The famous doctor and medical writer/professor Atul Gawande has written extensively on the huge benefits that a simple checklist affords in medicine, in industry, in life: Checklists offer protection against arrogance and forgetfulness, as well as being mindful of every last and important detail. Dr. Gawande explains how surgery, the construction of airplanes, and any other multi-stepped and multi-faceted procedure that involves multiple decisions –each simple, but dependent on each other– benefit from the use of a simple checklist.

That is: Before going ahead with x, perform or check:

1. xxx
2. xxx
3. xxx

By implementing such a simple concept in hospitals, many lives have been saved, industrial accidents have been avoided, and outcomes have improved in many areas. Checklists are “Best Practices” mandated into operating procedures that are enforced. People are often loathe to submit to something so simple as following a checklist srupulously, but it works. It goes without saying that a checklist consulted during the process of medical software selection can yield great benefits as well (it may even, in the very long run, help save lives!)

We, as people implementing complex medical software systems, have to be humble and systematic enough to learn a great deal from this idea:

Before you go whole-hog with a decision to implement a particular EMR / EHR, or before deciding on the type of EMR /PM you want: think it through, weigh the implications of decisions, in other words: make a smart checklist. Don’t be swayed by a glitzy demo. Weigh each critical point and factor it into your decision..

If you have thought these issues through for your practice, and can work up a meaningful checklist about what you need in a product, and which products offer you what you need, more power to you: But many of us are not that clear-headed, especially when we have so many other things to do, and when advertising tempts us with benefits that may or may not be available to us with certain medical software.

If you do not have this checklist in hand or in your head, CTS offers you a thorough checklist, the EMR / EHR DemoScorecard , that is easy to use and completely free of charge: it is excel-based, allows you to choose only the features you need and want to compare, and helps you rate and score vendor demonstrations as you move along in the selection process.

Some of the specific uses of the EMR / EHR DemoScorecard

• Perform a pre-demo needs medical office needs analysis to make sure you evaluate the functionality needed to manage your practice
• Customize software demos to your exact requirements
• Score each software demo based on your ratings of chosen necessary features
• Compare features and options for different packages side-by-side
• Streamline the demo process and save valuable time
• Reduce your risk of selecting the wrong EMR software by developing a fact-based analysis of each program

The areas covered in the medical software checklist include almost anything you might want to consider when making your software selection:
Areas Covered

• EMR / EHR
• Ease of Use/Learning
• Security/HIPPA
• Procedure/Diagnostic Codes
• Fee Schedules
• Insurance Companies
• Practice Management Accounting
• Work Flow
• Appointment Scheduling
• Insurance Verification
• Account/Patient Information
• Billing Claims
• Managed Care, Case Management
• Hospital Tracking
• Clinical Documentation
• Document Management Reporting
• Training  

It is easy to get the Demo Scorecard Checklist at no cost. Just sign up for the CTS Medical software selection kit, and you will be able to download the Demo Scorecard /Checklist right away.

Look at a service that compares high quality EMRs by module such as the CTS Medical Software download kit, and see what different vendors offer in the way of patient portal features.

When considering a Patient Portal for your EMR, don’t take an all-or-nothing attitude about the features you can manage to incorporate.

Many small to medium practices cannot get excited about the use of patient web portal modules for their still-new EMRs. They feel it will require too much input from their side (HIPAA issues, security issues, possible billing for e-visits, portability and export options to other systems) and just something else large to go wrong. Patient portals can incorporate so many functions, and they do require the attention of doctors, nurses and administrators.

But a modified – or not fully functional patient portal — offers so many advantages and efficiencies even to a smaller practice. In medical practices and EMRs it is important not to maintain an “all or nothing” attitude. Just because your practice may not be ready to go for the whole bells-and-whistles use of a patient portal does not mean that you should forego the obvious advantages that a modest patient portal – or a not yet fully utilized patient portal – can afford to your medical practice.

Here are some of these advantages:

1. Confidential email for simple queries that would take you, your receptionist, and the patient so much longer to answer than the simple query. This way, no one is obligated to get off the phone, return a call, or complete the circuit immediately. Queries can be answered at your relative leisure.
2. Easy way to transmit preventive care information. You can send patients exercise, diets, which you keep stored and organized in a database online. It saves you and your staff time.
3. Quick and more efficient way to collect revenues. Most people don’t have to think too hard to pay a bill online: easier and cheaper for the patient than to find an envelope, get your checkbook out, locate a stamp and get to the mailbox. So much less work for your office staff!
4. Requests for prescriptions are simple: even if you have not yet implemented e-prescription software, at least the request can be handled at your leisure.
5. It is definitely the direction the world is going in: Why wait till the 11th hour to implement something that will help you during hour #1?

Of course in situations where the insurer and the provider is one and the same (we are not naming names here, but we all know there are a few large examples of such companies) there is much greater incentive to create full-service patient portals. For instance, there is every reason to want to eliminate visits that are unnecessary, both for the doctors’ and patients’ sake, and for the sake of the bottom line: eliminating extra visits saves money. A small practice may not have the luxury of thinking big enough, and may be happier to have the extra appointments happen.

If you are considering a major EMR or EHR system, the system will surely offer a patient portal. If you are using, or contemplating using a smaller EMR, that does not incorporate a patient portal, there are stand-alone patient portals that can work with your EMR. These are generally simpler and have fewer functions, but nevertheless do enough of the job to be of great value to you, or much more value than no patient portal.

If you are considering a serious patient portal, here are some basic critical features to look for:

1. Integration of secure credit card and bill handling processes
2. The ability to hand off patients’ EMR data to a CCD/CCR (Continuity of Care Record / or Document). If you are buying into an EMR and its patient portal for the long term, or even the semi-long term, we are not far from the era of the ubiquitous use of a PHR (Personal Health Records) like Microsoft’s Healthvault, Epic’s Lucy, or Google Health
3. The availability of e-visits; clarification of costs for e-visits, if there will be costs. The ability for patients to update their EMR records through their Patient Portals (changes in medical condition, weight, symptoms)
4. On line prescription service to interface with an e-percription module.

Though you may choose not to integrate all the features that a patient portal offers, you need to create the beginning of a patient portal to make your patients lives’ – and your own work – easier in the long run.

Look at a service that compares high quality EMRs by module such as the CTS Medical Software download kit, and see what different vendors offer in the way of patient portal features.

What if this is not the first time you have chosen an EMR? If this sounds like reality TV rather than nightmare on Elm Street, console yourself by knowing you are not the first practice that has had to move from one EMR to another.

There are many reasons why, in this first serious generation of Electronic Medical Records, you might have to switch from your current EMR to a better model EMR. This is often not a matter of pique or keeping up with the Joneses, but of practice necessity.

Any of the following scenarios could require a switch:

1. You are using an uncertified EMR and you want to qualify for meaningful use standards and EHR stimulus incentives.
2. You have separate, stand alone Practice Management Software and you want to move to an integrated EMR/PM system
3. Your vendor has gone out of business, and is not upgrading or supporting his software (for instance, you cannot accommodate the new ICD-10 coding)
4. You never felt that the vendor provided decent support or training, the thing is a boondoggle, and you don’t want to throw good money after bad.

How to make this switch intelligently? There are many angles to this upgrade that need to be explored:

• First decide whether you want to move to a really different animal or stick with the same beast of burden; i.e., if you are using a client/server model, do you want to buy/lease another one, or do you want to try a web-based solution? Talk to people who are using both, talk to software reps, try to get honest technical input.
• Evaluate the big packages carefully using reputable information from a service like CTS, Inc. CTS also has software tools to help you compare features on packages. Make sure you are only considering CCHIT-certified systems that are qualified for Meaningful Use so that you can qualify for government payments and incentives as a result of using your new EMR.
• Think about financing. How do you aim to pay for this upgrade, or switch? Many vendors, like car salesman, offer financing packages. See what makes most sense for your practice: buying, or leasing, Talk to practices who have done this before. Don’t jump! Obviously, client/server models demand a bigger up front cost than web or cloud based EMR. How difficult would it be to move from one model to the other (if that is a move you are considering). Get tax and investing advice. Learn about the Section 179 Deduction and Bonus Depreciation.
• Make sure you have a list of qualities that your system must have and must accommodate before you meet vendors: Do you have multi-locations? Do you need mobile devices? Does the vendor offer different tiers of training options at affordable prices? Ask these questions of any reps trying sell you a system.
• Don’t confuse short-term expenses with serious long-term costs. Making the wrong decision by choosing an inexpensive, but low-quality system that doesn’t do what you need a system to do is much more expensive than paying for a few hours or even a few days of good advice. Hire a qualified consultant to advise you on the answers to some of these questions.

Words to the wise regarding consultants: A few hours of relatively expensive consulting time will be much less expensive than years of heartache and mountains of bills engendered by a poor move. Since your problem of data and system migration are not unique to you, many software consultants have realized that medical data migration is a very viable business these days. If you are going to hire a consultant, make sure you get solid references. Have your IT person (or IT designate in your practice) work with you to make up an exhaustive list of questions. Have respect for an occasional answer of “I don’t know how I would do that, but let me think about it and get back to you”. If he doesn’t get back to you after his honest humility has caused him to think, forget about him.

Another warning: Don’t buy or lease more system than you need, but don’t buy something this is closed and will not allow you to expand and include additional system functions. Leave room to grow in your system, and remember that technology, and government requirements, expand infinitely.

Before Electronic Medical Records, there was speech recognition software: Doctors have long used speech recognition software to dictate their notes for their records, and then used transcriptions specialists to type the notes up and add them to patient records, whether written or electronic.

In the old days, a doctor had to “train” his speech recognition software extensively to get used to his voice, inflection, and speech patterns. But now the same speech recognition technology has been improved to “learn” new voices and speech patterns quickly. And what’s more, speech recognition software can be used to populate charts and records of patients, and to write up free text notes without the expensive and time-consuming go-between step of transcription. This is also a part of EMR technology that will actually enhance medical practice management, and save doctors’ practices money, since transcription of notes is quite expensive.

Most EMR’s now have speech recognition capabilities either embedded into them, or appended as add-ons, and allow clinicians to dictate directly into patient records. In most cases, licenses to use the voice software will have to be bought individually.

Voice offers its own “copy and paste” function: Voice “macros” that have a canned piece of text which can be customized using the doctor’s voice and particular details related to the individual practice can be used again and again to make the doctor’s job easier. This way clinicians can dictate directly into free-text fields of the EMR and can see their dictation directly on the screen. Voice-recognition software also enhances electronic records by allowing doctors to add details that are not choices on a canned drop-down menu items and would to be typed in. At that point, only light editing will be required.

Most of the large EMR vendors now support direct voice control of edit functions. Voice control is much less time consuming than point-and-click screens, and enough doctors and nurses are not happy typists. Voice recognition is definitely a feature that adds to ease-of-use for an EMR. Of course voice recognition software also lends itself to use within portable devices, and allows the voice data to be fed remotely into an EMR.

Speech recognition options are some of the lowest cost investments in an EMR. While a total EMR solution can easily cost many tens of thousands of dollars or more, the speech recognition add-ons can cost as little as $2000.

Macros, which are the canned pieces of text that can help the physicians stay within compliance of CMS guidelines, can be bought and customized by a vendor or by the physician himself for the specific needs of his practice. Also, since so many doctors are already using voice recognition software for their notes, there will be a smaller barrier to adoption of this technology than to many of the other technology pieces employed by EMRs.

Most recent vintage Windows-based computers support the use of speech recognition software. Medical speech recognition software is more easily adaptable to windows-based systems, although there are ways to run it on MACs as well. Speech recognition software that is dedicated to medical users has dedicated medical vocabularies for many medical specialties and sub-specialties, medical templates, the ability to expand medical abbreviations, and are HIPAA compliant.

In sum, speech recognition software can make the transition to EMR much easier and less time intensive. It is easier to learn for most people than pointing and clicking through series of menus on the EMR (although you will still have to learn to navigate). It can afford you more time to be spent with your patients, and it should help make the flow of information through your practice smoother and easier.

If you have not yet moved to Electronic Medical Records, you are fortunate in one sense: If you had, and you were still coding procedures and diagnoses with ICD-9 codes, you would have to go about transitioning to the ICD-10 codes.

This way, if you haven’t yet moved to EMR, you will go directly to ICD-10.

A quick review of the differences between the two coding systems:

Like ICD-9-CM, the ICD-10-CM is based upon the International Classification of Diseases, which is published by the World Health Organization (WHO) and which uses unique alphanumeric codes to identify known diseases and other health problems. (Click here to see the WHO’s ICD-10 codes).

The United States has modified the WHO’s version of the ICD-10 codes to produce The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), and it is a revision to the ICD-9-CM system used by physicians and other health care providers to classify and code all diagnoses, symptoms and procedures recorded in conjunction with hospital care in the United States. The ICD-10-CM revision includes more than 68,000 diagnostic codes, compared to 13,000 in ICD-9-CM. In addition, ICD-10-CM includes twice as many categories and introduces alphanumeric category classifications for the first time. Obviously, such an expansion is going to make life harder for doctors and for software developers trying to keep pace with the upgrade.

The following changes have been made with the 5010 update to accommodate the new ICD-10 code sets:

• Increased field size to 7 alpha-numeric digits instead of 5 numeric digits
• Increased diagnosis codes allowed on a claim
• Added one-digit version indicator to designate ICD-9 and ICD-10

As of January 1, all electronic submissions are supposed to be made in ICD-10 format.

March 31, 2012 (just a days away) is the end date for submission of electronic medical claims in the 4010 format. After that date, HHS has ruled that it will not longer accept electronic claims submissions that are not HIPAA 5010 compliant.

HIPAA 5010 applies to all covered health organizations, including all health care providers, health plans, or health care information clearninghouses) and you are submitting electronic medical transactions. If you are still submitting medical transactions on paper, HIPAA 5010 does not apply to you. The most recent versions of paper claims are also compliant with HIPAA 5010 requirements.

You can find an overview of changes from the CMS (Centers for Medicare and Medicaid Services) at: http://www.cms.gov/MLNMattersArticles/downloads/SE0904.pdf

At this point, if you are purchasing or leasing any serious EMR system, it will be HIPAA 5010 / ICD-10 compliant. Do not consider using an older system that does not conform to the new standards.

Obviously, it is not only the hardware and software that have to accommodate these code changes, but your staff: the doctors, nurses, technicians and billing specialists. Training needs for these changes will be substantial, but not to panic: every person does not need to know about every change. There has to be a sense of distributive processing about this EMR –significant upgrade. But that is for another, upcoming discussion.

If you have not yet moved your medical practice into the world of EMR, or if you are just going into clinical medical practice, you are fortunate in one sense: If you had transitioned to an EMR years ago, and you were still coding procedures and diagnoses with ICD-9 codes, you would have to go about transitioning to the Version 5010 and ICD-10 codes, and making sure that your current EMR was keeping pace with the changes. This is not a small set of changes we are talking about

This way, if you haven’t yet moved to EMR, you will go directly to software using HIPAA Version 5010 and ICD-10-CM codes.

The version 5010 Standards:

Version 5010  refers to the revised set of HIPAA transaction standards; adopted to replace the current Version 4010/4010A standards. Every standard for electronic administrative transactions has been updated, from claims to eligibility to referral authorizations. A good place to learn about the details of Version 5010 is on the CMS site. Version 5010 supports both ICD-9 and ICD-10 codes.

A quick review of the differences between the two coding systems, ICD-9-CM, the ICD-10-CM:

Like ICD-9-CM, the ICD-10-CM is based upon the International Classification of Diseases, which is published by the World Health Organization (WHO) and which uses unique alphanumeric codes to identify known diseases and other health problems. (Click here to see the WHO’s ICD-10 codes).

The United States has modified the WHO’s version of the ICD-10 codes to produce The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), and it is a revision to the ICD-9-CM system used by physicians and other health care providers to classify and code all diagnoses, symptoms and procedures recorded in relation to hospital care in the United States.

The ICD-10-CM revision includes more than 68,000 diagnostic codes, compared to 13,000 in ICD-9-CM. In addition, ICD-10-CM includes twice as many categories and introduces alphanumeric category classifications for the first time. Obviously, such an expansion is going to make life harder for doctors and for software developers trying to keep pace with the upgrade.

The following changes have been made within the 5010 update to accommodate the new ICD-10 code sets:

• Increased field size to 7 alpha-numeric digits instead of 5 numeric digits
• Increased diagnosis codes allowed on a claim
• Added one-digit version indicator to designate ICD-9 and ICD-10

Obviously, the details are everything, and need to be studied carefully!

As of January 1, 2012 all electronic submissions were supposed to be made in according to 5010 standards. The ICD-10 diagnosis codes must be used for all health care services provided in the U.S. on or after October 1, 2013. ICD-10 procedure codes must be used for all hospital inpatient procedures performed on or after October 1, 2013. Claims with ICD-9 codes for services provided on or after October 1, 2013, cannot be paid.

A 3-month grace period extended the deadline for version 5010 submission, and March 31, 2012 (just a few weeks from now!) is the end date for submission of electronic medical claims in the old 4010 format. After that date, HHS has ruled that it will not longer accept electronic claims submissions that are not HIPAA 5010 compliant.

HIPAA 5010 applies to all covered health organizations, including all health care providers, health plans, or health care information clearing houses that are submitting electronic medical transactions. If you are still submitting medical transactions on paper, however, HIPAA 5010 does not apply to you. However, the most recent versions of paper claims are also compliant with HIPAA 5010 requirements.

You can find an overview of changes from the CMS (Centers for Medicare and Medicaid Services) at: http://www.cms.gov/MLNMattersArticles/downloads/SE0904.pdf

At this point, if you are purchasing or leasing any serious EMR system, it will be HIPAA 5010 / ICD-10 compliant. Do not consider using an older system that does not conform to the new standards.

Obviously, it is not only the hardware and software that have to accommodate these code changes, but your staff: the doctors, nurses, therapists, technicians and medical billing specialists. Training needs for these changes will be substantial, but not to panic: every person does not need to know about every change. There has to be a sense of distributive processing about this EMR –significant upgrade. But that is for another, upcoming discussion!

By Sheldon Needle

Most EMR and EHR vendors advertise their wide variety of templates. But do the templates make the EMRs easier to use, or do they complicate your patient histories and billing issues?

The question is not whether an EMR or EHR will use templates, but what kind of templates an EMR will provide. Some vendors discuss the savings in storage space, but the data storage issues are really the smallest issue involved.

The greater issues are flexibility, or the lack of flexibility, that a template creates for a doctor at the point of care in his clinical documentation; and the savings in time and precision that a good template will afford.

Another issue that a poor template can create is inaccuracy in billing codes which result in “downcoding” – that is trivializing the complaint and coding it as a minor appointment for the doctor, which will result in his receiving very minor payment from the insurance company. Of course “upcoding”, or making more of a visit and procedure than it should be, is dishonest and exploitive as well.

What this tells you as a doctor is that a template needs to be “customized” but not to the point where it trumps the diagnoses that the doctor makes for his patient, or does not allow the doctor to fully describe the point of care encounter..

There are two distinct categories of template type:

Documentation by Exception (DBE)
These are the more fully filled out forms, that prompt the doctor for less. They are “pre-answered” and thus describe a fairly healthy patient.

Documentation by Findings (DBF)
These templates inquire after individual complaints, and are not pre-answered. They prompt for individual findings and conditions, and thus take longer to fill out. Because they are more specific and exacting, they can support specific billing codes for insurance purposes. They can also be much more useful for a doctor in reviewing a patient’s conditions over time.

Since DBFs are more specific and more exact, EMRs that have DBF templates tend to have more templates than EMRs that have DBE templates.

Some physicians feel that this is unrealistic, and the time required to fill out DBF templates is just too great. But even if a doctor prefers an EMR with DBE templates, and wants the quick broad brush record that they offer, he has got to look for flexibility and adaptability in the template.

So, as in all things, the long run gains and the short run costs have to be taken into account when considering efficiencies in EMRs. Though the more fully filled out templates requires less time from the doctor, they do not allow for full and exact documentation, and in the long and short run they can create problems for both doctor and patient.

When a doctor considers the purchase of an EMR/EHR she must look into the flexibility of the templates available. Make sure it is easy to import notes and customize the template. Request to fill out a few templates when you are shown a demo, ask how to customize and adapt it. If the salesman tells you that tech support can do it for you, forget that EMR and move on to the next option.

There is no free lunch, and there is no work-free template worth its bytes, either.

The real problem of an established medical practice moving into the realm of EHR is not the cost of the medical software package; it is not the training necessary for staff; and it is not security and backups.

The real problem of moving into EMR/EHR is the problem of unstructured medical data.

If you are involved in a new or relatively new practice, this is a no-brainer. Begin with a serious search to compare medical software vendors who are available to answer your questions honestly. It is not truly so difficult to get on a friendly medical screen to enter your patient’s blood pressure or lab test values. You can get used to that.

Neither is it difficult to take notes on a notebook that upload to the EHR system.

The real problem is taking your notes and dictation on a patient that go back 15 years and finding a way to get his possible symptoms, his worry about IBS, his headache history, and his worries over his children into a metrically available rendition that that does not take you or a member of your practices days to decipher. These notes are usually on dictation, hand written notes, and referral letters.

The concerns are many: this can take what feels to be forever, and the anxiety issues and unclear symptoms may not translate easily into metrics but may be critically important in future diagnoses.

There are two critical questions here:

1. 1) Is it worth it? and
   2) If it is worth it, what to do to make this work efficiently?

In the long run, it doesn’t even matter if it is worth it. It will happen. Medicine as well as the rest of our cultural world, is becoming electronically-based whether we like it or not. But in the long run, it is worth it. Think of a patient going in to the hospital after a car accident, all by himself, and having all his data available to the admitting doctor in an instant: blood type, history, etc.

Think of a patient being referred to you, the specialist, and having all his patient history available in less than a minute. What a time saver! What insight!

Medical informatics has a number of methodologies it is using to translate unstructured data into useful and structured data.

Three basic methodologies exist to accomplish this:

• String matching
• Natural language processing for Medicine (NLP), which uses syntactic rules in extracting data from text documents
• Concept-based indexing which uses data base codes to group and relate medical concepts

These methods will be refined, utilized, and integrated in some way into most decent medical vendor software packages over the next few years. For you the physician or practice manager, this may start to pay off in a while, but you still have to get from hand written records into the database.

The obvious way to proceed makes use of our culture idea of, “going forward”:

1. Start with today’s records being input into the database electronically – this is the easy part.
2. Then get help in moving 1 year of back data scanned and automated. Get someone technically savvy and talk to the support people whose EHR software you are considering about OCR (optical character recognition) software that may be available from vendors.
3. Most vendors of decent repute will have voice recognition software incorporated into their total EHR solutions. Have them demonstrate how well it works in moving data into their files.

The real message to practitioners moving to electronic health records is, don’t look at the top of the mountain when you start climbing, just put one foot in front of the other. Delaying the climb will not get you anywhere, but starting the march will move faster than you think!

Source:

Though I saw a well-known EHR panel on the computer screens within an ICU, and the EHR being used to record certain patient data, doctors were taking their notes in long-hand. Later on the same day I saw the same doctors transcribing their notes onto their computers. The doctors, doing double duty on note taking were not available to their patients because they were acting as secretaries.

When a large clinical environment is incorporating an EHR it has to be done in a modular way that does not impact productivity any more than it has to. The task is hard enough. If you are using an EHR to record point of care patient information, give your doctors a Notebook so they can take their notes electronically. In fact, insist on electronic note-taking. Incorporate change with some forethought to peoples’ time and effort.

This real-life observation just underscores the need to plan for transition to an EMR rather than throwing an institution into the chaos of change for its own sake, or for the sake of Meaningful Use incentive payments. As in all things, the old US Coast Guard motto holds true: Semper Paratus! Always be ready and prepared.

Most good EMR / EHR systems can offer medical clients some guidance as to best practices in incorporating EMR / EHR systems within their practices.

The prospects for EHR in the coming year are exciting but more than a little daunting.  The issue is really how to find an EMR/EHR system that will organize and centralize the functions of your practice, without bankrupting you and throwing your staff and yourself into turmoil.

If you look at the websites for EMR vendors today, you can see that the functions they describe within their system –the integration of clinical records with practice management data, e-prescription, patient portals — could conceptually do wonderful things for you and for your patients in the way you handle their individual cases, but many of the details are still not working smoothly.

Here are some of the things to be aware of:

1. If you are getting a client/server system, make sure your internet connection has the bandwidth to support the sheer number crunching your system will need.  Otherwise your system may well freeze up on you or move at the speed of molasses.
2. If you are a small practice and getting SAAS software, hurray for you!  This could be just the right way to move towards EMR.  But beware of sticker shock.  The prices quoted to you on-line for monthly subscriptions to SAAS may well not mention additional fees you need to pay for licensing, installation, initial training.  Make sure everything is clearly stated in your contract.
3. Think hard about how you are going to transition your current paper based system to digital records.  Who will do the scanning?  What will you do with your dictation?   The whole issue of free form data (things like scanned documents that need to be OCR’ed in order to get into the database, your dictated notes, etc.).  It is not enough to just get everything on paper scanned.If you can afford to get a service that does transitions like this for a reasonable fee, consider this as a viable strategy.  It may save you lots of headaches.
4. Not everyone can necessarily get the benefit of “Meaningful Use” incentive payments right away.  It will depend on the nature of your practice, your specialty, your patient base, as well as how many Medicare or Medicaid patients you service, just to name a few variables. Do not let “Meaningful Use” be the only criterion you use in evaluating EMR software.
5. Find a company that will do serious training for you and your staff, and will not nickel and dime you for every question you have for them as you move into the implementation and use phase.

Remember, always read the fine print and ask every question you need to. Know that EMR software decisions is a very competitive business. The vendors need you just as much as you need them!