hen purchasing an electronic health records (EHR) system, there are four important choices that could make or break your investment. How much you spend is a factor in each, but cost alone is not the only choice. 

 

So what are these four essential choices that can empower (or hinder) how you use your clinic technology? You have a choice between cloud-based software or an EHR that runs on a server in your office. You have a choice between documentation that is customized to your practice, an EHR system that arrives loaded with general-practice templates, or one that requires you to create and load nearly all commonly used material and selections in drop-down boxes. You have a choice between robust service, maintenance, and training plans, or the least-expensive, do-it-yourself support plan you can find. And finally, you have a choice whether or not to pursue a certified EHR, allowing you to be eligible for incentive payments from Medicare and to have a system that meets federal guidelines.

 

EHRs have two main platforms for delivery of software and data service options: cloud-based services or software that runs on a local server in your office.

 

What is the difference? To keep it simple, you can think of cloud-based service as largely working over the Internet and a server-based service working through business-class servers in your office. A local server is going to require more hardware costs, IT expertise, and ongoing IT maintenance of your internal network than a cloud-based service where someone else is managing these components for you someplace else (i.e., the cloud). 

 

And what about costs? With very rare exceptions, most doctors just do not have the background or the experience to set up their own server. Firewalls, user permissions, and the security required for HIPAA really require an IT expert. Depending on the size of your in-office network, the cost of maintaining the network and paying an IT professional can range from $1,500 to $3,500 per year for a small- to medium-sized practice. Larger clinics can pay $5,000 to $15,000 annually. Since a small business-class server can run from $2,000 to $3,000, many clinics will spend about $5,000 annually on their server equipment and maintenance. Plus, every four to five years you usually have to replace the server and continually update the operating software that the server requires.

 

Cloud-based EHR systems, on the other hand, can range from $39 to $399 per month depending on the service plan and robustness of the software functionality. There is an upfront licensing fee for purchasing most cloud-based software systems depending on if it is certified software and how much functionality initially comes with it. 

 

With higher maintenance and hardware costs, why would a doctor choose a server? There are three primary reasons why investment in a server would make sense: 

 

 

There is also a fourth aspect to choosing a server that should be mentioned: the psychological component. Some doctors really like being able to see the actual equipment on which all their valuable clinic data is stored. Cloud-based services are stored on high-end, fast servers in HIPAA-compliant environments. You cannot see them, but you can usually access your data from almost anywhere over the Internet. Cloud systems are typically more mobile than local server environments.

 

Besides cost, there are other advantages to cloud-based EHR systems. Security and accessibility are probably the largest advantages. Cloud-based services are responsible for keeping your EHR data safe and secure in their HIPAA-controlled environment. With a server, you are responsible for the security of your data. Secondly, with cloud-based services, your clinic data is available from anywhere, just as long as you have a username and password.

 

What's the bottom line? Cost may be the number one factor for server versus cloud, but Internet speed and accessibility are important as well. It may be helpful to work with an EHR company that has experience in server-based and cloud-based services to understand all of your options. One area of confusion regards who owns the data if it resides in the cloud. You still own your patient data and can have a copy of your data should you decide to change software providers.

Selecting features makes a lot of doctors anxious. What do they need? What do they want? And what are they really going to use long after the ink is dry on their service contract? Many doctors want the best of both worlds.

 

Not wanting to be forced into a small-practice box, many doctors say that they want to customize their EHRs—but only to a point. They also do not want to do all the work themselves; they would like to have essential practice documentation information arrive loaded on their software. For example, the notes in pre-loaded EHR software can list information on orthopedic tests, their interpretation, and even how to perform the tests. Doctors also want to be able to easily add their information to an already existing library, while being able to turn on/off certain functions that are important to their practice. They want the software to feel personal, out of the box, and seamless.

 

If this description fits your own approach to EHR, then take note: this choice may be the most important to your own personal satisfaction with your software. There are some programs that come loaded with dozens and dozens of different screens for every kind of practice, but you cannot prioritize how they appear or turn them off. And there are programs that sell based on their customization capabilities but offer little more than a text box for each section of your SOAP note.

 

What's the bottom line? Documentation means being able to tell the story of your care as accurately and efficiently as possible. Yes, the best of both worlds is possible to find, but you have to know what is essential to your clinical workflow and work with a company that understands the variety of options in chiropractic care. If you want all the bells and whistles handy, make sure they will not slow you down. Ensure it is possible to turn off options or at least to prioritize how they appear. And if you want customization, make sure that does not mean you have to do all the work. If you choose a system that is not pre-loaded with chiropractic-specific nomenclature and templates, you do not have years to get your documentation right, as some doctors have done. Having the system pre-loaded with chiropractic templates and list selections is great when combined with the ability to customize lists and insert your way of saying things into the note. Being able to save commonly used phrases for later use is key. The workflow design is important so that you can access custom methods quickly.

 

There are a lot of factors that go into your EHR costs, and perhaps the most significant factor is service and support needs. There are associated costs with data storage, managed data services, customer service, ongoing training for new hires, and software updates. These expenses are the bulk of your annual fees for larger, more robust EHR systems. 

 

Do you need luxury-class technical support with e-mail hotlines, click-to-chat, one-on-one trainings, and other help available almost on demand? Or you can you thrive simply on watching a catalog of support videos while utilizing webinar-based training, or by just referring to a written manual—the bare-bones of tech support? 

 

The largest and most intensive maintenance and support contracts can range up to $6,000 per year for the above features; whereas, bare-bones service and support may cost only $39 per month. What your clinic needs depends on you and your staff’s technical confidence, the number of providers in your practice, and of course, patient volume. 

 

What is the bottom line? Some doctors try to get away with the lowest maintenance costs possible and will skimp on training and support. Beware if you are tempted to save costs here. If you pass up the upgrades, support, and training necessary to help your clinic run at maximum efficiency, then paying for technology that empowers your practice is an exercise in futility. Many doctors are often unaware of the full features and functionality of their software due to lack of training or due to an “I can figure it out on my own” mentality. Plus, due to changing government regulations and advancing EHR technologies in the healthcare industry, keeping your system updated is crucial to staying compliant. 

 

The Centers for Medicare and Medicaid Services (CMS) incentive program is not a good reason by itself to adopt an EHR system. With that said, a $39,000 incentive payment is moving some doctors to adopt an EHR system faster than they would have otherwise, and doctors want to know if it is worth it. Here are some guidelines to help you make this choice:

 

You know the saying, as Medicare goes, so too goes private insurance, and it may not be long before a certified EHR is necessary to be on a panel of preferred providers for general health insurance carriers.

With the right combination of allowed submitted charges, Medicare patient volume, and down time, most clinics can pay for the bulk of their EHR system, covering the costs of hardware, software, and time invested to train and prove MU. 

 

What is the bottom line? If incentives for MU will help raise your profit and pay you for your time, then incentives make sense. But keep in mind that a certified EHR is still worthwhile even if incentive money is unavailable. You know the saying, as Medicare goes, so too goes private insurance, and it may not be long before a certified EHR is necessary to be on a panel of preferred providers for general health insurance carriers. The sooner you adopt a certified EHR, the sooner you reap the benefits of a more efficient practice. (Note: CMS will begin penalizing providers who do not perform MU with a certified EHR starting in 2015.)

 

These four essential choices will not only affect how much money you spend on EHR, but will also help or hinder how well you use your clinic technology. These choices will determine whether your technology actually empowers your clinic, or if the technology becomes just another cost of doing business. Who can help you make the right choices for your clinic? You can start by finding a company that understands each of these essential choices and even offers solutions from both sides of each issue. None of these choices has a universal right or wrong answer, just an answer that is best for your clinic. Will your choice be the empowering choice for you?

 
Steven J. Kraus, DC, DIBCN, CCSP, FASA, FICC, is Founder and CEO of Future Health, the nation’s #1 provider of chiropractic-specific EHR/practice management software. He is an acknowledged expert in Health IT, including EHR (electronic health records) and the up-to-$39,000 ARRA incentive program to implement EHR.

Dr. Kraus has served―and continues to serve―on numerous committees and boards, including:

• ACA Computer & Technology Advisory
• ACA Legislative Commission
• ACA Quality Assurance and Accountability Committee

He lectures to state associations and at industry events regarding EHR and the relationship to documentation, and he presents monthly webinars on how EHR usage will impact doctors of chiropractic. For more information, visit www.FutureHealthSoftware.com or call Toll Free 1-888-919-9919, ext. 652.

s the original Chiropractic “Technogeek”, I feel obligated to make the lives of Chiropractors easier and more productive through the use of technology. One age-old issue screaming out for a technological solution has piqued my interest. It is well known that patients retain only 5-20% of what the doctor communicates; even less at a screening.  Without being able to reinforce the message we convey, and do so quickly and effectively we lose our patient's attention.Traditional solutions have relied upon everything from general pamphlets and videos espousing the value of Chiropractic, to expensive celebrity endorsements. We have struggled for decades attempting to “sell the invisible” and still only appeal to 8% of the population. 

 

The emergence of Static sEMG in the early 90’s attempted to provide a user-friendly technology that produced patient-friendly graphics, but was limited by technological and reliability issues.  This technology not only forged the way for evidence-based practice, providing objective data that Chiropractors need and patients want, but also provided an effective tool for internal marketing and spinal screenings, a mainstay for generating new patients.  Yet the problem still persists.  

 

What does a NASA researcher do?  Seek out data, and observe.  So that is what I did. Instead of interviewing doctors, I spent four months interviewing patients.

 

In the process of interviewing patients, an issue with significantly greater impact on the profession was exposed:  Those in pain easily garnered the support of friends and family members in choosing Chiropractic as the treatment of choice. Those not in pain seeking Chiropractic care for general health and wellness, clearly expressed one common challenge: Each and every one admitted they found it extremely difficult to justify their Chiropractic visits to family and friends.  

 

More important than this was the emotional response I received from patients who had taken home their Static sEMG test as it validated their complaints to cynical family members.  One patient actually cried saying “My husband didn’t believe me until I showed him my print out”.

 

You go to the doctor when you’re sick. You see the Chiropractor in pain. Why would you possibly go if not in pain?  

 

We’ve been attempting to implement the dental model of “preventive care” for years with little success. But to a Technogeek, this is just another fun problem to solve.

In reviewing the scientific literature on patient communication,I found some clear trends 1, 2, 3, 4.

1. If you don’t reinforce the message immediately, you can assume your patient will forget your advice making the interaction unproductive at best.
2. A follow up call or some form of personal communication immediately after each visit is ideal, as a reminder may help reinforce the importance of their visit. 
3. Any report of findings provided the patient via “internet patient portals” or email is significantly more effective as the patient not only can review it at their leisure, but can show family members and friends their results. In addition, it does not get lost as does paper. 
4. Visual data is significantly more effective. The more objective and personalized the data, the more effect it has on the patient and their family and friends. 
5. Making the communication “Smartphone Friendly” is crucial, as the proliferation of Smartphones requires that your communications be easily readable on them. Many use iPads and Smartphones more than computers for “skimming” their electronic communications.

My girlfriend’s trip to the auto mechanic lead to the solution. She kept complaining of engine roughness. I didn’t notice it and to be honest thought she was a bit paranoid. Instead of the mechanic listening, touching, feeling and expressing an opinion, they plugged her car into a computer. On the screen was a visual image showing her “mass airflow sensor” was defective, They even faxed the results from the computer directly to me knowing that I would need to be convinced also. I know she got great pleasure in using this data to show me how much more right she was then I. I’m happy that makes her happy.

In the days prior to objective data, we would pleasantly say “thank you”, and go off to get several opinions potentially putting off fixing the problem for months or even years! Sound familiar?

We in the Chiropractic Profession share the mechanics dilemma, and may learn a lesson from their approach. We live in a data driven society. Show them why with “instant” indisputable, objective data and we overcome not only their objections and reinforce the need for care, but overcome family members objections. In a data driven world, objective data rules, and those with it have the power to convince. Whether it be mass airflow sensors or wellness care. The key is finding a way to transmit this data in an electronic, instantaneous form which is visual in nature for maximum effectiveness.

I realized that it would be most intelligent to meet the patient where they lived… on their smartphone! Nielsen reports that more than 50% of mobile consumers are using smartphones. According to Nielsen’s monthly analysis of cell phone bills for 65,000+ lines, smartphone owners – especially those with iPhones and Android devices — are consuming more data than ever before on a per-user basis. This is an enormous captive audience waiting to be engaged.

It was crucial that this process maximized the use of technology to remove the need for human interaction and labor. Unnecessary labor is proof of a poorly designed system. This tool had to be fast, allow for instant communication, and provide indisputable, objective data which could be easily presented to skeptical family members and friends. Due to the fact everyone has smartphones, it has to be easily viewable on the tiny screen. Allowing the texting of the image via SMS would improve its effectiveness.

With major technological improvements that have tripled the speed of muscle tension measurements, the tool of choice for this objective data would be Static sEMG. Although Thermography was considered, it is too finicky due to sensitivity to environmental heat and cold, making screenings difficult. Additionally, patients can’t feel temperature differences between left and right sides of their spines, making the results less “believable”. Modern, Wireless Static sEMG can be performed in virtually any environment. More importantly, everyone knows the ache of muscle tension, making instant credibility the doctor’s reward when the graphed results reflect what the patient feels. New University research has validated Standing Static sEMG studies as clinically valuable6. Even more important, a major study by the Veterans Administration established the Static sEMG as capable of accurately tracking patient progress 7, 8.

Impersonal is ineffective. If the patient’s personal Static sEMG results, graphical in nature could be instantly transferred to the patient’s smartphone, that crucial communication between doctor and patient would be reinforced within seconds. Unlike a generic pamphlet on the value of Chiropractic, the patient needing to prove the necessity for care can instantly forward from their smartphone the test results to skeptical family members. Another requirement is for the graphical image to act as an “E-Business Card”, presenting both specific information on the doctor’s office, and an easily customized special offer. The impact on those who’ve received the forwarded, visually appealing graphic would provide powerful advertising for the clinic.

So I built this thing, filed patents and tested it. And guess what else happened. In Beta Testing all of the above conditions were met, and more. The big surprise was how many patients posted this graphic image on Facebook, and did so while still in the doctor’s office! Imagine the impact of your office information marketed by your patients at no cost to you? With the average person having 120 Facebook friends 5,9, the value in terms of marketing alone is quite significant.

The tool proved invaluable at screenings where not only did the patient walk away with an instant personalized message, but also knew exactly how to reach you to take advantage of the special offer embedded in the graphic. Even better, the doctor stored the prospective patient’s email address for instant follow-up and future email marketing.

The term “Viral Growth” is an understatement when it comes to the impact of these visual images flying around the internet. The biggest surprise of all is that each and every patient tested said, and without exception (after saying “Cool”, that is): “Now I can show my _______ why I need my Chiropractor.” It is unknown if this can get us beyond that 8% of the population we’re seeking. Considering the massive proliferation of Smartphones, it at least takes advantage of a new form of high-tech, low cost marketing with potentially powerful consequences.

Technology can be your best friend or worst enemy. By finding the best product and support for your needs, you will have a great partner in building your practice. Follow the simple guidelines above and you will enjoy all the advantages of technology without the stress.

1. Thom DH. Training physicians to increase patient trust. J Eval Clin Pract. 2000 Aug;6(3):245-53.
2. Betancourt JR. Cultural competence—marginal or mainstream movement? N Engl J Med. 2004;351(10):953-5.
3. Osborne H. In Other Words…Actions Can Speak as Clearly as Words. Boston Globe’s On Call Magazine. Jan/Feb 2006. www.healthliteracy.com/article.asp?PageID=3763 (accessed Mar 3, 2006).
4. Osborne H. In Other Words...Teaching with Pictures. Boston Globe’s On Call Magazine.  Nov 1999. www.healthliteracy.com/article.asp?PageID=3822 (accessed Mar 3, 2006).
5. Dunbar, R.I.M. (June 1992). "Neocortex size as a constraint on group size in primates". Journal of Human Evolution 22 (6): 469–493. doi:10.1016/0047-2484(92)90081-J
6. A Meta-Analytic Review of Surface Electromyography Among Persons With Low Back Pain and Normal, Healthy Controls. Geisser, Ranavaya, Haig, Roth, Zucker, Ambroz and Caruso published in the Journal of Pain, November 2005 p 711-726.
7. VAS Score Correlates with Static Surface EMG Signal Intensity in Chronic Spine Pain.  Ambroz, Alex MD,VA Medical Center, Martinsburg, WV Ambroz, Clara MD, MPH, Disability Evaluation Services, Martinsburg, WV Zucker, Robert  MD, MPH,VA Medical Center, Martinsburg, WV Benjamin, Eugene MD,VA Medical Center, Martinsburg, WV
8. Caruso, Marianne RN,VA Medical Center, Martinsburg, WV.  PAIN MEDICINE Volume 6, Number 2, 2005 p 28-29.
9. Marlow, Cameron:  “Maintained relationships on Facebook” 2009, March 9, www.facebook.com