Digitized Medicine

Single Vendor vs. Best of Breed for Ambulatory EMR Strategy

Selecting an EMR: Ready, Set…Go Compare!  is a series of blogs that serves as a resource for physicians who have decided to select and implement an ambulatory electronic medical record (EMR).

For a physician practice that is adopting health information technology (HIT) the two most important systems will be the selected EMR and the practice management (PM) system.   Most physician practices already have a practice management system.  The EMR and PM systems have different purposes. The EMR primarily has clinical functions and the PM system primarily has billing and scheduling functions. However, both of them manage the same patient encounter processes that start with the patient phone call for an appointment and end at the completion of the billing processes.  Any technology that is used to facilitate a single set of processes such as this must work seamlessly and facilitate an efficient workflow. In this situation the clinical, scheduling and billing information should be easily accessible at defined points along the encounter processes and shared between the clinical and administrative systems whenever and wherever needed to support an efficient work flow. This means that the EMR and PM system must work together and flow data back and forth.

There are two strategies that can potentially lead to an efficient workflow for the physician practice.  In the single vendor strategy the physician uses an EMR that includes an integrated PM system.  In the best-of-breed strategy the physician purchases an EMR that can be interfaced with a different PM system (either a new one or the physician's current one).  A third strategy that will not meet these workflow needs is to use an EMR that is not interfaced with the PM system.  This is not a recommended strategy becasue it causes inefficiencies such as the need for staff to duplicate entries of demographic information and charge codes in both systems.  That strategy is also likely to make it more difficult for the physician to meet the quality reporting requirements that Medicare and Medicaid will be providing bonuses for over the next 6 years.  

The ambulatory EMR market currently includes many small, stand-alone EMR vendor products that do not include a practice management system and other robust functionalities. There are fewer vendors with robust, integrated products that include a practice management system.  Smaller vendors sometimes cater their product to a niche set of specialty physicians.  Others offer products that can be customized to meet a large range of needs. 

When selecting an EMR physician practices will first determine what they need an EMR to do for their practice.  Once these EMR needs are identified, one of the next ways for physicians to further narrow down the list of EMR vendors is to weigh the risks and benefits of the single vendor (integration) and best-of-breed strategies against each other within the perspective of the practice's needs and technology prowess.   Some of the risks and benefits are noted in the chart below:

 

Single Vendor (Integration) vs. Best of Breed
These Risks/Benefits should be considered as general tendencies and discussed with EMR vendors during selection process and contract negotiations
Single Vendor	Best of Breed
Benefits	Benefits
Reliability-- seamless data flow on same technical platform	Potential for finding a strong EMR and strong PM systems that meet more functionality desires
Better workflow management (i.e. interoffice messaging)	A "boutique" or niche EMR may meet more of a specialty physician's desired functionalities
Single vendor accountability for issue resolution (no "finger-pointing" vendors)	Upgrades do not have to be made to both systems at same time
Single log-in to system, not multiple log-ins/passwords	Updates can be made to one system without impacting the other system
Fewer upgrades (one system)
Fewer vendor relationships to cultivate
One contract
Risks	Risks
Upgrades needed to one part of system may require other part to be "down" and/or upgraded at the same time, even if not desired on that part (i.e. PM system needs upgrade for "bug fix", but significant changes made to the EMR might not be desired yet)	The EMR and PM system may not interface well and thereby cause workflow issues (i.e. duplicated data entry in both systems such as demographics or charges , inefficient work-arounds, unexpected costs to fix such issues)
Unbalanced vendor expertise (strong EMR/weak PM or weak EMR/strong PM)	Multiple vendor products with mulitple interfaces complicate identifying source of issues and problem resolution
Chips are "all-in" with one vendor	More complexity and issues with interfaces
More reliant on good local IT support	Data reporting more complex with data on different platforms requiring robust  third party reporting tools
	More upgrades and testing and maintenance work

Both models have advantages and disadvantages.  Most notorious among the differences are the interfaces that are needed in the best-of-breed strategy.   The physician practice should become familiar with each strategy including the challenges of interfaces used in the best-of-breed strategy.   A decision on which model to select will be dependent on the EMR goals, budget constraints, desired future workflow, the technology prowess of the practice, risk-tolerance for notorious interface issues and on other things found to be most important to the practice. This author advises physicians to strongly consider using an integrated, single vendor strategy. A physician who is interested in understanding the finer points on interfacing disparate systems should proceed with due diligence to ensure selected vendors have recent experience interfacing their two products to each other.  At a minimum the EMR vendor should have experience with interfacing the demographics, charges and check-in/check-out between their EMR and the desired PM system. In addition the physician practice should request a site visit to a practice that is using these interfaces to discuss issues and verify their satisfaction with results. Be wary of vague statements by the vendor that they can interface but are unable to provide you any contacts of such an interfadce done within the past year.

EMR Selection Guide provides an outline of additional topics on the selection process

 EMR Implementation Guide provides an outline of topics on the implementation process

EMR Selection: Roles of Project Team, Project Manager and Decision Making Process

 

Selecting an EMR: Ready, Set…Go Compare!  is a series of blogs that serves as a resource for physicians who have decided to select and implement an ambulatory electronic medical record (EMR).

 

 EMR Project Team:

The implementation of an ambulatory EMR requires expertise and effort from a variety of individuals within the physician's practice.  Knowledge is needed for all of the processes used in the practice on a daily basis such as telephone answering, message taking, appointment scheduling, check-in processing, weight and vital signs recording, history-taking, encounter documentation, medication administration, referral management, discharge instructing, billing and check-out processing.  Establishing an EMR project team will help bring this collective set of knowledge together.  This is important because the initial goal of the EMR project team, even before selecting and implementing an EMR, will be to clearly understand why the practice is going to implement an EMR and how it will impact all areas of the practice.  Once an EMR product is selected and purchased, the focus of the team will naturally shift to the successful implementation of the selected EMR.

The EMR project team should include a physician champion, a project manager who leads the team and a broad representation of the office staff and clinicians.  At a minimum even a small office should include an office manager, nurse, physician and a representative from the “front” and “back” desks.

Creating a multidisciplinary EMR project team such as this will:

• Foster a team-oriented environment from the start
• Energize the staff
• Create a natural means of good communication
• Promote trust, “buy-in” and support from all areas of the office

The concept of a project team and adherence to project management principles may be new to the physician and to the office staff. They may not at first understand the purpose of following structured project management principles and they may feel that it is excessively rigid. However, during the EMR implementation the value of adhering to project management principles will become apparent when the team finds itself working harmoniously toward the same vision and a common set of goals. The team should therefore be educated about how project management principles provide the structure and means that foster:

• Clear expectations
• Realistic timelines
• Responsible management of costs (including the cost of staff time and effort)
• Proactive management of bottlenecks
• Effective decision-making
• Effective communication

Project management plans and principles are described in more detail in “EMR Selection: Developing a Project Plan and Adhering to Project Management Principles” (next week). 

The Project Manager:

During the selection and implementation of an EMR the practice should identify a single person to develop and coordinate the EMR project plan. The options for physicians are to:

1. Manage the project themselves
2. Assign management to someone else in the practice
3. Hire an outside IT consultant as a project manager

Before deciding to take on the responsibility of project management themselves a physician should consider carefully the amount of time and effort that this will involve. It is the opinion of this author that the physician champion should not serve as the project manager who is responsible for creating the project plans and coordinating all of the selection and implementation activities.  Assigning project management to an internal staff person may be considered especially if there is a trusted person with project management experience. It is the opinion of this author that physician practices strongly consider using a consultant experienced with EMR implementations and project management. Some responsibilities of the project manager are to:

• Develop the project plans and project timeline
• Identify tasks and available resources to do the work for each task
• Assign responsibility for tasks to individuals
• Monitor progress on tasks and progress on the timeline
• Manage project issues and project constraints that develop
• Coordinate communications within the office and among the vendors
• Coordinate demos, site visits, phone calls, travel arrangements
• Document meeting notes, phone call conversations, decisions made, action items and follow-up
• Create the EMR functionality scorecard, RFP and other documents
• Coordinate implementation activities with the EMR vendor
• Follow project management principles to keep the activities aligned with goals
• Coordinate contract negotiations
• Work closely with the physician champion
• Lead the EMR project team meetings

Coordination of the activities of a comprehensive work flow analysis and documentation of the practice’s requirements for an EMR will be time-consuming for the project manager early in the EMR selection process.  Developing a shared implementation plan with the EMR vendor and coordinating the execution of the project plan will be time-consuming later in the project.  

Decision-Making:

As the project manager, physician champion and EMR team are established there needs to be clarification about how decisions will be made going forward. Trust and support are strengthened by a clear and transparent decision-making process. The best practice in project management is to designate a single stakeholder who has the authority to make final decisions during the project. This is usually the physician champion or other lead physician in the group. At the beginning of the project everyone should be informed on how decisions will be made. The stakeholder most commonly will delegate day-to-day decision-making to the EMR project team which includes the project manager and the physician champion. Through regular progress reports the project manager should keep the stakeholder aware of all strategic decisions and other important decisions being made.  If a consultant is managing the project they should also follow these basic project management principles.   

When the project team cannot reach consensus on a decision the stakeholder serves as the escalation point.  If the stakeholder is unsure about a decision that has been made or is presented with an escalated issue that requires a decision, he/she should seek the perspectives of the individual project team members, IT consultants, EMR vendors and others in their practice who can provide valuable insights that will facilitate a good decision.

EMR Selection Guide provides an outline of additional topics on the selection process

 EMR Implementation Guide provides an outline of topics on the implementation process

EMR Selection: Physician Champions

 

Selecting an EMR: Ready, Set…Go Compare!  is a series of blogs that serves as a resource for physicians who have decided to select and implement an ambulatory electronic medical record (EMR).

 

An enduring axiom about electronic medical record (EMR) implementations remains unchanged: “If no physician champion, then don’t implement”.  The physician champion’s role in an EMR implementation is to keenly focus on strategic implementation decisions, education of colleagues on the EMR, process/work flow redesign and on the design, configuration, build and testing of the EMR.

In a June 30th Digitized Medicine blog (High Demand Persists for Chief Medical Information Officer (CMIO) and Health IT Physician Champion Roles) the evolution of the role of physician champions within health information technology (HIT) is described.  In the 1970s physician IT champions typically served as clinical "subject matter experts" to ensure that clinician's needs were identified and met by IT projects.  Since the 1990s the implementation of more expensive and increasingly complex clinical technologies, such as EMRs with computerized physician order entry (CPOE), has led to the need for an executive CMIO role at a majority of hospitals.  As described in the blog, the CMIO role is different than the physician champion role of the 1970s. The CMIO, in fact, needs to recruit , mentor and infuse the clinical expertise of physician champions from within the organization into health IT implementations.  Similarly, an office practice should identify a physician champion before selecting and implementing an EMR.

Most of the work involved in successful EMR implementations is not technical, but instead involves changes in process and work flow. The physician champion must be closely involved in the redesign of processes and work flow to ensure the changes align well with how the clinician works and thinks best.  The physician champions also are the “subject matter expert” for the EMR’s clinical design, configuration and build. They work on structured documentation templates, order sets, clinical decision support tools and, most important of all, work flow redesign to optimize how the EMR design is used. The champion is a key figure for strategic decisions that need to be made during an EMR implementation. The physician champion works with colleagues to identify their unique needs. At the same time he/she educates colleagues on the value of and garners their support for standardizing their template-based documentation and orders as much as possible.

The effort needed to garner support, design the EMR and redesign processes/work flow is often underestimated.  Implementations that proceed without physician champions or without enough time for the physician champion to adequately participate are more likely to encounter significant problems when the EMR “goes-live”.  Examples of such problems are:

• Documentation takes too much time because there are too many required answers that the physician has to enter
• Documentation takes too much time because of work flow issues
• Inability to easily get quality reports that were expected from the EMR, because the data is entered differently or in different places by different doctors
• Pick-lists have so many choices that it frustrates the doctors
• Poor template design makes it easier for clinicians to just free text; data needed for quality reports does not get entered into discrete fields that allow it to be reported on
• Poor work flow redesign slows down patient flow in the office, productivity goes down

Decisions about what quality data needs to be entered in the EMR and standardization over where it gets entered are needed before even designing templates.  Limiting the amount of “required fields” to these pre-determined data needs helps prevent documentation templates that are to elaborate to enter data quickly. This is important for the physician champion to drive because physicians generally expect to be able to capture quality data, produce quality reports and exchange information with registries or other health information exchange entities in their area once they have an EMR. These reports and registries are tools physicians expect from EMRs to help them improve population care.

Capturing and reporting on quality data will be required to qualify for “meaningful use” incentive payments for physicians using EMRs (under the ARRA/Stimulus package) most likely starting in 2013.  The physician champion will have a key role helping the practice qualify for these incentive payments as “meaningful users”.

The physician champion has strategic roles and post-implementation roles as well.  The physician champion will be a key participant in strategic decisions that the practice will have to make during the EMR implementation, including the go-live strategy ("big bang" vs. phased in) and what to do with the current paper charts or old EMR data.  Post-implementation the physician champion helps optimize and maintain templates, order sets, decision support rules and other EMR tools.  He/she should be the main point of contact with the EMR vendor and manage the timing and scope of future updates and upgrades to the EMR.

The importance of strong physician leadership is stressed in much of the EMR implementation literature. The following characteristics help this lead physician be effective:

• Well-respected as a clinician
• Strong interpersonal skills
• Ability to “makes things happen”
• Teaching mentality (a typical trait of most physicians)
• Strong negotiating skills
• Commitment to successful EHR implementation
• Ability to sell EMR benefits to other physicians and office staff
• Sets realistic expectations

It should be noted that although an interest in computers is helpful, technical skills are really not needed for this role. Much more important than technical proficiency is a willingness to learn and teach.

There is one final caveat based on personal experience that this author would like to share. Unless it is a small 1-3 doctor practice, the physician who is the designated EMR physician champion should not be the individual who develops, monitors and coordincates all of the tasks of the EMR implementation project plans. This is discussed further in "EMR Selection: Project Team, Project Manager and Decision Making".  The physician champion’s role is to keenly focus strategic implementation activities, process/work flow redesign and on the design, configuration, build and testing of the EMR.  Larger practices should consider compensating the champion for the time and effort required to successfully accomplish these tasks.

EMR Selection Guide provides an outline of additional topics on the selection process

 EMR Implementation Guide provides an outline of topics on the implementation process

Selecting an EMR: Effective Communication

 

Selecting an EMR: Ready, Set…Go Compare!  is a series of blogs that serves as a resource for physicians who have decided to select and implement an ambulatory electronic medical record (EMR).

 

Physicians who have decided to implement an electronic medical record (EMR) will create a solid foundation for success by focusing on a few key factors before selecting an EMR vendor.  Case studies of EMR implementations frequently cite effective communication, collaboration and the development of shared, achievable EMR goals as key factors for success.  All three key factors are facilitated by creating an internal project team.  Effective communication and the development of EMR goals by the project team before evaluating EMR products will proactively identify staff concerns, energize the staff and establish a collaborative environment.  This foundation of collaboration and communication will help the practice successfully get through more difficult times during the EMR implementation.

Communication is a variable that the physician leader can manage during an EMR implementation. Ensuring an environment exists where everyone feels safe to speak their minds is the essential first step. Case studies repeatedly show that poor communications within an office or a disjointed office staff are significant risks to successful EMR implementations. Even within cohesive staffs some individuals may feel threatened by the EMR implementation but not let people know about their concerns. Some may, in fact, correctly recognize that their current role and responsibilities will change or disappear when an EMR is implemented. These types of risks can be mitigated by focusing on the basic elements of effective and open communications within the practice.

Basic elements of effective communication during an EMR implementation for physicians and their practices to consider include: 

• Effective listening
• Resolving conflicts through candid dialogue
• Letting the team be honest with their concerns and ideas
• Agreeing to disagree— healthy disagreements can build better decisions
• Posting updates in a shared communication area such as a break room
• Posting project plan timelines and marking progress
• Providing project updates at every staff and physician meeting
• Ongoing, frequent communications to everyone throughout the implementation process, especially on specific topics or issues when they arise 
• Using other modes of communications if they "fit" the practice-- newsletters, email, even social media if you are so inclined
• Offering incentives to your staff (“what’s in it for them”)
• Make clear your commitment to a success EMR rollout (your staff will mimic your attitude to an EMR) 

Each physician and practice have their own communication strengths and weaknesses. Recognition of these will allow the physician and project team to establish more effective communications during the EMR selection process. Communication is also a necessary ingredient for collaboration to develop, both of which are key factors during successful EMR implementations.  

EMR Selection Guide provides an outline of additional topics on the selection process

 EMR Implementation Guide provides an outline of topics on the implementation process

Selecting an EMR: Readiness Assessment

Selecting an EMR: Ready, Set…Go Compare!  is a series of blogs that serves as a resource for physicians who have decided to select and implement an ambulatory electronic medical record (EMR)

Today’s Topic: Readiness Assessment, Action Plan to Mitigate Risks

It is important for physician practices to avoid known pitfalls and focus on success factors when implementing ambulatory EMRs. An EMR readiness assessment is an excellent tool for practices to determine whether they are prepared to do so. When used before starting an EMR selection process, it also helps prepare the practice for change and creates a healthy, team-oriented environment which is a critical factor during successful EMR implementations.

An EMR readiness assessment is a survey usually consisting of 20-30 questions. These questions are based on EMR implementation pitfalls and success factors that are commonly reported in the literature. Readiness factors include things like the physicians’ commitment to EMR use, office preparedness and ability to change, vision and goals, level of technology adoption and skills, level of EMR knowledge, how data is currently managed/used, how well the office communicates, the office decision-making process and the amount of supporting resources. Responses to the questions typically range from “strongly agree” to “strongly disagree”. It is given to all physicians and staff in the physician practice. A scoring system helps gauge the overall readiness of the office for an EMR implementation. For Texas physicians the Texas Medical Association (TMA) published an EMR readiness assessment in their member publication called, “Electronic Medical Record Implementation Guide”. The American Medical Association (AMA) published one example of a readiness assessment in “Health Information Technology Donations: A Guide For Physicians”.

Once the survey is completed and scored the results are analyzed and an action plan developed to improve the level of EMR readiness. Responses to individual questions will show specific areas of strengths and weaknesses. The action plan should focus on the identified weaknesses, or gaps in readiness, that surface in the survey answers. If the overall survey scoring results indicate that the practice is probably not ready for an EMR, the action plan should be fully executed and readiness reassessed before proceeding with an EMR selection. Even if the survey indicates the office is ready for an EMR, the responses should be evaluated to create an action plan to further prepare the office.

A critically important, additional value of readiness assessments is that it engages everyone in the practice at the very start of an EMR implementation. Two common pitfalls of failed EMR implementations are the lack of staff and/or physician “buy-in” for an EMR and resistance to change. It is unfortunately typical for practices to not have comprehensive discussions about the value of and preparedness for an EMR with all of the staff before an EMR selection process begins. The simple initial steps of asking for everyone’s participation and explaining the importance of their responses will be noticed and appreciated. It helps prepare the practice for change and establishes a team-oriented environment that becomes critical during the EMR implementation.

An additional value of the readiness assessment that multi-site practices may consider is to use the results to help determine the order in which their offices implement the EMR.

In summary, readiness assessment surveys basically determine inherent and potential risks that may adversely impact the successful implementation of an EMR in a physician practice. A gap analysis of the survey responses determines where risk exists. An action plan focuses on mitigating those risks. The scoring system helps the practice determine whether to execute their mitigation plan before proceeding with an EMR selection process. If the survey indicates the practice is probably ready for an EMR, the selection process may proceed concurrently with the execution of the mitigation plan. The participation of the entire office staff establishes a healthy team-oriented environment as the practice goes forward with an EMR implementation.  

EMR Selection Guide provides an outline of additional topics on the selection process

 EMR Implementation Guide provides an outline of topics on the implementation process

EMR Implementation: "I've Selected an EMR. Now What?"

Health information technology (HIT) is driving the transition of health care past the era of modern medicine into the contemporary era of digitized medicine. Knowledgeable and experienced implementations of HIT are known to improve the delivery of health care and improve health outcomes. However, knowledge and experience with implementations of comprehensive ambulatory electronic medical records (office EMRs) remain distant from the average office physician.  Less than 10% of U.S. physicians are using a fully functional EMR according to a 2008 article in the New England Journal of Medicine (NEJM, Volume 359:50-60, July 3, 2008, No. 1).  Also, the growing body of knowledge about successful HIT implementations does not contain a field-tested “cookbook” that physicians can follow to ensure their EMR implementation will be a success. This is concerning in light of a report from Modern Healthcare that 19% of ambulatory EMR implementations had failed and EMRs de-installed among 800 respondents to a 2007 Medical Records Institute survey. There are relatively small numbers of skilled and experienced EMR implementation resources, and those available tend to be concentrated among EMR vendors and some IT consultants.

A disciplined and knowledgeable approach to ambulatory EMR implementations will lead to a successful implementation. The unfortunate situations of EMR implementation failures are avoidable and most typically related to poor implementations rather than poor technology.  A study by Lorenzi and Riley (Lorenzi N. Riley R. Knowledge and Change in Health Care Organizations. Stud Health Technol Inform. 2000; 76:63-69) finds eight main reasons for EMR implementation failures. Only one of those reasons is technology failure. Most EMR failures are due to poor management of change, straying from basic project management principles, insufficient effort put into work flow redesign and configuring the EMR, uninformed decision-making, underestimating or ignoring the work involved, ineffective leadership and inadequate training.

Over the next 5 years the physician incentives in the ARRA/Stimulus Package will help pay for the purchase and meaningful use of office EMRs and will subsequently lead to record numbers of physicians seeking and implementing EMRs. This has raised the concern that physicians may hurry into the EMR implementation quagmire without knowledgeable and experienced resources to facilitate success. ARRA does fund a new entity, called “Regional Extension Centers”, that is intended to provide physicians assistance implementing EMRs. When these can be established and how successful they can be are unknown. At this point it is therefore important to educate physicians on HIT issues including the selection and implementation of EMRs. This is the impetus for two concurrent series of Digitized Medicine medblogs. The first one called “EMR Selection: Ready, Set...Go Compare!” was outlined in a July 28th blog entry. Today the outline of the second series, “EMR Implementation: I’ve Selected an EMR. Now What?” is described.

The goal is to develop a practical physician resource of best practices for the selection and implementation of office EMRs. The EMR Implementation Guide (miniaturized below) is a one-page conceptual overview of this process:

The descriptions in blue boxes on the left side depict seven high-level concepts for physicians to understand during an EMR implementation. These are primarily created from the office EMR perspective, but have relevance to hospital electronic health record (EHR) implementations as well.

The Tasks in the middle column are specific tasks or categories of actions that office physicians and staff will work on during the implementation process. Although an office physician may choose to lead the EMR implementation himself or to assign one of his staff to lead the effort, the amount of effort and time involved should be carefully considered. One blog will delineate the effort involved and make a reasonable case for hiring an outside consultant, project manager or advisor to manage the EMR selection and implementation. It is very easy for internally managed projects to allow daily office activities to overwhelm implementation efforts and result in a languishing implementation.

The Objectives column on the right identifies the purpose and goals of the efforts involved in each of the seven concepts of an EMR implementation.

This guide and the medblogs to follow are derived from ongoing personal research on the best practices for EMR implementations. Relevant references and websites are listed below and will be added to as appropriate. I hope physicians will find the information useful and I look forward to your comments.

Relevant references:

1. Arnold S. Guide to the Electronic Medical Practice: Strategies to Succeed, Pitfalls to Avoid. HIMSS. 2007.

2. Doctor’s Office Quality- Information Technology. Electronic Health Record Implementation in Physician Offices: Criticial Success Factors. Available at www.lumetra.com/uploadedFiles/programs/california-quality-connections/DOQ-IT-SuccessfulEHRImplementationBrief.pdf. Accessed July 29, 2009.

3. Forrester Research. Electronic Medical Records: A Buyer’s Guide for Small Physician Practices. California Health Foundation, October 2003.

4. Glaser J. Lessons Learned: Implementing a Clinical Information System Can Offer a Rich Education. Healthcare Informatics. September, 2002.

5. HIMSS Ambulatory Paperless Clinics Work Group. EHR Implementation in Ambulatory Care. 2007. Available at www.himss.org/content/files/Amb_EHR_Implemention081507.pdf . Accessed July 29, 2009.

6. Holbrook A, et al. A Critical Pathway for Electronic Medical Record Selection. Proc AMIA Symp. 2001;264-268.

7. Keshavjee K, et al. Best Practices in EMR Implementation: A Systematic Review. Proc 11th International Symposium on Health Information Management Research- iSHIMR 2006.

8. Larkin, H. How to do an RFP for an EHR. Medical Economics. Jan. 19, 2007.

9. Lorenzi N. Riley R. Knowledge and Change in Health Care Organizations. Stud Health Technol Inform. 200; 76:63-69.

10. Marcus, David D., Lubrano, John. Electronic Medical Record Implementation Guide. Texas Medical Association. 2007.

11. Markle Foundation. Achieving Electronic Connectivity in Healthcare. July, 2004. Available at www.connectingforhealth.org/resources/chf_aech_roadmap_072004.pdf. Accessed July 30, 2009.

12. McDowell SW, Wahl R, Michelson J. Herding Cats: The Challenges of EMR Vendor Selection. Journal of Healthcare Information Management. 2003; 17(3):17.

13. Miller J. Implementing the Electronic Health Record: Case Studies and Strategies for Success. HIMSS. 2005.

14. Misys Healthcare Systems. Critical Success Factrors for Practice-Wide HER Implementations (White Paper).

15. Smith D, Mancini MN. A Physician’s Perspective: Deploying the EMR. Journal of Healthcare Information Management. 2003; 16(2):71.

Websites:

1. American Medical Directors of Information Systems (AMDIS) http://www.amdis.org

2. Center for HIT http://www.centerforhit.org

3. Certification Commission for Health Information Technology http://cchit.org

4. College of Healthcare Information Management Executives http://www.cio-chime.org

5. HIMSS http://www.himss.org 6. Office of the National Coordinator for HIT http://healthit.hhs.gov 7. Texas Medical Association http://www.texmed.org