“They’ve realized now that the market share is here,” said Ana Cardenas, M.D., referring to companies that offer these systems.

Dr. Cardenas is a California dermatologist who purchased an EMR system this summer for her new practice after working in a group that adopted EMR during her time there. “They saw that the big money will come not from the big institutions that have already adopted but from the little guys converting over.” As a result, she said, some of the larger EMR vendors have brought out products designed to be affordable for solo practitioners.

As dermatologists consider taking advantage of lower prices on products scaled for their practices, Dan Siegel, M.D., a New York dermatologist and frequent speaker on technology topics at the American Academy of Dermatology Annual Meeting who recently purchased an EMR system for his new practice, said that they should remember that no system is perfect. “Nothing is ideal for everyone,” he said. Bearing that in mind, Dr. Siegel said, he sought a vendor that would integrate his front, middle, and back office operations into one system. “If there’s any problem you don’t have to call the medical record portion who says it’s a billing problem and end up with people pointing fingers at one another. One call gets it fixed—that was very important to us.”

Dermatologists who hope to enjoy such convenience should carefully investigate whether a package advertised as a single system actually is one, according to Dr. Cardenas. “Some vendors will say, ‘This is our product,’ but it’s not. Maybe their product is the billing portion, and they’re subleasing the EMR portion from some other vendor,” she said. When the user needs support for the EMR portion of the system, she said, they are expected to get it from a vendor whose real expertise is in billing.

Features Dermatologists shopping for an EMR system may wonder what features they should look for as they search. Dr. Cardenas suggested that the method of information input is an important consideration. “There is software that uses templates, and some also utilize macro-building—the more you do your notes, the more they know how you do your notes,” she said, describing the process by which a few keystrokes or clicks can input frequently- used terms or phrases.

“When you bring up the acne template, it tells you what you usually write, and you can check to change it or check to approve it.” Such templates are often mouse-driven or stylus-driven, depending on whether the system’s hardware is a stationary computer or a tablet PC. Other EMR systems may require typing; according to James S. Taylor, M.D., the head of the section of industrial dermatology and EMR user at the Cleveland Clinic Foundation in Cleveland, Ohio, his system has a computer terminal in every exam room and more in the hallways but no handheld computers. Notes can be typed during or right after an encounter or can be dictated for later transcription into the record.

Dr. Taylor noted that typing saves the clinic money on transcription. “But when we started, the biggest complaint was a lack of eye contact between physician and patients—physicians were said to be looking at the monitor and not at the patient,” he said. But that complaint has decreased with time, he said.

Reducing transcription costs can be one of the biggest benefits of adoption, said Charles E. Crutchfield III, M.D., a Minnesota dermatologist who has been using his EMR system for three years. Having spent nearly $1,000 a month on the transcription of consultation letters alone, Dr. Crutchfield believed that eliminating that expense could pay for an EMR system.

Now, he has a system that allows him to click his way through note-taking. “Instead of spending my time managing paper I’m managing the problems and concerns of my patients,” he said. “I can see the same number of patients and because I don’t have to commit time to charting and note-taking and prescription writing, I can spend it with the patient.” The result, Dr. Crutchfield said, is that he feels less rushed and his patients feel that they get a quality encounter.

Besides printing out his prescriptions, Dr. Crutchfield said, his EMR system also prints referral and consultation letters, which he can create in moments using macros, time-saving shortcuts that allow him to push a key or button to insert standard wording into a letter that incorporates what he feels the referring physicians really want to know: his exam findings, diagnosis, and treatment plans.

Such features are becoming somewhat standard in the industry, according to Margret Amatayakul, author of several books related to electronic health care transactions and principal of Margret\A Consulting. “The companies and products in the marketplace today that have been around for a few years have reached a level when they’re almost becoming commodities.

From a functional standpoint, when you buy a car you know it’s going to have a steering wheel and four wheels and an engine—the color and the size are different but the underlying functionality is the same. Most products that have been on the market for a few years have that basic functionality.” Another basic standard in the industry is an annual maintenance fee. “You should pay an annual fee,” Dr. Cardenas said. “Usually about 18 percent of what you pay goes into the maintenance and up keeping of the system each year. You need the upgrades and updates to avoid having an obsolete system.”

Practices that choose to rent their EMR system rather than buying the software also pay this fee; it is bundled into their monthly payment.

Finally, a learning curve is a standard feature of every EMR system. Dr. Crutchfield said that it took a few months to get used to his system, while new nursing staff need about six weeks before they feel conversant with the system. Dr. Taylor agreed that a few months were needed, noting that when the system was first implemented, fewer patients were scheduled to give physicians time to adjust. Dr. Cardenas said that the transition at her former practice went on for a year, during which time some adjustments Future horizons Other features are less standard but may be the wave of the future. Dr. Taylor notes that with the Cleveland Clinic system, he has remote access to his records 24 hours a day. “I frequently access the records at home; I’ll review lab results and I can write letters or send the results to a resident to contact the patient.” Dr. Taylor said that document scanning is also going to be implemented in the future, while dermatologists can already create diagrams using the system.

Another feature already in use by other specialties at Cleveland Clinic and coming to dermatology in the future will allow direct patient access to records, Dr. Taylor said. “The patient registers, receives a password, and goes to a secure Web site to view the problem list, medications, lab, X-ray, and pathology results, and future appointments.” This feature is already being used by his internal medicine colleagues, Dr. Taylor said. “They advertise it to patients and patients have responded,” he said. “They like to be able to go online and get their results.”

This is the wave of the future, Dr. Cardenas said. “In every other industry people are used to sitting down in front of their computer to do everything they want to do—and we’re very slow in getting there.” She said that her new system will create a patient portal —which will be connected to her practice Web site. “A lot of doctors have Web sites for advertisement, but they’re not being utilized because patients have no reason to visit.” But if patients can get vital information online, or make an appointment, they have a reason to visit the practice Web site, she said. “And while they’re there, they can find out that you do a certain procedure, or even find products for sale on your site. Now you’ve tied in a patient portal and information with ecommerce.”