Only 17 percent of physicians have adopted EMRs in their offices, while 31 percent of hospital emergency departments and 29 percent of outpatient departments use them, according to national survey data released in March by the Centers for Disease Control and Prevention (CDC). Surprisingly, adoption by physicians cuts across professional demographics, as the national data show no statistical differences in EMR use by region, metropolitan status, specialty, physician age, type of practice or number of managed care contracts. The CDC continues to collect information on the extent of penetration of EMRs, as well as selected attributes of the systems employed. Data on EMR adoption specific to Pa. has yet to be gathered.

Obstacles to EMR adoption by physicians remain. Many physicians may still regard the inevitable work flow disruption to be unacceptable. The systems are typically costly – ranging from $15,000 to $35,000 or more per physician for a small practice. No industry standard has materialized for data formatting, limiting a system’s interoperability – or capability to exchange data with systems from different vendors. Financial incentives to adopt EMRs remain almost non-existent in Pa.

Some of those obstacles are softening, however, and recent developments may spur skeptics and fence-sitters to consider making an investment EMR sooner, rather than later. National initiatives are promoting EMR adoption and hope to fuel statewide initiatives. Such an initiative has recently formed in Pa. to seek ways to expand physician adoption of EMR, expedite system interoperability and forge regional EMR networks. Securing funding for those goals is a top priority. Large Pa. health systems are expanding their hospital-based EMR systems, some of which have already established an impressive track record of quality, safety and efficiency enhancement. EMR companies are marketing low-cost EMR acquisition models to small and solo private physician practices. Pa. physicians who have implemented EMRs say the experience requires fortitude, but is worth the effort.

A National Priority

Despite the potential for EMRs to improve quality and reduce the frequency of medical errors, its use in the health sector lags behind other sectors in the economy, according to the CDC. Last July, President Bush appointed David Brailer as the National Coordinator for Health Information Technology, with the goal of building a national electronic health information infrastructure capable of offering EMR for most Americans within 10 years. A key building block of the plan is encouraging health providers to adopt EMRs to store clinical information.

In a report to the Department of Health and Human Services last July, Brailer described typical components of ambulatory care EMRs as including lists of problems, medications, allergies, tests and other patient information; while a comprehensive automated system may include medical history, patient demographics, nurses’ notes, electronic prescriptions, diagnostic test orders and evidence-based decision support tools such as practice guidelines.

EMRs in physician offices serve one or more functions, according to the Centers for Studying Health System Change, including the ability to access patient notes, generate treatment reminders for physician use, exchange clinical data with other physicians, obtain treatment guidelines, and write prescriptions.

Brailer’s report to HHS noted three initiatives at the federal level that are intended to spur the health sector’s adoption of information technology and promote the use of EMRs:

· Plans call for the Department of Defense and the Veteran’s Administration EMR systems to follow common standards for electronic interchange, and for those nonproprietary systems to be made available to providers.

· The Centers for Medicaid & Medicare Services (CMS) expects to issue standards for electronic prescribing.

· The federal government intends to fund research and demonstration projects for electronic health records systems.

The government has also requested private sector product certification to accelerate adoption of health information technology, which has resulted in the formation of the Certification Commission for Healthcare Information Technology (CCHIT). Meeting monthly, the commission hopes to boost provider confidence to invest in and adopt health information technology; ensure interoperability within the emerging health information infrastructure; and facilitate health information technology adoption incentives from public and private purchasers and payers, according Jay Srini, member of the advocacy and public policy steering committee of the Healthcare Information and Management Systems Society – a co-founder of CCHIT. The organization will set up and operate a certification process somewhat like Underwriters Laboratory, with initial certification targeting EMRs for ambulatory care and physician practices, and hopes to develop a three-year roadmap of standards for 2005, 2006 and 2007 for system functionality, security/reliability, and interoperability, as well as certification requirements for 2005, she adds.

According to Srini, certification is likely to level the playing field of physician practice EMR vendors, which may currently number between 200 and 300, while CMS and other major payers have made clear their intentions to use certification to designate qualifying information technologies for inclusion in pay-for-performance programs. For EMR system vendors, obtaining CCHIT certification will be voluntary, although Srini notes that some medical groups are already rumored to be delaying purchases in anticipation of certification.

In summer of 2004 CMS launched a four-state pilot project to help physician practices assess their readiness to invest in an EMR system for the ambulatory care setting, as a prelude to a federal pay-for-quality incentive system down the road. Known as Doctor’s Office Quality - Information Technology (DOQ-IT), the project is an attempt to show how EMRs in small- to medium-sized primary care offices can be used to improve quality of care, patient safety and efficiency for services provided to Medicare beneficiaries with chronic diseases, and collects quality measures reported by participating practices through a standardized EMR platform. CMS expanded the program last fall by asking state quality improvement organizations to prepare for a national DOQ-IT project.

Pennsylvania Push

That national impetus has spurred Pa.’s quality improvement organization – Quality Insights of Pennsylvania – to join with the Pennsylvania Medical Society (PMS) as co-founders of the Pennsylvania e-Health Technology Consortium, which formed in March and includes as members physician organizations, hospital systems, state agencies and health insurers. Charged by the CMS with fostering a Regional Health Information Organization (RHIO) capable of sharing EMR data across various providers, the consortium has formed governance and finance committees and is preparing for a July 26 informational summit in Harrisburg, according to Quality Insights of Pennsylvania Medical Director, Donald F. Wilson, M.D.

As part of its contract with CMS that begins in August, Quality Insights will work with physicians at the office level to develop EMRs, and will offer free consulting on vendor selection, practice workflow design and implementation strategies, says Wilson, who notes that a pre-implementation assessment by candidates is essential in order to prevent the frustrations of committing poor workflow procedures to an EMR system. Quality Insights will use an application process to select about 300 physician practices over the next three years for the project, and will concentrate on practices with one to nine physicians, while 20 percent of the selected practices can have over nine physicians, says Wilson. To be eligible to participate, practices must have "some" Medicare patients, although no hard number is defined, he adds.

The PMS also plans to develop education materials to help physicians select EMRs, including a list of trusted vendors, tips on vetting vendors, and best practices for implementation based on experiences of members who have done so, says Greg Swartzlander, PMS’s associate director of communication technology.

The consortium’s goal is to promote a coordinated effort to develop electronic information sharing statewide by seeking grants and by hosting forums for hospital chief information officers and for physicians who have adopted EMRs, says Wilson. Forming a RHIO requires a financing mechanism to create an infrastructure that provides the same level of information-sharing services to all members – including payors, providers, patients, employers and state agencies; as well as a governing structure and strategy, according to Srini, who adds that Pa.’s consortium must come to consensus on tactical questions, such as these: What is going to be the scope of the RHIO in terms of geography? What about metropolitan areas which span states? What information is going to be shared? What will be the level of sharing? With what security features? Especially in reference to those individuals who live near state borders, will preemption of state law be effected in terms of sharing patient information between physicians across state borders?

Among the members of the consortium is the Pa. Department of Community & Economic Development, Office of Technology Investment (OTI), which would like to identify ways of expanding EMR technology currently being used by health systems, according to Rich Overmoyer, OTI’s deputy secretary. OTI is exploring EMR grant possibilities for nonprofit organizations through the Benjamin Franklin Technology Development Authority, such as subsidies to hospitals that expand their systems to other areas in the state, while it has already given grants to startup EMR companies. Although Overmoyer says it would not be economically feasible for OTI to offer subsidies to individual physicians who adopt EMR systems, OTI plans to meet with other state agencies – including the Health Department – to explore additional grant mechanisms to fuel EMR adoption.

Several other grant sources exist for EMR development, and Wilson says one of the consortium’s main imperatives is to attract federal support for Pa.’s initiatives, while it will also look into the possibility of partnering with payors. While EMR initiatives in other states, such as the Massachusetts Health Data Consortium, have been supported by health insurer grants, Pa.’s consortium has just added to its membership list Pa.’s four Blues plans, who are still exploring the concept before deciding what role they will play. Other possible funding sources are broadband Internet carriers and large employer groups, says Swartzlander.

Whether Pa.’s health insurers will help fund the consortium remains to be seen. Blue Cross of Northeastern Pa. acknowledges that cost of EMR systems is the number one barrier to adoption, but maintains that the question of who should finance a regional data sharing network depends on yet-to-be-resolved issues of communication infrastructure, which can run the gamut from a large, central data repository to virtual connections among physicians maintaining data in their own offices, according to Tom Druby, chief information officer. Druby says that Blue Cross is actively participating in the consortium and believes that the biggest advantages of EMR will be enhancements in quality of care and patient safety, while specific roles of health plans – and all stakeholders – have yet to be defined and mapped out.

Highmark Blue Cross Blue Shield is adding two new indicators to its Quality Incentive Program for primary care physicians in July, one of which offers additional QIPs points for physicians that have an EMR system in their office that can record more than just claims information – i.e., a patient’s diagnosis and history, according to spokesperson Denise Grabner.

Independence Blue Cross says that it would support any technology that can improve quality and efficiency, but believes that a complex set of issues needs to be addressed for the appropriate deployment and use of EMRs, and says that the company will determine what role it will play in the effort as the consortium defines the benefits and costs of EMRs to various stakeholders, according to I. Steven Udvarhelyi, M.D., senior vice president and chief medical officer. Udvarhelyi acknowledges important potentials of EMRs, such as speeding the adoption of evidence-based medicine if accompanied by decision-support algorithms, and eliminating repetition of testing if made portable across different locations.

EHRs can facilitate pay-for-quality incentive programs, to the extent that they provide a less costly and more efficient way to gather clinical information from many physicians, while also giving physicians more confidence in the integrity of the data than the claims-based data typically used for those programs, says Udvarhelyi. He does not, however, view EHRs as a necessary ingredient of a sound pay-for-quality program, and believes that pay-for-quality programs will continue to evolve independently of EMRs – doing the best they can with existing data – because the marketplace is demanding them.

Others believe that EHRs ought to play a central role in quality improvement. The Pittsburgh Regional Healthcare Initiative (PRHI) tried to support a community-level chronic disease registry as a stopgap program for physicians without EMRs to allow them to improve their care by learning from a central database collating claims and laboratory data. But the project had to be discontinued because the database lacked key clinical information such as patients’ blood pressure and weight, and a mechanism had yet to be developed to collect and share such data, according to Tania Lyon, Ph.D., PRHI’s associate director of chronic care. Lyon said PRHI was close to landing CMS support for the project when CMS decided to stop supporting community registries in favor of EMRs – which Lyon believes is an even more powerful and comprehensive data sharing mechanism than registries. PRHI is a member of the Pa. e-Health Consortium and is lending its expertise to development of a RHIO in Pa.

Barriers and Advantages to Physicians

While most Pa. physician practices use a computer-based practice management system, typically driven by health insurers for claims submission purposes, few – perhaps 10 to 15 percent – have converted their patient records to an EMR system, and the consortium is conducting a statewide survey to assess EMR use, and barriers to use, of EMR in Pa., says Wilson.

In general, barriers to EMR adoption are likely to include a list of issues, says Wilson. An initial financial outlay may be beyond the means of physician practices earning thin margins. Larger practices may spend less per physician for a system, be better able to obtain technical support by hiring their own information technology specialist, and see a return on investment sooner than smaller practices because of their higher patient volume. Even then, financial benefits of better care, perhaps resulting in the need for fewer patient care visits, go to insurance companies rather than to physician practices. A learning curve during the first several months of implementing an EMR system generally curtails physician office productivity and requires them to see fewer patients during that interval. Technical barriers may impede interface between data sources, for example, requiring manual entry of lab and X-ray reports into the practice’s EMR system, or if scanned in, the inability to mine those data from the resulting JPG image file. Wilson estimates that, while technologies are improving, lack of interoperability across systems requires 50 percent of information flowing into a physician office to be re-entered into the office’s EMR system.

Sharing data across separate provider groups and networks can also entail legal issues, and networks must be set up in a way that does not violate state regulations, the federal anti-kickback statute, Stark anti-referral rules, HIPAA’s privacy and security regulations, and anti-trust laws, according to Edward F. Shay, Esq., a partner with Post & Schell, P.C., in Philadelphia. Once data sharing across business entities involves referrals, safe harbors and fair market value access considerations may come into play, he notes. Many of these legal issues will be played out when Medicare mandates standards for computerized prescription order entry systems that will be used for Medicare’s drug benefit, adds Shay.

Benefits of EMR adoption outweigh those negatives, Wilson believes. Patient chart information is available at various work stations within a physician office, across offices in the same practice group, or from a physician’s home. "It only takes one time in the middle of the night when you have a patient on the phone to realize how differently you can treat them when you have their whole record at your fingertips," says Wilson. EMR systems have security features – such as passwords that can be set to change periodically, fingerprint scanners and software encryption – that make patient chart data much more secure than they are on paper charts.

Office functionality gains are also abundant, Wilson notes. EMR facilitates patient population management, e.g., notifying all diabetic patients whose blood tests are overdue, or generating a report of all patients with test scores in the abnormal range as a prelude to more intervention. Disease management guidelines can be embedded in clinical records and alert the physician that routine preventive care is needed for a patient. Lab tests can be tracked and received automatically. The chance of medication errors can be minimized by prescription drug order entry software that eliminates illegible handwriting, checks for proper dosage and warns of possible adverse drug interactions.

Return on investment can be realized through enhanced efficiency of a paperless office, reduced or eliminated transcription costs, facilitation of appropriate higher-level coding accruing from more thorough documentation, and the ability to take credible clinical data to health insurers and negotiate bonuses for quality care. Large EMR vendors are attempting to hammer out national messaging standards to achieve interoperability, while many vendors are signing a pledge to be DOQ-IT compliant.

A small physician practice does not need to lay out tens of thousands of dollars in up-front capital investment for an EMR system, as costs can be amortized by paying monthly user fees for a system from a vendor who stores data in a remote, secure location. One such company, Ethidium Health Systems, offers such a service for a per-physician monthly cost of less than $400 in return for a Web-based platform that supports patient encounter and procedure data entry, E&M coding, electronic drug prescribing, lab data access, disease management protocols, clinical trials and other functions, according to the company’s President and CTO Matias Klein. Data can be accessed and typed in via desktop computer, PDA, or even cell phone, while training entails interactive CDs and a website that provide a self-tutorial approach to training, with the company offering additional training if desired, says Klein. The system also supports emerging national and international interoperability standards, he adds, allowing it to communicate with other vendors’ systems.

An EMR model that offers community-wide interoperability with economies of scale is possible when a larger entity purchases software from a major vendor, then re-sells or leases it to smaller physician practices. Anthony Alfieri, M.D., a practicing cardiologist who is part of a 20-physician group in nine offices in Delaware, partnered with the large health information vendor Cerner – which typically sells EMR systems only to large hospitals – to form Blue Ox Medical Solutions, which he says offers EMR capabilities to some 600 physicians at 200 sites in the five-state region – including 100 physicians in southeastern Pa. – for about $150 per month, per full-time physician user. A dedicated T-line is required for Internet-based data transfer, with Cerner storing the data in a bunker in Kansas City. The system cost Blue Ox $10 million to $20 million to develop, and $2 million to $3 million per year to maintain, while offering physician users a tiered database of patient information sharable across practices, including medicines, allergies, problems, demographics and insurance information, says Alfieri. Blue Ox has commitments from Delaware’s Christiana Hospital, and from major lab and radiology companies in Delaware to interface with the system for data sharing, while the company also hopes to achieve DOQ-IT compatibility, he adds. Return on investment depends on rate of adoption, and Alfieri says that training to use the system typically takes three months and a physician practice using the system, with its extensive documenting and coding capabilities, can save between $70,000 and $80,000 through eliminated undercoding.

Hospital-Based Systems

Pa. hospital systems have been early investors in EMR systems. Several are in various stages of updating their systems and are requiring their employed physicians to use them, while private physicians may soon have access to the systems.

The UPMC Health System has used Cerner as its inpatient EMR vendor since 1998, and now offers a patient chart and lab information module at nine UPMC hospitals, an electronic prescribing module at seven hospitals, an operating room module at five hospitals and an ER module at three hospitals, according to G. Daniel Martich, M.D., vice president of UPMC’s eRecord system. For ambulatory care, roughly half of UPMC’s 530 employed physicians have access to an EMR system from another vendor – Epic – in their offices, while the other half has a Cerner ambulatory EMR, which has resulted in some information barriers between the two systems, and required UPMC to devise work-arounds to minimize the roadblocks, says Martich.

UPMC wanted to make EMRs as non-onerous as possible, and is not requiring its employed physicians to use it during patient encounters, as long as the data is subsequently entered into the system. About half of UPMC’s primary care physicians enter data electronically while in the presence of a patient, while others continue write or dictate notes, to be transcribed and entered into the system later, says Martich.

UPMC hopes to begin leasing EMR modules to private physicians by early summer, beginning with non-employed physicians on the medical staffs of UPMC hospitals, who would be able to retrieve hospital patient data from their offices, Martich adds.

Various inpatient modules have produced documented improvements in efficiency and outcomes. Emergency rooms using the system to order medications and generate customized discharge instructions have saved an average of seven minutes per discharge over a paper-based system which, when multiplied by some 100 patient discharges a day and 30,000 a year, add up to a significant time savings, says Martich. A bar-code scanning system to accurately identify inpatients at UPMC-Presbyterian has reduced unauthorized drug errors from five to two per 1,000 doses administered, while intercepting one to two otherwise undetected medication errors per day. The clinical orders and documentation system has resulted in modest increases in pain assessment and interdisciplinary care plan compliance. The incidence of verbal orders not signed by a physician within 24 hours dropped from 56 to 15 percent.

About 20 percent of the University of Pennsylvania Health System’s annual patient visit volume is done through EMRs, and the health system hopes to roll out mandatory EMR use for all of its ambulatory visits within the next four years, according to George Brenckle, Ph.D., Penn’s chief information officer. HUP has had EMR capability under an older system since 1998, and converted to a new system – Sunrise Clinical Manager – last January, followed by Presbyterian Hospital in May 2004, and to be joined by Pennsylvania Hospital by the end of this year, notes Brenckle. All inpatient order communication is done electronically, while only 10 to 15 percent of results communication and patient charting is currently done electronically, and one of Penn’s priority projects is to promote electronic charting, he adds.

Since implementing its latest EMR system, Penn has seen transcription costs halved, while productivity has increased from three to seven percent. Although Brenckle acknowledges that productivity is a multivariate issue which is driven by factors other than EMR, he notes that Penn’s administration has decided that it is worth implementing EMRs, even after factoring in productivity lost to physician learning curves. Penn has also seen changes in where time is spent by physician who have adopted EMRs, e.g., more minutes with patients in the exam room for each visit, and fewer minutes on call-backs and prescription renewals, he adds.

Getting a stable, in-house EMR network in place, and training its physicians to overcome workflow and cultural obstacles to achieve 100 percent adoption takes a lot of time and attention, and Penn has not yet considered making the system available to private physicians, says Brenckle.

Temple University Health System has had an electronic prescription order entry system at its hospitals since the late 1980s and is a few months away from selecting a global EMR system that has outpatient functionality, according to John Cacciamani, M.D., medical director of clinical informatics. The model Temple is envisioning, depending on financing and physician preference, would expand data portals to all Temple hospitals and physicians, with the possibility of including non-Temple physicians through a "value-added reseller" model, or through an insurer- or employer-subsidized arrangement, he adds.

Acknowledging the huge workflow management and cultural changes that accompany EMR adoption, Cacciamani says that health systems with academic medical centers are lucky, in that most of their orders are written, not by community physicians, but by residents who tend to be younger, eager and computer-literate. Trying to get community physicians not to write orders by hand is more difficult, he believes.

Implementation of a new EMR system is expected to be completed at Thomas Jefferson University Hospital over the next year, and at its affiliated Methodist Hospital in the next 18 months, while its current inpatient ordering system – IDX, implemented in 1999 – is accessible by all of Jefferson’s employed and private staff physicians from their office or home, according to Jonathan Gottlieb, M.D., Jefferson’s senior vice president of clinical affairs. The system has dramatically decreased the turnaround time for radiology readings and has reduced prescribing and surgical errors, he says. While physicians and nurses report satisfaction with using the system, an unintended workflow consequence has been that the system has resulted in is less direct communication between physicians and nurses, and Jefferson has established scheduled communication sessions between them, Gottlieb adds.

Jefferson is exploring the purchase of a system that allows electronic medical documentation and charting, which it might offer to private physicians for a fair market value fee, but Gottlieb notes that interoperability obstacles still impede data flow capabilities between inpatient and outpatient applications, even by products from the same vendor.

Physician Experience

How quickly adoption of EMRs grows entails a "chicken/egg" scenario in which physicians may be waiting for adoption to become more widespread while their own reluctance prevents them from making the plunge. Most physicians have not yet adopted EMRs for several possible reasons: they are leery of the costs, they do not see a compelling return on investment, they reject the workflow change and practice disruption entailed, or they are uncertain whether a particular system chosen today would become obsolete in a few short years, or whether the vendor will still be in business. Early adopters acknowledge frustrations, while also declaring the move to be worthwhile.

Medical Associates of the Lehigh Valley, a 60-person group of family physicians, internists and pediatricians spread across 25 offices in Lehigh and Northampton counties, had been studying EMR systems for the past five years and decided last year that hardware costs have come down dramatically, while software capabilities have grown dramatically – allowing input of clinical information using customizable templates, with reliable voice recognition capabilities quickly evolving, according to Bob Stover, the group’s executive director.

Medical Associates has used its EMR system for one year and is promoting a shared ownership model to other physician groups to eliminate duplication of tests and procedures, and to allow providers such as orthopods and cardiologists to have access to the most updated record of a primary care physician’s patient, says Stover. The group hopes to have several hundred physicians in the region co-own of the system, which Stover says will bring the per-physician cost of the system down to $20,000 to $30,000, including the server system, licensing fees and training. Financing arrangements of $1,000 per month would make the system accessible even to solo physicians, he believes.

A physician’s learning curve for implementing the system typically lasts three months, and is often followed by another three-month interval of frustration that their workflow is not going as fast as they had hoped – an interval during which Stover says intensive training support is needed. Within six to nine months, he adds, physicians see a turnaround in their workflow and an average ten percent increase in their coding levels, aided by the system’s documentation and coding templates. A return on investment should be seen within 18 months, Stover says.

While Stover believes that Medical Associates’ system should be capable of communicating with other EMR systems, he says that the group’s priority is growing its own network to span the community, where almost all of a patient’s care is rendered. The group will share its experiences with the state’s e-Health Consortium, of which it is a member.

Some physicians have a longer track record of experience with EMR systems. Angela Haas, M.D., part of the Susquehanna Health System-owned Loyalsock Family Practice, is approaching her sixth year working in a paperless office practice and was the pilot physician for the health system’s EMR system – which has been customized for a variety of specialties and is currently used by 50 physicians employed by the system.

Half of the health system’s physicians still resist using the system, and the health system is keeping its use voluntary, recognizing the lifestyle and financial issues involved. Says Haas, "We’re taking motivated physicians – who want to do this – live." The health system has seen the quickest EMR adoption rates by its newly-recruited physicians and by physicians in its residency program, she notes.

Practice revenue is slower during the adoption process and evens out within a year, says Haas. New adopters who want to convert to EMR for all their patients might need to see one or two fewer patients per day during the learning curve, while other practices may use EMR only for one or two patients a day, or restrict their scope of practice for several weeks – performing only physical exams or only sick visits – to narrow the number of EMR data input templates to be mastered at a given time, says Haas.

Haas cautions that, "A computer only magnifies the inefficiencies in a physician office," and she notes that that the first year also includes the time-intensive stumbling block of converting paper records to the electronic format. "I did it nights and weekends. It was my hobby for six months, and I was committed to the pilot," Haas adds. Office staff now perform the conversion task for most physicians.

Physician adopters should see benefits of their fortitude in about a year, while Haas says that achieving a lab and radiology interface with the hospital brought benefits of improved documentation particularly quickly. A significant benefit to Haas is that she rarely has to stay later in the office to complete patient documentation, or take charts home to dictate, because the documentation is done during patient care hours.

Achieving a return on investment after purchasing an EMR system was only a minor consideration for Nick Leasure, M.D., part of a six-physician oncology/hematology group in West Reading. Organizing records in a system that could handily track and standardize quality care practices among the group’s physicians were the group’s primary motivations for leasing a software license from iKnowMed, an EMR system specifically designed for oncology applications. One year of using the system has allowed the group to eliminate redundancy in chemotherapy order writing, while effectively tracking medications and dosing, and updating regimens with the support of clinical guidelines specific to his specialty, he adds.

Leasure’s practice devoted a few months to pre-training its nurses to handle the new system’s charting functions before going live with the system and, once over the learning curve for actually using the system – which took three to four months – Leasure updated each patient chart by taking about five extra minutes per patient to input paper data selectively into the electronic system during that patient’s visit. Leasure’s practice still keeps skeletonized paper charts as a safety backup, which he says will be eliminated once the system is fully customized to his liking, over which his practice is negotiating with the software company.