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July 2009

Selecting an EMR: Ready, Set......Go Compare!

A comprehensive and disciplined ambulatory electronic medical record (EMR) selection process not only leads to the selection of a suitable EMR for a physician office, but also creates the blueprint for a successful implementation. Procuring an EMR is important, but unfortunately the poor implementation of even the most suitable EMR will lead to a failed EMR implementation. Modern Healthcare reported that 19% of ambulatory EMR implementations had failed and the EMRs de-installed among 800 respondents to a 2007 Medical Records Institute survey. This number did not include ambulatory EMR implementation projects abandoned before being completed. These unfortunate situations are avoidable and are more typically related to poor implementations rather than poor EMR selections. Preparation and execution of a comprehensive EMR selection process will not only lead to the selection of a suitable EMR, but also illuminate the passageway to a successful implementation.

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 selection and implementation quagmire without adequate preparation. Educating physicians on health information technology (HIT) issues, including the selection and implementation of EMRs, is perhaps the most important way to help physicians avoid failed implementations. These developments and concerns are the impetus for a new series of Digitized Medicine medblogs called, “EMR Selection: Ready, Set……Go Compare!”.  A second series, "EMR Implementations: I’ve Selected an EMR. Now What?”, will be developed concurrently. The goal is to create a physician resource of best practices for the selection and implementation of office EMRs.

The EMR Selection Guide (miniaturized below) is a one-page conceptual overview of this process:

Selecting EMR

The time frames in blue boxes on the left side are relevant for small physician offices with a dedicated project manager who facilitates the efforts. The time frame will be longer for larger offices, for offices lacking a dedicated project resource or for offices with more time constraints. The time frame can be shortened by adding more project resources and/or providing more resource time to the effort.

The Action Items in the middle column are the specific tasks for office physicians and staff to work through during the selection process.  Although an office physician may choose to lead the EMR selection project 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 selection and implementation efforts to take a lower priority to daily office activities and result in a suffering effort that may languish.

The Objectives column on the right identifies the purpose and goals of each phase of the EMR selection. In Month 1 the office is getting ready not only for the EMR selection, but also for the implementation. In Month 2 the office is continuing preparation activities and getting set up for the successful evaluation and comparison of an EMR that meets their needs. The results of these activities will later play important roles during contract negotiations and the implementation process as well. In Months 3-4 the active comparison of EMR vendors and products takes place along with continued preparation for an EMR. At the end of Month 4 an EMR is selected and contract negotiations begin.

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. DOQ-IT (Doctor’s Office Quality- Information Technology). Electronic Health Record Implementation in Physician Offices: Critical Success Factors

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

4. HIMSS Ambulatory Paperless Clinics Work Group. EHR Implementation in Ambulatory Care. 2007.

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

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

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

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

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

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

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


1. American Medical Directors of Information Systems (AMDIS)

2. Center for HIT

3. Certification Commission for Health Information Technology

4. College of Healthcare Information Management Executives


6. Office of the National Coordinator for HIT

7. Texas Medical Association

Pediatricians Draw Short Stick--Most Will Not Qualify for Maximum Health IT Incentive Payments

A majority of pediatricians will not qualify for the maximum physician incentive payments provided by the 2009 American Recovery and Reinvestment Act (ARRA) stimulus package. ARRA provides $19 billion of incentive funds to stimulate physician adoption of electronic medical records (EMRs), but the rules for physician payment under Medicaid differ from those under Medicare. Medicare will provide an amount proportionate to 75% of the physician's Medicare payments for the year up to a maximum allowed that year. For instance, to receive the maximum of $18,000 in 2011, physicians will need to have Medicare payments of $24,000 for 2011. The maximum total amount Medicare can provide physicians is $44,000 over 5 years. Medicaid, on the other hand, requires pediatricians to meet a minimum case mix of Medicaid patients and do not base the incentive amount on the physician's Medicaid payments.  Medicaid provides a higher maximum amount of $63,750 over 5 years, but requires pediatricians to have at least a 30% Medicaid mix to be eligible for the maximum payment (see below).  Pediatricians will qualify for only 2/3 of the maximum amounts if they have betweeen 20-30% Medicaid patient mix, or a maximum of $42,000.  Pediatricians who have a patient mix that is less than 20% Medicaid are not eligible for any incentive payments even if they are meaningful users of an EMR.

Maximum Medicaid Incentive Payment Schedule

 ARRA Medicaid

Pediatricians eligible for maximum with 30% Medicaid patient mix

Pediatricians with over 20% Medicaid patient mix are eligible for 2/3 of maximum

As mentioned, Medicaid differs from Medicare payments on how payments are based.  Medicaid physicians will be reimbursed not based on the amount of Medicaid payments, but on the allowable amount they spend purchasing, then operating and maintaining their EMR.  Pediatricians will be eligible to receive a one-time payment of 85% of the  costs to purchase and implement an EMR up to a maximum allowable of $75,000, or net $64,000 (0.85x75,000= $64,000).   Pediatricians who do not have an EMR yet gain a break in that the first year one-time payment is not based on achieving meaningful use, but on the purchase of an EMR.  Remaining incentive payments will be based on achieving meaningful use each year.  If the pediatrician already has an EMR, they can qualify for the first year one-time payment only by achieving meaningful use. 

So how many pediatricians will qualify?  A recent George Washington University School of Public Heatlh and Health Services analysis of data from the 2006 National Ambulatory Medical Care Survey indicates that only 50% of pediatricians will be eligible for any incentive payments.  Less than half (41.7%) of pediatricians will meet the 30% Medicaid mix required to be eligible for the maximum payment.


These estimates may be conservative due to the increase of people on Medicaid since 2006.  A recent American Academy of Pediatrics (AAP) member survey estimates that nearly 2/3s of pediatricians may become eligible for ARRA payments according to a Testimony before the US House Committee on Small Business, June 24th, 2009 by Susan Kressly, MD.   However, Medicaid pays pediatricians only 2/3s of what Medicare pays physicians for providing identical services.  This low reimbursement rate is a financial strain on private pediatric practices and results in a high concentration of Medicaid patients being seen by a relatively small number of office physicians and health centers.  The majority of pediatricians in private practice will fail to meet the 30% Medicaid mix required for maximum payment.  

Besides not providing proportional payments, Medicaid incentive payment rules differ from Medicare in another controversial way.  The ARRA statute appears to allow Medicaid plans within each state to modify the definition of "meaningful use" that the Department of Health and Human Services (HHS) is planning to announce later this year.  Since physicians will be required to be "meaningful users" of EMRs, issues will arise if states choose to deviate from the federal definition.  States could essentially exclude a physician from a Medicaid incentive payment if the physician fails to meet the state's definition of meaningful use even if the physician meets the federal definition.  Also, mulitiple state definitions will be confusing and cause difficulty especially for physicians who practice near state borders.  

Overall, pediatricians should be grateful that Medicaid is included in the ARRA incentive payment plans and that some pediatricians will be eligible for a maximum payment that exceeds Medicare's maximum; ARRA could have limited incentive payments to Medicare as in other recent pay-for-performance healthcare initiatives.  Pediatricians should also take note that the legislation does not at this time incur penalties on them for not achieving meaningful use of an EMR as Medicare does starting in 2016.  Nevertheless, the majority of private office pediatricians draw the short stick and will not see any incentive funds flowing their way.  This despite the fact that they will spend $25,000-50,000 per physician to implement an EMR in their office in order to utilize new technology to improve the quality of pediatric care.