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Mike Gleason 3/5/09

March 5, 2009 News 3 Comments

Moving Toward Specialty-Specific EMRs

I’ve noticed a trend over the past few years in EMR/EHRs. I’m seeing a lot of EMR to EMR conversions where the practice is not happy with their all-in-one EMR. The existing EMR is often their first one and they are looking to convert over to a more specialty-specific EMR/EHR. More often, practices are converting to their third EMR. One wonders how these practices, many containing 10 doctors or more, can continue to make costly EMR replacements.

Common reasons for the switch? In speaking with the practice administrators, consultants, and providers, I hear some pretty consistent thoughts. The practice needs better specialty content, relevant workflow, faster documentation speed, and a system designed or tailored to their specialty. A growing trend in healthcare practices over the past few years has been mergers between large, specialty-specific practices. These practices have tough decisions over which PM and EMR they should keep. Usually one group is forced to adopt the EMR and PM of the majority (often kicking and screaming).

I thought it might be interesting to bring this up to readers and see if they are experiencing this as well.


It seems that many of the generic, all-in-one, or multi-specialty (take your pick of labels) EMRs are not able to provide rich enough content for a specialist. The specialties I see most often struggling with customization of content in a generic EMR are urology, gastroenterology, neurosurgery, ENT, dermatology, general surgery, and plastic surgery.

These are just some of the specialties getting the short end of the stick in terms of standard templates and content in many of the all-in-one EHRs. The content in these EHRs heavily emphasize family medicine, internal medicine, pediatrics, and gynecology.

Most EMR/EHR vendors are in a mad dash to provide a wealth of content to prevent client attrition as well as add new customers to their client pool. The mistake that vendors often make is that they forget to run this content past the physicians, nurse practitioners and physician’s assistants using the software 40 hours a week or more. This content dash may be for naught if the providers are not included in the design and QA process.

There is a fine art to creating great content. It often involves a lot of tweaking and refining and testing. Content testing is most effective when done in an actual clinic setting, where users experience off-the-wall combinations of issues and can provide instant feedback on speed and effectiveness.

During the implementation process, a practice is asked what their top 10, 20, or 50 diagnosis codes may be. However, the list they provide rarely matches the mix of actual patient chief complaints during go-live. That’s why testing the customization on live charts prior to go-live is so critical. If the implementation process can focus on the 80% of the content they see daily, the other 20% can get created post go-live. After the go-live, physicians usually have a better idea of what additional customization is needed.

In order to get content to the level that specialists require, vendors have historically placed the burden of content creation on the practice. The creation work often falls on physicians, who have little time to learn customization, much less do the actual customization work. In other words, vendors measure the success of their software based on how successfully THEIR CLIENTS can learn how to customize THEIR software.

I’m reminded of a struggling physician who had completed three days of customization training. He relayed his frustrations to me this way. “I feel like I bought a Bentley, the nicest Bentley on the market. Unfortunately it has come with complete assembly required and the instructions are all in Chinese. I wonder if I’ll ever get to drive it?”

How can we let the success of our product depend on how well a physician can learn to customize it? Often, practices will not customize or improve their systems much beyond what they had at their initial go-live. They find a way to get by, which often includes scanning handwritten notes or dictation. Many vendors now offer customization for the client, but these services are billable to the practice.

I think practices can benefit from narrowing the field during their EMR search and focus on EMRs that cater to their specialty. Content delivered by specialty-specific EMR vendors can allow for faster adoption because the workflows make better sense and are more familiar to the clinical staff.


“This EMR workflow does not fit our office.”

“Our office has to adjust to the EMR workflow.”

“We don’t schedule like a family practice. We see patients every 10 minutes and may see 50 patients in a day, two or three days a week.”

These are common complaints that can be heard from specialists trying to cram a generic EMR in their office. If you deal with urine dips all day long, you need a fast way to enter results. If you have specific lab devices, you need an efficient interface with your EMR. If both the doctor and nurse work on the same patient encounter at the same time, they need to have dual entry capabilities in the EMR.

Many specialists have to fax letters and H&P reports to multiple providers for one patient. They need easy to use tools to indicate which items (the office note, the lab data, imaging reports, etc.) need to go to the primary care provider and which need to go to other treating providers. If an EMR can only generate one H&P or referral letter at a time and can only fax to one office or provider at once, you are not going to make the grade in a specialist’s office.

A specialist’s office may follow unique workflows that can’t be duplicated in some EMRs. For example, some EMRs do not allow a nurse to order labs on behalf of the physician, or allow lab results to forward automatically to the nurse. Often the nurse is the one monitoring the lab and e-prescribing process, then forwarding the record to the physician for sign-off.

Specialists often do not follow a typical SOAP-type flow in the patient encounter. You may need to order and result a lab prior to the physician seeing the patient. Office procedures such as EKGs or breathing treatments may need to be completed prior to the physician seeing the patient for the first time.

Specialty offices also need a greater focus on their specific body system in physical exam. A generic EMR often can’t provide that detail without massive and complex customization. Many specialists need to include lab data as well as note what specific data review process was completed prior to completing an assessment and plan section. Generic EMRs often lack this ability.


I was shocked when I first encountered a specialty office where they see 50 patients in less than a six-hour shift. A generic EMR rarely has the capability to effectively complete more than 25 to 35 office visits in a day with a very adept family medicine provider running the keyboard. Place one of these EMRs in the hands of a specialist and you can have a recipe for disaster. If the EMR does not have the generic content turned off and the specialist’s content customized with their specific phrases, the software may get tossed back in your face.

Many EMR implementation consultants do not know how to customize their vendor’s EMR for speed and efficiency. There is a fine art to making content that is complete, quick to document, and easy enough for a beginner to comprehend and use on a daily load of patients.

Many EMRs lack the ability to share templates between practices. Specialists may need the ability to import different types of formats, such as images, pictures, and drawings. This can be a bottleneck if the EMR vendor does not work with different document formats.

Tailored for my specialty

Given enough time, you can customize great HPIs, assessment and plan order sets, physical exam templates, nurse lists, history lists, etc. Many practices never get to this higher level of customization. A specialist will never achieve success in a generic EMR because they can’t afford to put in the hours required to customize the product to suit their needs. They can’t take the hit to their revenue or reduce their patient load. Many have minimal staff and lack the support staff to work on the back loading of data, scanning, or customizing.

Specialists have a very focused data set for patient history that is often hard to understand when you are trying to use a generic history form to gather data. Most practices fail to take the opportunity to change the forms used to gather information from patients, as well as tailor the history lists to their specific needs. When the form comes back across the counter or data is entered in the kiosk or Web site by from the patient, does it make sense? Is it even usable in the specialist’s EMR?

I guess the question to ask is, “Are generic EMRs doing more harm than good when implemented in a specialists office?" I’m interested in hearing from the practices. 


Mike Gleason is a 25-year veteran of the HIT industry with expertise in sales, support, and implementation of clinical and financial systems.

Comments 3
  • When physician-owners are more concerned with paint color than functionality, this can be expected. Paint color in this case is called CCHIT-certification. It has nothing to do with interoperability and usability. In the old days when a buyer didn’t want to do his homework, he simply bought “blue” (IBM’s logo color). If you bought blue, you couldn’t get fired for a bad decision or failed implementation. Later, SAP installations among the Fortune 500, resonated with the same, “You can’t go wrong in buying SAP”, but after others slipped on the same banana peel, companies became more thoughtful before laying down millions. For medical practices, CCHIT is like buying blue. They will come to their senses.

    A portion of this phenomenon was based on cheap money….and lots of it. With everyone getting stingier, forethought and due diligence will reenter the market.

  • GREAT insights from the real world, Mike.

    I’d contend many of the issues you spotlight are problems encountered by all practice types, specialist and generalist, and areas addressed poorly by most EHRs. Practicalities of day to day operations often seem at odds with many an EHR design.

    The assembly-required-Bentley-with-Chinese-instructions analogy is hot! Why end users, paying lots of money, are expected to expend lots more time and energy, at their expense, to make their system workable (which the vendor then may use to their financial gain with other clients) seems to me an odd and counterproductive business model.

    EHR designers would do well to remember the old “plug-n-play.”

  • Anyone buying an EMR needs to understand that some of the available products are very quick and easy to customize. There’s even at least one that “learns as you go”, so it creates the template the first time you see a patient with that condition. Ask the vendor to let you practice creating templates and lists before you purchase – you will see that some EMRs make this customization easy, and some make it very difficult indeed. This is a critical differentiator between EMRs and an essential part of due diligence.

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