Choosing and using an electronic medical record (EMR) can be daunting for all medical practices, but small groups — from 1 to 3 physicians — have special challenges.

The unique hurdles for small practices include the following:

• The cost of an EMR can be a greater percentage of income when fewer doctors are bringing in revenue.
• The work slowdown and potential income loss when an EMR is implemented can be a more significant hit to a small group. Practices typically require from 3 to 6 months to get fully up to speed with an EMR.
• Small practices rarely have an IT (information technology) expert on staff to maintain the system and troubleshoot if technical problems occur.

Nationwide estimates suggest that although about 24% of physician practices use EMRs, only 12% of physicians in practices with 5 or fewer doctors do so.

“A 1- to 3-doctor practice doesn’t have the luxury of a physician who can work part-time while choosing and implementing the system,” said Eric Fishman, MD, President and Chief Executive Office of EMRConsultant.com, (www.emrconsultant.com), a free online service that provides EMR recommendations for physicians. Dr. Fishman elaborated: “When you’re seeing half as many patients as usual because of work slowdown from implementation, that lack of productivity dwarfs the cost of licensing, scanner, or hardware.”

Bruce Kleaveland, President of Kleaveland Consulting, a health information technology advisory firm in Seattle, Washington, adds: “The most important distinction between small and large practices is that small practices rarely have dedicated IT support. A large practice might have someone whose sole job is to manage software, maintain the equipment, software, updates, backup, and make fixes when necessary. A small practice may have the same needs as a large practice from a system capability, but will not have IT support resources available.”

The following guidelines can help physicians in small practices choose the most appropriate EMR.

Consider a Web-Based Application Service Provider Model Rather Than a Client-Server Model

“I feel strongly that a small practice should go with an ASP [application service provider] model unless you’re large enough to afford a full-time IT director in your practice,” said Dr. Fishman. “It makes no sense for a small group to hire a $60,000 employee to maintain the software and equipment.”

With an ASP model, either an electronic health record (EHR) vendor, a hospital, or another entity hosts the server. Your office accesses the server via the Internet and your data reside on the remote server.

Your practice won’t need to buy an expensive server to host the software, pay for a license to use the program, or install updates and back up your data. Instead, you’ll pay a monthly fee, typically from $350 to $750 per provider per month (although some cost less). If you don’t already have a T1 line, you’ll want to get one to give your office a reliable, high-bandwidth connection to the Internet. This can cost an additional $500 monthly.

By contrast, a client-server system, more typically used in large practices, requires a hefty up-front financial commitment. You’ll need to buy equipment for a server, devote space for the equipment, and spend time on updates and backup. You’ll pay for software and installation, as well as a licensing fee for each professional who will use the software (not for administrative office staff).

Client-server EMRs cost an average of $20,000 to about $40,000 per doctor, although less expensive systems are available. For example, Amazing Charts costs $995 for the first provider, $200 per additional provider, and $500 per provider per year for maintenance and support.

Keep in mind that both ASP and client-server models will have numerous miscellaneous expenses in addition to the noted fees. Be sure to investigate and itemize them up front.

Although cost and efficiency favors ASP for small practices, this Web-based model has some downsides. “Your office will have trouble operating if the server goes down or the T1 line no longer functions,” said Dr. Fishman. “Still, the technical complexity of running a server yourself dwarfs the technical complexity of getting back online.”

Kleaveland notes, “I think an ASP is appropriate for many small practices; it eliminates the need to maintain the server on-site and do nightly backups and other maintenance. However, some doctors don’t feel comfortable having data off-site. Many also don’t like the idea of continuing to pay for a service until they stop using it.”

Many vendors offer both an ASP and a client-server version of their EMR software. Potentially, physicians could start with the ASP version, and switch to the client-server version later if they choose.

What to watch out for: It’s easier for companies to enter the ASP market. Make sure that the vendor you choose is financially viable and is likely to be in business over the long term with customer service and support.

Don’t Cut Costs to the Bone

Although a small practice needs to keep close tabs on its technology budget, forgoing key features can lead to trouble.

“The key with EHRs for small practices is: They need to be affordable but not lead to inferior products,” said Joseph E. Scherger, MD, MPH, Clinical Professor at the University of California, San Diego, and EHR expert and speaker. “The bar is being raised, and systems require registry functions, quality reporting, and clinical decision support. A bad decision today leads to a painful conversion to something else tomorrow.”

Especially if you plan to be in practice for more than 5 years, you’re wise to choose an EMR that has sufficient features and capabilities to stay with you if your practice capabilities evolve or regulations increase.

Also, if you want to earn CMS incentives for using an EMR, you’ll need a system that will enable you to prove “meaningful use.” The US Department of Health & Human Services notes that meaningful use would include e-prescribing, exchanging electronic health information to improve the quality of care, and having the capacity to provide clinical decision support to support practitioner order entry and submit clinical quality measures.

“I’m not certain users of the lowest end products will be able to prove ‘meaningful use,’ says Dr. Fishman.

“The only feature I think a small practice can forgo is the Enterprise level application,” says Kleaveland. “It’s designed to support hundreds of people. It has a very robust, high-capacity database, which is probably overkill for small practices.”

Look for a Vendor With Expertise in Small Practices

A small practice’s workflow and specific needs may vary greatly from that of a large practice, says Kleaveland. “You want to choose a vendor who knows your world and can develop products around that. Companies that focus on small practices may be more likely to have taken their particular needs into account.” Look for an EMR that is more than a generic “1 size fits all” product.

“Some systems are a bit more complex and may be more labor-consuming to deploy,” says Kleaveland. “A vendor that focuses on small practices understands that the 2-doctor practice doesn’t have a dedicated IT person on staff. Often they built the system and processes to accommodate that situation.”

Dr. Scherger added: “There are EHR companies that focus on small practices, such as eClinical works, Practice Partner (now owned by McKesson), Centricity (GE), and several others.”

Consider a Certified System

You can probably save money by buying an EMR that’s not certified by the CCHIT (Certification Commission for Healthcare Information Technology). It may be tempting to do so, especially because certification standards are still evolving. There is current debate as to whether the CCHIT will remain the prevailing certifying body.

Still, it’s most likely that the criteria developed by CCHIT will remain in place even if other certification groups are involved.

CMS is offering incentives (from about $40,000 to $60,000 over 5 years) for physician practices that show meaningful use of EHRs. To qualify for these incentives, the practice must have a certified EMR.

Certification is given to systems that show demonstrated ability to electronically exchange standardized patient summary data with clinical and administrative stakeholders, demonstrated practice of electronic prescribing, demonstrated reporting of quality and patient safety data, and the ability to provide security for patient data.

Some experts have questioned the necessity for certification in specific circumstances.

“Decide what you’re trying to accomplish,” says Dr. Fishman. If you’re trying to get the $44,000 in federal funded incentives and avoid the penalty in the next decade, you need a system that will permit you to prove meaningful use.

“If your goal is, ‘everybody’s getting an EMR and I should, too’ and you don’t overly care if you get the $44,000, you don’t need those required features. Some cardiologists or surgeons may not feel that incentive or penalty money is going to make or break them.”

Deciding whether to get certification will knock out some of the lower-end models.

Several excellent decision tools and resources can help with a small practice’s search for the right EMR. Check out the tool at www.emrconsultant.com. Additionally, consult with your professional or medical society or subspecialty society. The American Academy of Family Physicians (AAFP) and American College of Physicians (ACP) offer information on EMR systems that can help you determine the system that’s best for your practice.

How This 2-Doctor Practice Chose an EMR

Kenneth W. Ordene, MD, FACE, of Endocrine Associates of Central New Jersey, Freehold, New Jersey, conducted a thorough investigation before purchasing his EMR. His practice consists of 2 physicians and a nurse practitioner.

“I looked at EMRs at various meetings and in other doctors’ offices; I tested an online demo version; and I demoed my billing company’s EMR,” says Dr. Ordene. “I even bought an EMR system for $300 and tried to use it, but I couldn’t bring myself to make my own templates, and that’s what it required.”

Dr. Ordene says that because he bought his EMR prior to the government incentive program, incentives were not a motivating factor and he was not concerned about certification. “We had no more room for charts, and an EMR is so much better than paper charts,” says Dr. Ordene. “It improves medical care; you can read the chart better.”

Dr. Ordene ultimately chose MediFile, made by Health Administration Systems in Columbia, Maryland. MediFile is a client-server model, not an ASP. The system is also not certified.

Although Dr. Ordene is not a technophile, he is hands-on with the EMR system. “I’m not a computer whiz, but I know enough,” says Dr. Ordene. “I was the mover on this, even though I’m the older guy in the practice. As far as backing up data and implementing, either me or my business manager does it; she can do some things, and I can do some things.”

The cost of the EMR and annual fee for the practice were about $3400, including the license, says Dr. Ordene.

Dr. Ordene advises other physicians to look for 2 key features in an EMR: appropriate templates and excellent customer service.

As an endocrinologist, Dr. Ordene said that it was important for his EMR to have templates for his specialty. “A basic template in your specialty is invaluable,” he said. “I found that some vendors said their product had templates for your specialty, but they really didn’t. When I got to trying the product, there was no template there.

“Make sure you see the template for your specialty and try it, and make sure it will be there when you get the product,” he advised. “One practice was told by the vendor, ‘Yes, we have all the templates,’ but when they got the product, the program had changed and there were no templates. The practice has had the EMR for months and hasn’t even implemented it yet.”

Customer service is another must-have. “With any EMR, inevitably stuff goes wrong; things crash or don’t work; or you really don’t know what it’s going to be like until you use it,” says Dr. Ordene. “What we like about the company we chose is that their customer service is right in the US, and when we call with a problem, we always speak to the same person. It makes a big difference.”

Dr. Ordene added: “EMR is the wave of the future. It’s the standard of how things are going to be done, so you may as well get with the program. Now I’m very enthusiastic about it. It makes life easier.”

Read more articles at Medscape.com.