Physicians and other healthcare providers often find the jargon of Health Information Technology just as confusing as medical jargon is to patients. Hopefully, this brief glossary of names and terms, which is not intended to be exhaustive, will assist physicians investigating electronic medical record systems.
CCHIT – Certification Commission for Healthcare Information Technology (CCHIT); the recognized certification authority for electronic health record systems.
Client(s) – A client is the requesting program or the user’s computer in a client/server relationship.
Database – A mechanism for organizing the data in an electronic medical record (EMR), electronic health record (HER) and practice management system (PMS).
DOQ-IT – Doctor’s Office Quality - Information Technology
EHR – Electronic Health Record; a longitudinal digital record intended to interact with systems outside the office, i.e. lab facilities and government agencies.
EMR – Electronic Medical Record; a digital means of recording patients’ histories, physical examinations, progress notes, laboratory reports, and other diagnostic tests for the office or hospital, usually at a single location.
IT – Information Technology
PHR – Personal Health Record; a patient-centric repository of information, which can often be modified by the patient.
Physician Portal – A Web-based communication method between physicians and patients.
PMS – Practice Management System; software generally used for billing purposes.
P4P – Pay for Performance
RHIO – Regional Health Information Organization; a means to connect different healthcare providers, laboratories, hospitals, and other agencies.
RxHub – A consortium of Pharmacy Benefit Managers whose mission is to improve patient safety and contain healthcare costs. RxHub connects physicians, pharmacists, and payers via secure electronic transmissions, consistent with HIPAA regulations, to confirm formulary information. RxHub transmits up-to-date patient medication history and pharmacy benefit information to physicians in their offices and at hospitals. Physicians receive this information prior to writing any prescriptions, thereby minimizing patients' risk of adverse drug events.
Server – In the client/server programming model, a server is a program that awaits and fulfills requests from client programs in the same or other computers. A given application in a computer may function as a client with requests for services from other programs and also as a server of requests from other programs.
SureScripts – An organization of approximately 85% of the nation’s pharmacies, SureScripts, through its Electronic Prescribing Network, links pharmacies and physicians, allowing the electronic exchange of prescription information.
TIFF, JPEG – Image storage standards; digital image file formats designed for maximal image compression; TIFF = Tagged Image File Format; JPEG = Joint Photographic Experts Group.
VAR – Value Added Re-Seller; a company that sells software and, frequently, hardware.
On July 29, 2006, the Certification Commission for Healthcare Information Technology (CCHIT) released, on its Web site, the names of 18 software vendors that have met the Commission’s 2006 Ambulatory EHR Criteria for many common ambulatory care settings. The 2006 list finally grew to over 80 vendors. The 2007 list has shrunk down to seven vendors. Since the standards become more encompassing each year, the number of vendors who qualify will wax and wane. Keep an eye on the vendors who consistently re-certify.
Certification does not mean that a non-certified system doesn’t comply. Rather, it means the non-certified company chose not to pay the fee for evaluation of the software. The advantage of the certification process to your medical practice is that you can now compare apples to apples, without receiving a degree in Information Technology (IT). Most of the features the majority of physicians want in an electronic health record system are currently in place in the certified products.
Since the technical aspects of each software package are consistent, you can focus, instead, on more practical matters, such as the price of the software, support, training, and installation, as well as the ease of use, the degree of interoperability, and the financial strength of the company (i.e. will they be around in three years?).
There are at least three ways to acquire and use the software: (1) purchase the license; (2) subscribe annually and run the software from your office; or (3) subscribe annually and run the software remotely. This latter option is usually known as the ASP (Application Service Provider) model. Purchasing the license outright (option 1) is the least expensive option in the long run. If you purchase the license, you must set up the network in your office with a Server and multiple Clients. In this model, the Server does most of the work and may cost as much as two or more Clients. Most software companies provide the minimum specifications for the Server and Client; however, I recommend that you seek that advice from an IT specialist when purchasing and, ultimately, connecting the network. You can choose a VAR to purchase some of or all of the software and hardware components and complete the installation.
If you select the subscription model (option 2), you avoid the upfront cost associated with the purchase of a license; however, you will still incur the cost of setting up a Server/Client network. After two to three years, you usually are past the break-even point, and the cost of use continues to grow. Some vendors permit you to use the subscription to test drive the product. They will then roll part of the subscription fees into the purchase of a full license.
The ASP model (option 3) requires the software vendor or VAR to set up a server outside your office. The server can be one mile to a thousand miles away. The office connects to the server through an Internet connection. The vendor or VAR is responsible for maintenance of all software. The Internet connection can be expensive, since it must be “up and running” 99.9% of the time. This level of service costs between $350 and $750 per month per connection. Most vendors or VARs recommend having two lines of connection to further reduce the risk of disconnection. Remember, if your Internet connection goes down, so does your access to the EHR. The Internet connection may be completed as a license purchase or a subscription.
Annual software support usually costs between 15% and 20% of the license fee. With subscriptions and ASPs, the support can be bundled into the monthly rate. You must be certain that the support hours correspond to the bulk of your office hours. After-hours support, including support on evenings and weekends, is usually available for an additional fee. If you are not using a VAR, you should enter a separate hardware support contract with a local company. However, distributing hardware and software support between two separate sources may potentially lead to finger pointing if, and when, a serious problem arises with the system.
Ease of use can be determined only by using the product. I recommend that you attend trade shows and visit practices that already have the system in place. If you arrange for a demonstration in your office, block out at least two uninterrupted hours. You and your staff need to have hands-on experience with the system to make an educated decision. Never rely solely on a salesperson’s canned presentations. Some vendors will give you access to Web-based versions of the software or give you time-limited demo copies to use in the office. If you qualify, enroll in DOQ-IT. Even if you don’t qualify, take advantage of all the free tools on the DOQ-IT Web site to prepare for and implement an EHR. The Medical Society of New Jersey (MSNJ) and many local county medical societies are also a good resource. They offer presentations by physicians who are trained to discuss this topic.
The degree of interoperability is one of many features that make current and future versions of EHRs so useful. To assist you, CCHIT has a Buyer’s Guide on its Web site (see list of links at the end of this article). Currently, many of the EHRs permit receipt of laboratory results, electronic requests for medication refills, and electronic transmission of medication prescriptions.
Many software companies are publicly held, and their financial information is readily available. Privately held companies may provide you with financial data upon request. When you do make your purchase, always request a copy of the source code, via an escrow account, in the event of the financial failure of the company. This improves your options if transitioning to another vendor becomes necessary.
Related Links
www.aafp.org
www.aap.org
www.acponline.org
www.cchit.org
http://ehrphrpatientportal.blogspot.com/
www.ipro.org
www.msnj.org
http://www.qualitynet.org/ (this is the new website for DOQ-IT)
Sidebar: Read about Dr. Volpe's personal experience implementing and utilizing EHRs here.
This article has been reprinted with the permission of Medical Liability Mutual Insurance Company (MLMIC). It originally appeared in the Fall 2006 issue of Dateline, MLMIC’s newsletter for physicians and surgeons. It has since been updated to provide the most current information.
