Electronic Medical Records

Intoduction: History

The deluge of regulatory changes in healthcare in the past few years shouldn’t come as a surprise for those who’ve followed the industry and information technology trends, but the extent to which these changes will alter the very fabric of the healthcare system may daunt even the most seasoned of healthcare professionals. These industrial and regulatory changes, when they are complete, will utterly revise healthcare in the United States forever.

In 2008 the National Quality Forum released a report in which it identified areas in healthcare that needed ameliorating, including population health, coordination of care, safety, efficiency, patient engagement, and the reduction of racial disparities. In 2009, the American Recovery and Reinvestment Act (ARRA) used these areas to create the fifteen criteria for Meaningful Use, which was determined by the ARRA provision called Health Information Technology for Economic and Clinical Health (HITECH), which focuses on improving the affordability of healthcare and specifically outlines the promotion of health information testing, grants and loans funding, demonstration programs, privacy, and provisions monetary incentives for practices that demonstrate Meaningful Use with an electronic health/medical records (EHR or EMR) (Blog). Of the Health Leader’s Media survey respondents, 37% said that ACOs will have a positive impact on their practice, and 12% said strongly positive, 15% negative or strongly negative, and 35% neutral. A quarter of respondents said developing an ACO is a top priority for them (Health Leaders Media 4-5).

Meaningful Use incentives began in January 2011 (Medical Group Managment Association 1). More will be added in 2013, more in 2015, and after 2016 the fiscal penalties for not demonstrating meaningful use begin (Ingenix “Right Time” 2; MGMA 26). HITECH set aside up to $20 billion for meaningful EMR implementation and use incentives (MGMA 3). Under Medicare, practices and hospitals can earn up to $44,000 in incentives over a five year period; under Medicaid, you can earn up to $63,750 over a six year period (Ingenix “Right Time” 2). EMRs better document and organize the care process so physicians can more easily produce the reports that the government and payers require under their respective care quality indicator programs. Along with the obvious boon to the practice an implemented EMR would bring, 82% of physicians and practice administrators said that the possibility of being reimbursed for their EMR investment makes them more likely to adopt the technology (Ingenix “Right Time” 2) . Practices look to EMRs also because Medicare and commercial payers continue to create programs that connect a percentage of reimbursement according to a practice’s reporting of care quality and patient outcome indicators (Ingenix “Right Time” 3).

Meaningful use doesn’t stand alone in the new regulations. ICD-10 billing and diagnosis codes will be almost completely revised at the end of 2011, throwing yet another wrench in the way doctors are doing things. Furthermore, many practices are currently looking to replace their practice management systems (PMS) to comply with the new 5010 electronic data interchange transaction standard, which has an implementation deadline of January 1, 2012 (Ingenix “Right Time” 3). These standards will hopefully fix the lack of interoperable standards for information exchange, making it less likely that a patient’s data would get trapped in an outdated system (Laserfiche 4).

Another policy-driven change in healthcare is the development of accountable care organizations (ACOs). ACOs are organizations that follow a payment and delivery reform model tethers provider reimbursements to both quality metrics and reductions in the total cost of care for select populations. Despite the large changes these organizations will bring, top leaders in healthcare organizations seem ambivalent about the role accountable care organizations are going to play in the new healthcare environment (Ingenix “Right Time” 3). Many large commercial payers, following Medicare’s lead, are forcing providers into ACO-like organizations in order to manage care. The risk shifts from the payer to the provider, as providers are increasingly required to build infrastructure in order to effectively manage more medical cost and quality risk, (Healthcare Billing and Managment Association 24). Nevertheless, according to a survey by Health Leaders Media, 41% of CEOs and other top executives answered “neutral” when responding to a question about how ACOs will effect their organizations over the next three years, though 45% believe ACOs will have positive or strongly positive effect on their organization (HealthLeaders Media 2).

Types of EMR

The needs of practices differ widely based on their size, specialty, and ownership; so naturally, with over three hundred EMR vendors out there, the type of EMR and its functions differ as well. Ideally, all EMRs should possess an ability to interface or integrate with the practice management and coding solutions in order to decrease the change of a claims denial and set the practice up for compliance reporting required for Meaningful Use incentives (Ingenix “Finding the Right Fit” 4). There are many more ways EMR vendors facilitate Meaningful Use designation, but they depend on the type of EMR. All EMRs are designed to improve medical record and chart accessibility and security, decrease costs associated with handling and storing paper records, and can even offer advanced dianostics like lab tests, CAT scans, MRIs and stress tests, electronic prescription (eRx) functionality, and even practice managment functions (Laserfiche 9).

Traditional EMRs: Client-Server Setup

The oldest type of EMR, traditional EMRs began gaining a foothold in the nineties, and are typically a combination of hardware and software. Called a client-server setup (CSS), this EMR includes a main server that routes key software and data to client computers via a secure intranet. The CSS’s best quality is its ability to be fully customized according to an individual practice’s workflow and data preferences, yet extreme customization may fall by the wayside as the government increasingly standardizes and regulates health information exchange. Another distinguishing characteristic of a CSS is that all hardware and software is on-site, fully bought by the practice. This means that the installation involves considerable time and costs and that the practice assumes responsibility for all maintenance, updates, and re-training (Ingenix “Right Fit” 2).

The CSS’s practical applications vary according to customization, but generally, the practical application of a CSS requires doctors to type their notes into the system either during or after appointments. This clunky, outdated method of data storage usually impedes doctors’ productivity by forcing them through intrusive pull-down menus, check boxes, and multiple screens, hindering their preferred workflow and disrupting patient care (Laserfiche, 3). A 2006 study on the effects of traditional EMR on physician-patient communication implied that using computers in the exam room negatively effects patient care by “inhibiting eye contact, decreasing dialogue, and reducing emotional responsiveness” (Laserfiche, 3). Furthermore, because traditional EMRs only convert patient files into an electronic format on a day-forward basis, doctors still must consult paper charts created prior to implementation (Laserfiche, 8).

Hybrid EMRs: Application Service Provider (ASP)

An ASP resembles a CSS in that the practice still has its own server, however the server is at a remote site where an external vendor maintains it. In order to use the EMR, the physician’s office accesses the remote server through standard Internet protocol (IP) using an http or https address. Because it uses the web to connect the servers, ASPs are often called with web-based or even software as a service (SaaS) solutions, yet these terms are best reserved for cloud-based EMRs (Ingenix “Right Fit” 2). The password-protected internet access of the ASP allows for increased file security, with employees only having access to the patient records they manage. Also, those who have an ASP have the option of backing up entire record repositories onto CDs, DVDs or other media (Laserfiche 10). Like CSS EMRs, ASP are easily customized, and share the same difficulties regarding customization versus standardization (Ingenix “Right Fit” 3).

The costs for purchasing, installing, and updating an ASP, while less than a traditional EMR, can still burden some practices. Every time changes are required to the service, the vendor must update not only every client server, but all client desktops as well. Like CSS EMRs, because of the difficulties in updating ASPs, updates occur less often and less comprehensively. Whatever the EMR type, however, updates still require staff retraining (Ingenix “Right Fit” 2). Nevertheless, because the vendor maintains the server, many of the long-term maintenance costs may shift away from the practice to the vendor.

Cloud-Based EMR: SaaS

The newest kind of EMR is the cloud- or web-based software as a service (also called software as a solution). What this means is that there is no hardware to purchase, and no software to install. The practice accesses and employs the software through a secure site on the world-wide web, only requiring access to the Internet to use. These EMRs offer the functionality of traditional EMRs to varying degrees, but system maintenance and software licensing are not required. The vendors of these EMRs typically charge for their products using a subscription model, usually priced per physician, and many per patient encounter (Ingenix “Right Time” 3).

Two main advantages of cloud-based solutions are that they have rapid provisioning and cumulative value, respectively meaning that the updates are immediate and only implemented once, and that everyone who uses or is effected by the system benefits from the changes. As such, vendors of cloud-based EMRs can adapt quickly and efficiently to the changing healthcare landscape. Other benefits of the cloud-based EMR are the comparatively minimal up-front costs, which translate into quick return on investment (ROI) and comparable cost of ownership.

While less customizable than CSS or APS, cloud-based software can and often does offer some of the same tools through customization, including applications that help with the business side of the practice, such as employee, accounting, and legal document storage and organization. Cloud EMRs possess the most interoperability with a wealth of systems and health industry partners, from hospitals and insurers through labs and pharmacies (Ingenix “Right Fit” 3). Most EMRs come with or have an optional eRx application, either through a partnered vendor or their own.

Implementing a cloud EMR is the easiest of the types because it doesn’t require installation of any hardware or software. Training is likely to take the most time, and the method the vendor uses to train varies. Many vendors enable the scanning of paper records into the system as searchable, catalogued documents, facilitating the switch from paper to electronic records (Ingenix “Right Fit” 3).

The challenges for the cloud-based EMR reside in protecting patient privacy, preventing system crashes, and disaster backup; most vendors anticipate these issues and needs though. The other downside is that costs associated with this EMR are ongoing because of the pricing model; however, the lack of up-front costs (including the time and resources required for implementation) and maintenance costs may more than compensate for the long term costs.


A practice can chose from a variety of applications they can add to their EMR in order to increase their clinical efficacy and efficiency. The adaptability of these add-ons allows specialty practices to incorporate applications taylored to their specialty, or even to their practice itself, though as aforesaid extreme customization can impede easy system interoperability.

The majority of practices would benefit from an EMR that has access to national electronic prescribing networks so their physicians can select drug formularies based on insurance coverage; this way, doctors can know and work around their patient’s out-of-pocket cost before they fill the prescription (Ingenix “Right Time” 4). Add ons can also include applications for generating and storing documents and data in the areas of accounting, admissions, back office, billing, credentialing, human resources, and legal (Laserfiche 8). What’s nice about add-ons is that they can be incorporated at any time, so a practice doesn’t have to feel pressured to implement everything at once.

EMR Implementation and Optimization

Who is Where?

Senior hospital leaders overwhelmingly believe their organization is on the right track to achieving the goals health reform seeks to implement, but they are skeptical about where their peers are in the process (Ingenix “Right Time” 3). The data for where doctors are in the implementation stage vary according to each study based on its data-collection date and the number and type of physicians/organizations surveyed, but it’s clear that physicians are all over the map in their journey to Meaningful Use achievement. The Centers for Disease Control’s National Center for Health Statistics estimates that only a small fraction of the 43% of office-based physicians who were employing an EMR in 2009 had fully functional systems with the capability to achieve Meaningful Use standards, using systems with the ability to record clinical notes, prescriptions, and laboratory and imaging results (MGMA p.1). Yet a recent survey published in The New England Journal of Medicine found that only 13% of 2,758 surveyed physicians had a basic EMR system in place, and only 4% responded that they had a fully functioning EMR (Laserfiche, 2). The Healthcare Billing and Managment Association, however, estimates that only 10% of physicians are utilizing fully functional EMR systems, with over 70% of the remaining practices expected to purchase a system in the next three years (Stack 22).

In perhaps the most recent survey , conducted by the Medical Group Management Association (MGMA), indicates that 52.3% of respondents use an EMR while 35.8% use paper records and charts. A small minority (5.5%) use a Document Information Management System (DIMS), in which paper records and charts are scanned as images and filed electronically (Laserfiche 3). Of the respondents who currently use paper records, MGMA found that 62.9% plan to seek the HITECH incentives, yet only 26.8% of these practices were in the process of implementing an EMR; 29.6% were in the process of selecting an EMR, and 22.7% intend to implement an EMR within two years but had not begun the selection process (Laserfiche 4).


Vendors offer various methods of training for using their EMR. Some vendors offer multiple training program types, while others only one. EMR vendors may employ pre-recorded videos, instructor-led Webinars, offsite training, onsite personalized training, or a train-the-trainer approach where they intensively train a physician (preferably, though it could be a practice administrator) from the office who then trains the rest of the physicians/users (Ingenix “Right Time” 5). In the MGMA survey, 39.9% of respondents said they midly underallocated time for training and 13.3% said they severely underallocated time for training. Unfortunately, these responses were not quantified based on EMR type, so we can’t say for sure which EMR is likely to take the most or least time for training (7).

EMR Implementation Concerns, Risks, and Satisfaction

Though the cumulative benefits of adopting EMR technology include streamlining workflow, increasing efficiency, reducing costs, and improving patient care, the risks associated with adopting may initially outweigh the benefits. At least on a short-term basis, practices must consider the initial capital and time investments, especially for the smaller or indepentently-owned companies.


The cost of implementing an EMR varies according to the type of EMR, but can include fees or charges for hardware, software, site preparation, installation services, application development, configuration managment, data conversion, user training, maintenance and support services, and quality assurance and post-implementation reviews (Laserfiche 4). According to a 2008 survey conducted by the Texas Medical Association, the median reported implementation cost of EMR per physician was $25,000, with median monthly maintenance fees of $425 per physician (Laserfiche, 4). However, this statistic does not clarify whether it was the median for all EMR and vendor types or only for the more expensive traditional kind.

A practice wants to make sure it receives sufficient return on investment (ROI) without diminishing provider productivity. While ROI may vary per practice and EMR, the long-term monies saved by using EMRs may be enough to incite practices to adopt. Yet according to a recent AMA study, physicians receive only 11% of the money saved through the actual use of EMRs, with the bulk of savings going to insurers. Furthermore, ARRA incentives won’t “defray the cost of maintaining a traditional EMR during that five-year timespan” (Laserfiche 4), though cheaper EMRs could actually lead to profit from the incentives payments.

According to the Ingenix survey (of 1001 physicians and practice managers), 82% of respondents said that burdensome cost was one of the top three risks of EMR deployment, including 46% who said it was the top risk (Ingenix RT, 3).


Practices must also consider the disruption of productivity deploying an EMR would cause: The Ingenix survey indicated that this was in the top three risks for 75%, and 24% responded it was the top (“Right Time” 3). The MGMA survey showed that of the 35.8% of physicians that still use paper records, 78.3% felt there would be a significant to very significant loss of provider productivity during implementation, and 67.4% feared for loss of productavity after the EHR transition (8).

According to recent research conducted by The Economist Intelligence Unit on behalf of Laserfiche, 80% of organizations that have formally attempted to improve business processes over the past three years have faced significant employee resistance. Three major causes of this reluctance to change were: 1) 31% said the new process added more work, 2) 31% also said employees had little or no say in determining the new process, and 3) 28% indicated the new process didn’t match how employees thought their jobs should be done (7).


When a practice invests in an EMR, it also invests in the EMR’s vendor, so assessing the vendor’s viability as a business can be as important as the viability of its software. To judge a vendor best, do your research: read industry reviews, ask for customer references, and research the organization’s size and try to determine the likelihood it would acquire or be acquired by other organizations. This last point is also important because of the proprietary nature of software; if a practice wants the flexibility to change EMRs if the practice or regulatory standards change, it should know if it can import its existing records into the new EMR or if the records must be converted out of a proprietary format first. If a practice’s EMR stores information in non-proprietary formats like TIFF or ASCII, interoperating or integrating with other systems may simplify the process (Laserfiche 11).


Practice satisfaction with EMRs depends on their ability to integrate with existing practice management systems, increase the quality and safety of patient care, decrease practice costs, and increase productivity and practice revenue. A little over two thirds of those MGMA surveyed that were in all stages of EMR implementation were satisfied with the first three criteria (MGMA 14). Regarding the improvement of cost, productivity and revenue, EMR satisfaction rates differ significantly according to the level of implementation the practice has achieved, with those who have fully optimized their EMR holding the most satisfaction. This finding indicates that practices most likely need to fully implement their EMR before they can reap the promised benefits fully (MGMA 14-15).

In spite of the widespread adaption of EMRs, their de-installation occurs regularly. According to Laserfiche, industry estimates of the de-installation rates of traditional EMR systems range from 20% to 78%. Mark R. Anderson, CEO of the A.C. Group explains that this high rate of de-installation for traditional systems is because so many practices are going from basic-level one practice management software packages to more integrated EMRs (Laserfiche 2). No percentages of de-installation per type of EMR were found, though based on the diverse kinds of EMRs out there, it’s likely that both installation and de-installation rates would differ per EMR.

Summary Conclusion

Modern EMRs are designed to improve the security and accessibility of medical records, decrease costs for providers and payers, interoperate with existing practice management systems, and even access national prescriber and insurance networks. EMRs come in three types: client-server setup, application service provider, and cloud-based EMRs. All EMRs are customizable to various degrees, and may include add-on applications for business, legal, human resources purposes, to name a few. The training method vendors use to teach practices how to use their EMR vary in location, method, and audience.

Incentive monies from the HITECH portion of the ARRA provide reimbursement for practices’ adoption and demonstrated meaningful use of an EMR. Currently, a little over half of doctors and practices are using an EMR, with about a third still using paper records. The biggest two risks in adopting an EMR are high cost and reduced provider productivity. The extent of these risks depends on the type of EMR and the vendor’s billing practices, and on the vendor’s ability to adapt to the existing schedules and work habits of a practice. Of those practices that are implementing or have implemented EMRs, those who have fully optimized their use of the EMR seem to better perceive the benefits of increased efficiency, productivity, and revenue. A practice’s EMR satisfaction also depends on the EMR’s ability to integrate with existing practice management systems. Hopefully for practices, vendors will also make their EMR flexible to adapt to the various industry changes that continue to regularly occur, such as revisions to the ICD-10 diagnosis codes. Anything that can make a doctor’s job easier can potentially lead to improved patient care.


Clinic Service Blog. “Meaningful Use: A Summary History.” Clinic Service, Inc.. N.p., 14 March 2011. Web. 5 June 2011.

HealthLeaders Media. “Overall Cross-Sector Survey.” HealthLeadersMedia.com/Intelligence, 2011. Web. 5 June 2011.

Ingenix. “EHRs and Small to Mid-Size Physician Practices: Finding the Right Fit.” ALN Medical Management. Ingenix, Inc., 2006. Web. 5 June 2011.

Ingenix. “The Right Time for an EHR.” ALN Medical Managment. Ingenix, Inc., 2010. Web. 5 June 2011.

Laserfiche Institute. “A Guide to Hybrid EMR: The Natural Approach to Electronic Medical Records.” Laserfiche. Compulink Management Center, Inc., 2009. Web. 5 June 2011.

Medical Group Management Association. “Electronic Health Records: Status, Needs and Lessons—2011 Report Based on 2010 Data.” Medical Group Management Association. PNC Bank, 2011. Web. 5 June 2011.

Stack, Ted. “The Year in Review.” Billing: The Journal of the Healthcare Billing and Management Association 16 (2001): 18-30.