Interesting, indeed, do you think that is why she left MQ

can't find message I left. either [2008-05-20]
If one leaves a comment that is not 'approved' or 'welcome', it gets quickly deleted or one gets a 'warning'! Today I posted two really nice comments and I cannot find them!

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.??????

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/

Interesting, indeed, do you think that is why she left MQ? [2007-07-15]
It says she worked for them until recently. Also says she is very active as an advocate for veterans and more recently in fighting the cause against US companies that outsource American jobs to foreign countries. Hmmmm

VR is here to stay [2008-07-03]
I think it serves any professional to keep up with any technology affecting their chosen profession. A medical Transcriptionist who refuses to learn editing of voice recognition files will end up being left behind. Having said that, if you're thinking about transcription work, then choose a school who isn't afraid of current technology and includes it in their curriculum. I love voice recognition. Working with it on a high-end technical level has made me understand that there isn't now, nor probably ever will be, a substitution for the human element. Trained editors will ALWAYS have job security. Because any speech rec system is only as good as the people behind the scenes writing the software. It's not an unlimited technology, and it simply cannot interpret certain things. I love reading some of the gobbledegook it spits out, and snicker while I edit it. Please stop being afraid of technology. Learn it, embrace it, get good at it, and secure your own future.

This is a skilled trade [2008-04-08]
You know, an apprenticeship is just what we need. Really. I also think we should be paid hourly, and that hourly rate would increase significantly after a year or two of on-the-job training wherever you work. At the very, very least we should get paid as much as coders; and everyone knows they haul it in compared to medical transcriptionists. By the way, the coders rely on what we transcribe. Interesting.

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.??????

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/

Loved it! [2007-06-10]
I loved Medware for the short-time I worked for them. I was working a full-time in-house position,which I was trying to get out of. I worked for Medware part-time trying to transition out of the in-house position. They were absolutely wonderful people to work for!!!!! I was working 4 hours a day part-time for Medware plus my 40-hr a week job (supervisor/transcriptionist). My plan was to work for Medwarefor 3 months to become eligible for their insurance and leave my in-house position and work for Medware. It became too much, as my husband and I also have our own business and I do the office work. I left Medware. However, I would work for them again in a second. It appeared to be a very competent, helpful company. I highly recommend them!!!!

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.

Foreign speaking docs [2005-12-01]
They keep the FSDs HERE for us to struggle with and send the easier stuff to India where the MTs who don't speak English are given an 8 week crash course in English diction, typing and computer processing. Those of us who have worked our entire adult lives in this profession are left to keep the FSDs from getting their backends sued for malpractice. I'm proud of my profession and resent being demeaned and cheated out of what I've spent a lifetime perfecting by seeing it given away by a money hungry, two-faced oursourcing country that swears on a stack of Bibles that we do not now and never will outsource outside the United States. Way to go Spheris.

TRANSCEND: appointment of Lance Cornell as Chief Financial Officer [2005-11-02]
TRANSCEND SERVICES, INC. today announced the appointment of Lance Cornell as Chief Financial Officer. Mr. Cornell replaces Mr. Mark D. Meersman, who has decided to return to the position of partner-in-charge of inProcess Consulting, a management consulting firm that he left six months ago to join Transcend. Mr. Cornell is a Certified Public Accountant with over 18 years of experience in accounting, finance and financial management, including controller and chief financial officer positions with publicly traded companies. Prior to joining Transcend, Mr. Cornell was Chief Financial Officer for nearly five years at Facility Resources, Inc., a private consulting firm specializing in facility-related project management, systems implementation and outsourcing for large corporations. Prior to that experience, Mr. Cornell served in chief financial officer and controller positions in two separate publicly traded companies in the healthcare information systems industry. Mr. Cornell received a B.S. degree in Finance with highest honors from the University of Colorado. Larry Gerdes, the Company's President and Chief Executive Officer, commented on the announcement: We welcome Lance's financial executive experience to our executive management team and thank Mark for his many and varied contributions to our Company. Mark has assisted the company in the automation and analysis of financial data that will prove helpful as we focus on improving our overall profitability. Lance not only understands the challenges facing the Company, but also sees the opportunities for the Company to grow and prosper in the $6 billion market for medical transcription services in the United States. We are particularly excited about his experience in planning and financing growth strategies, including acquisitions. Mr. Cornell commented: I am excited about the potential effects that the Company's BeyondTXT speech recognition functionality and its strategic acquisition initiative should have upon the Company's financial performance. I look forward to helping the Company achieve its growth and profitability objectives. About Transcend Services, Inc. Transcend believes that accurate, reliable and timely transcription creates the foundation for the patient medical record. To this end, the Company has created Internet-based, speech recognition-enabled voice-to-text systems that allow its skilled medical language specialists to securely and quickly produce the highest quality medical documents. The Company's wide range of transcription services encompass everything needed to securely receive, transcribe, edit, format and distribute electronic copies of physician-dictated medical documents, from overflow projects to complete transcription outsourcing. For more information, visit http://www.transcendservices.com.

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 .