My heart broke a bit when my normally attentive OB/GYN walked into the exam room with a tablet PC and barely looked up from the screen during my visit. Studies have shown that exam room computers have positive impacts on physician—patient interactions without significant negative effects on other areas, such as time available for 

. Integration of computers into the delivery of care improves patient satisfaction. However, even skilled physicians commonly display troubling behaviors, such as spending too much time looking at the computer monitor, typing while patients are talking about intimate concerns, reading silently from the monitor, using templates to lead interviewing rather than listening to patient narratives, and turning their backs to patients in spite of mobile computer monitors. 

Electronic medical records are a wonderful asset and can help prevent drug interactions and allergic reactions by automatically checking patient history. Many malpractice carriers offer physicians a discount for using one. Plus, physician users always have access to their patients’ records, a crucial factor when a patient is taken to an emergency room and cannot give a verbal history, or when a patient is traveling and enters a hospital or visits a different physician. There is also no need to worry about illegible notes and scrawled—and sometimes misread&mdash;prescriptions. Electronic medical records have the potential to bring a new level of care to patients while making physicians’ lives easier. So, how can you make the most of what technology has to off er and not compromise your patients?  

This is an obvious recommendation, but it is an important one. Until voice recognition improves dramatically, cost concerns will demand that physicians type their notes or enter them through templates. Your typing speed and accuracy will improve with time, and you’ll be grateful not to deal with your hand-scrawled notes.  

Integrate typing around your patients’ needs. 

Regardless of your note-taking style—whether you type during the visit, immediately afterward in the exam room, or later in your office&mdash;it is important to know when to push the computer screen away. Using an EMR may require a heightened recognition of sensitive psychosocial concerns. Patients need to have eye contact and feel connected to their physician.  

Templates are an excellent way to structure notes but can be disastrous when used to structure interviews with patients. Their closed-ended, question-and-answer format allows little room for patients’ narratives to evolve, a key task in patient-centered care. Don’t change your interviewing style to fit a template.  

Unless a physician reviews notes at the beginning of the day or in the hall before entering the exam room, there may be little chance to focus attention on the presenting patient until after entering the exam room. Try to listen to patient concerns before opening up the EMR to review the last visit’s notes. 

Keep your patients informed about what you are doing - as you’re doing it. 

If you sit silently looking for information on the computer—opening and closing windows or scrolling though text&mdash;you risk alienating your patients. Instead, try to keep talking as you go about the work of both searching for and entering data into the EMR. Let the patient know you are just making a notation or looking something up for them. 

Many patients like seeing their lab results and the charts and graphs that EMRs provide. However, even computer-savvy patients may find that their emotions override their ability to quickly grasp where to look. Use a finger, pen, or cursor to guide the patient’s gaze when discussing data viewed on the monitor. This is a great time for showing, for instance, a trend between rise in body weight and cholesterol to illustrate cause and effect. Patients will sometimes get the message more clearly when shown charts.  

We’ve all seen the movies with the doctor scribbling in silence. Instead, try saying things like “Would you mind if I typed while we speak?” or “May I show you what I’m doing?” when using an EMR to promote, rather than hinder, the physician— patient relationship.  

The reality is that even with the availability of mobile screens, many experienced clinicians still stare at the computer monitor. Remember that you are speaking to and caring for the patient, not the EMR. The EMR is an inanimate tool to aid patient care and it is the patients who deserve our primary attention. EMRs in the examination room are quickly becoming a reality. Paying attention to how we integrate our clinical styles with the use of this technology will ensure that they are used in ways that best fit the social, emotional, and medical needs of our patients.  

If you don’t mind a Web-based solution, 

 is an excellent, and free, EMR. The online system allows users to log on from anywhere at any time without installing special hardware or software. Providers can also easily manage patients, their schedules, and all of the communication between staff with Practice Fusion’s Practice Management service. The EMR was designed by physicians and allows users to build charts “your own way” with templates that cover more than 30 specialties, typing, drag-and-drop features, and dictation. Users also have the ability to write prescriptions and refills. Support staff will conduct training sessions over the phone as needed, and training videos are available online. Although the software is intuitive enough that not much training is needed, watching the videos will show features that may be missed otherwise. As a free service, PracticeFusion’s site comes with advertising, but it is unobtrusive and medically oriented. Those who find the presence of advertisements too intrusive can opt for the fee-based service without ads.  

An oncologist colleague of mine uses the 

, a suite of healthcare IT software solutions from GE Healthcare that includes software for independent physician practices, academic medical centers, hospitals, and large integrated delivery networks. The various modules perform practice management, revenue management, medical imaging, and other functions. Because my colleague is a poor typist, he delays his note taking until after the patient leaves the office. He does share flow sheets and graphs with his patients, as he states they love seeing the information presented this way.  

iPhone users can take advantage of numerous native applications in a variety of categories, including games, business, news, sports, health, reference, medical texts, travel, and now EMRs. Thanks to 

, users can now carry their office in a pocket with the $149 iChart program, the first complete handheld EMR system for the iPhone. iChart was designed to act as an electronic “personal medical assistant” and focuses on streamlining the daily “chart, bill and fill” routine of any healthcare provider. The convenience of having all your patient data in your pocket cannot be overstated. The program has an intuitive interface and is a pleasure to use.  

Track patients within hospital, clinic, or home-care settings. 

Write prescriptions with a built-in drug reference and drug interaction checking.

Track labs and studies with built-in lab menus.     

Write SOAP and procedure notes with built-in smart menus.

Sync data to an online data center for further editing and printing.  

Using custom notes or templates is essential to cut down on the amount of data that needs to be added with the keyboard—a tedious process, as anyone with an iPhone/iTouch will tell you. Writing prescriptions is also a pleasure on the HIPAA-compliant iChart, with the entire application and data stored on the iPhone encrypted and inaccessible by other applications on the device or attached to the device. All data transferred in and out of iChart via iChart Sync is encrypted using 128-bit SSL and proper authentication.  

, which allows you to run your office the way it runs today. It fits right into your office flow, with scheduling, messaging, reporting, and documentation of notes, phone calls, addenda, and more. The electronic chart is quite similar to the paper charts we are all used to. Clicking on the tabs at the top of the electronic chart brings users to the various sections (eg, demographics, summary sheet, prior visits, imported items, and account information) of a patient record. Amazing Charts is designed with consideration of a few critical points that are surprisingly overlooked by most EMRs on the market today. First, users can view all of a patient’s information on one page. When a patient’s chart is pulled, by default, it opens to the most recent encounter; that information is used as a starting point for the current visit. In this way, the patient chart is a progressive record. As items change, users change them in the note. Since most of us document the same review of systems, exams, etc, over and over again during the day, using prefabricated templates makes documenting this mundane information much easier. The included templates allow users to document common history and physical findings, or add/ edit templates with ease.  

If you are completely confused on how to start looking for an EMR, visit 

, which claims to have assisted more than 7,500 medical practices pick the most appropriate EMR software packages.  

Whatever EMR program or technology you decide to bring into the exam room, remember to stay engaged and focused on your patients. No one wants to look at the top of your head while you peck away at a keyboard. You can use the best of modern technology without shortchanging your patients.  

Dr. Tice is a psychiatrist with more than 20 years of clinical experience. She has authored dozens of health and technology articles, and specializes in online medicine and patient education.

Articles

Feature Articles

Technology and medicine are a wonderful combination, but not if the doctor hides behind it, a real concern in a world of EMRs and handheld medical devices.

Communication Breakdown: Technology in the Exam Room

Dean Heller, MD, President of VideoMD—an online library of physician-created, patient education videos&mdash;explains the benefits to both patients and physicians of 

How did the idea to create VideoMD arise? 

What need does it fulfill for practicing physicians? A number of colleagues and I realized that the audiences of our hospitalbased lectures always included quite a few patients. When asked why they attended, many said it’s because there’s not enough time during offi ce visits to talk about education. It dawned on us that, because of how busy doctors are, and because we’re always talking about procedures and results of tests while a patient is in our office, there’s just not enough time for full education on all disease processes. That was the initial basis of VideoMD; it’s a convenient way for doctors to help educate their own patients. 

The other impetus was that practitioners are faced with a media that misreports or gives a slanted perspective on health information, and it’s been a detriment to patient—physician relationships. A trial may come out and the data may not be that bad, but people may get distorted or incomplete information from the media and decide to not take a drug, or they may hear “this drug could be killing you.” It creates problems for doctors who get 30 calls about the same thing. So, rather than answer the same question 30 times a day, you can post a video online about that particular issue and refer patients to it.  

How would an interested physician get involved? 

The site is free to use. It takes just a minute to register online. The site is fully uploadable, just like YouTube. Doctors go online, register, and then make their own video. We’re trying to save doctors time in the offi ce and help educate patients. They don’t have to make expertly produced videos. We tell our users to produce it just as if they were talking to their patients in the offi ce; it can be with a hand camera or on a laptop or however they want to do it, and they can post it right to the site. All their videos are viewed on one page; a patient searches for the doctor by name, and then all of that doctor’s videos will show up on one page. We also have, for doctors who are camera shy and don’t want to do their own videos, some stock animated videos on multiple procedures—or they can just do audio with slides. With the animated videos, a doctor can put all the ones he or she wants on one page for their patients to view. Although they’re stock videos that patients could see elsewhere, it’s coming from their own doctor who has looked over the information, and it has their name on it.  

Why would physicians post a video to VideoMD as opposed to their own sites? 

The overwhelming majority of physicians don’t have websites. I actually don’t have a personal website for my practice. It’s just not a technology that’s easy for doctors to keep up, and the beauty of VideoMD for any individual doctor is that you can post your video and then we’re responsible for the site. We manage the site. For those who do have their own site with videos on them, we tell them, “If you’ve gone through what it takes to make a video, why not post it on both?” I think VideoMD is a way for doctors to contribute to the education of all patients. We give doctors the choice to post their videos as a “featured video” or only on their own page. If they chose it to be a featured video, we check the medical content, and if it’s good, we put it on the “Featured” pages, where it’s searchable by anyone by disease, condition, and keyword.  

What have been the experiences of physicians who use VideoMD? 

Doctors and patients have both been positive about it. We’ve signed up more than 1,000 doctors, a reasonable percentage of whom have posted videos. A number of doctors using the service are sending patients for any number of reasons, including general education and procedural information. For example, I’m a cardiologist, so I do catheterization. When someone’s coming in for that procedure, I say “go to my page on VideoMD and watch my video on heart catheterization.” That way, when I enter the room, they’ve received the basic education, making it that much easier for both of us to discuss the procedure.

Tech Sectors


Dean Heller, MD, President of VideoMD—an online library of physician-created, patient education videos—explains the benefits to both patients and physicians of www.videomd.com. 

Tech Sectors: Online Patient Education: Show, Don't Tell with Online Educational Videos

Remember in the 1960s Star Trek series when Dr. McCoy would pass his medical tricorder over a prostrate body to discover not only which species of alien had invaded the young ensign, but also how to expel the creature with a dose of medicine? McCoy’s tricorder combined both a universal diagnostic device and a medical information database of boundless proportions. Who could want anything more?  

That futuristic vision of point-of-care information technology is still a long way off, but the concept was a remarkably accurate prediction of where we are heading today. “Point-of-care” is an amorphous concept that changes depending on your point of view. For small medical practices, point-of-care generally means providing evidence-based medical advice to physicians as they are diagnosing and developing their plan of action. Information sources range from reference materials to patient records to drug reference tools and so on.  

Until the 1990s, many primary care practices relied on textbooks, and later, referenceable CD-ROMs. But as we were forced to see more patients in a shorter amount of time to make ends meet, we moved to more concise, pocket-sized guides that summarized the important facts. Those guides are now being supplanted by applications and databases that run on tablets, handhelds (like PDAs and PalmTreos), and increasingly on smartphones (like the BlackBerry, iPhone, and the new G1 running on Google’s open mobile phone platform called Android).  

There are three different models for point-of-care information delivery: static, push, and pull. With one of the most popular mobile point-of-care applications ever, 

—a free drug and formulary reference&mdash;users download a fixed database that resides on their device. The database is not updated until the user downloads a new version. On the other hand, 

 (5MCC) Online provides instant access to the essentials of 700+ medical conditions. Users “pull” information, including dermatology images, videos of medical procedures, AAFP patient handouts, and more. By contrast, Skyscape’s MedAlert “pushes” up-to-the-minute clinical information, such as drug updates, journal summaries, and clinical trial results by specialty, to a cell phone, smartphone, PDA, or desktop.  

With the addition of wireless networking technology, healthcare providers can get real-time, point-of-care information on differential diagnosis, testing, and treatment options as they see the patient and come up with the plan. The power to hop onto Google and search for any subject puts a virtually unlimited source of information right at our fingertips, although sorting through the data to differentiate the wheat from the chaff remains the most difficult aspect of such a plethora of information.  

Of course, short of simply knowing the information from our extensive training and continuing medical education, the most logical way to be presented with this medical data is through our electronic health record during the patient encounter. This is the actual point-of-care, and having evidence-based information pop up in one’s EHR at that moment would be remarkable.  

The EHR could intelligently and proactively retrieve pertinent information as demographics, symptoms, vital signs, and other relevant data is entered into the patient’s chart. This data could be analyzed behind the scenes, patterns could be recognized, and recommendations presented to the physician.  

As we gaze ever further into the future, perhaps to when intergalactic space travel or beaming ourselves from room-to-room is actually possible, physicians may someday have chips containing all of the known information about health and the medical sciences embedded into their brains. Until that time arrives—may you live long and prosper.   

What point-of-care references and diagnostic aids do you use? Are you satisfi ed with the products currently on the market? 

Dr. Bertman is Physician Editor-in-Chief of 

. He is a Clinical Assistant Professor of Family Medicine at Brown University and president of 

, a leading developer of EHR software. He is also the founder and president of 

, a consumer website focusing on personal medical topics. He is in private practice in Hope Valley, RI.

Columns

Remember in the 1960s Star Trek series when Dr. McCoy would pass his medical tricorder over a prostrate body to discover not only which species of alien had invaded the young ensign, but also how to expel the creature with a dose of medicine? 

Tech Talk: Point-of-Care Information

 is a social networking site that is all about connecting physicians to each other and to information that’s tailored to physicians in three areas: clinical, business, and personal. Our focus is not just clinical; that’s because we see doctors as human beings first and doctors second. Our site has broader implications for enhancing a physician’s life, as opposed to enhancing just his or her ability to either diagnose or treat a specific condition. 

I thought that no one had really gotten it right when it came to developing an online place for physicians, much like a virtual physician’s lounge, where they could be comfortable with each other and discuss not just clinical issues, but business, personal, and other interests, regardless of whether they were clinically oriented. All of this was very exciting to me because I have a father, cousins, and uncles who are all physicians, and so I have an intimate personal and familial interest in enhancing physicians’ lives. I understand that they have needs that go well beyond clinical interests. 

3 How many physicians have joined so far? 

We launched the site at the end of June 2008, and there are now roughly 3,000 physicians who have joined, so it’s growing pretty rapidly. We expect to have well over 10,000 physicians before the end of this calendar year and possibly much higher. 

4 How does iMedExchange diff er from other physician social networking sites? 

Many of the sites out there, such as Sermo, are clinically oriented, and not business- and personal-oriented. Our view of the physician’s interest is much broader and more comprehensive. Our business model is also very different than Sermo’s, whose interest is in aggregating the information from the posts and the comments the physicians post on their site and selling that information to both Wall Street and to pharmaceutical firms. We don’t do that. The information on our site is confidential, both on an individual and collective basis. We make money to support the site through online advertising, much like Facebook or LinkedIn. We have created a place where advertisers can focus on physicians, and have physicians receive content targeted and tailored specifically for them. 

5 What features are unique to iMedExchange?

In addition to a comprehensive view of physicians’ interests, we have partners in an area of the site called “Resource Centers.” These partners include HealthDay, which provides summaries of 26 articles per day by specialty, as well as talks from the 300 conferences each year. We also have the medical law letter, which provides interesting information on malpractice and other medically related legal issues. We have a fi nancial resource center, with partners like the Abernathy Group, that manages money for physicians in New York. In the personal area, we started out with the wine merchant Ambrosia, which provides interesting information on how to choose wines. In fact, there’s a widget on the page that allows users to do wine and food pairing, so you can say “tonight I’m going to have fi sh,” and it will give you lots of wine suggestions depending on the type of fi sh that you’re serving. 

We also have discussion groups and forums so that physicians can again talk to each other on topics unrelated to the practice of medicine if they so choose. We have a lot to offer in terms of content that is specially tailored to interests of physicians. We spent an enormous amount of time and effort asking physicians what they wanted in terms of an online social networking site. In fact, during the nine months prior to our launch in June, we had 225 physician advisors who owned a small amount of equity in iMedExchange giving us regular feedback on the site, and we continue to ask our members and our advisors for their thoughts on how we should continue to enhance iMedExchange. You know our site is very much in the interest of physicians when more than 90% of our investors are also physicians.

Pulse

Clifford Chirls discusses the features of the new social networking site iMedExchange and explains how it diff ers from other social networking
resources for physicians.

5 Questions... with Cliff Chirls, President and COO of iMedExchange

Electronic prescribing is rapidly gaining support from a diverse array of healthcare organizations, government agencies, and technology corporations, including 

; the Department of Defense; the Institute of Medicine; 

; as well as Dell, Microsoft, Sprint, Fujitsu, and 

. Although it may seem as though everyone loves electronic prescribing, there are a few notable exceptions, especially within the physician community. 

, accounting for roughly 10% of healthcare costs, or about $286.5 billion. Forrester Research has estimated 900 million prescription-related phone calls per year, with 30% requiring callbacks to physician offi ces to clarify prescriptions (Forrester Research, 2002; Medco Health, via ePharmaceuticals). In addition, pharmacists make 500 million calls to physician offices annually to get approval for expired refills. The Institute for Safe Medical Practices estimates up to 3 million of the 8.8 million adverse drug events that occur annually are preventable. Preventable errors include unclear telephone orders, ambiguous orders, illegible handwriting, incorrect dosages, and unclear abbreviations. Electronic prescribing has been heralded as a technology that will improve effi ciency, reduce these errors, and decrease costs. But is everyone on board? 

Increased electronic prescribing will benefi t the electronic prescribing vendors, as they earn revenue by selling software to physicians. E-prescribing vendors include standalone e-prescribing software, as well as software integrated into EHRs. Refer to the table for a list of standalone products and vendors off ering EHRs with integrated e-prescribing capabilities, or standalone e-prescribing software, along with Web addresses for each. 

 product is Web-based and currently available at no charge to physicians in the US. Cost of other standalone or integrated e-prescribing programs varies from $20 to $80 per physician, per month. 

Capabilities of e-prescribing software vary by vendor. SureScripts has identified five core features: e-prescribing (the ability to transmit prescriptions electronically to pharmacies); eRefills (the ability to receive refill requests from pharmacies electronically); Rx history (the ability to access a patient’s prescription history); eligibility (the ability to determine a patient’s prescription benefits); and formulary (the ability to determine the cost of drugs for each patient depending on the benefits plan). SureScripts has currently certified six products as GoldRx, meaning that they are capable of each of these functions. The vendors are Allscripts, eRx, DrFirst, eClinicalworks, NextGen, and Networking Technologies (vendor for RxNT). 

CMS has been a strong advocate for e-prescribing, and as a result of legislation passed in July 2008, beginning January 1, 2009, doctors will get a 

, continuing into 2010. The bonus drops to 1% in 2011 and 2012, and then to 0.5% in 2013. CMS believes that e-prescribing will increase generic drug prescribing, reduce drug costs, reduce adverse drug events, and improve effi ciency of the healthcare system. 

CMS has defined e-prescribing as “the transmission, using electronic media, of prescription or prescription-related information between a prescriber, dispenser, pharmacy benefi t manager, or health plan, either directly or through an intermediary, including an e-prescribing network. E-prescribing includes, but is not limited to, 

two-way transmissions between the point of care and the dispenser

Insurers and third-party payers love e-prescribing

Major insurers, in my experience, tend to believe e-prescribing will reduce adverse drug reactions and decrease drug costs by encouraging better compliance with drug formularies and more use of generics. 

 estimates that it will save $250 per doctor per month with e-prescribing, due to increased use of generics. Anthem BCBS of New Hampshire has announced it will provide 

 to every physician in the state. BCBS of Massachusetts estimated that it saves $20 to $25 per prescription when an e-prescribing prompt causes a physician to switch his drug choice to a 

. Henry Ford Medical Group found that e-prescribing increased its use of generic drugs by 7.3% and saved the plan 

Consumers may benefit from faster transmission of their prescriptions to pharmacies and not having to wait for prescriptions to be filled. However, patients may experience a hassle factor if their prescriptions are sent electronically and there is no record of the prescription when they arrive at the pharmacy. This may require re-contacting the physician to call in the prescription. Currently, Schedule II medications (most narcotics and sedatives) cannot be transmitted electronically and must either be called in by the physician or prescribed on paper. Consumers are the theoretical benefactors of e-prescribing if the prescriptions are more legible (fewer errors), if physicians adhere to the benefit manager’s formulary (lower costs), and if physicians utilize decision support (fewer drug reactions and allergic reactions). In a survey by the Commonwealth Fund, 71% of consumers 

 over traditional paper-based prescriptions. 

Some, but not all, physicians love e-prescribing 

Physicians have been slow to adopt e-prescribing. Currently, only about 

6% of office-based physicians are e-prescribing

. Further, physicians e-prescribe only 2% of the 1.47 billion prescriptions that are eligible for 

. Reasons cited for this include hardware costs, software costs, and training costs. In addition, it has been said that old habits die hard, and physicians have been reluctant to change their workfl ows in order to accommodate e-prescribing. Many observers have noted that it is hard for an electronic prescription to beat the convenience of a pen and prescription pad. The current ban on e-prescribing of controlled substances is another barrier to physician adoption of e-prescribing. Physicians can benefi t by receiving refi ll requests electronically instead of by phone or fax. This can significantly increase office efficiency. A Brown University study suggested that e-prescribing can cut physician time spent on renewals from 35 to 17 minutes per day and staff time spent on renewals from 

. Although initial prescriptions are probably faster with pen and pad, refi lls can be performed faster electronically than by paper methods. 

Physicians can improve patient safety by using e-prescribing with decision support that identifi es allergies and drug interactions. Further benefi ts of e-prescribing are gained when the e-prescribing is integrated with an EHR so that the e-prescribing process automatically assists in maintaining an accurate drug list and assists with the medication reconciliation process. 

Pharmacy Health Information Exchange (PHIE) loves e-prescribing

In 2008, SureScripts merged with Rx Hub to form (you guessed it) 

. This entity provides the electronic infrastructure for e-prescribing and connects physicians, pharmacies, and prescription benefit managers (PBMs) together. Once on this network, physicians can transmit prescriptions to pharmacies, pharmacies can request refill authorizations from physicians, and pharmacies can access formulary and benefit information from PBMs. Some e-prescribing software allows physicians to access formulary information about their patients as well as prescription histories from PBMs through the PHIE. The PHIE earns revenue by charging pharmacies for transactions (either initial prescriptions or refill requests). 

Most large pharmacies love e-prescribing 

Pharmacies generally favor e-prescribing, as is seen in the 2001 founding of the SureScripts Electronic Prescribing Network, which makes e-prescribing possible, by the National Association of Chain Drug Stores and the National Community Pharmacists Association. Currently, more than 70% of the pharmacies in the US are connected to the 

 and can receive e-prescriptions electronically (most of the remaining 30% can be reached by fax). E-prescribing reduces time spent faxing or calling physicians. Some pharmacies may be able to interface the SureScripts network directly to their in-house computers, reducing time and labor spent re-entering prescription information. Dispensing errors due to illegible handwriting or data entry errors can be reduced. Patient waiting time can be reduced for prescriptions received electronically before the patient arrives at the pharmacy. 

On the down side, pharmacies must pay a transaction fee for each refi ll request sent out, as well as for each prescription received. However, labor savings on these transactions should exceed transaction costs. 

Not all pharmaceutical manufacturers love e-prescribing 

Pharmaceutical manufacturers have mixed feelings about e-prescribing. They view positively the eff ects of e-prescribing on patient compliance with prescriptions. However, they have expressed concern that e-prescribing could push more prescribers to substitute generic medications for brand name medications. 

Physicians pay software vendors for the e-prescribing software they use. Free e-prescribing software is available from the NEPSI (eRx Now). Increasingly, both CMS and other payers are realizing that physicians will need fi nancial incentives to switch to e-prescribing, as noted above. Private insurance plans are increasingly willing to subsidize the cost of the software used by physicians. Pharmacies that either receive e-prescriptions or send refill requests electronically to physicians must pay a per-prescription transaction fee. This transaction fee paid by the pharmacies is split between the software vendor and the SureScripts network. 

Dr. Hier is a professor of neurology and rehabilitation at the University of Illinois at Chicago, and the outgoing Physician Editor-in-Chief of 

Electronic prescribing is rapidly gaining support from a diverse array of healthcare organizations, government agencies, and technology corporations.

Everyone Loves e-Prescribing! Right?

These three physicians decided to take the bull by the horns and start their own EHR companies. Why did they do it? Each wanted to create software to fit their own needs, but soon realized that other physicians were struggling with the same challenges and would benefi t from this new technology. 

Randall Oates, MD Founder, SOAPware, Inc. 

For Randall Oates, MD, the founder of SOAPware, Inc, the development of a commercial EHR system was incidental. The EHR system that would become SOAPware started during Oates’s third year as a family physician in Springdale, AR. “I can vividly remember an evening during the flu season of 1987,” says Oates. “It was around 7:00pm, and I had seen around 70 patients during the day. When I sat down at my desk, I had 70 charts waiting for me, and I found myself writing the same sentences over and over and over. I had always been an Apple/Mac enthusiast, so I decided to use my word processing program to copy and paste notes from each patient, then change what was different.” Oates spent parts of the next two years “fiddling around with Hypercard; by 1989, I was printing out my prescriptions and doing all my chart work electronically.” 

Oates showed his ad hoc solution to colleagues at the 1990 AAFP Assembly Scientific Exhibit and observed interest in his adaptable and user-friendly program. “By the end of 1990, there were 30 doctors using my prototype, and I had people calling me constantly with questions.” Oates ceased distributing the program himself at that point. However, among the fans of Oates’ product was Greg Lose, an Apple sales representative at the University of Arkansas. “He was an enthusiast, and in 1992, I hired him and said, ‘If you can turn this into a commercial product, great.’ I haven’t written a line of code since he joined; he’s now the CIO of the company.” In 1994, now-CEO David Powell joined to help expand the business, which was incorporated as SOAPware, Inc. the following year. 

Throughout the evolution of SOAPware, from the personal tool of one physician to a commercial product, Oates’s watchword has remained the same: flexibility. Oates notes that some systems utilize menus and structured entry of information, which produces granular data suitable to drive outcomes research but limits choices; others allow for free-text entry. “Within any part of the SOAPware chart,” he says, “any or all of the information entered can be either free text or structured, granular, coded data. Out of the box, you can start with a completely freetext chart—the electronic equivalent of a paper chart, in fact&mdash;and then, as your facility with the program increases, gradually switch over to customized, structured entry throughout.” 

Flexibility extends beyond data entry, as well. “Doctors want an EHR to be as fl exible and versatile as a paper chart,” says Oates. “When you have a paper chart, you can add a photo, imaging result, or other document to any part of the chart. Similarly, in SOAPware, any kind of document, including audio and video fi les, can be dragged and dropped into any section of the medical record.” Meanwhile, users can enter data with digital “ink” using a tablet computer or via speech recognition, in addition to standard entry using a keyboard. 

The visual interface of SOAPware is likewise quite flexible; users can view charts and other records on an iPhone, on multiple large monitors, or any way in between. The interface itself can also be customized by the user. “The product should look different for each user,” says Oates, “and it shouldn’t force anyone into a linear workfl ow. It’s common for a program to refuse to allow a doctor to enter an examination fi nding until all vital signs have been entered; we try to avoid that sort of linear approach.” 

Another priority has been bundling an effective electronic prescribing application. “The problem with e-prescribing is that it’s ineffi cient, involving lots of duplicate data entries,” says Oates. “But starting on January 1 of next year, there will be a 2% bonus from Medicare for doctors that use electronic prescribing. We’ve put basic e-prescribing into even our low-end product, which has simplifi ed record-keeping, allowing demographics to be transferred from the other parts of the system rather than keyed in separately, for example.” 

At present, SOAPware is the least expensive CCHIT-certifi ed EHR, starting at $2000 for a certifi ed system. The system currently has approximately 30,000—40,000 users, spread among 5,000–10,000 sites. “I’ve gotten so involved in the software, I’ve been seeing very few patients,” notes Oates. “I hope to get back to regular practice once we get through the current product release cycle. For now, we’re trying to create a billing application to make SOAPware into a complete turnkey solution.” The goal, he says, is to make the system simple, flexible, and well-supported. “We want a new doctor to be able to come in, watch an hour or two of instructional video, and go out and start working.”

Andrew Ury, MD Chief Medical Officer, Practice Partner 

"When we first started out, the first reaction from most physicians was not ‘I like this, I don’t like that, let’s adjust the system,’” says Andrew Ury, MD, the Chief Medical Officer for Practice Partner. “The first reaction from most physicians was ‘you can’t create an electronic health record system; it’s not possible.’” For Ury, whose interest in computers and computing dates back to high school, the transition to electronic management of patient records was comfortable and natural. For many of his colleagues in the comparatively technophobic early 1980s, the change was nothing short of a complete cultural transformation, a fact that made Ury’s ambition—the development of the fi rst-ever commercial EHR&mdash;a considerable challenge. 

The Stanford-educated Ury completed his residency at the University of Washington in Seattle in 1981. He began work as a doctor, but the increasing popularity of the personal computer (PC) and his own inclination toward adapting his practice to available technology—Ury was typing, rather than handwriting, practice notes long before he developed a formal EHR system&mdash;opened up additional possibilities. 

“PCs created a signifi cant technological opportunity,” says Ury. “Most medical advances affect only a small percentage of your patients, even if you’re a specialist and especially if you’re a family physician. I felt that EHRs could be a transforming tool, to increase the quality of care we provide to all patients.” Ury founded Physician Microsystems, the company that would become Practice Partner, out of his home in 1983; the company’s roster initially included just Ury and one parttime employee, but that expanded to four by 1984. “I was working as a doctor full-time, and then on Wednesdays I’d come home and work for Physician Microsystems,” he says. “In the middle of 1984, my wife came home one day and found programmers in the basement; she said it was time to move out. So we moved out.” 

Ury released his first products, billing/scheduling applications, in 1985; medical records went beta in 1986 and live in 1987. The initial record was designed to be very dictationfriendly, and was able to build a patient chart from a loaded transcription. Over time, voice and handwriting recognition were added to the system. “Although I always intended Practice Partner to be a commercial system first and foremost,” says Ury, “I did use it in my own practice. I found from the beginning that it helped me and my staff increase efficiency and save time while also improving quality of care. It’s one of the very few products that can accomplish both of these things.” 

By 2006, thousands of practices were using Practice Partner to maintain records and accomplish related tasks. About 18 months ago, the company was sold to 

, a move that accelerated the system’s growth and visibility. 

Today, 25 years removed from the founding of Practice Partner, Ury continues to ask how technology can be leveraged to increase efficiency and improve quality of care. “We founded the Practice Partner Research Network about 10 years ago; today, around 130—140 individual practices are members,” says Ury. The Network utilizes periodic extracts of data from member practices—all of whom employ Practice Partner EHR software&mdash;to analyze the cost and return on investment associated with the EHR, and to explore ways that systems like Practice Partner can produce ever-more desirable outcomes. Visit 

Jonathan Bertman, MD, FAACP President, Amazing Charts Clinical Asst. Professor of Family Medicine, Brown University 

Jonathan Bertman, MD, is not your everyday interviewee. This is clear from his first answer to the first question: “I realized how technology could improve life the fi rst time I picked up a television clicker,” he says. “I thought, ‘I don’t have to get off the couch! This is brilliant!’” He brings to the EHR industry the perspective of a relative newcomer—Bertman only started his own family practice in 2001&mdash;and he is characteristically direct about the problems he sees in the industry (and the solutions he proposes). 

“Before I started my own practice,” Bertman says, “I was in another practice that used an EHR. Th e system we used there had all sorts of bells and whistles, but because of those bells and whistles—and because of a design that required many clicks to document every finding&mdash;all seven docs in the practice were just entering every fi nding in a miscellaneous text window. It kind of defeated the purpose of the system.” 

When Bertman struck out on his own and began shopping around for an EHR system, he found that this problem, along with several others, was endemic to most available systems. “Let’s say you want to document an ear infection,” he explains. “So with a typical EHR system, you open the chart. Then you open the physical exam window. Then you click on a button that says ‘Head/ENT,’ then you click on ‘Ear,’ then ‘right side,’ and then you click on your diagnosis.” The process, Bertman maintains, makes it tedious and diffi cult to document even the briefest finding. “These systems are so focused on getting granular data that they’re actually extending the patient encounter. This might be reasonable if you see four or five patients a day, but when we’re being forced to see more and more patients to make the same money, it just doesn’t work.” 

In his search to find a workable EHR system for his own practice, Bertman identifi ed other problems with the status quo, as well. “EHRs were uniformly very diffi cult to learn, and atrociously priced,” he says. What’s more, most systems off ered no way to test out a program before it was purchased, making any potential purchase a tremendous risk. 

Faced with a host of EHRs that wouldn’t work for him, Bertman hit upon a simple solution: he built his own. 

“I figured, this isn’t that hard,” says Bertman of the origins of Amazing Charts. “I essentially wanted to use templates to document the things I write over and over again, save them to a database, and retrieve them when I see the same patient again.” Bertman learned how to use 

, and developed within six months a very simple record-keeping application that worked well for his practice. “My practice worked like every other practice,” he says, “so I thought, ‘I’ll put it online; if people like it, they can pay me a little bit of money.’” 

So he did. At first, there was no response. Bertman continued to improve the system, to make it more functional for his own purposes, and put improved versions online. He allowed users to download a free trial. “Finally,” he says, “a couple of people downloaded it and tried it out and liked it. In 2001, one of those people did an interview with AMA News, and enough people read that, and things went from there.” 

Amazing Charts, the product of Bertman’s refi nements, is a fairly simple product designed to be effi cient. “To document an ear infection, you open the entire chart in one window,” he says. “You right click in the window for the physical exam, delete the text that says ‘TMs normal,’ and put your diagnosis in its place. You can then save it as a new template.” 

Today, Bertman considers Amazing Charts to be about 75% complete; it currently features scheduling and messaging applications, but practice management and billing functionality is still incomplete. But physicians seem to be responding; approximately 70 new practices a month buy the system, which costs only about $1,000 following a free three-month trial. Meanwhile, Bertman continues to tailor Amazing Charts to the needs of the user: “Feedback comes directly to me, and I adjust it. That concept—the ability to reach me personally and tell me what they want&mdash;really resonates with people,” Bertman says. “Once we become like a big business, we lose our edge.” 

Frank Ferrara is a freelance healthcare writer and former 

Cover Story

These three physicians decided to take the bull by the horns and start their own EHR companies. 

November 2008

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