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From what I've read [2008-06-14]
M-TEC and Andrews are in the very top of the best schools around. I've checked their websites and the prices are around $2500-4000. They also are really good about job placement (from what I've read). I also found a Sylvan program for MT which is very reasonable, but I cannot attest to how good the program actually is. I do, however, know it's a reputable company.

where can we access and read this study? nm [2008-06-06]
nm

Electronic Health Records on MSNBC--interesting article [2007-07-20]
Ifound this pretty interesting. Thought I would share with all of you. If you have already seen the article, sorry for the duplication. Electronic health records don FONT-FAMILY: Arial>Electronic health records -- touted by policymakers as a way to improve the quality of health care -- failed to boost care delivered in routine doctor visits, U.S. researchers said on Monday. http://www.msnbc.msn.com/id/19684970/from/ET/

I'd never read this article from May, [2007-07-06]
but had just heard about it. There are some very important details given about this company.

Read Book [2006-10-12]
Order book Working at Home the American Way in Medical Transcription. www.medtrans4u.com Lots of tips on getting a medical transcription job TODAY.

look who wrote the article - an Indian. SM [2005-09-09]
You should send the hospital administrator an anonymous letter and let them know that their records are being sent to India. Spheris just got in trouble for not informing a hospital in California that they were sending the records overseas.


Google

If I might add a word or two [2008-07-22]
Make sure you fully understand the rules of being an IC. The number one rule is: The element of control. An IC has it. A service cannot tell you the hours and/or days you have to work, the pay rate, or anything else of that nature. The rules that apply to the service (which is an IC faction) also apply to you. Here's a web site with the rules: http://www.irs.gov/businesses/small/article/0,,id=99921,00.html

From what I've read [2008-06-14]
M-TEC and Andrews are in the very top of the best schools around. I've checked their websites and the prices are around $2500-4000. They also are really good about job placement (from what I've read). I also found a Sylvan program for MT which is very reasonable, but I cannot attest to how good the program actually is. I do, however, know it's a reputable company.

No surprise statement you made...This board has (sm) [2008-06-09]
more take-offs than the 3 most heavily departing airports in the US: RANK AIRPORT: 1. Flag of the United States Hartsfield-Jackson Atlanta International Airport Atlanta, Georgia, United States ATL/KATL 994,346 2. Flag of the United States O'Hare International Airport Chicago, Illinois, United States ORD/KORD 927,834 3. Flag of the United States Dallas-Fort Worth International Airport Dallas/Fort Worth, Texas, United States DFW/KDFW 684,779 HURRY UP AND READ THIS BEFORE IT'S TAKEN OFF! LOL OFF!!!!!

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.

link? [2008-04-18]
Do you have a link to or source for this study? I'd like to read it. Thanks, Amy

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.

Study on outsourcing -- For Real! [2008-04-08]
Put this under your hats, but there has been a study performed in Ohio regarding the cost effectiveness of outsourcing transcription versus bringing American MTs onboard to handle all of it. Oh, happy day!! The concensus is ..... sit up and read this twice ...... it is more lucrative to hire more people who are skilled and pay them a nice hourly rate with benefits than tooutsource some or all of the work.Hang in there. What goes around, comes around. It's about timethat the true cost effectiveness of inferior work be scrutinized. There are managers and QA's and editors and customer service people up the ying-yang who may have to worry a bit because I truly feelthat doctors across the county (many of whom have invested in outsourcing medical transcription)are beginning to realize that it definitely is a skill/profession that needs to stay here in The States. Woooohooo!

can't find message i left [2008-04-01]
left a quick message for an article I just read and I have no idea where it is. All I can find our these chatty things.??????

Google to test pilot storing patient health records.... [2008-02-21]
I read this article on the Fox News page this morning. A worthwhile read for all interested - http://www.foxnews.com/story/0,2933,331613,00.html

Very interesting [2007-07-21]
article. We are just in the beginning phase of going electronic at my place of employment. I think it is a pain in the butt, especially when we have those in authority who have no idea what they are doing. We have records stored everywhere currently. We have some as hard copy in charts, some in a program called Ecet, and others just floating around. It is totally chaotic.

Electronic Health Records on MSNBC--interesting article [2007-07-20]
Ifound this pretty interesting. Thought I would share with all of you. If you have already seen the article, sorry for the duplication. Electronic health records don FONT-FAMILY: Arial>Electronic health records -- touted by policymakers as a way to improve the quality of health care -- failed to boost care delivered in routine doctor visits, U.S. researchers said on Monday. http://www.msnbc.msn.com/id/19684970/from/ET/

VBC- just another way to rip us off. Dowetypereportslikethisnottomentionalltheworkwedonotgetpaidfor! [2007-05-26]
Do we get paid when the doctor changes his mind and redictates? No. Do we get paid extra when the doctor does not dictate the date of exam or the correct one, and we have to dig through 100 patient sheets? No. Do we get paid for looking up the spellings of doctors' names and addresses? No. Does the amount we are now getting paid cover software expenses, AAMT dues, business license, tax accountant, reference books, computers, car expenses for those accounts that insist on tapes that only put 1-2 reports on the tape that do not even cover gas or time spent driving/getting dressed, IT techs, phone lines, template setups, training other MTs, call-in systems, transcribers, foot pedals, office rent, medical expenses related to work injuries, paid time of when seeing a doctor for these injuries, surgeries, etc.? Not hardly. I have 7 years of experience working over 120 hours a week, 7 days a week and make less per line than the first 2 weeks I was interning in college. Jeesh, we have to hit the space bar to separate words. If you have radiculopathies as bad as I do, each keystroke hurts like heck, and I should get paid for it. Unfortunately, I cannot say space to my computer, and it magically puts it in. Just for once, instead of the doctors cutting our paycheck, why not going after the overpaid HIM department who came up with this hairbrain idea!!! They are on salary. It does not cost them money to go to the bathroom, yet everytime we take our hands off the keyboard, we pay! How would the HIM department like to read their reports like this? Laboratorydata:Completebloodcountstodayevealawhitebloodcellcountof,000/mm3,hemoglobin of2.3gm/dL,andaplateletcountof93,000/mm3. I say they can pick up my medical bills, which in the last 2 years were over $3 million with us paying over $90,000. Did I remember to include all the money it costs in lost work to apply for a job only to get ripped off on your paychecks or have them pay so late that after late fees, there is nothing left. Oh yeah, advertising, websites, e-mail accounts, FTP, cell phone, fax lines, equipment, equipment, equipment.

i so don't agree w/this post...I made more doing [2007-02-18]
so I continue to say to the newbies to the field, be careful what you read on these types of bulletin boards and/or forums - everyone's experience is different and please do not book your $$ on people whose experiences have not been as good as others..... I'm telling you, I'm in this biz close to 30 years and 10 years on my own and this year I made a fewgrandmore in $$ working for a nat'l than last year.......... If you plug it out, stick to a schedule,it still can be done, and I'm doing editingtoo (love it, easier on hands) and am twice as fast as I am on regular typing reports so.......again, some are just AGAINST editing, whereas I LOVE editing (did it 30+ yrs ago for a newspaper)..... Best of luck - remember to try to be optimistic (glass half full) versus choosing to be pessimistic (glass half empty) - THAT, TOO, WORKS REAL WELL.........

Offshore Outsourcing to India by US and EU [2006-05-10]
Posted May 1, 2006, this article analyzes the legal and cross-cultural issues that affect data Privacy Regulation in business. It examines India's lack of law enforcement and scores it workforce regarding the potentiality of selling confidential information and India's lack of faith of its ability to enforce any laws it has declined to adopt to protect personal information. A long but must read for those concerned about offshoring.

outsourcing [2006-05-10]
This was a great read - I sent it to the senators of my state. Thank you for sharing!

What a Hoot!! See Msg.... [2006-04-25]
I used to IC for Dr. Fishman's group or ortho in WPB, and at that time he was selling his VR on the side, too. His VRsworked so well (NOT!) that he had a large group of in-house MTs plus outsourced the remainder of the dictation to ICs, of which I was one. Hahaha! Thanks for the post- I just about split my side laughing when I read it.....Poor Dr. Bloch....

Real nice to know [2006-03-29]
that the doctor has so much more respect for a machine than he does the human ears that have to make a living listening and typing the reports day after day! This is what the doctor said... “Try a few charts each day, and sit down where it’s quiet, where you can relax and concentrate on your speaking habits. Tech support is great; they’ll help you, and be sure to read the help file “How to Speak to a Computer”—and the manual. Especially for often repeated phrases, the voice-actuated “macros” are great, a real time-saver. It’s well-worth the time you invest in learning how to use this tool.” What are the pitfalls? “Mumbling,” says Dr. Block, “that’s the main problem. Doctors are used to dictating in a low, monotone mumble, as fast as they can. A person might be able to handle it by going back and listening to the recording again and again. But for voice recognition, doctors need to speak in a normal, conversational tone of voice, just like we are doing right now. Speak normally, and Dragon has no problem, it works very well. It’s really quite simple.”

Experience & proficiency requirements [2006-03-01]
What are the experience and proficiency industry requirements for U.S. MTs? Per this article (http://www.fortherecordmag.com/archives/ftr_071805p26.shtml), Competition from overseas sources is also emerging in large part due to the lack of minimum wage laws in those countries. Low entry-level wages and lack of adequate compensation for skilled, experienced MTs have discouraged many individuals from selecting medical transcription as a viable career option at a time when the MT workforce is aging. Compounding the problem is the fact that many new MT graduates are not able to find employment because they are unable to meet experience and productivity requirements for U.S. MTs as mandated by the industry. A real eye-opener to say the least. Wholesale giveaway of good quality American workers.

Neurologist saves $12,000 per year on medical transcription [2006-02-22]
Recognition vs. Transcription W. Palm Beach, FL neurologist saves $12,000 per year on medical transcription using state-of-the-art voice recognition software [ClickPress, Tue Feb 21 2006] Dr. H. Steven Block, M.D. uses Dragon NaturallySpeaking Medical Edition, voice recognition software for medical professionals, to eliminate a very real business problem--medical transcription costs-- which six years ago, began topping the $1,000-a-month mark. Today, a doctor can easily spend three times that amount. Very open about his high regard for the Dragon Medical VR product, Dr. Block had much to say about its place in his solo practice: “I purchased Dragon Medical from Eric Fishman’s company, Nuance, which is actually located in the same building as my practice, on the floor above me. Neurology is all about ‘nuance’, no pun intended. But ‘nuance’ is really the best word to describe the health effects of a neurological problem. It has been a major focus of my practice.” “Very subtle neurological changes can have devastating health consequences. You have to be able to communicate those subtleties in order for a medical record to have any meaning.” “I see some really sick patients. Using an on-the-spot note generation product like Dragon, instead of a transcription service, let’s me get back to the referring physician with a fast note, usually within 10 minutes of seeing the patient. That kind of speed in delivering a medical exam note with ‘nuance’ can mean a great deal to everyone involved. You see, I can’t type. I never learned how to type. My kids who grew up instant-messaging can type faster than I can speak. They don’t need Dragon. But for me, Dragon is a wonderful tool.” Dr. Block, 49, is no stranger to high technology tools: “There are only so many hours in the day,” he laughed, driving down the road, talking via wireless cell phone headset, “and I’m very detail-oriented. I couldn’t be without Dragon, quite frankly.” One word I did not hear from Dr. Block is the word “downtime”. It doesn’t seem to exist in his vocabulary. Having traveled the long and winding upgrade path for both Dragon and laptop hardware, Dr. Block has watched and participated in the evolution of the product for six years. “Like a surfer looking for the perfect wave,” he joked. The improvement he’s seen in the most recent version of Dragon Medical—combined with a high-RAM laptop with at least 512MB—has boosted performance to an almost unbelievable 99.5% real time voice recognition accuracy level, according to his observations. His advice to new users: “If you haven’t tried Dragon Medical in the last four years,” he said, “try it again, the way it is now, with the new speech engine. It uses mathematical models to analyze word groups. There is a learning curve, but the training is not that bad, consisting of you reading a 15 minute script into a microphone, then a little touch-up here and there.” “Try a few charts each day, and sit down where it’s quiet, where you can relax and concentrate on your speaking habits. Tech support is great; they’ll help you, and be sure to read the help file “How to Speak to a Computer”—and the manual. Especially for often repeated phrases, the voice-actuated “macros” are great, a real time-saver. It’s well-worth the time you invest in learning how to use this tool.” What are the pitfalls? “Mumbling,” says Dr. Block, “that’s the main problem. Doctors are used to dictating in a low, monotone mumble, as fast as they can. A person might be able to handle it by going back and listening to the recording again and again. But for voice recognition, doctors need to speak in a normal, conversational tone of voice, just like we are doing right now. Speak normally, and Dragon has no problem, it works very well. It’s really quite simple.” He stated that using a handheld Sony digital voice recorder with removable memory stick allows him to dictate anywhere, anytime, then later, “feed” the sound file to Dragon, achieving about 98% voice recognition accuracy. (Please note: If you are considering making a recording for later voice recognition by Dragon, be sure and use 16-bit resolution .avi format, or Dragon won’t even try to “digest” it. It won’t bother with a recording of poor quality, because the end result would be useless.) Although he is considering it, Dr. Block has not yet adopted a commercial EMR(Electronic Medical Records) software system for his medical records, mainly because of concerns about interoperability standards. (Coming soon to an EMR near you.) However, by using Dragon Medical as his “front-end” for the creation of detailed paper medical records, email reports, and digital-FAX messages, Dr. Block not only uses computers, but has also created a highly personal and expressive way to “chart” a patient, unmatched in detail, depth, and the “human touch” by out-of-the-box EMR software. Would EMR software developers do well to discuss with this doctor any design plans for a voice-controlled, voice-recognition-based EMR program? I think so. Will a “hands-free” EMR workstation which responds to voice commands--as does the entire Dragon program--ever be used to help maintain a “sterile field” in the medical environment of the future? It certainly worked well on the Starship Enterprise, didn’t it?

Evergreen+Spheris=India [2005-09-07]
I'm sure everyone noticed in sm's submitted article about India's opportunities for housewives in medical transcription, that one of their work sources is Spheris. Another submit states that Evergreen Hospital is outsourcing to Spheris ---- does Evergreen know their medical records are going to India? Doubt it!!!! PS. The article about India said Stheris -- it's an error -- wonder how many of these errors show up in transcribed reports. Hmmmm

Seventeen employees will lose their jobs [2005-08-17]
2005-08-16by Lori VaroshJournal Reporter KIRKLAND -- Seventeen employees of Evergreen Hospital Medical Center in Kirkland will lose their jobs, most by Aug. 31, victims of a trend toward outsourcing the work of medical transcriptionists. Spheris, a Franklin, Tenn.-based contract medical transcription company, will begin today to take over the work of typing doctors' dictation into Eastside patients' records, hospital spokeswoman Amy Gepner confirmed Monday. The practice is increasingly common among area hospitals. It provides benefits in expertise and cost savings, supporters say. But critics warn that, without careful safeguards, the practice can put patients at risk. Outsourcing has become the area standard, said Caitlin Hillary, spokeswoman for Overlake Hospital Medical Center in Bellevue, which outsourced its transcriptionists in 1999. Such companies have the expertise and the employee base to handle the peaks and valleys of patient loads, she said. Overlake had been having trouble recruiting transcriptionists before it outsourced those jobs, and the solution has worked well, Hillary said. Job quality is `inferior' But others find outsourcing generally ``is inferior to having long-term, loyal staff,'' said Diane Clark, supervisor of transcription services for the UW Medical Center, which outsources about half of its transcription work. Because they offer lower pay, transcription companies attract people with less experience, Clark said. Those workers have no particular loyalty to the medical center, and no personal investment in the work. And, because they often work on a per-line basis, ``the faster they type, the more money they make,'' which can result in mistakes, Clark said. Nor do physicians always review the transcriptions as they should, she added. If the doctors' notes are not transcribed accurately, ``it could result in patient care issues,'' Clark said. Outsourcing can work if the companies routinely sample the work for accuracy and have a second pair of eyes proof-reading the transcription. Spheris was chosen because of its quality, said Evergreen's Gepner. Physicians at the Kirkland hospital read and sign off on all transcriptions before they go into a patient's medical record, she said. In an April memo to physicians obtained by the Journal, however, medical staff warned that problems are possible during a transition period to the new system. ``There will be a period of time in which the new dictation service will need to adapt to the phraseology and individual traits of our Evergreen physicians; during that time there will be more blanks and errors, so please pay close attention to your dictation for accuracy,'' the memo said. The taxpayer-supported hospital expects to save $400,000 a year over its current costs for transcription services, including salaries and benefits, Gepner said. But the move is also being made because existing transcriptionists cannot keep up with the workload without a $500,000 to $750,000 investment in equipment as well as personnel. ``It doesn't make business sense to be significantly increasing the cost,'' Gepner said. The hospital's administration proposed outsourcing and the hospital district's commissioners approved because it was ``best for patient safety,'' Gepner said. ``What we need to do is get (the information) as fast as we can in the patient record,'' she said. Spheris already is capable of working with the new patient records system Evergreen added two years ago, she said. The contract with Spheris also requires that no work be sent out of the country and that all 17 Evergreen transcriptionists be offered jobs, Gepner said. ``Three have chosen to go with Spheris,'' she said. The company has taken out ads in local newspapers seeking more transcriptionists. Some employees complain, however, that the contractor is simply not offering a living wage. Spheris offered 7.5 cents per line, said one transcriptionist, who asked for anonymity for fear that a ``measly'' severance package would be withdrawn. An average Spheris worker would make less than two-thirds that of an Evergreen employee, according to the figures the Transcriptionist provided. Evergreen transcriptionists earn $13.50 to $19.62 per hour, plus a 7-cent per line bonus for more than 938 lines a day. At a consistent day's work of 1,200 lines, the midrange Evergreen employee would earn $150 a day, compared to $90 for the Spheris worker. ``I have to pay a mortgage, pay bills,'' the transcriptionist said. ``I can't live on that kind of wage. ... I'd just be giving my expertise away.'' In a letter to the hospital district's Board of Commissioners in June, transcriptionists complained that they learned by e-mail that their jobs would vanish and that the severance package offered is ``insulting.'' Evergreen didn't want to provide as long a period of extended health care for laid-off workers as the standard set by Overlake and Group Health hospitals, explained Carter Wright, spokesman for SEIU, the health-care workers union. ``Evergreen is not only getting rid of jobs, they're trying to do it on the cheap,'' Wright said. ``There's concern about cutting down errors in hospitals and streamlining medical records,'' he said, ``but it's really important to make sure the information is accurate. Accuracy can literally be a matter of life and death.'' In the June letter, transcriptionists urged commissioners ``to look at the human cost of your actions. We are not only employees of this hospital, we are members of this community, a community that you have sworn to represent.'' The hospital that touts its role as the biggest employer in Kirkland is sending Kirkland jobs elsewhere and dumping employees into the pool of 600,000 state residents without health insurance, a transcriptionist complained. Outsourcing is best for patient safety, Gepner said. ``We're putting patient safety concerns over public relations concerns.'' Lori Varosh can be reached at lori.varosh@kingcountyjournal.com or 425-453-4234.

Losing medical integrity [2005-08-05]
Losing medical integrity By Pius KamauDenver Post Columnist Not too long ago, all my local transcriptionist had to do was call me when she couldn't understand something in my medical dictation. Now, I no longer know who transcribes reports of my surgical procedures and physical exams or where they are. I only know that most hospital transcriptions have been outsourced. At times, the resulting inaccuracies are incredible or enormously amusing. Transcription is only one of many medical fields facing outsourcing, which is rapidly making inroads into American health care. The stability of medicine is being chipped away to satisfy America's Wal-Mart belief that cheaper is better. While the public prefers not to know how fundamental changes in health-care delivery may be adversely affecting it, real harm to patients has resulted from outsourcing. Recently a lab that processed specimens from across the nation was found to have misinterpreted Pap smear results. In some cases, a pathologist hadn't actually read some slides. Such labs aren't chosen because they do a better job than local pathologists. Simply put, they're cheaper. Cost-cutting is the new mantra, and shoring up profits the prevailing credo in a world where the quick fix trumps the long-term, universal good. The net result has been to throw many competent lab techs out of work. Valuable, highly qualified people have forever been lost to the medical world. My former medical transcriptionists were used to my accent, and offered occasional advice on how Americans pronounce certain words. They were replaced by others who find American speech heavily accented and sometimes indecipherable. Hospitals are not factories; they don't manufacture screwdrivers or light bulbs. Hospitals are small communities, where sundry departments and personnel form a mosaic that fulfills the essential function of the institution: to heal the sick. It's a cohesion that has slowly been dismantled to squeeze out more profits for investors and HMO moguls. The practice of medicine is unique in that each person in the system plays a vital role. Frequently, we discuss puzzling radiologic images, weird pathological presentations, and brainstorm difficult surgical cases in corridors and lunchrooms. Unfortunately, there's now a move to outsource imaging technology as well as other forms of testing and therapeutic modalities. Without casting aspersions, I believe many of us wouldn't like to discover that our scans are read in Beijing, Bombay or Manila. Hospital staff collegiality has suffered irrevocable damage. X-ray, lab technicians and other medical colleagues have been let go or moved away because their expertise was deemed useless. Change is inevitable. But it should always be geared toward making patient care better and safer, not jeopardized by profit- taking. It's conceivable that future insurance policies will offer several options: Pay more if you want care in local facilities or pay nothing if your treatment is provided in Mexico, South America or Africa. If you could save a few dollars, would you do the latter? Looking at this as well as other aspects of our failing system, it's easy to see that the businessmen we have entrusted our health care to will do anything they can to shortchange the public, as long as we let them. The question is: What will it take before we all say enough? I want my transcriptionist down in my medical records office. I don't want to talk to a radiologist in Bombay or Nairobi about a patient in Denver. I want a pathologist I can interact with on a regular basis. Surely you don't want your surgeon to be located in Guadalajara? Pius Kamau of Aurora is a thoracic and general surgeon. He was born and raised in Kenya and immigrated to the U.S. in 1971. His column appears on alternate Wednesdays.

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 .



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