Electronic medical records (EMRs) are like the proverbial light at the end of the tunnel. They may represent salvation or a runaway train coming at you full bore.

When it comes to physicians adopting EMR in their practices, the tired clichés (particularly the one about the carrot and stick) tend to get worn out.

The US government holds the stick while medical practitioners ponder the pros and cons of adapting the technology. For those who make the commitment and bite the carrot, government financial incentives can make it all a bit tastier. Ignore the carrot, and you may eventually choke down castor oil in the form of monetary penalties.

The first significant rumblings came in 2004 when President Bush set a 10-year goal to get most Americans a personal electronic health record (EHR). The idea is similar to EMR, but the differences can be vast depending on the level of complexity that practitioners choose.

With the recent signing of the American Recovery and Reinvestment Act—otherwise known as the stimulus bill—the Obama administration earmarked $19 billion for the adoption of EMRs. Specifics on how that money will be given and/or awarded are still sketchy at this point, but the hefty amount is more proof that government officials are keen on electronic records.

When Peter J. Polack, MD, FACS, began to run out of physical space for his charts, he decided to heed the heavy hints from government officials and seriously explore the EMR route. It was either that or knock out a wall—”Should we buy or rent more office space, renovate, and/or pay rent to store charts?” asks Polack, an ophthalmologist at Ocala Eye PA, Ocala, Fla. “I had been looking at EMR systems for about 15 years. We looked at the writing on the wall and decided to go with EMRs.”

For Polack’s nine-physician ophthal-mology practice with 150 employees, the transition has not been without its challenges. However, he believes that if EMRs can work for ophthalmologists, they can work for plastic surgery practices and other highly specialized groups. Whatever the specialty, the first step is to do your homework before you purchase any software, hardware, or services.


Many doctors find the product and then try to figure out how to make it work.

Polack wanted to avoid this common problem by figuring out exactly what was needed, with input from all the stakeholders, including naysayers. “We were biding our time because we knew that the failure rate for EMR was high—30% to 50%—and it is almost always due to poor planning and poor change management,” Polack says. “We got a committee in place, planned out the project, and eventually the committee came up with a short list of what we needed.”

Once Polack and his colleagues knew what they wanted, it quickly became evident that a so-called ready-to-use system would not fly. That type of setup might work, and may even be preferable for a small practice, but it would not work for Ocala Eye. Physicians with well-established workflow procedures had no interest in adapting to the whims of an out-of-the-box system, so Polack and company chose a highly customizable unit.

With the help of three full-time information technology (IT) staff, Ocala Eye embarked on a road that involved more expense on the front end as the techies developed specialty-specific templates, and integrated all facets of the workflow.

“Our system gives us flexibility and customization to adapt it to the way we do things,” Polack emphasizes. “I can log on to the same terminal and see similar info in a completely different way than another doc because that may be better for me. I can look at trends in measurements at a glance, and that is really the power of a good EMR system.”

A less sophisticated system, on the other hand, may simply allow you to scan your record—essentially a stopgap measure that does not allow you to analyze the information in an in-depth manner.

For practices in a bind, Polack says the no-frills scanning can buy some time, but will it be enough to garner the stimulus goodies and/or EMR rewards? It’s hard to say, but the stakes could be high when new regulations ramp up at what could be a dizzying pace.

Just 2 years ago, a physician reimbursement initiative, essentially a checklist done through EMR, offered a 1.5% reimbursement increase for specialty-specific criteria. Polack points out that the bonus of 1.5% does not sound like much, but it could mean $100,000—the salary of an administrator—at a big practice.

Talking Points

  • $19 billion in federal funds are earmarked for the adoption of EMR technology. Specifics on how that money will be given and/or awarded are sketchy, but the hefty amount shows that government officials are keen on electronic records.
  • Approximately 7% of practices have implemented EMR, and the majority of those are medical networks and organizations.
  • Failure of physicians to properly implement EMR is almost always due to poor planning and poor change management.
  • Most systems will offer a license per physician that costs about $3,000 to $10,000.

“They now have some tagged to EMR-related things, such as e-prescribing for Medicare patients—and having a significant percentage of your practice in EMR,” he notes. “When you add these things together, you are looking at possibly $44,000 per physician. That is for 2011. You will get incentives for doing these things, but gradually you will get fewer incentives, and then you will start to get penalized.”

Why all the interest from government officials? Patient safety and practice efficiency are often cited by bureaucrats, but an undeniable element of the push for EMR is to establish a higher measure of control. After all, paper records are relatively difficult to audit, but electronic data is much more manageable.

“Medicare and insurance companies will be able to see what you’re doing and how you are doing it, and it will make it easy for the government and insurance to regulate the way that you practice medicine—and it will all be tied to reimbursement,” Polack muses. “It’s pretty clever. Doctors have to pay for a system that is going to help the government police them better. That may sound a bit cynical, but remember that I am also a big proponent of EMR.”

Polack’s dose of realism is based on his belief that EMRs are going to be a fact of life and that ultimately the pros will outweigh the cons. Right now, he says roughly 7% of practices have implemented EMR, and the majority of those are medical networks and organizations.

Ironically, smaller one-person practices have been slow to adapt despite the relative ease for these practitioners. “The smaller practices really don’t have a clue as to how to get started,” Polack says. “And they are already hearing that in the next year or two they better have a significant portion of their practice in EMR or they are going to lose out on those first couple years of bonuses and start to get penalized.”


For practices big and small, sophisticated EMR technology should have a sensitivity and adaptability built specifically for the medical practice.

Practices in general come with a lot of peripheral technology such as ultrasound, lasers, diagnostic equipment, and imaging equipment. In a truly integrated system, all of these elements work together seamlessly to store and present information in a useful way. Depending on the size of your practice, Polack says you might want to hire full-time IT people who understand the issues of a medical network, including the HIPAA implications.

As for price, most systems will offer a license per physician that costs around $3,000 to $10,000. Typically, a percentage of the licensing cost is added (on top of the price) for yearly support.

If you have more than two physicians in a practice, you will likely need server software and hardware and an overall network infrastructure that supports the EMR system.

When all is said and done, Polack says you might want to forego a wireless system. “Everyone thinks wireless is real sexy, and we have both wired and wireless, but wireless adds a whole other level of complexity,” Polack warns. “You have cordless phones and microwaves that interfere with it, and you can’t use wireless access points that you get from a retail store because you can’t afford to move from one side of the building to the other and have the signal drop. If you lose the connection with the EMR system, you may lose the work that you’ve done.”

When you factor in the people, hardware, software, and the huge investment, does Polack ever wish he just knocked out that wall in his office?

“It depends who you ask,” Polack says with a chuckle. “When you have a hitch, you are always going to have naysayers who don’t want to spend the money and don’t believe the government is serious. The majority in our practice are gung-ho, and there are a couple who are less so. But I think that even they realize that this is inevitable and ultimately beneficial.”

Greg Thompson is a contributing writer for PSP. He can be reached at [email protected].