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Lessons learned
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The best advice can come from those who have experienced EHR

While EHRs have made significant progress over the past 10 years, it’s only been in the last few years that EHR adoption has gained momentum. According to a 2009 AAD dermatology practice profile survey, 28 percent of respondents said they had implemented an EHR system in their practice. In 2011, a new survey by the AAD, specific to EHR usage, indicated 38 percent of respondents had fully implemented EHR. Despite the relative newness of EHRs, some dermatologists have been successfully using them for several years and will share lessons they have learned along the way.

Personal considerations

Choosing an EHR system is an individualized process that should be based on criteria set by each physician or practice. Whether a doctor is in private or group practice may also play an important role in determining which system to use. Speaking with other physicians and viewing how they use their EHR system can be an important part of the decision, but ultimately, what works well for one physician may not work well for another. The best way to decide on an EHR is to try it out.

“Don’t simply buy something based on someone else getting it, but actually play’ with it and make sure that it makes sense to you,” cautioned Daniel M. Siegel, MD, president-elect of the American Academy of Dermatology. Dr. Siegel also serves on advisory panels for software makers Encite and Modernizing Medicine and for DermFirst, an EHR consultancy. Dr. Siegel, who works in a three-person group practice, advised dermatologists to choose programs that fit their individual needs.

“If the program seems intuitive, that’s a good start. If, on the other hand, the program seems confusing and chaotic, it’s probably not the way you want to go. If it’s confusing to start, it probably won’t get much better,” Dr. Siegel said.

Maithily A. Nandedkar, MD, a solo practitioner at Professional Dermatology Care in Reston, Va., has been using EHR for more than five years. Before purchasing her first EHR system, Dr. Nandedkar created a list of must-haves that an EHR system would have to meet. First, she said that she needed to feel confident that the vendor would be in business longer than she would. She noted that it’s not uncommon for EHR vendors to come and go, making it more important than ever to gauge the current and future technological landscape before signing on any dotted lines.

Dr. Siegel experienced this first hand after implementing an EHR system with a big-name company. Despite the company’s prominence in other areas, it didn’t survive in EHR software production. Unfortunately, the capricious nature of the EHR market is costly for many dermatologists. If the EHR company is bought out, it’s not unusual for the new vendor to stop support of the old company’s products, forcing physicians to make the switch to a new product or begin the arduous task of finding another EHR system to use. Besides the cost of transferring data and researching new systems, the largest casualty, however, is the weeks or months of lost training for both the old and new systems.[pagebreak]

Another important consideration for Dr. Nandedkar was the accessibility of EHR support. EHR companies must be able to provide support 24 hours a day, seven days a week, she said, and the system must be versatile. “I must be able to alter templates or make adjustments as needed.”

EHR systems also must be able to adapt to the physician’s personal workflow. According to Dr. Siegel, an EHR program needs to work in the way that physicians think. “Is it easier to look at other programs or change the way you practice? Generally, it’s easier to find another program,” he said.

Do your homework

Knowing what you want from an EHR system is just as important as understanding what you’ll actually get. Dr. Nandedkar spent between three and four months researching EHR vendors before purchasing. “I called all the different vendors in my area and asked for demos. And then I asked for contracts, so I could read them and see what I would actually get with my money,” she said.

Once a dermatologist has narrowed down his or her list of EHR options, the best way to gather important decision-making information is to send each company a request for proposal (RFP), a listing of key questions. Financial stability, staff and client numbers, and revenue spent on research and development are just some of the questions that are fair game to ask companies. An RFP template can be obtained by downloading a copy of the dEHRm manual from the AAD website at www.aad.org/hitkit.

If physicians are thorough with their research, they’ll be met with fewer surprises later on. “I read every contract. I knew what I was getting into, so nothing was surprising,” Dr. Nandedkar said.

It’s a process

Because technology is continually advancing, keeping up with EHRs is an ongoing process. When Dr. Siegel was asked how long his EHR implementation process took, he answered jokingly, “We’re still implementing.” Many dermatologists who implemented EHR more than five years ago are now adding on to their current system or swapping systems completely in order to take advantage of the newest technology.

Dr. Nandedkar described the process of learning to use EHR as a layered approach that involves steadily building a knowledge base. As with any new and complex system, there’s a learning curve; the more you get to know the system, the more use value it has. “It’s been five-and-a-half years, and even now we’re using aspects of the system that I didn’t use in the beginning. It just keeps on getting better and better,” she said.

Go wireless

When asked what advice she’d give physicians preparing to implement EHR, Dr. Nandedkar said, “Go wireless. Don’t be tied to hardware. You want to be able to dump a computer and throw some software onto a new one as fast as you can.”

EHR technology is now trending toward cloud computing. This gives physicians the freedom to access the EHR program and all the data from anywhere there’s an Internet connection. Dr. Siegel counsels dermatologists to have at least two different ways of connecting to the Internet. In addition to convenience, cloud-based EHR is also decidedly less costly than purchasing a server-based system. Cloud systems eliminate additional IT staffing costs, which are necessary for physicians maintaining their own server, another costly purchase. For more information about the financial impact of EHR, see “Exploring the costs."

However, no matter what kind of system dermatologists use, it’s important to have a backup method of accessing data, Dr. Siegel said.[pagebreak]

Is your data really accessible?

As technology improves, it’s inevitable that physicians will also need to improve their EHR systems, especially physicians who adopted EHR more than five years ago. If physicians decide to change EHR systems, they must first be able to gain control of all of their data from the old system. One common issue faced by dermatologists looking to obtain their data is that even though they own the data, it’s not released in a usable format. If dermatologists want to be able to physically see the data, companies may charge additional fees to translate it into something readable.

Mark Kaufmann, MD, an associate clinical professor at Mount Sinai School of Medicine who serves on the advisory board for Modernizing Medicine, experienced this frustration when his first EHR company was bought out by another company, and support for his old system was discontinued. When he decided to switch vendors rather than adopt the new company’s system, Dr. Kaufmann was offered his data in PDF format for $5,000. Instead of paying what he considered an exorbitant fee, he enlisted a few college students to help him transfer the notes instead.

Since physicians need to be able to access their data at any time, and in any format, owning the data can help ensure better control when the unexpected occurs.

“I would make sure that any contract I signed said that not only do I own the data, but that I also own the ability to access the data in a form of technology that is current to the time, so that I can physically access it in a meaningful manner,” said Dr. Nandedkar.

EHR or not?

With such high financial stakes, EHR isn’t for everyone. First, dermatologists should evaluate how long they plan to stay in practice. “If a person plans on retiring in the next three to four years, I would probably say ignore this whole thing,” Dr. Siegel said. The time it takes to get the process effectively underway as well as the financial investments may not make sense for dermatologists nearing the end of their career.

“If you’re in this for the long haul, then you have to do your due diligence and find an EHR that works for you, your staff, and that you can foresee for the next three to five years,” said Dr. Nandedkar. “Everybody has to do their own thing. What works for one person will not work for another,” she said.

To learn even more about EHR and other health information technology, visit the Academy’s online HIT-Kit at www.aad.org/hitkit.