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Recently, I was able to participate in a meeting held by the Office of the National Coordinator (ONC) in an attempt to categorize the various features offered by different electronic health record (EHR) systems. The idea was to create a quick and easy way for doctors and other EHR purchasers to be able to compare the products on the market today—not unlike a Consumer Reports-type spreadsheet. Some favored a list of modules and features, as if physicians were buying a washing machine. But unlike a washing machine, which only needs to do one thing—get clothes clean—EHR systems need to do many things at once. Moreover, features in an EHR system that sound very similar like e-prescribing and internal messaging may perform quite differently depending on the system. It’s not enough that the feature exists. It also has to be efficient and easy to use or it might as well not be there at all.

Perhaps having a list of features is necessary to differentiate among EHR systems, but it is certainly not sufficient in guiding a doctor’s decision to buy one. For that, you need to be able to measure value. Value can be measured in terms of increased productivity, time saved, and improved health care quality, among other variables. In assessing a product’s value, there are six questions to consider:

  • Is it easy to use?
  • What’s the average time it takes a user to complete a note?
  • How much extra staff time is spent on regulatory and compliance issues (box checking)?
  • Are customer needs and wants for the product taken into account?
  • Does the company continue to innovate beyond industry standards?
  • Does the customer get access to individual and collective data?

Ease of use

Some systems are easier to use than others. Systems that have great user experience remove the extra clutter of options on the screens and only show the user what they need to see when they need to see it. Navigation becomes second nature, so that physicians can focus on treating their patients instead of spending countless minutes looking for what they need on the screen.

Time to complete a note

Some systems are faster than others. Time is money and productivity depends on being able to document routine notes in under a minute. If a system requires five to 10 minutes to write a note, that adds up to numerous patients not seen in a day or hours spent charting at home after the day is supposed to be done.

Compliance time sink

In the shift to value-based medicine, there is an increasing documentation burden on physicians to capture quality measures. From 2014 to 2015 dermatologists had to report on nine PQRS measures instead of just three. Thus, a high-value EHR system should collect these data automatically in the course of documentation. If the physician has to answer a barrage of questions following the patient encounter in order to collect this information, that is precious time wasted.

Getting what you ask for

Since physicians spend eight to 10 hours a day with their EHR system, they would like input into how their software is developed. Many EHR companies are trying to please many masters with a single product—from an internal medicine doctor to a trauma surgeon. Whose feature requests are honored, if any? In order for a product to provide value to its physician users, it is vital that a company be nimble enough to accommodate specialty-specific requests. For example, dermatologists have for years wanted an integrated practice management system that offers friendly ways to configure fee schedules for all insurance types, more intuitive scheduling bells and whistles including scheduling by resource and workflow tools to room patients more effectively. In addition, some software includes a dermatopathology module enabling dermatopathologists to benefit from direct integration with the health record, having access to all the clinical information while ordering physicians automatically get their results, improving quality of care and making sure no diagnosis slips through the cracks. If a needed feature cannot be developed by an EHR system, the purchased product quickly becomes obsolete. It is imperative that any rating system take EHR flexibility and company responsiveness into account.

Innovate beyond industry standards: Telehealth

Doctors do not simply do what CMS or private insurance dictates. While we must be mindful of insurance regulations, we ultimately do what is best for the patient. Likewise, EHR vendors cannot merely follow government guidelines but must be continually innovating for their customers. For example, payers are behind in telemedicine reimbursement, but that doesn’t mean dermatologists or their EHR systems should be. A direct-to-patient mobile telemedicine app can integrate seamlessly with the health record, and established patients can download the app on their Android or iOS device, take a photo of their rash and forward it on to their dermatologists for evaluation and management. Since dermatologists have access to prior treatments, allergies, and comorbidities on their device at the point of care, the technology can help prevent medical errors. Dermatologists also improve care by providing timely access to their patients when their rashes are still active and can be compensated for it, improving their bottom line as well. Perhaps in the future, this will be a feature that all EHR systems are mandated to have, but today it is cutting edge technology that few possess the ability to deliver well.

Access to actionable data

As healthcare shifts from fee-for-service to value-based payments, physicians will need more visibility into where they fall in the spectrum of quality and cost. A new “Merit-based Incentive Payment System” will take affect in 2019, using data from 2017 to adjust Medicare payments upward or downward to physicians by up to four percent in 2019 rising to nine percent in 2022 (See figure). The challenge facing most vendors and providers is that Medicare PQRS performance and cost utilization benchmark data will, at that point, be two years old. As a result, providers will not have the timely feedback they need to make course corrections in improving quality or reducing costs, ultimately hurting their bottom line. EHR systems that can provide users today with up-to-date benchmarking on where each provider falls on the spectrum of quality measure performance and cost utilization will be a critical to the future financial health of the practice. Because this data is to be collected in less than one year, providing this information to physicians and doing it well is one of the most important issues facing EHR purchasers today.

While the answers to all of these questions determine if a physician should buy a particular EHR system, what happens if you learn the EHR system you already purchased or the one purchased by your organization years ago does not provide you with a high-value product? Luckily, switching costs continue to decrease as vendors invest in being able to convert providers off of legacy systems. Thus, no one should be plagued with a low-value EHR system. Perhaps the ONC will develop a value-based comparison tool in the coming months, but even if they do not, purchasers will be able to create their own by merely asking the right questions. n

Michael Sherling, MD is the co-founder and chief medical officer of Modernizing Medicine and a practicing dermatologist in Lake Worth, FL.

To learn how features of Modernizing Medicine address some of the concerns discussed above, including an integrated practice management system, visit

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