Electronic Medical Records When starting a new practice, introduction of an electronic medical record should be of paramount importance due to potential cost savings (reduced staffing, elimination of paper storage systems, time to acquire chart data, integration with billing systems, reduction of duplication of demographic and charge data), convenience (instantaneous access to charts anywhere, no lost charts, embedding external letters/xrays/op reports directly into the chart), and streamlined practice operation (everyone in the practice including secretaries, can access the charts at different levels of access granted and input data, integration with a scheduling program module).   Prior to starting a new practice, it is strongly suggested EMRs be investigated months in advance since selecting an EMR and then implementing the use of such may require significant time investment since several people must be trained to use the system, each with their own particular frequently used part of the program that may not be familiar to others using a different segment of the program. Although the physician should investigate possible EMRs themselves, a survey of some of the more popular is included here with ratings on applicability to the usual chronic pain management practice.  Algos EMR Assessment  If you are planning on taking patients with you from your current practice (if permitted by your current contract), then it is suggested you begin dictating summary notes that encompass the entire patient history and physical exam along with the procedures that have been performed and results of such procedures.  If possible, ask for the transcriptionist to deliver the text data to you in a digital format (eg. email, CD, floppy disc, memory card, etc).  This type of data is very easy to input into the new EMR and will save countless hours reconstructing charts from patient memory or reading through old patient records once your new practice begins.  It is also very important to acquire (if permitted), demographic data in a digital format.  If your practice is beginning without prior patients transferring to your new practice, implementation of a EMR is even more simple.  If you have doubts about the need for an EMR or Electronic Health Record, click here to see "50 reasons to purchase an EHR". Also, an excellent resource to ask questions about EMRs are the forums.  The best forums (not specific to a particular brand) where the docs and geeks mix are at:  http://www.emrupdate.com/forum/ HOW TO SELECT A EMR FOR PAIN MANAGEMENT   Pain management is a diverse field encompassing office based chronic pain management, acute pain management with injection therapy alone (eg. disc herniations),  chronic interventions without significant office interaction, hospital based pain management, and multi-specialty pain management.  The particular needs of a physician for an EMR is highly dependent on the style of practice in which he is engaged.  Those with a chronic pain office based management will need more features on their EMR than a physician that is a part time anesthesiologist performing occasional injections in the operating suites.  In the latter situation, there are some EMRs developing currently for dictation only, however in such a situation, there would probably be little need for an EMR.   Office base chronic pain management has very little to do with anesthesiology or the training obtained in an anesthesiology residency.   Therefore, physicians moving from anesthesiology to chronic pain management will find they effectively need to undergo a paradigm shift in their thinking about how to treat patients.  For those that do make the transition to office based pain management, an EMR is a valuable tool that has the potential to save not only time, but a significant amount of money.  But naive physicians are sometimes fleeced by EMR salesmen stating the physician will derive "x " amount of dollars per year savings, so berating the physician for being so short-sided as to not want to pay 5 times "x" for the EMR.  That type of faulty logic and absurdly high pressure salesmanship must be the first and most important issue to understand about EMRs.  EMRs advance very rapidly over time therefore it is foolish to consider paying a high amount of money for a program that will be eclipsed in a year.  Also, the prices of EMRs are beginning to fall, and in some cases the cost of the EMR is almost nil yet packs advanced features.  If you have a procedure based practice without routine follow-up visits, then you need a EMR with potentials for data storage and possibly billing output to a third party biller.   On the other hand, an office based chronic pain practice may require full featured EMR, practice management, and billing. There are several components that need to be understood:  EMR refers to the charting component with doctor generated notes, nursing generated vital signs, etc.   Some bundle a Practice Manager (PM)  module that refers to the software that permits scheduling of patients, searching by data field, generation of productivity reports, and may include a billing module.  Usually, the billing module is separate from the EMR and is most often not integrated, however there are several billing programs that integrate reasonably well with the EMR.   Factors to consider: 1. Upgrade Capability:  most EMRs have the capability to upgrade to changing computer software operating systems and to interim advances in the EMR software itself.  Some will permit the addition of other modules such as a "fax module" permitting scheduling programs to automatically call patients the day before their appointments to remind them of the appointment time, etc.   The ability to upgrade depends on the degree of continuing software development within the company selling the EMR.  If a company is very small, they may not continually upgrade.  If they are too large, the upgrades are cumbersome and contain so many bells and whistles that you may not use them and they may crash your system. Upgrades are a cost of business item and are rarely free.  The upgrades may be purchased outright or may be automatically implemented through the internet by a upgrade coverage plan.  The best EMRs have automatic checking for upgrades then upgrade during off hours of operation automatically.  The worst EMRs require manual upgrades of each computer that may be performed only outside hours of operation, and may require an information technology specialist to install them.   It is my experience upgrades are not well tested prior to implementation and often require further upgrades to fix "bugs" that cause the system to crash. 2. Choice of in-house server or web-based system.  The traditional EMR uses a central office-based server for the main patient databases (turnkey purchase).  This type of system requires purchase of a server ($500-5000) and implementation of either a wired and/or secure wireless intraoffice network.  Unless you are a technogeek, it is often better to have an IT person set up the networks and databases for you.  Some EMRs ask that you pay for their IT persons to travel to your office to set up the system, however this may result in a system that is not easily repaired by local IT people who did not set up the system.  Some systems do not use servers to store the patient data but rather store parts of the data on several computers.  This is undesirable.  Servers must use special operating system server software that may require licenses to use.  The software plus licenses may cost several thousand dollars, but mine was purchased for about $1000 (Windows Server 2003 plus licenses).  Servers in an office may require a specific database software such as SQL that may add an additional $4000 onto the price of the system although there are some EMRs that include a "light" version of the SQL software for free.  Other database systems other than SQL are usually bundled into the EMR software. There are some EMRs that use a "synchronization"  between the input device (tablet, laptop, hand-held) and the server but these are very undesirable due to the data being synchronized only at the beginning and at the end of the day.  This creates chaos in the front office when the plan for future scheduling, labs, etc are not known to the secretaries, thereby necessitating a separate communication system for such data.   Networks within an office may be wired only if the physician inputs data from a static computer such as a computer on a desk in the exam room or a plug in CAT5 cable into a laptop.  The advantage to wired only systems is security and speed.  But many physicians find sitting in front of a computer while talking to patients to be impersonal and distracting if the physician is unable to multitask.  The wireless systems with encrypted security are fast enough now that most software applications run sufficiently fast for physician's use.   Most offices have a combination of wired systems (between the server and the static computers) and a wireless system for physicians to use a laptop, tablet, or hand-held computer to input patient data.   Finally, it is imperative data backup is performed frequently and stored off-site in case of fire.  We have found a tape backup system run every day at the end of work is an inexpensive means to provide data security. The web-based systems (ASP) use a high speed cable or DSL to access patient data stored on a EMR vendor central server off site.  The entire office can be wireless in such situations, although when numerous computers in an office are simultaneously using a single DSL line, the system may become slow.  The advantage to web-based systems is security of data with built in back up systems (although recently hackers have demonstrated no off site patient data is safe), and the lack of need for an in-office data backup system, and often the lack of need of a server system.  Also, the cost of such systems is often "pay as you go" with either charges per patient or a subscription charge per month, and may be an order of magnitude lower than that of a central office based system.  Disadvantages include loss of control of the databases (some companies charge a premium for you to have access to all your files in case you wish to transfer data to another system), dependency on the internet (some locations have frequent outages and interruptions of internet service which can loose the data being input by a physician into the patient file or can cause the EMR to be unusable disrupting billing, scheduling, etc), and limitations on accessing the patient data by billing programs or modules. 3. Data input methods: One of the most difficult aspects of the EMR is training the physician to employ data entry.  It is solely through this necessary component that the majority of cost savings of EMR is realized (up to $20,000 per physician per year), but it is also one of the most difficult things for physicians to use well in practice.  Some of the factors involved in deciding what method(s) of data input to use include the capabilities of the physician, physical set up of the office, whether the physician is comfortable inputting data and conversing simultaneously with the patient, network setup, EMR capabilities, and the actual input mechanism.  Most physicians incorporate at least two different data input methods.  Data input techniques include:     Typed data input:  The physician types in everything as a narrative into the medical record.  This does not work well for physicians without lightening fast typing, but does provide a more even flow narrative that prevents auditors accusing the physician from using a "cookie cutter" approach to every patient thereby triggering an audit.  Most physicians do not type significantly.     Typed data in formatted fields  Physicians type in data in pre-formatted fields such as SOAP note entry.  Uncommonly used.     Pre-defined templates  Drop down lists or separate windows open with templates and sub-templates available for ROS, HPI, PE, etc.  There are not many EMRs that have pain management specific templates available so some physicians use neurology, neurosurgery, or orthopedic templates. Some templates have graphic interfaces in which a drawing of a hand, back, foot, etc will be available for the physician to draw the area of pain or lesions, etc.     Advantages of templates include large amounts of data can be entered all at one time.  Disadvantages include cumbersome use especially when enormous numbers of templates and sub-templates are used.  These are not always intuitive and can create a steep learning curve for the physician.  Also, some templates require the physician go back and click on each of the positive findings in a negative template or even worse, manually remove each positive finding in a negative ROS template.  Templates are also easy marks for Medicare auditors when the same phrases are used repeatedly without change or comment over and over or the patient note will be identical from one visit to the next.      Templated formats of data entry can be configured to work from the keyboard, mouse, light pen, or touch sensitive screen.     Physician defined templates   In nearly all EMRs, the physician can create their own customized templates which is quite advantageous for pain management since usually such pre-created templates do not exist.  Alternatively, the physician may purchase or use the templates of another pain physician.  Creating these templates is a work of trial and error, and may not be useful to transfer such templates from one EMR to another brand of EMR due to constraints in the way templates are employed or divided on each system.  Advantages include customization to the physicians lingo.  Disadvantages include creating "cookie cutter" patients and time involved in template creation.                    Dictation-transcription with cut and paste entry  This method is still used by some physicians, but is expensive because the transcriptionist costs are not eliminated.  In this model, the data is dictated into a dictaphone or audio recorder or telephone then is transcribed into text by a transcriptionist.  The transcribed data is subsequently pasted by a secretary back into the EMR.  This system probably ultimately costs more than a paper system and demonstrates the inflexibility and intransigence of physicians unwilling to upgrade their data entry skills.  In such cases, the EMR becomes just another office expense without significant cost savings.     Voice recognition systems  Dragon Naturally Speaking 8 is the best example of this with the physician dictating directly into the computer with approximately a 98% accuracy.  There is a Dragon Medical version with thousands of medical terms for about $1100 compared to $100 for the non-medical version.  The non-medical version can be trained to recognize medical words and the training can be done on-the-fly or by letting the program read some of your dictations or medical articles to acquire words it does not yet know.  There is also the possibility of creating your own templates in the medical version that can be activated by one word.  Training time is usually a few hours and require reading stories into the computer program.  Once up and running, Dragon works with nearly any EMR with a maximum speed of about 160 words per minute which is far faster than can be typed.  Advantages: personalization of the EMR that helps avoid "cookie cutter audits" and narrative rapid entry.  Disadvantages: must proof read everything since Dragon will make up words or phrases if it does not understand you.  Also a noise limiting microphone is required that can be cumbersome as a headset, although built in array microphones or noise canceling gooseneck USB microphones are available for some laptops and tablets.  Dragon does not work well on hand held computers because the processor speeds available are not fast enough. There are other voice recognition systems such as Microsoft Speech, IBM Via Voice, but these are not nearly as accurate as Dragon.       Writing recognition programs:  Tablet PCs now have available on the XP Tablet PC edition operating systems, a writing recognition program that have advanced enormously from the old HP Newton software.  Now, real script writing (even doctor's handwriting) can often be recognized with surprising accuracy and converted into text.  While writing significant amounts of text is far too laborious for routine chart entries, the writing capability gives rapid annotation or insertional ability to physicians who wish to append templated or Dragon notes.         Some of the more advanced text intensive programs such as Praxis and to a lesser degree Chart Logic, will create quasi templated inputs and will "fill in the blanks".     4.  Functions and Features    Many functions and features incorporated into EMR programs designed for primary care will have little use in pain management.   Some of the features may be selectively eliminated by the user but often they cannot.  Therefore the EMR is filled with screens listing "immunization shots and dates" or tracking of height and weight vs age charts.  In systems where the user can bypass these useless screens, the EMR can be user friendly, but if not, the EMR becomes cumbersome requiring extra unnecessary steps.  It is important to have quick access to the features needed by the physician but also be user friendly to the rest of the staff. To answer functionality questions, in assessing an EMR (ALWAYS TRIAL AN EMR OR HAVE AN ON-LINE DEMONSTRATION ASKING THE DEMONSTRATOR TO SHOW THE FOLLOWING BEFORE PURCHASE!!!) a. View:  How fast can the patient's chart be pulled up on the computer in real time, how fast and how many clicks to the progress notes, med lists,  and problem lists; can a split screen be used for old notes on the left while entering new notes on the right (not many EMRs can do this);  is the print scalable or is it too small to read on a small tablet PC or chosen data entry device? b. Document: How fast can the visit be documented?  (ask specifically to document a chosen phrase that is not templated...eg. "the patient is exhibiting signs of slurring of the speech and is disheveled in appearance").   c. Identify:  If you need to place alerts on this patient such as "high substance abuse potential" to appear on a popup note when the chart is opened is this possible?  If you need to send an intraoffice mail on this patient can it be done easily while in data entry fields of the patients chart or does one need exit that section of the chart before sending such mail? d. Decide:  Are there references such as PDR, drug dosage availability, clinical references available within the program that can be easily accessed? e. Prescribe: Since many states have specific forms and paper that must be used for scheduled narcotic scripts, prescription fax services embedded within the program are only useful for non-narcotic scripts. Therefore, if your state has certain requirements for such scripts, ask if the output program for printing scripts can be modified to comply with state laws (if not, you will be writing every Schedule II prescription by hand).  Many EMR tout the advantages of faxing directly to the pharmacy, but again this cannot be done with narcotic scripts.  The pharmacist must receive the original script for schedule II drugs and this works best if the program can be set up to print the prescription on special paper required for such (sometimes this paper can be obtained through prescription pad printers if they pre-print your practice information at the top.  NOTE: IT IS ILLEGAL TO PRE-PRINT SCHEDULE II SCRIPTS.  The amount and directions for taking the schedule II drug may be printed at the time of prescribing but not before. f. Order: labs, non-medications, x-rays.  Usually this is not feasible unless a script or order is generated for such or you have a direct fax link to each of the entities that require such orders.  Often an original signature is required so the utility of this part of the program is questionable.   g. Communicate: Ask to see a copy of the letter that will be generated to referring physicians from the information input at the time of the demonstration.  Do not accept at face value flawless letters that are pre-entered into the demonstration program.  The letters generated by these programs in real life often have grammatical errors or may have information in a format that is not usable to referring physicians.  Fax or email capabilities should be available in real time from the program so the letter can be transmitted immediately. Do not be swayed by claims of patients being able to email you securely.  YOU DO NOT WANT PATIENTS BEING ABLE TO EMAIL YOU WITH CLINICAL QUESTIONS AS YOU WILL BE INUNDATED WITH EMAILS AND CANNOT GENERATE PATIENT CHARGES THAT ARE PAYABLE FOR SUCH.  Some offices permit billing questions to be emailed to the office, but this is only useful if you have an in-office billin in your practice.   h. Code: Ask to see how ICD9 and CPT codes are generated.  Is code generation automatic and is there an easy override?  Is there an integrated list of such codes in the EMR (most do have this)?  Is there a SNOMED or equivalent clinical vocabulary used to define diagnoses and procedures in a way to be compliant with insurers requirements?  If there is not automatic code generation, how many clicks and/scrolls does it take to find the correct CPT code?  Is there a built in cross reference of acceptable ICD9/CPT code matches or exclusions? i. Consent: Are there appropriate HIPAA safeguards on accessing patient data?  What mechanism is used to document requests for patient information and to whom it was sent? j. Aggregate: Are past entries available to be viewed in a single screen or are several screen openings required to view past data? k. Devices: Is there a separate entry for information about implantable devices such as serial numbers, model number, implant or revision date, etc. l. Scanning: How easy is it to input scanned letters, old charts, or to import and embed xrays or MRIs? m.Demographics: Is there an embedded photograph of the patient in the demographics or working page of the chart? Does the demographic database permit secondary and tertiary insurance information? n. Imported Demographics and Clinical Data from Other EMR: How easy is it to import and export data from other medical records to the new medical record and what formats of data are accepted (eg. Excel, delimited text file, Access, etc).   If you already have a thriving practice with an EMR currently but the new EMR will not permit imports from the old EMR, forget it and move on to another new EMR. o. Scheduling: Is there an integrated scheduler (STRONGLY RECOMMENDED) instead of a separate scheduling program?   How fast can the new appointments be entered?  Does the scheduler have a search option to search for open appointments rather than having to scroll through dates one by one?  Can new appointments be generated without having to type patient name or information in the chart?  Is drop and drag possible? Is it easy to configure new schedules for physicians?  Are schedules color coded by physician or by location? f. Billing: Does the program have an optional billing module for in-house billing?  If not what program will integrate seamlessly with the EMR to provide such billing module including transfer of demographics and patient charges /codes generated by the EMR program? (if you are considering billing in-house and the EMR does not have a company they can recommend for seamless transfer of billing data to a separate billing module, consider rejecting the EMR and look for another.  Otherwise , there may be required significant manual entry of already entered data and demographics that can cost an additional $20,000 per year in staffing costs.     5. Usability of the EMR a. Input:  Decide what capabilities the physicians have for input...if the physicians cannot be trained to rapidly input data, EMR will be useless.  Because there may be other physicians/PAs/NPs added to the practice, there should be a number of methods to input data to the EMR. b. Customize: How easily can the EMR screens be customized to suit the workflow of the individuals?  This is not a significant issue in a small practice, but if the practice grows to 5-10 physicians, then this feature may be useful. c. Understand: Can the physicians and staff understand the icons, terminology used by the EMR describing different modules and screens, and menu categories? d. Integrate: Can the EMR integrate with billing and practice management software easily or is the EMR a stand-alone unit? (not advisable) e. Access:  Can the EMR be accessed remotely and data entered remotely in real time?  (not through synchronizing the system at the end of the day?.  It is critically important for pain management that 24 hour access be maintained due to untoward side effects of medications, significant side effects of interventional procedures, anyone with an intrathecal infusion device, etc.   Can the EMR be accessed from satellite offices?  From home?     6. Support Access An EMR will not always work as intended due to the necessary integration of the EMR software with the server, individual computer operating systems, intranet, and internet.  There may be firewalls that impede proper operation or network connection problems with wireless components.  Additionally, there may be bugs in the EMR that cause the program to crash when certain other programs are in use or when sequences of specific operations are performed.  When Microsoft upgrades the computer operating systems through "Service Packs", sometimes perfectly good EMR systems go bad.  Antivirus programs can sometimes interfere with EMR, and integration with other practice management or billing programs can cause bugs.  Therefore, some level of support will always be necessary with an EMR program that is relied upon as the backbone of a physician's practice.  Support can come via subscription, pay-per-incident, or can be bundled as part of the fees assessed yearly to keep the program active.  The most unscrupulous companies will chage both licensing fees yearly and service fees yearly, and if both are not paid, the program (that you purchased and own) will simply stop working.  These companies are to be avoided as there are cases where all fees were paid, yet the company pulled the plug on the program anyway.   Furthermore, any company can go out of business, and with a setup as in the latter scenerio, the physician may be left with a dead program, unable to access his own data, and no recourse except to sue a bankrupt company.  Also note some companies will charge you outrageous fees to download the data from the program you own since they control the access codes to the databases.  An out of business company will forever make your patient data unavailable if you cannot freely export your own data. Hints on support: a. As if there is a real live tech support person immediately available in the US (not India) during your working hours to troubleshoot your program? (most have the capability of using a terminal emulator program and trying to troubleshoot your program over the internet in real time). b. Is there training available for use of the program and what is the cost? (some programs have hidden costs of training that are not listed when discussing the purchase of the program).  Is there a person from the company that can be made available to work with your own IT person to help with setup and implementation of the program or if program incompatibility occurs later? c. How long has the company been selling the programs to the public?  If less than 3 years, be very cautious since the company may not exist the following day.  Absolutely avoid any EMR programs currently being developed by pain management physicians...there must be a track record for these companies otherwise do not do business with them.  Your patient data and the survival of your office are at risk.     7. Pricing and Hidden Costs In past lives, many salesmen for EMRs must have been used car salesmen.  Some may continue in that line of work as they attempt to hawk their extremely expensive EMR wares.  They will mislead, misdirect, mischaracterize, and misconstrue the capabilities and costs of the EMR.   Nearly all are on a commission and for some, the commission may be 3/4 of their income.  Therefore there exists a tremendous impetus towards high pressure sales with unnecessary extras jacking up the price of the EMR substantially.  Very few websites for these companies will actually give any indication of the cost on their websites.   Many will not break down their prices for you until after you have listened to an exhaustive 1.5 hour long and usually well rehearsed on-line demonstration.  Some companies (either due to incompetence or in an effort to reduce the sticker shock of the product) will not demonstrate all requested modules at the same time, claiming "another department" handles other modules (eg. practice management or billing) even though these are integrated modules.  Once you discover the price of the EMR product and the price range of competing products, it is easy to understand their surreptitious approach to one of the most important aspects of the product: the cost. The  EMR companies claim they cannot discuss costs until they know the specific needs of the office, but they also refuse in advance of their demonstration or contact by a salesman to give a pro forma cost for a typical office setting.  The reasons for this cloak and dagger approach will become clear when you examine the hidden costs as discussed below.  Because of the unscrupulous nature of many of the salesmen with the concealed costs, an increasing number of individuals are selecting web based solutions.  However even these have costs on the back end (data transfer to a transportable file that may be uploaded into another EMR) that may not be apparent. Note: in buying an EMR, the adage "You get what you pay for" simply does not hold true.  There are some inexpensive systems that would fulfill the needs of most practices from well respected EMR companies while there are companies that charge $50,000 per physician to acquire an EMR with virtually no service support.  It is estimated there are nearly 250 companies with EMR products in 2005, so there is a huge variety in pricing.. There are three basic methods of financing an EMR for your practice:  a. Purchase the software (may still have to pay licensing fees),  b. Subscription Plan (licensing fees and all costs are rolled into a monthly fee but the software is installed on your computer), and  c. ASP (Application Service Provider) in which the program resides elsewhere and is accessed by your office via the internet.  In the case of ASPs, these may be offered by the vendor or by a third party.  The third party ASPs may end up costing many times more than a simple purchase of the original product from the vendor as is the case of eClinical Works. CLICK HERE FOR SELECTED 2005 PRICE COMPARISON OF EMR's Direct acquisition costs-non-web-based systems (Turn-key System Purchase):               a. Software acquisition- this cost ranges from $0  to over $75,000.  Some companies charge acquisition costs based on ranges of numbers of upper level providers using the system (eg. 1-5 or 6-10), based on the number of computers that will be used, or some have a flat fee for the software.  Remember however, if you do not control the database import and export capabilities for free, you really own nothing, and are in effect paying a ransom rental fee for use.  Initial license fees based on level of provider or number of computers used are extra.  Some EMRs require SQL database software systems by Microsoft at a substantial premium.   b. Hardware acquisition- Includes server costs, computer terminal, laptop, handheld, or tablet PC costs with their own operating software.  Most EMRs require at least XP Professional as an operating system while some have specific requirements for Windows CE on the portable computers.   Most of the computers used will not be crunching multiple programs simultaneously therefore the top of the line Pentium processors are not needed.  Also, the storage needed on each computer is usually modest, therefore huge local data storage capabilities are not needed.   Cable or DSL at approximately $50-100 business rate per month will be required if there is internet access used, and then each computer will need firewall protection in addition to the server itself.  A battery backup system to last 20-30 minutes should be acquired for critical units such as the server, one computer for checkout of patients, and a hardwired computer for physician data entry or battery backup for the wireless intranet in case of transient power failure.  The wireless intranet system consists of a wireless access point (a hardware device costing about $75) with a G or super G wireless system in each tablet, laptop, or non-hardwired static computer.  It is suggested that a hardwired system be employed to as many computers as is possible, saving the wireless for physician tablet/laptop/handheld use. Hidden and indirect costs-non-web-based systems: a. Recurring license fees-  as a way to generate a continuing revenue stream, some EMR companies charge a fee every year for continued use of the software you purchased.  Yes, this is unethical and may be illegal in certain jurisdictions, but no one challenges their modus operandi.  These fees may be based on a tiered level dependent on the level of access required (eg. doctor, nurse, secretary), or may be based on the initial purchase price or may be based on the number of computer terminals used.  Ostensibly some of these licensure fees cover upgrades even when unwanted or unneeded.  These license fees may be up to $2000 per physician per year.    Cable or DSL at approximately $50-100 business rate per month will be required if there is internet access used, and then each computer will need firewall protection in addition to the server itself.    b. Service plan fees-  Many EMR companies require these fees that permits access to real-time trouble shooting.  The tech support is only consistently useful when the recommended hardware systems are purchased  (usually are way overkill on what is actually what is needed to run the system).  Consistent hardware means the tech support person does not need to know about bugs that plague other systems and are therefore an incentive to purchase far more computing power and spend far more money on hardware than is required.  For non-specified hardware systems, tech support may only be able to debug your own EMR program and not the errors that result from other program incompatibility or operating system errors.   In such cases, physicians may find themselves paying for EMR support in addition to having a local IT person on their payroll to help debug the system.   Service plan fees can cost up to $900 per month for a 2 physician office. c. Training costs- Training is optional for some of the EMRs while for others it is mandatory.  Often this is a hidden fee and may cost up to $35,000 to train an office.  Most are fall less than this.   d. Practice management module- The costs included in the EMR may include the charting module only.  Scheduling programs, which are a necessary and integral part of the office , may be bundled separately or as part of a comprehensive practice management module, or may not be available at all.  Basic scheduling program modules cost about $3000 but may be as high as $10,000.  Comprehensive practice management modules may cost up to $50,000 e. Additional software modules or switches- As EMR software developers learned from the multibillionare Bill Gates, it is easier to build in many additional modules into the base software and only activate them for an additional fee.  In this way, software developers can continue to extract the maximum possible revenue from the physician if he asks about additional bells and whistles.   Some of these include a fax server program for up to $5,000,  modules to permit tablet PC operation even though the sales pitch says nothing about an extra charge for this, and additional fees to permit remote access to your own database residing on your own server. There are many other hidden costs that vary from one manufacturer to another.   f. Database download fees-  This is by far the most disgusting and revolting fee:  a stiff charge to access your own database to download the data into an excel or delimited text file for transfer to another EMR.  Software manufacturers rarely tell physicians about this fee up front and use it as a bludgeon to keep the physician in their revenue stream using their software. Ask about this fee up front. g. Back up data fees- The up front cost for a tape drive to back up both data and software is about $1000.  The office must run this tape system every night, then take the tape to a secure location off site.  Alternatively, some of the EMR companies will charge approximately $100-300 per month for electronic transfer of the data to a secure server of the company.   Example of hidden costs from a vendor quote: Patient Records for Windows License $28,800.00 -License quantity (16) is an estimate based on 4 concurrent physicians and 12 related support staff (nurses, MA's, scanners, system mgr, billing mgr, etc) that will require access to the EHR. Appointment Scheduler for Windows Base $3,125.00 -License quantity (4) is an estimate based on the needs of a 4 physician office. Appointment Scheduler for Windows Additional Seat $1,390.00 Medical Billing for Windows Base (includes 2 seats) $4,500.00 CodeWizard Base Subscription (MBWin - includes 2 users) $1,000.00 -Practice Partner CodeWizard provides comprehensive claims scrubbing, coding assistance and code lookup functionality in Practice Partner Medical Billing. CodeWizard is provided on an annual subscription basis -- Please note that the pricing is per charge poster and the base $1,000 subscription includes two users. Additional subscriptions are $400 annually. Medical Billing for Windows Additional Seat $950.00 CtreeServer- c-tree Server Database - 32 Connections $1,595.00 PRO-ECG-USB ECG $4,490.00 PRO-SPIRODLX Spirometer $1,995.00 Dragon Naturally Speaking $995.00 -One license is required for each voice profile. (My clinic) may require more than one license. Order Entry $2,400.00 for 16 Users -Order Entry provides the ability to order tests, procedures, etc. at the point of care and provides feedback on late orders and their costs. The number of Order Entry licenses must be equivalent to the number of Practice Partner Patient Records licenses. Custom Laboratory Interface: HL7 $0.00 -Requires prior approval by management and review by PMSI Interface Department before quoting. As a reference, lab interfaces typically range $3k - $5k. Practice Partner Clearinghouse Enrollment Fee $100.00 for 4 users. -This is a one-time enrollment fee for the Practice Partner Clearinghouse. Please consult with your sales executive to discuss different pricing options. System configuration, $3,000.00 for 2 days. -Implementation services performed by PMSI Project Manager(s). May involve a combination of both on and off-site participation. Includes travel expenses. Pre-Implementation Consulting $3,000.00 for 2 days. -Pre-implementation consulting is designed to map workflow changes, unusual circumstances, and to provide additional consultation time to help end users adapt to a more computerized environment. Set-up, Implementation, and Training for Order Entry $600.00 -This assistance provides you with access to an off-site, dedicated Project Manager who will assist you with preparing and planning your Order Entry project. Includes up to four hours of one-on-one instruction via phone and dial-in connection. Software training, $12,000.00 for 8 days. -Training services performed on site by PMSI certified trainer(s). Includes travel expenses. Go-live training, $3,000.00 for 2 days. -Training services performed on site by PMSI certified trainer(s). Includes travel expenses. On site follow up training, $3,000.00 for 2 days. Annual Support for: Ctree Server 32 Connections $239.25 Annual Support for: Patient Records for Windows $4,320.00 Annual Support for: Appt Sched Win Base (includes 2 seats) $468.75 Annual Support for: Appointment Scheduler for Windows $208.50 Annual Support for: Med Billing Win - Base (incl. 2 seats) $675.00 Annual Support for: Medical Billing for Windows $142.50 Annual Support for: Order Entry $360.00 Annual Support for: Digital Spirometer $250.00 Annual Support for: ECG $475.00 Clinical Tools - Base (includes 10 users) $600.00 Clinical Tools - Additional users $360.00 Formulary Tracking $1,180.00 Patient Education Suite of 5 modules $2,400.00 Shipping and handling charges $ 50.00 List Total $87,669.00 plus $7,000 a year in annual support fees Coming soon:  Recommended EMRs for Pain Management