by J. Gordon Wright, MD, FACS, RVT

After many years of searching for even one EMR that I like, I am still bewildered and disappointed at how difficult it is to find an EMR that is actually good for an office based sub-specialty practice like phlebology. What do I mean by “good” and why is a good EMR so elusive? I think I have found an answer to those two questions, which you might have also asked yourself while searching for an EMR for your phlebology practice.

What defines a good EMR: Although commercial vendors will entice you by promoting and emphasizing every conceivable benefit of an EMR, the reality is that there are only three core benefits of an EMR:

• The EMR must increase the profits of the practice
• The EMR must increase the Doctor’s efficiency
• The EMR must do a better job of documenting the clinical encounter than is currently done

When evaluating an EMR, it is helpful to keep focused on these three things and rate them as one or zero. With this scoring system, an EMR can have a “Goodness Score” ranging from zero to three. If an EMR’s “Goodness Score” is zero or one, forget it. You should only consider EMRs that have a score of at least two, and you really want to find an EMR that has a “Goodness Score” of three, with some ancillary benefits, as well. In my opinion, if the three core benefits are not there, then it does not matter how many ancillary benefits the software possesses. Do not be distracted by the myriad of features, promises, technical strength, future-speak, or anything else that the software vendors spin your way, and keep your eye on profit, efficiency, documentation. Things like training, support, number of installations, years in existence, upgrade policies, data design, software language, integration, hardware requirements, among others, are all important, but only if the software does what you require.

Why has the good EMR has been so elusive for phlebologists?: I believe that most phlebologists are disappointed because EMRs are rarely developed with a phlebology practice in mind. Based on the desire to capture as much market share as possible, most EMR developers let this business principle dominate and drive most of their design decisions. In other words, EMR software developers try to design their product to be as general as possible so it will appeal to as many doctors as possible. Unfortunately, this results in an EMR that is often counterproductive to sub-specialists like phlebologists, and results in a low “Goodness Score” with respect to the phlebologist.

The downfall of the EMR that has been designed for the general practice is that it includes a myriad of choices that are of no importance to the phlebology specialist.

For example, the list of medications I prescribe for my patients is blessedly short, yet for the general practitioner, the EMR must keep a list of several thousand possible medications, each with a range of possible dosing schedules, and formulations (tablets, capsules, slow-release, etc.). Similarly, the list of diagnoses I encounter in my phlebology practice is limited, yet the generalist must be prepared to diagnose everything from the worried well to terminal cancer. Although I want to be able to easily and quickly record all of the symptoms related to my patient’s vein disease, I really do not care if they have tinnitus, insomnia, or a sore shoulder. The list of symptoms I do not care about is actually much longer than the list of symptoms relevant to my task at hand. Yet to create a generalized EMR, the developers must have a nearly complete list of signs and symptoms readily available to the physician. Although some EMRs have been developed for certain sub-specialties like orthopedics, cardiology, Ob-Gyn, etc., even these sub-specialties have too broad a scope for the sub-sub-specialist, like a phlebologist. Furthermore, as one of the newest sub-specialties, the software industry has not really given phlebology much attention yet.

Most importantly, as the number of symptoms, signs, diagnoses, and associated conditions increases, the complexity of decision support goes up exponentially. With even a small increase in the number of procedures or possible diagnoses, it quickly becomes impossible for current micro-based operating systems to handle the processing power required to make suggestions (decision support) for the next steps in a logical clinical algorithm.

However, because phlebology has a limited number of procedures and branch points in its clinical pathways, a well designed phlebology EMR could figure out and suggest things like what the next appointment should be, and when it should be scheduled. A well designed phlebology EMR should be able to easily figure out the CPT codes, ICD-9 codes and modifiers needed to maximize billing, and should be able to “know” if a Medicare patient is in a global period, put alerts in the face of the physician and make adjustments to the modifiers used for billing based on the global period status.

Additionally, for a sub-specialty/procedure-oriented practice like phlebology, the process of requesting insurance pre-determinations and responding to them in a timely and efficient fashion is often a very important, yet complex and labor intensive undertaking. A well designed EMR for a phlebology practice should be able to manage, automate, monitor, advise, assist, and report on this process. The letters requesting the pre-determination (and even the language used to describe the patient’s symptoms, physical exam and ultrasound findings) should be custom-selected to reflect the requirements for medical necessity, based on the patient’s insurance company. The more generalized the practice, the more difficult this becomes. So much so, that (to my knowledge), no generalized EMR has ever even tried to develop a successful way of improving the inefficiencies of the paper-based pre-determination process.

Having said all that, there are three EMRs that I am aware of that have been designed specifically for the phlebologist. They are VeinWrite, Sonosoft, and VeinDraw. Although the relative merits of these three EMRs are beyond the scope of this article, I believe that any phlebologist who is looking for an EMR that has a “Goodness Score” of at least two, should start with these three EMRs. While various practitioners will find one of these three EMRs a better match for their needs than the other two, they represent the only EMRs that are designed specifically for phlebologists, and are a good place to start your quest for the paperless nirvana.