I'll quit paying taxes if they use it to train overseas MTs

IC Taxes [2008-07-28]
Make sure you either get with a good accountant or get a really good tax program (we use TurboTax every year) because as an IC, taxes don't get taken out of your check, but you get to take deductions for everything that you use for your business. If you own your house, you can deduct the square footage of your office space from your mortgage, you can deduct part of your electricity bill, cell phone, internet, any equipment you have to buy, milage if you have to travel for work - the list can go on and on. Just make sure to keep receipts and good records - I got audited my first year as an IC. I passed with flying colors because everything was legit and I had a receipt to back it up. Hope this helps you and good luck!!! =)

you are an IC if the company you work for does not pay your taxes.... [2007-12-30]
When you are an IC, you tell the company who contracts with you how much work you can provide. It is no different than any other contractor who tells you they will do something for so much money. If they do not perform what is promised, you will probably not rehire them. Same thing goes for IC's. You can be let go for not keeping your end of the bargain. There are great tax benefits for being an IC, but I strongly recommend you seek the assistance of a professional CPA for this come tax time.

Not paying for spaces? [2007-05-07]
Another creative way to say we won't pay you to hit the space bar. Too bad.

Yes, but even when the overseas business build plants [2006-04-04]
breaks and incentives that it is the exact same thing, just on our home soil. One state gave Mercedes the land to build 2 plants for free plus no taxes to the state for 10 years, plus other perks picked up by the state residents. I think I'm going to get religion so I can legally stop paying taxes and ask for my SS account to be refunded (like that would ever happen!)

Wait a second....speaking of taxes. [2006-03-31]
As long as NAFTA is in effect, don't these foreign companies MTing for the US (and also the foreign MTs) get away with paying NO taxes? I saw we all stop paying. This country is one big mess.

I'll quit paying taxes if they use it to train overseas MTs [2006-03-21]
G et AL can take a bite out of that one if they think that is the direction they will take this program! After all, the approved programs are online and AAMT provides certification overseas, so what is to stop the big MT corporations who are devoloping facilities to house 5000 MTs in India and other locations from using MY tax money to train overseas MTs???

IC Taxes [2008-07-28]
Make sure you either get with a good accountant or get a really good tax program (we use TurboTax every year) because as an IC, taxes don't get taken out of your check, but you get to take deductions for everything that you use for your business. If you own your house, you can deduct the square footage of your office space from your mortgage, you can deduct part of your electricity bill, cell phone, internet, any equipment you have to buy, milage if you have to travel for work - the list can go on and on. Just make sure to keep receipts and good records - I got audited my first year as an IC. I passed with flying colors because everything was legit and I had a receipt to back it up. Hope this helps you and good luck!!! =)

Working as an IC sm [2008-07-20]
I likeworking as an IC more than working as a full time employee....I just do not make good employee material due to my health. Although I really, really need health insurance, I just cannot deal with shift work but I will have to at this point and time in my life. I did just accept a job as an employee, tho, because I am getting older and I have to think about taxes, Medicare, etc.....So, I am praying that it will work out.......as I am determined to MAKE it work. You can make more money as an IC because taxes aren't taken out, BUT........you do have to put aside monies for paying taxes, etc...and with what most MTSOs are paying these days, the cost of living, the awful state of the economy, it is pretty hard to do that. Also, MOST companies even dictate a schedule to you anyway, even as an IC, which is wrong on so many levels, and I think we as MTs all know this.

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.

Stand firm! [2008-04-08]
I agree. I actually knew someone who typed some work with no spaces after a new client complained about the cost and said something about being ripped off because of paying for spaces. The gal that did this was actually a past president of AAMT, years ago I might add. She took it on the chin, took the next few tapes home, and returned a few reports with no spaces, no line spacing, etc. The office manager flipped her lid and went nutso on her. Hmmm, my friend said, I don't do anything I don't get paid for. End of story, end of a headache account. I still smile when I think of that story. That would be like a surgeon saying, Oh, I don't get paid for the stapling your wound shut, so I had the nurse use the masking tape. Single spacing after a period makes me crazy too. Do the math. It just to rip us off a bit. Think about how many spaces are saved over thousands and thousands of transcribed lines with single spacing after periods, and know if you are doing that you are undermining the profession and everyone in it. Quit being stupid. If your employer disagrees, tell him/her to have at it themselves.

some companies do this [2007-08-22]
I have gone to Washington DC to train for a company before. They paid. Breakfast, lunch included. Transportation from hotel to company provided. I was only responsible for dinner moneywise. Group of about 14 of us. Made really good friends. No longer work with the company but still keep in touch with other MTs from training. This was about 5 years ago.

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...

I came across a website that [2007-06-02]
has information for workers whose jobs were replaced by overseas competition. There are all sorts of rules. A petition must be made by 3 workers who have lost their jobs, all from the same location. Would they mean the company location, or would the fact most MTs work at different locations mean we couldn't file a petition I wonder. I'm not in that situation, but I think it's a good idea to know what's available. http://www.doleta.gov/tradeact/petitions.cfm

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.

VBC stands for visible black character. They are trying to drive our salary down even further! [2007-05-26]
VBC means no payment for spaces, formating, paragraphs, nothing. These HIM department people just sit at the desks all day coming up with more ways tocut our pay even more the whole while theycollectingsalaries increases yearly, and AHID (formally AAMT) will probably endorse this as a way to brown nose other healthcare-related industries to get them to become members, thereby increasing AHID (AAMT memberships with dues/revenue pretty much the same way they did with overseas transcription companies, which as everybody knows has resulted in lower pay for US transcription.

Supply and demand [2006-07-31]
That is only going to supply the industry with cheaper labor! If the demand is that high for MTs then it would seem we would be paid more since there do not seem to be enough of us, right? Then here comes AAMT to the rescue with the latest of their nutty ideas - training people to do our jobs for even less! Seems to me that would flood the labor pool with new MTs (I use the term loosely here) and drive down our wages. I am so glad I gave up my membership and CMT years ago when I saw the direction they were going. I still have friends who are AAMT members who, IMHO, appear to be brainwashed. One person told me recently that the USA does not have enough people interested in becoming an MT and that is why AAMT is recruiting overseas and it will not impact our jobs at all. Argh!

Scribe Healthcare Technologies Exceeds 6,000 Users [2006-04-20]
Scribe Healthcare Technologies, a leading healthcare technology company based in the Chicago area, today announced growth has exceeded 6,000 users. Scribe platform users include physicians, clinicians, administrative personnel, and transcriptionists. Lake Forest, IL (PRWEB) April 20, 2006 -- Scribe Healthcare Technologies, a leading healthcare technology company based in the Chicago area, today announced growth has exceeded 6,000 users. Scribe platform users include physicians, clinicians, administrative personnel, and transcriptionists. �Until recently our growth has been primarily organic, selling to hospitals and profit driven medical practices. In 2005 we started targeting Medical Transcription Service Organizations (MTSOs) using our technology to run their businesses. Now with the launch of a joint venture �in2scribe�, we hope to become the foremost industry resource for MTSOs.� says Vice President of Sales Marketing, John Weiss. �As a result our growth rate continues to ramp.� Scribe technologies are modular and Web-based, leveraging the Internet and standard Microsoft applications. Scribe offers a variety of technologies that help MTSO manage their business, recruit and train transcriptionists. About Scribe Healthcare Technologies, Inc.Scribe Healthcare Technologies is a privately-held healthcare technology company based in the Chicago area. The company has developed a proprietary web-based platform that complements and extends the value for patient registration, Practice/Hospital Management and EMR Solutions. Scribe�s platform includes complete solutions for dictation, transcription, document management, EMR-Lite, Web portal, online prescriptions and reporting with data analytics. Scribe serves more than 6,000 users. Business partners and resellers include consulting firms, transcription companies, and business process outsourcers. Additional information is available at www.scribe.com. About in2scribeIn April 2005, the owners of Scribe Healthcare Technologies, EFD Transcription Services, and PENATCLE Electronic Records and Systems fulfilled their dream to create a network that would pull together resources to help to improve the efficiency, productivity, and profitability of the highly fragmented, mid-sized medical transcription firms. Utilizing the talents and experience of our members, a common technology infrastructure, and a central management point, in2scribe offers a menu of services to our members including new profit centers, benefit plans, level-loading of your work load, and more. More information is available at www.in2scribe.com.

Yes, but even when the overseas business build plants [2006-04-04]
breaks and incentives that it is the exact same thing, just on our home soil. One state gave Mercedes the land to build 2 plants for free plus no taxes to the state for 10 years, plus other perks picked up by the state residents. I think I'm going to get religion so I can legally stop paying taxes and ask for my SS account to be refunded (like that would ever happen!)

Wait a second....speaking of taxes. [2006-03-31]
As long as NAFTA is in effect, don't these foreign companies MTing for the US (and also the foreign MTs) get away with paying NO taxes? I saw we all stop paying. This country is one big mess.

Dismaying, dismal [2006-03-28]
I have recently completed the course and an externship and do not have my first MT job yet. I did very well in both classes and externship and was told by the program's administrator that I would make an very good MT. A local clinic may have a job for me doing clerical work, but they are laying off 75% of their transcriptionists because they have recently made the switch to electronic medical records, and there are very limited openings for beginners, overall. I have just started paying off an educational loan while still unemployed, and I am beginning to see opportunities for what I have struggled for just drift away, while I am being conceptualized into coder or some other job description byour industry'sleadership.

MT re-training [2006-03-25]
quote: Emerging roles for the Transcriptionist include database administrator, data abstraction, data coding, etc. :end quote I don't know if this fellow has considered the training required for each of these position-types. Coding requires some sort of training (even if its in-house), database administration requires a lot of training (at least a thorough f/t 1-year certificate). For that, you need to know sql statements, tables in the database, how to path information (its not just which table within something), the same for data abstraction. When these folks look at MTs and say oh they can change their job to X, they must remember that in order to do so, the MT must have other training. So, instead, why not train those in other countries to do that instead of training them to be MTs and training US MTs to be something else. MAYBE the MT WANTS to be an MT. (some of this is tongue in cheek)

Another thought.... [2006-03-24]
I myself do NOT feel comfortable having my information sent overseas, including my name, DOB, and often SSN listed in the demographics screen of each note. I have heard stories of prosecution (or lack there of) by identity theft from people in other countries. Maybe Americans should start boycotting or protesting the healthcare industries that outsource overseas!!!!!!!!!!!!

I'll quit paying taxes if they use it to train overseas MTs [2006-03-21]
G et AL can take a bite out of that one if they think that is the direction they will take this program! After all, the approved programs are online and AAMT provides certification overseas, so what is to stop the big MT corporations who are devoloping facilities to house 5000 MTs in India and other locations from using MY tax money to train overseas MTs???

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.

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.

Integrity [2005-10-11]
You're so right!! Outsourcing is really a dangerous business because it isn't about quality of patient care; it's all about money. I have been a medical Transcriptionist for 29 years and I have seen this profession devolve to that of a factory worker on a production line. Not that there's anything wrong with working in a factory, but we have a much more grave responsibility upon us because what we put in a report, if incorrect, can potentially cause harm or even death to a patient. This fact alone motivates me to give meticulous attention to make sure I get it right, even if it takes long periods of listening and re-listening and lots of research to do so. We need to stop and think, if this were my mother, my father, my loved one, or myself, would I want someone to be racing through the process of transcribing a history and physical, consultation, operative report, or any other medical report to see how many lines can be produced for the day?? If this is what we've devolved into, then it's time for me to get out of this profession because I refuse to be driven by how many lines per hour I can transcribe versus the quality and accuracy of what I transcribe. There are so few who really understand, especially in management, what being a really good medical transcriptionist entails. Transcribing medical dictation and doing it accurately requires a tremendous amount of knowledge, skill, and research, as well as paying attention to the smallest of details in order to prevent harm to patients. I fear we're headed in a very dangerous direction. The fact that an organization like AAMT ascribes to this line-count/productivity mentality baffles me. Patients' health and lives should be our top priority and we should be so very careful not to misinterpret what a doctor is dictating. This often involves a lot of painstaking effort, but it's worth the time it takes to get it right.

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.

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.

Court records sent abroad [2005-08-25]
Trial and hearing tapes were farmed out to Hong Kong for transcription, in violation of rule Marion County judicial officials are investigating what appears to be an unprecedented security breach in which workers in Hong Kong prepared hearing and trial transcripts in a yet-to-be-determined number of cases. The outsourcing of what is supposed to be an in-house court function has alarmed Indianapolis judges because these records often contain sensitive information and are critical for appellate judges to understand what transpired in courtrooms months or years before. Local officials have informed the Indiana Supreme Court of the breach, and the court, which enforces rules on the handling of court records, is awaiting information from Marion County. This is prompting a thorough investigation, said Marion Superior Court Judge Jane Magnus-Stinson, a member of the court's three-person executive committee. We're talking about the record that goes up on appeal. If it's wrong, that's big stuff. She said no judge is believed to have authorized a court employee or court employees to send official trial tapes offshore. A spokesman for the Virginia-based National Association of Court Reporters said he was unaware of any U.S. court sending transcription work overseas and that the group has tried to determine whether it's going on. The best-quality transcript is prepared by someone who was present at the proceeding, said Marshall Jorpeland, the national group's communications director. The best-educated English speaker in Hong Kong isn't going to know street slang unless they've moved there from here. Other concerns include Social Security numbers appearing in transcripts, as well as the names and addresses of crime victims or their family members and sensitive information about employment or income, Jorpeland said. Marion County's judicial leaders are trying to figure out how much work was sent overseas in violation of a local court requirement that transcriptions be done in-house by county employees to protect against privacy violations -- including identity theft -- and to ensure accuracy. At least one court reporter has acknowledged some work on major felony cases was sent to a private firm, said Mark Renner, the Marion Superior Court administrator. Renner declined to release the name of the court reporter or the judge for whom the reporter works. The employee has not been reprimanded but could face disciplinary action, including a possible dismissal. Renner said the breach occurred after an experienced court reporter hired an Indianapolis transcription firm, Baynes Shirey, which does business as ClearPoint Legal, to prepare transcripts. That work was then outsourced to Scriptero, a Hong Kong company that has more than 50 clients from all over the world that demand at least 4,000 transcripts a year, according to court officials and the company's Web site. Neither company responded Tuesday to requests for comment. No one is accusing either firm of wrongdoing. Renner said he intends to send a letter today to Baynes Shirey asking for a complete list of proceedings the firm has transcribed for Marion County's court system. On its Internet site, Scriptero says it is often hired to transcribe depositions, which usually are closely reviewed for accuracy by participants, and that it uses only native-language transcriptionists. The Hong Kong firm boasts a 99.75 percent accuracy rate, but that's been of little consolation to local officials. This assignment of transcripts to anyone other than another Superior Court reporter shall cease immediately unless the Judge of your Court gives you express permission to so assign the responsibility of transcription to some outside entity, Renner wrote in an e-mail sent Friday to court officials. Renner said a Porter County judge notified Marion County officials of the breach last week after hearing about it from a member of the Indiana Shorthand Reporters Association An e-mail that was ultimately received by the Judge in Porter County from the company in Hong Kong confirmed that they had in fact been doing work from Marion County, including full transcripts from jury trials, Renner told court officials. Tina DeBone, president of the Indiana reporters association, said she blew the whistle to court officials but did not name any of the firms involved. She said no Porter County judges were involved. DeBone said she heard about the violation from a court reporter in Arizona who had been approached by the Hong Kong company. DeBone, a victim of identity theft, said she was worried about sensitive information falling into the hands of terrorists who might use it to enter the United States. Farming out transcription work is in complete violation of the reporter's contract that each reporter signed, Renner said in his e-mail. These contracts, signed with Marion Superior Court, do not provide for hiring private companies to do transcription work.

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 .