How to choose a EHR (electronic health records) system for solo doctors

These are the things I would look at when deciding which system to use:

Look at reviews– AAO/AAOE and ASCRS/ ASOA survey results- we know that surveys are not always accurate but this is a good starting point. But if there’s a common theme among the reviews, negative or positive, it probably indicates something. The most reliable reviews will be ones from your friends and colleagues. One of the benefits of joining our google group is that you get feedback about EHR systems from people who have been actually using them!

What type of practices use this EHR– some EHRs are geared for inpatient care, this probably won’t work so well if you are focused on outpatient care. Some EHRs are geared towards larger practices, others towards smaller and solo doctors.

For all specialties or ophthalmology only– one of the advantages of using an ophthalmology only software is that there are probably already many templates, more ICD 10 and CPT codes are preloaded, and there is better support for quality measures for MIPS. But I suppose that for a multispecialty system, if there are enough ophthalmology users, all of this is supported. Be sure to find out how many users there are, and how many ophthalmology practices and individual ophthalmologists are using it.

What is the cost– some programs have a initial cost, plus monthly fees. Get the quote from the EHR company, and then phone other doctors that use the software to verify the costs and make sure there are no hidden fees. Make sure that the cost includes e-Rx and the patient portal. Eye MD was $10,000 up front and $300 every month, which is in the ballpark of what other systems cost. Find out the cost of adding another doctor or optometrist.

I would definitely urge people to NOT pick a software based on cost- you should pick the one that will help your practice grow and succeed, even if it costs a little extra. This is not the place to save a few dollars! Too often I have heard of people picking the cheapest system with the idea that “when I get busier I will pick a better EHR.” Guess what, when you’re seeing two patients a day that is the time to learn your system inside out so when you’re busier it’s a well oiled machine. It’s going to be painful to make a switch, even if you’re only seeing five patients a day.

Which practice management systems does the EHR integrate with- this is a question that many people don’t consider. Ho Sun and I are strong believers of keeping your billing in house, which means you want a practice management system that is easy to use. Still, the EHR should drive your practice management software decision, not the other way around. Many companies will say that having the same program is beneficial, but I have heard of some of them doing that as a way to hold you hostage to their company. As long as the EHR and practice management system are bidirectionally integrable, you have nothing to worry about. You should definitely find out what the cost (if any) of integrating the practice management system and the EHR is.

You definitely don’t want to be manually copying and entering ICD10 and CPT codes from your EHR to practice management system to do billing. You’d have to pay for someone to do it, and this introduces room for error and claims rejection.

What is the ease of importing testing– also known as DICOM- most ophthalmologists will have a IOL master or Lenstar, as well as a camera, OCT and visual field. You definitely want ease of use in importing these images into your EHR not only to document but to show to patients in the exam room. Does the EHR do this efficiently? If it is cloud is there lag time? Are the quality of images good? Is it compatible with all instruments from different manufacturers, even older models if you’re buying used equipment? Show the vendor a list of your equipment and make absolutely sure that it’s supported.

How long has the vendor been around– ask how many users they’ve had every year, and how quickly they are growing. Sometimes a EHR may be acquired by another company and that might cause changes. You might even want to google “(name of EHR) acquisition (or merger).” My practice management system was acquired by another company and I noticed a immediate drop in customer service (to their credit it has rebounded since then). Ask if the users have a hard time with the ICD 9 to 10 transition?

Upgrades to the software– try to find out the upgrade history of the software, at least for major upgrades, and why they were done. Find out if upgrades in the software are supported in the cost, and who performs the upgrades (will it cost extra to pay my IT company, or will you do it for me).

Could or server based– back in the stone ages of 2014 when I started my practice, use of the cloud wasn’t as prevalent as today. It seems like everything these days like music, pictures and documents are backed up in the cloud. There’s no doubt that computing is moving to the cloud. However, my EHR program is server based and I’m very happy with it. And when my practice management system asked me whether I wanted to switch to their cloud based system I declined. Guess what, I declined. I must be a dinosaur!

Although I know I’ll eventually have to replace my server, some colleagues on cloud based systems have had lags or delays in accessing their data, or even worse lack of access for an hour or so, which is unacceptable in a busy clinic.

Ease of use– are there templates? Drop down boxes or check boxes? Can they be modified to your liking? How much typing do you do? In addition to the demos shown to you by the company, I would say it is extremely important to go to someone’s office who is using the system and have them walk you through entering a note for your most common conditions (cataract evaluation, intravitreal injection for diabetic macular edema, blepharoplasty evaluation for instance). Does the software feel natural to use?

Are there templates for commonly performed office procedures? Well, I guess you could use a paper template and scan it in, I still do so for my cataract surgery notes.

Do you like to draw pictures? My own opinion is drawing is overrated (I only use it as required when billing for indirect ophthalmoscopy) but you may differ.

e-Rx (electronic prescriptions) is a requirement under the MIPS quality measures for EHR use (although in 2018 you can still avoid MIPS penalties even without e-Rx) so if you choose to implement e-Rx, practice writing a few prescriptions through the EHR to make sure it’s easy to use.

Does the system generate notes to referring doctors and can you fax them directly out of the system? I use this feature all the time and it means I don’t have to dictate, although I have to type a little extra in my notes. Does the system accept incoming faxes? Mine does but I never use it, just scan the faxes in.

Is the system preloaded with ICD10 and CPT codes that you commonly use, and does the system suggest them? If it isn’t preloaded, you can certainly set it up on your own, but there should be some type of a mechanism to suggest diagnosis codes based on your physical exam entries. Then the codes you select can automatically be sent to your integrated practice management system.

Is there internal messaging for flags to be sent to other employees or for the doctor to review? My system has this but I never use it. Other practices find this to be a huge timesaver.

Implementation time– how long does it take to learn how to use the software? If you are implementing EHR in a existing practice, how much did other practices have to cut down on patient volume for training? This is a question you want to get multiple answers to, and to try to get answers from people other than references from the EHR company if possible. If you’re starting solo from scratch you will have plenty of time to learn the ins and outs on your own.

How much training do I get– my EHR company has free unlimited training but my practice management system gave me eight hours with a trainer, but answered my questions for free without charging me extra. I guess I made up for it by only really using seven of the eight hours. Make sure there is a trainer available around your planned implementation date so you can go live at the date that you desire. How is the training done, live or via the internet? Are the available time slots convenient? This may sound silly, but my practice management system didn’t exactly provide convenient times for me. I would try to get this in my contract with the company to have X number of sessions within a certain time period within my implementation date.

How are questions answered– live person or email? How long do current clients have to wait for an answer when they phone in? I would actually try to phone customer support to see how long the wait time is, and whether it is outsourced overseas. My practice management system makes me email them which isn’t a big deal right now since I only contact them a few times every year, but this would be frustrating if I were trying to get quick answers.

Remote access– how can you access the program when you are at home? Is there mobile access on your iPhone and how much information is included? One of the biggest weaknesses of the system I use is limited information on the iPhone app, but I’m lucky in that it’s rare that my patients call me when I’m not in the office. This might be different if you take ER call.

Patient web portal and education brochures– both of these are requirements under MIPS, although again just like e-Rx you can avoid the penalty for 2018 even without using this. Truthfully very few patients access my patient portal. But patient education is very useful. Who creates the educational brochures, and can they be printed or are they sent through the portal to the patient? I like to print them and have the patient read them when they are dilating so I can answer their questions. The AAO patient education brochures are integrable with several EHR companies including Eye MD, the cost is around $300 per year.

How do you attest for MIPS quality measures– through the EHR, or through a clinical registry. Does the EHR company do anything to help you meet the EHR part of MIPS? For the old meaningful use, my company would arrange for a quick phone/ internet conference every quarter where they would check my scores to make sure I was doing what I needed to do, and let me know if I needed to do anything differently.

I don’t know how MIPS will be scored in the future, but make sure you can either submit quality measures through the EHR or that the EHR is compatible with a clinical registry. Otherwise you will have to submit quality measures through claims, which is more limited and results in a lower score. Ask what the EHR company does to help their client meet quality measures IN YOUR SPECIALTY (if it is a internal medicine EHR it may not measure cataract surgery outcomes), and make sure that you speak with people who got high scores in MIPS to show the software works.

What happens if I leave- this question was probably more common in 2011 and 2012, but even with more mature systems, some docs choose to switch their EHR system. Ask to find out how many people have left your company, and how it is handled. Read the contract carefully and don’t sign it until you are happy with it!

Truthfully i didn’t even know what questions to ask when I did my EHR search when i opened my practice. Thankfully Ho Sun’s original blog saved me. My EHR search was real easy. I looked at his blog and saw how happy he was with his system, Eye MD. Additionally I briefly looked at two other systems and did demo webinars over the internet. I went to “test drive” Eye MD at a local office and spoke at length with the doctor and office manager. This was enough for me, and I’ve been very happy with my system to this day.

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