice should be involved in
promoting the benefits of using the patient portal.
The front office can display signs and posters, staff
members can distribute brochures to patients, and
providers can discuss the use of the portal during
patient visits.
2
Simplify registration
Have a staff member assist patients with registering for the portal. If you can overcome the registration barrier, patients will be more likely to
use the portal.
3
Engage
A portal that provides mostly administrative
functions, such as scheduling appointments and
obtaining lab results, will be helpful but not as
interesting to patients. Patients will be more likely
to use a portal that is designed to address their
personal needs. Portals that include interactive
and personalized tools will be more engaging.
4
A two-way street
One of the best ways to convince patients to use the portal is to communicate with them through it. Communication should go both ways. If a
patient sends the physician a secure message
through the portal, reply using the portal function
(using case-by-case discretion, of course).
Source: HealthIt.gov

32. 32 MedicalEconomics.comMedical Economics
Nicole Gendron, BVCHC communications
manager and project manager for portal
implementation. “Only in the last year has it
become available in Spanish. We are hoping
this will drive up our enrollment numbers.”
Embracing secure messaging
Many physicians remain reluctant to adopt
portal technology out of fear that secure
messaging with patients will cause them to
lose control over their personal time or ex-
pose them to increased liability. But Daniel
Brown, MD, of Family Medicine Associates
in South Attleboro, Massachusetts, has em-
braced email communication with his pa-
tients and has been rewarded for it.
“It ends up being one of those unpredict-
able factors that increase the bond between
provider and patient by increasing the level
of trust or comfort,” he says. “I especially love
receiving comments that say, ‘Wow! I can’t
believe how fast you got back to me.’ The
portal is a very, very significant factor not
only in my satisfaction as a provider but also
the satisfaction of my patients.”
Brown, whose 12-provider private prac-
tice has registered 75% of its patients for
the portal, responds to patient messages
periodically during the evenings and week-
ends, a habit he believes ultimately makes
his workweek more efficient and enjoyable.
“If I check five or six times over the course
of a weekend and take care of 15 or 20 mes-
sages that may have come in, that makes
Monday morning a lot easier, “ he explains.
“If some nights, I go back and see if anything
has come in, it will make tomorrow morning
a lot easier.”
Occasionally, a patient will send him a
never-ending email, a problem Brown solves
with a no-nonsense reply.
“I tell patients upfront that if I get a long
message from you, my response will be: ‘I’m
your doc, not your pen pal. Too much here
for this format. Let’s have you come into the
office,” he says.
Brown, who uses athenaCommunicator,
says the portal and related add-on services
produce benefits that go beyond decreasing
phone calls and reducing mailing costs.
“The portal helps increase my efficiency
and productivity by helping to shape a pa-
tient’s next visit or by not tying up a spot
in office for someone who has a new prob-
lem, a higher reimbursed visit, rather than a
quickie follow-up just to find out that cream
worked and the rash is gone,” he says.
Salvatore S. Volpe, MD, a Staten Island,
New York-based internist and Medical Eco-
nomics editorial board member, suggests
providers attend more Health Information
Management Systems Society meetings so
they can see firsthand the money-saving ad-
vantages today’s rapidly improving portals
offer.
Volpe estimates his eClinicalWorks por-
tal saved him “at least half a full-time em-
ployee” by streamlining appointments and
reducing calls to the office for medical refills
and referral requests. He also praises use of
a mobile app that enables patients to share
their health information with any doctor
with Internet access.
While debate continues over charging
patients for portal access, Volpe agrees with
the providers who view the technology as a
part of doing business and a product that
can pay for itself.
“I decided I wasn’t going to charge people
for it,” says Volpe. “It introduced efficiencies
into my office, which covered whatever ad-
ditional cost there were to have a portal.”
It makes a huge di fference because
people want to tal k to their provider.
If your physician tells you, ‘You can
email directly with me,’ it’s very power ful.”
— Jose Polanco, MD, medical director, Blackstone Valley Community Health Care,
Pawtucket, Rhode Island

33. 33 Medical EconomicsMedicalEconomics.com
Financial considerations have stopped
him from opening the portal’s secure mes-
saging feature to patients, however.
“Once Medicare starts reimbursing, I’ll
build it into my workflow,” he says, “But until
it gets reimbursed, it is hard enough to do
patient-centered medical home and not get
reimbursed from CMS [Centers for Medi-
care and Medicaid Services]. To add this ad-
ditional feature would be very hard.”
The future of the portal
As portals continue to evolve, Ernst &
Young’s Oldenburg hopes physicians “re-
frame” their view of the technology and no
longer see it as “one more thing that is being
thrown at them.”
“It is something that can be transfor-
mative in the way they practice medicine
and transformative for their relationships
with patients and the loyalty they build,”
she says.
But Joanne Rohde, chief executive officer
of Axial Exchange in Raleigh, North Caro-
lina, believes patients will not fully embrace
portals until the technology becomes a gate-
way to self-care, not simply an alternative to
phoning their doctor’s office.
“Patients definitely want to get more in-
volved in their own healthcare, but patient
portals right now aren’t necessarily the right
mechanisms to do so,” she says. “Patient
portals as mandated by MU2 are doing ad-
ministrative tasks, such as appointments
and refills. They aren’t making sure you are
managing your blood pressure. They are
not making sure you understand your dis-
ease state. That’s what the industry needs to
move toward for self-care.”
Rohde is hopeful Apple’s new “Health”
app, a partnership with Epic and Mayo
Clinic, may provide the kick-start healthcare
needs.
“The key is getting both the patient and
the physician to step on the treadmill, be-
cause we are in an Internet-enabled world
and healthcare is the last industry not to be,”
she says.
The portal helps increase
my efficiency and productivity
by helping to shape a patient’s next visit .”
— Daniel Brown, MD, Family Medicine Associates, South Attleboro, Massachusetts

34. MedicalEconomics.comMedical Economics34
e-book
Digital publication
Seventy percent of physicians now use elec-
tronic prescribing through their electronic
health record, and in 2013, the number of pre-
scriptions sent electronically topped 1 billion,
according to the latest report from the Office
of the National Coordinator for Health Infor-
mation Technology (ONC).
The report, which analyzed data from
Surescripts, looked at the volume ofe-pre-
scriptions from December 2008 to April 2014,
after the Medicare Improvements for Patients
and Providers Act (MIPPA), an e-prescribing
incentive program, was passed. The report
found a ten-fold increase in providers’e-pre-
scribing rates during that timeframe.
Minnesota had the largest increase, with
only 4% of its physicians e-prescribing in 2008
and 100% of physicians doing so in 2014. As
of April, Indiana had a 95% e-prescribing rate,
followed by Massachusetts at 94% and South
Dakota at 90%.
The report credits the jump in e-prescrib-
ing to the MIPPA. Before it’s implementation,
the rate among physicians was at 7% in De-
cember 2008. The number of pharmacies that
accepted e-prescriptions also increased dur-
ing that period, from 76% in 2008 to 96% in
2014.
The global e-prescribing market is grow-
ing at a rapid pace. It’s projected to balloon
from $250.2 million to $887.8 million by 2019,
according to a report released in June by
Transparency Market Research. ONC report shows 7 in 10 physicians are using EHRs for patient
prescriptions
by Alison Ritchie Contributing editor
E-prescribing rates
soar among physicians

35. 35 Medical EconomicsMedicalEconomics.com
e-book
Digital publication
E-prescribing is bringing substantial benefits
to the nation’s healthcare system, but signifi-
cant barriers remain to its more widespread
adoption, a new research study concludes.
The study, in the form of a systematic re-
view, examined the findings of 47 articles
looking at e-prescribing—which the authors
define as “the computer-based electronic
generation transmission, and filling of a pre-
scription”—from a variety of clinical and fi-
nancial perspectives. The results appear in
an article titled “Electronic Prescribing: Im-
proving the Efficiency and Accuracy of Pre-
scribing in the Ambulatory Care Setting” in
the Spring 2014 issue of Perspectives in Health
Information Management.
The benefits found in the review include:
Improved patient safety: E-prescrib -
ing makes prescriptions more legible, de-
creases the time needed to prescribe and
dispense medications, and reduces medica-
tion errors and adverse drug events (ADEs)
due to the presence of medication decision
support (MDS) systems. One study of 12
community-based practices found that er-
ror rates dropped from 42.5 to 6.6 per 100
prescriptions one year after the adoption of
e-prescribing.
Greater efficiency: Though it takes
about 20 seconds longer per patient to enter
a prescription into a computer than to write
it by hand, “this time is offset by the time
saved because of the fact that less clarifica-
tion is needed for electronic prescriptions,”
the authors say. At the pharmacy, meanwhile,
prescriptions received electronically produce
less paperwork and fewer issues that need to
be resolved compared with paper prescrip-
tions.
Cost savings: The authors cite a study
by the clinical network Surescripts showing
an estimated $140 billion to $240 billion in
savings and improved health outcomes over
10 years, mainly due to better medication ad-
herence and reduced ADEs. The Surescripts
study also found a 10% increase in the num-
ber of e-prescriptions filled compared with
written prescriptions.
In addition, e-prescribing systems that use
MDS can help doctors choose lower-cost al-
by Jeffrey Bendix Senior editor
E-prescribing
is benefitting healthcare system,
but barriers to adoption remain

36. 36 MedicalEconomics.comMedical Economics
ternatives to brand-name drugs can reduce
prescription drug costs. The authors cite a
2005 study involving 19 physicians that found
a 17.5% decrease in prescriptions for high-
cost drugs compared with the control group,
leading to a savings of nearly $110,000 over 12
months.
Barriers to the greater use of e-prescribing
include:
Implementation costs: “New technol-
ogy requires training and information tech-
nology support for installation and upkeep,”
the authors note. “A practice must take these
costs into account when deciding whether
to implement an e-prescribing system and
when choosing a stand-alone system or one
that is integrated into an EHR system.”
Alert fatigue: Faced with numerous
alerts each time they enter a prescription,
many providers stop reading the alerts, with
the result that they may ignore a potentially
dangerous interaction.
Privacy issues: Without effective firewalls
and other safeguards, prescription data trans-
mitted electronically may be breached, lead-
ing to HIPAA violations and fines. In addition,
“most information breaches actually occur as
a result of employees’ actions, so continuous
training on security is imperative and can in-
cur additional costs,” the authors write.

37. 37 Medical EconomicsMedicalEconomics.com
e-book
Digital publication
Voice recognition software, scribes allow physicians to focus on the
patient, rather than the computer screen
by Beth Thomas Hertz
Ways to optimize
EHR documentation
at your medical practice
Electronic health record (EHR) systems are
built to help physicians improve their practic-
es. But EHRs may also come between a physi-
cian and a patient during an encounter. Many
physicians believe they spend more time typ-
ing into a computer instead of looking their
patients in the eye. The bottom line: EHRs re-
quire physicians to rethink their documenta-
tion strategies.
When physicians are trying to decide what
is best, Peter Basch, MD, chair of the Ameri-
can College of Physician’s Medical Informat-
ics Committee, advises them to look at their
overall goals.
“The issue is not just typing. The issue is
understanding where we are in the evolu-
tion of having a computer in the room with
a patient,” he says. “Is there is value in having
a third party in the room with the doctor and
patient? That third party is information that
helps us deliver better, safer and perhaps even
less expensive healthcare.”
He compares the new paradigm to a pilot
using a checklist prior to takeoff.
“A good pilot doesn’t just make eye contact
with the copilot or stare out the window. A
good pilot also attends to other appropriate
information for helping to better assure a safe
flight,” Basch says. “The same is true in medi-
cal care. We quickly forget why the computer
is there. It’s not a punishment for not taking
typing in eighth grade. The primary purpose
is not the documentation. The primary pur-
pose is, at least in my opinion, how we better
interact with the information.”
Options are available to physicians look-
ing for a way to improve their doucmentation
strategies. They range from typing furiously,
while potentially ignoring the patient, to us-
ing scribes, voice recognition technology, or
even continuing to take notes by hand and
entering them into the computer later.
How EHR is used is key
No matter what input method is used, physi-
cians must prevent the computer from im-
peding communication with ­patients, Basch
says.
“Triangulate the screen so that the doc-
tor, patient, and family can see it and use it
as a tool to improve education, safety, and
outcomes,” he suggests. “Do not keep the

38. 38 MedicalEconomics.comMedical Economics
back of your head to the patient the entire
visit and shield the screen so the patient
can’t see what you are doing. That’s like pa-
per records, but worse.”
Jason M. Mitchell, MD, who directs the
Center for Health IT at the American Acad-
emy of Family Physicians, suggests that one
way to keep the physician focused more on
the patient rather than the computer is to
have patients and office staff enter key in-
formation before the physician comes in to
visit with the patient.
Also, “having polished typing skills
makes a huge difference, as does the use
of keyboard shortcuts, ‘auto text’ abbre-
viations, checkboxes, dropdowns, pick lists,
templates, and appropriate history reuse
from the longitudinal record,” he adds.
Is typing a real option?
Among the various options for documenta-
tion, some physicians find that frantically
typing during the visit works for them. It can
slow a physician down, but it doesn’t involve
additional costs or staffing.
“I have seen examples of this approach
working really well,” Basch says. “If you are
a ‘touch typist,’ a good approach is do the
minimum. Pay close attention to making
sure the right boxes are clicked, but have
someplace in your EHR field in which you
can type quick notes so that you have accu-
rate, contemporaneous notes.
“You don’t have to ask the patient to stop
talking so you can type grammatically cor-
rect sentences such as ‘Patients has had
a sore throat since Tuesday.’ We certainly
didn’t do that on paper. We scribbled TUES-
sore throat. You don’t have to do any more
on the computer,” Basch adds.
Voice Recognition software
However, Nick van Terheyden, MD, chief
medical information officer for Nuance,
whose Dragon Medical software is the most
commonly used voice recognition technolo-
gy in healthcare today, sees that technology
as a much better option.
“Historically, physicians wrote their notes
on paper. Starting in the 1970s, documenta-
Documentation strategies
PROS
ISSUE CONS
Pros & Cons
❚ No extra expenses or equipment ­required Typing ❚ May make it hard to focus on the patient,
especially if you aren’t a fast typist.
❚ Frees up more of physician’s attention;
allows instant review
Voice
recognition ❚ Additional cost of software, some learning
involved; still need to review for accuracy
❚ Allows physician to focus solely on patient;
having a second perspective can improve
accuracy
Scribe ❚ Ongoing salary and benefits for employee;
potential discomfort for patient in having an
additional person in the room
❚ No training or extra investment required
Keeping
Paper ❚ Hard to share with other providers; may
hinder reimbursement process; illegible
handwriting can lead to errors; may seem
antiquated to younger patients

39. 39 Medical EconomicsMedicalEconomics.com
tion had to be legible in order for them to be
paid. This gave rise to a large transcription
industry,” he says.
Early voice recognition technology could
create a first draft, but it had to be cleaned
up by a medical editor. However, today’s
technology can create a highly accurate
transcript that the physician can review in
real time and share immediately with other
providers if needed, he says.
Most physicians can learn to use voice
recognition very quickly, he says. The tech-
nology lets users specify the dialect with
which they speak and their medical special-
ty, and creates a profile to assist them. Some
physicians may find they need to adjust
their style of dictation, though.
Van Terheyden’s brother is a physician
who realized through using voice recogni-
tion that he wasn’t as fluent as he thought
he was when he dictated, and worked to im-
prove how he presents information.
“He is now proud of his clinical notes,”
van Terheyden says.
Such improved clinical notes offer a com-
plete narrative of the patient’s story. More
intricate details from the visit that may have
been missed in the past are captured.
“We all look at lab results and vital signs,
but we are really interested in the details of
how patients present,” he says. “Eighty per-
cent of my diagnostic process comes from
the patient history, about 15% from my ex-
amination, and about a 5% contribution
from the investigations and tests that con-
firm or refute my findings.
“If you only capture information from
drop-down lists and checked boxes, you lose
some of the fine details,” he adds. “Speech
preserves it.”
As a bonus, patients can review the dic-
tated notes on the computer screen with the
physician and correct any errors. “Who has
the most vested interest in the successful
outcome of the interaction? The patient,” he
says. “They can make a wonderful, positive
contribution.”
Voice recognition is a time saver for
many physicians, he says. One physician
he knows works in several locations, one
of which does not have speech recognition
capabilities. This physician often works an
extra hour or more a day to complete his
documentation at that location.
Van Terheyden notes that there are many
pricing models for voice recognition tech-
nology, based on how many patients the pro-
vider sees and the activities he or she needs
to document. Some EHR systems come with
the technology built in, so physicians do not
see it as a separate cost. For others, the soft-
ware needs to be added. Most systems will
work with piggybacked voice recognition
software, although not all.
Many primary care practices can save
enough money from eliminating transcrip-
tion to recoup the cost of the software and
microphone in three to six months, he adds.
Also, voice recognition turns dictation
into actionable data tagged against a medi-
cal vocabulary, van Terheyden says. This
gives providers real-time feedback, such as
suggesting a diagnosis that might be indi-
cated by the constellation of symptoms. It
can also help ease the transition to the In-
ternational Classification of Diseases—10th
Revision (ICD-10) because it prompts the
physician to enter details, such as laterality,
up front.
Basch notes that some physicians use
voice recognition in a hybrid manner, using
a minimal template with key boxes and us-
ing voice recognition to add a narrative that
accurately reflects what the patient said.
“This is a very powerful thing, particu-
larly for patients who have had bad experi-
ences with other doctors,” he says.
Scribes
Another documentation strategy is hiring
scribes. Scribes can be highly accurate and
serve as a backstop for catching physician
errors. However, they have several disadvan-
tages, namely their ongoing salary, which
they likely will expect to increase each year.
Also, having a third person in the exam
room can make some patients reticent to
discuss their condition in a frank manner.
Basch recalls that when he was in train-
ing decades ago, the most efficient doctor
he ever saw was an ear, nose, and throat spe-
cialist who used a scribe. The scribe would
tell the doctor the key points from the last
visit or remind him of things he wanted to
recheck, while he examined the patient and
offered comments aloud.
“Certainly that is a way to do it but since
it is expensive, it is not for everybody,” Basch
says. “If you hire the right person and they
know medical terminology, it can be a time
saver. But know that you are still signing the
notes, so you still need to review them.

40. 40 MedicalEconomics.comMedical Economics
Mitchell says that the usefulness of
scribes can depend on the physician’s prac-
tice style.
“Significant benefit comes from a bidi-
rectional interaction of the physician and
the EHR. Data validation tools, data reuse
mechanisms, and clinical decision support
tools are all dependent on the provider di-
rectly interacting with the EHR. This is com-
plicated by putting a scribe between the
physician and the EHR,” he says.
“Some systems (SOAPware, for exam-
ple) are introducing the concept of ‘virtual
scribes’ as a part of the EHR itself. This keeps
the physician interacting with the record
and the patient and benefiting from the data
management and decision support tools
that EHRs have to offer,” Mitchell adds.
Still attached to paper?
Despite the spread of EHRs, paper charts are
still very much in use. Basch, who has been
in practice for 33 years, says they appeal
particularly to older physicians who feel un-
skilled in rapid typing or proper use of voice
recognition.
“If this is an issue for you, don’t struggle
with it,” he says. “Work with colleagues, a
physician champion, your organization,
or a vendor to come up with alternate
mechanisms for data entry in the room
with a patient so you can focus on the
things that you need to. See if you can
get a tablet that supports handwriting
recognition. Or even stick with paper. In
contrast to what some say, paper doesn’t
kill. Paper usually cuts. Medical errors can
kill.”
Using paper in the exam room and input-
ting your notes later is better than leaving
medicine, he says. “If you are a talented per-
son, don’t give up.”
Mobile platforms can provide a mid-
point for some physicians. For example,
iPads can accept dictation and allow inter-
action. A software program that Nuance
makes, called Florence, helps physicians
access information from complex medical
records. Instead of navigating a menu tree to
find lab results, they can just say, “Show me
the lab results.”
Mitchell agrees that physicians must use
whatever tools are necessary to provide the
best care to their patients. “The wrong EHR
badly implemented and poorly used by a
physician can cause far more harm than
effective use of a paper chart. However, the
right EHR, well implemented and skillfully
used by a physician is far better than a paper
chart,” he says.

41. 41 Medical EconomicsMedicalEconomics.com
e-book
Digital publication
Value-based incentives can help practices offset EHR costs and
derive a return on investment
by Ken Terry
Utilize your EHR system
to boost practice revenue
It’s difficult for small practices to get a return
on investment (ROI) from their electronic
health record (EHR) systems, even if they re-
ceive government Meaningful Use payments,
health information technology consultants
say. Still, it’s possible for practices to achieve
ROI if they participate in alternative delivery
models that help them garner value-based re-
imbursement.
The two traditional sources of ROI are
increased efficiency and higher charges,
based on better documentation. Using an
EHR to increase efficiency requires major
changes in office processes, and the gov-
ernment has recently increased its scru-
tiny of certain documentation techniques
that help practices justify higher charges.
As a result, says Michelle Holmes, a prin-
cipal with ECG Management Consultants in
Seattle, Washington, not many small practic-
es can achieve ROI on their EHRs in a fee-for-
service world.
“The big Meaningful Use incentive dol-
lars were in the early years,” she notes. “So
at this point, the practices’ spend is greater
than what they take in, unless they’re doing
something in addition to the EHR implemen-
tation.”
Nevertheless, Holmes and other experts
say, it’s possible for practices to achieve ROI
if they participate in alternative delivery
models that help them garner value-based
reimbursement. These include accountable
care organizations (ACOs) that participate
in shared savings programs; Patient-centered
Medical Homes, which many insurers incen-
tivize; and pay-for-performance programs
that pay quality bonuses.
All of these models, to varying extents,
require the use of EHRs. Therefore, Holmes
notes, not having an EHR represents an
“opportunity cost” that can be quantified
and weighed against the cost of installing a
system.
Most practices are still not receiving
much, if any, income from value-based re-
imbursement. But ACOs and medical homes
are increasing, and some physicians are be-
ginning to see the possibility of achieving
ROI.

42. 42 MedicalEconomics.comMedical Economics
Nephrology group counts on
ACO
Simon Prince, MD, is part of a seven-doctor
nephrology practice in Manhasset, New
York. The physicians have attested to Mean-
ingful Use for two consecutive years, but
those payments covered only 20% to 25% of
what they invested in their EHR, Prince says.
While the EHR has made the practice
more efficient in some ways, in other ways it
has decreased efficiency and productivity, he
says. For example, documentation of patient
encounters takes him longer than it used to.
On the other hand, improved documentation
has led to fairer reimbursement, in his view.
With these and other factors included
in the analysis, he says, the ROI on his EHR
“is around a wash,” at best. But the group’s
participation in an independent practice as-
sociation that has turned into an ACO could
change the picture in the long run, he says.
The ACO, which Prince leads, includes 325
doctors in 100 practices. It participates in the
Medicare Shared Savings Program (MSSP)
and is one of 29 ACOs that qualified for bo-
nuses in that program’s first year. The ACO
also holds shared-savings contracts with sev-
eral private payers.
To participate in the ACO, a practice
must either have an EHR or plan to acquire
one within 12 months. The EHR is necessary
partly because the Centers for Medicare and
Medicaid Services (CMS) factors the per-
centage of ACO members who have achieved
Meaningful Use into its bonus calculations.
Also, some of the quality measures in the
MSSP require clinical data that’s easier to
collect with EHRs.
Prince believes that once the MSSP bo-
nuses start flowing, they will help him and his
colleagues in the ACO achieve ROI on their
EHRs. He’s not sure those bonuses will be sub-
stantial, but he believes that value-based pay-
ments will continue to increase for practices
that participate in the Medicare and health-
plan shared savings programs.
Meanwhile, he points out, the ACO has
barely begun to take advantage of its EHRs.
The 30 EHRs used by member practices can-
not yet exchange information with each oth-
er; when they do, it will be much easier to co-
ordinate care. Currently, he notes, the ACO’s
population health management software
uses claims data, combined with clinical data
that practices enter on a web portal and lab
data feeds.
Incentives pay
for small practice’s EHR
Jeffrey Kagan, MD, of Newington, Connecti-
cut, practices internal medicine with one
other physician and a nurse practitioner
(NP). The group’s EHR cost about $120,000,
including interest payments. Meaningful
Use incentives will cover most of that.
Learning the EHR slowed the doctors and
the NP initially, but productivity has rebound-
ed, and they see more patients now than they
did before implementing the system. More-
over, Kagan notes, “We’re billing at higher lev-
els than we did before.”
So even though the practice is paying
about $5,000 a year for software maintenance
and may have to buy some new computers, it
has achieved ROI on its EHR, he says.
Kagan, a Medical Economics editorial
board member, expects further ROI from
participation in an ACO and from pay-for-
performance. The EHR allows his practice
to pull quality data that it sends to the ACO.
In turn, the ACO reports on the physicians’
performance to CMS’ Physicians Quality Re-
porting System (PQRS), which pays bonuses
for reporting.
In addition, when insurance companies
ask Kagan to fill out quality improvement
forms, he can use the EHR to complete them,
which results in small additional payments.
While Kagan is not yet getting pay-for-per-
formance bonuses from the health plans, he
says, “I think that’s coming.”
Other sources of ROI
As Kagan’s story shows, it’s still possible to
get ROI from a combination of meaningful
use incentives, efficiency, and higher charg-
es. But it’s getting harder to pull off.
“Some people do get ROI, but it requires
real change,” observes Rosemarie Nelson, a
Medical Group Management Association
healthcare consultant in Syracuse, New York
and Medical Economics editorial consultant.
“People want to keep what they do the same,
so they try to retrofit the technology into their
current processes. But in order to take advan-
tage of what the technology offers, your pro-
cesses must change.”
Nelson says she has seen practices that
don’t take advantage of their EHR’s ability to
track test orders against results to see if they
came back. Instead, nurses print out the or-
ders and put them in a tickler file. Nor do they
use patient portals that enable patients to
EHR
return on
investment
According
to a survey
of 49 community
practices in
an EHR pilot
program:
$43,743
the amount
the average
physician is
expected to
lose over five
years using
an EHR
27
%
number of
practices that
would have
received a
positive return
on investment,
according to
results of the
survey.
Source: Health Affairs, March, 2013

43. 43 Medical EconomicsMedicalEconomics.com
self-register and enter their chief complaint
and family/social history before scheduled
visits.
Holmes agrees that process redesign is es-
sential if practices want to increase efficiency.
But because of the tight MU deadlines, she
says, “people aren’t taking enough time to
implement these systems in a way that might
increase efficiency.”
The amount of additional revenue prac-
tices can realize by coding higher depends
on whether they were undercoding before
they got their EHRs, Holmes notes. But even
if they could raise their charges by improv-
ing documentation, CMS is looking closely
at physicians who copy parts of past notes
into current notes or who document by ex-
ception. The threat of being accused of fraud
has thrown a chill into physicians, she says.
As a result, many are coding more conserva-
tively.
Other factors
Another key factor in ROI is the 5-year cost
of an EHR system. Vendors of web-based
EHRs claim that their products are cheaper
than site-based systems because they have a
lower upfront cost. But Nelson says that the
research she’s seen shows that the differenc-
es in 5-year costs are “insignificant.”
Holmes contends, however, that there is
a difference in cost that depends on the size
of the practice. Larger groups can get econo-
mies of scale by hosting their own EHR, but
small practices can’t. Therefore, the latter are
probably better off with a cloud-based EHR,
she says.
Costlier EHRs have sophisticated features
not found in modestly-priced systems, in-
cluding business intelligence and advanced
reporting features that can be useful in popu-
lation health management.
Holmes doesn’t think that small practices
need these features.
“That’s one way to look at the ROI,” she
points out. “How much are you paying for the
stuff you’re actually using? If you’re paying $1
million for the EHR, but you’re only using the
features and functions you could have gotten
in a simpler EHR for $250,000, you may have
overpaid.”
Nelson sees the cost/benefit ratio in terms
of how well a practice implements its EHR. “A
really good Amazing Charts implementation
probably has a way better ratio than a poorly
implemented NextGen,” she says.
Finally, don’t forget about the practice
management system that comes with most
EHRs. If that doesn’t work well, you’re going
to feel the pain in your bottom line.
For a variety of reasons, including the chal-
lenge of maintaining an interface, it makes
sense to buy an integrated EHR/practice
management system, rather than separate
systems, Nelson notes. And if you outsource
your billing, you should hire a service that
uses the practice management system that
comes with your EHR, she adds.
If you’re not getting ROI on your EHR,
don’t despair; that EHR could be the ticket
to future revenue streams. But to enjoy those
added revenues, you’ll have to start partici-
pating in the programs and alternative care
delivery systems available to you.
Also, don’t worry if you and your col-
leagues can’t yet use your EHRs to optimize
your income from these new models. As
Prince explains, “We’re succeeding despite
the challenges that we have with getting any
data out of our EHRs. We find that the ROI
from that perspective is limited for now, but
the potential is there.”
Estimating a return on investment
When constructing a business plan for the purchase or switch
of an electronic health record (EHR) system, most practices
need to consider four cost centers:
❚ hardware,
❚ software,
❚ implementation and training,
❚ support and maintenance.
ROI is calculated by:
Gross revenues collected
– Direct costs of an EHR
– Indirect costs of operating EHR
– Financing costs associated with purchases
= Net profit (or loss)

44. Copyright 2014, Advanstar Communications Inc. All rights reserved. Reproduction in whole or in part is
prohibited without prior written permission of the publisher.