How to Choose an EHR for Your Direct Primary Care Practice

(From a Physician Switching After Almost 5 Years)

https://youtu.be/dgLs7GwMck0

One month shy of five years. That is how long my practice, Big Trees MD, ran on the electronic health record we opened with. Almost five years of charts, patient messages, labs, and the muscle memory that lets you find a note without thinking about where your cursor is going.

This month, that ended. Not because I went looking for something shinier, and not because we outgrew it. It ended because the terms under which my patients' data lives changed, and I could not accept those terms. I had to make a decision about where the memory of my practice would live.

It was not on my bingo card for 2026.

I practice full scope family medicine, including obstetrics, in Arnold, California, up in the Sierra foothills of Calaveras County. I own the practice with my husband, Dr. Jeremiah Fillo, and our team is fully virtual. When an EHR change hits a practice like ours, there is no health system IT department to call. There is me, my husband, our team, and a lot of coffee.

So I am documenting the switch, and I am sharing the framework we published in The Toolkit's Battle of the EHRs issue, where over 200 DPC EHR users told us what they use and why. You will notice I never name a vendor in this article. Not the one I am leaving, not the ones I am evaluating. That is on purpose. The names change. The framework does not.

If you would rather listen than read, this whole framework is a podcast episode on My DPC Story, and the real time play by play of our switch, spreadsheets included, is in our Patreon community.

An EHR is the memory of your practice

An electronic health record is not a filing cabinet. It holds patient conversations, the labs you ordered and the ones you decided not to, the care plans you built, years of clinical reasoning, and in our practice, more than a few pet names. When you switch, you are not moving a file. You are moving the memory of every relationship you have with every patient.

Here is why the DPC version of this decision is different. In the fee for service world, an EHR is built to generate a bill. Every click path and required field exists so a claim can go out the door and survive an audit. The physician is not the customer. The billing department is.

Direct Primary Care flips that. There is no claim. There is a membership. So the question stops being "how does this system help me bill" and becomes "how does this system help me take care of people and run a small business at the same time."

The 10 categories that actually matter for a DPC EHR

In the Summer 2025 issue of The Toolkit, we laid out ten categories to score from 1 to 5, for a total out of 50:

1. Mobile use. Can you message a patient back from the school pickup line, or are you chained to a desktop?

2. Onboarding ease. How long from signing to seeing your first patient, and how much of that is you learning versus you waiting?

3. Support quality. When something breaks at 7 pm on a Thursday, who answers, how fast, and is it a human who actually knows the system?

4. Integrations. Does it talk to your lab vendor, e-prescribing, fax, scheduling, and payment processor, or do you become the human API?

5. Scalability. Will it still work with twice the panel, a second physician, and a virtual team?

6. Membership billing. Can it charge a family monthly, prorate a first month, pause a membership, and reconcile with your bank without a side spreadsheet?

7. Communication tools. Secure messaging, texting, video visits. One inbox or four?

8. Charting speed. Not features. Speed. How many clicks from "patient is here" to "note is signed"?

9. Lab workflow. Ordering, receiving, reviewing, and getting results to patients without printing anything.

10. Automation. Reminders, recalls, welcome sequences, even birthday messages. The work a small team cannot do by hand.

These ten categories live on our free downloadable worksheet, How to Interview Electronic Health Records, at mydpcstory.com. And the line at the bottom of that worksheet is the one to remember: the highest score is not always the winner. You weigh the scores against your vision.

Start with your vision, not the demo

The biggest mistake I see physicians make is starting with the demo. The sales rep shows you the prettiest screens and you fall in love with a feature you will use twice a year.

Start with these five questions instead. I have had to answer every one of them myself this month.

1. What problem am I really trying to solve? Is it truly the EHR, or is it a workflow, training, or team communication problem wearing an EHR costume? If your inbox is a mess because nobody owns the inbox, a new system gives you a new messy inbox. For me, the honest answer was that my workflow was fine. The terms around my patients' data changed, and that is a real root cause.

2. What data will not transfer, and how will I handle it? Ask your current vendor and the new one, in writing. Care plans, secure message history, PDFs, attachments, images. Not "can you export my data," because the answer is always yes. Ask what will actually land in the new system, in what format, and what you will rebuild by hand. I expected to move medications over by hand and was relieved to find I did not have to, but I still checked every list against what the patient is actually taking.

3. What will the downtime look like, for me and for my patients? How long to slow the clinic, retrain, and verify the data landed correctly? Are you willing to trade short term disruption for long term gain? Sometimes the honest answer is "not this quarter," and that is okay.

4. How does this system grow with me? Another clinician, new procedures, a new lab vendor, telehealth. If your vision changes in three years, does the tech still fit? This is the question I wish I had weighted more heavily five years ago. I chose well for a two physician practice opening its doors. I did not fully anticipate what a growing panel and a virtual team across time zones would demand.

5. Am I making this decision from clarity or from burnout? If you are overwhelmed, this may not be the moment for a major systems change. Talk to trusted peers. Look at your life wheel. Being forced into a change does not make it a bad change, but forced and rushed are different things.

Write your answers down physically before the first demo, so you have something holding you to your own vision once the screens start sparkling.

How to run an EHR demo on your terms

Build a fake patient before the call. A family of four on one membership. A patient with three chronic conditions and a lab due. A pregnant patient if you do obstetrics. Then ask the rep to walk your patient through the system while you watch. Sales demos are choreographed. Your patient is not.

Count clicks from "patient arrives" to "note signed and next visit scheduled." Out loud or in tally marks, either way, that number is your charting speed score.

Ask about migration before you ask about features. What exactly transfers and what does not? How are care plans, attachments, and secure message history preserved? What is the timeline, who owns it, what does it cost, and is that cost in the contract?

Then ask the question nobody asks: how do I leave you? What does export look like in five years, in what format, at what fee, with what notice period? Credit to my husband for this one. A vendor who gets uncomfortable with that question is telling you something.

Ask about membership billing like a bookkeeper. Prorating, pausing, family plans with one payer and four charts, declined cards, and reports that reconcile to what actually hit your bank.

And ask about ownership and the roadmap. Who owns this company? Has it changed hands? Is it planning to? Google the owner and look at their business history. In a moment when private equity and venture capital are creeping into Direct Primary Care, you deserve to know whether your EHR was founded by someone solving their own frustration with healthcare or someone on their fourth startup. The features in the demo are a snapshot. The company behind them is what you are actually signing up with.

Finally, ask other DPC doctors. Message someone who has been on the system for two years, not two months. Ask what slows them down, not just what they love. That is what the third column of the worksheet is for.

Run the real math, not the pricing page

Per patient per month pricing is only the top line, and the top line can lie. Build four buckets:

1. The subscription, projected at your panel size today and in two years. A price that looks great at 200 patients can look very different at 600.

2. The add-ons. E-prescribing, controlled substances, fax, texting, video, lab interfaces, payment processing. Get every one in writing.

3. The switching cost. Migration fees, your time reviewing charts, your team's time learning, slower weeks, and any period paying for two systems at once. Your time has a dollar value. When I Googled the base hourly rate for a nurse practitioner in California, it was $79. Keep that number in mind when you value your own hours.

4. The exit cost. Export fees, early termination fees, and the notice period where you pay for a system you no longer use.

Add all four buckets over three years and divide by 36. That is your real monthly cost. Then ask one more question: if system A saves you 15 minutes a day over system B, that is over 60 hours a year. What is an hour of your life worth?

The costs no spreadsheet captures

Patient care does not pause for software. Your patients will not know you switched systems, but they will feel it if a message goes unanswered or a refill gets delayed. Communicate the transition, set expectations, and give your most complex and most vulnerable patients extra follow up.

The emotional weight is real. You might feel frustrated, regretful, or betrayed, especially if your EHR is no longer owned by a team you trust. Almost five years is a long time to trust something with your patients' memory, and I am feeling the weight of it this week. But this is part of being a physician entrepreneur. You prepare as well as you can, something you did not plan for lands on a Tuesday, and the skill is staying flexible when it does not go your way. You are not the first, either. Plenty of doctors on the My DPC Story podcast have had a vendor change out from under them and came out the other side.

And implementation is not the finish line. Treat the first 90 days as a pilot, keep a running list of frustrations, and advocate for yourself with your vendor. You are not being difficult. You are protecting the integrity of your practice.

The data has changed, and you can shape the next round

When we surveyed over 200 DPC EHR users for the first Battle of the EHRs, it was the first real community data behind what DPC practices actually use. No vendor sponsorships, no paid rankings. That issue is still free to read at mydpcstory.com.

But things have changed since we published it. Companies have changed hands, terms have changed, and features have shipped and disappeared. My own month is proof that last summer's snapshot is a snapshot, not a map.

So we are doing it again. The second Battle of the EHRs opens for voting in the first quarter of next year, and the only way to vote is through the My DPC Story newsletter. Sign up at mydpcstory.com so you are first to know when voting opens.

Free tools to take with you

Everything below is a free download from The Toolkit:

• How to Interview Electronic Health Records, the 10 category comparison worksheet. Print one per EHR you are considering.

• The patient handout on choosing healthcare vs. health insurance, written for patients, perfectly timed for open enrollment.

• The Lean Startup Business Plan, whether you are opening or five years in and never wrote one down.

• The First Year Roadmap, month by month from EHR setup through your first twelve months.

• Every issue of The Toolkit, including the new Battle of the Support Stack.

Where my practice lands

We are one month shy of five years and we are moving. Two physicians, a virtual team, a growing panel, no IT department, and the same worksheet I just handed you.

The full story, the demos, the migration answers, the four bucket spreadsheet, and the second guesses live in our Patreon community if you want to follow along in real time.

Choose systems that work for you, not the other way around. The tools in your practice should feel like extensions of your values, not obstacles to them. No technology is perfect, and the one you pick today may not be the one you retire on. What matters is choosing it with clear eyes, from your vision and not your exhaustion, and knowing how to leave it if you ever need to.

And if you are in the middle of your own not-on-the-bingo-card month, I will leave you with what my dad always told me: things are always temporary, pumpkin. This too shall pass.

Listen to the full episode on My DPC Story wherever you get your podcasts, and leave a voice message at mydpcstory.com/contact. You might hear it on a future episode.