Finish above: Suits have no clue about MT skills.

Few drs. know/care/or pay for MT services. It is the suits [2008-04-09]
x

Finish above: Suits have no clue about MT skills. [2008-04-09]
x

BINGO ! [2008-10-27]
You hit the nail on the head! Gutless. There aremany socially adept, mentally healthyat-home workingMTs who choose towork fromhome forgood reasons; avoiding daycare costs, caring for an elderly parent in the home, disabled and working from homeismore desireable for them, etc. But a great many at-home MTsI have dealt workfrom homedue toof lack ofhealthy mental self-image, and because theylack good psychologicalhealthas well as thesocial skills that would allow them to interact on a daily basis with an outside group. This type of person suffers from very low self-esteem, self-image issues (often obese), may not play well with others, and consider being bullied over the phone to be the lesser of two evils. In these cases, working alone from home makes their lives a lot less stressful. Unfortunately for the rest of us, whether at home or in the workplace, this type of person is easily manipulated, belittled, often abused by family members and coworkers, incapable of defending themselves, and scared to death to demand that their right to be treated civilly be honored. They are the first tocave in to intimidation, and when grilled for answers they give way like Jello.They are too frightened to step up and do the right thing, for themselves or others, and they silently refuse to face the confrontation thatcould resultfrom demanding the legal rights of their profession. The general attitude of this type of personis don't rock the boat and I won't get yelled at, go with the flow to avoid confrontation, and this attitude is fostered bythemany managers that lead by fear and intimidation. Unfortunately, unless a large group of confident, independent, strong and intelligent young women are recruited into this industry immediately, there will be no union, MTs will continue to cower from management like scared mice, wages will continue tolower (although corporate salaries do not), and as these frightened creatures die off, this industrywill die with them, and because of them. Go ahead and flame me; I'm fireproof.

Time to introduce a bill [2008-06-27]
This is great news but from my experience, the bottom line is all most companies care about. The company I worked for never paid for enough quality control hours-usually only one hour per day and outsourced it's MT work. Records came back with incorrect names, gender, diagnoses, procedures and labs because the outsourced Transcriptionist could not flag the work for the dictating doctor (boss said doctors were too busy to deal with it) and/or entered anything just to get the chart to clear medical records. They only dealt with issues when lawsuits arose and my guess would be that since most cases are arbitrated, the doctors were the winners yet again. All this is to say, even if the suits know they will get better quality, they do not care because they are only concerned with lining their pockets. It is not just MT jobs that suffer because of outsourcing. Will you (or anyone else for that matter)be denied work or insurance in the U.S. because an overseas transcriptionist entered erroneous information in your medical record? U.S. citizens would probably be outraged to discover this is happening to their private information despite HIPPA. I believe it is time to get tough and form a coalition to introduce a bill to end outsourcing of medical transcription. Time to take a stand and fight back.

Outsourcing [2008-04-22]
I worked for an imaging center (I was already gone) that laid off the MT's and outsourced the work back in 2002. It lasted about a month. The doctors got mad and insisted to the suits to bring the MT back. They wasted so much time correcting and filling in blanks. They were spoiled with their MT and even stated that they did not read their reports when they signed them because they had that much confidence in the MT. Good news for the MT, she came back and demanded more money...and got it. Lesson learned.

You're right but ... [2008-04-11]
Yes, absolutely, the suits and middle managers have no clue at all, nada, zip, zilch about medical transcription. However, many doctors actually invest in offshore MT companies .... according to Wall Street Journal. It was, oh, maybe 10 years ago that there was a caption or article about medical transcription being where the money is, as in investments, etc. You're right. Typically the MDs don't know and don't care who transcribes their dictation. Most do care, however, about quality at least to some degree. I'm just glad someone came up with a study as to cost effectiveness for whatever reason. It's like they're thrown us a crumb. Hope we get the whole cookie soon.

WELL if we EVER decide to unite based on [2007-08-18]
what we have in common!!! IF THIS CONCEPT ever gets off the ground, refuse any job that pays VBC - unless of course THAT is how we are allowed to return reports in: thepatientisa35yearoldmalewith... The suits think they'll just train the next batch of scribes to get less for more work. SAY NO TO THIS - by never accepting the new job. Or, don't complain if you DO accept it...

Medical Transcription Recognized as an Apprenticeable Occupation [2006-03-14]
CHICAGO--(BUSINESS WIRE)--March 10, 2006--Graduates of selected medical transcription training programs will now have access to registered apprenticeship programs, as the U.S. Department of Labor (DOL) has now declared medical transcription to be an apprenticeable profession - the first step in establishing a national apprenticeship program. The Office of Apprenticeship Training, Employer and Labor Services approved the application for apprenticeability determination submitted by the Medical Transcription Industry Association (MTIA) along with the American Association for Medical Transcription (AAMT). Having a recognized apprenticeable occupation will provide a pipeline of medical transcription professionals entering into a workforce facing a serious labor and skills shortage. stated Keith Flannery, Vice President, MTIA. Workforce development under the standards established by this apprenticeship program will aid in facilitating the transition between student and an employable, productive, and qualified medical transcriptionist. Given the challenge the industry faces in recruiting qualified candidates to meet the ever-increasing demand for real-time, quality healthcare data, a registered apprenticeship program couldn't be developed and launched at a more critical time, stated Peter Preziosi, PhD, CAE, AAMT Executive Director. Workforce development is essential to ensuring that documentation experts are in place to assist the industry in transitioning to an electronic health record and to preserving the quality and integrity of the health record in that future. The Registered Apprenticeship Program, sponsored by the Medical Transcription Industry Association (MTIA), will offer structured on-the-job learning and related technical instruction for qualified medical transcriptionists entering the profession. The two associations, along with the Office of Apprenticeship Training, Employer and Labor Services, are finalizing program details. Medical Transcription is a crucial process in the provision of quality healthcare in our country. This is a hallmark program for the industry, said Sean Carroll, President, MTIA.

AAMT to start offering its first medical transcription training program in the Philippines. [2006-01-29]
IT education institution Informatics recently signed up with the American Academy of Medical Transcription (AAMT) to start offering its first medical transcription training program in the Philippines.The training modules intend to improve both English communication skills and medical knowledge from basic to intermediate in students hoping to work in the medical transcription business growing in the country. Among the modules are English grammar and style essentials, foreign accent dictation, human anatomy and physiology, pharmacology, diagnostic procedures, laboratory medicines, medical word building, and medico-legal concepts and ethics. Participants with medical backgrounds would have 150 hours of lecture and 160 hours of on-the-job training. Those without medical skills would have 220 lecture hours and 160 hours of on-the-job training. The program intends to train about 2,000 medical transcribers to enter the workforce this year, according to Informatics director for corporate learning Paul Dumaguin. Statistics from the Medical Transcription Industry Association of the Philippines indicate that over 7,000 medical transcribers are needed to meet the demand of the medical transcription business. The US is currently the biggest source of medical transcription and 45 percent of the work is being done by India. Dumaguin said that medical transcribers can work for existing firms, but have an option to work at home as independent transcribers. “Trainees typically obtain employment with an MT outsourcing firm, but with the growth of the industry, they have other options as well, such as putting up their own MT businesses,” Dumaguin said. The worldwide medical transcription business is expected to grow to 25 billion US dollars within the next three years.

The Top 10 Reasons to Become a Medical Transcriptionist [2006-01-19]
January 17th 2006Work From Home You've seen the commercials: medical transcriptionists are in high demand. Should you consider this field? Below are the top ten best reasons to become a medical transcriptionist. If these characteristics are something you're looking for in a job, then medical transcription may be for you. To get started, try “Working at Home the American Way in Medical Transcription” by Debra Jan Hebert, an experienced (http://medtrans4u.com) medical transcriptionist. 10. Quick entryMany lucrative professions require extensive training and advanced degrees. Other jobs in the medical field can take eight or more years of grueling, expensive schooling to begin. In medical transcription, you can begin your work in a year or less, avoiding huge debts and student loans. Some employers require no training, especially not if you already have good English skills and some experience in a medical field. 9. Contribute to societyAs a medical transcriptionist, you can contribute to society in many ways. In addition to the economic contributions you'll make to the overall economy, experienced medical transcriptionists become well-versed enough to catch errors or even act as patient advocates. Medical transcriptionists can see inconsistencies and correct them as well. By quickly returning transcripts to hospitals, private practices and individual doctors, medical transcriptionists can ensure fast patient care in the medical system. 8. Work from homeWhile the Bureau of Labor Statistics reports that 70% of medical transcriptionists still work in hospitals or physicians' offices, medical transcription is becoming increasingly popular as a work-from-home profession. The convenience of a home office appeals to some people on its own virtues, while parents may value the opportunity to stay close to their young children and still support the family full time. No matter what the reason, if you're looking to work from home, you should seriously consider medical transcription. 7. Excellent payWhile compensation methods may vary, almost all medical transcriptionists enjoy excellent pay, even in entry-level positions. According to (http://medtrans4u.com) DJS Enterprises, you can earn as much as $50,000 to $80,000 a year as a medical transcriptionist. If your pay is production-based, as you gain more experience and dexterity in medical transcription your salary will steadily increase. If you're looking for a job that can really support your family working from home, medical transcription may be for you. 6. Job securityThe US Bureau of Labor Statistics reports that the job outlook for medical transcriptionists is definitely positive. The medical transcription field is expected to grow at a faster than average rate through the year 2014. This indicates that medical transcriptionists will have plenty of opportunities to find steady work, even if they work at home on a freelance basis for at least another 8 years. 5. Job satisfactionWhile job satisfaction may vary from job to job and person to person, if you enjoy being able to visibly track the progress you've made in a day, medical transcription can bring you a high level of job satisfaction. As your completed medical reports pile up, you'll be able to see how much you've accomplished. 4. Set your own hoursMost of the medical industry operates 24 hours a day. Many hospital and at-home medical transcriptionists are able to set their own hours at any time to accommodate their families or other commitments. No matter when you're able to work, there's a medical record waiting to be transcribed. In medical transcription, you can work when it's most convenient for you. 3. Comfortable work environmentWhether they work in a hospital, a private office or from home, medical transcriptionists enjoy a comfortable work environment. Noise levels are low, safety risks are minimal and strenuous labor is negligible. In medical transcription, you'll enjoy a comfortable office and dedicated work station to transcribe. And what could be more comfortable than working in your own home? 2. Transferable skillsMedical transcriptionists acquire many transferable skills that they can use in other jobs if ever they want to leave the industry. In addition to a basis in the medical field, transcriptionists learn skills that could apply as a court reporter or an administrative assistant. Transcriptionists also develop their English skills, which can be useful in all types of positions that involve writing and editing. Whether medical transcription is a step on your path or your dream job, the skills you learn can improve your overall career outlook. 1. Rewarding workWhy do people become doctors? The vast majority of the people who endure 8 or more years of schooling and incur substantial debts and student loans to become doctors do so because they love to help people and to cure them of their illnesses. Every member of the medical field helps in this endeavor. What could be more rewarding than to contribute to the speedy treatment of people who desperately need your help? If these ten things sound like characteristics you're looking for in a job, look into medical transcription. You can learn more about medical transcription from books, the Bureau of Labor Statistics and other materials online.

Spheris India looking at expanding in tier-II cities [2005-10-20]
BANGALORE: US-based medical transcription company Spheris, which recently acquired HealthScribe, is looking to expand in a tier-II cities in India, preferably in the South by 2006. Spheris India (formerly HealthScribe), based in Bangalore, recently opened an additional 300-seat center in Coimbatore this month. The company has over 2000 employees in India at present, and plans to ramp up the headcount to 3000, next year. “We feel that large cities are very competitive while smaller cities have a lot more candidates who are serious in taking up medical transcription as a full-fledged career,” said Suresh Nair, CEO and MD, Spheris India. Elaborating this aspect, he said that unlike BPOs or call centers, which require good spoken English skills, medical transcription is more knowledge-oriented and needs good grammatical skills. Commenting on the merger with Spheris- the second biggest medical transcription company globally, he said that the move had made HealthScribe a truly global company with access to bigger funds and support for growth. The company has already added 15 new accounts from the Spheris' stable. Nair said that next year, he plans to start a technology development team that would build solutions based on their delivery platform and sell them commercially. Nair also revealed that by end of 2006, Spheris India would look at new areas like medical coding and billing. Spheris' revenues globally are in the region of $200 million. He expects Spheris India to grow at 60% this year. “The medical transcription industry has made a comeback in India and US customers are sending more and more work to us,” he said.

Dictaphone Expands ichart Speech-Certified [2005-09-09]
Dictaphone Expands ichart Speech-Certified Transcription Network; Responds to Increasing Demand with Certification Program and Call for Additional Transcription Partners American Association for Medical Transcription (AAMT) Annual Convention and ExpoHONOLULU--(BUSINESS WIRE)--Sept. 6, 2005--Today at the American Association for Medical Transcription (AAMT) Annual Convention and Expo, Dictaphone announced the creation of the healthcare industry's first Speech-Certified Transcription Network in response to the substantial growing demand for its ichart(R) Managed Services solutions. ichart Managed Services combines Dictaphone's industry-leading speech recognition technology with transcription services performed by Dictaphone's Speech-Certified Transcription Network, which has been trained to edit on the company's speech recognition platform. This combination of labor and technology delivers lower-cost, high-quality medical transcription with rapid turnaround. All Dictaphone transcription service partners are required to pass its rigorous certification program to ensure even higher levels of service excellence and proficiency in speech recognition editing. ichart Managed Services is quickly proving what we suspected when we introduced the product less then one year ago: that using speech recognition to drive down the enormous costs and improve the quality of transcription is the future of medical documentation outsourcing, said Don Fallati, senior vice president of marketing for Dictaphone. The overwhelming response we've had from the market is driving us to create the first Speech-Certified Transcription Network, offering our clients the most talented and best-equipped group of 'speech recognition-enabled' transcription service providers. Speech-Certified Transcription Providers are thoroughly trained, evaluated and benchmarked against specific industry-standard quality, speed and customer service metrics. Those that meet the strict criteria will receive certification and will be reevaluated quarterly to ensure continued adherence. Tamara Brown, president and CEO of Encompass Medical Transcription, Inc., a member of Dictaphone's Speech-Certified Transcription Network, said, ichart has allowed us to increase the volume of work Encompass can do with our existing staff and enabled us to train new medical transcriptionists to generate high-quality reports at a higher level of productivity. Headquartered in Wisconsin, Encompass is a U.S. medical transcription company that employs only U.S.-based medical transcriptionists. We welcome and encourage other medical transcription companies to join the Speech-Certified Transcription Network, Fallati said. The interest we've seen from potential partners wanting to participate in the program has been significant and reflects the broad momentum in our industry for acquiring the skills associated with speech recognition. About Dictaphone's ichart Managed Services Dictaphone's ichart Managed Services offering aims to meet the needs of organizations currently relying heavily on outsourced transcription but who are attracted to the savings that can be generated by speech recognition. The program blends Dictaphone technology with transcription services performed by Dictaphone's Speech Certified Transcription Network who have been trained to edit on the company's speech recognition platform. Customers receive a blended line rate covering work that is transcribed traditionally as well as documents edited from speech recognition. Frequently, significant savings can be achieved by healthcare organizations over current line charges. About Dictaphone Healthcare Solutions Group Dictaphone is the world's largest supplier of dictation, transcription and speech recognition systems and services that simplify and enhance the production and management of paperless electronic patient information. Through the integration of speech recognition and natural language processing within existing health information management workflow, Dictaphone systems are helping healthcare organizations save money and improve patient care by increasing the speed, accuracy and usability of their medical documentation. For more information, please visit www.dictaphone.com or call 1-888-350-4836.

INDIA - Why medical transcription is such a major draw [2005-08-20]
The medical transcription business is drawing people from other sectors. That’s because the income can be quite substantial. Transcriptionists are paid anywhere between 60 paise to Rs 2.0 per line. At a minimum of 6 hours and transcribing 800 lines per day, transcriptionists can make around Rs 1,200 a day. Working 26 days a month, they earn more than Rs 30,000 (USD 450 - 500)a month. They send their reports to an Editor for proof-reading who are paid upwards of Rs 40,000 per month. As a result, hundreds of professionals are quitting their regular jobs to assist US doctors in transcribing their conversation with patients. X-ray, pathology, surgery and discharge reports of US patients are also being transcribed out of India. To be a transcriptionist, an aspirant has to acquire skills in medical terminology. The next step is the editor. Level three is a quality analyst (QA) who has to work out of the office of the MT firm. It’s a daily ritual for thousands of homemakers across India. After sending husbands to work and kids to school, they download voice files and start transcribing medical illnesses of patients in the US. Slowly, medical transcription from home is becoming a phenomenon, particularly in tier-II cities where the BPO boom hasn’t yet caught on and educated women are still not being encouraged to venture out of home. “Almost half of our 600 home employees are women. Working from home allows them to spend more time with family,” said Mr Rajiv Shetye, VP, Spryance, a Boston-based medical transcription firm which now has 1,200 employees in India. According to estimates, India has about 100 medical transcription companies and the big ones include Accusis, Spryance, Stheris and Heartland. About 10,000 people work in the $120 million-strong industry. Still, there is a lot of untapped potential. The US market for market transcription is about $12 bn per annum, which is more than double the BPO exports of India. More than 700 million hospital events need to be recorded every year. According to Nasscom, about 1.6 lakh such transcriptionists will be needed in India by 2008. Earnings depend on how much time a person is able to devote. Billing is based on the number of lines transcribed. HARSIMRAN SINGH

Electronic Health Records: Just around the Corner? Or over the Cliff? [2005-08-02]
We recently implemented a full-featured electronic health record in our independent, 4-internist, community-based practice of general internal medicine. We encountered various challenges, some unexpected, in moving from paper to computer. This article describes the effects that use of electronic health records has had on our finances, work flow, and office environment. Its financial impact is not clearly positive; work flows were substantially disrupted; and the quality of the office environment initially deteriorated greatly for staff, physicians, and patients. That said, none of us would go back to paper health records, and all of us find that the technology helps us to better meet patient expectations, expedites many tedious work processes (such as prescription writing and creation of chart notes), and creates new ways in which we can improve the health of our patients. Five broad issues must be addressed to promote successful implementation of electronic health records in a small office: financing; interoperability, standardization, and connectivity of clinical information systems; help with redesign of work flow; technical support and training; and help with change management. We hope that sharing our experience can better prepare others who plan to implement electronic health records and inform policymakers on the strategies needed for success in the small practice environment. Policymakers and physician leaders are counting on electronic health records to improve quality of health care and revitalize practice , and a recent report forecasts that widespread use of electronic health records will save the health care system $77.8 billion annually—5% of total health care expenditures in the United States. It is difficult to get an accurate figure for use of electronic health records by primary care physicians, but estimates range from 5% to 13%. Seventy-eight percent of physicians in the United States practice in groups of 8 or fewer; therefore, understanding and overcoming the obstacles faced by small practices will be essential to successful use of electronic health records. Although the experience of small physician practices that implemented electronic health records has been usefully described, more work is needed. Our independent, community-based, 4-internist primary care medical practice went live with an electronic health record system on 14 July 2004. We report on our experience. Our medical practice, Greenhouse Internists, has operated in Philadelphia since 1989. We serve an economically and ethnically diverse urban and suburban population. We derive approximately 60% of our revenue from capitated managed care and participate in Medicaid (through 2 Medicaid health maintenance organizations) and Medicare (fee-for-service and capitated managed care). We handle more than 16 000 patients encounters yearly, and our focus is comprehensive ambulatory care. We have 1 registered nurse who handles clinical and administrative contact with insurers, forms, telephone triage, and routine prescription refills; a front desk staff that handles reception, referrals, and telephone calls; and medical assistants who handle chief symptoms, vital signs, phlebotomy, and electrocardiography. We have no mid-level practitioners. Before we instituted electronic health records, we used computers for scheduling and billing only. When our malpractice carrier stopped offering occurrence coverage and we had to accept claims made coverage, we used the 2-year savings window to invest in an electronic health records system. Our motivation was complex: We hoped it would automate frustrating repetitive processes (such as prescription refills) and minimize some of the ways in which we routinely failed to meet patient expectations (such as one of us not knowing what another had said the previous day to a patient on the telephone). We hoped that the system might pay for itself, but we were not at all confident that it would. We made a leap of faith that pay for performance was coming and that this investment would eventually position us for greater success. Like many of our colleagues, we believed that we would have to implement an electronic health record system sooner or later, and the one-time cash surplus made it possible for us to do so sooner. One of us had experience in managed care and population health and was hoping to use those insights at the practice level. We chose our system on the basis of recommendations of colleagues and because it was offered by a large national company. We hoped that the latter attribute would make it more likely that we could count on long-term support. We did not interview multiple vendors because we believed that all full-featured products would have unanticipated advantages and disadvantages. To support our electronic health records system, we needed to change the practice management system that was in place for scheduling and billing. To minimize the impact on physician–patient interaction, we opted for an encrypted wireless network with Tablet personal computers (Hewlett Packard, Palo Alto, California), which we purchased from a different vendor. None of the physicians was especially computer-literate. The total quoted cost of our system, including hardware, software, training, and 1 year of support, was approximately $140 000, which is within the range that other investigators have reported on a cost-per-physician basis. Staff and Physician Training Training meant different things to different team members. None of the physicians had previously used a Tablet PC with a Windows XP operating system (Microsoft Corp., Redmond, Washington), and we needed training on the device as well as on the new system. Some staff members had never used a mouse (our previous practice management system was not Windows-based). The medical assistants, who had previously made notes by hand, were now asked to use wireless-equipped laptops with mouse pads or track-ball pointers. For the system itself, 2 types of training were given. Super users were taught how to set up and administer the record (and therefore were enabled to make some structural changes to the system). Regular users were trained in basic system operation but were not given administrative training and privileges to make changes to the system. Super users were charged with customizing the system for our particular practice environment and developing work flows, which were clearly defined and documented steps to guide everyone on how to use the new system to accomplish the work of the office. After 2 rounds of planning meetings and 2 days of on-site training, we went live, meaning that we committed to using our electronic health record to document clinical care from that time forward. Training requires organizational redundancy or reserve; in a busy physician practice, neither is present. Our business manager incurred an injury that kept her out of work for 1 month before we went live; during that month, much of our focus became covering her core functions (payroll, billing, scheduling, and staff management) rather than training. For the first 3 days of live operation, we reduced our appointment schedule by 50%; thereafter, we attempted to maintain our schedule at two thirds for 2 weeks, but ongoing demand for appointments made this impossible. Hardware and Performance We had put in place a complex computer network that none of us knew how to support, maintain, or operate. Shortly after we implemented the practice management system, we experienced a virus attack that crashed our system. After the virus was removed, we experienced several lengthy losses of both telephone and data service. Identifying the cause of each of these system failures was a diagnostic problem well beyond our skills, with several possible corporate culprits. Before we went live, we had had a limited, inexpensive relationship with a small local computer support company; because we were paying annual support fees to both hardware and software vendors, we thought we would not need these local services after implementation. We were wrong. In fact, our relationship with the local company expanded rapidly in time, importance, and cost after implementation. Because we now rely on our system for core clinical functions (prescriptions, telephone calls, and accessing records), small technical malfunctions create major operational problems. Our expanded relationship with the local computer company now costs an unbudgeted $2000 per month, and the response time of our technical support is often inadequate. Redesign of Office Work Flow A well-run primary care office is a complex interdependent operation with well-defined work flows. General principles that guide the design of work flows in our office include simplicity and accessibility for patients, safety, comprehensive documentation, and delegation. We operate under the assumption that the physician is the most skilled, and most expensive, person in the office and should only do what no one other than a physician could do. Our entire office meets monthly for 1 hour, and weekly meetings of staff teams are held to adjust work flows as conditions or demands change. Responding to a request for a prescription refill, for example, requires 3 or 4 people performing interrelated but distinct tasks to deliver it safely, reliably, and promptly; we average 30 to 40 such requests daily. The collective integrated operation of our office thus represents 15 years of weekly and monthly staff meetings that constructed our functional systems piece by piece over time. On 14 July 2004, we had to redesign every office system we had in place. Our commitment that going live would mean that documentation of clinical care on or after that date would be created and found in the electronic health record seemed simple, but clinical care included not only office visits but telephone calls, prescription refills, handling of laboratory results, and other functions. Each of these tasks had a work flow, and all work flows had to be redesigned more or less simultaneously. A clear go-live date was desirable because, as a matter of patient safety, we needed to know where to look for information, and the longer we ran parallel paper and electronic systems, the harder that would be. The process of radically redesigning 15 years of accumulated work flow in a short interval was extremely stressful. The system we chose is designed for flexible application in a variety of settings, ranging from large integrated delivery systems to smaller practices. Although the vendor urged us to think through and document the new work flows in advance, we found ourselves making innumerable decisions about how we would use the system before we really understood how it worked, and our vendor did not know enough about how our office worked to help us. We were forced rapidly to adjust our work flows during implementation, which seemed akin to redesigning an airplane in flight. Decreased Competence and Increased Effort Going live rendered everyone in the office incompetent to do their core jobs. The front desk had to use new on-screen forms to record telephone messages; pairing electronic messages with paper charts required the file clerks to follow a new work flow; physicians had to find telephone messages on their computer desktop rather than neatly piled in a physical telephone message bin. The medical assistants had to record vital signs and chief symptoms in the computer and had to learn how to record results of a tuberculosis skin test, visual acuity test, or urinalysis. Everyone in the office simultaneously experienced pervasive anxiety and unhappiness. Waiting time for patients dramatically increased. In short, people were miserable at work. We began to have weekly full staff meetings and weekly physician meetings, all of which were more acrimonious than they had ever been. Variations in clinical style and work flow among the physicians—which had seemed acceptable if unnoticed before—now became a subject of group scrutiny. What did we have to change, and what could we hang on to? What did the physicians have to do the same way, and where could we tolerate difference? All these issues had to be renegotiated at a time of enormous stress on the practice. We observed that a culture of blame set in: Things were not going well, and it had to be someone's fault. Several staff members complained that the work environment was less collegial, and they often felt criticized, as one put it, by everyone. They did not associate these feelings with the electronic health record and, at least initially, neither did we. Coincident with our shared frustration came a dramatic increase in workload, especially for the physicians. Even when we had reached the point where we could competently use the new system, every patient represented a new patient to the electronic health record, and the old paper chart had to be abstracted and data moved into the electronic chart. Some aspects of chart abstraction could perhaps have been delegated (for example, entering medication lists or immunization histories), but we worried that our staff—who have only limited clinical training—might make mistakes, and decisions about what data to abstract require the clinical judgment of a physician. At first, the system shut down daily at midnight for backup and maintenance; backup was later moved to 2:00 a.m. to accommodate 2 of the doctors who were trying to work from home in the evening. The stress level in our office remained high for about 3 months, by which time we had seen most of our complex patients and entered their long medication and problem lists into the system. We had now begun to realize some of the benefits of computerization, including computer-generated prescriptions, faster access to specialist correspondence, real-time access to charts anywhere in the office, the ability to message or route information and tasks electronically in the office, and the ability for the same chart to appear on multiple desktops. Within 4 to 6 months, waiting time had improved and staff were more excited and confident. Patient Acceptance Patients have been impressed and pleased to see their prescriptions appearing on wireless-enabled printers sitting unconnected to our Tablets. They have also enthusiastically benefited from occasional use of the Internet or such tools as the National Cholesterol Education Program Risk Calculator during their visit. Some patients, however, found the increased waiting time during the early phase of implementation unacceptable, and many left our practice because of it. At a time when everyone in the office was stressed, our customer service skills were not at their best. Several patients have asked a version of a question posed by a supportive, long-established patient: Doctor, do you find you are spending more time interacting with the computer than with your patients? For a while, the answer was clearly yes. Financial Impact Our total annual budget for technology support before implementation was approximately $10 000, which comprised maintenance and support of our previous practice management system and limited network. Our postimplementation annual budget will be $40 000, which includes annual support payments to hardware and software vendors and our local computer support vendor. We will have $24 000 in annual carrying costs for the financing of our system purchase over the next 5 years. The clearest savings we have seen was from the elimination of $45 000 in annual transcription costs. Although the file clerks no longer do filing, they now scan and name correspondence (see the following description), and we have been able to eliminate only 1 staff position for an additional annual savings of $20 000. We expect savings on chart supplies to be offset by increased costs of toner and printer maintenance, technical support, and replacement of equipment. At best, we see the expense side as a wash. On the revenue side, we accrue no additional revenue from any current payer for having an electronic health record. We had already maxed out on most quality incentives for which we were eligible when we were using well-organized paper charts and office systems. The electronic health record may enable us to see more patients in the same time or offload physician work more reliably and safely because the system provides clear, timely, legible documentation to support expanded clinical team activities, but this reallocation will require substantial staff retraining. Within 1 year of implementation, we expect to free up our current file room space and perhaps make it clinically productive and revenue-generating. As an offset to these potential gains, it is possible (although unlikely) that physicians will be less productive because the electronic health record generates more work for them. For example, whereas the physicians used to dictate notes, they must now type them. Physicians must also participate more in filing. Our electronic system offers us 24 document types (for example, consultation or laboratory report), and each document must be assigned a type and given a name. Because accurate labeling and data entry are essential both to take advantage of the information retrieval capability of the system and to find anything once it is filed, the physicians must oversee and modify the categorization and manual input of key data elements. As a result, we often feel like data input drones. No wonder one of us described the new work flow as a physician speed-up. Computerization in a world without established standards that link medical data systems is inefficient. When we have a working interface, as we do with our main outside clinical laboratory (which handles about 80% of our laboratory testing volume), the reports come named, and the individual laboratory results automatically populate flow sheets and letters to patients. Results can be efficiently retrieved and graphed, and trends can be analyzed. Unfortunately, most of the information we receive (such as radiology reports, consultations, and procedure reports) does not come to us in a format that the system can recognize electronically. Our colleagues in integrated delivery systems and the Veterans Administration do not face this problem because most of their clinical data are generated within their system and the interfaces already exist. National standards on the interoperability of medical data systems would be a big step forward for small practices. For now, we may switch referral patterns to hospitals and specialists who will give us information in a form that flows most easily into our system. Lessons Learned It is naive to assume that small practices will move to electronic health records without a variety of supports, one of which is certainly financing. None of the many beneficiaries of our investment—patients, insurance companies, our specialist colleagues, health plans, our liability carrier—have directly shared in the cost of implementing an electronic health record system. Enhanced reimbursement models will be needed for wider adoption. This could be achieved through performance incentives tied to implementation of such systems in capitated contracts or through a common procedural terminology code for data transfer to reflect the one-time increased effort and cost of moving data from paper to electronic format. A recent report estimates incentives of $12 000 to $24 000 per full-time physician per year would be needed to make the business case for immediate adoption of electronic health records, with those incentives transferring to performance-based incentives over time. Any of these incentive models would work for us and make adoption easier in other small practices. Although some predict that vendors will shift their focus to the small practice market, it is difficult to see how vendors will support implementation of an electronic health record in the small practice setting while keeping prices affordable. Small practices need much more training and support from vendors than do large groups. The support provided by our large national vendor presupposed the existence of dedicated information technology staff and an administrative layer that could plan work flow and train staff. Neither of these infrastructures are present in a small office, and both are critical to success. In addition, small practices need structured assistance to develop their capacity to manage organizational change. Models of shared local training and support must be developed if small offices are to be successful in implementation. Perhaps the most important asset we could have used to ease the pain of implementation was more clinical capacity. A decline in productivity after implementation of an electronic health record seems inevitable, and if a practice is already straining to meet patient demand, an absence of reserve magnifies the stress of implementation. For us, the financial stress of acquiring the electronic health record precluded simultaneous addition of a new mid-level practitioner or physician, which argues even more strongly for the need for financial support. Patients want and expect their physician, especially their primary care physician, to have a comprehensive grasp of what is going on with them medically and to be able to respond to such questions as, How much weight have I lost? or What was my cholesterol level last time? Clearly, aggregating comprehensive clinical information at the point of care is a basic function of excellent primary care. Why is it that every academic health center and hospital acquires state-of-the-art cardiac imaging tools promptly, but primary care offices and residency training programs are still using paper records? Given their experience with other customer service operations, such as retail, banking, or travel, patients assume a level of information technology infrastructure that most of us in health care simply do not have. Unsupported by technologies now taken for granted almost everywhere else, we in health care regularly fail to meet basic patient expectations. A major factor that prompted us to adopt an electronic health record was the hope, now at least partially fulfilled, that it would improve our ability to meet patient expectations and improve our job satisfaction. Despite the difficulties and expense of implementing the electronic health record, none of us would go back to paper. We find ourselves able to be better physicians: We communicate more quickly and clearly with patients on the telephone and by letter, transmit important clinical information (albeit on paper produced automatically by our system) more efficiently to specialists, and spend less time paging through charts to find out what the previous cholesterol values (for example) had been. Practicing with a computer in hand allows us to access current health information for ourselves and our patients without having to leave the room or interrupt the flow of a patient encounter. We have already caught a glimpse of population health possibilities when, on the same day as the withdrawal of valdecoxib from the market, we were able to identify and send letters about the withdrawal to the 16 patients in our practice who were taking the drug. We expect soon to produce a list of patients with diabetes so that we can audit their care and see how well we meet our care standards. We also plan to use our electronic health record to provide each of these patients with an individualized report on services for which they appear to be overdue. If the United States is to realize the benefits of information technology in health care, substantial investments will be needed to shepherd small offices through what is an arduous process. We believe that many practices will examine the current environment and defer a decision to adopt an electronic health record, and given our experience, it would be hard to disagree with them. All the hoped-for benefits to the overall delivery system and to patients will only accrue if small offices, which are the access points to health care for most patients in the United States, successfully adopt information technology. We believe that new models are urgently needed to deliver both financial and administrative support to those who would accept the challenge. Author and Article Information From Greenhouse Internists, P.C., Philadelphia, Pennsylvania. Acknowledgments: The authors thank their office staff for their courage, flexibility, and support throughout this project. Without their willingness to try something new, implementation of the electronic health record would not have been successful. They also thank business manager Debbie Preite for her leadership and willingness to learn more about computers than she ever thought she could, or wanted. Finally, they thank Cheryl Norvell for manuscript assistance and Steve Downs, Holly Humphrey, and David Reuben for their encouragement and review of an earlier draft of the manuscript. Potential Financial Conflicts of Interest: None disclosed. Requests for Single Reprints: Richard J. Baron, MD, Greenhouse Internists, P.C., 345 East Mt. Airy Avenue, Philadelphia, PA 19119; e-mail, rbaron@greenhouseinternists.com .