By John Carruthers, staff writer, February 01, 2013
As the move toward an electronic health record (EHR) mandate continues apace, physicians are increasingly reminded that computer-based record-keeping, prescribing, and office management are taking over as the new status quo. Selecting an EHR, for most physicians, will affect their workflow and patient interactions for years to come. While every practice will have a different fit with different systems, focusing on the vendor, planning for the future, and approaching the purchasing process with a detailed list of features in mind should set the foundation for a successful adoption.
Selecting a product... and a company
In addition to providing the software, dermatologists will also depend on their chosen EHR vendor for upgrades, service, and information about how their record system will adapt to regulatory changes. That fact, according to West Virginia dermatologist Beth Santmyire-Rosenberger, MD, who has been with her vendor since opening her office in 2005, led her to focus as much on the vendor as the software they produce.
“I picked my EHR system after doing a lot of research on functionality, but I was also interested in picking a company that I thought would be around as long as I was,” Dr. Santmyire-Rosenberger said. “One very important factor to consider is longevity. Changing products, companies, or plans is very time-consuming and expensive. I thought the company I chose looked strong, and though their software didn’t have the perfect bells and whistles that some of the other companies did, I thought that I could make theirs work best for me in the long run.” [pagebreak]
The need to select a vendor with staying power, according to New York dermatologist Mark Kaufmann, MD, who presents on meaningful use and EHR adoption at the American Academy of Dermatology’s annual and summer meetings, often puts one directly at odds with the desire to look for a product that offers the specialized functionality that dermatologists prefer.
“A lot of smaller companies make these features their focus — visual presentation, photos, and illustrations,” he said. “But dermatologists could be slowed in their enthusiasm by concerns about the longevity of the company. No one wants to be stuck with an orphan system after the vendor goes under.”
In addition to staying power, larger vendors also have significantly larger research and development budgets, due to their more substantial client base, according to Michael Derick, the information technology manager for Derick Dermatology in Barrington, Ill.
“The bigger players out there have more robust interfaces with laboratories, they have better patient portals for interactions over the Internet, and they have a lot more sophisticated R&D in general because of the size of their subscriber bases,” Derick said. [pagebreak]
In assessing a company, Dr. Santmyire-Rosenberger said, there are some simple questions that can illustrate a company’s standing at the outset.
“When you select your company, ask, are they CCHIT certified? Have they been certified for very long, and do they get re-certified every year? It’s a sign of a company in its infancy if they don’t,” she said. “Every company has to start somewhere, but you don’t want them to start with you.”
In looking down the road at looming EHR requirements, Dr. Kaufmann said that it’s important to consider two of the most significant changes to meaningful use under new stage 2 criteria. The first, he said, is that the patient participation element becomes a requirement for the first time. Under stage 2, dermatologists will need 5 percent of their patients to participate in interactions with the office through the patient portal of their EHR system.
“If you don’t have 5 percent of your patient population accessing the patient portal aspect of your EHR in stage 2, then you will not qualify for incentives. This is the first time any measure has been put upon a doctor that is completely out of their control,” Dr. Kaufmann said. “It’s basically up to your patients to engage you. You may have to initiate a conversation through the portal with a patient. If they respond, that counts as an interaction. This is something that doctors will have to get into the habit of doing — asking patients to contact them through the portal. This is the big effort on the government’s part to involve patients in their own health care. And if the number is 5 percent for stage 2, you can bet it’s going to be [something like] 25 percent for stage 3.” [pagebreak]
In addition to meaningful use, changes to the ICD code set or any number of billing processes can require a vendor to put out an update. Before signing any contract, Dr. Santmyire-Rosenberger said, dermatologists must ensure that the upgrades will come at a cost and frequency palatable to their time and budget.
“ICD-10 is coming up, and I know that when the day comes and it has to be functional, the vendor will have the new codes in my system and be functional. It’s all taken care of for me, which is something that I made sure to confirm far ahead of time, but something that also goes back to selecting the kind of company I’m dealing with. I needed to know that I would have the support that I needed with each new change,” Dr. Santmyire-Rosenberger said. “As far as anything that’s required for meaningful use, they have it built in, and failing that, they have a workaround. Stage one went rather smoothly. My vendor has a customer support website that is updated frequently, and they also send messages when there’s an upgrade that needs to be done.”
One important question to ask in relation to upgrades, Derick said, is what happens to a practice’s customizations when the new system upgrades take effect. In his practice’s case, each new upgrade would have wiped out the hours of effort and significant financial outlay required to hone templates to the physician workflow. As a result, he said, the practice eventually left the vendor for another one with a more easily modifiable EHR.
“Imagine you spent the money and time to customize all these templates and sub-templates for your use. Then the new version comes out and you want to upgrade, and the vendor tells you that you’ll lose everything you did,” Derick said. “You’ll have to spend all that money and time again or get off the upgrade train and lose the benefits of the future improvements.” [pagebreak]
Perhaps the most important aspect of a contract in terms of continued vendor relationship, Dr. Santmyire-Rosenberger said, is the service contract that covers upgrades, service calls, and maintenance.
“One thing people should consider when choosing a system is what costs are covered under your service contract. There are companies that charge for every little update, and those vendors usually update frequently. Mine are included in my quarterly service fee,” Dr. Santmyire-Rosenberger said. “Obviously I’m happy with the service, because I can’t even remember how much it costs off the top of my head, and I’m usually very good about that with other expenses. It’s not very much at all, for what I get. I’ve always felt like it was worth it.”
Security and server models
While file cabinets are increasingly relegated to the scrap heap, the data storage receptacle itself remains a decision of paramount importance in EHR adoption. The two main models of data storage — client server and cloud — basically boil down to data storage on an in-house machine versus data storage on third-party servers over a broadband connection. Both have their proponents and detractors. For Dr. Santmyire-Rosenberger, her rural setting keeps her skeptical of making always-on broadband a record-keeping necessity. [pagebreak]
“I have my own server in my office, and I’m happy with it, because I don’t like depending on the Internet in West Virginia. But it’s not perfect anywhere,” she said. “There are lots of built-in security measures to both the system and my server; that’s one of the benefits of having my own server. You have to be logged on to my intranet to get access to it. That really narrows down potential access. We back up anything to a portable hard drive every day and somebody in my office takes that home every night. That’s a little extra work for the security, but we feel we’re in good shape with that arrangement.”
Dr. Kaufmann, whose EHR operates on the cloud model, said that after 10 years of using and researching EHR systems, he’s finally seeing cloud computing come into dominance thanks to the efforts of consumer electronics companies.
“We as doctors are going to follow the general trend in technology. And thanks to Apple, the general trend in computers is basically the cloud. As long as people start to believe that the cloud is secure, and they should, they’ll begin to understand the amount of leverage that you get by using the model,” Dr. Kaufmann said. “When I first started 10 years ago, no one would have considered a cloud system because of worries about who owns the data and what happens if the system goes down. Well, it turns out that the cloud operators are more than happy to give you your data if you choose to leave, and as far as security, most people will understand that three to four redundant servers across the country are a lot safer than the tape drive from your server. In a well-run company, your data is safer in the cloud than in your own office.”
In addition, he said, the all-important cost factor places the advantage soundly in the corner of cloud computing.
“From a cost perspective, it’s much less expensive. From an access perspective, it’s much easier to only need a browser to access your system from anywhere,” Dr. Kaufmann said. “As time goes on, this is going to become the prevalent technology.” [pagebreak]
In selecting a system, according to New York dermatologist Mark Kaufmann, MD, who presents on meaningful use and EHR adoption at the American Academy of Dermatology’s annual and summer meetings, dermatologists should consider the core job duties of a dermatologist and evaluate how well each system addresses these needs.
“Basically, dermatologists all need to be able to photograph, and most need to be able to draw, and so imaging is important to most every practicing dermatologist, whether medical, surgical, or cosmetic,” Dr. Kaufmann said. “All dermatologists are going to be able to want to locate a lesion, explain removal, and take pre and post-op pictures.”
The difficulty that many dermatologists have, according to Dr. Kaufmann, stems from the fact that most vendors don’t address their efforts to the needs of smaller specialties. The visual interface and functionality necessary for many dermatologists, he said, often require more research to find.
The goal in adoption, according to EHR consultant Margret Amatayakul, MBA, who has participated in the Academy’s vendor demonstration forums, shouldn’t be to simply qualify for meaningful use incentives (physicians who adopt this year can still earn up to $39,000 from Medicare over the next four years). It should be to improve one’s practice and record-keeping efficiency in a way that also qualifies for the bonus. This, she said, should lead dermatologists to look further than a vendor’s advertised claim of being certified for government incentives.
In addition to functionality, dermatologists should also consider how an EHR software package interacts with and adapts to changes in hardware. Recent years have seen an impressive jump in tablet and mobile computing technology, along with comparable adoption rate increases across all specialties. Some EHR packages, Dr. Kaufmann said, don’t offer tablet or smartphone functionality, which may become a concern for dermatologists hoping to harness new hardware for workflow changes.
Physicians in the process of selecting an electronic health record (EHR) system should focus on the core goals for EHR use in their practice, according to Dr. Kaufmann. The following checklist, based on Certification Commission for Health Information Technology (CCHIT) criteria for dermatology and discussions with EHR-using dermatologists, provides a quick guide for what to look for in a dermatology practice EHR.
- Interoperability with other EHR systems.
- The ability to efficiently upload, store, and archive photographs, as well as the ability to annotate them with text and draw on them.
- The ability to compare two photographs on a single screen.
- Tagging of images using ICD codes and/or SNOMED (a collection of medical terms with codes, synonyms, and definitions that helps support effective clinical recording of data for future self-auditing or outside research use).
- The ability to draw on and annotate body diagrams with text, and capture characteristics of a lesion via mouse or touchscreen indication with accompanying text, including:
- The option to easily add a freehand diagram for patient encounters integrated into the notes, rather than attached as an image file.
- The ability to log the statuses of dermatologic specimens removed from a patient, from time of removal though final action by dermatologist.
- The ability to export data to quality reporting registries.
- The option to operate under a touchscreen interface on mobile devices like tablets and smartphones.
- A library of cutaneous anatomic diagrams.