Have you ever worked on a project that fought you every step of the way? I remember when I was rebuilding the heads on my truck engine. I had the worst time imaginable reinstalling the exhaust manifold. I tried, and tried, and finagled, and twisted, and griped until I remembered something Tripp Weeks, the president of XLEMR once told me.

“Insanity is doing the same thing over and over while expecting different results,” he said. It was at that point I realized I was trying to pound a square peg into a round hole. My approach just wasn’t working; I needed to take a step back, regroup, and come up with a different strategy. Sure enough, after analyzing the problem for a while, I came up with an easy, workable solution.

Are we doing the same thing in healthcare IT? Conventional EHR software uses relational databases, either through a local server or a web-based application. This architecture works well for some industries. However, it is rigid by nature, and is not easily adapted for the needs of a diverse user group.

Physicians are a diverse group, with requirements and workflows that are unique to each practice. In addition, their environment constantly evolves due to regulatory, payment, and technological change. Rigid, inflexible systems sap productivity, engender frustration among users, and ultimately lead to declining revenue. This is why most physicians are unhappy with their EHR system.

The HIT industry has tried incremental changes, tweaking user interfaces or other variables. Like my problem with the exhaust manifold, the conventional solution still does not seem to be working, despite the industry’s constant finagling and twisting. It’s time to step back, re-asses the situation, and create a new paradigm, a revolutionary solution.

XLEMR is that solution. We took a radical approach to EHR architecture by building our system on Microsoft Office. This gives us a solid foundation, while empowering easy, rapid, and inexpensive change to accommodate the evolving needs of physicians. If you are tired of trying to pound a square peg into a round hole, please contact us at info@xlemr.com. We would love to listen to your concerns and frustrations.

John Lynn recently posted a blog over at EMR and EHR discussing the question of vendor size and their propensity to discontinue an EHR. Contrary to focusing on the top vendors, John states that most of the EHR systems shut down within the past five to seven years have been operated by market leaders. John concludes that vendor size should not play a prominent role in EHR selection, as it is no guarantee their software will be around for the long haul.

Why might larger EHR vendors be more likely to discontinue a product? Larger companies like GE play in many different markets. They offer a huge variety of products and services. If one of their products does not meet performance expectations, large vendors are quick to cancel it since they have so many other revenue streams.

Smaller vendors usually focus on one or two main products. They have much more of a vested interest in ensuring their EHR remains viable for the long term. They also tend to offer better service, since their resources are focused on the EHR, rather than divided up between many different industries and markets. Smaller vendors usually only shut down their EHR if they go out of business.

Which begs the question, how likely is it that a small vendor will cease operations? John made the point in his blog that smaller vendors may be in “a better financial position than a HUGE company with a lot of overhead.” Large vendors may have millions of dollars in overhead related to employee costs, office buildings, IT infrastructure, and research and development for unrelated products.

XLEMR, on the other hand, is a small company that uses independent contractors. Instead of hiring employees, potentially laying them off, and paying associated costs, we work with a group of contractors on an as-needed basis. We work in virtual environments, which means we don’t have the overhead necessary to support large office buildings or IT infrastructures. Instead, we funnel all of our resources into developing and supporting our EHR and related products.

Small EHR vendors may not be the appropriate choice for every situation. However, we feel that the small vendor is a perfect fit for solo-practitioners, small, and medium-sized medical practices. Our organizational structure give you direct access to our developers for support, without having to go through project managers, phone trees, or other encumbrances. If you are interested in more information about XLEMR and how we can help your practice, please drop us a line at info@xlemr.com or visit us on the web at http://www.xlemr.com.

Physicians in the market for EHR may wonder about the comparative benefits and drawbacks of web-based versus client-server systems. Each system has positive and negative characteristics. Which is right for you depends upon several factors, but chief among them would be budget and how long you hope to use the system. Practices with little or no budget, or providers that expect to retire within the next five years may want to go with a web-based system like Practice Fusion. Otherwise, we feel like client-server systems, like XLEMR, offer the best value over the long term.

Pricing Models:

Web-based EHRs require little or no up-front costs. They are usually priced on a per-provider per month basis. Prices range from free, like practice fusion, to $600 per month for a combined practice management and EHR system. This is also known as the “Software as a Service” model.

Client-server systems, by contrast, require purchase instead of monthly rental. Although prices fluctuate, most client-server systems range between $10 and $20,000 for a single provider. Most vendors offer financing, which makes the price comparable with web-based systems. Client-server systems are normally licensed per provider, so expect the price to scale accordingly.

Which is right for you? Have you ever wondered whether you should buy a car or lease it? The decision between client-server and web-based systems is the same. Client-server systems offer the best value over the long run. Once you pay off the software, it is yours forever, and your monthly costs go down. Web-based could be the right choice for you if you have poor credit, a very limited budget, or expect to retire or sell your practice within five years.

IT Infrastructure

Proponents of web-based software claim you will not need to invest heavily in IT. There is some truth to this, as you will not need servers for web-based software. However, you will still need computers for each staff member. If your office doesn’t currently have computers, or has outdated computers, you may still face a heavy investment.

Client-server systems do require a server. However, this doesn’t necessarily mean you must spend tens of thousands. A server in the $1000 - $2000 price range should be sufficient for most small practices. So while you may save a little with web-based systems, it’s more important to pick the system that best meets your needs.

Web-based systems require constant high-speed internet access. If your internet fails, you loose access to your system. This may not be a major concern if you practice in an urban area. Otherwise, you may want to consider a client-server system. You will still need some internet access for electronic prescribing, billing, and other features. However, client-server systems do not rely on the internet to access your data.

Which is right for you? If you live in an urban area and already have current computers, web-based software may work well for you. However, if you live in an area where high-speed internet is not available, or not reliable, you should definitely consider client-server software.

Data Security

Web-based systems store your data in secure centers, which could be located anywhere around the world. Most vendors invest heavily in securing their data centers, much like your bank or credit card company. However, data centers located overseas are not subject to HIPAA law and may have lax security. Ultimately, data security is your responsibility.

Client-server systems usually house all the data in servers at your office. This gives you more control over your data, since you can put your hands on it at any time. However, you will need to take steps to backup your data and invest in appropriate security technology, such as anti-virus software and firewalls.

Which is right for you? We feel like it is better to have total control over your data, even though it will require more work on your part. Current HIPAA law requires business associates (BA) agreements with any third party that has ongoing access to your data. Ask if your web-based vendor where their data centers are located and if they will sign a BA agreement. Keep in mind that web-based systems can be easily compromised by poor password management policies.

Usability and Customization

Usability of an EHR system depends on several factors, and does not necessarily depend much on whether the system is web-based or client-server. Web-based and client-server systems both usually offer some degree of customization. However, the customization these systems support may be limited to text-based templates. Overall, most EHR systems are fairly static and use a “one size fits most” approach.

Static, cookie-cutter systems may not be a problem if your practice is primary care. However, specialists or other practices with unique needs may find them extremely limiting. Trying to twist your workflows to fit one of these EHR systems may slow you down, causing you to lose revenue and otherwise lead to frustration and headache.

Which is right for you? Again, web-based systems are great if you have a very limited budget. We designed XLEMR based on Microsoft Office, which lets us easily customize your EHR. This gives you a dynamic system that can change to meet your evolving needs. Although XLEMR may require more up-front investment than a web-based system, you won’t be stuck with a cookie-cutter system.

I think purchasing an EHR really is a lot like getting married. The initial attraction is important, but the long-term practical concerns are critical. Sometimes we are over-critical when looking for someone to marry; perhaps doctors have unrealistic standards for EHR software.

Just like looking for a marriage partner, doctors should embrace the 80/20 rule. Look for a system that has 80% of what you want, and the other 20% is something you can live with or change over the long term. It’s not a question of lowering standards, but rather setting appropriate standards.

We feel like the ability to change should be one of those standards. A practices needs will change over time due to a variety of factors. If you’re stuck with a static EHR that can’t evolve to support you, you will start looking for a “divorce.”

That’s why we designed XLEMR using Microsoft Office. Pretty much every business out there uses MS Office to create and change their own documents. Shouldn’t medical practices take advantage of this? MS Office provides an easy interface for your staff that’s flexible allows the EHR to change with ease.