The Silver Sage Center for Family Medicine has used eMDs since it opened in 2005. Six years later, it became the first Priority Primary Care Provider (PPCP) practice in the state to successfully achieve Meaningful Use Attestation of an electronic health record. How this small practice got to that point, outpacing larger, better-financed groups, is a tale of luck, determination, and good fortune in choosing the right electronic health record (EHR). It is also a story of a successful collaboration with the local Health Information Technology Regional Extension Center (REC), HealthInsight.

Andy Pasternak, MD, the practice’s owner, and his partner worked for a local hospital-based primary care group before striking out on their own. Dr. Pasternak had prior experience with EHRs in his training, and he believed that they were the wave of the future. He also thought it made sense to start his new practice with an EHR so that they wouldn’t have to migrate from paper to electronic records later on.

Dr. Pasternak chose eMDs partly because Family Practice Management (FPM), a publication of the American Academy of Family Physicians, has consistently rated it highly in a physician survey that it conducts periodically. Also, unlike most of the other leading EHRs, eMDs has functionality suited to smaller offices as well as significant familiarity with their unique implementation needs. “ The company’s philosophy was, ‘We don’t care how big or small you are; we want to help you implement an EHR,’” he recalls.

After selecting eMDs, Dr. Pasternak received his training at the company’s Austin headquarters. Then he returned to Reno and trained his partner and the rest of their staff on both the EHR and on eMDs’ integrated practice management system. The billing and scheduling modules are so intuitive, he says, that the staff mastered 75 percent of their functions within three days.


At the outset, Silver Sage used eMDs mostly for documentation, billing and scheduling, Pasternak notes. The first step beyond that—and eventually, toward Meaningful Use—was to use eMDs DocMan, which allowed the practice to electronically fax documents, scan, and efficiently organize paper documents that came into the office, allowing easier data retrieval. Then Silver Sage implemented an interface with LabCorp which brings in structured results that can be graphed and queried, and also automatically completes the order tracking process in eMDs.

In 2007, HealthInsight, Medicare’s Quality Improvement Organization (QIO) in Nevada, offered to help Silver Sage participate in a clinical reporting project. The QIO provided assistance as part of a Medicare program to aid small primary care practices in implementing EHRs. Later, HealthInsight, functioning as the Regional Extension Center for Nevada, worked with Silver Sage to prepare the practice for Meaningful Use.

HealthInsight consultants convinced Dr. Pasternak that it was worthwhile to add a second lab interface with Quest, which would give the practice a high enough percentage of structured lab data to meet a Meaningful Use requirement. HealthInsight also persuaded him to start using the eMDs Patient Portal to communicate with patients, a key part of Meaningful Use. In the year since Silver Sage added the patient portal, approximately 1,000 patients have signed up to use it.

Today, the practice uses the portal to send lab results and x-ray reports to patients. Many patients are now using it to request prescription refills, reducing staff time spent on the phone with pharmacies. Silver Sage will soon let patients book some appointments online, starting with routine visits such as physical exams.

Meanwhile, Dr. Pasternak and his partner are using eMDs to send clinical summaries to the portal to remind patients of what was discussed during their visits. This feature, which also satisfies a Meaningful Use requirement, can be triggered automatically at the end of a visit.

The two doctors have been prescribing electronically for the past two years— another Meaningful Use criterion. “Because we can immediately send prescriptions electronically and have them waiting for patients at the pharmacy, I have found this to be a big time saver, and our patients like it too,” says Dr. Pasternak. Moreover, he points out, the drug interaction and allergy alerts in the e-prescribing module help ensure patient safety.

Silver Sage’s participation in HealthInsight’s quality improvement program focused on raising cancer screening and immunization rates. Silver Sage uses the reporting capabilities of eMDs to track which patients need preventive and chronic care services. HealthInsight also assisted with clinical transformation, workflow and other process improvements. This capability helped them become the only Nevada practice to achieve the HealthInsight Physicians Office Quality Award from the QIO in 2009 and in 2010. They also received the award in 2011. It also paid off when the practice had to attest to its ability to send quality data to the Centers for Medicare & Medicaid Services as part of Meaningful Use.

“If we tried to do that with paper charts, we would probably have to hire two part-time employees just to go through the charts,” Dr. Pasternak observes. “The ability to run a report in seconds on who’s had their mammogram and who hasn’t is pretty amazing.”


The rapid growth of the practice has made it essential to increase efficiency—one reason for expanding the use of the EHR. Since its start in 2005, Silver Sage now has about 12,000 active patients, and its two providers receive about 9,500 patient visits per year between them.

Largely because of eMDs, Dr. Pasternak says, Silver Sage has been able to accommodate this growth without increasing staff. “Our staff-to-provider ratio is pretty good for a primary care office,” he points out. “For two providers, we have five and a half staffers working for us, and we’re doing our own billing. There’s no way we’d be able to do that with a paper system.”

Because of eMDs’ template-driven, multi-problem system which allows him to switch from one template to another on the fly to accommodate “wandering” histories, “I’m able to use a tablet PC to document 75 percent of a visit while the patient is talking to me.” In most cases, he says, this includes the chief complaint, the history of present illness, the review of systems, and decisions on which tests to order. It’s not uncommon,” he says, “to see 25 or 30 patients in a day and leave the office at 5 p.m. with all of his documentation finished.”

Patient satisfaction with the practice is very high, and Dr. Pasternak attributes that partly to the EHR. “Patients are kind of fascinated when they walk in the room and see us using a tablet PC. The majority of them really like the e-prescribing and the patient portal, which lets them view their notes right after the visit.”


Recently, Dr. Pasternak analyzed the costs and savings associated with the EHR. “Despite the initial investment in hardware and software, there’s no doubt that we’ve been able to save money over the past six years,” he says. “And those savings will continue. While we have to replace our computers periodically, we still come out ahead, and I think we’ll continue to have that return on investment.” He estimates Silver Sage is saving about $76,000 annually using eMDs when compared to the costs of a paper based system and its transcription, chart supplies, additional staff and electronic billing services costs.

In addition to these savings, the federal incentive program has been a financial plus too. Dr. Pasternak gives eMDs and HealthInsight credit for helping his practice be an early qualifier for Stage 1 of Meaningful Use. “It would have been much more difficult and would have taken us longer to attest if it had not been for HealthInsight and eMDs,” he points out. Silver Sage has already qualified for $36,000 in federal incentives and is eligible for an additional $52,000.

Moreover, Dr. Pasternak views the EHR as a necessity for survival in the emerging healthcare environment. “With the financial realities of primary care, using an EHR to full capacity is an essential tool for small offices to stay competitive with larger systems and remain financially viable,” he says. Finally, he’s grateful to eMDs for its strong and continuing support of his practice. “A lot of times, small practices feel they’re at a disadvantage, because the big hospitals have more resources and more IT infrastructure. Having a company like eMDs behind you really helps level that playing field for small practices.”

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