Technology and the Practice

Steven M. Hacker, MD

There are three main types of software that every practice needs to consider purchasing: practice management software, electronic health records (EHR) software and bookkeeping software.
Practice management software helps you “manage” your practice. It includes patient check-in and billing software. A few years ago, most practice management systems were standalone. They were separate from EHR vendors. Practice management software is critical for a practice to function, bill and collect payments. As a result, adoption of practice management software was early. Most insurance providers no longer accept paper claims.
In contrast—even with government incentives—adoption of EHR is slow. Most EHR systems remain difficult to implement, and many doctors are too comfortable with paper charts. I believe this will change, but the incentives for physicians must be greater. Many EHR vendors now bundle their software so that it contains EHR and practice management applications. The advantage of getting both applications from one vendor is interoperability.
Be aware that there are some EHR vendors that are actually pure document management systems. This means that they help you store images of paper, notes and X-rays, similar to the way you store photos or documents on your personal computer. A document management system is not a true EHR, in that it does not enable the “databasing” of elements of the patient record. This is a critical component of the “meaningful use” definitions. The government believes that that the ability to database elements of medical records is critical. Elements that would be databased include providers, patient demographics, medications, illnesses, social history and allergies. It is generally assumed that databasing will enable greater efficiencies and fewer medical mistakes. Theoretically resulting in reduced costs.

Hosted Vs. Server-Based EHR
I prefer hosted ASP (application service providers) or web-based systems. It is more costly and difficult to keep the software updated and maintained when it resides on a local server in the office. This is called a server-based EHR system. A web-based or hosted ASP system is more analogous to a tenant-and-landlord relationship. There are fewer upfront costs, but these may include monthly fees. I have done it both ways and found that the hosted ASP system works better. When I had a server-based EHR system, I had many maintenance headaches. The costs to maintain my servers also increased year after year.
Hosted ASP vendors are required by federal law to follow HIPAA regulations. Most vendors will allow you to download patient data at any time. This will help prevent data loss. It will also ensure that you have a second copy of data in the event you terminate with your ASP provider. It is a good idea to have your IT (information technology) consultant set up a schedule of periodic downloads of your patient data, including demographics and billing information. The information should be backed up by a local server or to a remote storage facility.
After you select a vendor—but before you sign any contract—make sure you have the right to terminate “at any time for any reason without penalty.” And make certain that upon termination you are granted full rights and access to download all data related to your practice. It’s much easier to start your practice with EHR than to go back and do it later. However, if you do choose to convert later, it is not complicated. Most EHR vendors will help you with the process of converting paper charts to EHR.

Bookkeeping and Hardware Requirements
In addition to practice management software and EHR software, there is a need for bookkeeping software. Bookkeeping software helps manage accounts payable, accounts receivable, cash flow, profit and loss, inventory tracking, supplies, and sales of goods in an office. A well-known example of this type of software is QuickBooks. Some practice management software programs incorporate their own proprietary bookkeeping software.
In addition to software, you need to purchase hardware. The hardware requirements will depend on the type of practice management, EHR and bookkeeping software used. Inexpensive desktops in the front office for clerical work are ideal. Physicians may choose laptops, tablets or desktops to run the EHR. Even with ASP-hosted solutions, you still need to backup your work daily. Backups of data can be sent to servers or to less expensive external storage devices.
If you are currently investigating an EHR system, here are some questions to ask EHR vendors before making a purchase:
1. Does this system incorporate EHR, practice management software and bookkeeping capabilities? Or, will it integrate with my existing practice management and bookkeeping software?
2. Does this EHR meet the criteria for “meaningful use”?
3. How long has this company been in business? (I recommend looking for companies that have been in business for more than five years)
4. Is this system CCHIT certified?
5. Will I have access to the data in my records at all times?
6. What type of technical support is available?
7. Can this system be accessed from any location?
8. Does this EHR have attributes specific to my specialty?
9. Will the vendor help facilitate federal incentives?
10. What is the total cost to get the system installed and working?
11. Are there any monthly maintenance costs?
12. How much local networking software will I need to purchase?
13. What additional computer hardware will I need to purchase?
14. Will I be required to purchase any third-party software? What are the upfront and monthly maintenance costs for the third-party software?

Steven M. Hacker, MD, is a Palm Beach, Florida-based dermatologist, founder of and the author of The Medical Entrepreneur. Contact him at

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