As you set up your practice, an integral part of your business operations may involve purchasing and implementing a computer system. Even if you are not very comfortable with computer systems, many are easy enough to use with adequate training. Consider that more and more practices are adopting EHRs and with more regulations such as Health Insurance Portability and Accountability Act (HIPAA) and electronic prescribing, a computer system may be inevitable in the future of health care.
There are several levels of how a computer system can be integrated into your practice.
The cost is determined by what level of involvement you desire. If you are just setting up your practice, it may be easier to start with an EHR rather than trying to convert your practice at a later time. However, it is significantly more expensive and time consuming to implement an EHR system as you start your practice. Some hospital systems are helping practices by offsetting expenses with a system that is compatible with the hospital’s system. This would be worth investigating if it is true in your area.
Steps for Choosing a Computer System
1. Determine to what extent you would like to use a computer in your practice.
2. Perform a financial analysis to see what is affordable and what your return on investment (ROI) would be. Investigate options such as hospital system financial support. Contact banks or lenders in your area if financing will be needed.
3. Research vendors and systems.
4. Meet with several vendors for product demonstrations. If possible, visit pediatric practices that are currently using the system.
5. Contact SOAPM and the AAP Council on Clinical Information Technology (COCIT), and review the publications and advisories on PMO and the COCIT review of available systems (additional information follows).
6. As you refine your search, make sure you understand the initial costs of acquisition and implementation, as well as any ongoing maintenance costs.
7. Once a decision is made, define an implementation and a transition strategy.
Information is available through SOAPM, COCIT, and PMO to help you plan these processes (additional information follows).
8. Schedule installation of required wiring, networks, telephony, hardware, and software. This is especially important if you are constructing a new office and can install the necessary wiring during the building process.
9. Plan and carry out implementation of products with all necessary training and customization.
How Will the System Be Used?
When looking to purchase a computer system for your practice, the first question that you must answer is, “For what will I be using the system?” The answer will determine the type of system you need, the investment that will be required, and the timeline for installation.
The simplest use of computers in an office is like what you would do at home—word processing, spreadsheets, simple accounting, and possibly Internet access.
The next step would be to use a computer system to run PMS. This software typically would allow you to use a computer for appointment scheduling, billing, and storing patient demographics.
The final step for using a computer in a pediatric office is for EHRs. This is essentially patient charting completely on the computer.
The cost of and time for installation increases as you proceed from stand-alone computer to full-scale PMS and EHR. Sample costs are listed in the Table.
Electronic Cost Comparison
Single-User Computer
PMS PMS and EHR
Software cost $500–$1,000 $1,000–
$5,000/FTE
$1,000–
$50,000/FTE Hardware cost $2,000 desktop $1,000–$2,500 per
desktop/laptop/tablet
$2,000–$4,000 per server
Additional for printers, scanners, modems, networking equipment Implementation cost $75–$150 per hour of training/implementation (usually some
hours included in purchase price)
Average 35 h for implementation for EHR
Time frame 2 wk–1 mo 3 mo 3–6 mo
Implementation difficulty
Simple Moderate Complex
Maintenance/support (yearly)
None–$100 $500–$1,000/FTE $1,000–
$4,000/FTE PMS, practice management software; EHR, electronic health record; FTE, full-time equivalent.
Financial Analysis
Dependent on which system you buy, there is usually a significant up-front expense.
However, it is extremely important to investigate what the recurrent expenses include.
Hardware and software maintenance can be very costly and are a necessary burden to keep your business running. Additionally, hidden expenses for upgrades, support, and additional training should be outlined before you sign any contracts.
Benefits of an Electronic Health Record
Why go electronic if it costs so much? There are many benefits to being on a computer system. You gain accuracy, efficiency of charge capture and billing, legibility, and accessibility. Improvement of coding is more easily achievable with electronic capture.
Increased legibility and better documentation result in improved patient care and decreased medical liability. Depending on your practice, you may see improved work flow. Locating and pulling charts are no longer an issue with EHRs. This results in more rapid processing of refills and forms. There are no longer concerns about lost charts. If you do internal billing, you can take advantage of electronic filing and posting, which can significantly reduce your accounts receivable. These are some of the most tangible
benefits to being electronic. While not helpful for most pediatricians, there are also significant savings of transcription costs. With these benefits, it generally takes 2 to 3 years to get an ROI. The other important point is that it is far easier and less costly to start a practice with information technology (IT) in place than to implement at a later date.
The AAP SOAPM e-mail list provides pros and cons from various members. Visit http://practice.aap.org/content.aspx?aID=1971 to view comments. Also see the article titled “Electronic Health Records: Should I Convert My Office to Paperless?”
There are many resources to help you to calculate your ROI available from Physicians Practice and the Medical Group Management Association. Because you are just starting in practice, you may need to talk to other practitioners to get a better feel for work flow, time costs, and expenses.
Evaluating Software
Once you’ve determined the computer needs of your practice, the next step is to evaluate vendors of PMS and EHR software. One of the best ways to evaluate software is to ask around in your local community or the AAP to see what other pediatric practices are using. The Certification Commission for Healthcare Information Technology is an organization that certifies health care software that meets certain standards. The AAP COCIT Web site (www.aapcocit.org) also has many valuable resources.
The AAP offers answers to some frequently asked questions as well as reviews from fellow AAP members.
• “Electronic Medical Record FAQ” (www.aapcocit.org/EHRfaqs.pdf)
• EHR reviews (www.aapcocit.org/EHR/readreviews.php)
• “Implementing an Electronic Health Record” (www.practice.aap.org/ehr.aspx) There are some features of the PMS and EHR that you should investigate that are unique to pediatrics.
Practice Management Software
• Is it capable of family billing using head of household?
• How are siblings linked in the system? If you update one child’s address, will all the siblings be updated?
• Can you put alerts on the account for special situations (eg, child with special needs requires extra time for appointments)?
• Can you design appointment templates that can specify different types of appointments (eg, well-child appointments vs sick-child appointments)?
• Can you easily move appointments from one physician’s schedule to another?
• Is it capable of running queries so that you can do studies or single out patients within certain demographics (eg, to determine your payer mix or how you are being paid for certain procedure codes)?
Electronic Health Records
• Does it have growth charts? Does it have specialized growth charts (eg, preemie charts, Down syndrome charts)?
• Can you create forms (eg, school)?
• How well does it handle immunization records? Can you add new ones (as vaccines are developed)? How does it handle reminders if a child is due for vaccines? Can it communicate with statewide immunization registries?
• How do you enter notes? Via templates? Can you type free text also? Can you customize the templates?
• How does it handle documenting a sick visit in addition to a well check?
• Does it have coding assistance?
• Does it offer electronic prescribing? Does it have a weight-based prescribing system for calculating pediatric dosing?
• Does it have laboratory report integration and ordering? Can you set pediatric norms for laboratories? Can you interface with local hospital laboratories and major laboratories? For how much?
• Can you use images or photos (eg, drawing of lesions)?
• Can you capture signatures (eg, for waivers)?
• Is there an online interface available where parents can request refills, schedule appointments, or preregister online?
• Are there pediatric-specific educational handouts?
• Can you integrate a spirometer, electrocardiogram machine, or vitals machine?
• Is it capable of sending charges electronically?
• Will it support patient self–check-in?
General
• What is your support turnaround (including after hours and weekends)?
• How frequent do you have upgrades? Who does those upgrades?
• Are upgrades included in the maintenance cost?
• Who performs support for your system? Is there someone local who will come onsite? Or is it done remotely?
• Is there a resource for users of the same specialty to network and share ideas for using the system?
• How long has the company been in business? What is the company’s business plan? Does it give you a feeling of confidence in that it will be there for the duration of your practice?
• How do you store backups for patient data? Is it done locally? Is there off-site storage?
• What are the security features? HIPAA compliance features?
Once you have chosen several vendors, schedule demonstrations. Make sure that the vendors demonstrate a pediatric scenario for you. For such an expensive capital purchase, it is wise to meet with at least 3 different vendors. When you have decided which ones you like the most, visit practices that are using these systems in real life. These practices can give you a much better feel for how the system works in everyday pediatric practice.
It is also a good idea to get information about obstacles they encountered, how they would do things differently if they could, and whether they would purchase the system again knowing what they do now. The implementation of an EHR in an existing practice can be a very painful process. Depending on what stage they are in the implementation process, you could take their advice accordingly. In general, once you are 2 to 3 years into a system, you will find that the EHR was a good choice and that you wouldn’t go back.
However, those first years can be very strenuous as you make the transition!
Technical Support
There are many ways to implement a computer system. The larger your practice and the more features you make electronic, the more likely you are to need technical support. This may take the form of a staff member who is technically savvy and a local engineer from
your vendor. It may be a local computer support business or your local “geek squad.” If your system is large enough, you may need to hire an IT specialist. Regardless of the system, you are likely to encounter needs for upgrades and maintenance (eg, backups), as well as troubleshooting problems. The problems will range from simple (eg, the mouse doesn’t work) to complex (the network is down for your satellite office). In general, it is wise to have someone you can call for help when these issues arise.
Data Storage, Backups, Power Outages, and Disaster Plan
Lastly, it is important to consider how you will protect your data. There are frequently news reports of patient data being stolen by employees. Once you are electronic this issue should be examined carefully. It is much more difficult to steal 1,000 paper charts than to steal a computer containing that same information. Investigate your vendor’s capacity for security and virus protection. EHRs must be compliant with specific HIPAA rules.
Backup for your data can be done many ways depending on your system. Investigate options with your vendor. If your system is on site, certain precautions should be taken to have some form of off-site storage for your data.
You should also have a disaster plan in place. This will be important in case of extreme disaster to your practice (eg, fire, water damage), but also in other cases when something as simple as the power goes out to your building. For power outage or when the system is down for some reason, a common plan is to go onto paper. The data is scanned into the computer when power is restored. Design a plan that works for you and your practice.
For information on implementing an EHR, visit http://practice.aap.org/ehr.aspx.
For additional information on PMO about EHRs, visit here. This section of PMO also provides articles provided by those practices who switched to EHRs.