If you are planning to create a free or low-cost tattoo removal practice, one of the things you’ll have to know more about is how to maintain medical records. Beyond the question of “paper or electronic,” you’ll need to envision the workflow: how the process gets done and how it’s recorded. And how do you choose a note-taking and record-keeping system that supports that vision? We’d like to share what we learned from our research that led us to choose an electronic medical record (EMR) system over a paper system, and the methods we used to develop, and select from, a field of 18 candidate EMR companies (Advanced MD, AestheticPro, Aesthetic Record, Athenahealth, Care4software, Clinicea, DrChrono, eClinical Works, Envision Med Spa, Jane, Kareo, ModMed, Nextech, Patient Now, Practice Fusion, Praxis, Remedly, and Zenoti). We hope that you glean more from the methods we used to assess each platform’s features, interface and workflow than our particular preferences. This article is not intended to help you decide what you want, but rather to help you ensure the system you choose will meet your requirements.
Electronic medical record or electronic health record?
Both an electronic medical record (EMR) and an electronic health record (EHR) are digital records of a patient’s health information. Typically, an EMR contains the patient’s medical and treatment history from one practice and an EHR contains the patient’s records from more than one practice and multiple doctors. Many software publishers appear to use the terms EMR and EHR software interchangeably. However, in this article we refer to it as electronic medical record (EMR) software.
Benefits of using electronic records over paper records
There are a number of benefits of electronic medical records (EMR) versus paper charts. And each of them influenced us to make the switch from paper to electronic records.
The benefits include the fact that:
- There’s no need for physical storage to deal with all the paper.
- EMRs are more secure, since they are backed up electronically, and protected with robust encryption.
- EMRs can be easier to use. Paper forms can make providers’ work even more stressful, because of such things like the challenge of keeping notes legible and having limited space to write down pertinent information.
- Charting becomes less time consuming and less error prone when using EMR software. It is easier and more efficient for a medical director to perform any needed chart review from their desktop, including remotely, rather than having to retrieve or be delivered paper files. Being less time consuming and more efficient can make it easier to recruit providers to volunteer their time at the clinic.
- Most EMR software packages come with a HIPAA compliant patient portal or the use of a disposable link to share. These options allow for the access and completion of, for example, intake and medical history questions, allowing the setup process to go smoother and faster. And these options can also help in facilitating ongoing secure patient-provider communication.
- Having EMR software makes it possible to collect details for reporting of evidence-based outcomes and “successes,” more easily articulating the goals and outcomes of any funded grant requests from a funder. Additionally, data supplied from an EMR
ssystem can also better support future grant proposals, easily demonstrating the benefits of the tattoo removal program. In turn this should help to keep funders happy and future potential funders hopefully more convinced of the needs and benefits of such a program, and more likely to offer financial support.
- EMR software can also be helpful in tracking results and data over time from each tattoo removal treatment. This can lead to a better understanding of machine settings relative to skin type, for desired outcomes, particularly with dark skin tones, which could help determine the number of sessions required.
With all the benefits outlined above for using EMR software, we suggest that any existing community-based tattoo removal program consider converting to EMR software. And any program not yet established should launch operations with EMR software rather than paper charts.
Why we are sharing our research
We are offering our findings here as a service to anyone in the market for EMR software, particularly for tattoo removal procedures, and especially for a community-based program offering free or low-cost tattoo removal. The software companies are not all easy to find, and in most cases pricing and other important details can’t be found online. In almost all cases we were only able to uncover the details by speaking to a representative at the company, and that was not always easy to accomplish. Our hope is that, by having this information more readily available, more community based-programs will implement EMR software to make their tattoo removal programs more effective and efficient.
This article is not meant as a software review and is to be used only for informational purposes and is not a recommendation or an endorsement. We are only sharing our experiences and what we discovered, and how those discoveries helped to guide us in selecting our EMR software.
Why we decided to conduct a survey to find EMR software and how we decided who to survey
When we began our search for EMR software, as mentioned above, we were struck with how challenging it was to find many of the software programs to consider. We also noted a fair amount of paid placement in the form of ads and reviews that appeared to be lead generators for some of the software companies themselves, which left us wondering how objective the reviews actually are. This experience made us decide to conduct our own survey to find a larger sample of software packages to consider and the best possible solution for our own community-based tattoo removal program.
Since we were looking for EMR software to specifically support laser tattoo removal, we decided to survey dermatologists (SIC Code 801119), med spas (SIC Code 804974) and tattoos removed (SIC Code 801107) locations using EMR software, within the region where we are located, which includes the four largest San Francisco Bay Area counties by population, and only interview practices that offer laser tattoo removal. We built the lists using Reference Solutions by Data Axle (formerly ReferenceUSA), a subscription database that can be accessed remotely, and is offered for free with a library card at our local public library. By selecting the SIC Codes (Standard Industrial Classification Codes, used by government agencies to classify industry areas) mentioned above, the database produced 216 unique practices in Alameda, Contra Costa, San Francisco and Santa Clara counties. Among the practices we were able to reach, 53 practices offered tattoo removal of which 35 were using 24 different EMR software programs and 18 were utilizing paper charting. After conducting the telephone survey, two software programs advanced to the demo round, AestheticPro and Remedly. The other four on the Reference Solutions by Data Axle list, were eliminated because their price exceeded our budget.
In addition, we attempted to survey 210 of the community-based programs listed in our online tattoo removal directory. We didn’t include programs offered by hospitals, jails, prisons or programs outside of the US. We excluded these institutions because the type of EMR software they use is typically larger scale, enterprise software programs, not the type we would be using. Of the programs that we were able to reach, our online tattoo removal directory list produced eight unique EMR software programs with three programs making it to our demo round – Envision MedSpa, Jane and Zenoti, and with two, Envision MedSpa and Jane, advancing after their first demo. Zenoti and the five other software programs produced from our online tattoo removal directory survey, and the other five that also appeared on the Reference Solutions by Data Axle list survey results, were all excluded, because their price exceeded our budget.
Our search and evaluation criteria for EMR software and what we learned
After we searched and compared software programs, completed the first round of demos, and interviewed tattoo removal programs serving the same population, we ultimately figured out what we needed. For a complete list of our “must-have’s” see, Software programs meeting our budget needs and passing first demo, but eliminated from consideration after second demo, section below.
Here are the important things we discovered.
We quickly discovered the best charting for us was determined by our preference and workflow requirements and that alone eliminated a number of programs from further consideration. Referencing each treatment separately with related details all on the same template/page and ease of photo comparisons were both important to us. In general we value software that helps us keep treatment notes organized, includes machine settings for tracking purposes, is easily readable, and easily referenced, bringing forward past notes, and offers smart phrase options to save time throughout.
Patient Engagement, patient portals versus temporary links
A “patient portal” is a secure website where patients can interact with their health information. It is common practice for EMR developers to offer extra engagement features in their patient portal, such as an internal messaging tool or a refer-a-friend program, as a way of making their product stand out. We found that extra engagement features are more common among EMRs whose target demographic are aesthetics- or wellness-focused (i.e. medical spas, dermatologists, therapists, and chiropractors). These features are often used as a means to increase return appointments by keeping patients engaged and informed/interested in treatment offerings. It’s worth noting, despite our decision to avoid it, that this strategy is very effective in many healthcare industries: marketing research shows that driving engagement up can drive a business forward.
It is also common practice for EMRs to make form-filling tools mutually inclusive with their patient portal – a patient can’t fill out intake forms until they’ve logged in to the patient portal. In our experience shopping for EMRs, we found that it’s unusual for an EMR to offer alternatives to this process. We prioritized EMRs that offer an alternative: those that don’t require a patient portal login for patients to fill out intake forms. We learned from colleagues – who are actively engaged in this community service work with the same population – that required patient portal logins and passwords are both barriers for many patients. To quote a colleague with a very large program and years of experience: “They’re just not going to do it.” We concluded that patient portal setup and login would inevitably slow our whole process down. And worse yet, it could discourage people from even getting started.
The process should be as simple as possible for the patient. Our version of “data-driven engagement strategy” focused on making sure we don’t let people slip through the cracks. People are more likely to engage with an automated email or text message saying “please fill out this form,” that isn’t behind a log-in screen — so we prioritized an EMR that can send temporary links to documents without needing a patient portal.
A number of the software packages that we considered, and then eliminated, require that an appointment be set before patient paperwork can be sent. That does not support our intended workflow. Our intake paperwork needs to be completed, along with a good faith medical review, before the first treatment is scheduled. Some EMRs offered automated text messaging, which we found either too expensive or lacking in customizability. This specific need – in terms of what we want from a patient portal, electronic form-filling and appointment reminders – was one of the most divisive elements in our “must-have” list, and it served us well by narrowing the field of EMR candidates.
Acquisition and reoccurring cost of software
The price of the software acquisition and any ongoing costs are important, as we’re a nonprofit offering these services by a volunteer staff and at no charge to the patient. We explained this to each software publisher and asked for a discount. If none is noted, it means they didn’t offer one.
Each provider’s volunteer shift is expected to be four hours per week, and we plan to have a number of providers offering tattoo removal at several locations. Consequently, pricing plans that charge by provider or location were considered not affordable for us and were not evaluated after the telephone survey. However, a program that we may have eliminated because it exceeded our budget could be a possibility for a tattoo removal program with few providers and one location.
Features that were easy to eliminate
The focus of our search was on how well the program handled and supported tattoo removal. Many programs make billing a big part of their offering and integrate that into their pricing model. Since we don’t charge or bill for anything, we ignored this and any other features of the software that we did not consider core to supporting tattoo removal. The features that we eliminated include: the capability of front desk upselling/marketing, package selling, lead management, social media, online appointment making option, patient billing, insurance billing, lab work and pharmacy.
Adding procedure pictures to chart notes
Adding pictures to chart notes is an important feature. And being able to compare pictures by date is also important. If patients are unsure about how well the process is going in terms of their tattoos disappearing fast enough, showing them pictures can be motivating and offers hope. It can help them remain committed to a process that can be time consuming and painful.
Learning curve and training
For our purposes, the software learning curve cannot be steep. A manual with screen shots and clear and simple instructions should be enough to support users learning the software during an on-the-job training experience. This was also a high priority in our selection process, and we eliminated any program that we felt would take too long to learn.
Software programs we eliminated due to price or other considerations
As mentioned previously, pricing plans that charge by provider – and or location – were deemed out of our budget and were not evaluated after the telephone survey. It should also be noted that during the telephone survey we always inquired about a discount.
Twelve of the eighteen EMR software programs considered were eliminated due to price: AestheticPro, Aesthetic Record, Care4software, Clinicea, DrChrono, eClinical Works, Kareo, ModMed, Nextech, Patient Now, Praxis and Zenoti. As mentioned previously, the software we disqualified for price (with the exception of Care4software) may be worth considering for tattoo removal programs with a single provider and one location. However, further research would need to be conducted, as each was eliminated because of price prior to seeing if they met any of our other requirements (one exception, Care4software).
For more details regarding prices we were quoted and for any other reasons we eliminated these twelve, please see this link.
Software offered for free to qualifying members with a National Association of Free & Charitable Clinics (NAFC) membership
We learned that one of the many benefits the National Association of Free and Charitable Clinics (NAFC), offers its more than 1,400 members the possibility of being able to use one of the two software programs described below for free.
Athenahealth clinics that do not charge for their services and are members of the National Association of Free & Charitable Clinics (NAFC) may be considered for a free subscription to AthenaHealth EHR. However, they must submit an application to the athenaGives program. Space in this program is limited. As we understand it, applications are reviewed in December of the year the application is received. About 28% of NAFC members utilize Athenahealth. If accepted into the program, the implementation date will be determined by the implementation specialist, and will likely be either in May or November of the following year. Instead of a demo of the software, it was suggested that we review the videos found at their website, which focus on athenaCommunicator, athenaClinicals, and athenaTelehealth, as those are the services available to the clinics that are part of its athenaGives program. Otherwise, the cost is $700 per provider, per month just for the EHR. The possibility of being able to use this software for free could make it something to consider. But because we couldn’t sit for a demo or get all our questions answered, we were not able to thoroughly evaluate this software. Especially since, after repeated attempts, we couldn’t find anyone interested in providing us a live demo, we decided to eliminate this software from our consideration.
Practice Fusion, a subsidiary of Allscripts, is free with a membership in the National Association of Free & Charitable Clinics (NAFC), and renewed annually for members in good standing. About 30% of the NAFC members utilize Practice Fusion. Otherwise, the cost is $149 per provider per month, which permits three users to signoff on chart notes, documents and perform all other EMR tasks. There are no onboarding fees. They don’t provide any customization. Clients create templates, etc. An Updox subscription is available for $30 – $60 per month. Secure texting, patient reminders, broadcast, video chats, electronic forms, Fax, etc. Updox (integrated at no cost with NAFC membership), which is a third party subscription, is needed for some of the features described when using Practice Fusion. We wanted to sit for a second demo as Practice Fusion made the cut after the first demo. Although we could not arrange a second demo (we were told only one demo is available for free subscriptions) we were able to get our follow-up questions answered and consequently eliminated this software from consideration. More details as to how we made that decision can be found at this link.
We also learned from observing conversations on the NAFC listserv that some members use Epic through a partnership with their local community hospital, as a “community connect” practice (i.e. private, non-hospital-owned practice). There can be costs associated with such a relationship, but many find it a good solution and fundraise if need be to pay for the integration.
Checking references and looking for user complaints before advancing to short list
Post demo phase and before advancing to the short list, we searched the internet for user complaints including at these websites, G2, Truth Radius, Reddit, GetApp, Capterra, and SoftwareAdvice. We were looking for reasons to disqualify any software from further consideration because of meaningful complaints, but none were found.
In the case of Jane, at the end the only software that was not eliminated from consideration, we also spoke with a credentialed medical user at a tattoo removal clinic running multiple locations, which we uncovered on our own. We asked them many questions, looking for reasons to disqualify Jane from further consideration, but we found none.
Software programs meeting our budget needs and passing first demo, but eliminated from consideration after second demo
All software with a price that fell within our budget and with favorable answers to the first-round survey questions, were then moved to the software demonstration phase. Software company reps were then asked a second set of survey questions during the demo, and their answers supported our requirements and were further investigated. And finally, before advancing to our short list, each software program was then checked for user complaints, as outlined above. Below are the four software programs meeting our criteria.
From our experience with the interview surveys, and first round demos, and especially from speaking with other community-based tattoo removal programs, a “must-have” list evolved making it quite clear what we needed in an EMR software program. We made this list available to each EMR software provider prior to their second demo, and emphasized that these were our non-negotiable requirements. The list quickly helped us to eliminate software that didn’t have what we needed and to then eventually make for an easier decision on what to select. The must-have list also helped us to see that getting what we needed was ultimately more important than meeting our arbitrary budget of not exceeding $300 per month. Fortunately we were able to accomplish both.
Advanced MD is a software program we found from searching the internet. $264 per month for medical director, and other providers and users – who would each have a separate login and be able to sign off on their own procedures – would be included in that price. The Subscription price is normally $999 per provider per month. It commences with a 12-month contract and in month 13 converts to a month-to-month subscription. Onboarding is usually $4,000, however, nonprofit organizations are only charged $250. Training is usually $3,000, but in our case it would be a one-time fee of $299 for the 20 hours of training along with the full setup and configuration of the “office key,” which is what they call their database. We eliminated this software from consideration after the second demo. More details as to how we made that decision can be found at this link.
$199 per month for up to 25 users, $324 per month, up to 50 users. Online University is free for the first 90 days, and then it is $199, for 90 days or $100 per month. There are no additional onboarding/start-up fees. We eliminated this software from consideration after the second demo. More details as to on how we made that decision can be found at this link.
$200/month (usually it is $250 per month) per practice, reflects a 15% discount. No matter how many providers, it’s same amount per month price. For two-way texting add $75 per month for 750 messages to start (Trulia). Onboarding/setup is usually $1,500, but they offered it to us for $250. There’s no discount on two-way texting. We eliminated this software from consideration after second demo. More details as to how we made that decision can be found at this link.
EMR Software, sole finalist for consideration
If your organization is a registered charity, a nonprofit, or it currently offers services for free (or a mix of free and discounted services), it may be eligible for a Jane bursary, providing you with a free subscription or a reduced rate. Apply at their website on the pricing page under Bursary Program or use their contact page to speak with a team member to learn more about the eligibility requirements. Otherwise, it’s $74 to $369 per month with pricing breakdown on their website. If there are any charges, discounts apply for part-time staff, and they’ll tailor a pricing model that works for you. Regarding onboarding and training, self-onboarding is the only onboarding option for which there is no cost. For support with onboarding questions and needs, and training, the user schedules support calls which are without limit. They are normally one hour in length, but could be longer. They have found that one hour is the right amount of time for the user to retain what they’ve learned.
Of the four EMR software programs that made it to our short list, Jane was the only one that met all of our “must-have” requirements and consequently was our final selection. We also found without exception that everyone we spoke with at Jane was very helpful and knowledgeable, and we always felt as though our interests and needs were being considered first. We were also pleased and impressed with how prepared they were in answering our specific questions and addressing our needs during the second demo process using our “must-have” list. We didn’t experience this with any of the other
s three software companies making it to this round. We were encouraged by Jane to apply for their Bursary Program and are happy to say that we were awarded a free subscription to their software. Even if it was not free to us, we still would have selected Jane as our first choice, as it is the best match and meets our needs at this time.
It should be noted, however, that neither Jane nor any other software programs that we considered at any time were made aware of the fact that we planned to publish this article on our search and findings and our ultimate selection.
More details as to how we made the decision to select Jane as our EMR software solution can be found at this link.
If you’re considering – or are in the market for – EMR software, we hope that the information included in this article will save you time and money, and help you navigate and assess your options. It can be a challenge to distinguish which company’s software features will integrate well with your intended workflow while still meeting your budget, so it’s important to think ahead. Dedicating some time to conducting a survey helped us develop a list of viable candidates, considering all that we were able to uncover. And developing a “must-have” list that defines how the process should work – for example, how patients access forms electronically – was vital for sussing out the right EMR company from among those candidates.
A community-based free tattoo removal program may have needs that are less than a for-profit practice, but its needs might also be so specific that they can easily be overlooked by an EMR software developer. In product demonstrations and conversations with sales representatives, be prepared to drill down on the specifics that matter to you. And make sure they stay focused on your needs. We found that the presenter’s goal was to show us all the things their software was capable of and some even talking more about what it could do rather than showing us with their software. Your goal is to make workflow faster and easier for the people running your practice.
And remember, if you are a nonprofit, or soon to be nonprofit working with people in reentry or those leaving gangs, victims of intimate partner violence or human trafficking, and are serious about starting a free or low-cost community-based program, feel free to contact us. We will be happy to provide technical assistance, as needed, and a complimentary copy of our book, Tattoo Removal: Establishing a Free or Low-Cost Community-Based Program, A How-to Guide. If you decide to go with Jane for your community-based tattoo removal program EMR software, we would be happy to provide you with our Jane templates and the procedure manual we created.
Other cloud based tools we heard about while conducting this survey
Programs of any size should consider using the free version of Teamup, a calendar and scheduling cloud-based software, for scheduling volunteer health care providers. Providers can log on with a link, and sign up for shifts. They can also modify their availability as needed. Everything is in one place, making it easier for everyone, including those responsible for making sure that all shifts are covered.
Three community-based programs from our tattoo removal directory not using EMR software offered the names of three different electronic scheduling and communications software they use with their paper medical records system. We thought it would be worthwhile including those software programs here (Acuity, Daysmart, and Vagaro) for tattoo removal programs that are not yet ready for an EMR software solution. Lastly, Jotforms, a HIPAA compliant online forms builder, may be another option for smaller programs to consider.