This is the start of a new series of posts that I plan to do over the next week or two. I’ll probably try and space them out so that they don’t overwhelm anyone. However, it’s going to be a series of common EMR implementation issues that I hear over and over again.

This series was prompted by a post on HIStalk by Inga where she talked about her visit to the doctor and his complaints about his EHR implementation. As I read through the list of complaints, I realized that they were all complaints that I’d heard before. If I’ve heard them all before, then they must be pretty common and worth talking about more.

Ideally the discussions in this EMR implementation series will help practices and doctors that are implementing an EMR to avoid these issues. I also know that I don’t necessarily know all the answers to avoiding these problems. So, I welcome others feedback on ways to avoid these problems in the comments as well.

Today’s Common EMR Implementation Problem: Many Unexpected Expenses

I can’t tell you how many times I’ve heard a doctor or medical practice talk about all the hidden expenses that they incurred during their EHR implementation that they didn’t plan for. Here are 3 tips to help you avoid this situation.

Unexpected EHR Expense Tip #1 – Plan for hidden expenses. Add $5000+ to your budget for hidden expenses. Hopefully you won’t have to use it, but if (and likely when) you need to use it you’ll already have it in your budget.

Unexpected EHR Expense Tip #2 – Get your EHR vendor to outline everything and anything they could charge you for. Once they’ve done that, consider putting the list of expenses in your EMR contract so that new expenses from your EHR vendor won’t appear. Here’s just a few EHR expenses that you might incur (and may not expect):
-Up front fee (almost everyone just focuses on this)
-Maintenance Fees (monthly, annually, etc)
-Upgrade Fees (to update your software…these are sometimes called Hot Fixes)
-Interface Fees (both sides of the interface..ie. lab and EMR company)
-Device Integration
-Training Fees
-Support Fees
-Licensing Fees (to license their various databases and/or clinical content)
-Install Fees
-Other non-standard modules – You mean you didn’t realize that the patient portal was an extra $150/month?
-EHR or PMS data migration Fees
-Template Creation Fees
I’m sure there are others that I’ve missed. I look forward to seeing the comments on this. I’ll update the post with other suggestions as they come in. As you can see, EHR vendors can charge you in lots of interesting ways.

Unexpected EHR Expense Tip #3
While EHR vendors can often throw unexpected fees at you, it’s probably even more likely that the other outside purchases you have to make during your EMR implementation will be a surprise. Here’s a list for you to consider the other EMR implementation related fees that might come unexpectedly:
-Server cost (almost everyone focuses on this)
-Software cost (including the operating system or third party software your EHR vendor might require)
-New Desktop/Laptop Costs
-Upgrading Desktop/Laptop Costs – You might find that your existing computers aren’t powerful enough to run the EHR you chose. This is particularly true if you’re using something like voice recognition with your EHR.
-Fax Server
-Fax Server Software
-Scanners – Yes, that is plural and people often start with one scanner and then have the unexpected cost of another scanner because they could really use 2+ scanners. Other times people use a cheap all in one scanner which quickly dies after they start scanning in bulk and they realize they need to buy a $1000+ scanner that can handle the required scanning
-Printers – You’ll likely need a few of these to print our prescriptions, patient education, etc etc etc. Plus, you’ll often need a better printer than the one you have.
-Dragon Medical Voice Recognition – The software, the mic (spend extra for a great one), etc. Some don’t realize all of this costs and doesn’t usually come with the EHR software.
-New Network Ports – You could go wireless, but many like the reliability of a wired connection. This costs to run the lines and cut out new internet connections
-Bigger Internet Connection – This is particularly true with a SaaS EHR setup. You think your current internet connection is enough and then you realize you need to pay for a bigger pipe (internet connection) or possibly even a second “backup” internet connection
-Backup Software
-Backup Hardware
-Off site Backup Service
-Cables – Lots and lots of cables required. Sometimes you even have the cable, but then realize you want a longer one. Unexpected expense!
-Power strips and other peripherals – $10 here and $10 there. This stuff starts to add up. Plus, get ready for things like your mouse to start breaking now that you’re using it a lot more.
-UPS (uninterruptible power supply)
Chip Hart added the following suggestions (Thanks!):
-Practices should purchase 25-50% more laptops/tablets (and/or batteries) than they expect.
-All those laptops and tablets will need a SECURE storage and recharge barn.
-You may be paying a carpenter and electrician.
-Integration fees? Data conversion fees?
-Will you need hands-free headsets for your staff, now?
-Maybe it’s time to get bigger monitors.

Hopefully the above lists will help you plan for all of the various fees that are associated with an EHR implementation. Many of these EMR costs are necessary, but end up being really annoying when you didn’t know they were coming. Check through this list to see if you’ve planned for all the EHR costs.

In a future post, I’ll see if I can’t take the above list and give you some ideas on how you can save on some of the costs above.

Great counsel and advice for those still looking at various EHR software (especially specialists)
@EMRAnswers
Linda Lia
Customizable content “offered”, doesn’t mean your specialty is available. Big difference. Ask for a “live” demo. #EMR #HITsm #healthIT

EMR implementation in 6 weeks. Hospital EMR people will balk at this. However, it’s possible in the ambulatory setting. I wouldn’t recommend it, but one time I had to do it.
@PediatricInc
Brandon Betancourt
New Post – Going from paper charts to EMR in 6 weeks; a summary http://bit.ly/npmSEH #EMR

Everyone hates redundant work. So, this tweet caught my eye:
@TheNerdyNurse
The Nerdy Nurse
In Case You Missed it: : Teetering Between EMR and Paper Charting: Frustration and Duplication – What kind of nerdy… http://bit.ly/elw0yT
Here’s my response on the blog post:

Great article. The redundancy is killer!! We did a partial EMR implementation at first. Then, we ended up using the redundancy to push through the rest of the EMR implementation. So, while I hate redundancy as much as the next person, it was interesting how we could use redundancy in order to drive the adoption of EMR technology.

It seems the real issue you pose is who is required to do the redundant work. I suggest you have the person who needs to be most bought in to the EMR to do the redundant work.

I didn’t dig into the following research, but it’s interesting to note that they said a VC investment increase in HIT of 27%. If anything, that sounds low to me. Although, many of the HIT projects are likely still in the Angel investing stage as opposed to VC.
@starkehealth
Jomo Starke
VC investment in HIT increases 27% per research http://bit.ly/nCa3Hs #healthIT #HITsm via @Lumeris via @HITstrategy

I can’t remember exactly where I saw someone talk about the “WIIFM” (What’s in it for Me) principle, but it really is an important principle that when understood can have an amazing impact for good. This post isn’t about whether you should live a life asking WIIFM. I’ll leave that question to people much smarter than me. Instead, I want to look at how applying the WIIFM principle to others can help those working on a successful EHR implementation.

In most cases I’m talking about, the WIIFM should be changed to “What’s in it for Them?” Understanding the answer to this question can help you as an EMR consultant, an EMR vendor or even a practice manager or doctor that’s trying to work through an EMR implementation.

One of the first things I cover in my e-Book on EMR selection (It’s free, check it out) is the idea of getting buy in from those that will be affected by the EHR implementation (that’s usually everyone). One of the best ways to get EHR buy in from people is to understand the WIIFM. It’s not fool proof, but it’s one good strategy for getting people on the same bus, going the same direction.

Let me tell you that there’s always a way to find a WIIFM in an EHR implementation. This list of EMR and EHR benefits is a great place to start. However, many of those benefits can be extrapolated in ways that will show what’s in it for every person in the clinic.

Let’s say for example, that your goal for implementing an EHR is to increase clinic revenue by freeing up chart storage space so you have an extra exam room for another provider. You can then talk about what that new revenue can be used for to improve the clinic. Maybe it could include bonus checks or other incentives. These become tangible things that staff can use to better understand WIIFM in an EHR implementation.

I’m sure many of the nay sayers out there are thinking, but an EHR doesn’t provide those benefits. That’s why it’s so important that you define which benefits your clinic is striving to achieve before you select or implement an EHR. The list of benefits you use to show WIIFM ends up being your goals for your EHR implementation. They can be used to define your EHR selection process. They can be included in the EHR contract so you have some assurance or protection if the EHR vendor can’t deliver on their sales promises. Not to mention, after the EHR implementation you have a way to measure if it was a success or not based upon those goals.

Test the WIIFM principle. Not from an arrogant Me Me Me approach. Instead, step into the other people’s shoes and ask WIIFM. This approach can really help improve any EHR Implementation if applied correctly.

I know I’ve written about ERP and EMR before, but the more I think about the EMR selection and implementation process, the more I see the same issues that are experienced with an ERP implementation.

The one issue that is a bit different about EMR versus ERP is that there are only a small handful of ERP vendors to choose from. However, we have 300-600 to choose from in the EMR world. That’s an important and challenging difference.

However, the similarities to ERP are many. One of the most striking is how the EMR like the ERP is something that’s going to be used and have an effect on the entire organization. As such, the need to manage the participation of multiple stakeholders is so key.

The key to a successful ERP implementation is to have a great project leader.  Someone who is great at working with various departments. They are great listeners who hear and understand each departments needs. Then, they have to be great at making the case for each depaartment’s needs.

The same is true for EMR. You need an EMR implementation champion who is great at listening to all areas of the clinic: nurses, doctors, front desk, billing, medical records, etc. Sometimes this can be done well by a physician lead, but is more likely to be a practice manager, IT support (if they have project management skills), or an outside consultant. 

It’s easy to underestimate the challenge of “herding sheep.” Done right, it can work very well. Done wrong and your clinic is likely going to have the opportunity to try again after the failed EMR implementation.

There are other comparisons worth considering, but this one was striking me today. I’ll be interested to hear stories and experiences from those who have implemented an EMR. Did you have a strong leader to help pacify the different stakeholders in your clinic? 

About a month ago, the market finally fell enough for my wife and I to buy our first house. It’s pretty exciting to finally be able to do it since we pretty much tried to buy a house every year since we moved to Las Vegas 6 years ago. Thankfully, we never did until now (although that’s another story).

After purchasing the home, I found myself spending a fair amount of time having to repair a number of things around the house. One day I pretty much spent all day being a plumber as I (and a nice friend) replaced the garbage disposal, fixed a leaking sink, replaced the mechanism (whatever it’s called) in the toilet. Turns out that none of these things are really all that difficult. Although, it definitely had the initial learning curve for me to realize that it’s pretty straightforward once I got into it.

After spending the day as a plumber on my new house, I couldn’t help but think, “I’m doing the job of a plumber and all I want to really do is blog.”

Many of you are probably wondering what any of this has to do with EMR and healthcare IT. Well, I am the EMR blogger who loves analogies (see marriage and divorce, pregnancy, marriage for money, weight loss, and Katherine posted a Lady or the Tiger one that I enjoyed).

The comparison seems obvious to me. There’s a whole lot of doctors out there that really don’t want to be IT project managers. They don’t want to be EMR implementation specialists. They don’t want to be EMR Contract negotiators. They don’t want to be software evaluation specialists. They want to practice medicine by providing care to patients.

Of course, many of you might easily suggest that I could have paid someone else to do the plumbing and I could stick to the EMR blogging like I want. This is absolutely true. I’m sure there were plenty of plumbers that would have been happy to take my money. Unfortunately, they charge an arm and a leg and I like my limbs. Plus, there’s something valuable about having the knowledge of how something that I’m going to use every day is done.

Extend that to doctors. They could certainly hire an EMR consultant to come and help them do their EMR implementation. In fact, my first job doing EMR was partially to solve this issue. They needed someone who could take care of the EMR implementation from top to bottom. If you find the right person, there’s no doubt that it can work very well. However, similar to the plumber, there’s a cost associated with doing that. Plus, if you use a consultant, you’re outsourcing some of the knowledge and expertise that you would gain if you and your staff put your nose to the grindstone and did it yourself.

Plus, while I can’t say that I particularly enjoy plumbing, I have to admit that there really was an amazing feeling of satisfaction knowing that I was able to accomplish a task which I’d never done before. I think many doctors and clinics have had that same sense of satisfaction after implementing an EMR in their office.

I got the following email from a reader of EMR and HIPAA which really hit me when it comes to providing the right resources for medical practices that are researching and implementing an EMR system in their practice.

I remember achieving a feeling of solace after discovering your site.

When initially researching and realizing how much misleading information is out there, it’s very overwhelming and leaves the researcher of a very important IT addition to a medical practice feeling very alone.
Your transparent and no bones about it approach (whether positive or negative) is appreciated by many.

Don’t ever change.

While I definitely appreciate and am flattered by this reader’s nice comments, I was struck even more by their description of the challenge a medical practice has in finding quality, transparent, and unbiased information in what someone in my recent survey called a “sea of bias.” The “feeling very alone” is something that I’m sure most wouldn’t admit but many have likely felt. I know I’ve certainly felt it.

All of this has me pondering more ways that I can get better information into the right hands. My e-Book on EMR selection was a good start. More “cliff notes” like versions of my websites would probably be good for doctors since they likely don’t want to read all 1000+ posts on EMR and HIPAA and 500+ posts on EMR and EHR.

I also think that Meaningful Use Monday is a good series to help providers that are evaluating meaningful use and the EHR incentive money. I just feel like there’s probably more that I could and should be doing to connect doctors with good information.

In fact, writing this post reminds me of something someone I respect told me at HIMSS, “John, you have a platform now and you better use it for good. And I’m going to hold you to it.”

To be honest, I wasn’t exactly sure how to take the comment. I guess now that I’ve had some time to digest it, I find it an awesome responsibility even though I still just consider myself a regular old blogger. I do find the concept that this is a platform that can be used for good very inspiring. Hopefully, I and now the other Healthcare Scene bloggers can live up to this high standard.

With that in mind, I’m always open to hear new ideas on how a regular old blogger like me can have an even greater impact for good in healthcare IT. Let me know in the comments or on the EMR and HIPAA contact us page any ideas, pain points or other thoughts on helping doctors.

Some very interesting commentary from an EMRUpdate thread:

Six-plus years ago, I started my own office and my husband insisted on an EMR – mainly because the real estate prices were so high that he did not want to pay for file storage.

I have posted on this site over the years: early on, I was told I was crazy for picking an Application Service Provider (I think it’s now called “cloud computing”), and the site had a smartest-guy-in-the-room vibe.

But my EMR worked so I didn’t need help or a tech consult. So I went on my merry way and grew my practice – and downloaded quite a few babies, too! EMR was a big deal for me back in 2004; but now I never really think about it. Maybe the reason is that I was never searching for “THE PERFECT EMR” – I picke one that was “close enough” and made it work. EMR has just been a tool for me: I use it and I no longer think about it.

There are a lot of interesting parts about this EMR story. However, the one that struck me most is how now she doesn’t even think about her EMR software. Using the EMR is just completely natural for her.

Reminds me of when I talked to an old family friend who’s a doctor. I told him how I wrote a blog about EMR. After the initial pleasantries he described how he’d been using an EMR for so long (10+ years if I remember right) that he barely remembered what it was like to practice medicine without it. Needless to say, there’s no way he would practice medicine without an EMR.

Of course, for the other 50-75% of the world that doesn’t have an EMR, the question is how long will it take you to reach that level of comfort and what can you do to make your implementation reach that level as quickly as possible. Hopefully the lessons learned on this blog help many people achieve this goal.

The following is an interesting comment that’s kind of an extension to my previous post about a visit to an EMR using Doctor’s office. I think many of you will enjoy it.

Can you imagine this in a manufacturing environment? If GM, Ford, etc were legislated (incented?) to implement automation and safety changes that caused them to cut production in half…and cause the workers to be a bit distracted from what they were doing on the other 50% (then maybe tax them higher if they don’t put the changes in place within 3 years)….how healthy would that be for GM? And for the cost and quality of the cars being built?

Of course, not all EMR software causes you to cut production in half. EMR also doesn’t have to mean you’re distracted the other 50% of the time. Take a look at this post by Dr. Koriwchak that talks about some of the principles he used in his EMR implementation. My favorite comment he made was that he “rejected the notion that we would have to decrease patient volume and lose revenue, even temporarily, to get EMR implemented.”

So, if you see the HITECH act / EMR Stimulus money incentivizing what’s described above, then maybe….just maybe…you’re looking at the wrong EMR software.

I must admit that I’m a little reticent to post the following story that I was sent to by a regular reader of EMR and HIPAA. I’m not afraid for the story to be told (I’m sure you’ve read and/or experienced it already), but I’m concerned that stories like this ignore what could be done to avoid the situations described. There are often solutions to the issues you’ll read in this story. Let me provide a few of them up front, and then I’ll include some other commentary in the story in [italicized brackets].

1. Selecting an EMR that will maintain your efficiency is key. Certainly there’s some drop in efficiency during the beginnings of any EMR implementation, but 4 months after you shouldn’t still be at 50%. Selecting the right EMR can help avoid this.
2. Doctors need to be deliberate about how they use the computer in the exam room. Communication is the key here. Only chart what’s necessary and efficient in the exam room. Save the rest of that time for the patient. The problem is that most first time EMR users are overwhelmed by the EMR and the patient can see it. Get enough training up front so you can avoid feeling so overwhelmed by it.
3. Offload as much meaningful use items to your other staff (ie. seems like the nursing staff can ask the smoking question right?)

Ok, now for the story I was recently emailed. Also, this wasn’t probably intended to be published, so be generous with the writing style.

Had an interesting….well, maybe more REVEALING visit at a doctors office last week. Had to take my wife to an ENT for sinus and hearing issues. The office was part of 100+ ENT group and was fully electronic…no charts or stacks anywhere. But it took her 20 minutes to do “the clipboard” when we got there (my wife was aggravated by the time she was done. do you know how many times she had to put Name, Address, Phone Number, SSN, etc)…and when taken back to the exam room, the MA spent about 10 minutes on the terminal there, asking more questions (HPI, allergies, vitals, etc), plus entering some things from the clipboard. [Why aren't more EMR software implementing patient kiosks for their paper work? I implemented it in a clinic and it was great! Walmart like signature pads and all.] I could see from my chair they used one of the “big names” for EMR, one I’m very familiar with. Very detailed, busy screens…and very data-hungry. Forget to fill in a box or try to move on without closing a box…”BEEP”.

Anyway the ENT comes in and went straight to the terminal, which was mounted on a cantilever arm on the wall. Pretty expensive set up, but took up no footprint on a counter or moving cart. He said “Hi”, introduced himself and rummaged on the screen for the Chief Complaint and medical history. I asked him if he liked using the EHR and his immediate response was “I hate it”. When he saw I was involved in the industry—even if with another product—he opened up. He had been using it for four months or so, and was clumsily navigating his way around. He said his patient load was down just about 50%. [This is a real travesty. 4 months later and still at 50%. Either this was implemented wrong or you need a new EMR software.] He said the financial impact was palpable..and that’s why they were “phasing” the implementation in his large group.

The first question he asked my poor wife whose head is exploding and she can’t hear much, is “What kind of smoker are you?”. I laughed out loud and he turned and looked at me…he smiled and said, “You know I HAVE to ask that question now, right?” Your meaningful use and up-coding dollars at work. [Of course, this was probably asked on the intake paperwork as well.]

He eventually got to the exam…and needed to order a hearing test…and went back to the terminal, where it took him more than 5 minutes to document his exam…and order a hearing test (which was done on site and immediately). He kept saying, “just a couple more things to enter….”. After the hearing test, he came back in with the results…and spent more than 5 minutes again, typing his results and impressions into the terminal, then spent a lot of clicks entering a prescription for steroids (prednisone) to knock out the infection. My wife told him she was already on a daily dose of the drug for other issues and was carefully managed by her Endocrinologist to deal with her thyroid issues. This information was “on the clipboard”, sitting on the counter. While distracted with typing in more data, he said, “…then get approval from your Endocrinologist before doing this”…and kept typing.

There is a big problem in there. No cross checking…pre-occupation with typing, clipboard data sitting there, and not really hearing some dangers…what if she can’t take the extra prednisone…no discussion of that. And a whole bunch of other things we don’t have to get into here.

This doctor was a very reputable doctor, in practice specialty for more than 25 years. Seemed very personable and professional. But what impact did the technology he had been using for about four months have on him? Loss of focus? Does pre-occupation with data, government requirements (smoking?) and documenting live during a patient visit distract more than it helps? Not only is he losing 50% of his patient volume, is he really losing more contact with the remaining 50%? What kind of “healthcare improvement” is that?

Your discussion this week about the daughter who was lobbying for her dad to use an EMR [here's the post in case you missed it] may suggest why adoption rates have been so low for ten years…and NOW need government incentives to be used broadly in the market: THEY JUST DON’T ADAPT WELL TO THE USER’S ENVIRONMENT. That’s the way technology gets traction…it adapts to the user’s way of doing his/her job…and makes it easier and more accurate. Maybe the daughter doesn’t understand that quite as well as dear old Dad does. [Or maybe dad has only seen these "Jabba the Hutt" EMR vendors who as you describe don't adapt well to the user environment. Hard to blame him though since they are all over the place and it's hard to find the good ones amidst the 300 other EMR vendors.]

The coming EHR era…may have different implications than anticipated by those wise folks at ONC and the HiTECH Policy and Standards committees. Only if the EHR is designed from the ground up to help the providers do their job better and more efficiently…without losing the volume of patients they need to see…can it all work and do what has always been expected of it: Improve Healthcare…and start to reduce costs.

John’s Moral of the Story: This is the story you want to avoid in your EMR implementation. Choose your EMR wisely. It’s worth spending the time and energy up front to get the right one for your practice. Be trained well on the system so you can feel comfortable using it in the room while still providing excellent patient care. Minimize the effects government initiatives have on your patient care.

Side note: If you don’t read my other site EMR and EHR, go check out this post I just did about EMR training. I think you’ll really enjoy it. While you’re at it, go and like the EMR and HIPAA Facebook page. There’s got to be more than 142 of my readers on Facebook.

I have often found doctors talking about the 2014 mandate for adoption of EHR software. In fact, this post was inspired by a bunch of people searching online for the term “2014 EHR Mandate.” I think that they found my site because I previously did this post about Obama’s goal of Full EHR adoption by 2014.

If I’m remembering right, this was actually just an extension of Bush’s goal of having 100% EHR adoption by 2014. Obama took Bush’s original EMR aspiration and kept it going.

Although, I do have a real problem with people who like to call it an EHR mandate. It’s really not a mandate. A mandate for me implies that you are required to do it or there’s some grave consequence to it. It’s not like you’re going to be thrown in jail for not using an EHR or not be able to practice medicine if you don’t use an EHR (although some have hinted at this idea). Certainly the HITECH act has provided some Medicare penalties that could be considered a grave consequence to not adopting an EHR. Although, when you consider this example of the Medicare penalties it doesn’t look all that grave of a concern to me.

What other penalties are there to not adopting an EHR by 2014?

There certainly are other potential issues with not adopting an EHR that are worth considering:
1. Ability to Sale Practice – I don’t think we know all the details of how this will play out, but be sure that many younger doctors are going to want to purchase a practice that has an EHR. The common thinking I’ve seen going around is that a practice will be more valuable if it is electronic.

2. Government Mandated Reporting – While the government can’t really mandate the use of an EHR, it seems reasonable that the government could require certain reporting be done. Of course, you could manually do this reporting, but at some point the manual way will be much harder than using an EMR where the reporting can be automated.

3. Reimbursement Requirements – At some point the insurance companies are going to require their data electronically. So, if you’re going to want to keep accepting insurance, then you’re going to need to be electronic. I think the insurance companies are still watching and waiting to see what happens with meaningful use before they decide how they’ll approach it. However, you can be sure that they want more data and electronic is the way to make that happen. Of course, you could always go back to cash pay if you don’t like it.

4. Patients – It hasn’t happened quite yet, but get ready for a new patient base that wants their doctor to be electronic. No, you won’t have a “Got EMR?” sign outside your office to market to patients like we once talked about on EMRUpdate. It will come in more subtle things like the ability to schedule an appointment online. The ability to request refill requests electronically. Not having to carry (and possibly lose) their prescription to the pharmacy and then wait for it to be filled. Not having to fill out the same paperwork over and over and over again. Once patients get a real taste for these features, they’re going to be more selective in the doctors they choose to use.

5. ROI for Your Practice – There are plenty of arguments for and against the use of an EMR from an ROI perspective. I personally side on the positive ROI side based on this list of potential EMR benefits. Certainly it takes a smart EMR selection process and a well done EMR implementation to achieve the ROI, but I know a lot of people who’ve saved a lot of money thanks to their EMR. Add in things to come like doctor liability insurance discounts and the ROI will get even better over time. I know one practice who was having tough times financially. Their implementation of an EHR helped to solve some of those financial issues.

I’m sure there are plenty of other reasons that could “force” you to move to using an EMR. Of course, this CDC study on EHR adoption says Physician EMR use is at 50%. Although, in that link I use their study to show that it’s probably closer to 25% EHR adoption. Either way, we still have a long way to go to achieve Obama’s dream of 100% EHR adoption by 2014.