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September 2009

How to Select an EMR Without a French Toast Fiasco

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).

Electronic medical records (EMRs) admittedly have nothing to do with French toast, but common pitfalls encountered when selecting an EMR for a physician practice are very similar to the pitfalls encountered when going grocery shopping.  Consider the following series of events subsequent to my family deciding at dinnertime that I am going to cook French toast for breakfast tomorrow.  Knowing we are out of milk I realize I need to go grocery shopping this evening in order to be prepared for the morning.  I check the refrigerator and note that not only do we need milk, but we need eggs as well.  I check the bread drawer and see a nearly full loaf of bread. When looking in the spice cupboard I see a small container of cinnamon, but it is nearly empty. With eggs, milk and cinnamon in mind I proceed to the store and go promptly to the dairy section.  After selecting the needed milk and eggs I head back toward the front registers.  Along the way, however, four other items conveniently catch my attention and find their way into the grocery cart.  I had quickly convinced myself that not only were they were needed, but they were also good deals.  

In retrospect, I was wrong about that.  But at least I maintained some semblance of shopping discipline by resisting the temptation to pick up several other items that were on sale such as maple syrup.

I drive home and begin putting groceries away.  As I put the first “extra” purchase into the pantry, I am disappointed to see that my wife had already purchased a large quantity of the same thing.  My purchase subsequently sat on the shelf unused and was thrown out a year later when it reached its expiration date.

As I put the second extra purchase away, I was happy to see we have none of this item.  However, as time went by we never needed it.  It was also thrown out a year later when the expiration date passed.

As I put the third extra item away in the refrigerator, a delicious family dessert, a cold, dark feeling creeps through my chest and stomach as I read some fine print on a label that I had not seen while hurrying through the store.  My fear confirmed-- it contains peanut traces.  My daughter is severely allergic to peanuts.  I had made this spontaneous purchase with family enjoyment in mind.  My wife and daughter did not experience the intended joy.

As I put the fourth extra item away, a kitchen appliance that was on sale at half-price, my wife walks in and remarks how happy she is that I had remembered to get a replacement for our broken appliance. However, this half-priced, off-brand appliance never worked the way it was supposed to work.  We threw it out within a month.

The next morning I get up early to fix the French toast.  When I open the bread sack I discover that it is moldy.  When I look for the maple syrup in the cupboard I find none.  I now spend added time and effort to go back to the grocery store a second time.  I realize that I am fighting a fire that I could have prevented with better preparation the first time.  Its not the store's fault I was not prepared.  For added insult the maple syrup is no longer on sale less than 12 hours from my first visit. 

As I prepare the French toast, I lament over my failure to spend the time and effort necessary upfront to adequately identify our grocery needs. I lament lacking the discipline to create and adhere to a simple shopping plan. I recognize that overlooking the value of good preparation and making hurried decisions on-the-fly resulted in more work to do and ended up being costlier.

And then the final curtain falls on the French toast fiasco.  In the same instant I initiate a motion of my right hand toward the spice cupboard, a hot pain sears through my head as I realize my failure to remember the cinnamon.  To my mental lamentations I quickly add, “failure to write down a grocery list”.

The pitfalls encountered when selecting an EMR are quite similar to the French toast fiasco.  EMR selection pitfalls occur when a practice fails to spend the time and effort needed upfront to identify a shopping list of what is really needed or fails to adhere to a shopping plan that maintains a disciplined focus on comparing how well EMR products align with the practice’s known EMR needs. These pitfalls include:

  1. Purchasing an EMR that does not meet the needs
  2. Having to go shopping two or more times to get all needs met
  3. Purchasing EMR items/functionalities that are not needed—unneeded functionalities that sit on the shelf unused
  4. Unplanned purchases of additional items
  5. Purchasing an EMR that fails to do what the practice thought it would do
  6. Creating unrealistic EMR needs that cannot be met with today’s technology
  7. Preventable increases in total EMR cost

EMR selection pitfalls can cause a significant amount of dissatisfaction with the selected EMR as well as unplanned additional work, unplanned additional costs or even EMR implementation failures.

The following strategy will help a physician practice prepare a “grocery list” of realistic EMR needs and establish a plan to select an EMR that is aligned with the practice’s needs:

  1. Gain insights on realistic EMR “best uses” for physician practices. This may include performing an EMR needs assessment, performing a current/future office workflow analysis, networking with colleagues already using EMRs and other research on available EMR best uses
  2. Identify why your practice wants to implement an EMR (what are your realistic goals?)
  3. Identify the most important future workflow changes that you want the EMR to facilitate
  4. Identify what EMR functionalities are needed in order to facilitate those prioritized workflow changes or to meet your other EMR goals (i.e. e-prescribing, real-time eligibility verification…)
  5. Create a “grocery list” of these EMR needs
  6. Prioritize the list of EMR needs
  7. Go shopping with your list in hand
  8. Compare prices, quality and usability of EMRs that meet all of the highest priority needs on your list


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



Site Visits Help Physicians Select an EMR Product Aligned With Practice Needs

One of the important ways for a physician practice to analyze whether an electronic medical record product is a good fit for their practice is to visit another physician practice that is actively using the product.  Ideally the selected practice is the same specialty and has a similar practice model, case mix and other attributes of the visiting practice.  Even if those attributes differ significantly, however, site visits provide an opportunity for the visiting practice to gain other information that will help them select an EMR product that is aligned with their unique needs.

 Site visits are time-consuming for the physician and are therefore usually reserved until late in the EMR selection process when the number of potential EMR products has been narrowed down to two or three.  It is important for the physician practice to be prepared to get the most out of the time spent and effort exerted.  The following is a list of suggestions to help physicians maximize the value gained from site visits.  If you are a physician already experienced with site visits and have additional advice to share with your colleagues, please feel free to comment to this blog:

  • Site visits can provide valuable insight on:
    • Workflow
    • Workarounds
    • Implementation "Do's and Don'ts"—write them down
    • Technical glitches
    • Quality of customer support
    • How the vendor works with physician offices

  • Try to select sites similar to your specialty, patient mix, patient volume, practice size, practice model and office structure

  • The most important thing to do is to stand back and observe workflow for an hour or two


    • Observe the front desk, check-in, clinical care, workroom and back desk areas
    • When you observe effective workflow, visualize how that would work in your office


  • Observe for inefficient workflow or workarounds and ask why it is done that way. Observe for computer glitches and ask how often they occur. Clues to look for include:


    • Pen or pencil being used for something—what and why?
    • Printer or fax noise….paper being printed for some reason…what is done with it?
    • Staff gets up and walks to a different area to get/do something…why? Workaround?
    • Paper chart being used for something
    • Paper being routed somewhere, used for something
    • Excessive amount of time spent entering something in computer…is that typical?
    • Screen response time is longer than 5 seconds….how long does it get?
    • Impatience with computer… is computer slowness an issue for that person?
    • Frozen screens, frozen cursors
    • Staff or physician reboots a computer or laptop
    • Person left screen, then went right back into same screen…why? How often does that happen? Same questions when you see multiple clicks without anything being entered.



  • Visualize whether your desired workflow appears feasible using this product

  • Ask questions:


    • What workarounds are they currently using that they hope to remove in the future?
    • What problems are they most looking forward to having resolved?
    • How well does the EMR vendor respond to requests?
    • How much software training time was provided?
    • What EMR implementation difficulties did you overcome?
    • What are the software upgrade and update schedules like?
    • What are their favorite (specific) electronic medical records features?
    • What are their least favorite features?
    • How well does the EMR system fit into each element of your medical practice?
    • Do they get the quality reports they need? What reports do they wish they had?



  • Understand the site's technical infrastructure and how it is different from what you are planning. For example, if they are not using wireless but you are planning to, consider how that changes the picture. Alternatively, if you were not planning to do something they are doing and you see it is effective, should you reconsider?

  • Observe how physical set-up is different from yours. What works and what doesn't work so well. What did they change? What would they like to change now that they have used the EMR for awhile?






If you are experienced with site visits and have other advice to share with physicians, please feel free to comment on them

Why Will Government Pay Physicians Up to $63,750 to Adopt, Use EMRs? And Hospitals Millions More?

The 2009 American Recovery and Reinvestment Act (ARRA) includes a $19 billion investment to modernize the nation’s health information technology (IT) infrastructure. Over $17 billion are set aside for incentive payments to individual physicians and hospitals who can qualify by implementing and meeting the requirements for “meaningful use” of electronic medical records (EMRs). There are also $2 billion allocated to build the IT infrastructure needed to allow EMRs to “connect” with each other and share data in a private, secure and effective manner.

ARRA Funds


Individual physicians who achieve meaningful use of EMRs can qualify for $44,000 under the Medicare rules or $63,750 under the Medicaid rules. Hospital incentives are based on a complex formula that starts with a $2 million base with additional funds calculated on total discharges if they achieve meaningful use of an EMR.

ARRA delegates the responsibility for defining “meaningful use” to the Department of Health and Human Services (HHS). Currently HHS plans to finalize the definition for “meaningful use” by the end of this year or early in 2010. Although we do not know what the final definition will be, HHS has overseen the development of a Meaningful Use matrix that is published and posted on the Office of the National Coordinator of Health IT (ONCHIT) website. The final definition will likely be based on this matrix.

Why provide billions of dollars to physicians and hospitals for using health IT?   Health information technology has been shown to improve the quality of care and to reduce the cost of health care. The maximum benefits of electronic medical records (EMRs), however, cannot be reached until the majority of physicians and hospitals are actively using EMRs and share data between them.  The prevalence of EMRs among physicians and hospitals are currently too low to garner the full value of health IT:

Low EMR Adoption Rates

Low Adoption

Although nearly 50% of large physician practices have adopted electronic medical records (EMRs), most medium and small practices have not. So despite efforts to encourage adoption of health IT in the past decade, only 17% of physicians are actively using EMRs. Also, less than 10% of physicians using an EMR have a fully functional EMR with advanced features such as e-prescribing, real-time eligibility verification and secure physician-patient messaging according a New England Journal of Medicine study. Similarly, hospitals continue to lag in the adoption of advanced clinical technologies.

Studies have shown that cost is the predominate obstacle for both the adoption and use of EMRs and that providing financial incentives would be a facilitator of EMR adoption.

Facilitators to Broad Adoption of Health IT 

EMR Facilitators

According to a Congressional Budget Office (CBO) report last year, the upfront cost of an ambulatory EMR ranges from $25,000 - $45,000 per physician.  Smaller offices tend to be in the upper end of this range.  Annual operating costs range from 12 – 20% ($3,000 - $9,000) per physician.  The total cost of EMRs tends to be higher for systems that are able to do more.  Although EMRs that are purchased under an ASP model will have much lower upfront capital cost, the significantly higher annual operating costs will, at a minimum, level out total cost over the long term.  Operating costs include software fees, technical support, IT maintenance, equipment replacement/upgrades and other vendor fees-for-service.  

The HHS definition of "Meaningful Use" will detail what physicians and hospitals have to do in order to qualify for the ARRA incentive payments. Although we do not know the final definitions at this time, we do know that demonstrating “meaningful use” will require the physicians to:

    1. Use an HHS-certified EMR
    2. Use e-prescribing
    3. Be able to connect their EMR to other health information systems (information exchanges)
    4. Be able to produce quality reports on specified quality measures

From a high-level perspective, the Meaningful Use matrix recommendations are to gradually “bend the curve” towards a transformed, modernized healthcare system. In 2011-12 the incentives are based on the adoption of EMRs that can capture quality data. In 2013-14 the incentives bend the curve by requiring not only capturing data in an EMR, but also reporting on the data and improving processes. In the final phase during 2015-16 the incentives bend the curve further by focusing on the use of quality reports to improve patient outcomes.

Bending the Curve Towards Transformed Healthcare
Achieving Meaningful Use of Health Data

Bend Curve


With the ongoing absence of other significant triggers, the ARRA health it incentives could provide the boost of momentum necessary to modernize the nation’s healthcare infrastructure. At the least these incentive payments will accelerate our nation’s slow adoption of EMRs which is suppressing the value that health IT can bring to healthcare.

Understand the Differences Between the Client-Server vs. ASP Models When Selecting an EMR

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).


Electronic medical records (EMRs) can be provided to the physician practice by vendors through one of two different delivery models. It is helpful for physicians to understand the differences between these two models before evaluating EMR vendor products. The most common delivery model used by EMR vendors is the traditional “client-server” model. In this model the EMR software is installed on a server that is located in the physician’s office. The physician and staff access the EMR through computer devices that are connected to the server through a local area network (LAN) set up in the office. The computers may be connected wirelessly to the network if desired.

The second delivery model that has recently gained momentum in the market place is called the Application Service Provider (ASP) model. In this model the EMR software is located on a server at a remote location designated and hosted by the EMR vendor. The physician practice is able to use the EMR by accessing it online through an internet connection.

The following chart summarizes the differences between the client-server and ASP models:


Client/Server vs. ASP EMR Model Comparison



Location of EMR server

Physician's office

EMR server hosted by EMR vendor remotely offsite

Security updates, maintenance to EMR server and operating system

Managed by practice through local IT support

Managed by EMR vendor

Updates to EMR software

Commonly the practice provides the vendor internet access to the EMR server and the vendor downloads the updates to the server;  alternatively, the vendor can supply the practice with the updates that the practice is then responsible to download into the server

EMR vendor downloads updates to the EMR server

EMR upgrades

Same as updates

Same as updates

Daily back-up of patient data and billing data

Managed by both the practice and the vendor

Practice decides with vendor who the responsible party is

EMR server issues- technical support

Managed by the practice with local IT support and EMR vendor support

Managed by EMR vendor

Both models have advantages and disadvantages to consider. The physician practice should become familiar with each model. Although it is helpful to decide on a model before evaluating EMR vendors in an EMR selection process, it may be necessary for physician practices to initially look at EMR products provided under both models. Also, some EMR vendors give you the choice to have their product delivered under either model.  Some of the risks and benefits are outlined below:

Client-Server vs. ASP (Risks/Benefits)

These Risks/Benefits should be considered as general tendencies and discussed with EMR vendors during selection process and contract negotiations

Client Server




Data ownership and control within office

Lower initial costs (costs tend to merge over the long-term)

More customizability potential

Accessibility from any internet connected computer

More control over timing of server and software updates

Less dependency on finding and paying for  good local IT support

Better integration and connectivity potential

Ease of upgrades and updates done by vendor

Quicker EMR response times

Lower hardware requirements for office computers



Higher capital expenditures

Higher annual operating expenditures

Some C/S systems requires third party involvement to provide remote access (i.e. Citrix)

Data loss due to vendor bankruptcy or other major vendor issues

Online backup is usually an additional cost

Degradation of the support services provided by the vendor for EMR server/security supported remotely

Dependency on good local IT technical support and EMR server security and maintenance

Slower EMR response times and dependency on internet conection

Computers in office share some of the EMR processing with the EMR server (i.e. office computers will generally cost more)

Unannounced server updates or software updates by the vendor on the EMR server (unplanned downtimes)

The client-server model has some similarities to loading Quicken on your home computer and then using Quicken to pay bills online:

  1. Quicken will periodically suggest that you to take updates to the program that you then download and install from the internet. Similarly, EMR vendors will periodically make available updates to the EMR software for a variety of reasons such as to fix or prevent known issues. You are encouraged to load these updates to the EMR server in order to keep your EMR up-to-date.
  2. Microsoft and your computer’s virus software will periodically advise you to take security updates on your computer. Similarly, Microsoft and the EMR server’s virus software will advise you to take updates to the EMR server. These updates are important in order to keep the server secure and protect it from viruses and other problems. Recently these updates are being advised to be taken at an increasing frequency (i.e. daily). Many people choose to manage EMR server maintenance, though, by “packaging” updates together and installing them on the server only once or twice monthly.
  3. You may later decide to purchase and install a Quicken upgrade to get a new version that has new features or to improve current features. Similarly, the EMR vendors are always working on improving their EMR. Upgraded versions periodically become available, typically every 12-18 months.
  4. You may decide to purchase a new home computer that is faster or more powerful, especially if the Quicken program is responding too slowly as you work on your bills. You then load your current Quicken software onto the new computer and follow the instructions that allow all of your old Quicken data to be available when using Quicken on the new computer. Similarly, the EMR server will need to be replaced as it ages, especially if the EMR is responding too slowly as you do your work. It is also not uncommon for new servers to be needed at the time of EMR upgrades due to additional demands for more power or memory in order to run the upgraded EMR efficiently. Also similar to the Quicken example is that when your EMR program is loaded onto a new EMR server, the vendor helps you take steps to ensure all of your EMR data can be accessed.

You may not be able to access the EMR for a short period of time when updates and upgrades are being installed on the EMR server. It is important to schedule these changes at a time the EMR program will not be in use by anyone, and everyone should be made aware of time this is going to occur.

The ASP model has similarities to online banking that you access on your home computer and use to pay your bills online:

  1. You do not have to take updates to the online banking program because the program resides on the bank’s online banking server. The bank will update their software as needed. Similarly, the EMR vendor will advise you about updates needed to the EMR program, but they will physically load the updates into your EMR system themselves. The only impact on you is that your access to the EMR may be disrupted for a short period of time while updates are installed.
  2. The bank will take care of any Microsoft or virus software updates needed for the online banking server. Similarly, the EMR vendor that hosts the EMR server is responsible for server maintenance. The only impact on you is that there may be a short period of time that you may not be able to access the EMR (while updates are being installed and the server rebooted).
  3. When there is an upgrade to the online banking software, you do not have to purchase and load that software on your computer because you just use the internet to access the program that is loaded on one of the bank’s servers. Since the bank physically hosts the server, the bank loads any upgrade to the server at the bank.  The only impact on you is that you may not be able to access the online banking software for a shot period of time while it is being upgraded.
  4. If the online banking server is too slow, customers will start complaining and the bank may decide to purchase and install a faster, more powerful server to resolve the response time issues. Also, as a server ages it may need to be replaced for other reasons. When the bank installs a new server and installs the the online banking program onto the new server, they will also need to do something with regards to all of your banking data so that the program allows you to access it the next time you log on from home.  Similar to the bank, EMR vendors using the ASP model will encounter reasons to load your EMR program onto a more powerful, faster server and arrange for all of your patient data to still be accessed by your practice the next time the EMR is accessed online. During the installation there may be a period of time during which you cannot access your EMR.

It is important to discuss with EMR vendores the situations in which you may not be able to access the EMR.  There are a variety of ways to minimize the amount of "downtime" that a practice will encounter.  Detailed discussion about these situations before selecting an EMR is suggested.   

The decision on which delivery model to select will be dependent on the physician practice’s EMR goals, budget constraints, assessment of risks/benefits and on which products best fit the needs of the practice. 

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