Which Electronic Health Record Should You Buy? A Review of Three Products

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There are a lot of electronic health record (EHR—also called electronic medical record, or EMR) companies vying for your hard earned cash. How do you decide among them?

For this article, we chose to review three EHRs: ICANotes, Valant, and Practice Fusion. Why these three? ICANotes and Valant are currently the only EHRs that fulfill the following two criteria:

  1. each is specifically designed for mental health professionals; and
  2. each is certified for meaningful use (see the article below for more information on meaningful use). We added Practice Fusion to our list because, while it is not designed specifically for psychiatrists, it has good psychiatry templates, it is certified, and it is free, although you have to pay for an e-billing option.

Regarding our methodology, we wish we could say we had a room full of Consumer Reports employees test-driving the EHRs for hours, but alas, the reviews were based on two physicians poking through trial versions of the products as time permitted. So these are relatively subjective impressions and we urge you to do your own test-driving before you make any big financial decisions.

In addition to the aforementioned features, each of the three EHRs we review here offers the following basic features: HIPAA compliant; electronic chart documentation; e-prescribing; scheduling; billing; document management (eg, you can scan in paper records and affix them to the electronic chart); and dictation management (eg, you can upload a dictation from Dragon software). Some have special features, which we have indicated in the relevant sections.

Before you jump into an EHR, you need to consider the fate of all your manila folders. What, if anything, in your current charts should be ingested into the EHR? The easiest solution is to do nothing, and start your EHR experience at ground zero with new patient encounters only. You’ll still need to refer to your paper charts for a while, but eventually they become useless artifacts.

On the other hand, you might choose to scan documents into your EHR. From a technical standpoint, this is very easy to do with a standard desktop scanner. From a practical standpoint, however, it can add up to a lot of hours. Someone needs to thumb through the paper charts, decide what’s important and what’s not, and then scan. In all probability, that someone will be you.

ICANotes
(http://icanotes.com)

ICANotes was started by psychiatrist Richard Morganstern 15 years ago, originally for his own use. Gradually, he built it up, eventually commercializing it 12 years ago. Currently there are 3,500 users, making it, as they claim, “the most widely used web-based Electronic Health Record Software for psychiatrists and other mental health professionals.” For those who are curious, “ICANotes” is an abbreviation for “Intuitive Computer-Assisted Notes.”

Cost

  • EHR: Prescribers: $149/mo ($1,788/ yr) plus $65 annual licensing fee. Nonprescribers: $69/mo plus $65 annual licensing fee. A variety of discounts are offered for group practices, new practices, students, non-profits, and so on, so you are encouraged to call them and negotiate.
  • E-prescribing: Additional $45/mo ($540/yr). They use DrFirst.
  • E-billing: Can integrate with existing billing. Or can use one of their vendors—fees vary. One, for example, charges $39/month for up to 100 claims, then 39 cents a claim.
  • Training: Included in the monthly fee.

Special Features
Secure inter-office messaging, ability to graphically track data such as PHQ-9s and labs. They say they will have a secure patient portal operational by December 2011.

User Experience
ICANotes is probably the most “psychiatric” of the current crop of meaningful use certified EHRs. The home page makes you feel like you’re in your office, with cartoon file cabinets containing patient charts. All that’s missing is a couch. However, like many offices, the program is visually somewhat cluttered. We wouldn’t say that this is a deal-breaker, though, since over time we found it easy to cut through the clutter and accomplish our needs.

The essence of any medical record, paper or electronic, is creating notes. ICANotes has a psychiatry-specific template system that allows you to create a narrative note that reads as though you typed it, but in fact is created by clicking on buttons. For example, for one trial patient, I started with the HPI (history of previous illness). The screen prompted me with the fragment: “Patient has symptoms of ” and showed me 14 different broad options, such as depression, ADHD, psychosis, and dementia. I clicked on “depression,” and this sentence appeared: “Mr. Smith has symptoms of a depressive disorder.” At the same time, a list of specifiers appeared, such as “precipitant,” “speed of onset,” “current symptoms,” and “suicidality.”

I clicked “no precipitant” and got the following sentence: “Mr. Gardner reports there is no apparent precipitant for his depressive symptoms.” Next, I wanted to say something about how quickly his depression developed. I clicked “speed of onset” which branched out to choices such as “gradual, slow, insidious, rapid, sudden.” I chose rapid, and four more options popped up: “hours, days, weeks, months.” I chose “weeks,” and the automatically generated sentence was, “His depressive symptoms began rapidly over a period of weeks.”

In this way, ICANotes allows you to create a complete narrative note by clicking on any of hundreds of buttons. The advantage is that you don’t have to keep typing the same sentences that you use over and over again with certain kinds of patients. The disadvantage is that it reduces the complexity of a psychiatric patient to a series of pre-fab words and sentences—although you always have the option of positioning your cursor into the note and free-typing various details. For example, it turns out that Mr. Smith is depressed because his wife left him. There’s no button for “his wife left him,” so you can type it in yourself, or you can even create a custom button that, when clicked, would add that phrase.

ICANotes Advantages:

  • Smartly designed for creating elegant narratives with little actual typing.
  • Self coding (which picks appropriate billing codes for you) will help you use more lucrative E and M codes for Medicare and Medicaid patients.

ICANotes Disadvantages:

  • Narrative format may make it more difficult to find specific elements of the history from past visits—some prefer having checklists.
  • The screens are quite busy with buttons (though presumably one gets used to this over time).

Valant Medical Solutions
(www.valant.com)

Valant was founded by psychiatrist David Lischner in 2002, who, like the founder of ICANotes, found himself dissatisfied with the electronic charting options that existed. His brother happened to be a software developer, and in 2005 they had created a “virtual office” for small psychiatric practices. In 2007, they developed this further into the first version of Valant software.

Cost

  • EHR: Prescribers: $600/yr, or $50/ mo. Non-prescribers: $500/yr, or $40/mo. A variety of discounts are offered for group practices, new practices, students, non-profits, and so on, so you are encouraged to call them and negotiate.
  • E-prescribing: Additional $600/yr. Like ICANotes, they use DrFirst.
  • E-billing: $800/yr for standard module, $600/yr for paper claims, and other discounts. If you’re happy with your current billing service, they can use existing biller.
  • Training: Included in the monthly fee.

Special Features
Ability to graphically track data such as PHQ-9s and labs. They say they will have a secure patient portal operational by January 2012, including tablet computer functionality that will allow patients to input demographics and symptom scale scores and incorporate the information directly into the record.

User Experience
Valant has a cleaner and more ergonomic look and feel than ICANotes. Your dashboard includes a list of “Action Items,” such as, “patients missing demographic information,” “prescriptions pending,” and “undocumented sessions.” The best way to create a note is to go to your appointment calendar and choose a patient from there. You choose from a drop down menu of various note templates—some are default templates chosen by Valant because they are particularly popular. Others are from various other practices all over the country. This is quite different from the ICANotes model, in which you must use the one template system offered. The advantage of the Valant approach is that you have many choices of templates, including many with mental status checkboxes, which some people like, especially very busy clinicians in psychopharm practices.

A quirk of Valant that takes some getting used to is that in order to create notes, you have to open templates in Microsoft Word. Depending on which template you choose, you will see the note populated with some information, and fields or checkboxes to add new info. For example, let’s say you are seeing Sally Smith for a routine quarterly psychopharm appointment. You would open her chart within Valant, then select “new template clinical note from last.” Instead of this opening within Valant, Microsoft Word starts up and allows you to open Sally’s last note in Word. There are fields to add new info and checkboxes for elements of the MSE. Now you want to view her diagnoses and change her medications—but you can’t do that in the Word template. Instead, you have to switch to Valant to make such changes. It seems unnecessarily cumbersome, but perhaps once you get used to it, it becomes second nature.

On the other hand, a really convenient feature that is only offered by Valant is that you can easily make PDFs of as many patient notes as you want, allowing you to scroll down and view past trends/medications/other information very efficiently. And, of course, you can email or fax such PDFs to referring physicians. (You can make PDFs with the other EHRs by using a traditional PDF maker program.)

Valant Advantages:

  • Nice dashboard that keeps you up to date on all patients related tasks.
  • Very close to having a functional patient-related portal and tablet functionality.

Valant Disadvantages:

  • Somewhat cumbersome documentation process.

Practice Fusion
(www.practicefusion.com)

Practice Fusion is an EHR that can be used by various medical specialties. The company tells us that psychiatrists are some of the top users of its platform.

Cost
One of Practice Fusion’s selling Points—and this is a key differentiator—is that it’s free. The cost of the service is paid for by advertising (big pharma is everywhere!). Users can opt out of sponsored mode for $100 per month, although a minority of users apparently do so. If you were to opt out, the cost would be on par with Valant, and users still need to pay for electronic claims submission regardless of the mode selected.

Special Features
Secure inter-office messaging, ability to graphically track data such as PHQ-9s and labs, a functioning patient portal, and the ability to order and review labs electronically.

User Experience
Practice Fusion is funded by drug company banner ads, and therefore is very well-funded and slickly designed—in a good way. Writing up an H and P or a progress note is similar in some ways to the experience in ICANotes. There are clickable statements organized by diagnosis, and you can easily create your own statements as well. The ultimate syntax of the note is less elegant than ICANotes, but that probably won’t matter for most users.

Practice Fusion has many other useful features such as the ability to automatically fax notes to referring doctors—a nice tool for building up a new practice; robust lab integration; and an already functioning patient portal system, although at this point it only allows patients to view their medical information, and does not include the ability for them to fill out clinical forms and send the information to you.

Practice Fusion Advantages:

  • No cost in sponsored mode.
  • Customizable text-based templates.
  • Laboratory integration: studies can be ordered with the EHR; results drop directly in the EHR.
  • Tablet computer functionality.

Practice Fusion Disadvantages:

  • Pharmaceutical advertising in sponsored mode (three different psychotropic medications in the test drive alone!).
  • Presence of various features of more use for non-psychiatric physicians, which could be distracting to some.

What about non-certified EHR systems? While we didn’t have space to review every program available for psychiatrists, there are a number of EHRs on the market that are not certified for meaningful use by the federal government, but may cover all of the other bases. To learn more about those we suggest you visit the American Psychiatric Association’s ever-growing list at http://bit.ly/sF6yHU or their LinkedIn group at http://linkd.in/rDWWJB (both require APA membership). Or you can check out software reviews at http://www.softwareadvice.com/medical or the American Association for Technology in Psychiatry’s LinkedIn group at http://linkd.in/uEBZdN.