Shirley Grace


About two-thirds of the world agrees that driving on the right side of the road is the, er, right side. But in times past, people generally took to the left. Why? Because if you are on the left, you can easily use your right hand to draw your sword against an approaching enemy, and you can mount your horse from the road shoulder, rather than in oncoming traffic (and you won’t be impeded by your left-hanging sword either).

That’s how many standards come about - need and practicality. In a perfect world, a standard achieves global adoption - everyone on the same side of the road, writing in the same direction across a page, or omitting the “u” from “color.” In reality, though, don’t plug your made-for-America hairdryer into a Brazilian outlet without a converter, unless you like the smell of fried circuitry.

Healthcare IT is no exception; standards will help pave the way to interoperability. However, lovely as that would be, in reality the interoperable wires are crossed, especially with electronic medical records, or EMRs. “The optimal goal is you walk into a cardiology practice and you bring your data in, the cardiologist plugs it in and away you go,” says Jon Bertman, a Hope Valley, R.I.-based family care physician who is also the creator and founder of Amazing Charts EMR. “That’s not here yet.”

That’s for sure. A myriad of healthcare IT-standards development organizations are scurrying to put forward “the” last word on the subject. Any success? Some, in a fractured sense. The only real results so far are the acronyms - HL7, HIE, CCR, CCHIT, RHIO, among many, many others - that point toward the goal, but don’t quite get there.

Why is this all so hard? Are we anywhere close to settling on an industry-wide standard? And what can you do as a physician to help forward the cause?

Remember the Five Ps - Prior Planning Prevents Poor Performance?

So true, but not heeded in terms of EMR interoperability. A few decades ago, some entrepreneurial soul thought, “Hey, I know! We can use a computer to organize patient data!” Thus, the putty that fills a market niche is created.

By and by, others joined in - with competing solutions. No single EMR emerged early on as the undisputed market leader, unfortunately. Compare this to the Apple iPod or Microsoft Windows. Whatever their failings, they dominate their markets and so define the standards, which makes things easier for everyone - manufacturers, vendors, and users.

Not that there’s no standardization at all with EMRs. With meds, for example, most vendors use the same nomenclature, developed by First Databank (a commercial company owned by Cerner). But for, say, managing referrals, there’s no such common protocol. “Everyone has their own little customs,” says Scott Decker, senior vice president for NextGen Healthcare.

And there are many organizations that dictate healthcare IT interoperability protocols to a certain degree, although no single organization can claim “King of the EMR.” Here’s a brief rundown of some of the major players:

 is certainly in the mix of developing a nationwide standard. In 2004, President Bush created an agency specifically to address healthcare interoperability issues, called the Office of the National Coordinator for Health Information Technology.

, or Regional Health Information Organization, to promote the exchange of health information. Think of RHIOs as data way stations, each harboring a portion of the citizenry’s health information - at least in theory. Although there are about 100 RHIOs across the U.S., very few are actually fully functional, due to lack of public trust, unclear leadership and financing, and, paradoxically, hazy standards.

 - The Certification Commission for Healthcare Information Technology is an independent, voluntary, private-sector nonprofit whose main point is to promote EMR adoption through credentialing. EMR vendors can apply for such certification of their systems. Currently, there are 50 CCHIT-certified ambulatory EMRs, although Decker notes that because CCHIT tweaks its criteria every year, it’s getting harder for EMR vendors to make the grade. Decker says that for 2009, CCHIT is all about interoperability, a new focus for the credentialing group. “It’s not the end-all, but it’s a start,” he says.

 - The American Association of Family Practitioners and the American Society for Testing and Materials, along with many other physician organizations (including AAP, AMA, ACOG, AOA, ACOFP, MGMA, MMS, and AAN), have joined forces to develop the Continuity of Care Record, or CCR. This standard protocol delineates how to pass pertinent patient data between two disparate EMRs using XML technology, which is the exact same technology that allows banks, retail stores, and other industries to conduct business on the Internet.

- Health Level 7 is another standards protocol; this one is backed by the auspices of the standards development organization ANSI (American National Standards Institute). HL7 uses templates, standard vocabulary, and much more recently, it’s been investigating XML technology, among other defined protocols.

It’s a challenge, getting an EMR to be interoperable. Or maybe you know it as EHR, or “electronic 

 record.” At one time, these two terms had disparate definitions, with “EMR” meaning a piece of medical data - such as a lab report - as opposed to “EHR,” a whole patient record. These days, the two terms have become fairly interchangeable.

But dissenting confusion lingers. Electronic medical records have also been called - brace yourself for more acronyms - Computerized Medical Record (CMR), Electronic Patient Record (EPR), or Digital Medical Record (DMR). Sheesh, three decades after this technology’s inception and we can’t even settle on what to call it, much less define nationwide standards to communicate practice-to-practice or practice-to-hospital. (Our standard, by the way, is to use “EMR.”)


A number of barriers block the way to widespread EMR interoperability. One echoes the “too many cooks in the kitchen” clichÃ©. Each EMR vendor has developed its own solution that includes proprietary programs and data conventions, and each vendor naturally touts its solution as the best one for you.

And as in any sector, EMR vendors generally don’t like to share. And who can blame them, really? Opening the export floodgates has a definite down side: While doing so is certainly helpful to you, your patients, and U.S. healthcare quality, it unlocks the exit door for clients.

Well, that’s just vendor greed or paranoia, right? Perhaps not. For the first time in our annual Technology Survey, the number of practices who said they use an EMR actually decreased. OK, maybe it’s just a blip - or not. It could be an indication we’ve reached a second wave of EMR purchasing, that many physicians are unhappy with their first EMR purchase. “People try out vendors,” says Bertman. “Then they find out it’s overpriced. They want to transfer their data.”

Why should vendors risk losing their paycheck-funders by allowing clients to grab their data off one EMR and load it onto another? What’s in it for them? That’s normal business, American-style, and so these are valid questions.

Another impediment to EMR interoperability is the way many EMRs are designed. Not to get too geek-speaky here, but the programming languages used to write all but the most recent EMRs are problematic to widespread use. Have you ever struggled to install some software on your computer that works great on your friend’s setup but it keeps crashing on yours? Same goes for first-generation EMRs. Many were created in such old-school languages as Visual Basic and C++, which are highly system-dependent. Making them work across all systems without hiccupping is a real challenge.

The same goes for the EMR’s data. Passing data between two EMRs requires flexibility on both sides. Many EMRs are incapable of bending and stretching their data architecture to fit another. Imagine trying to yank on a bathing suit that is two sizes too small.

Still another issue hampering true interoperability is that it does not mean just EMR-to-EMR. It also means provider/patient communication, claims submission, insurance verification, test results sharing, computerized physician order entry, electronic prescribing, and probably other functions. This requires a national platform that payers, physicians, vendors, pharmacies, hospitals, and you name who else, must agree to. See the problem?

Yes, you’re a physician - certainly more than a full-time job. And you’re in a career that’s fraught with regulations. But hammering out EMR interoperability standards - that’s an opportunity to participate in something where the rules are not yet etched in stone. Hmm, you could get involved. But how?

 EMR vendors aren’t the only ones guilty of foot dragging. The phlegmatic adoption of EMR technology by physicians in the U.S. hasn’t helped the cause either. If you’re still paper chart-based, you’ve got two hurdles to clear: the technology itself, and then the subsequent interoperable data sharing. This is a concern for many doctors, says Decker. “It’s a cultural challenge; there’s still a lot of nervousness. Do I really want to send out my patient data?”

 Certainly no technology meets every healthcare need - even EMR. But take a look at “Physicians’ Use of Electronic Medical Records” below. Overlay these results onto “Test Results or Medical Records Not Available at Time of Appointment, Among Sicker Adults.” The two charts dovetail pretty neatly, don’t they? When building a cabinet, such dovetailing is great. With patient care, not so much.

 If you don’t already have an EMR, choose a vendor who puts interoperability way high on its priority list. For those who claim they do, push them to define what interoperability means to them. Communicating with other products they’ve created? Uh-uh, not good enough.

Keep your data door open to the outside world.

 “It’s one thing to say you’re interoperable,” says Bertman. “It’s another to let you truly take the data out.” Decker recommends putting CCHIT certification in your EMR RFP (Request for Proposal), which hopefully you’ll choose to write before you invest in this technology.

Even if you already have a system in place, ask your vendor where it stands on interoperability. Make it very clear that this is of supreme interest to you. “Demand that vendors go down the CCHIT path,” he says. After all, McDonald Happy Meals were only a special, temporary promotion when they first came out in the late 70s. It was customer support that got them onto the permanent menu, much to our kids’ delight.

 such as eHealth Initiative, an independent, not-for-profit organization whose stated goal is to “drive improvement in the quality, safety, and efficiency of healthcare through information and information technology.” Also consider CCHIT, which also is largely volunteer-driven, or maybe just CHIT, the Center for Health Information Technology, which is part of the AAFP (the co-sponsor of the CCR).

Basically, the louder you proclaim you want full EMR interoperability, the more quickly a viable solution will gel. And it is happening. “Clients are really starting to push it,” says Decker. “And it’s the right thing to do.”


But we’ll only get there if we work together, says Julie Klapstein, CEO of Availity, a health information exchange organization based in Jacksonville, Fla., in a podcast of her talk at the Third Annual World Congress Leader Summit, titled “The Road to Interoperability.” She succinctly summed up the issue of successful EMR interoperability: It requires that many disparate bodies work together - and that’s hard.

“Collaboration isn’t for sissies,” noted Klapstein. “It takes real innovation. [Participants] have to agree to collaborate on a common portal and a common solution. … It’s really about leadership over self-interest in proprietary solutions.”

This article originally appeared in the October 2008 issue of Physicians Practice.

Articles

How far away are we from having electronic medical records that can truly talk to each other, across health systems and across regions? We decided to find out.

The Road to EMR Interoperability


The first time North Shore Cardiology invested in an EMR, its vetting process consisted of exactly one issue - seamless integration between its practice management system and the new EMR. Fluent communication across these two major pieces of medical software, the physicians reasoned, was critically important for paperless success. Surely, matching the brand would guarantee that success, with price and functionality fading to the background. “We ‘needed’ seamless,” recalls Jay Alexander, one of North Shore’s cardiologists. Done deal. 

A few months later, the EMR lay essentially dead in the electronic water, with only two of the Chicago-based practice’s dozen cardiologists still consenting to use the system, which turned out to be as flexible as a lifetime civil servant at the passport office. Worse, the group lost about a half-million dollars on the failed endeavor. 

“Boy, were we dumb,” says Alexander. 

We certainly don’t agree with this harsh assessment. In fact, what happened to these “dumb” heart specialists could easily happen to you. 

You’re beyond busy treating patients and running your practice. You know that an EMR would help you, but the choices are overwhelming. Your knowledge is piece-meal and rife with buzzwords. Web-based or installed? CCHIT-certified? E-prescribing? PQRI? Finally, you buy one that “looks good,” but the problem is, it doesn’t work right of the box. And you find yourself having a similar experience to the North Shore docs, with a frustrated staff and a seriously depleted bank account. 

But it doesn’t have to be that way. North Shore rallied from its mistake, performed all the necessary due diligence, and is now very happy with its second choice, Minimally Invasive EHR by Medical Informatics Engineering. You, too, can learn to navigate through the selection process thoughtfully and logically to maximize your success. Here’s how. 


Going paperless changes your practice at every level. So the first step is to agree as a practice that you’re going to go for it. This in itself can be a challenge, especially in group practices, because you probably have large variations in age, attitude, and aptitude. “We’re like most cardiology groups,” says Alexander. “Young guys who had EMRs in their residencies, and old guys who couldn’t turn a computer on five years ago. We had a guy who couldn’t use a cell phone. You’re only as strong as your weakest person.” 

So ask yourself: Why do you want an EMR? Perhaps some pivotal event convinced you of the need, as it did for Jeffrey Hyman, a practicing internist at Treat & Release Walk-in Clinic in Brooklyn, N.Y. (which is part of the 55-physician, multipractice University Physicians Group, of which Hyman is medical director). A few years ago, he needed a specific patient chart. “It was misfiled,” he recalls. “That was after having 5,000 misfiled charts before. That was the chart I needed; the patient was in the ER. It just pushed me over the proverbial cliff, and I said ‘that’s it.’” 

And thus began Hyman’s search for the right EMR. He and the two other physicians with Treat & Release spent six months winnowing down all the choices, ultimately choosing iMedica. 

Your ah-ha! moment might not be as dramatic as Hyman’s. But whether by calm discussion or a fiery baptism borne out of disaster, you’ll need to be naysayer-free to ensure ultimate success. Make sure all deciders are on board with the idea of going paperless, or at least that they have their tickets in hand, ready to board. 

That said, also be sure to temper any über-enthusiastic physicians so you don’t make a snap decision based on incomplete knowledge. Tina Stuart, office manager for Ohio-based Springfield Urology, loved the fact that the three young, computer literate docs at her practice all wanted an EMR, but she found herself pulling on the reigns time and again. “They wanted it to happen yesterday. I kept having to remind them I couldn’t just press a button and make it happen.” 

List everything you hope the system will do for you. What can’t you live without? Is PQRI something you want to participate in? E-prescribing? What are the drop-dead requirements for your specialty? Specialty practices have special needs, such as a pediatrician’s need to have age- and growth-adjusting benchmarks for young patients, for example. 

If you’re in a less mainstream specialty, you might have to negotiate with a vendor to modify its EMR to fit your needs. Springfield Urology found that its specialty was a rarity when it comes to off-the-shelf products. Luckily, NextGen agreed to meet their needs, which worked out well for Springfield Urology. “But we had to wait awhile. It was supposed to be done by February, but the templates weren’t ready until July,” Stuart says. Still, worth waiting for. Here are two other important changes to keep in mind: 

Work flow interruptions. There’s one aspect your new EMR will definitely affect, regardless of system choice: “All EMRs impact work flow. Anyone who says otherwise is full of it,” says Alexander. Map out your current work flow to see where certain steps might be eliminated - sometimes literally, such as the time it takes to walk a chart down and put it in the exam door folder-holder. Properly used, an EMR will significantly tighten your intra-office communication. “The back office knows what the front office is doing,” says Stuart. “A doctor can actually see if he has a patient ready. Little things like that sound silly, but people aren’t having to run around the office.” 

A paperless work flow also eliminates material waste. Springfield Urology’s surgery scheduler experienced a dramatic change in her workday duties, much to her delight. “She had to make copies and copies of things to prepare for surgeries,” says Stuart. Now, everything the physicians need for the surgeries is instantly accessible. “A piece of paper can get lost; the computer never gets lost.” 

Work flow changes also will occur right in the exam room. You’re used to charting by hand. You do it your own way, with abbreviations and symbology that make sense to you and those with whom you work. With an EMR, you’re forced to be more mindful and standardized. You’ll be stepped through the process. The EMR may ask you to make some decisions about how to proceed, depending on your inputs, a patient’s information, and alerts that may pop up suggesting this or that treatment option. 

This is all good because you’ll create a more thorough note. But count on it slowing you down while you’re with your patient - a slow-down that may be permanent. “I don’t think you can be as fast on a system as on paper,” says Alexander. “There are so many other advantages, though - the ability to pull data and saving money on not pulling charts are other ways to help your bottom line.” 


However, if your EMR is ill-suited for your specialty, then you’ll slow down due to frustration from not being able to navigate the system easily. This was North Shore’s main problem with its first EMR, says Alexander. “The EMR expected us to modify our work flow to the EMR.” Not good. 

The money flow. The last preplanning consideration is, of course, the money. Prices vary widely, but “nothing’s cheap,” says Alexander. “You have to believe it’s going to cost you about $30,000 to $40,000 per physician eventually.” Not that you need drop this giant wad all at once. Instead, leverage the cost by investing in a system that offers a modular installation. An EMR so full-blown you suspect it might also whip you up a nice latte sounds great, but you’ll pay dearly if you want it all up front. 

Bringing in the system little by little will keep your bookkeeper happy, and it will allow you and your staff time to absorb this paradigm shift gracefully. Don’t tick off your staff with too much change all at once. You’ll get resistance, tension, and money wasted in return. 

Take a hard look at your current financial standing, and consult with your accountant about where the money might come from to cover your EMR purchase. This look should include some projection metrics, such as cost-benefit and ROI analyses. Calculate as best you can how your money flow will shift post-EMR. Some metrics to include:

Number of patients you see now, and how many you think you can see with the EMR. 

Staff salaries, and reductions you might make due to increased efficiency in work flow. 

Cost of handling a chart by hand, including the time it takes to pull it, transport it, lose it, search for it, refile it, etc. 

Paper, copier maintenance, and other supply costs. 

New revenue streams from being able to participate in bonus programs, such as PQRI or e-prescribing. 

Temporary staffing needs to help convert all your paper into a digital form. 

Naturally, you’ll want to set a budget. Include implementation, training, hardware, and licensing. This last one can be tricky. One EMR’s licensing may look cheaper at first glance. Find out if said license is “per user” or “per team.” A “per-user” license can significantly drive up cost. 

To stay organized and on track when investigating the market: 

. Ideally, the team will have one decider. This will help keep the process from languishing in committee for months. For smaller practices, though, it may make more sense to simply agree by consensus. 

But holy cow, there’s so much you need to know. So split up the work. Three-physician Springfield Urology sat down and made lists of what each wanted, says Stuart. From this, they developed a vendor questionnaire. “We each took a point that was important to us, and tried to hit each company with it. I only asked two questions, and each doctor had two questions. That way, we didn’t all have to remember everything.” 

. Set up a spreadsheet to house your research, with one column per vendor candidate. Row headers will list aspects for which you need information: vendor history, financial stability, and future plans; certification; system pricing (based on modular installations, hopefully); system functionality and how it fits with your specific needs; technology needs (e.g., desktop/tablet PCs?, wireless vs. wired connection?); and support offerings. Create a separate binder for each vendor to hold any paper-based info each may give you. 

. “When you’re in the hallway doing rounds, or you’re at CME, ask, ‘Which one of you jokers uses an EMR?’” suggests Hyman. “That gives you a scratch list.” Or poll your medical society. 

Also, see who’s in the news and what’s being said about this or that vendor. Seek out objective assessments, not just market-speak. 

. Vendors have a product to sell and they’re going to present it in the most positive light possible. It’s your job to ask the right questions so you get a complete picture. 

Also, investigate the stability of each company. “You see some [companies] who look like they’re building their EMRs in their basements,” says Hyman. “Look for the company behind the company.” One way to feel good about a company is to find out if its EMR has made the grade with certifying bodies, such as CCHIT, TEPR, AC Group, KLAS, and MS-Hug. 

Find out whether you can get to the inner part of the company, says Hyman, because you may discover post-purchase that you need some programming adjustments. “Every doctor charts differently. It’s not standard like banking,” he says. “What’s the accessibility of the engineering team of the company? Too rigid? Stay away. This is not balancing a checkbook. This is how you write.” 

. Seeing a product in action at an actual practice is key, but learn from the experience, notes Alexander. “When I went to a cardiology practice, that doctor was more interested in his note, in fitting his info into the note, than he was in the patient. I saw that and I was uncomfortable, but it didn’t hit me; I thought it was him. But it wasn’t.” 

Stuart strongly agrees. “It was one of those things that you just have to experience because [all the vendors] say they’re good.” 

. There’s nothing like a hands-on experience to tell you whether a product is right for you. “[A vendor] needs to give it to you for a few weeks. It’s like test driving a car. If you don’t do that, you’re making a mistake,” says Alexander. 

Sure, you’re excited to get rolling with an EMR, and who can blame you? But realistically, your selection process will take six months to a year if you want to end up with a decision you feel good about. It’s much more complicated than, say, a new practice management system. “With EMR it’s a completely different transition,” says Stuart. “There are a lot of little steps that have to be put into place. A lot that can be misunderstood.” 

You want to do this right the first time, so take the necessary time to sort out what you want and who you want to do business with to keep you from suffering the same fate as North Shore. “You’re really only allowed a certain number of screw ups,” says Alexander, recalling his own first EMR financial fiasco. “Half a million - that’s the number.” 

is a former associate editor for Physicians Practice. She can be reached via 

This article originally appeared in the May 2009 issue of Physicians Practice.

You’re ready to buy an EMR. But how do you know which one is right for your practice?

Smart EMR Selection


How long does it take for a new treatment for a given disease to make its way into routine patient care - after it’s been proven to be more effective than the previous standard? About 17 years, according to the Institute of Medicine. That huge lag time between the reaching of conclusive evidence for a new protocol and its inclusion into ordinary practice is one big reason that protocols in many practices are obsolete or incomplete, the IOM claims - with only half of today’s patients with many common diseases receiving adequate care. 

What’s the problem? Is the research industry failing to get the word out? Nope, just the opposite, in fact. Modern physicians are drowning in a sea of information - and all of this new data is presented as vitally important (though a good bit of it is actually pure dross). 

For primary-care physicians alone, that means reading about 90 journals regularly just to keep up. That’s about 15,000 articles per year, or 40 a day - in their spare time. 

Integrating preventive care into your practice

Enter evidence-based medicine. The idea is to provide a framework for treating your patients with the latest proven research backing you up. Most physicians are aware of the evidence-based medicine concept, now 16 years old, and agree with it in principle. What doctor wouldn’t want to apply the latest proven treatments to patient care? And yet, the fact is that evidence-based medicine has not been fully embraced by many physicians - at least, not in practice. 

What’s the problem? And how do you bring such a strategy into your practice and still have time for your family and a decent night’s sleep? 

The end of World War II marked a turning point for medical research; many countries began investing earnestly, and by the 1970s, there was more information wafting about than any physician could reasonably absorb. “So we took it upon ourselves to try and help with that,” says internist Brian Haynes, a professor at the Michael DeGroote School of Medicine at McMaster University in Hamilton, Ontario. David Sackett, a physician who founded the department of clinical epidemiology at McMaster, pioneered the research effort that led to the development of what was dubbed (in 1993, by fellow researcher Gordon Guyatt) “evidence-based medicine.” 

Evidence-based medicine is a systematic, corroborative method of practicing in which your medical decision making is supported by facts. By using evidence-based techniques, you can go beyond using just your current clinical knowledge and experience. 

Its proponents argue that evidence-based medicine is not a replacement for the way you practice medicine; it’s an enhancement. You are, in essence, bringing in evidence that gives credence to whatever medical decisions you need to make for your patients. 

It is not “cookbook” medicine, as some critics have complained. Evidence-based medicine evangelists note that if you practice with the stance that “that’s the way I’ve always done it,” you’re behaving more robotically than if you incorporate evidence-based protocols, through which you open yourself up to new ideas and scientific exploration. “The evidence is just a tool that can be helpful in some patient situations,” says Haynes. “We’re not inventing a new way of practicing medicine. We’re simply trying to get evidence wedged into the process to support the clinical practice.” 

Evidence-based medicine is a logical progression of steps - rules, essentially. Say, for example, you have a 24-year-old male patient with a history of narcotic dependence for back pain. He presents with shortness of breath and increased fatigue five days after his long-acting oxycodone dose was increased. During his workup, which includes an echocardiogram showing cardiomyopathy with ejection fraction of 10 percent, he develops a fever of 39.6 degrees Celsius. Using evidence-based medicine protocols, you would: 

 based on a particular patient problem to drive your inquiry. The question can relate to diagnosis, prognosis, treatment, outcome, or any other cogent factor - whatever makes sense for that patient. In this case, you might ask, “Will gentle exercise help, or more meds beyond the beta blockers?”

 for relevant information. Technology is extremely useful here, which we’ll discuss below. 

 Is it valid, useful, and pertinent to your patient’s situation? After a thorough evaluation of all found studies, you know that yes, there are some additional medications from which he could benefit. Strict compliance is essential. Physical therapy has also shown to be helpful, albeit somewhat less so. 

 You know your patient better than any preponderance of evidence. Suppose this patient struggles with both finances and treatment compliance. Knowing that, you decide to try the physical therapy first - it’s cheaper for your patient and more likely something he’ll do. 

That’s about it. You stay in complete control of the clinical issue and its resolution. Perhaps you know this particular patient lives too far from the facility he’d need to frequent for the best treatment, or the most- recommended treatment is formidably expensive, and the second-best one is a fifth of the cost. Now you’ve got a set of facts that address risk and feasibility that you can discuss with your patient, and settle on a course of care. 


So that’s all well and good for one patient, but what if you’ve got 2,500 active charts? You certainly don’t have time to slog through voluminous piles of research every time a clinical situation presents itself to you. “It’s like drinking out of a fire hydrant,” says Chrissie Ott, a family physician from Portland, Ore. 


Indeed, about 5,000 new studies come off the press every single day. Some bear important proof of a new treatment for a heinous disease. Others might be useful, but the sample size is too small to be credible. Still others are good for lining your parakeet’s cage. How can you get to what you need expeditiously yet still perform your due diligence? 

With a little help from some friends. That means seeking out high-quality resources you can trust to do some legwork for you, so you can quickly check the facts and apply them to your patient’s situations. But where exactly to turn? 

 The clinical guidelines proffered by various specialty associations - as opposed to evidence-based medicine, per se - are what some physicians say amount to cookbook medicine. But the guidelines are based on the existing evidence, not the other way around, and they are formed by teams of doctors and researchers who spend their days sifting through all that data. The guidelines save you time. 

You’ll find scads of evidence-based guidelines within these organization Web pages, and “all are free and easily accessible,” says Robert Goldszer, chief medical officer at Mt. Sinai Medical Center in Miami Beach. He agrees that evidence-based guidelines can be very helpful. “Even on smaller things, like treatment of upper respiratory infections,” he says. “If people really followed guidelines from evidence-based medicine, we would … be spending a lot less on antibiotics because we wouldn’t have [as many] resistant organisms; we wouldn’t have given so many antibiotics to people. 

“That’s a very common issue with evidence-based medicine,” he continues. “Evidence-based medicine for upper respiratory infection is Tylenol, Sudafed, liquids, and stay in bed and it gets better. It’s not the Z-Pak.” 

Another issue with guidelines is agreeing on them. Love of autonomy is a prime characteristic of many physicians. Is it possible to agree on standards of care? “It’s a challenge but it’s been done plenty of times by many, many organizations,” says Goldszer, including the CDC, the AMA, and a host of others. 

Consider setting up practice-level guidelines to follow based on the guidelines of large, well-established organizations, including:

U.S. Department of Health and Human Services

 - the Centers for Medicare and Medicaid Services and the National Guidelines Clearinghouse; 

Agency for Healthcare Research and Quality

 - Independent, not-for-profit organization that certifies healthcare organizations and programs in the U.S.; and 

Other large, “blue-chip” medical associations

 - The American Diabetes Association, the American Heart Association, the AMA, the ADA, and the like. 

You can turn to your guidelines whenever you need to add heft to your clinical decisions, especially difficult patients. Show them exactly where you’re getting your facts from. Posting your guidelines - in the office, on your Web site, or both - can be a positive marketing tool, as it shows your practice does everything it can to operate thoughtfully. 

Moreover, following proven protocols can protect you from legal threats. “If physicians adhere to guidelines and do what’s recommended by national organizations, then they’re much less likely to have liability,” says Goldszer. “They’re doing the ‘right’ thing. They’re doing the recommended standard of care. If you’re worried about malpractice - which many people are - if you adhere to the guidelines, then you’re practicing standard of care and you’re much safer that way. [Physicians] are worried about standardization, but everything you read about quality improvement is that standardization helps. Variation hurts us. Guidelines and evidence-based medicine are steps towards standardization, and away from variation.” 

 If ever the use of technology made sense for the medical world, organizing and vetting research data might be the most important reason. An EMR, for example, is designed to do so much more than just store electronic records. Many systems include decision-support software architecture to help you treat your patients without wasting time. 

Most well-implemented EMRs alert physicians to treatments a patient might need but is not getting, based on the patient’s stored data and regularly updated clinical guidelines. 

Reputable EMR developers consult credible guideline sources to set up their alerts, so you can feel good about their basis. You can often customize them, too, to address special needs you may have with your local population or payers. 

Still, those evidence-based alerts can be annoyingly intrusive. “Physicians may be getting a whole lot of alerts/reminders they don’t want to see,” admits Sarah Corley, chief medical officer for NextGen, an EMR maker whose alert system is called Healthmonitor. “That’s the difficult part of EMR development: Where’s the best place to present the information, and who should be seeing it? What works for one practice won’t work for another.” 

You can put your own EMR data to work, too. “Good EMR software can make it a breeze to maintain a disease registry,” says Cyrus Peikari, a solo internist practicing in Dallas, Texas. “It can allow you to run reports to make sure your diabetics have a recent A1c, lipid screen, etc.” And you’ll know exactly how often and for whom you should be focusing, because you’re evidence-based. Not too much testing, and not too little. 


Looking beyond your own office, you’ll find a trove of evidence-based tools and resources through the Internet. Some are more useful than others; the trick is to know where to go so you quickly get good information you can trust. You might use Google, and that can be OK, as long as you know how to critically appraise the research studies you unearth. That takes time, of course. Medically focused Web crawlers, such as PubMed or 

 corporate parent) will trim out much of the schlock for you. 

But you can also find dedicated, Web-based tools to keep you evidence-based. Following are a few biggies often cited by physicians as their go-to sites for evidence:

 - Contains more than 76,000 pages of text, graphics, a drug database, and links to outside study abstracts. About 3,800 physicians from 18 specialties monitor 400 journals, critically appraise the study results contained therein, and incorporate the best information into UpToDate three times a year. This makes it more than simply a “journal watch,” as the actual content of a new study is considered critically. It costs about $500 a year, give or take, with many caveats and subscription types available. Ott has decided that, for her, despite it being “a little pricey,” she considers UpToDate superior to purchasing updated text books. 

 - Offering some free access, the Cochrane Collaboration is very clear about avoiding what it calls “conflicted funding,” that is, funding from for-profit industries such as pharmaceutical or medical device companies. Within the collaboration’s library, you can search the “Cochrane Database of Systematic Reviews” for analyses of healthcare interventions. This organization also pulls in studies written in foreign languages. 

Full access to the Cochrane Collaboration will cost you about the same as UpToDate. All of its review abstracts, however, are free. One great feature of the reviews: They contain a plain-language “translation” that you can use to help explain the efficacy of a treatment (or lack thereof). Do you have a patient who fervently believes in taking only Vitamin C for a cold? Show her the evidence-based review in the Cochrane Library that concludes, through exhaustive research, an analysis of all available data on that subject: that unless she’s a marathon runner or an alpine skier, Vitamin C will do little to staunch her runny nose. 

- Want to pay zero? eMedicine may work for you, but this WebMD-owned site does accept advertising. It does claim to be peer-reviewed; you’ll have to decide for yourself how to judge clinical studies that have been funded by the for-profit industry, such as pharmaceutical companies. 

 - American College of Physicians members have access to this service. You’ll find a decade’s worth of archived articles here, with obsolete material constantly weeded out. Content comes from about 100 clinical journals, with articles going through a stringent criteria acid test. 

 - Ground Zero for evidence-based medicine methodology, McMaster’s Health Information Research Unit spends a great deal of time researching and forwarding the subject. Experts there also vet articles in support of the ACP Journal Club. You’ll find a wealth of evidence-based medicine links on the McMaster University Web site, through the Evidence-based Practice Center Web page. 

Again, that’s a tiny sample of what’s out there. Note that many products you’ll find on the Web, such as UpToDate and PubMed, are downloadable to your PDA or iPhone, too. For a good list of other evidence-based medicine links and tools, visit 

McMaster’s Evidence-based Practice Center

, and then click on “Partners/Links.” 


By now, the evidence-based medicine ball is rolling downhill, gaining momentum in the medical world. “I’m a big believer in evidence-based, standardized medicine,” says Goldszer. “But it’s variable. Hopefully, some younger physicians coming out are more amenable to using guidelines. I think some of the older are more resistant.” 

Is such resistance futile? No, just fairly irrelevant. There’s simply too much important data that physicians need to know, says Haynes. “There’s such wide acceptance now that we have to pay attention to evidence or research. 

 we do that or when we do that - both are debatable issues.” 


Contrarians would be served best by channeling their energies into demanding improvements to the implementation process, rather than mere resistance to evidence-based medicine itself. It’s all part of the time-consuming maturity of a good idea. 

And mature it must. “We shouldn’t have to wait for a generation to pass when new practitioners take over before the new evidence is in place,” says Haynes. “It has to be generated at a much faster pace. We don’t want to kill the old practitioners; we want them to catch up.” To be sure, evidence-based medicine offers structure to the complex world of modern healthcare, but it’s far from a cure-all. Pamela Wible, a family physician in Eugene, Ore., notes that it’s “an imperfect tool. It can inform, but it should never dictate. Medicine is an art, when you really get down to it.” 

Think of the limitations of evidence-based medicine as a canvas upon which you do your best work. Sometimes, there will be a dearth of evidence to support your decisions. 

Granted, change is difficult, and you need time to learn, acknowledges Haynes. “It’s quite difficult to pick up a new way of managing patients - particularly if you’re on your own - or a new drug from a treatment you’re already used to managing. You have to remember how to spell it when prescribing it. You have to remember what to say when the patients ask what the side effects are. You don’t have experience with the drug.” 

You’ll also find that people rarely fit into the same mold. Compliance is a particularly unruly wild card. Even if you do determine a certain course of action to be the most effective, says Ott, “if a patient is not organized enough for a certain blood pressure medication, then you make a decision for the ‘best’ treatment. The most important thing is that the blood pressure be treated.” 

“You’re not always going to have a study - nor do you need one - for every patient,” Ott adds. “That’s really important to the art of medicine.” 

The art, of course, lies within you, when you’re faced with a sick patient and uncertainty swirls about while you decide on a treatment course. You can - and should - turn to techniques and methodologies to assist you in that decision. But in the end, the pressure’s on you to make the right call on behalf of that person. 

And that is why evidence-based medicine will never replace actual doctors. We will always need human beings to treat human beings. “I wouldn’t go to a doctor who didn’t have the expertise or experience in the condition I’m trying to get help with. That can’t be replaced; it’s essential to solving health problems,” says Haynes. “But evidence is also very useful in doing that. They’re not against each other, they’re not either/or. The two of them together, expertise and evidence - that’s going to be the best recipe for improving a person’s health.” 

is a former associate editor with Physicians Practice. She can be reached via 

This article originally appeared in the April 2009 issue of Physicians Practice. 


Evidence-based medicine has been around for 16 years. But even though most physicians agree with the concept, it has not yet become the standard of American practice. Why not? And how can you make evidence-based medicine work in your busy office.

Evidence-Based Medicine Examined


One day, you notice it: A good employee has stopped being good. Her work, once so exemplary, has steadily deteriorated, although she’s weirdly possessive about it. What’s amiss? A derailed love life and no one to go home to? Financial troubles, enough to make her embezzle? Perhaps. Then, the tip-off: No one is bigger buddies with all the drug reps than she, and, most tellingly, she eagerly volunteers for snoozefest tasks like drug audits. 

All signs point to a drug-using employee. What now? 

Unfortunately, there’s no easy answer to this question. Rose Samaniego, practice coordinator with Oncology Consultants in Houston, knows this all too well after having found herself facing the above scenario a few years ago while at a previous practice. The employee - an experienced RN - had become addicted to her husband’s back pain pills, which she’d been pilfering to cope with life stressors. One day, while on a rare day off due to some unavoidable minor surgery, a fake prescription arrived at the practice for the employee. Busted.


Certainly, such felonious behavior is legitimate grounds for dismissal, but taking that immediate, drastic step did not feel right to Samaniego or the practice’s physician. “We were a family; it wasn’t just an employee,” she says. 

They opted to try to help the employee instead of dismissing her. Samaniego offered the embarrassed staffer counseling and assistance with finding drug rehab services. She accepted the help at first, but then resisted, saying she could solve it on her own. But she couldn’t. In the end, she lost both her job and her marriage. 

Anytime you lose an employee for this reason, it’s a tragedy, but not just for that person. “If you have an abuser, it’s like an iceberg,” says 30-year veteran practice administrator Chris Kelleher of Columbia-based South Carolina OB/GYN Associates. “You’re only going to see the tip of the problem. … Ninety percent of the stuff is under the water. It’s what you don’t see that’s really scary.” 

So true. With substance abusers you have a serious clinical liability issue on your hands, possibly unbeknownst to you for months. Critical bits and pieces might get left out of patients’ charts or follow-up duties such as calling patients regarding test results might not get done. This undermines the care that you’re giving - perhaps with dire consequences. 

Confidence within your practice can suffer lethal blows in terms of working relationships, too. “There’s such a trust between the physician and the nurse. The physician looks at the nurse as a physician extender - lots of autonomy,” says Kelleher. “You get an impaired employee, and that creates a huge chasm between trust and liability.” 

Discovering you’ve got a doped-up employee immediately presents you with some quandaries. “Because we are healthcare providers,” says Kelleher, “we have a dual sword: We care [about the drug-using employee] because as healthcare providers, that’s what we do. But we also have a responsibility to the patients to do no harm.” 

You also have a responsibility to yourself. Prescriptions written in your name can jeopardize your license. If you do nothing, you may be sending a “watch my practice” red flag to the authorities. 

Finally, what about the rest of your hard-working, drug-free staff? “It does impact the other members, who have to double-check the other employee,” says Kelleher. That fosters resentment. After all, what’s their reward for picking up the slack? More work. 

 Yes, such confrontation is beyond hard. Kelleher points out that “personnel management is the hardest money you’ll ever earn.” But it’s essential you push through and do what needs to be done. 

You want to protect your own license to practice, so inform the DEA. This is the law. Here’s the scary part: You don’t really know the scope of the problem, says Helenemarie Blake, a medical attorney with Fowler, White, Burnett in Miami. Your drug-using staffer is already an established liar. Is her claim that she’s doing it for her own personal needs really true? Or is she in fact involved with distribution? That’s an exponentially bigger issue. “If [a faked prescription] hurts somebody or kills somebody and the physician didn’t do anything about it, the physician can be held liable,” warns Blake. Aiding and abetting are not recommended ancillary services that will build your practice. 

As for pressing charges with the police, do you have to? Yes and no. There’s nothing on the books saying you must. However, “on the DEA report, there’s a question that says, ‘What law enforcement agency did you report to?’” says healthcare attorney Lourdes Martinez, a partner with the New York City-based Garfunkel, Wild, & Travis law firm. If you leave that blank, you could be leaving yourself open to a legal stinkeye. Report the incident as a theft, she says. 

 Reporting the incident does not preclude you from helping your employee. Get that individual to see a qualified therapist “and have that physician certify [the employee] is being treated,” says Martin Kalish, a trained rheumatologist who is now a partner with the law firm of Arnstein & Lehr in Miami. This can help your employee if the DEA does pursue charges. 

Make it clear to your at-risk employee that you care and you want to help, but due to her actions, she is officially “on notice.” Keep a careful, written record of how the whole affair plays out - for everyone’s protection. 

The best way, though, is a pre-emptive strike at the problem: 

 Always keep your pad (which should be the serialized kind) with you when you’re seeing patients. Do not leave one in each exam room for convenience’s sake. When you go out to lunch, lock it up every single time. If you think no one would ever swipe your pad out of your lab coat while you snarf a burrito in the next room, you’re wrong. And for heaven’s sake, never pre-sign some of the pages. Any gained efficiency is outweighed by the risk. Finally, consider using pads with carbon copies so you have proof that you - and only you - wrote a prescription. 

 The expediency of e-prescribing is indisputable, and the added layer of security is even better. Of course, you don’t want to broadcast your access info. 

Establish prescription call-in protocols.

 Take time to approve call-ins, and ideally, have just one person authorized to do this task. Perform regular oversight. 

 Decide what these are. Write them down. Post them in obvious places. Make your practice’s expectations clear - repeatedly. “It has to be an issue that you don’t just put in an employee handbook and forget about,” says Kelleher. 

Broach this subject during interviews. That way, the employee - if you hire him - can never claim he “didn’t know.” 

 “Be more attentive to the individuals and employees,” advises Samaniego. “Be there for them. Not only on a professional level but a personal level. Get to know them.” Socialize with your staff, enough to know what’s normal and what’s not in anyone’s behavior. Is Miranda in the back office just a chronic kvetcher about money because she’s addicted to buying shoes, or something more nefarious? 

 Not about silly, interpersonal junk they should’ve outgrown in grade school. But if one of their own is in trouble with drugs or alcohol, then snitching becomes the right thing to do; make that clear to your staff. Chances are, they’ll know about a problem long before you pick up on it. Confrontation can be a stopping point for many, so maintain an open-door policy and an anonymous “comments” box. 

People caught in addiction are by definition bad at self-advocacy. If you can smooth a path to redemption for your employee, then do so. But do it wisely; don’t sacrifice yourself, says Blake. “The bottom line is you need to protect your livelihood and your practice if you have any hope of being strong for your family and for helping this employee.” 

This article originally appeared in the April 2009 issue of Physicians Practice.

One of your employees has succumbed to addiction. What should you do?

Author | Shirley Grace

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