EHRs Especially for Specialists

About five years ago, two cardiology practices shopping for an EHR surveyed the same field of vendors and made two different picks that illustrate what matters to specialists when they go digital.

The 16-physician, Fla.-based, Jacksonville Heart Center chose a system from NextGen Healthcare, a major vendor which sells to every specialty under the sun. The Jacksonville cardiologists didn't want to select a minor-league vendor that might fold three years later, or lack the resources to invest in research and development, says Mark Masters, the group's chief administrative officer.

"NextGen was a monster company with plenty of capital," says Masters. "They looked like a strong player going forward." In addition, he added, NextGen did a good job catering to their specialty's needs, setting up the Florida cardiologists with electronic forms, or templates, for echocardiograms, EKGs, and other matters of the heart.

However, NextGen wasn't good enough for the 8-physician, N.J.-based, Westwood Cardiology Associates, which chose an EHR from a niche vendor that the Jacksonville group had passed on - GEMMS, which makes EHRs only for cardiologists.

"We really wanted a cardiology-specific program," says cardiologist Elliott Lichtstein. He notes the competitors of GEMMS, such as NextGen, were more geared toward primary care. "It's hard to be good at everything."

Five years later, specialists of all stripes still ask the same questions about EHRs. Will this vendor be around tomorrow? And will it supply specialty-specific features? Pediatricians, for example, look for automated growth charts and a tool for calculating medication dosages based on a child's weight. Surgeons want separate templates for presurgical and postsurgical workups. And specialists performing consults want a system that will generate an impressive consult letter.

The good news in 2010 is that while some small niche vendors - often launched by a visionary specialist with a knack for computers - have indeed fallen by the wayside, others such as GEMMS have endured. At the same time, mainstream vendors once considered weak in building specialty-specific products are now earning gold stars.

"These companies are far, far ahead of where they were five years ago," says Rosemarie Nelson, a healthcare IT consultant in Jamesville, N.Y., with the Medical Group Management Association.

However, the issue of vendor robustness and survivability isn't going away, especially in light of last year's economic stimulus legislation that awards cash bonuses to physicians who demonstrate "meaningful use" of EHRs beginning in 2011, but promises to penalize nonadopters beginning in 2015. High-income specialists such as neurosurgeons might not bother chasing after the bonus - $44,000 over five years under Medicare, almost $64,000 over six years under Medicaid - like family physicians might, but nobody wants to lose money on account of their meaningful use status.

Now physicians are asking if a particular EHR will give them the necessary features to meet meaningful use requirements, including the ability to exchange data with other EHR systems. In addition, does the vendor have what it takes to get its EHR certified, another prerequisite for meaningful use money?

Alas, buying an EHR isn't as easy as buying a toaster, particularly if you're a specialist. But don't leave the store. We've gathered buying advice from a wide range of physicians, executives of medical software companies, and consultants.

Eyeing specialty needs

For primary-care physicians, some experts would argue the task of selecting an EHR has been made easier by the work of the Certification Commission for Health Information Technology (CCHIT). Since 2006, this private, nonprofit group has been vetting EHRs that meet hundreds of performance standards, such as the ability to display a problem list, transmit an electronic prescription, or create an audit trail identifying everyone who's looked at a patient's record.

These standards expand from year to year, motivating EHR vendors to have their products certified under the latest set. Plus, certification initially was time-limited - three years for products in 2006 and 2007, two years for those in 2008. So vendors that want the CCHIT sticker on their system have had to reapply for it - an expensive proposition in terms of the $37,000 application fee and the hundreds of thousands of dollars sometimes spent on software programming. So it takes a well-heeled company to keep its EHR certified.

At the beginning, CCHIT standards for ambulatory care EHRs largely reflected how family physicians and general internists practiced medicine, which was fine for them, but not so fine for, say, allergists or OB/GYNs. Consequently, CCHIT began creating additional stamps of approvals for ambulatory care EHRs geared toward individual specialties. The first two were for cardiovascular medicine and children's health in 2008. This year the group began certifying systems for dermatology and behavioral health, and next year, it plans to roll out certification programs in women's health and oncology.

"We started with a one-size-fits-all approach and then specialists said 'That doesn't work for us,'" says CCHIT executive director Alisa Ray. "We're responding to them."

The roll call of products qualifying for certification in cardiovascular medicine and children's health is instructive. Most of the systems are from "generalist" medical software companies like NextGen, Allscripts, GE Healthcare, and eClinicalWorks, many of which are publicly traded. But scattered in the lists are products from privately owned vendors that make just one kind of EHR - GEMMS, in the case of cardiovascular medicine, for example, and Connexin Software, which sells Office Practicum to pediatricians. By earning - and re-earning - expensive CCHIT certification for their systems, niche EHR vendors arguably demonstrate that they're "players" who can keep up with the Allscripts and GE Healthcares of the world.

Starting over with certification

Besides giving physicians some assurance they're buying a robust EHR, CCHIT certification has been a prerequisite for participating in important digital ventures, whether it's a state health information exchange in Vermont or an EHR demonstration project by Medicare. Now that physicians are eligible for five-figure bonuses for meaningful use of EHRs under the American Reinvestment and Recovery Act, certification has taken a new and confusing twist. Yes, you must use a certified EHR to cash in, but CCHIT isn't the only game in town. Late this summer, the Department of Health and Human Services assigned the job of vetting EHRs for meaningful use purposes to not only CCHIT, but also two other firms - the Drummond Group of Austin, Texas, and InfoGard Laboratories of San Luis Obispo, Calif.

Here's another twist - HHS standards for determining whether an EHR can perform key tasks such as e-prescribing and information sharing are different than those that CCHIT has been using. Consequently, EHRs already certified by CCHIT must earn their meaningful use certification all over again this fall from one of the three companies chosen by HHS. However, CCHIT spokesperson Sue Reber says software programs that have met her group's exacting requirements will have an easy time passing muster with the HHS standards which are far less demanding.

How many niche EHR vendors will apply for - and receive - certification for meaningful use remains to be seen, but healthcare IT consultant Mark Anderson in Montgomery, Texas, predicts a good number will make the cut.

"The requirements are so watered down that anybody can pass them, including the mom-and-pop companies," says Anderson.

Templates for success

Aside from certification, picking the right EHR for your specialty is largely about picking the product with the best templates to chart patient visits and order treatments. Each specialty has its own peculiar set of diagnoses, medications, and lab orders, not to mention its own choreography for where patients go in the office (procedure room, X-ray room, orthopedic cast room, refraction room, audiology screening room, etc.) and what clinician sees them there. Good templates reflect all this.

Ideally, you'd like to find an EHR vendor that has specialty templates already built and ready to go. At the same time, there's no escaping the need to tweak even the best of templates to match a physician's exact practice of medicine, whether it's the first clinical question posed to a patient with eczema, or preferred medications for treating depression.

"You need to put in a few nights tuning them up," says pediatrician Andrew Baumel of Mass.-based Framingham Pediatrics, who uses an EHR program from eClinicalWorks. Adds consultant Rosemarie Nelson, "None of these applications are plug-and-play."

Sometimes the tune-ups are super-quick. Urologist John Lin in Gilbert, Ariz., was in a lecture hall when he heard the presenter mention a prescription cream that could treat a rare penile disorder called balantis xerotica obliterans. With his laptop, Lin logged into his Allscripts EHR program remotely and added the drug to the medication list in his assessment and plan template. "It took me about 60 seconds," says Lin. The moral of the story? Ease of use is paramount.

If you're in a small group, you're probably wise to avoid building your own specialty-specific templates from scratch, given how that's been the downfall of many initial EHR enthusiasts. Even when the software lets you create templates, "only one out of 20 doctors takes the time to do it," says Chip Hart, director of pediatric solutions at PCC, which makes EHRs exclusively for pediatricians. However, you can hire a computer whiz to build what you need, notes Bruce Kleaveland, an MGMA healthcare IT consultant in Seattle, "and for a 40-physician group, that's not an unreasonable proposition."

Another option is resorting to any number of consultants and EHR resellers that design specialty templates that you can bolt onto the platform of a mainstream EHR program. A NextGen reseller called EPracticeWorks, for example, offers urologists 100 specialty-specific templates for office procedures like bladder irrigation, procedures done in ambulatory surgery centers such as vasectomies, and history-of-present-illness forms for disorders such as bladder cancer and infertility.

eClinicalWorks tries to take the hassle out of template creation by automating the task with a tool called eCliniSense. When you enter a diagnosis for a patient, the program will display what medications, tests, and referrals you've ordered and what instructions you've given to previous patients with the same problem. You can choose from this menu to treat the patient in front of you, as well as click an onscreen button and turn the menu into a template for future use.

Tips to remember

The basic dos and don'ts of selecting an EHR apply to primary-care physicians and specialists alike, but as in the case of templates, specialists have special concerns.

Clinical content. The clinical decision support function of your EHR ought to reflect the prevailing clinical guidelines for your specialty, particularly those recommended by your specialty society. Some EHRs sold to pediatricians, for example, incorporate protocols from the "Bright Futures" initiative for health promotion and disease prevention developed by the American Academy of Pediatrics and other groups.

Diagnostic imaging. Specialists ranging from orthopedists to cardiologists have diagnostic imaging equipment in their offices, along with PACS (picture archiving and communication systems) for storing and viewing the images. So how do X-rays and echocardiograms fit into an EHR? Most EHR vendors don't engineer their systems to make them double as PACS, but instead allow you to interface your existing PACS (via software) with your EHR.

"You can view the PACS image inside your EHR program," says Michael Lovett, NextGen vice president of sales solutions.

However, the high cost of interface software deterred both the Jacksonville Heart Center and Westwood Cardiology Associates from taking that approach. Instead, they operate their PACS and EHR systems separately, and scan written imaging reports from the former into the latter.

Medical devices. Testing devices such as otoscopes, spirometers, EKG machines, and Holter monitors are designed these days to download their results into EHRs, so buy these types of equipment - as well as your EHR - with connectivity in mind.

Multispecialty groups. By virtue of their diversity, multispecialty groups need a mainstream EHR that can be customized specialty by specialty with off-the-shelf templates. Such groups, therefore, should assemble an EHR selection committee that represents each of its medical fields, says consultant Bruce Kleaveland.

Training and service. Vendors aren't created equal when it comes to teaching physicians and staffers how to use a drop-down list, remove software glitches, or return a phone call pronto about a crashed system. Niche EHR vendors may lack the staff or budget to pay attention to you, or they may treat you like family - it just depends on the company. The giant EHR vendor may have more bodies at the help desk, but you may feel as lost as a shopper in a big-box store. Again, it depends on the company.

"With PCC, I'm a big fish in a small pond," says pediatrician Joe Hagan Jr. in Burlington, Vt. "With Allscripts, I'm not even a minnow."

Big picture, hard choices. Specialists may have their personal wish list for what boxes and buttons belong where on the screen, but as evidenced by last year's stimulus legislation, the federal government also has a strong opinion on what an EHR should look like (that's what certification is all about). One big federal priority is interoperability, which allows a physician to connect electronically to labs, pharmacies, and hospitals, and share patient records digitally with doctors and their EHRs across town - all admittedly good things. So specialists may have to sacrifice some of their own personal concerns for the sake of using an EHR that plugs into the national health information network the feds are trying to create.

Whichever product you favor, it's wise to consider the financial strength of the vendor along with the strength of its product. Like or it not, you are essentially placing a bet on the future. Which companies will be around in five years? Which will be goners?

"Any vendor can fold, big or little," says consultant Rosemarie Nelson.

Fortunately, experts agree that using an EHR can benefit both your practice and your patients. Do your research, take your time, and don't sweat the small stuff.

Show me the function

In the final stages of EHR shopping, physicians need to find out if a system works as well as the sales brochure says it does.

One moment of truth is the product demo. Salespeople will want to trot through their standard simulations of, say, documenting a physical examination or prescribing a drug. However, EHR shoppers must insist on seeing simulations of patient encounters and clinical tasks that are unique to their practice, experts say. That's especially important advice for specialists, whose needs go beyond documenting the average office visit in primary care.

Put vendors to the test when they glibly answer "Yes, it can" when you ask "Can your software do this?" Oftentimes, "Yes, it can" means the software has never performed a certain task before, but the vendor can build in that function tomorrow, says consultant Mark Anderson. And tomorrow never comes.

The other must-do part of due diligence is visiting a practice like yours that bought the EHR you're eyeing.

"If you're a 30-doctor orthopedic practice, find an orthopedic practice about that size for a reference," says Anderson. "If you visit a two-doctor orthopedic practice, the way they work will be different."

In Summary

Cardiologists, orthopedic surgeons, OB/GYNs, neurologists, and other specialists will feel hamstrung using an EHR designed for primary-care physicians. Fortunately, they'll find what they need from niche EHR vendors as well as mainstream companies that customize their systems for a given medical field. Here's the lay of the land.

• Mainstream EHR vendors have improved their specialty-specific offerings.

• Some niche vendors have survived the ongoing shakeout in the EHR industry.

• CCHIT is creating stamps of approval for specialty EHRs.

• Even the best specialty templates may need tweaking on your part.

• You can buy specialty templates for your EHR from third-party sources.

• Choose an EHR that can download data from medical devices.

• Some groups get by without interfacing PACS and EHR software.

Robert Lowes is an award-winning journalist based in St. Louis who has covered the healthcare industry for 21 years. He can be reached via editor@physicianspractice.com.

This article originally appeared in the November 2010 issue of Physicians Practice.