Wendell Murray Associates Inc.
Electronic Medical Records
Please note that this section is still being developed. More shortly.
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What I do

I provide consulting services in the area of electronic medical records (EMR) systems and related areas. I advise Gateway Medical in Chester County among other practices and other participants in the market.

I provide a full range of services related to selecting and implementing systems. You can see a presentation on the financial impact of the implementation at Gateway Medical Associates.

I offer the following:

Cost of my services

I generally charge $100/hour. I may vary that amount lower or higher depending on the type of work.

Evaluation and implementation of an EMR system

On average a good implementation of any good-quality EMR system makes a practice money, improves the quality of care provided and generally makes life easier for the provider and support staff. I emphasize "on average" because there is significant variation around the mean. Some implementations fail completely - occasionally the software does not perform adequately, often the implementation is poorly done, often there is insurmountable resistance from those who use the system, some muddle by without any discernible improvement in practice financials or operations and some work very well.

This is a good article on some key issues to keep in mind when implementing a system.

This is a portion of an excellent and comprehensive questionnaire for vendors and a survey of EMR products, created by a company called AC Group, which has been active in EMR-related activities for many years. This is the 2007 edition. The full report can no doubt be obtained from AC Group directly.

Cost/return on investment

Depending upon many factors an investment for a practice can range from roughly $5,000 to $40,000 per provider. Go here to see pricing from a leading software vendor, eClinicalWorks, as an example of costs, including some relevant pricing of hardware. Implementation costs can be substantial and are in addition to the software and hardware costs.

Keep in mind you will likely earn back a significant percentage of the amount invested - often 25% or more per year - thereafter. The time frame from initially considering an EMR system to using one productively can be as short as 3 months or as long as 24 months.

Here is a summary of a study conducted at the University of Rochester regarding the financial benefits resulting from the implementation of an Allscripts TouchWorks EMR system at five ambulatory offices affiliated with the University of Rochester Medical Center. The ROI reported here exceeds 50% per year exclusive of the return provided by higher coding levels.

A summary of EMR adoption rates and related information in California is available here.

The various aspects of evaluation and implementation are addressed well in a section of the American Medical Association website.

AMA recommendations regarding EMRs

Relevant topics are accessible through links below.

Practice self-assessment
Vendor assessment
Risks and benefits
Impact on workflow
HIT terms
Changes to CMS anti-kickback rules

Software available

There are a number of good to excellent software commercial systems available. One of the best is the eClinicalWorks system. Since 2006 eClinicalWorks has generally appeared at the top of most software rankings.

Other systems for medium to small practices that show up towards the top of rankings include the following:

CompanyProduct name
Greenway MedicalPrimeSuite
MediNotesCharting Plus
SageIntergy EHR
McKessonPractice Partner
Medical Communcations SystemsmMD.net
e-MDse-MDs EHR
GE Medical SystemsCentricity

Open source software

Other options include several "open source" programs. A system that is fully featured is OpenEMR. There is sample version of it on this website OpenEMR sample. A username and password are required for access to this version. E-mail me to obtain a username and password for access.

There is also the Physicians Office version (VistA Office EHR or VOE) of the Department of Veterans Affairs VistA system. VOE generally appropriate for implementation in multi-office clinics. VistA itself particularly with the enhancements added by DSS, a top program enhancement vendor to the VA is an outstanding system for hospitals and hospital systems. Press here for a thorough review of the VOE system.

The primary advantage of VOE and any other open source software is the fact that there is no software licensing fee for using the software. The software is free in other words, although there are potentially significant costs for implementation and maintenance of the systems.

This is a good analysis of other open-source programs by the same authors go here.

Hardware needed

Hardware selected can vary depending on the investment budget and preferences of the providers and staff. The options for hardware can range from using the latest equipment - particularly in regard to touchscreen tablet PCs - to using used equipment as both input devices and as servers. Excellent used equipment is cheap and readily available.

There is the option of using so-called "thin client" versus "thick client" technology. Thin or thick refers to the processing and storage capabilities of devices. Thin clients generally have no hard disk storage and perform processing primarily to communicate with a server located elsewhere. The server located elsewhere does all the processing and provides hard disk storage.Thin clients can be older computers that have older central processing units (CPU) or they can be specially designed devices which are generally small and light, about the size of a paperback or small hardcover book. Wyse Technology and Neoware are two main manufacturers of thin clients. The advantages of thin clients are several: simplicity of design and operation, cost, security, easy software updating (because done on the server rather than the client device) and small "footprint" or size of devices.

Healthcare Information Technology

The use of computer technology in healthcare is an important topic. There are several indisputable facts:


There are several distinct types of digital clinical records. Two in particular are important: electronic medical record (EMR) and personal health record (PHR). The distinction made between the two is that EMR usually refers to a record on a patient's medical history kept by a provider or by an insurer while a PHR is a record controlled and usually maintained by the patient himself or herself through a website. There has been a number of attempts to establish and encourage usage of PHRs. Notable is Medem's iHealthRecord. There are others.

Articles on EMRs

Below are several good articles in .pdf format that address cost savings to physicians practices of implementing EMR systems. The It Ain't Necessarily So article contends that there are no cost savings from implementing EMR systems. The points that the author makes are well worth noting.

I happen to disagree with the author in general, but I agree to the extent that poorly implemented systems or alternatively software and hardware acquired without a solid plan for their use usually lead to poorer service to patients, negative financial performance and lower productivity. Well-planned, well-implemented and subsequently well-managed systems inevitable on the other hadn lead to better service and higher productivity and consequently lower costs.

Physicians' Use of Electronic Medical Records is a good summary of EMR implementations based on a survey of practices of various sized conducted in 2000-2002. More products have been introduced into the market and improvements have been made to products available at that time, but the data reported are still accurate and the analysis still relevant.

Electronic Health Records: Around Corner? Over Cliff? is a useful article published in the Annals of Internal Medicine that has received wide circulation due to its frank and not necessarily positive presentation of the experience of a 4-physician practice in Philadelphia PA in implementing an EMR system. The article listed after it is a response from a practice in Missouri, published as a letter in the same journal.

The two articles published by the Academy of Family Physicians and authored by Dr. Ken Adler (co-author in one) are good presentations of the issues a practice should consider when selecting an EMR system and of the results of a non-scientific, but somewhat illustrative survey of user satisfaction with various systems.

How to select an EHR system

EHR satisfaction survey

What's plaguing HIT?

Physicians' Use of Electronic Medical Records

Electronic Health Records: Just around the Corner? Or over the Cliff

Response to article above

Time-motion study

It Ain't Necessarily So

Organizational issues in EMR implementation

Practical issues for selecting and implementing an EMR system

Clinical information systems are worth investing in from any perspective - financial, quality of service, quality of care, practice management, reduction in medical errors.

In a healthplan proposal in 2005 the Bush Administration set a goal of 2014 for implementation of an EMR system in all physicians practices reimbursed by Medicare. Not only that, but the likelihood is high that the federal government will mandate EMR system use at some point during the next 4-5 years, if not in the current Bush Administration, then in the next Administration.

Sample implementation

Click here to see an analysis of the impact of an EMR system (integrated with a practice management system) that the Gateway Medical primary care practice in Chester County PA implemented in 2006. The investment in the system will pay for itself within a year or so. In other words a return on investment appr aching 100%. This kind of financial return is not unique. In fact investment returns of 25%-100% are the norm for good-quality software that is well-implemented. Selecting the right software and implementing it correctly is not all that hard, but one has to be methodical and knowledgeable.