High Cost of EMRs and DIY

[Toffler]

The main problem with most EMRs for the small practice is cost. As well, for all that money, you get a difficult to use EMR that is not intuitive. Slows things down actually, staff hates the change. Next, the systems always, inevitably crash, sometimes with data corruption. It usually takes the systems designers to clean up the mess, generally with a high charge for support.

Here is what I'm doing. I built an EMR 4 years ago with File-maker pro 6. It was weak in many ways, but kept track of every thing well and it did not crash. For scanning I used Adobe Acrobat. Fast and could be stored directly in Filemaker.

Over the last 3 months, I have built a new EMR in Filmaker Pro 7. Advantages are that it holds 8 terabytes of information and I was able to import my old records from FM 6 into the new product. The cost of 1 copy of FM 7 is about $200.00. The Adobe Acrobat about $250.00. For checking for drug interactions I use the Medical Letters software which is $95.00. For rapid text entry, I use Macro Express which costs about $40.00. By combing several stand alone products I've got an excellent EMR. Some features I built were point and click exam, point and click ROS, ICD-9 codes (from the AAFP web site, downloaded and imported), Rapid entry of medications to patient drug list using point and click.

All the stand alone products work well and everything has been stable. It is networked on 3 computers.

The bad part is that I have spent a good deal of time building it. I actually enjoyed it, but the time was probably worth $30,000 to $50,000 and obviously I could have bought a good EMR for that. The same could be said for the time I've spent golfing in the last 3 years as well though.

I just always felt the EMR companies rip us off, IMHO.

Toffler

[Scroggie]

Welcome to Docsboard. There are several of us with homegrown EMR's here. Al where are ya. I use MS access front end and MySQL backend myself. Somewhere we have links to download our stuff to see if it has features you can use. May BD can post em.

[swampfox]

I am an old programmer and thought about doing what you are doing and decided on soapware. Still alot of work to set up and troubleshoot, not very expensive, and works well. I think the time you spent is work something. I also tell everybody in primary care to put the system in during the summer, when it is slower.

[Hal333]

Is it HIPPA compliant?
Can folks just edit old records at will?
Are scanned documents integrated?
If you have a heart attack can your partners keep it up and up to date?

What you have is a hobby.

I have been using MediNotes for two years now.

It's remarkably inexpensive and works well for me.

There others out there in the under 10k range and I'm sure they are just fine.

Congrats on your homebrew system but newcomers need to understand that it really isn't practical for almost every one else.

I even tried Amazing Charts for a while. It is amazing for the price and I suspect superior to almost every other homebrew system.

Terrabytes of data?

Hmmmm.

[Toffler]

Is it HIPPA compliant?

I don't know if it is HIPPA compliant. I've never been able to find information on precisely what that means for an EMR. If I could find the requirements I think I could build that functionality into the EMR. My EMR does have an audit log and password protection and I can turn on the password protected screen saver on using keystrokes. Every user must change their password every 90 days. Access to certain parts of the EMR can be controlled by password. For example, only I can delete a medication from the medications list and only I can write a prescription. I am still deciding how to use the password protection best so as not to impede work flow.

Can folks just edit old records at will?

Some parts of the record can be edited at will. For example, the PMH, SH, FH, Medications list, active problems and inactive problems, patient's address and phone numbers and call all be edited. The Progress notes are time and date stamped and once signed cannot be edited.

Are scanned documents integrated?

Yes. A copy of Adobe Acrobat is stored in a container field in the patient's record. Adobe scans well and does not take up a lot of space.

If you have a heart attack can your partners keep it up and up to date?

No. My partner is 77 years old and refuses to use the computer for anything. He hand writes all his notes. His notes do not meet guidelines for the level he charges. I hope he retires soon.

Terrabytes of data?

I don't have Terabytes of data. My entire EMR takes up about 40 Kb. However, Filemaker will handle up to 8 terabytes. I doubt a practice of 10 physicians could exceed it's capacity. This is not unusual and many database systems handle many times more. MS Access is not one of them.

Toffler

[Hal333]

I didn't mean to be so critical as I sounded.

Sorry.

Have you tried Amazing Charts?

They used to let you download it and use it for free for a while.

Hal

[docporter]

Can folks just edit old records at will?
Oh boy. I always laugh when I see a question like that. I use a homebrew EMR of sorts, constructed with MS Word. It is completely editable all the time, any time. Not only that, there is no way to tell whether it has been edited or not. That's just the way I want it. Why would one want a record that isn't editable? Heck, I make typos, forget to enter things sometimes, even enter wrong things sometimes.:eek: If and when I discover a mistake, I just correct it. The notion that a record should not be editable comes from lawyers, who may want to use it against you sometime. There is no other good reason why a record should not be editable. (In a practice where many have potential access to a record, it would make sense to limit the ability to edit a record to the person who created it, but not to prevent editing entirely.) Lawyers, politicians and bureaucrats are the only ones interested in locking everything up (as long as they have the keys). I know, I know, it's not "HIPAA compliant" (I bristle whenever I hear the word "compliant"). So what? Being a "country doctor" who has only one employee and submits only paper claims, I'm not subject to HIPAA. Before the invasion of the lawyers, politicians and other scoundrels, the "medical record" was whatever a physician felt it was useful to record to help him care for his patient. In my practice, it's still that way.:)

[alborg]

docporter>>> Before the invasion of the lawyers, politicians and other scoundrels, the "medical record" was whatever a physician felt it was useful to record to help him care for his patient. In my practice, it's still that way.

I agree! Good job... :cool:

HAL333 >>> Congrats on your homebrew system but newcomers need to understand that it really isn't practical for almost every one else.

So why do you think that Microsoft has made so much money on their MS Office series? For that matter, why is Filemaker 7 also so popular? It doesn't take rocket science to write your own EMR if you've successfully gone through medical school. It just takes true diligence and a focus. You're not just realizing a saving of $30000 once, it's a lifelong affair- your system can by upgraded by you for free with exactly those things that you desire. That can save you hundreds of thousands of dollars over the years...

>>> Al where are ya.

Hi Scroggie!! I apologize for being so quiet. I've been busy this summer doing a lot of projects (currently I have my in-laws from Panama visiting!). Of course, I work on my MS Access-based EMR almost daily tweaking it here and there.

The MS Word EMR Project that I put together last year for the first time has so far been downloaded over 900 times. The version 5 will be a MS Office 2003 product, and as always will be free, and will be out in about a week.

At the end of this year I'll be publishing a book on programming your own EMR (using the MS Word platform frontend with a Jet 4.0 backend), which hopefully will make it easier for folks to do it themselves and thus save big bucks! It's actually been quite fun putting together my thoughts on this matter; things seem to just flow out onto the paper. It's my way of making it "open source" and I hope that it'll encourage folks to rethink their EMR plans. :)

Regards,
Al

[mbenjam]

Can we see your EMR, Toffler? Sounds awesome!

[algosdoc]

I have used Amazing Charts for 2 years and am planning on switching very soon.
Upside: dirt cheap, built in scheduling program, interoffice sticky notes, easy setup
Downside: crashes or becomes very slow frequently, Dragon does not work because the word "in" is interpreted as a field in amazing charts for inches....Dragon then proceeds to dictate an entire paragraph into the inches field. Other issues: not tablet friendly, small print on the screen (not scalable), inability to format the output to conform to state prescription laws for schedule II drugs therefore requires a paper chart to hold schedule II scripts, poorly designed ability to look at old notes (takes several clicks), billing company is in-house at Amazing charts and exported billing data is not well liked by many external billing companies, many many bugs in the program that need continual revisions, and Access database that severely limits both storage capacity and speed of operation.

[alborg]

>>> I have used Amazing Charts for 2 years and am planning on switching very soon.
Upside: dirt cheap, built in scheduling program, interoffice sticky notes, easy setup
Downside: crashes or becomes very slow frequently, Dragon does not work because the word "in" is interpreted as a field in amazing charts for inches....

What is this, a bash inexpensive and physician made systems discussion? Amazing Charts is an excellent system from what I've read from numerous other users over the years and in the recent aafp.com survey of 408 physicians it scored well against the likes of e-MDs, but at a much less expensive cost.

BTW, you posted the same letter at the "other" EMR website :mad: , again bashing AC. Seems like a vendetta to me...

>>> Access database that severely limits both storage capacity and speed of operation.

Yes, AC is a MS Access database, and thus it's built upon a Jet 4.0 backend platform that can handle up to 2 GB of data and is maximized to accomodate up to 20 simultaneous users. Jet 4.0 comes free with MS Access and most programmers (like me ;) ) love to work with it. Now, that said, next year AC will offer a whole new system with an optional SQL backend, but I'm sure that this option is going to cost users at least an extra grand for this added muscle which isn't needed.

The EMR that I use at my medical office is a MS Access database very similar to AC. I have used it for over 10 years, and the power of MS Access has been appreciated by everyone of my staff.

I recently reviewed the EMR industry at a talk at the Washington Hospital Center and synopsis of this discussion was presented at the following site-

URL: http://www.medicaltabletpc.com/comp...tpage/Itemid,1/

In my discussion I reviewed all areas where one can get review, s.a. Klas, TERP, AC Group, the aafp.com 408 physician poll, etc. Most of these reviewers I've found to be biased against inexpensive EMRs, although even in this environment AC did well when compared to the heavyweights.

Now, every EMR will have its dissatisfied users. Heck, in the research I did for my presentation I found that of all initial EMR startups, 50% will fail, and of those that eventually make it, only 40% of users avail themselves of most of the EMR's power. So either you are:

- in the ~75% that have failed or failed to optimize your use of your EMR or
- you represent a competitor to AC trying to trash the reputation of this decent EMR.

Which is it? :rolleyes:

Cheers,
Al

[algosdoc]

Alborg, get a life. It is a free country and being a practicing physician having hands on experience with AC for 2 years (far more than you my friend), I have every right to discuss the downside of cheap EMRs so that others can learn about the lack of capabilities. It strikes me as strange that you are so protectionist regarding a simple EMR program? Do you receive kickbacks for your defense?
When you have used the program day in and out for years, then you will have enough experience to make comments about it, but since you have not, it appears you are simply blowing smoke. Go back to your open source EMR and try to develop something constructive....

[alborg]

>>> I have every right to discuss the downside of cheap EMRs so that others can learn about the lack of capabilities.

Fair enough. It just seemed odd that you are attacking AC in numerous sites. That seems to go beyond "discussion" and into the realm of "flaming". Just my thoughts... :)

Now- which EMR have you chosen to use in your office that is so great? What great capabilities does it have that AC lacks that has made you do the switch after 2 years of AC use?

Yeah, I do like low priced EMRs because they are the ones forcing the eventual collapse of the outrageously expensive EMR prices. Alas, there are few of them indeed! We need to help them grow and prosper. Others, like you, have agendas that are contrary to this...

>>> Do you receive kickbacks for your defense?

No, but I've followed the evolution of that program and like the direction that it's going. This program together with SOAPware sells 10 times more software units than e-MDs! AC must be doing something right. Bertman plans on rolling out a complete remake in the next 3 months- why not wait for it to come out? Heck, Praxis folks waited 7 years for their 3.0 version to come out!

Being a MS Access programmers are almost like being in a club- we all respect and enjoy watching the development of each other's "toys".

>>> Go back to your open source EMR and try to develop something constructive....

I'm sorry to hear that you think that the MS Word EMR Project isn't "constructive". Beauty is in the eyes of the beholder, I guess. You should try it sometime... you might actually like it. :rolleyes: Just don't flame my program too... :mad:

Cheers,
Al

[algosdoc]

Having suffered through innumerable crashes of the AC program over the past two years, so many bugs they cannot be counted, a non-scalable prescription program that has required our paperless charting system to have paper charts, and reduced efficiency due to the lack of controls and output from the program, having survived numerous updates with some introducing more bugs than the program had initially, etc etc, the patience of my staff and myself with AC has run thin. The support I have had from AC on repairing the numerous crashes has been excellent, but awaiting for implementation of basic EMR feature addictions has cost us thousands of dollars each year in lost productivity. AC is indeed a good basic program, but I think before any adoption of new software being dumped into our computers, they definitely need a long beta test period given the history of bugs in AC.
I also believe strongly in less expensive EMR just as you do. After examination of over 20 EMRs, we have decided on QD Clinical. It has many advantages over AC although it costs significantly more, yet much much less than eMD or ECW or any of the big boys...
I have not used your program so no flames here :-)

[mel]

What else made you pick QD Clinical, I have to admit I've never heard of them, I just googled their site, they need my details for a demo. :mad:

[algosdoc]

Easy screens without 8 gazillion tabs to click, can go from scheduler directly to patient charts, has PDA patient input capabilities (we currently use a questionnaire on every patient visit) that embeds the follow-up patient info or initial history directly into the chart, also has psychometric testing available on the PDA (SF36) that is scored and embedded in the chart, scalability of the output to prescriptions making their program compliant with state law, built in layered templates, designed to be used on a tablet with no typing, intuitive program that is easy to learn.

[MattBeckwith]

I type 110 WPM, so free-text the patient history. The ability to take a history without typing (and the associated searchable data points that result) are a major asset of high-cost EMR's. This is an asset I do not need.

On the other hand, the low-cost EMR's I've seen do not have certain other bells and whistles which are integral to an efficient practice.

One critical example is the maintenance of a Problem List, Family History, Medications, Allergies, Surgical History and Social History. Even many of the high-cost EMR's (such as Misys) do not have this: you have to go into a progress note to access some of this data.

Since I'm an ex-computer programmer, I could probably design my own EMR based on one of the relational databases out there. Because all I'd need is a set of searchable lists (denoted above) and free-text files of progress notes keyed on date.

[algosdoc]

I am also a very fast typist made necessary by the lack of hierchial templates in AC, but my fast typing will not last forever. Others in my practice cannot type so fast, therefore the push for an EMR that is suitable to all in the practice.

[alborg]

>>> One critical example is the maintenance of a Problem List, Family History, Medications, Allergies, Surgical History and Social History.

Once CCR comes into full swing, all EMRs should have that as a standard feature!

Al

[alborg]

Toffler:

Where are you? How have your self-programmed EMR evolved? :cool:

Cheers,
Al

[r2t2ellis]

DIY is something I would recommend if you have the time and want to commit to a project that never ends. I have worked four years at it and there is never a quitting place. However, I am very proud of what I can do with a patient record now compared to paper.