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  • Electronic Medical Records (December)
  • Which Electronic Health Record Should You Buy? A Review of Three Products

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

The Carlat Psychiatry Report, Volume 9, Number 12, December 2011
https://www.thecarlatreport.com/newsletter-issue/tcprv9n12/

From The Carlat Psychiatry Report, December 2011, Electronic Medical Records

Issue Links: Learning Objectives | Editorial Information | PDF of Issue

Topics: Computers in Psychiatric Practice | Free Articles | Practice Tools and Tips

Print Friendly, PDF & Email

Daniel Carlat, MD

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.

Table 1: Side-by-Side Comparison of Key Features

Click here to open pdf

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.

David Frenz, MD

Medical director, Addiction Medicine, HealthEast Care System, St. Paul, Minnesota

Dr. Frenz has disclosed that he has no relevant relationships or financial interests in any commercial company pertaining to this educational activity.

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  • Pharmacogenetics (October)
  • Keeping up in Psychiatry (September)
  • Research in Psychiatry (July/August)
  • Marijuana (June)
  • Psychiatric Diagnosis (May)
  • Issues in Psychopharmacology (April)
  • Schizophrenia (March)
  • Women’s Psychiatry (February)
  • Ethics in Psychiatry (January)

2013

  • Military Psychiatry (December)
  • Depression (November)
  • Treatment of Dementia (October)
  • Anxiety Disorders (September)
  • Natural and Alternative Treatments in Psychiatry (July/August)
  • Autism Spectrum Disorder (June)
  • Practice Tips (May)
  • Substance Abuse (April)
  • Medicolegal Topics (March)
  • End of Life Care (February)
  • Antipsychotic Update (January)

2012

  • Screening Tools and Tips (December)
  • Medical Comorbidities (November)
  • Devices in Psychiatry (October)
  • Eating Disorders (September)
  • Bipolar Disorder (July/August)
  • Risk Management (June)
  • Antidepressant Roundup 2012 (May)
  • Gender and Sexuality (April)
  • Personality Disorders (March)
  • ADHD (February)
  • Natural Treatments in Psychiatry (January)

2011

  • Electronic Medical Records (December)
  • Insomnia (November)
  • Psychotherapy (October)
  • Alcoholism (September)
  • Anxiety Disorders (July/August)
  • Schizophrenia (June)
  • Managing Side Effects (May)
  • Antidepressant Roundup 2011 (April)
  • DSM-5 and Diagnostic Issues (March)
  • Drug-Drug Interactions (February)
  • Bipolar Disorder (January)

2010

  • Hospital Psychiatry (December)
  • Psychiatric Medication in Pregnancy (November)
  • Maintenance of Certification (October)
  • The Neuroscience of Psychotherapy (September)
  • Treatment of Depression (July/August)
  • Email and the Internet in Psychiatry (June)
  • Substance Abuse (May)
  • The Diagnosis and Treatment of Dementia (April)
  • Ethics in Psychiatry (March)
  • Natural Treatments in Psychiatry (February)
  • ADHD (January)

2009

  • Treating Schizophrenia (December)
  • Treatment for Anxiety Disorders (November)
  • The Latest on Antidepressants (October)
  • Topics in Neuropsychiatry (September)
  • The Interface of Medicine and Psychiatry (July/August)
  • Generic Medications in Psychiatry (June)
  • The Treatment of Eating Disorders (May)
  • Healthcare Policy and Psychiatry (April)
  • Antipsychotic Roundup 2009 (March)
  • Psychiatric Medication in Pregnancy and Lactation (February)
  • Transcranial Magnetic Stimulation (January)

2008

  • Treating Fibromyalgia and Pain in Psychiatry (December)
  • Issues in Child Psychiatry (November)
  • Improving Psychiatric Practice (October)
  • Treating Personality Disorders (September)
  • Bipolar Disorder (July/August)
  • Antipsychotic Roundup 2008 (June)
  • Atypical Antipsychotics in Clinical Practice (February)
  • Neuropsychological Testing (May)
  • Psychiatric Medications: Effects and Side Effects (April)
  • Update on Substance Abuse (March)
  • Anticonvulsants in Psychiatry (February)
  • Brain Devices in Psychiatry (January)

2007

  • The Treatment of Insomnia (December)
  • Avoiding Malpractice in Psychiatry (November)
  • Update on Eating Disorders (October)
  • Complex Psychopharmacology (September)
  • Laboratory Testing in Psychiatry (August)
  • Psychotherapy in Psychiatry (July)
  • Posttraumatic Stress Disorder (June)
  • Topics in Geriatric Psychiatry 2007 (May)
  • Pregnancy and Menopause in Psychiatry (Apil)
  • Antipsychotic Roundup 2007 (March)
  • Understanding Psychiatric Research (February)
  • Antidepressant Round-up 2007 (January)

2006

  • Technology and Psychiatric Practice (December)
  • The Use of MAOIs (November)
  • Medication Treatment of Depression (January)
  • Seasonal Affective Disorder (October)
  • Treatment of ADHD (September)
  • Topics in Bipolar Disorder (August)
  • Neurotransmitters in Psychiatry (July)
  • Treating Substance Abuse (June)
  • The STAR*D Antidepressant Trial (May)
  • Natural Treatments in Psychiatry (April)
  • Medication Treatment of Anxiety (March)
  • Panic Disorder: Making Treatment Work (March)
  • Antipsychotic Roundup 2006 (February)
  • Antidepressant Roundup 2006 (January)

2005

  • Self-Help Books and Psychiatry (December)
  • Genetics and Psychiatry (November)
  • Pregnancy and Psychiatric Treatment (October)
  • Benzodiazepines and Hypnotics in Psychiatry (September)
  • Geriatric Psychiatry Update (August)
  • Chart Documentation in Psychiatry (July)
  • The Treatment of Bipolar Disorder (June)
  • Weight Loss and Smoking Cessation in Psychiatry (May)
  • Treating ADHD (April)
  • Drug Industry Influence in Psychiatry (March)
  • Atypical Antipsychotics 2005 (February)
  • Antidepressant Roundup 2005 (January)

2004

  • Sexual Dysfunction (December)
  • Suicide Prevention (November)
  • To Sleep, To Awake (October)
  • Women’s Issues in Psychiatry (September)
  • OCD: An Update (August)
  • Chronic Pain and Psychiatry (July)
  • Neuroimaging in Psychiatry (June)
  • Natural Medications in Psychiatry (May)
  • Posttraumatic Stress Disorder (April)
  • Treatment of Alcoholism (March)
  • Battle of the Atypicals (February)
  • Antidepressant Roundup, 2004 (January)

2003

  • Research Methods in Psychiatry (December)
  • Antidepressants in Children (November)
  • The Treatment of Dementia (October)
  • Bipolar Disorder, Part II: The Novel Anticonvulsants (September)
  • Bipolar Disorder: The Basics (August)
  • Drug-Drug Interactions in Psychiatry (July)
  • Managing Antidepressant Side Effects (June)
  • Antidepressants in Pregnancy and Lactation (May)
  • ADHD: Medication Options (April)
  • Panic Disorder: Making Treatment Work (March)
  • Atypical Antipsychotics in Clinical Practice (February)
  • Medication Treatment of Depression (January)

2019

  • Autism in Children and Adolescents (November/December)
  • Depression in Children and Adolescents (May/June/July/August)
  • Substance Use in Children and Adolescents (September/October)
  • Trauma in Children and Adolescents (March/April)
  • Anxiety in Children and Adolescents (January/February)

2018

  • Psychotropic Risks in Children and Adolescents (May/June)
  • ADHD in Children and Adolescents (November/December)
  • Depression in Children and Adolescents (September/October)
  • Autism in Children and Adolescents (July/August)
  • Anxiety in Children and Adolescents (March/April)
  • Suicide in Children and Adolescents (January/February)

2017

  • Adolescents (November/December)
  • ADHD in Children and Adolescents (September/October)
  • Psychosis in Children and Adolescents (August)
  • PANDAS, PANS, and Related Disorders (June/July)
  • Marijuana in Children and Adolescents (May)
  • Tourette’s and Other Tic Disorders in Children and Adolescents (March/April)
  • Autism in Children and Adolescents (January/February)

2016

  • Gender Dysphoria in Children and Adolescents (November/December)
  • Technology Issues With Children and Adolescents (September/October)
  • Mood Dysregulation in Children and Adolescents (July/August)
  • Eating Disorders in Children and Adolescents (May/June)
  • Conduct Disorder in Children and Adolescents (April)
  • Sleep Disorders in Children and Adolescents (March)
  • ADHD in Children and Adolescents (January/February)

2015

  • Antidepressant Use in Children (November/December)
  • Foster Care and Child Psychiatry (September/October)
  • Autism (July/August)
  • Trauma (May/June)
  • Anxiety Disorders (April)
  • Schools and Psychiatry (March)
  • Emergency Psychiatry in Children (January/February)

2014

  • Antipsychotics in Children (December)
  • ADHD (November)
  • Gender and Sexuality (September/October)
  • Psychotic Symptoms (Summer)
  • Medication Side Effects (May)
  • Food and Mood (April)
  • Learning and Developmental Disabilities (February)

2013

  • Complex Practice Issues (December)
  • Diet and Nutrition (November)
  • Child Psychiatry in DSM-5 (August/September)
  • Medication Side Effects and Interactions (June/July)
  • Problematic Technology (March/April)
  • Autism Spectrum Disorders (January/February)

2012

  • Bipolar Disorder (December)
  • Substance Abuse (October/November)
  • Transitional Age Youth (July/August)
  • Rating Scales (May/June)
  • Eating Disorders (March/April)
  • Behavioral Disorders (February)

2011

  • Treatment of Anxiety Disorders (December)
  • Trauma (November)
  • Bullying and School Issues (October)
  • Hidden Medical Disorders (August)
  • OCD and Tic Disorders (June)
  • Suicide and Non-Suicidal Self Injury (April)
  • Sleep Disorders (March)
  • ADHD (January)

2010

  • Use of Antipsychotics in Children and Adolescents (December)
  • Learning and Developmental Disabilities (October)
  • Major Depression (September)
  • Treating Children and Families (July)
  • The Explosive Child (May)

2019

  • Dual Diagnosis in Addiction Medicine (May/June)
  • Medical Issues in Addiction Practice (November/December)
  • Alcohol Addiction (September/October)
  • Legal Issues in Addiction Medicine (July/August)
  • Traumatic Brain Injury and Addiction (March/April)
  • Board Certification in Addiction Medicine (January/February)

2018

  • Opioid Addiction (November/December)
  • Addiction in Older Adults (October)
  • Sleep Disorders and Addiction (September)
  • Adolescent Addiction (July/August)
  • Pain and Addiction (May/June)
  • Cannabis and Addiction (March/April)
  • Stigma and Addiction (January/February)

2017

  • Pregnancy and Addiction (November/December)
  • Detox (Sepember/October)
  • Dual Diagnosis (August)
  • Alternatives to 12-Step Programs (June/July)
  • Recovery (May)
  • Psychiatric Uses of Street Drugs (March/April)
  • Sex Addiction (January/February)

2016

  • Prescription Drug Monitoring Programs (PDMPs) (November/December)
  • Addiction in Health Care Professionals (September/October)
  • Dialectical Behavior Therapy in Addiction (August)
  • Motivational Interviewing (June/July)
  • Benzodiazepines (May)
  • Opioid Addiction (March/April)
  • Families and Substance Abuse (January/February)

2015

  • The Twelve Steps (November/December)
  • Designer Drugs (September/October)
  • Residential Treatment Programs Decoded (July/August)
  • Nicotine and E-Cigarettes (June)
  • Drug Screening (April/May)
  • Integrating Therapy and Medications for Alcoholism (March)
  • Detoxification Protocols (January/February)

2014

  • Behavioral Addictions (December)
  • Risk and Reimbursement (November)
  • Stimulant Abuse (September/October)
  • Self-Help Programs (June)
  • Opioid Addiction (May)
  • Coping with Bad Outcomes (March)
  • Change Management in Addiction Treatment (January/February)

2013

  • Cocaine Addiction (December)
  • Relapse Prevention (November)
  • Cannabis Addiction (August/September)
  • Addiction in DSM-5 (June/July)
Editor-in-Chief

Chris Aiken, MD

Dr. Aiken is the director of the Mood Treatment Center in North Carolina, where he maintains a private practice combining medication and therapy along with evidence-based complementary and alternative treatments. He has worked as a research assistant at the NIMH and a sub-investigator on clinical trials, and conducts research on a shoestring budget out of his private practice.

Full Editorial Information

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