Free EMR Newsletter Want to receive the latest news on EMR, Meaningful Use, ARRA and Healthcare IT sent straight to your email? Join thousands of healthcare pros who subscribe to EMR and HIPAA for FREE!!

Dr. Lynn Ho – Ultra-Solo Doc: Meaningful EHR User With Amazing Charts

Posted on August 2, 2011 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

1.  Please tell us about your background and training and when you became a sole practitioner?

I graduated from NYU School of Medicine and finished a family practice residency at the University of Rochester in 1989. Before opening my micropractice, I had worked in a variety of different settings, including an HMO, community health centers, a university health center and a typical private office practice. I opened my no-staff micropractice in 2004 after reading Gordon Moore’s groundbreaking articles on solo-practice and seeing a local colleague succeed with a similar type of practice in Rhode Island.

2.  I understand your practice is defined as a “micro practice”. Can you explain what you mean by that and how it differs from a traditional practice?

In my particular case, ‘micropractice’ refers to a small, low overhead, no staff, high tech – high touch practice.
– a small practice (850 patients vs. the usual patient size panel of 1500-3000 patients)
– that because of low overhead (25-30% of gross collections vs. usual 60%, attributable to not paying staff salaries and leveraging computers to run an efficient and effective practice)
– is able to spend adequate amounts of time with the patient during each patient encounter (30-60 minutes vs. the national primary care average of about 7.5 minutes)
– which leads one to be able to better provide the cardinal primary care functions of supplying “access, continuity over time, coordination and comprehensiveness” in a patient centric manner.

3.  What led you to make the change from traditional to micro practice?

The current financing model of delivering primary care – cranking on volume of visits to meet overhead and salary – is bankrupt and broken. I wanted to move to a model that would be better for patients and lead to more professional satisfaction for myself. I wanted more control over the way I practiced medicine.

4.  When did you start using Amazing Charts (AC) and why did you choose them over other EHR vendors?

One of the key underpinnings of running a micropractice is achieving and maintaining low overhead, (around 30% of gross earnings). I did know that I did NOT want to work just to have to pay for my EHR.

When I first started my practice my AC license cost me just $500. Back in 2004, AC did not have a lot of bells and whistles but as a startup I was nowhere near using the program to its fullest capacity. Starting out is tough! I had the naive idea that with a laptop, an all-in-one, an internet connection and an EHR as the centerpiece of my technology stable, I was set for life. I was blissfully unaware of what my burgeoning technology configuration (see list below) was going to evolve to include, and how many other pieces of technology were going to have to ‘play nice’ with my EHR. Luckily for me, and because AC is very responsive to requests from users, all of the software pieces that I use integrate well with my EMR, both via formal interfaces and in my informal workflow.

To reiterate, low cost, ease of set up, maintenance and use, and ability to easily integrate with other workflow processes are the EMR qualities that I’ve found to be essential in my micropractice, and I find that AC meets and often delightfully exceeds these criteria.

Instant Medical History – automated patient entered histories
Updox – document management and patient portal
Paperport – document management
Appointment Quest – online patient entered appointments
EZ Claim – practice management
Zyantus (clearing house) – electronic billing
Shortkeys – macro for documentation
HowsYourHeath – web based patient entered practice quality tool
Brinkster – website hosting

5.  Did you have any prior experience using EMRs?

No – actually I had never really used a computer (except for email, and that was a Mac!) before opening my practice in 2004.

6.  I understand you are in the process of attesting to Meaningful Use. Was it necessary to upgrade your current EHR in order to meet requirements for MU?

I had to upgrade to the latest version – version 6 to use the wizards that would count up my data.

7.  How long have you been working towards MU?

I’ve been counting data for about 2 months, and am on track to “pass” by month 3.

8.  How much additional time is it taking to meet the criteria for attestation?

It takes about 2-5 more minutes per encounter to include the documentation for Meaningful Use.

9.  Can you give us an overview of what the process has been like thus far?

Generally speaking, I find it exceptionally vexing to have to spend extra time documenting what I already do for bean counters. I could be using this extra time to actually improve patient care instead of just filling in boxes. Luckily, on a visit by visit level, the MU wizard in my EMR makes it mindless, simple and not too painful to collect the required data and document the required work processes.

10.  What changes have you had to make in your practice as a result of meaningful use?

I have not materially had to change office processes, though I have had to change documentation procedures so that items are compiled correctly for MU.

For example: I used to send patient summaries via email to most patients.
5 clicks: copy content – return to demographics screen – open email to patient – paste – send, about 30 seconds.
Now, in order to document that I am sending these summaries for MU, I have to click on the MU box, print that to a secure email, click( 2x )and type (2x ) within the secure email program to attach label and send, wait for the CCD to print and then click to return to the note. 8 steps and some are slightly more than just a click. It all takes about 90 seconds.

Another example – Smoking documentation requires a formal reassessment of the data as MU needs it, but it’s usually not the way I’ve previously free texted it.

It’s just a little more cumbersome, might take about 2-5 minutes more per patient encounter.

11.  Word is that you’re a “paperless office.” How do you handle things like the patient intake paperwork to avoid having lots of paper lying around?

Patients send me their clinical histories before every visit electronically using Instant Medical History from my website or from an office kiosk, so I don’t use paper for those forms at all.

I do have new patients sign a laminated “HIPAA-consent to bill-consent to email form” – one signature gets it all. Then I scan in the page along with a copy of the insurance card to a file. I rinse off the marker from the laminated sheet under the tap and am ready for the next new patient.

I use EDI interfaces for most labs and some x Rays and consults, and most consultants fax me their information electronically.

Other non interfacing labs and radiology reports come in via paperless fax to a folder on my computer.

If there is a particular consultant or facility that mails me information more than twice, I will call them and ask them, going forward, to fax their information to me.

There are a number of tricks to minimizing use of paper in the office. Having paper embedded into your office routine requires extra labor (opening mail, scanning, shredding, filing, retrieving files) and the expense of storage space and materials.

12.  Who has been helping you through the meaningful use process (consultant, your EHR vendor, your REC, etc.)?

Mostly the EHR folks- attended a webinar and then had some back and forth with the developers, as I was an early beta tester for the MU process.

The REC folks came by, but since the processes were in place they just encouraged me to actually decide to apply for MU by dangling the financial rewards in front of me.

13.  What would you offer as guidance to your fellow doctors regarding EHR’s and obtaining MU status?

If the processes that MU is supposed to document are already in place – if you are already leveraging your EMR to help you in your practice in a meaningful way, then depending on your Medicare/Medicaid revenues/patient mix, it may be worth it to apply. The question there is, are the monies received – or the penalty that you would incur, worth the time it will take you to: 1) learn about the MU program, 2) learn how to use the MU features of the EMR, and, 3) actually do the documentation?

Payout is also dependent on your payer mix and volume of the practice. For example, because my straight Medicare income was about $10K last year, I stand to get, over 4 years, about $22K so, coupling the payment with the curiosity factor of seeing what our cutting edge HIT people are up to, I decided it was almost ‘worth it’ for me.

If the processes are not in place – items such as, ‘you don’t use the EMR to collect demographic data’ to ‘your EMR does not support E-prescribing’, then there’s the additional work of adopting these processes into your workflow. Again you’d have to weigh the payment against the work of adopting new workflows AND becoming schooled and practiced in MU deployment. This work is not an insignificant burden and many small primary care practices that run with very tight margins and lack breathing room will not be able to succeed.

Of course, if you work for Kaiser or another large group, I would imagine that they would deploy both IT and clinical staff to do this work for you.

Center for Family Medicine Earns Maximum Incentive for MU – Interview with Dr. Muir

Posted on June 9, 2011 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Interview of Dr. Peter Muir of Springfield Center for Family Medicine

How long have you been using EMR? Which EMR do you use?

We have been on NextGen Ambulatory EHR since 2003 and NextGen Practice Management since 2006 for billing and scheduling.

Did you have to upgrade your EMR to meet the certified EHR and meaningful use requirements? How much did it cost for you to do that if you had to?

Upgrades are provided as part of NextGen maintenance fees.

What criteria did you find most important in your selection of an EHR?

We selected NextGen EHR in 2002 because the company was focused on clinical offices. It was not a product purchased from another company. NextGen invests heavily in improving the product, which was important to us. I have even attended a development think tank at the company’s headquarters in Horsham. I also wanted the capability to self customize templates and gain full access to data with tools such as Crystal Reports. In addition, the EHR handles routine activities (time, date, etc.) which lets you focus on tracking health maintenance and prevention.

Having demographics, scheduling, clinical and billing in one database makes reporting much easier and more comprehensive than those EHRs with separate databases or separate vendors. Kudos to NextGen for addressing this. It was done so long ago that I take it for granted now, but it has had a huge impact on operability.
It really can take up to a year to migrate information from paper charts into structured data. We were not under a time pressure since we had a self-imposed timetable in 2003. This allowed our docs to progress at their own pace. I changed to doing all my documentation in the EHR approximately 3 months after startup. The first year was stressful but after that you would not go back to paper charts. Because we started the process so long ago, we were really on the ‘bleeding edge.’

How many hours of extra effort do you estimate it took for you and your staff to meet the meaningful use criteria?

It is really difficult to estimate since we have been constantly evolving since 2003. In fact our motto is that the only constant is change. Our work flows are constantly being fine tuned.

What were some of the changes you had to make to your practice style or documentation methods to meet meaningful use?

Cindy Brewer (our business office manager) focuses on office/clerical and I focus on clinical. For Meaningful Use, we had to capture some information as structured data that is not necessarily the most useful for our clinical purposes. For example, race/ethnicity groupings have more in common with government categories than the genetic risk grouping I use clinically. (eg. I differentiate between Northern and Southern Europe descent, and between India and Asia, due to differences in genetic risk.) As a result, we capture that MU-required info in the registration process rather than the clinical process.

I go after smoking cessation aggressively, but in the past would not always document it if it was not the main purpose of the visit. Often, we would document it in the plan as text rather than in the social history smoking cessation check box. Only the later can be easily tabulated for Meaningful Use, so a minor change in our work flow was required to meet that requirement.

There was no real change in our practice style from the patient perspective.

Who helped you through the process (your vendor, a consultant, your REC, etc)?

CMS web site for requirements and advice, attestation process, etc.
NextGen Healthcare for upgrades to software, pathway documents and webinars – very helpful
GBS of Youngstown, Ohio is our NextGen vendor for hardware and software – very helpful
GBS also did our server and security upgrades in 2010 in anticipation of the process

In 2006 I also helped start CCHIE (Collaborating Communities HIE) connecting to and using HealthBridge as our data engine. Southern Indiana HeathLINC (Bloomington) was also connecting to HealthBridge around the same time.

Subsequently, they have added two regions in northern Kentucky and GDAHIN of Dayton OH. Marty Larson is Executive Director of CCHIE and GHADIN. CCHIE board includes: Jim Gravell (Catholic Health Partners), Mark Weiner (Community Mercy Health Partners), two Health Commissioners (Charles Patterson and Shelia Hiddleson), and others.

HealthBridge also spawned the TriState REC. CCHIE is part of the TriState REC. Ron Mayse of CDI Springfield (CCHIE & REC) was of great help for technical support and advice on Meaningful Use. Charles Baumgardner of Far North Computers was helpful for network and security.

I continue to assist CCHIE and the REC as a physician informaticist. I feel it’s important to keep learning by doing.

What would you have done different in your efforts to show meaningful use?

Initially I thought that PQRI (now PQRS) would fulfill the clinical Quality Measures menu component, so I left it towards the end. Fortunately, the required information was already being captured by the time I made the discovery. (BTW, these may be difficult for specialty offices.)

What benefits did you receive from being part of the ONC Meaningful Use Vanguard Program?

I have been using computers to assist medical practices since 1980. The Vanguard Program provides recognition which may allow a greater input in system design and operation, which interested me. The flow of information between systems is critical and has not received enough attention (multiple database silos still exist within and between different vendors). Problems that face healthcare include ICD-10 implementation, variations in LOINC classification, and a lack of standardization.

Meaningful use Stage 1 has a relatively low bar. Are you concerned that stage 2 and 3 might be a much harder challenge?

I think the set points of some items do not jive with real practice. For example, patient portals that are tethered to a vendor would require a patient with three doctors on three different systems to have three different portals. A regional solution would provide for improved flow between offices.

The signal-to-noise ratio is critical, as important information can be buried within a lot of routine data. In other words, a paragraph of pertinent positives can be more helpful for diagnosis that pages of negatives.

What do you say to your fellow doctors who are concerned about implementing an EHR in their practice?
Unless you are planning to retire in the next couple of years, the longer you delay the process, the more compressed the time you’ll have to implement an EHR and the more financial and staffing impact it will have. Those who have waited will know specifically what targets they have to meet for meaningful use, but the activities of daily practice are much broader and more demanding.

The reason for using computers in practice should be to improve patient care, safety and outcomes rather than just meeting meaningful use. Do not select a system that just meets the meaningful use requirements; select a system that assists you in providing better medical care.

Interview of the Happy EMR Doctor – Dr. West

Posted on June 2, 2011 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Hi Dr. West, could you tell us your educational background and EMR experience?

I completed my fellowship in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. I began using an electronic medical record when I opened my practice in December 2009.

1. You’re on your second EMR after a failed EMR experience. I know you can’t reveal the name of your first EMR vendor, but what went so wrong?

Lots of things, but mainly it was the fact that it didn’t perform as the vendor described it would. Different parts were always malfunctioning. For example, the History of Present Illness section of my notes would sometimes get deleted when we tried to format the notes for faxing to a referring doctor. Different buttons on the screen which were supposed to be for functions were never functional. You would click them and nothing would happen. The accounting part of the software would not allow patients to be issued refunds in the case of overpayment, and so our financial books could not be kept accurate. Etc, etc.

2. What frustrated you the most about your first EMR?

That the company would make promises to fix it and never completely get it done. When one fix was completed, another part of the system would develop a new bug that was not there before. I think they were amateurs who basically got in over their heads and could not dig themselves out of the hole.

3. I know you are very happy with your current Free EMR, Practice Fusion, but after your failed EMR experience did you want to quit using EMRs all together? If not what or why were you still convinced there had to be a way to make EMRs work for your practice?

No, we had heard stories of other companies who had needed to change vendors and were prepared to keep on our mission of being an electronic practice. But it was indeed a scary time because we had just gotten burned with our first vendor. That said, I can see how many doctors who are less certain about the EMR concept for their practices may not have tried again at that point.

4. What do you think other doctors and healthcare professionals should avoid so that their initial experience with EMRs are less traumatic and more rewarding?

I think they should avoid rushing into a relationship with an EMR vendor; they should avoid signing a contract that does not include a satisfaction and money-back guarantee; and they should avoid continuing with an EMR vendor that has not provided a system to their satisfaction after an introductory period.

5. What should doctors and practice managers be looking for in their pursuit of finding an EMR that fits their needs?

I recommend searching for a vendor that is willing to let a provider test drive the EMR in the provider’s practice for an introductory period before committing to it. I think that a month would be enough time to find out all the problems, if any. There may need to be a deposit for this, but that should be fully refundable. They should be looking for a vendor that does not have a lot of very specific hardware requirements since hardware is not easy to return in the case where a provider needs to switch to an different EMR vendor.

6. What specific questions should other practices ask before signing a contract to have an EMR software package installed?

I think many of the answers are in my answer to question 5.

7. American Medical News reported the results of a recent study conducted by UC Davis which connected decreased productivity with EMR systems because of a lack of customization for given specialties. Was this an issue for you?

No. Practice Fusion is designed such that you can build your own templates to include whatever you like in the notes. After you create your own templates to your liking, I found that I could see patients faster and complete their notes sooner than before. All of my daily notes are essentially done by 5 pm.

8. Did you try other EMR software in between your first disastrous EMR experience and your current EMR?

We interviewed other vendors and viewed demos, but we had no other EMR in practice.

9. If you did, could you tell us about why you chose not to use them and could you tell us what the Practice Fusion EHR had that enticed you to go with them?

We went with Practice Fusion because it was free and web-based. Therefore it could be tried and discontinued, if necessary, without additional cost to us.

10. You’ve commented on your time being freed up because of using EMR, what was the most time consuming element in your pre-EMR life that no longer exists in your current, happy, para-EMR life?

If you mean before using any EMR whatsoever, then I would say charting in general. At Hopkins you had to dictate all your notes, spend additional time reviewing and editing them, and then sign. Now, using customized templates that I designed myself, that is all gone.

11. Besides Practice Fusion being free, can you tell those who might want to test the waters what you like the most about it?

It’s very intuitive. I like to call it the Gmail of EMRs. I imagine that eventually nearly everyone will have an account.

12. Explain the benefits of customized templates and details regarding how you designed your templates?

Benefits include a more uniform approach to common problems, such as diabetes and thyroid nodules. All patients with these conditions follow a thorough and well-defined path of questions designed to gather the most meaningful and relevant information.

13. How have you handled the issue of making each record unique to your patients’ medical issues when using templates?

Well, you still have to add unique contextual details, and for this you have to type a sentence here and there. These can be as long or short as you like.

14. Medicare and Medicaid decided to eliminate consultation codes. Is that one of the reasons you have decided against taking Medicare patients?

Yes, but only one of many reasons.

15. Why did you opt out of participating in the EHR government incentive plan? Aren’t you forfeiting a substantial sum of money by not participating?

On the surface it would appear so. It’s been an issue of angst for me personally, and I may blog on this inner struggle in the future over at

16. In a recent survey conducted by the AACE, it was revealed that because of Medicare’s decision to remove the code allowing the consult charge, 4 out of 5 endocrinologists were going to reduce the number of patients seen in their practice. Are you aware of any groups working to reverse Medicare’s decision? What impact will this have on the future of Medicare?

I previously blogged on this at Happy EMR Doctor.

As far as groups working to reverse Medicare’s decision, I am aware that AACE already sent CMS a letter, and I found this letter as well.

In making this change, Medicare will save a lot of money for itself and shift the burden of payments back to patients who cannot find a subspecialist within travel distance who will accept Medicare. They will be forced into paying out-of-pocket for needed medical services. What most patients don’t know is that, under current Medicare rules (unlike commercial insurance companies like Blue Cross Blue Shield), patients cannot send in claims to Medicare for services rendered by doctors who have opted out of Medicare. To see an opted-out doctor, patients are forced to sign a Medicare contract stating that they will not send in any claims, despite having had necessary medical services. Medicare makes it more financially painful not to use their contracted doctors than do commercial carriers who have out-of-network options. As for the future of Medicare, I think that less doctors will be available in the system to supply demand to a growing number of baby-boomer Medicare patients.

Welcome to the EHR, EMR and Healthcare IT Interviews Site!!

Posted on May 19, 2011 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

We’re just getting started with the new EHR, EMR and Healthcare IT interviews website. Thanks for stopping by. Our goal with this site is to interview some of the smartest minds when it comes to EHR, EMR and healthcare IT. We’ll certainly interview a number of people that you know, but also interview a number of people that you probably didn’t know before.

We’ll also do everything we can to interview as many doctors as possible. Our goal will be to find doctors in every different stage of the EMR implementation and selection process. Doctors who haven’t even selected an EMR. Doctors who have been using an EMR for as long as they can remember. Old doctors. Young doctors. Doctors who used one EMR and then switched to a different EMR. Doctors who have been part of a failed EMR implementation. Etc etc etc!

Then of course, we’ll do what we can to interview EMR vendors, healthcare IT vendors, EMR consultants, Practice Managers, Nurses, IT Consultants, etc.

If you couldn’t tell, we want to get all perspectives possible about the goods and bads of EMR. One of my favorite ways to learn is by learning from other’s experiences. Hopefully this blog will become a fantastic resource for those wanting to learn from other smart people.

If you’re someone who would be willing to be interviewed or if you know of smart people we should be sure to interview, just leave a comment on this post.