a supplement to the 2006 and 2007 electronic health records vendor reports
prepared by the american academy of neurology professional association electronic health records Work Group and
practice management & technology subcommittee July 2008
TABLE OF CONTENTS
AANPA Reviewers ....................................................................................................3
Why the AANPA Does Not Endorse a Vendor ......................................................3
General Comments on EHR Marketplace..............................................................4
AANPA Criteria for Selection of Vendors .....................................................4
Table of Vendors.............................................................................................5
Neurology Clients .........................................................................................11
Installation and Training ...............................................................................12
Support Costs ................................................................................................14
Interface and Interoperability........................................................................17
Transitioning to an EHR ...............................................................................20
Return on Investment .............................................................................................22
Typical Patient Note .....................................................................................27
Vendor Script from Chart Challenge ............................................................31
The American Academy of Neurology Professional Association (AANPA) held its third
year of electronic health record (EHR) vendor demonstrations in 2008. This was the first
year that the event was open to the general membership at the AAN Annual Meeting,
allowing attendees to observe the head-to-head demonstrations between six vendors and
evaluate the products for themselves.
The AANPA, which focuses on legislative lobbying and advocacy programs, is a
companion organization to the American Academy of Neurology (AAN).
Six vendors participated in the EHR Chart Challenge:
• Amazing Charts
• NextGen® Healthcare Information Systems, Inc.
• Sage® Software Healthcare, Inc.
Structure of this Report
Many sections list information by each vendor in alphabetical order. So although
Amazing Charts is always listed first and Sage Software is always listed last, it should not
be construed as reflective of a ranking.
AANPA acknowledges several limitations to this evaluation process. Individual product
demonstrators bring varying levels of expertise and ability to relate to an audience. In
addition, time constraints limit the amount of information that may be disseminated at the
time of the presentation. The AANPA has asked companies to provide additional
information in order to attain material that may have been omitted by the presenter.
Some information in the report is based on evaluators’ perceptions; other information has
been supplied directly by the vendors. We try to make the source of information clear
throughout the report.
Since a report on technology is filled with abbreviations and acronyms, be sure to
reference the Acronyms section (page 26) for clarification when reading the report.
The 2006 and 2007 EHR Vendor Reports include additional resources and can be
accessed at www.aan.com/ehrreport.
The evaluators and authors of this report comprise 11 neurologist and practice manager
members of the AANPA with varied practice experience and levels of EHR use. The
EHR Work Group and Practice Management & Technology Subcommittee (PM&T)
report to the Medical Economics & Management Committee at the AANPA.
Orly Avitzur, MD, MBA—Chair Daniel Hier, MD, MBA
Solo Neurology Practice University of Illinois Physician Group
Gregory Barkley, MD Joel Kaufman, MD
Henry Ford Health System Lifespan/Physicians Professional Service
J.D. Bartleson, MD
Mayo Clinic James Selwa, MD, MBA
Wayne State University School of
Neil Busis, MD Medicine
Pittsburgh Neurology Center
Bruce Sigsbee, MD
Gregory Esper, MD Penobscot Bay Neurology
Steven Zuckerman, MD
William Henderson, FACMPE Solo Neurology Practice
Upstate Neurology Consultants, LLP
Amanda Becker, Associate Director, Medical Economics, staffs the EHR Work Group
and PM&T Subcommittee. The AANPA engaged the services of consultant David Kibbe,
MD, MBA, Principal of The Kibbe Group, LLC, to assist and guide the evaluation
Disclosure: No members of the EHR Work Group or Practice Management &
Technology Subcommittee have stock or a financial interest in any of the vendors
evaluated in this report.
WHY THE AANPA DOES NOT ENDORSE A VENDOR
The AANPA cannot name one vendor to recommend for its members. There is no one-
size-fits-all solution. The “best” EHR will vary by practice. Neurologists in solo practice,
small group practices, and multi-specialty practices may all have different needs and
resources available to them. Each practice must determine what its priorities are, as well
as do due diligence in selection. This report can serve as a supplement to that process but
is not intended to serve as a substitute.
GENERAL COMMENTS ON EHR MARKETPLACE
There has been a growing trend in mergers and acquisitions in this market. EHR product
sales have slowed recently, possibly due to a general slowdown in the economy. Google
Health began offering online personal health records in May 2008. At the same time, both
the Centers for Medicare & Medicaid Services (CMS) and states (Minnesota for e-
prescribing and New York for health information technology grants), are moving toward
requiring EHRs for providers, often specifying systems certified by the Certification
Commission for Health Information Technology (CCHIT), to meet their requirements for
increasing patient safety and reducing health care costs. Some experts predict that in the
next 12–18 months a number of new application service provider (ASP) EHR products
will be offered, thus reducing physician costs. A shifting political, regulatory and
economic landscape will likely influence this marketplace considerably in the near future.
The 2008 EHR Chart Challenge was held on Tuesday, April 15, 2008, during the AAN
Annual Meeting in Chicago. The event took place from 1:00 p.m. to 4:00 p.m. in a room
inside the exhibit hall and was open to Annual Meeting attendees at no charge. Following
the event, attendees were could visit vendors at their booths in the exhibit hall for more
Vendors were each allowed 20 minutes to complete items from the script (see Index page
31). Members of the audience were given time to ask questions after each demonstration.
The attendees had score sheets for their own use, and the EHR Work Group and PM&T
members conducted more detailed evaluations of each vendor based on the items from
The AANPA sent the script to the vendors prior to the event so they had time to prepare.
Onsite, an AANPA reviewer asked each vendor to populate two new and unscripted
items to show how well the product could add fields and handle data entry.
AANPA Criteria for Selection of Vendors
One of AANPA’s goals was to showcase a diverse group of products in a number of price
ranges. The group wanted to bring back popular vendors as well as new vendors to the
membership. The group expanded on the minimum basic functionality requirements that
it had used last year.
Table of Vendors
This table shows a history of the vendors evaluated since 2006. To access information on
the vendors from previous reports, visit www.aan.com/ehrreport.
Vendor 2006 2007 2008
Amazing Charts X
eClinicalWorks X X X
e-MDs X X X
Greenway Medical Technologies, Inc. X
Medical Communication Systems X
Misys Healthcare Systems X X
NextGen X X X
Practice Partner X
Sage Software X
Amazing Charts is perhaps most distinct from the other five products reviewed at the
Chart Challenge in 2008. It is characterized by simplicity of installation, low cost, and a
simple interface. It sacrifices more elaborate features for a much lower purchase price. It
will appeal to practices that want a simple and inexpensive EHR without the “bells and
whistles” of more expensive and robust EHRs. Amazing Charts has approximately 1,700
clients of which approximately 30 are neurology practices. Pricing is advertised on the
website as $995 for the first provider and $200 for each subsequent provider (there is no
additional charge for non-provider staff). Amazing Charts offers a free three-month trial
use. The EHR can be downloaded from the Internet or loaded onto a Windows®-based
PC from a single CD-ROM. One of the AANPA reviewers verified that a working
version can be loaded onto a PC in less than one hour without technical help from the
Amazing Charts is programmed in Microsoft® Visual Basic® and uses Access as its
underlying database. The vendor plans to offer a Microsoft SQL server™ version of the
product this year. Customized neurology templates for the history and examination can
be built within Amazing Charts. It is important to understand that Amazing Charts stores
the history and examination as text fields rather than as discrete database fields. These
fields can be searched by “free text” searches but do not constitute true database fields as
are found in other EHR products. Amazing Charts is compatible with voice recognition
software such as Dragon NaturallySpeaking as well as a variety of scanners and digital
Amazing Charts supports inter-office messaging and can both import and export
continuity of care record (CCR) documents. Amazing Charts can print superbills and
export data to a practice management program but does not come with an integrated
practice management system. Amazing Charts can interface with a billing service for a
flat fee. Amazing Charts can print out prescriptions entered into the EHR. In order to e-
prescribe via the SureScripts® network there is an extra fee of $35 a month, which allows
for drug/drug interaction checking as well as formulary checking. Offsite backup of data
is $250 a year. Lab interfaces are generally available from the cooperating laboratory at
Amazing Charts generally performed well during the EHR Chart Challenge scripted
demonstration. The test patient could be selected off the online schedule. Amazing Charts
does not have a room notification feature such as found in some more elaborate EHRs.
Medications, problems, and allergies can easily be reviewed. Vital signs can readily be
updated. Additional items can be added to the history or physical examination as “free
text” items using modifiable macros.
As previously noted, unlike most of the other EHRs reviewed in the Chart Challenge,
Amazing Charts stores the history and examination as text rather than as discrete
searchable fields. Printed notes have a clear and neat appearance. Notes can be exported
in CCR format or converted to Adobe® Acrobat® PDF files or faxed. Adding fields to the
problem list was easy to do. Although Amazing Charts has built-in help for evaluation
and management (E/M) coding, it does not have a true automated E/M coder since bullet
items from the examination and history cannot be counted in an automated fashion.
Prescription writing was easy to perform. Detecting drug-drug or drug-allergy
interactions depends on on-line access to the New Crop e-prescribing module which is an
extra expense of $35 a month. Number of falls can be added as a free text field but cannot
be specifically searched with the current version of Amazing Charts. A report writer can
search a limited number of discrete fields including medications, diagnoses, age, etc.
Amazing Charts does not currently provide support for neurology clinical practice
guidelines or specific pay-for-performance (P4P) initiatives; although the vendor
indicated that it is responsive to customer requests as they arise.
In summary, Amazing Charts is a surprisingly powerful EHR that is easy to use and to
install. It lacks some of the features of more expensive EHRs but stands out as an
extremely high value at its current price point. Lack of strong integration with practice
management software will make it not attractive to some busier and large practices.
However, small practices that already have practice management software will want to
look at Amazing Charts as a relatively inexpensive and low risk pathway to EHR.
eClinicalWorks performed very well at the vendor demonstration. eClinicalWorks elected
to demonstrate its newest beta software that was not to be generally available until the
end of April. Unfortunately it was not configured for the 1997 neurology single system
exam, (which is an option), and used the general 1995 coding rules, which caused a loss
of points on the coding score. Otherwise it could have done even better. One of the key
differences of this software is a Web-based architecture that combines HTML, embedded
XML, Java™ and Java script™ Web Client on a J2EE application server platform running
a SQL™ Database. From a practical point of view this means that there is not a large
piece of software sitting on each workstation and there is no need to use Windows
emulation software such as Citrix®. All entries are Web based, fast and already set up for
data extraction, reporting and exporting in standard formats. The interface was
aesthetically pleasing and easy to use, though it may be a bit busy for some.
There are many features which were useful, but may or may not be needed in all
practices. The system autosaves to prevent loss of data. In addition to uploading from a
practice’s dictation service, input can be made by typing, writing, or even by voice
recognition with Dragon. Patients can be tracked through the office including the posting
of wait times. If used with a tablet, an actual signature can be entered directly on the
screen, in addition to an electronic signature. This can be used to have the patients sign
forms such as consents. The internal messaging system includes the use of secure notes
and open “stickies.” The practice can have control over the content (what information
gets printed) and formatting of the letters and other output; these were one of the most
visually appealing demonstrated. It tracks the top labs and medications for each diagnosis
so they can easily be picked again. The prescription writer remembers common previous
scripts, can be connected to services like SureScripts, and the user can choose to fax,
print, or send scripts electronically. Patients can fill out bubble sheets (such as those for
standardized tests) for items such as the review of symptoms or historical data, which can
then be scanned into the system as data elements. A third party scanner can be attached to
“scrape” demographic information from driver’s licenses. The coder shows how it arrived
at the E/M levels and the medical decision-making and other areas can be over-ridden if
eClinicalWorks provides the software but does not provide, nor does it support, the
hardware; however, it is very clear which hardware is needed. This means that each
practice will either have to purchase and arrange for technical support for their own
hardware, over and above the price of the software or use the available application
service provider (ASP). This is the mechanism by which eClinicalWorks houses all their
hardware and all the practices’ data at its company’s location. It is easier but more
expensive and a practice’s data is not under the practice’s direct control. If a practice
buys hardware, it has the choice to buy outright or rent the software monthly, which is
more expensive in the long run.
Comparing pricing is difficult for a wide variety of reasons, but the general consensus
was that eClinicalWorks was in the upper middle of the pack of reviewed companies.
It is noteworthy that eClinicalWorks has grown very rapidly in the last few years with
several large, high profile contracts including the City of New York Department of
Health and Mental Hygiene and several large hospital systems. While this speaks well of
the company’s software, reputation, and long-term viability, how this will affect the
company’s flexibility and responsiveness to the needs of a small neurology practice
remains to be determined.
The overall impression of the e-MDs product is consistent with the 2007 review. It
remains a robust, user-friendly product with a sophisticated underlying database
structure. The product touts two major updates per year and the level of technological
advance was evident during the Chart Challenge.
e-MDs offers a suite of programs to provide an EHR, billing and practice management as
well as a document management module and eFaxing capabilities. In addition, there is an
available patient portal to enable secure messaging with patients, as well as a personal
digital assistant (PDA) module for the capture of hospital charges and clinical data. All
modules share a common database (based on Microsoft SQL), and this facilitates the
response time in clinical documentation. A rules module enables users to define their own
quality measures. Documentation links to an underlying controlled vocabulary which
facilitates clinical queries and P4P documentation. In addition, there is a Doctor’s Office
Quality Information Technology (DOQ-IT) link which further enhances the ability to
demonstrate adherence to clinical guidelines. A result tracking function creates reminders
and work tasks to make sure that follow up on tests ordered does not slip through the
From reviewer comments, the customization and appearance of the referral note was an
outstanding feature of this product. They were also impressed with the decision support
features which are triggered based on a structured vocabulary infrastructure and do not
require additional user input. The reviewers also noted that this product offered “bubble
sheets” which can be scanned into the record to automatically populate demographic and
historical fields—thus facilitating data entry by eliminating the need to manually enter
During the Chart Challenge, the billing module used the 1995 single system specialty
exam, but the 1997 version (also available) was needed to correctly code the visit. They
provide neurological templates with the product, and there is an online community which
is said to share templates. The product is designed to use the tablet PC (right clicks are
not required) but like other products, Dragon voice recognition can be used.
In summary, along with the rich feature set, e-MDs meets the AANPA standards and is
certainly worth consideration for a small neurology practice.
MediNotes presented for the first time to the AANPA. The Chart Challenge
demonstrator was not facile with the neurological information but rather showed use for a
general physician. It was easy to change blood pressure readings through a dropdown
box. The system allows one to put additional data easily into the exam from a dropdown
list that is pre-populated. Entering new data not pre-populated was complex, requiring
several clicks. The note and system did include physician referral information important
for a consult. Neurological exam options were few. The coder does calculate a value, but
it was unclear how the coder works.
The product does not have strong functionality for neurology in terms of exam items and
was poor at adding new items. It could not identify drug interactions because there was
not Internet access in the room. Reports for items such as falls were hard to access. There
was excellent ability to produce a referral letter that could be faxed or mailed. They did
not provide a written note for review.
It is unclear whether several of the shortcomings were due to demonstrator’s limitations
or that of the product. However, the MediNotes website indicates that they have
customized neurology-specialty content, including templates and graphics, to help with
documentation, such as a mini-mental status examination template. The site also claims
that users may customize the program on the fly.
NextGen’s product performed fairly well during the chart challenge. It was readily able to
demonstrate patients who were scheduled, and notification of users regarding patient
arrival and office room readiness was highly acceptable. The problem list, medications,
and allergies were easy to find and easy to read and navigate, and it was not challenging
for the operator to complete blood pressure charting; however, the presenter had
difficulty adding “pill rolling tremor” to the examination.
The printed notes were of high quality, and electronic notes are able to be exported in the
new CCR format, which is an advantage for patients and doctors alike. Like most EHR
systems, it does have the ability to print, fax, or e-scribe, and two favorite pharmacies can
be kept on file for each patient. Other perks include nice graphics, large calculators, and
an excellent ability to drill down on the muscle examination.
Drawbacks included difficulty adding diagnoses to the problem list; this was a little more
stilted, and it is notable that the operator did look a bit uncomfortable performing this and
several other functions with the software. It also appeared that the provider would have to
manually enter the correct level of diagnostic decision making, rather than a coding
calculator automatically doing this for the provider. Another drawback is that the
software appeared to miss a drug/drug interaction and a medication added in a duplicate
The format is not XML based and thus is not available from Internet Explorer™.
However, there is a patient portal through which patients can enter historical elements on
line, and the vendor has integrated Instant Medical History™ (IMH) software.
Overall, the software performed fairly well and is a viable option for healthcare
providers, noting of course, the above limitations.
Intergy by Sage Software did not perform well in this year’s Chart Challenge. This was
the first time this vendor had attended AAN, and the presenter failed to follow the script;
this was the likely reason for the overall poorer scores by the evaluators. This is
unfortunate since Sage has about 400 neurology practices using its product with an
average size of the neurology group of 2.3 providers and has received CCHIT
The product appears easy to move around in, but at first glance the interface looks busy
due to the various pods on the main screen. It listed the physician’s patients for the day
and their time of visit, but did not indicate if the patient had checked in.
The encounter note is built upon the structured database MEDCIN® which allows for
uniform data descriptors and data codification. This should allow for effective data
retrieval, but that was not demonstrated. The neurology templates that ship with the
product have been enhanced by a neurologist user who cooperated with Sage to improve
them. The encounter note can be completely customized for any neurological condition
or type of visit. It also allows the physician to add dictation markers into the note—short
spoken notes that clarify or detail any aspect of the examination. If a user chooses to add
information beyond the established note, it can be typed in, dictated via voice
recognition, (which was demonstrated), or dictated through WAV sound files via a PDA
or similar device.
The product has the standard expected elements: allergy recording, problem list and
health alerts, disease management, etc. There is a CPT® coding tool which can be set to
the 1995 or 1997 standards. As with all such tools it works accurately only if all the pre-
requisite patient examination data has been entered into the system. It was not clear from
the demonstration how this feature was accessed.
The product has interfaces with the major labs such as LabCorp® and Quest® that enable
uploading of lab orders and downloading of the results directly into the patient’s chart.
The product also has an imaging interface which allows all paper records the office
receives to be scanned directly into the patient’s chart in any category the physician
The product can do e-prescribing and does have a drug use review (DUR) feature. It was
possible to add a drug as demonstrated. There is an ability to set up prescription favorites
that shortens future prescription entry. It appeared that actual prescription writing was
more cumbersome on this system than on others that were reviewed, but the dropdown
menus could expedite speed. The product could track the number of patient falls, but it
was not clear how easy it was to report on those falls (i.e., data extraction).
The presenter did not enter a blood pressure or diagnosis but suggested how it was done.
The output of the encounter note, while good, is not as polished as some other products.
We did not see any printed output to make an evaluation as to how it looks when sent out
of the office or clinic.
One interesting note is that a version of the same software can run on a PDA or Windows
Mobile phone. That allows the physician access to the patient information in a secure
manner even if no direct computer network is available. The EHR was designed to run on
a tablet PC to speed data entry. The product also has an integrated practice management
component that can be used to handle the detailed scheduling, billing, and management
functions of the product.
Sage uses remote monitoring software (RMS), which regularly reports on both hardware
and software issues to their central monitoring division. This enables the company to
proactively address any actual or potential problems at a client’s site.
It is important to ascertain the number of established neurology clients the vendor has,
and whether the product is designed to meet the needs of a consultative specialty.
The table below lists the number of neurology practice clients for each vendor, the
average size of the practice, and the market size targeted by the vendor.
Vendor Neurology Practices / Average Size
Amazing Charts >30 neurology practices; average size 1.6 providers
eClinicalWorks 90 neurology practices; range from solo to 70+
e-MDs 30 neurology practices; average 2-3 providers per clinic
MediNotes >120 neurology clients; average size 1-3 physicians
NextGen 15 neurology clients of varying sizes, plus another 15 multi-specialty
practices that include neurologists
Sage >400 neurology practices; average size 2.3 providers
Installation and Training
A practice should not overlook the time and costs associated with installation and training
and should consider how the vendor offers training: whether it is on-site, via the web, or
Much of this information is provided directly by the vendor and should be verified by
practices before entering into a contract.
Amazing Charts offers one-on-one and group training via WebEx™. It also provides a
self-help guide, a user bulletin board, and the Amazing Charts Wiki. Training is provided
for free during the three-month trial period. After the trial period ends, additional training
is done for support/maintenance clients only, at a cost of $500 a year.
Amazing Charts offers on-site training for $1,000 a day (which includes all expenses and
travel). Of the 1,900 current practices, only three have requested on-site training; this is
perhaps attributable to the success of the remote training. If new staff members are added
to a practice one year after installation, Amazing Charts will train that staff for free if the
practice has purchased the support/maintenance at $500 a year.
eClinicalWorks offers on-site training for each practice. After a practice has gone live,
eClinicalWorks provides regularly scheduled Webinars on various topics that are free of
charge to the practice. eClinicalWorks also offers optional training classes at its corporate
training center in Westborough, MA.
On-site training is $750 per day per trainer plus $250 per day travel for expenses per
trainer plus airfare. Training costs are based on the number of trainers per training days
needed, which is determined by the number of users and locations. Remote training can
be done at a rate of $100 per hour. If new staff members are added to a practice one year
after installation and the practice requires eClinicalWorks to train the new individual on-
site, the practice will be charged at a rate of $750 per day plus travel expenses. In most
instances, however, practices can designate a super user that can train the individual
without the added expense of having eClinicalWorks train. Training is not an annual cost;
training fees apply only when training is needed.
e-MDs offers three training options: customer onsite training, e-MDs classroom training,
and online training. In addition to these three training option, e-MDs has an annual user
conference that gives customers the opportunity to receive additional training on
advanced features and workflows within the software. The conference also offers the
opportunity to glean knowledge from development and support personnel and to interact
with seasoned users in like specialties for tips and suggestions.
MediNotes offers two or four days of on-site training and eight hours of Internet training.
Training is done by site. Additional Internet training is $75 an hour.
NextGen offers a “train-the-trainer” methodology to training customers. This process
typically includes the training of a practice’s core group of users via the NextGen
Learning Center and classroom training at NextGen facilities—who in turn will train the
end users at their practice. This methodology transfers ownership of the training process
to the practice—enabling the streamlined training of new employees and further reducing
the cost of implementation.
NextGen offers e-learning courses, self-tutorials and tests on the NextGen system.
Additional classroom training is available at NextGen facilities located across the
country. Occasional online training conferences are available via WebEx. While training
typically takes place via a combination of e-Learning courses at its facilities, on-site
training is available.
NextGen did not share costs, but stated that specific pricing for training is provided to the
practice with each proposal. Training is priced by the hour, with different hourly rates
depending on the type of training. Additional costs associated with on-site training
include reimbursement for actual travel expenses (typically airfare or mileage, meals, and
hotel). If new staff members are added to a practice one year after installation, the “train-
the-trainer” system should prepare the practice to handle that training in house. Many
client practices attend the annual Users’ Conference where many additional training
opportunities exist, included in the price of the conference.
Sage offers training via CD or DVD, WebEx, Internet, and on-site. Training costs are
dependent upon products chosen and number of users. Traditional training services are
available for one year based on the effective date of contract. Additionally, clients who
choose a special Sage training program have 24/7, ongoing access to the interactive
learning modules, based on the specifications of their contract. Additional training hours
cost $175 an hour. On-site training costs can include trainer travel, food, and lodging
If new staff members are added to a practice one year after installation, Sage provides a
web client portal site where users have a login and password that allows them to
download information, sign up for training and more. Online documentation, computer-
based training, and training CDs are always available to Sage’s clients.
Sage provides training with each new release, and training methodologies will vary for
each upgrade. This training can be on-site, CD-based or Web-based. To provide group
interaction and to gain more insight into Sage’s products, Sage hosts local and national
seminar events throughout the year. A schedule of these events is accessible on the client
portal for users to review and register. All user events have specific fee schedules and
options which are published at the time of event, providing clients with numerous
participation options available at various pricing levels. Additional training can be
purchased as needed. After implementation, training is either an as-needed cost or
included in the annual support contract, depending on the type of training chosen or
Support costs can include hardware and software support, upgrades, and licensing fees.
These can be hidden costs that practices should inquire about in detail prior to purchasing
Amazing Charts does not sell hardware. Maintenance and support—which includes all
software updates, medication, International Classification of Diseases (ICD-9), CPT,
Healthcare Common Procedure Coding System (HCPCS) databases, and training—costs
$500 for the first provider and $100 each additional provider. Prices do go up over time,
however, clients paying with a credit card that is automatically rebilled annually get
“locked-in” at the price paid for as long as the credit card automatically rebills.
Support hours are 8:00 a.m. to 8:00 p.m. EST. Amazing Charts does not have a
guaranteed response time, but generally responds immediately. Clients can ping the
company online to chat and get called back. Amazing Charts offers after-hours support
for emergencies only (e.g., a crashed database and an inability to log into the program to
see patients). There is no additional charge for after-hours support providing the client
has the support/maintenance package. Amazing Charts offers a few interfaces and
optional services for an additional charge. For example, e-prescribing through a third-
party allows drug/drug and formulary checking and has an additional charge of $35 a
month per full-time employee. Other optional services include off-site backup ($250 a
year) and third-party software integration ($240–$500 per practice). In general, lab
interfaces are provided at no charge.
eClinicalWorks provides software support but not hardware support. eClinicalWorks
charges an annual maintenance and support fee. Maintenance is calculated at 18% of the
license fee per year. Maintenance includes product upgrades and content usage for drug
database and drug interaction checks and continued interface with medical devices and lab
interfaces. Support is calculated at $600 per provider per year, which includes unlimited
telephone support. Annual software support costs cover software version upgrades.
There are several methods of purchasing eClinicalWorks software:
• Upfront—client pays a one-time license fee and yearly maintenance and
• Subscription—client pays a monthly subscription fee that includes software,
maintenance, and support.
• ASP—client pays a monthly subscription fee that includes software,
maintenance, support, and hosting fee.
The guaranteed response time for software support problems varies by importance, as
shown in the table below.
Description Response Time Resolution
Critical – The system cannot function. Any suggested 1 hour 4 hours
alternative has had a drastic impact on productivity.
Important – The system can function with the suggested 4 hours 5 days
Minor – The system requires a functional enhancement. 48 hours Next upgrade
Support is available Monday through Friday 24 hours per day, and Saturday and Sunday
from 8:00 a.m. to 8:00 p.m. Web encounters may be entered 24 hours per day, 7 days per
week. eClinicalWorks does not charge any additional support fees. There is an additional
cost for utilizing a clearinghouse. The price is dependent on clearinghouse chosen and
which options are selected per clearinghouse.
e-MDs charges $2,000 for annual hardware support. The amount is based on the current
average remote support contract fee for the industry. The hardware products include the
manufacturer’s standard warranty, which can be enhanced by adding more years,
accidental breakage coverage, or both. Vendors’ warranties on hardware do not affect the
cost of hardware support in years one through three. e-MDs has a 24 business hour
response time for all hardware and software support issues. Software maintenance costs
$1,600 per license per year. All software upgrades are included in the annual
maintenance fee. The support fee includes licensing fees. Support hours are 7:00 a.m. to
7:00 p.m. CST.
There is a one-time set-up fee for connection to a clearinghouse; after that claims support
is included in the annual support cost. Drug database upgrades, ICD-9 code changes, and
patient education materials are included in the cost of the annual maintenance.
MediNotes does not offer hardware support. Software support costs $955 per year. The
annual software support cost covers software version upgrades, licensing fees, and
unlimited support. For software support problems, 98% of calls are answered in the first
minute. Support hours are 7:00 a.m. to 7:00 p.m. After-hours support is available as
needed and costs $75 per hour, with a two-hour minimum. E-prescribing costs an
additional $500 per provider, per year.
NextGen can provide support if hardware is purchased from NextGen, but customers are
not required to buy hardware from the company. The cost for hardware support varies
depending on the model and item purchased. Specific pricing is provided to the practice
with each proposal. The client can choose which hardware pieces to cover under the
warranty. If hardware is purchased from NextGen, the manufacturer’s warranty is
assigned to the customer.
The specific effect of vendor’s hardware warranties on the cost of hardware support
varies depending on the nature of the individual warranty. There is not a guaranteed
response time for hardware support as part of the standard agreement. Department
timeframes for responding to support requests are 10 minutes for urgent issues and two
hours for non-urgent issues. NextGen is willing to discuss contractual terms deemed
important during a finalist vendor selection.
Software support, updates, documentation, and maintenance are covered under the annual
maintenance agreement, which is 19% of all one-time licensing and interface costs.
NextGen supports the current version, plus one prior. Licensing fees are one-time fees
paid at the time of initial purchase.
Support is available Monday through Friday between the hours of 8:30 a.m. and 5:30
p.m. customer local time, with the exception of holidays, and unless otherwise specified
in the contract. After hours emergency support is also available at an additional cost.
Additional services and third-party software are available for additional costs.
Sage sells annual software and optional hardware maintenance with the Intergy® by Sage
software and Intergy EHR software licenses based on a percentage of the licensed
software purchased. Its customers can choose one of three tiers of support with various
components such as hours of coverage and system reviews. Its maintenance agreements
include toll-free telephone support, a client portal login that includes the logging and
tracking of support calls, license fees for future version releases, RMS and software
version releases. Sage’s software and services license agreement defines the scope of
services for support. The client can choose which hardware pieces to cover under the
warranty. Vendor warranties on hardware vary greatly and virtually never include labor
and never include data restoration. For this reason, they do not affect the cost of hardware
support. Sage’s service level agreements target goals for response time for hardware
support problems are based on severity and priority levels, as shown in the table below.
Priority Level Description Target Response Time
Priority 1 Main/entire system down Immediate to 30 minutes
Priority 2 Issue that stops patient or cash flow Within 4 hours
Priority 3 Non-emergency—All other issues Within 8 hours
Software support provides updates of the most current version released under a client’s
support contract. Labor costs may apply. Initial software licensing fees are not included
in the support fee.
Support days and hours are based on the “tiered” service levels:
• Silver Program—offers support Monday through Friday (excluding holidays),
between the hours of 8:30 a.m. – 5:30 p.m. local client time.
• Gold Program—offers support Monday through Friday, 7:00 a.m.–7:00 p.m. and
Saturday 7:00 am–noon local client time.
• Platinum Program—offers support 24 hours per day, 7 days a week.
In both the gold and platinum programs, hardware services after 5:30 p.m. are limited to
Priority 1 “main/entire system down” calls only.
After-hours support depends on the level of support contract; however, a client may also
contract for ad hoc after-hours support. Depending on the type of service needed,
different rates may apply. For example, if a practice requests a weekend upgrade of a
specific system, the client will be quoted an hourly rate (a minimum amount of hours
may apply). If a practice does not have a 24/7 maintenance agreement and needs after-
hours service, rates will depend on whether it is a weeknight, weekend night, holiday, etc.
Electronic data interchange (EDI) services, including billing clearinghouse, drug
utilization database upgrades, and on-line verification of costs are covered under a
separate transaction agreement and are based on EDI services chosen.
Interface and Interoperability
An individual patient's care is often fragmented between different health care providers
and different places of service (e.g., hospital, office, outpatient testing center). An
ambulatory EHR in a physician's office will be most useful if it can gather information
from and send information to electronic health applications at the other sites where the
patient has received or will receive care, such as other EHRs, outpatient testing
laboratories, and radiology information systems. An EHR’s utility will also be greater if
it can interface with different types of input systems (such as scanners and voice
recognition), and if users can access it on different types of devices (such as desktop
computers, laptops, tablet PCs and smartphones or PDAs). The ability of an application
to work with other applications, from different vendors at different locations, is termed
There are two basic ways to achieve interoperability:
• The products adhere to commonly accepted standards (they "speak the same
• An interface (off-the-shelf or custom-made) translates the data from one
application into a format understood by the other application.
EHRs can use one or both of these approaches. The approach will vary depending on the
characteristics of the two applications that are trying to share information.
The vendors of all the products reviewed in this report stated that their applications were
interoperable with other electronic health care applications. However, there are
substantial differences in their potential for interoperability. The products vary greatly in
terms of programming language used for interface and underlying database structure.
Some are based on proprietary technologies known only to the company. Others are
based on open source tools, which are readily available to all developers. Vendors use the
term “interoperability” liberally. It is important to get a clear definition of this term prior
to purchase. A practice should ask vendors if additional software must be purchased for
interoperability with specific third parties.
In terms of programming language for interface and underlying database structure, the
• Amazing Charts uses Visual Basic and Microsoft Access.
• eClinicalWorks uses XML, Java, and Visual Basic.
• e-MDs uses Delphi and .C# for programming the interface, HL7 for message
format, and Microsoft SQL in the underlying database.
• MediNotes uses HL7.
• NextGen is written in Visual Basic and Visual C++®. The NextGen system
operates in the managed code environment of .NET and can run on computers
using Windows 2000, XP-Pro or Vista® operating systems. Utilizing relational
database management, the NextGen system runs on a Microsoft SQL Server or
• Sage uses .NET application using Progress® database, a non-proprietary, ANSI
SQL-compliant database. It supports all CCHIT-required interface specifications.
Prospective purchasers need to research these differences or use a consultant to help
clarify those differences prior to making a purchase. Because this is beyond the expertise
of the average neurologist, the neurologist should discuss interoperability of systems
under consideration with a consultant to make an informed decision. Interoperability is
actually a property of two or more systems, not solely the characteristic of the EHR a
physician is evaluating. Neurologists will first need to determine what other applications
or devices they wish their EHR to interface with, and then determine how easily the
different programs can be made to communicate with one another.
Scheduling / Practice Management
Some products have scheduling and practice management integrated into the EHR.
eClinicalWorks, e-MDs, NextGen and Sage offer a joint EHR and practice management
solution. Amazing Charts offers a link through X-Link middleware software (which costs
$1,000), to the most common programs, including Medisoft™, Lytec™, AdvancedMD™,
and others. MediNotes does not have integrated scheduling and billing but interfaces with
over 75 practice management solutions. Fee structures vary and an integrated practice
management solution may have an additional cost.
Interfacing with Labs, Fax, Email, and the Continuity of Care Record (CCR)
Amazing Charts interfaces with a number of lab companies (Quest, LabCorp, and
others). Amazing Charts can import and export the CCR, has intra-office messaging built
in, and ties to UpDox™.
eClinicalWorks can interface with systems that are HL7 compliant.
e-MDs interfaces with labs, hospital information systems, diagnostic equipment, and
national registries via HL7 messaging. The product provides a fax server application, an
internal email product for communication within the clinic, and importing and exporting
CCR files from both the charting and document management applications. Continuity of
care document (CCD) reporting will be available later this year.
MediNotes e™ uses HL7 standards for labs and does not currently have the capability for
fax or email out of its system. MediNotes is currently working with CCD standards, not
The NextGen system features a proprietary interface engine called Rosetta, which is
maintained in accordance with HL7 specifications to facilitate data exchange with third-
party systems. NextGen® EMR can interface with laboratory systems, radiology systems,
pictorial archive and communication system (PACS), specialty medical devices, hospital
systems, transcription software and third-party practice management systems. NextGen
EMR provides a variety of faxing solutions for faxing prescriptions, documents and
images. NextGen EMR allows integration of external messaging application
programming interface (MAPI)-compliant e-mail, such as Microsoft Exchange,
eliminating the need to access an external e-mail system. NextGen EMR supports the
CCR format. NextGen EMR users can securely send health records to a patient or other
Sage products bi-directionally interconnect via EDI with more than 50 laboratories. Sage
uses a fax server for inbound and outbound fax. The EHR supports the CCR and CCD
This table presents a broad, high-level price comparison for the products reviewed in this
report. It is up to each purchaser to carefully assess the costs for a product, which can
include license per provider, annual fee, support and more. Vendors will often negotiate
prices for individual practices and may provide discounts for multiple providers.
Amazing Charts $
Transitioning to an EHR
A practice should consider the time it will take to transition from paper to the EHR. Each
of the vendors was asked to state how long it takes to implement their product. It is
important to use realistic considerations as to how a practice’s workflow and time will be
spent when transitioning to an EHR.
Vendor Transition Time
Amazing The vast majority of its practices are writing notes and using the software within a
Charts day since the product is intuitive to use.
eClinical- It can take 10–16 weeks from signing the contract to the go live date.
e-MDs On average, implementation takes 60-90 days including training and “go live”
support. Total implementation will vary according to the number of providers,
number of facilities, type of clinic, data conversion, among other factors.
MediNotes The implementation process runs approximately 6–8 months if the client follows
the MediNotes implementation plan.
NextGen Implementation typically takes approximately 3–6 months, though the timeframe
varies depending on a variety of unique factors per customer, such as size and
scope of installation. To smooth the transition to a paperless environment,
NextGen typically recommends a combination of chart abstraction and scanning.
Sage On average, implementation takes 60 days, but because a number of factors can
affect timelines, implementation timelines are highly individualized to each
practice. Timelines are developed with the customer after significant discovery.
The advantages of documenting with EHRs include streamlined workflow, data capture
immediately at point of care, productivity enhancement after initial implementation,
elimination of the duplication of effort, enhanced delivery of care, and HIPAA
compliance. Studies have shown that physician behaviors can be changed when keeping
workflow in mind and when educating continuously.
While it seems almost obvious, it should be pointed out that a provider will most likely
require a computer with each office visit. Questions this might generate include:
• Does the physician see patients only in one room?
• If multiple rooms, is there a computer in each one?
If using digital voice recognition, a practice could consider setting up a network to
function as a “roaming user.” In this setup, one network computer houses the primary
digital voice training data; this can be accessed via other computers to allow dictation
from remote rooms within the office.
Before deciding on an EHR and how to document, a practice should determine its
optimal workflow strategy by assessing the following:
• Pre-visit flow
• Visit flow
o E/M: Visit
o LP Visit
o EMG Visit
o EEG Visit
o Chemical denervation visit
• Post-visit flow
Pre-visit workflow—Before the visit, the practice should identify how appointments are
made and discuss whether office staff can begin to populate fields including
demographics, primary care referring physicians for referral letters, and even certain data
that may be present on a questionnaire (e.g., items from past medical, social, and family
history). This will reduce the time the physician spends entering data into the EHR during
the office visit. For Medicare (and other insurance) billing purposes, the physician must
review the past, family, and social history along with any other historical items that are
populated by non-medical professionals.
The physician should decide which items should be populated in the EHR at check-in,
such as vital signs, height and weight (for BMI calculation), medications, and allergies.
The physician can decide whether some of the past, family, and social history can be
entered without disturbing flow. Potentially, if patients have filled out a review of
systems form, a licensed practicing nurse or a registered nurse can upload it as long as the
physician reviews it.
Workflow based on visit type—For the E/M visits, physicians should ask themselves the
following questions before deciding which documentation options they are most likely to
• Would I rather write, dictate, type, or enter data via a point-and-click field entry
• Am I comfortable with computers?
• Am I comfortable navigating multiple screens within a database (meds, allergies,
• Am I comfortable typing during a visit? (Timing is everything.)
• Would I have time (and patience) to train a voice recognition system; if so, would
I use it?
• Am I involved in clinical research trials requiring distinct data field collection?
For instance, if physicians are uncomfortable with computers, they may decide to use a
back-end voice recognition solution, the digital recorder, which can be transcribed by
voice recognition software. If physicians are comfortable with computers but dislike
typing, they may use front-end voice recognition, dictating directly into an EHR. The
user should be aware of the time that is required to learn the point/click method and the
time required to train the voice recognition system. After considering all of this,
physicians may simply decide to continue dictation with transcription in the standard
fashion, allowing the transcriptionist to upload the document to the EHR and send it to
the physician for signature.
For procedural visits, physicians should understand how their generated office reports
should be placed into the medical record. For instance, some EHRs have standard lumbar
puncture pre-completed notes. These and other templated procedural notes take minimal
time to input, and are highly user-friendly. Standard electromyography reports are often
generated on another machine, and will require direct upload to the EHR. Some EHRs
may have functionality to customize EEG reports by the point/click method; this type of
data entry can certainly assist physicians in various types of research in which they may
be involved. For chemical denervation documentation, EHRs may have pictures with
ability to label injection sites as a documentation method, they may simply have
point/click field-entry documentation, or physicians may be required to describe in text
what they did. If a practice sees a high volume of chemical denervation patients, then this
will be a highly important feature for it to assess.
Other procedures (e.g., carpal tunnel or other injections) can likely be uploaded via word
processor template if not customizable within the EHR.
Post-visit workflow—The practice should decide the location of the printer. A printer in
the room allows the physician to sign the prescription directly and give it to the patient.
But, if it is at the front desk, the physician has to accompany the patient to the front desk
and sign the prescriptions there. Of course, all this can be avoided if the EHR can
transmit the script directly to the pharmacy. A physician should use the EHR’s functions
for medication entry, problem list and allergy entry rather than simply dictating them into
RETURN ON INVESTMENT
EHRs represent a large investment for neurology practices. Five-year costs can run from
$5,000 to $25,000 per physician. Key to decision making is analyzing how much return
on investment (ROI) a practice can expect after implementing an EHR.
What are some financial benefits of an EHR that accrue directly to the practice?
• Fewer chart pulls—EHRs obviate the expense involved in pulling a chart—
finding it, delivering it, and then re-filing it—if a practice completely eliminates
paper chart systems. If practices continue to have paper chart systems, they will
require review from time to time, which will reduce these costs but not eliminate
them. Chart pulls are estimated to be as much as $5 per pull in clerical labor.
• Lower transcriptions costs—Practices that effectively use EHRs, especially after
implementing documentation templates, may save 60–100% of their annual
transcription costs per physician (up to $6,000 to $8,000 per year per physician).
• Decreased malpractice premiums—Although not a widespread practice, a few
insurers are offering discounts of up to 5% on malpractice premiums annually.
This could save some practices up to $2,500 per physician per year.
• Staff reductions—Efficiencies in office operations, telephone triage, prescription
refills, chart pulls, and transcription can lead to staff reductions, but more often
lead to reassigning staff to new duties (e.g., switching from chart pulling to
scanning outside notes or backing up the system, changing from calling
pharmacies to electronically sending prescriptions). Some practices have reported
reductions as high as 20% with aggressively implemented EHRs. Certainly, some
aspects of EHRs such as electronic prescribing can be performed much more
quickly and accurately than calling in prescriptions.
• Reduced storage expense—Practices that implement EHRs can eliminate the costs
of record storage by up to 80 to 90% if they proceed with a paperless strategy and
“scan in” existing paper charts. A small practice may save up to 300 to 400
square feet of storage for an annual saving of up to $6,000 per year in rental
• Higher E/M coding—Most practices experience an upward trend in E/M codes
with an EHR. This is due to better documentation that is reflected in more level 4
and 5 codes.
• Reduced lost charges—Integration of the EHR with the billing system should
reduce lost charges by as much as 2%.
• Office efficiency—Office efficiency can improve dramatically with an EHR and
this may lead to reductions in staff. Practices need to be committed to overhauling
their workflow and patient flow to fully exploit the power of their EHR. For a
successful transition, everyone in the office must approach the transition with
flexibility and a willingness to change.
What are some non-financial benefits that practices may experience after
implementation of an EHR?
• Records can be accessed 24 hours a day, 7 days a week, 365 days a year.
Physicians can use the Internet to access patient records from home or the hospital
when away from the office.
• Records have improved legibility.
• Practices are better able to participate in QI (quality improvement) and P4P (pay
for performance) initiatives.
• Practices can use an EHR to support a strategy of workflow re-engineering.
EHRs can be the foundation that allows many practices to execute a strategy to re-
engineer workflow and to become leaner and more efficient operations.
• Switching to an EHR may facilitate expansion of a practice to multiple sites, since
work at one site will be immediately available to all sites with a centrally
organized EHR system.
What are the characteristics of practices that are most likely to get a positive ROI
from an investment in an EHR?
• They eliminated most or all transcription and the associated expense involved in
transcribing their notes.
• They integrated billing and scheduling with their EHR.
• They emphasized improving their workflow, not implementing the EHR.
• They aggressively moved to eliminate paper and tried to go entirely electronic.
They eliminated paper storage and saved space and rent charges.
• They valued both financial and non-financial benefits of the EHR.
• They emphasized electronic interfaces and electronic information exchange as a
way to minimize data entry costs.
• They decreased staff costs by using the EHR.
The EHR landscape is always changing. Although some programs require participating
practices to use a certified product, not all vendors can afford to go through the process.
CCHIT may not be the final regulatory target, yet, since it is being used today, it is
worthy of discussion.
The stated aim of the Certification Commission for Health Information Technology
(CCHIT) is to encourage the adoption of EHRs by establishing standards of functionality
and rigorously evaluating which EHR products meet those standards. This is supposed to
improve consumer confidence in certified products so that medical practitioners will be
more willing to invest in this technology. Besides functionality, the CCHIT has
implemented standards of interoperability and security- thus removing the necessity of
buyers from the need to research whether a certified product possesses these features. It
would seem that CCHIT certified products have a clear cut market advantage, but we are
unaware of any objective information which would substantiate whether the CCHIT has
been successful in its mission.
Should you insist on a CCHIT certified product?
The following are arguments given by the smaller EHR vendors to point out the potential
shortfalls of the CCHIT process and certified products.
• Cost—The EHR product will be more expensive. It costs each vendor $28,000 to
have a product tested by the CCHIT, which is actually a small portion of the
additional expense that successful certification requires. The larger fraction of the
cost goes to the extensive development of the product demanded by the exacting
standards required for certification. These requirements, many of which may not
be used by most neurology practices, may cost vendors hundreds of thousands of
dollars for software development.
• User-friendly features—The CCHIT does not assess the ease of use qualities of
any product. The judgment of individual CCHIT criteria is on a “pass-fail” basis.
Therefore, how many steps are needed, how long it takes to complete computer
tasks, and how difficult a given EHR is to learn are not considerations in
evaluating an EHR product. In fact, some of the smaller vendors assert that the
complicated CCHIT requirements invariably add clicks and additional computer
input in order to satisfy some of the standards. The implication, not proven, is that
CCHIT products are less efficient because they require more data input steps than
functional but non-certified EHRs.
• CCHIT products are geared to larger, primary care groups—In fact the CCHIT
acknowledges this shortcoming:
CCHIT acknowledges that these criteria may not be suitable for settings
such as behavioral health, emergency departments, or specialty practices
and our current certification makes no representation for these.
Purchasers should not interpret a lack of CCHIT Certification as being of
significance for specialties and domains not yet addressed by CCHIT
Criteria. (CCHIT, 2006)
In contrast, the advantages of choosing a CCHIT-certified EHR product include:
• Guaranteed functional, interoperable and security standards—CCHIT is a well
respected, forward thinking entity that currently has about 250 criteria serving to
set high standards for ambulatory EHRs.
• Regulatory standards—Even though the CCHIT is theoretically a private,
independent agency, it actually functions with the authority of the federal
government. As a result of this special influence, CCHIT certification is
increasingly being required to fulfill CMS initiatives as well as some state
Many of these requirements are reasonable and in fact necessary for the development of a
National Health Information Infrastructure. For example, a standard clinical vocabulary
eliminates many problems with system interoperability (a hurdle which would not likely
be overcome without governmental intervention). Records must be exportable in a
universal format so that chart information will be accessible in any certified EHR. These
are just two examples of highly desirable EHR features that would not likely have been
implemented if left to vendor choice.
Some more tangible advantages enjoyed by CCHIT-certified products currently include:
• Certified products qualify under a special exemption to the Stark and anti-
kickback laws, allowing a local hospital or health system to cover most of the cost
for a practice.
• Pay-for-performance initiatives for 2008 specify that to qualify for the criteria in
EHRs, the product must be certified or have provable functionalities (obviously
favoring the CCHIT products). In the future, physicians may be required to report
on all P4P or quality data using a CCHIT product. In fact, as further governmental
mandates regarding electronic prescribing and EHR are implemented to qualify
for CMS reimbursement, predictably certified products will be required.
• Some professional liability insurers are offering premium discounts for the use of
So, should a practice require CCHIT certification when selecting potential EHR
products? In order to answer the question, a practice must define its current EHR goals
into the next few years. Again, most neurology practices will use only a fraction of the
features of a certified product. The CCHIT criteria should be reviewed to see their
relevance to a practice’s needs. A less complicated and possibly less expensive product
may offer all the functionality with a greater ease of use and lower price tag than a
certified product. Other considerations not addressed by the CCHIT include company
financial stability, product training and support. These are important considerations when
making final decisions regarding which EHR to purchase. Therefore if all other
considerations were equal, given the choice between a certified vs. a non-certified
product, the current and expected regulatory demands clearly favor the certified product.
This table shows the CCHIT certification status of the six vendors reviewed in this report.
2006 CCHIT Certification 2007 CCHIT Certification
Amazing Charts Not certified Not certified
eClinicalWorks eClinicalWorks Version 7.0 Release 2 eClinicalWorks 7.6.15
and eClinicalWorks Version 7.5
e-MDs e-MDs Solution Series™ 6.1 e-MDs Solution Series 6.1.2
MediNotes MediNotes e 5.0 and MediNotes MediNotes e Version 5.2
Clinician Version 2006
NextGen NextGen EMR 5.3 and NextGen EMR 5.4.29 and
Healthcare NextGen EMR 5.4.28 NextGen EMR 5.5
Sage Software Intergy EHR by Sage v3.00 and Intergy EHR by Sage, Version V4
Intergy EHR by Sage v3.50
ASP Application Service Provider
CCD Continuity of Care Document
CCHIT Certification Commission for Health Information Technology
CCR Continuity of Care Record
CDA Clinical Document Architecture
CMS Centers for Medicare and Medicaid Services
CPT Current Procedural Terminology
DOQ-IT Doctor’s Office Quality Information Technology
DUR Drug Use Review
EDI Electronic Data Interchange
HCPCS Healthcare Common Procedure Coding System
HL7 Health Level Seven, Inc.
ICD-9 International Classification of Diseases, Ninth Revision
IMH Instant Medical History
PACS Pictorial Archive and Communication System
P4P Pay for Performance
RMS Remote Monitoring Software
XML Extensible Markup Language
Reason for Consultation: Parkinson’s disease
Consult Requested By:
Dr. Robert White
112 Hillcrest Avenue
Lakeland, FL 33815
Patient Name: James Wilson
DOB: November 1, 1930
This 77 year old man was referred for evaluation of his Parkinson’s disease. He has had
symptoms of Parkinson’s disease for the past 6 years. Symptoms began with slight shuffling of
gait and slowness of movement. Subsequently he developed cramped handwriting and low voice
volume. 5 years ago he was started on carbidopa/levodopa 10/100 three times a day and the
dose was gradually increased to 25/250 three times a day. There has been no drooling. He has
not had any on-off phenomenon or freezing but in the past several weeks has noticed some
wearing-off of drug effect just before taking his next dose of carbidopa/levodopa. He has no
dyskinesias. He has fallen twice in the past 6 months. He dresses himself without assistance but
notes it takes him longer to dress than previously. He has no memory or speech complaints. He
has complained of urinary frequency which is especially troublesome at night. He was seen by
another neurologist 6 months ago for worsening symptoms of Parkinson's disease and started on
benztropine 0.5 mg twice daily. His gait has continued to deteriorate despite the benztropine
Review of Systems:
Eyes: Previous cataract surgery OU
Ears, Nose, Throat: Negative
Gastrointestinal: chronic constipation
Genitourinary: urinary frequency
Musculoskeletal: bilateral osteoarthritis of knees
Skin and/or Breast: Negative
Neurologic: slow gait, bradykinesia, resting tremor, and low voice volume
Psychiatric: Episodes of depression
Past Medical History:
Carbidopa/levodopa 250 mg po three times a day
Benztropine 0.5 mg po twice a day
Lisinopril 5 mg po daily
Operations: Appendectomy (1985), left hernia repair (1992)
Injuries: Fall with fracture of right wrist (2007)
Alcohol: Social use
Other Drug Use: None
Exposure to HIV: None
Falls in Past 6 Months: 2
Mother: Deceased from breast cancer
Father: Deceased from coronary artery disease
Children: 3 children, all alive and well
No family history of Parkinson’s disease or degenerative neurological illness
BP: 120/75 (sitting)
BP: xx/xx (standing) [BP given at Chart Challenge]
Weight : 75.2 kg
Height: 178 cm
Thin, stooped posture, face expression-less with masked facies and decreased eye-blink noted
Carotids: No bruit
Heart: No murmurs
Peripheral pulses: Normal
Ophthalmologic: Normal disk, retinal vessels, no hemorrhages or exudates
Alertness and Attention: Alert, attentive
Orientation: Oriented to person, place, time
Memory: Recalls 3 of 3 objects at 5 minutes
Language: Repeats no ifs ands or buts, names watch and pen, follow 3 step commands
Mood: Mood is depressed
I Not examined
II (VA) 20/20 OU with glasses
II (Visual fields) Full to confrontation
II (fundi) Flat optic disks
III, IV, VI (EOMS) Full EOM except some limitation of upgaze
V (sensation, mastication) Normal
VII (facial strength) Normal
VIII (hearing) Hears whisper in both ears
IX, X (swallowing, phonation) No trouble with swallowing, low voice volume
XI (shoulder shrug) Normal
XII (tongue protrusion) Normal
Gait and Station
Gait is slow and shuffling, stooped posture, some festination
Unable to do tandem gait. Postural reflexes are diminished.
Motor Right Left
Grip 5/5 5/5
Biceps 5/5 5/5
Triceps 5/5 5/5
Deltoids 4/5 4/5
Hip Flexors 4/5 4/5
Hip Extensors 4/5 4/5
Knee Flexors 5/5 5/5
Knee Extensors 5/5 5/5
Foot Plantar Flexors 5/5 5
Foot Dorsiflexors 5/5 5
Additional Motor Testing Side
Tremor Pill-Rolling Bilaterally
Tone Cogwheel rigidity Bilaterally
Pinprick, vibration sense, proprioception normal in both arms and legs bilaterally.
Biceps 1 of 4 1/4
Triceps 1/4 1/4
Brachioradialis 1/4 1/4
Knee 1/4 1/4
Ankle 0/4 0/4
Finger Jerks Absent Absent
Babinski Sign Absent Absent
RAM slowed in both hands. No Ataxia elicited. A slow pill-rolling tremor at rest noted in both
hand. Finger-to-nose and heel-on-shin testing was performed slowly.
Medical Decision Making:
Parkinson’s disease moderately advanced.
By history he has wearing-off phenomena and has been subject to at least 2 falls in the past 6
months, one with a fractured wrist. Gait has slowed and by history his postural reflexes are
diminished. He in addition has complaints of urinary incontinence at night.
I doubt that this is either vascular Parkinson’s disease due to stroke or Lewy body disease.
Because he has some proximal muscle weakness, I will obtain and ESR and CPK and aldolase
to exclude possibility of polymyositis.
In view of his gait instability, I am referring him for 6 weeks of physical therapy 2 times per week
to improve gait and stability.
I plan to continue his carbidopa/levodopa 25/250 however, in view of his wearing off symptoms I
plan to add ropinirole 0.5 mg po TID. In addition, because of his urinary incontinence at night I
will add oxybutynin 5 mg at bedtime.
Education/Instructions given to: (x) Patient ( ) Spouse ( ) Parent ( ) Other
Barriers to Learning: None
Content: I explained how the ropinirole would help with wearing off symptoms. I explained how
the oxybutynin would help with his urinary incontinence.
Evaluation/Outcome: The patient expressed understanding of his new medications.
Return Visit: 4 weeks to review progress
A copy of this consultation has been mailed to Dr. White.
AAN EHR Chart Challenge Script
a) If EMR has scheduling feature, open EMR and demonstrate that James Wilson is on
schedule to be seen today.
b) If EMR has visit notification feature, show Mr. Wilson has arrived in Office and is in
examination room ready to be examined. Open Consultation Note on Patient James
Wilson. Note should be complete except for documentation of Additional Motor Testing.
Current medications, allergies, and the problem of Parkinson’s disease (332.0) should
already be loaded into EMR.
c) Show how physician would review diagnoses (problem list), medications, and allergies in
EMR prior to completing his/her note. Show how physician would review Vital Signs
taken by medical assistant. Update standing BP at time of vendor demonstration (BP to
be given at demonstration)
d) Complete section entitled additional motor testing.
e) Save revised note.
f) Demonstrate how completed note can be printed out and mailed to referring physician.
g) Demonstrate how completed note could be exported in Continuity of Care Record format
h) Add depressive disorder (311) and Urinary Incontinence (788.39) to problem list
i) If Vendor has an automated coder, Run Single System Examination CPT Coder based
on Consult Note and find correct level of service for consultation and show CPT code. If
the Vendor has an automated E&M level coder, show what level of service the coder
selected for History, Examination, and Medical Decision Making.
j) Write prescription for oxybutynin 5 mg po bid #60, 5 refills
k) Demonstrate whether prescription can be transmitted electronically through Surescripts
network or faxed directly to a pharmacy.
l) Write a prescription for a second drug to be specified at time of vendor demonstration.
Drug to be specified.
m) Demonstrate that drug interaction checking can detect interaction between oxybutynin
and second drug (to be specified at demonstration)
n) Show a searchable field entitled “Number of Falls in Past 6 months” has been added to
EMR as part of past medical history
o) Run report on the database: Find all patient with diagnosis of 332.0 and who have fallen
in past 6 months
p) Run report on the database: Find all patients with diagnosis of 332.0 are taking
q) If time permits, Vendor will be asked to demonstrate how a new field could be added to
the neurological examination. The field will be specified at the time of the vendor