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Known Pitfalls and Proven Methods for a Successful EMR Implementation

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Article written by Ursula Pennell and Eric Fishman, M.D.

Deciding to adopt an EMR is one of the most important decisions made by any practice. The transition to an EMR from a paper system can be challenging due to the fact that it will change the way everyone works. EMR’s can change current documentation method(s), workflows, billing practices, scheduling, patient follow-up methods, communication/messaging, etc.. EMR adoption usually requires reengineering current systems and can dramatically change the way practice’s runs. Considering the vast changes that have to occur to adopt an EMR, extensive planning must occur for a successful implementation.

Below are common pitfalls that have been identified by experts in the field. Use this information to help you plan your implementation and to not fall prey to common errors that may be avoided.


Planning Phase

As the saying goes “Fail to Plan; Plan to Fail” and isn’t that the truth. The planning phase is the most extensive and time consuming phase of the implementation process. The planning phase provides a great opportunity to map out the entire process which may include planning the following: conversion of data from the paper charts and what information to convert, current workflow analysis, redesigning new workflows for the EMR, deciding on methods of documentation (template creation, voice recognition, voice capture, partial dictation), staff training strategies, software testing, hardware testing (whether to consider using mobile devices and wireless technology), security rights and authorized access and system piloting. EMR adoption should be an evolution not a revolution and with proper planning you can get your EMR up and running smoothly with a minimal amount of staff frustration and loss of productivity.

  • Identify goals and base your planning strategies around these goals. First identify broad goals for the EMR and then develop more refined goals. Examples of broad goals may be: to identify and follow-up all patients who are not meeting the preventive health maintenance guidelines; analyze patient profiles based on demographics; create a referral tracking system; create tight security controls to reduce the risk of compromising the integrity of the chart; ensure that the hardware configuration will allow the provider to maintain eye contact with the patient etc.. Identify specific areas within the EMR to reach goals successfully. Share all goals with the staff as well.
  • Decide what data needs to be retrievable:It is common for practices to begin entering data into an EMR only to discover that the data is in a non-reportable format, not been consistently entered or not entered in any standardized manner by all providers. Therefore, this data is not reportable or incomplete, rendering it useless for queries. Identify what data will be useful for reporting purposes such as certain diagnoses and medications prescribed per physician; graph of BMI in a pediatric population after a pediatric exercise program was introduced; incidence of tobacco use within the patient population; diabetic patients who have not received a HbgA1c in a specified period of time etc..

    Your pre-determined goals and data that you want captured for reporting purposes should drive the decisions made during the planning phase. Utilize this information to create customized libraries, pick-lists, standardized and/or required data fields that everyone will use consistently for desired reportable information. Ask the vendor how data in certain areas of the system is stored and ask if this data is reportable in that format.

  • Be aware that “Free Text” may not be reportable.For many EMR programs, if the data is not in discrete data fields, the information cannot be captured by an internal report writing program or a third-party report writing program. Utilizing a fully-integrated speech recognition software programs within the EMR, which captures voice dictated text, is in a free-text format as well and therefore may be non-reportable. There is a growing trend in the industry at utilizing artificial intelligence to attempt to capture free text as discrete data usable by the EMR for reporting. This functionality may be available in the not too distant future.
  • Phased implementation is highly recommended.Most EMR’s lend themselves well for phased implementation because many of their functions are in discrete modules such as lab order entry, messaging, E&M coding, preventive health maintenance, patient tracking, e-prescribing etc. If a phased implementation is chosen, map out the phasing and rationale for the order of implementation. The staff will appreciate adding additional modules after they have adequately digested previous modules.
  • Create timelines but be flexible.Time Lines are great tools for project planning but be aware that they must constantly be re-evaluated especially if you are designing time lines for phased implementation. Keep assessing progress as the implementation process proceeds and ensure staff that time lines are adaptable to current situations to help reduce their stress level. Entire implementations including training can span a couple of weeks for small practices (1-2 physicians) to several months for larger practices.
  • Perform a workflow analysis:analyze existing work processes while looking for opportunities for improved productivity and efficiency. Design new work flows that could be accomplished with the tools available in the EMR and develop a transition plan.
Staff Considerations and Planning
  • Appoint a Physician Champion.A physician champion can be instrumental in the success of the EMR adoption. This person should be motivating, enthusiastic, have a good working knowledge of the EMR and be able to articulate the specific benefits that the EMR will provide.
  • Appoint an in-house Project Manager.Most vendors will supply a project manager for large group installations but in addition, have a key person on staff to oversee the entire project. This person should have extensive knowledge of all areas of the EMR as well as how the EMR will interact with each type of provider and support staff. This person is crucial for the “Big Picture” viewpoint and to know the rationale for decisions that are made.
  • Communicate to the staff the practice’s desire to acquire an EMR before the purchase.Better yet, have them be included in the decision of which EMR vendor to choose. It is common for a physician to choose an EMR with no input from the support staff. This can create a feeling of resentment among staff and a feeling that their input is not useful or necessary. The staff will more likely embrace a system that they have had input in choosing and will be more acceptable to the adoption.
  • Be aware that support staff may feel that they could be replaced by an EMR.In certain cases this may be accurate particularly with file clerks or other types of staff but be sensitive to this possible concern.
  • Have end-user staff be involved in the system set-up.Many times practices rely on only one person to set-up system files, pick-lists, defaults, templates or libraries, customizable options etc.. This presents a problem in that only one person has an understanding of the rationale for the decisions that were made at that time and that knowledge will be lost if that person leaves the practice. It is best to utilize the end-users for system-set-up decisions because they are the ones who will be performing the tasks that the system parameters will affect. They have the detailed knowledge of present procedures and workflows and therefore may know ramifications of such system set-up parameters on other functionality.
  • Map out Workflows utilizing current staff members:Map out current workflows on paper and bring in the end-users who perform the current workflows to help design new workflows for the EMR. No one knows their job better than the person who does it everyday but more often practices do not go to the source for their crucial input.
  • Learning curves are usually underestimated.The learning curve for complete and successful adoption of the EMR is usually vastly underestimated. Even if productivity is not affected initially during the go-live phase, most providers do report an increase in the length of time necessary for documentation, especially if templates are used and the provider’s are not familiar with them. Most providers will spend additional time at the end of the day documenting notes after a go-live. Usually within 6 months to one year, most providers are leaving the office at their normal times. It is difficult to predict length of learning curves and the impact of learning curves on productivity. Utilize the vendor’s knowledge for benchmark learning curve estimates.

Testing Phase

Software/Hardware Testing
  • Test software extensively before implementation.Never assume that the software functions in the way you think it should. Set-up a test database for software testing and for staff training. Thoroughly and completely test all areas of the software and utilize the end-users to test their specific functions.
  • Perform Volume testing, if possible.Take a typical day and do a dry run in a test database. This step is often overlooked but can provide important information regarding the time it takes to enter data with typical volume or increased volume.
  • Ask for a list of known bugs from the vendor for the version you are about to install.If bugs exist, ask the vendor to create work-arounds and identify dates for patch fixes. You do not want to identify a major system flaw or bug during the go-live phase when this could be prevented.
Hardware Testing:
  • Prepare Infrastructure:A crucial part of the success of implementation will rely on the success of the hardware infrastructure readiness. Note: the hardware testing will be much more extensive if a client/server environment exists or is chosen as opposed to a web based or ASP environment where the software and server is hosted by a vendor off-site.

    For a client/server environment, the project should be planned in advance to define locations of workstations, printers, kiosks, servers, and/or wireless device access points etc. Existing hardware systems may need to be upgraded and/or reviewed to determine the stability of the system prior to any software installation. In addition, cabling may need to be run to new locations to accommodate access to the network. New systems need to be purchased and delivered well in advance of implementation to allow for testing. Once the infrastructure is in place the testing phase should begin to ensure all aspects of the network and hardware are functioning properly. Phase 2 of testing begins once the EMR software has been installed complete with a dummy database to enable appropriate testing of the applications in the new environment. All testing should be complete before staff training dates are scheduled. A test environment should be established for future updates, this will allow the IT Director to install future software updates/upgrades in a non-production environment for testing prior to updating live units.

Staff and Testing:
  • Pilot systems before implementation.Pilot workflows, procedures, modules, templates, documentation time etc. in a live environment utilizing a small group of staff long before go-live. This is critical to identifying issues that are unforeseen during the planning phase.

Training Phase

  • Not enough time is allocated for training.This is a very common error made by most practices. Keep in mind that not only are staff required to learn the EMR but also new workflow and procedures. Training sessions are best if kept short and scheduled in increments. Small groups are more beneficial for more personalized training. Allow staff to practice what they have learned using a hands-on approach before introducing new information. Utilize the vendor’s experience with training time but be willing to alter for your individual practice.
  • Training should be performed outside of clinical work sessions.Practice administrators, in their concern to not adversely affect productivity, will attempt to train staff as they try to perform their clinical duties. This leads to poor understanding of the software and frustration. Train users right the first time. There are several methods practices can utilize to effectively train staff such as reducing or blocking schedules, hiring temporary employees, training outside of clinical time etc.
    Staff should also be paid if they are being trained outside of their usual work schedule.
  • Set-up a training room for staff to practice.Giving staff time and a quiet location to practice. This can lead to a comfort level with the software and lessen the apprehension of go-live.
  • Appoint Superusers.Designate certain users to be “Superusers”. Their role is to provide immediate, first line response to staff with questions and issues during go-live. Designate a superuser for each type of clinical role (MA, nurse, receptionist, provider). Superusers should have a more extensive knowledge of the software and workflows. Being able to provide immediate support to staff during a go-live situation will more likely ensure that productivity is not interrupted.
  • Miscommunication risk with Train the Trainer method.One concern with Train the Trainer method is the potential miscommunication and/or misunderstanding of information from one person to another. Trainers supplied by the vendor usually train large groups of users simultaneously and are more experienced with training the software. Train the trainer methods can provide a cost savings to the practice however.
  • Evaluate staff’s readiness for go-live.Assess staff’s knowledge of the software and workflows. Create mock live situations and walk-through the workflows considering all possible scenarios. Be prepared to delay go-live if staff is not sufficiently prepared.

Go-Live Phase

  • Schedule the go-live in close proximity to the end of the training sessions.Try to avoid a long delay between the training sessions and the go-live. No more than a week should be allowed between the end of training and the go-live. This will ensure better retention of the information.
  • Reduce provider schedules:Reduce the number of patients a provider is required to see during the go-live phase. Learning an EMR can be a difficult process, especially for providers. By reducing schedules for some period of time this can take the pressure off significantly. Many practices reduce schedules by 50% for one to two weeks after the go-live and then 25% for several additional weeks. Another method that has been used is to add 15 minutes onto comprehensive examinations and 5 minutes onto follow-up visits. Note: this method may involve some planning ahead to accommodate the scheduling templates.
  • Provider Adequate Resources.Be certain to supply the staff with well trained individuals such as vendor trainers, superusers, in-house project manager etc. during the go-live phase. Create a Help Desk Hotline in case trained personnel are not immediately available. Communicate the chain of support method to all users before go-live. Put a sticky label on each PC with the help desk hotline phone number. Have systems in place if bugs or issues are discovered.

Post Go-Live

  • Post Go-Live Assessment is necessary:Now that the EMR has been implemented, many practices feel as though the installation is complete. However, nothing could be further from the truth. Practice administrators must continue to assess the staff’s level of frustration, monitor productivity, measure patient cycle times, re-evaluate workflows, learning curve assessment, is the EMR meeting the established goals etc..
  • Evaluate the Go-Live with Staff:Query the staff regarding the go-live process. Get their feedback as to what was helpful and what was lacking. This information can help with future implementations especially if new modules are to be introduced in the near future.
  • Provider on-Going training and support:Practice administrators should continue to offer training sessions well after the go-live for reinforcement and refreshment. Staff usually cannot absorb all the information given during the initial training sessions and therefore follow-up training sessions should be offered.

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Evaluation and Management Coding and Electronic Health Records

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By Eric S. Fishman, MD
President,
EHR Scope, LLC dba

EMRConsultant.com
info@emrconsultant.com

Introduction

This document is intended to provide an overview of the guidelines that are used by physicians and auditors to determine the level of evaluation and management service provided during patient encounters. We will review both the complex nature of the rules as well as how electronic health records can assist physicians and their staff with the task of determining the level of service. We will also provide detailed information designed to assist clinicians with evaluating how well electronic health record applications perform automated evaluation and management coding services. Please note, however, that the information contained herein should not be used to determine the actual level of service for an encounter. This should be based upon the 1995 and 1997 Evaluation and Management Documentation Guidelines published by the Center for Medicare and Medicaid Services as well as the Current Procedural Terminology book, published by the American Medical Association, and as are updated from time to time..

Background

In an effort to improve medical documentation, the Centers for Medicare and Medicaid Services (CMS) (formerly the Health Care Financing Administration) expanded the documentation guidelines for evaluation and management (E&M) services in 1995 and again in 1997 1,2. These documents are both currently in effect and provide the basis for chart audits by CMS and other billing agencies.

The number one source of physician income in the United States is the fees attached to the E&M Current Procedural Terminology codes. The rules surrounding how to determine which E&M code to use for a specific encounter are complex. Choosing a code and billing at a fee that is not supported by documentation can result is severe sanctions and financial penalties. These two factors have resulted in a tendency to choose a code that is lower than what would be appropriate for a specific encounter. Electronic Health Records ( EHR ) have played a significant role in improving coding accuracy by improving documentation and through the automatic calculation of the level of service. In this document, we will review what type of documentation is needed to support a specific E&M code, and how electronic health records can assist in making this determination.

The Clinical History

There are three components to the Clinical History:

  1. History of Present Illness (HPI)
  2. Past Medical, Family, and Social History (PMH, FH, SH)
  3. Review of Systems (ROS)

The History of Present Illness

The level of HPI documented may be determined by either of two methods:

  1. The number of HPI elements that are needed to characterize the clinical condition, and are included in the document. The possible elements are: duration, severity, location, quality, timing, context, associated signs and symptoms, and modifying factors.
    • When the document is scored by this method, one of two HPI levels may be chosen:
      • A brief HPI: This consists of an HPI that contains one to three elements. e.g., “Three day history of severe headache” captures duration, location and severity. If no additional elements are documented, then this would be regarded as a brief HPI.
      • An extended HPI: This consists of an HPI that contains 4 or more elements. e.g., “Three day history of severe, throbbing headache with associated photophobia” records duration, location, quality, severity and associated signs and symptoms.
  2. The second method of determining the level of HPI does not include analysis of the HPI elements above, but rather is used when the HPI contains “the status of at least three chronic or inactive conditions.1” In this situation; the HPI is considered to be at the extended level. The following is an example of an HPI that contains three chronic conditions and their statuses:

Example: The patient has a history of diabetes, hypertension, and hyperlipidemia. Her blood sugars have been well-controlled on diet and oral hypoglycemic agents. The patient’s blood pressures have fluctuated significantly based on the patient diary and are suboptimally controlled on her current regimen. The patient’s most recent LDL was less than 100 and the patient is currently taking 40 mg of Lipitor per day.

The Past, Family, and Social History (PFSH)

There are three components to the PFSH1:

  • The past history: “the patient’s past experiences with illnesses, operations, injuries and treatments1”
  • The family history: “a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk”
  • The social history: “an age appropriate review of past and current activities”

There are two potential levels for these sections: pertinent and complete. A pertinent PFSH contains at least one type of history. A complete PFSH may require two or three types of histories, depending on the type of service provided. For example, a new patient evaluation requires that all three areas be documented before it can be scored as a complete PFSH.

The Review of Systems (ROS)

The review of systems is an “inventory” of body systems where the patient is asked to report signs or symptoms they are currently having or have had in the past. The recognized systems include constitutional, eyes, ears nose mouth and throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, neurological, psychiatric, endocrine, hematologic/lymphatic, and allergic/immunologic.

This information may either be documented in the history of present illness or in a section titled review of systems. There are three levels of ROS used for scoring purposes. The first is a problem pertinent ROS that is limited to symptoms that are dealt with in the HPI. If between two and nine systems are reviewed, the ROS is scored as extended. If 10 or more systems are reviewed the ROS is scored as complete. The ROS is also considered to be complete if the systems with pertinent positives or negative are documents and there is “a notation indicating all other systems are negative…”

These rules may be difficult to remember, and the history is only one of the three components taken into consideration when determining the final code. For example, for a new patient evaluation or consultation, to reach a level 4 (e.g., 99204) the history must contain:

  • an extended HPI (4 HPI elements or three chronic conditions with statuses); and,
  • a complete PFSH (all three areas documented); and,
  • information from 10 or more ROS systems.

For an established patient visit, only a detailed history is needed to obtain a level 99214 level of service. One pattern of documentation that would meet this requirement would be:

  • an extended HPI
  • one item in the PFSH
  • information from 2 or more ROS systems.

Since most encounters are a mix of all three components in differing levels of detail, and it may be difficult for providers to retain the rules in memory, electronic health records can assist in this endeavor, as they can usually reliably record which details of the history are added and calculate the score for the history section.

The Physical Examination (PE)

As noted above, CMS expanded the documentation guidelines in 1995 and again in 1997. Both guidelines are currently in effect and differ very little other than in the physical examination. Auditors have been instructed to use either the 1995 or 1997 guidelines when determining the level of service, whichever is most advantageous to the provider.

Both sets of guidelines recognize four types of examination:

  • Problem focused (a limited examination of the affected body area or organ system)
  • Expanded Problem Focused (a limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s)
  • Detailed — an extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s)
  • Comprehensive — a general multi-system examination, or complete examination of a single organ system and other symptomatic or related body area(s) or organ system(s).

The 1995 Guidelines list the following as “Body Areas:”

  • Head, including the face
  • Neck
  • Chest, including breasts and axillae
  • Abdomen
  • Genitalia, groin, buttocks
  • Back, including spine
  • Each extremity

The following are listed as “Organ Systems:”

  • Constitutional (e.g., vital signs, general appearance)
  • Eyes
  • Ears, nose, mouth and throat
  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Genitourinary
  • Musculoskeletal
  • Skin Neurologic
  • Psychiatric
  • Hematologic/lymphatic/immunologic

In order to encourage more detailed documentation that would better support the level of service billed, the 1997 Guidelines were created. They detail what information is needed at a much more granular level in the form of “bullets” (e.g., auscultation of heart). They also divided the physical examination into a general multi-system examination and 11 separate single organ system examinations: Cardiovascular; Ears, nose, mouth, and throat; Eyes; Genitourinary — female; Genitourinary — male; Hematologic/lymphatic/immunologic; Musculoskeletal; Neurological; Psychiatric; Respiratory; and Skin. Determining the level of service became even more complicated as a specific pattern of bullets unique to each examination type is required to determine whether the examination is problem focused, expanded problem focused, detailed, or comprehensive. Specific “scoring” rules are provided for each single organ system examination. In general, for a comprehensive examination, a specific pattern of bullets in “shaded” and “un-shaded” boxes is needed from the single organ system examinations. For a detailed examination, 12 or more bullets must be recorded. For an expanded problem focused examination, 6 or more bullets are needed, and for a problem focused examination, one to five bullets must be documented 1.2.

Electronic health records are particularly helpful when the 1997 guidelines are used to determine the level of service. Relatively simple algorithms can compute the bullets with identified information and inform the user of the type of examination (e.g., detailed) that has been documented.

Complexity of Medical Decision Making

The levels of E&M service recognized in CPT for complexity of medical decision-making include: Straightforward, low complexity, moderate complexity, and high complexity. There are three components that are used to determine the level of service:

  • The number of diagnoses (including “rule-outs”) and the number of management options that must be considered. The following point system is used to make this determination on a per diagnosis basis:
    • Self-limited or minor (1 point) (maximum two points allowed)
    • Established problem, stable or improved (1 point)
    • Established problem, worsening (2 points)
    • new problem (to examining physician), no additional workup planned (3 points) (maximum three points allowed)
    • new problem (to examining physician), additional workup planned (4 points)
  • In order to support this, the following information should be documented as appropriate:
    • the status of the problem(s)
    • the diagnoses considered (e.g., rule out)
    • initiation or changes in treatment, including therapies and instructions
    • referrals
  • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed. There are four levels: Minimal, limited, multiple, and extensive that are determined by a point system. The following items should be documented as appropriate:
    • diagnostic services ordered or performed during the encounter (1 point)
    • the results of diagnostic studies reviewed during the visit (1 point)
    • the decision to obtain additional information from another source such as old records or family members (1 point)
    • the results of a discussion held with another physician who performed a diagnostic study (1 point)
    • pertinent findings obtained from the review of old records or from additional history obtained from other sources such as family members (2 points)
    • direct visualization and independent interpretation of an image, tracing, or specimen that had been previously interpreted by another physician (2 points)
  • The risk of significant complications, morbidity, and/or mortality, as well as co-morbidities, associated with the patient’s presenting problems, the diagnostic procedures and/or the possible management options. The determination of risk is complex3 and rather than using a point system clinical examples are provided in tables contained within the CMS E&M guidelines in each of the following areas.
    • level of risk associated with the presenting problems.
    • level of risk associated with the diagnostic procedures that have been ordered.
    • level of risk associated with the management options have been selected.
  • The highest risk in any one of the above three categories is used to determine the overall risk.

The overall level of medical decision-making is determined by the highest two of the three above elements. For the number of diagnoses or treatment options and the amount/complexity of data reviewed the points are totaled. The maximum number of points allowed from each section is 4. As noted above, risk is calculated somewhat more subjectively.

For example, if the total number of points from both the number of diagnoses or treatment options and from the amount of data reviewed were three, and the risk was low, the level of complexity would be moderate.

Calculating the level of complexity is very difficult without the use of tables or algorithms. Electronic health records can assist this process greatly by identifying information generated during patient care that is relevant to complexity. Algorithms can then determine the level of complexity. Some areas such as the status of a condition and risk are more difficult to determine via algorithms, however once the data is entered the number of points and final level of complexity can quickly be determined.

Final Calculation of the Level of Service

For most encounters, the final determination of the level of service is made by summating the three components (history, physical, and complexity) or by using a time element. For some encounters (e.g., new patients) all three areas must have documentation in order to reach a higher level of service. For other encounters (e.g., established patients) the two highest levels, whether they be from the history, the physical examination or from complexity, are used to make the final determination.

The Role of Electronic Health Records

A high frequency of under-coding has been identified amongst primary care physicians, in particular for follow-up visits. This has been attributed to the complexity of the rules within the guidelines and concern over not having adequate documentation to support a higher level of service. EHRs have the potential of improving documentation and can automatically determine the appropriate level of service based on this documentation. This has resulted in fairly significant improvements in reimbursement for certain groups.

As the 1995 in 1997 CMS guidelines contain a great deal of information and a fair amount of complexity, an EHR that provides automated evaluation and management coding needs to undergo careful testing by experts. As the physician is ultimately responsible for the code assigned to the encounter, steps should be taken to ensure that the manufacturer has done their due diligence before purchasing a system. You may wish to inquire as to whether or not the suggested level of service generated by the system matches the level of service assigned by an auditor for the same document. We would suggest carefully comparing the coding level recommended by the EMR with your own opinion of the proper coding level, prior to submitting your bills.

Some Common E&M Codes

Encounter Level New Office Visit Revisit Consultation
Level 1 encounter 99201 99211 99241
Level 2 encounter 99202 99212 99242
Level 3 encounter 99203 99213 99243
Level 4 encounter 99204 99214 99244
Level 5 encounter 99205 99215 99245

Bibliography

  1. 1995 Documentation Guidelines For Evaluation & Management Services, Center For Medicare and Medicaid Services, 1995
  2. 1997 Documentation Guidelines For Evaluation & Management Services, Center For Medicare and Medicaid Services, 1995
  3. Grider, D. Medical Record Chart Analyzer, AMA Press, 2002
  4. Current Procedural Terminology, AMA Press, 2005

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Medical Software Comes in Many Styles

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See which type of Medical Software would be Most Appropriate for Your Medical Office

By Eric Fishman, MD
President
EMRConsultant.com
info@emrconsultant.com

The HITECH ACT discusses Electronic Health Record Software extensively, with the phrase EHR mentioned more than 100 times within the document. However, there are a variety of other forms of medical software.

EHRScope.com provides an incredible listing of medical software. Providing links to over 300 Electronic Health Record software programs, it is the most comprehensive database of medical software available.

However, as above, medical software can include Electronic Health Records, such as those which we evaluate, as well as other forms of medical software.

Electronic Health Records (EHRs) are also frequently called Electronic Medical Records (EMRs). If you’re interested in learning about the differences between EMRs and EHRs, there are a variety of articles on this category of medical software.

Other categories of medical software which may be of interest include Medical Billing Software. Medical Billing Software can be incorporated into an Electronic Medical Record Software program, in an integrated EMR / Medical Billing software program, or it may be a stand-alone program. In fact, many of the earliest forms of medical software were stand-alone Practice Management Software (PM) or Physician Practice Management Software (PMS) and these were, by far, the most popular medical software programs in the 1980s and 1990s. However, current state of the art medical software usually includes a medical record software component along with the practice management / aka medical billing software program.

Another interesting concept which needs to be addressed when discussing medical software is whether you want a client/server medical software program or a ‘Software as a Service’ aka SaaS program. As a basic principle, if you are a solo physician or practicing in a small office you almost always will want Software as a Service (or SaaS) as this will minimize your dependence upon an internal information technology support person. Once you reach 5 physicians, and certainly having reached 10 physicians, it becomes reasonable to consider a client/server medical software program, whether this be an EMR or a medical billing software program. Please don’t interpret this to mean that all 5 physician offices require a client/server medical software program, but rather that offices smaller than 5 physicians should, at least at this point in time, almost never consider client/server software because of the inherent complications and expenses associated with maintaining the medical software on servers within your office.

Other common classes of medical software include e-prescribing software. E-prescribing software has, at least in the past, frequently been a stand-alone medical software program. However, at this point in time there is a significant movement to have this software incorporated into a more comprehensive software program such as an integrated EMR/Medical Billing software program.

Then there are various Medical PDA software programs, but again, as time goes on, these stand-alone utilities are being incorporated into comprehensive medical software suites. In the 1980s and more so in the 1990s, these PDA medical software programs included software programs which would have various medical information available within them, including standard diagnostic and physical examination software programs. This information is now more appropriately incorporated into more sophisticated databases such as those which are incorporated into medical decision support software as a part of an EMR. However, there remain various PDA medical software programs for most medical specialties. Again, most of these have been incorporated into fully functional EMRs or combined EMR/PM systems.

Brand names of these various long-existing types of medical software include “Epocrates,” “Harrison’s Manual of Medicine,” “Washington Manual of Therapeutics,” and “Tarascon Pharmacopoeia” as well as a variety of medical dictionaries which were available as software programs.

And, then of course there were a variety of medical software programs that were specifically developed for The Palm. Various programs include, for instance, medical terminology in English and Spanish.

To learn more about Electronic Health Records, visit EHRScope.com

Providing Better Healthcare Services through a Medical Kiosk

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Online technology has advanced tremendously during the past few years, allowing healthcare providers to provide top-of-the-line multimedia information systems in the form of the medical kiosk. This technology allows patients to check-in on their own, check their insurance or co-payment options, fill out forms, check their medication dosage and even perform non-invasive medical tests without assistance – all at the push of a touch screen panel. Paperwork can be totally eliminated, patient registration becomes a lot faster, and medical staff can shift their focus from administrative tasks to providing proper healthcare to their patients.

There are hundreds of millions of people who use the Internet and from these figures it can be estimated that each day, over 10 million Americans go online seeking health related information. As people become more informed they become more focused on health and wellness, and identifying ways they can receive proper healthcare. People are ready to make the extra effort to search for the highest quality and the most cost effective healthcare service available in the market.

The prohibitive costs of healthcare have caused hundreds of thousands of Americans to seek healthcare in other countries that foster medical tourism. These countries are popular for their very low cost of medical procedures, and patients appreciate the very little or no waiting time in the rendering of medical services. These factors cause a great deal of satisfaction to these travelers. Best of all, the quality of healthcare provided is comparable to that offered in the U.S. and may even exceed that of western countries.

The increasing popularity of medical tourism should serve as a wake up call for healthcare providers in the United States. The practices need to further improve the quality of healthcare and customer service that they currently offer their patients. While cost is a top factor, the long waiting time for medical service is another reason that drives patients in the U.S. to seek healthcare elsewhere. Healthcare providers can improve quality of service with the help of innovative medical kiosks.

Features and Applications of a Medical Kiosk

Similar to multimedia kiosks found in commercial establishments, a medical kiosk is a self-service information gateway that is designed specifically for hospitals, clinics and other healthcare services. The kiosk is interfaced with the providers existing electronic database or medical record system, allowing patients to check-in and check-out much faster and much more conveniently.

The patient or user interface is usually a touch screen or a keyboard connected to a computerized system that is also equipped with security cameras, card scanners and printers allowing a fully automated registration process. Similar to the kiosks found in commercial establishments, medical kiosks can be stand-alone units, placed on a countertop or can be mounted on a wall. Some advanced systems can even be mobile in the form of a tablet PC, allowing patients to conveniently check or fill-up required information and perform other functions.

The following are the basic applications for a medical kiosk, which medical establishments can apply according to their needs and structure.

  • With a medical kiosk system, the patient can either check-in, make an appointment with their doctors, fill-up forms, select an appropriate room and check their insurance status or if there is a need, transact their co-payment collections using their credit cards. All these can be done in a self-service manner and without assistance from front desk personnel, thus reducing waiting times and improving the registration process significantly. Other features in a self-service patient check-in kiosk include:
    • Patient information gathering through online forms/checklist
    • Checking of patient health history
    • Self-service appointment scheduling
    • Informed consent forms
    • Room assignment / finding your way in the hospital
    • Patient satisfaction surveys
    • Checking of payment options / co-payment collections through credit cards
  • A medical kiosk can also be an information portal where patients can learn more personalized information about their diseases that they otherwise will not see in a single brochure. The system can show multimedia information and videos that were previously reviewed and approved by certified specialists in a particular field. These multimedia tools can be great vehicles to educate patients in order to gain awareness and understanding about certain diseases. Although face-to-face doctor-patient interaction cannot be replaced by videos, the time needed to educate patients can be greatly reduced relieving busy medical specialists and providers.
  • Some medical kiosks are also designed to provide or dispense an unassisted, non-invasive medical testing kit which can immediately be retrieved, analyzed and recorded by the same system. This type of kiosk can be a very useful tool in screening or diagnosing new patient conditions, and it can help facilitate the monitoring of existing conditions. The following are some of the features of this unit:
    • Dispense recyclable or disposable unassisted and non-invasive medical testing kits
    • Dispense basic healthcare and medical items
    • Perform test procedures using instruments installed (ex. Heart rate; blood pressure; etc)
    • Analyze test results, make a preliminary diagnosis and provide status and information to patient
    • Send a report of the results to a medical professional who will provide the final diagnosis
    • Send report to the patient’s insurance company
    • Include results in the patient’s electronic patient record (EPR) stored in the providers electronic medical record system
    • Reclaim test kits, dispose non-reusable items and maintain hygiene by decontaminating itself before use by next patient
    • Reusable test instrumentation parts and components will be sterilized before use by next patient

The Benefits of Having a Medical Kiosk

Having a fully-automated and fully integrated medical kiosk system that can process patient check-in, provide medical information, or dispense medical services can be very beneficial to practices, as it can:

  • Reduce waiting time and improve customer service to deliver better patient care while allowing them to control their own healthcare experience
  • Provide greater convenience and privacy to patients (particularly for those who prefer not to tell front desk personnel why they need to see the doctor), providing them the same self-service options that they enjoy in other industries
  • Reduce costs through the elimination of paperwork, reduced overhead cost, and optimize staff time allocations from administrative to more patient-care related tasks
  • Ensures data are accurate and compliant to HIPAA standards
  • Streamline the workflow and increase the productivity in the medical procedure area, which will eventually be translated to increase revenue

Points to Consider While Choosing a Medical Kiosk System

There are certain considerations to make before purchasing a medical kiosk system for a clinic, hospital or medical practice. Some of these considerations are discussed here:

  • The kiosk system that you intend to buy should be designed according to the patients stepping in your healthcare facility. Patients’ needs may range from faster check-in services, more informative healthcare education and training, or the ability to perform basic tests without assistance from staff.
  • Choose the type of hardware that will be well-suited for the establishment. Larger space can allow stand-alone systems, while limited-sized practices can do better by accommodating wall-mounted kiosk or tablet PC’s.
  • The medical kiosk system should have HIPAA compliant screens, including fully secured privacy protection of patient’s records and medical information. This includes privacy filters, secured patient identification systems, video monitors and recording systems.
  • The kiosk should have multilingual support and interface for languages commonly used in your area of operation.

It is also important to note that the medical kiosk system should be user friendly and very easy to navigate, particularly for patients unfamiliar with multimedia technologies and computerized systems. These systems will ensure that your patients can receive good customer service and enjoy a more convenient and higher quality healthcare experience.

7 Critical Factors When Purchasing the Right EMR Software

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Jumping in head first is not a good idea when implementing electronic medical record ( EMR ) software in your practice. If you do not properly prepare, you may not select the best EMR for your practice. As a result, you may select a great EMR, but just the wrong EMR, and this can be catastrophic to your business.

Purchasing the best EMR takes time. You need plan accordingly. We’ve provided you with 7 tips that will enable you to purchase and implement an EMR successfully.

Research. Become familiar with the industry and learn what people have to say about EMRs. Unfortunately when you speak to sales reps from the EMR Companies they will be biased about their product. Look for unbiased information. There are EMR Consultants out there that will help you find the right fit for your practice. In addition, there are several EMR, EHR and HIT blogs that provide unbiased information about the EHR Industry.

Rational Planning. You are not going to be able to reduce your medical costs after five minutes of using your EMR system. Therefore, make sure to set EMR goals that are reasonable to attain. Write out an EMR implementation planthat will include milestones that you want to reach as well as what you are looking to gain from an EMR.

Attitude. Make sure that your entire medical practice has a positive attitude about using an EMR solution. Keep your staff involved in the EMR selection process so they have a better understanding about what will happen. Making sure everyone is on the same page is critical for EMR success.

ROI. Determine what type of Return on Investment can be expected when implementing an EMR system. EMR software can be extremely costly depending on what type of EMR features you are looking to implement. Therefore, it is important to have an idea of what your EMR budget will be, as well as the cost savings expected from a proper EMR implementation.

Technical Competency. Discuss with your staff how tech-savvy they are at using computers. Making sure your staff feels comfortable using new technology will help prepare everyone for this transition to an EMR.

Hardware. Selecting the correct hardware will save you thousands of dollars when purchasing an EMR solution. Not only will it save you money, it will also improve the functionality within the EMR. There are several hardware companies that have partnered with EMR vendors, so be sure to ask them what hardware will work best with the EMR product. Ask the EMR vendor if they offer bundled solutions. Another alternative is to speak with an IT consulting company at the beginning to enable a smooth EMR implementation. Of course there are dozens of additional considerations when selecting and implementing an EMR, and the above may be considered a very basic overview. To learn more about EMRs, please fill in the brief form below.

Implementation Process for an Electronic Medical Record (EMR)

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By Eric Fishman, MD
President
EMRConsultant.com
info@emrconsultant.com

It is unlikely that you will find the process of implementing an Electronic Medical Record in your office to be an easy one. However, there are a variety of activities that you can do to simplify and streamline the process, and increase the probability of success.

First, please understand that not only do you need to learn a new complicated and sophisticated software program, but you also need to undertake a significant modification of your current workflow.

At EMRConsultant.com we believe that we have realized a mechanism to split these two processes, thereby significantly increasing the probability of a successful implementation.

Assuming that you have made a decision that you will be implementing an EMR in the ‘not too distant future’, but are not ready to purchase one immediately, we have found that modifying your workflow to one which will more closely model the workflow that will be imposed upon you by the EMR can be very helpful during the extended implementation process.

Our current recommendations are that, again assuming you have not yet chosen which EMR you will be utilizing, are that you start to modify your workflow by utilizing a Tablet PC, and voice recognition software, so that you can get used to the process of keeping a portable computer by your side, and completing as much of the patient documentation as possible during the actual encounter.

Our current specific recommendations in this regard are that you utilize a Motion Computing LE1600 Tablet PC, with 1 GB of RAM. If you know that you will be utilizing an ASP model EMR eventually, you can save a few dollars by purchasing one with a 30 GB hard drive. If you are unsure, or if you know that you’ll be utilizing a client server model, we would then recommend that you purchase the tablet with a 60 GB hard drive.

Adding Dragon Medical 9 Medical voice recognition software, and possibly a Bluetooth wireless microphone completes the initial setup.

It is our opinion that this hardware / software combination will be compatible with the overwhelming majority of EMR software packages that you are likely considering as your final choice.

There are a number of advantages to utilizing this model during the extended implementation procedure. You will have spread out the costs associated with implementing an EMR by months. The above configuration is likely to cost less than $6000.00, and you will start saving money from the onset, as your transcription costs will either be significantly diminished or altogether eliminated, thereby allowing you to save toward what will be the larger expense of the software licenses and implementation fees.

Further, there will be many fewer issues you will need to deal with during the actual implementation of the EMR itself. You will already be familiar with the hardware that you will be carrying around. You will already be familiar with the most appropriate input mechanism for a portion of your report – namely Dragon Medical, and your workflow will have been modified such that your medical reports will now be completed while your patient is leaving the office.

If you have any questions about our recommendations, we will be happy to hear from you at 888.519.3100.

Yours,

Eric Fishman, MD
Managing Member EHR Scope, LLC

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Terminology in the HealthCare Records Industry

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By Eric Fishman, MD
President
EMRConsultant.com
info@emrconsultant.com

There are a number of acronyms concerning the industry. Some are confusing and some are redundant. However, there are some subtle differences between the various acronyms, at least according to their most common usages. Following is our interpretation of this rather confusing array of terms, as of 2005.

Note, that after each term, I indicate the number of results that Google offers when searching for this term, as of March 2005. It is my belief that these numbers will migrate over time, indicating the trends both of verbiage, as well as the trends towards utilizing terms which indicate greater levels of interoperability. This position is similar to that taken by Naisbitt in his 1982 book Megatrends; namely that the frequency of printed usage of different terminology indicates important societal trends.

Following are a variety of terms which are frequently utilized to describe, with various intonations, the process of documenting information concerning the medical care of patients.

  • Document Management System – 65,000 Google search results
    (when adding +medical) in March 2005
    • A Document Management System implies the ability to manage the individual documents within an individual physicians office. It lacks, in general, the interconnectivity capabilities of both an EMR and an EHR.
      • An example would be a scanning system which can scan in previously produced documentation, whether that documentation be produced by handwriting, dictation, or some other means.
      • A second example would be a template driven document production system.
      • Voice Recognition software, including Dragon Medical®, when used alone, can be part of a document management system, and when utilized with PaperPort for filing can be another example of a document management system.
  • Automated Medical Record – 500 Google search results in March 2005
    • This term is obviously used only infrequently at present. However, it was an early stage of ‘automating’ the process of medical documentation.
    • “Information stored on a standard personal computer doesn’t comply with legal requirements for electronic medical records, so a paper file must be maintained. The computer information is used as a working file, and then pages are printed and filed in the chart.” http://www.aafp.org/fpr/july96/computer/records.html
  • EPR – Electronic Patient Record – 66,000 Google search results in March 2005
    • This is rather similar to Computerized Patient Record. It is an older term, and is remaining popular largely because of the Medical Records Institute, the entity which runs the TEPR, Towards an Electronic Patient Record, convention; TEPR is now in its 21st year.
  • CPR – Computerized Patient Record – 28,000 Google search results in March 2005
    • The CPR is defined as a computer-based record that includes all clinical and administrative information about a patient’s care throughout his or her lifetime. The documentation of any practitioner ever involved in a person’s healthcare would be included in the CPR, extending from prenatal to postmortem information. This is one of the original phrases for what was until recently called the EMR, but is now generally referred to as the EHR. (adopted from HIPAAdvisory.com – http://www.hipaadvisory.com/action/ehealth/EHR-reality.htm)
    • Interestingly, a current search of Google for Computerized Patient Record will result in dozens of articles from the mid to late 1990’s.
    • The VA program, continues to use this terminology, calling their VISTA system a CPRS or Computerized Patient Record System, as early as 1996. See: http://www1.va.gov/CPRSDEMO/
  • Computerized Medical Record – 10,000 Google search results in March 2005
    • This term is relatively infrequently used in this century. However, in the 1990’s it was more common.
    • “At this level, physicians and staff collect information on paper and scan it into the computer. As with the automated medical record, it’s departmentalized, so patients must provide their names and other information each time they visit a different department. However, the computerized medical record addresses some legal issues–such as preserving data integrity–because information can’t be altered on screen.” From the AAFP, 1996; http://www.aafp.org/fpr/july96/computer/records.html
  • CCR – Continuity of Care Record – 5,000 Google search results in March 2005
    • This is a standard of ‘interoperability’ which has recently become popularized. It is a “snapshot” of a patient’s care which can frequently be downloaded into a “Thumb Drive” or other very small portable memory storage device, and brought by a patient to various health care facilities. It frequently includes:
      • History of Present Illness
      • Current Medical Conditions
      • Past Medical History
      • Allergies
      • Medications
    • The EHR ideally would provide this function, however as true interoperability between EHR platforms is not likely in the foreseeable future, the CCR allows for selected information to be shared between providers. It uses neutral technology, so there is not need to purchase proprietary software to interpret the record. Waegemann, CPRI, 2004
  • PHR – Personal Health Record – 58,000 Google Search results in March 2005
    • The emphasis in the PHR is on the individual patient.
    • With a PHR, patients can frequently carry around a thumb drive or card holding digital data to their various physicians, having each physician add to the data. It is similar to the CCR standard, but is more patient centric, as opposed to physician centric. Some of these allow the patients to update their own information.
  • EMR – Electronic Medical Record – 225,000 Google search results in March 2005
    • This implies a level of sophistication above a “Document Management” system. Not only does an EMR allow for you to create documents within your office, it allows you to import information from a variety of external sources, such as:
      • Laboratories
      • Radiology facilities
      • Pharmacies
    • While there are precious few black and white distinctions regarding this nomenclature, an EMR will frequently have the ability to “upload” or transmit information to a pharmacy, specifically regarding individual prescriptions for an individual patient.
    • Definition “Electronic record with full interoperability within an enterprise (hospital, clinic, practice).” Peter Waegemann May 2003 – Healthcare Informatics
  • EHR – Electronic Health Record -109,000 Google search results in March 2005
    • This implies a sophisticated level of interoperability within the community. The implication of the “Health” as opposed to the “Medical” in EMR is that it is a longitudinal record of an individual patient’s health record.
      • The EHR is generally not considered ‘owned’ by any one physician, but rather is compiled, in many instances, from pieces of information which can be added by any / all of the following:
        • Family Physician – Primary Care Physician
        • Specialist(s)
        • Laboratory
        • Radiology facilities
        • Pharmacies
        • Insurance carriers
      • Each of the above entities is capable of both receiving information from and providing information to the longitudinal EHR. Obviously some entities will do more “uploading” and others will do more “downloading”. However, the bi-directional free interoperability of the EHR is its major distinguishing feature, differentiating it, in common parlance, from an EMR. It is also broader in context that the EMR, as it is the aggregate of the total experiences related to patient care, not just documentation of medical information.
        • HIMSS provides the following definition: “The Electronic Health Record (EHR) is a secure, real-time, point-of care, patient centric information resource for clinicians. The EHR aids clinicians’ decision making by providing access to patient health record information when they need it and incorporating evidence-based decision support. The EHR automates and streamlines the clinician’s workflow, ensuring all clinical information is communicated and ameliorates delays in response that result in delays or gaps in care. The EHR also supports the collection of data for uses other than clinical care, such as billing, quality management, outcomes reporting, and public health disease surveillance and reporting.” HIMSS 2002

It is my opinion that the relationship between the number of search results for EMR and EHR will reverse itself within the next 12 – 24 months, as more and more emphasis is being placed on the interoperability of the various programs.

Finally I am hesitant to offer costs of various levels of sophistication. However, having frequently been asked, here goes:

  • Many Document Management Systems will cost between $1000.00 and $5000.00. For instance, one could consider voice recognition software and a collection of MS Word macros a document management system.
  • Many Electronic Medical Records packages will cost around $10,000.00 per provider, inclusive of all associated installation and training costs.
  • Most Electronic Health Records packages will cost a medical group substantially over $10,000.00 per provider, and will probably cost between $25,000 and $50,000 per provider for a complete implementation.

What is E-prescribing and What are the benefits?

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By Ursula Pennell
© 2009 EMRConsultant.com
info@emrconsultant.com

E-prescribing Overview:

E-prescribing has been described as the solution to improved patient safety and reducing sky-rocketing medication costs. It is estimated that approximately 7,000 deaths occur each year in the United States due to medication errors. These errors are predominately due to hand-writing illegibility, wrong dosing, missed drug-drug or drug-allergy reactions. With approximately 3 billion prescriptions written annually, which constitutes one of the largest paper-based processes in the United States, the writing of prescriptions can be streamlined and efficient by using an e-prescribing system.

What is e-prescribing?

E-prescribing is simply an electronic way to generate prescriptions through an automated data-entry process utilizing e-prescribing software and a transmission network which links to participating pharmacies.

  1. Improved patient safety and overall quality of care:
    • Illegibility from hand-written prescriptions is eliminated, decreasing the risk of medication errors and decreasing liability risks.
    • Warning and Alert systems are provided at the point of prescribing: It has been documented that medication errors are often the result of inadequate access to current drug reference information. E-prescribing systems can provide an overall medication management process through drug utilization review (DUR) programs. DUR programs perform checks against the patient’s current medications for drug-drug interactions, drug-allergy interactions, diagnoses, body weight, age, drug appropriateness, correct dosing; contraindications, adverse reactions, duplicate therapy alert etc. and alerts the provider if interactions are found. E-prescribing software can also include such drug reference software programs as ePocrates Rx. Pro and the PDR.
    • Access to patient’s medical history. Knowing the patient’s medical history at the time of prescribing can serve as an alert to drug inappropriateness.
  2. Reduces or eliminates phone calls and call-backs to pharmacies. Physician offices receive over 150 million call-backs from pharmacies with questions, clarifications and refill requests. According to HIMSS article on e-prescribing under Topics and Tools at their website almost 30 percent of the 3 billion prescriptions written annually require a call backs. This equals 900 million prescription-related telephone calls annually1. Medco® Health Solutions, Inc. conducted a survey in 2003 of Boston area physicians and 88 percent of those surveyed said they, or their staff, spend almost one-third of their time responding to phone calls from pharmacies regarding prescriptions. Medco reported that one practitioner in the survey indicated that in a time study of his four physician practice, the average phone call between a pharmacist and practitioner lasted eight minutes and was costing his practice more than $200 per week in wasted staff time2. These call-backs interrupt office flow and reduce productivity related to chart-pulls, re-filing charts, follow-up calls, faxing prescriptions etc.
  3. Eliminates faxes to pharmacies.
  4. Streamlines the refill’s requests and authorization processes. Refill authorization from the pharmacy can be a completely automated process and refills can usually be generated in one click. The pharmacist generates a refill request/authorization that is delivered through the network to the provider’s system, the provider then reviews the request, approves or denies the refill and the pharmacy system is immediately updated.
  5. Increases patient compliance. It is estimated that 20% of paper-based prescription orders go unfilled by the patient. E-prescribing systems expedite the filling of prescription at the pharmacy and drug literature can be printed for patients as well.
  6. Improves Formulary adherence. By checking with healthcare formularies at point-of-care, generic substitutions and generic first-line therapy choices are encouraged thus reducing patient costs.
  7. Increases patient convenience by reducing patient trips to the pharmacy and reducing wait times.
  8. Offers true Provider Mobility Full mobility can be attained when using a wireless network to write or authorize prescriptions anytime from anywhere.
  9. Improves reporting ability. Query reporting may be performed which would be impossible with a paper prescription system. Common examples of such reporting would be: finding all patients who have had a particular medication prescribed to them during a drug recall, the frequency of medication prescribed by certain providers etc..

Note: controlled substances are currently not permitted to be filled via electronic means. If a user attempts to send a controlled substance electronically – a system message informs the user that this medication can not be filled this way and offers options to print or fax.

What your practice needs to do to get started e-prescribing:

  1. Decide whether you wish to choose a stand-alone e-prescription software or a full EMR system which includes e-prescribing functionality.
  2. Choose an e-prescribing software vendor. The e-prescribing vendor will need to utilize a company which supplies the electronic prescribing network (hub or gateway for transmissions). There are a few different e-prescription networking companies. Among the industry leaders are SureScripts (http://surescripts.com/), RxHub (http://www.rxhub.net/index.html), and ProxyMed (http://www.proxymed.com/). It is unlikely that physicians would have any reason to have direct contact with the electronic networking vendor. SureScripts, the nation’s largest electronic prescribing network, provides a true, seamless electronic connection between physician offices and pharmacies. This network provides secure and reliable two-way transmissions between physicians and pharmacies. More than 85% of chain and independent pharmacies have tested and certified their systems to connect to the SureScript electronic prescribing network.
  3. Install an internet connection; high speed is highly recommended.
  4. Purchase hardware such as desktop PC’s, laptops, pocket PC’s, tablet PC’s , PDA’s utilizing a wired or wireless network.

References:

  1. HIMSS – e-prescribing article under website
  2. Medco® Health Solutions, Inc. – News and Pressroom article on 2/7/2003
    “Boston Area Physicians Embrace E-Prescribing Technology as a Tool To Improve Healthcare”.

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The Importance of Voice Recognition in an EMR

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By Eric Fishman, MD
President
EMRConsultant.com
info@emrconsultant.com

In the beginning there was memory. The physician’s memory was the original repository of the patient medical record. Memory was supplemented by handwritten notes on papyri in ancient Egypt and Babylon and on paper from medieval times to the 20th century. With the advent of recording devices in the 20th century, handwritten notes gave way to the infinitely more time effective practice of dictating patient notes into a recorder which were then transcribed into a typewritten or word processed document. Of course, that practice introduced an extraneous third party into the medical record keeping process: the transcriptionist with the attendant additional expense to the physician and loss of privacy for the patient.

In the 1990’s, speech recognition software came to market and products such as Dragon Medical® enabled physicians to either speak directly to their computers to produce patient records and reports instantaneously or to continue dictating on recorders which could then be ported onto a computer so that a digital voice file could be transcribed by the software to produce the patient record. The transcriptionist was often eliminated from the process and efficiency increased in terms of time and money spent to produce the patient record.

At the current time, 21st Century technology offers physicians and health care providers a medical record paradigm that will not only vastly upgrade the process of producing, maintaining and safeguarding medical records but will, in a direct and fundamental way, actually improve the quality of medical care. The technology is Electronic Medical Records (EMRs). EMRs produce the most accurate and complete patient health record possible to date and help physicians practice better medicine as well. EMR technology is available in a plethora of shapes and sizes with a great variety of possible features. The technology can change the way you interact with your patients, from before they make their first appointment to after they’ve left your office, and have questions about their visit in your office.

As a practicing physician you are aware of the repetitive nature of some aspects of your practice, specifically with regard to patient diagnosis. It is very likely that you and/or your staff have asked the same or at least very similar questions to each of the thousands of patients you have treated. Unless you are practicing in a tertiary referral center, and never see the same condition twice, the patient answers likewise tend to be repetitive. Similarly, physical examination findings fit into certain categories that are seen over and over again. For this reason, most of the current high-end Electronic Medical Record products very capably utilize ‘pick lists’ or ‘click and point’ methodology to complete large portions of the patient medical record.

These point and click systems are particularly adept at documenting, for instance, allergies to medications, medications that are currently being taken, past medical history, family history, social history, and major portions of the physical exam. This is the case because of the narrow range of options which are available as patient responses. For instance, your patient either smokes or doesn’t smoke. And if he/she smokes, it is probably 1 ppd, or 2 ppd, or some other value that can reasonably easily be foreseen by the experts who have designed the point and click system for your office.

However, the historical portion of the patient medical record typically has a great deal of information that cannot be easily foreseen by the developers of the point and click templates. For instance, as an Orthopedic Surgeon, my patients frequently find themselves in automobile accidents. It is not likely that the author of whichever EMR may find its way into my office has contemplated the various street names and intersections in my community. Therefore, in a typical point and click system, there will be a scarcity of relevant information concerning the specifics of the accident. And I find that these specifics are important for a wide variety of reasons, not least of which is that they remind me of the particulars regarding this patient when they return to the office. Utilizing templates for the historical portion of the report, while feasible, tends to produce extraordinarily repetitive reports, each of which sounds not only vaguely similar to the previous patients, but in many cases essentially identical to other patients. This certainly makes it difficult to recall the characteristics of this particular patient.

Based on extensive, personal experience I can unequivocally state that production of a medical record with a system that restricts the user to point and click templates exclusively is far from perfect. At one point in time I undertook the academic exercise of trying to put together a decision tree regarding the mechanism of injury for the occupant of a motor vehicle who was involved in an accident. I started with a Microsoft Access database and started branching. First, was my patient the driver, front passenger, or rear passenger? For each of these 3 options, I then wanted to know if there were 1 car, 2 cars, or multiple cars involved. We now have 9 options. Then we need to know if the car was stopped, traveling slowly, traveling at a moderate rate of speed, traveling quickly, or traveling at an unknown rate of speed. With these 5 options we are now up to 45 mechanisms of injury. Was a seat belt in use; was the headrest properly positioned. 4 more options, and now we are at 180 choices. Was the vehicle impacted from the front, rear, left side, right side, left front, right front, left rear, right rear. Another 8 options to consider. Next, did any portion of the patient impact any portion of the vehicle? This gets a little more difficult to enumerate, but I classified the body into 8 different areas that were likely to have been injured. Then I wanted to know was there a substantial amount of damage to the vehicle, etc.

Eventually, I had an untold number of different mechanisms of injury for an automobile accident, each of which could very easily be documented for each of my patients. It would merely take a few clicks of a mouse, and I immediately had paragraphs of text on my document which covered, or so I thought, essentially every possible option.

Did it work? My answer is a resounding NO. This was, as I mentioned, a ‘home grown document management system’, and I could customize it at will within my office. I found that in at least 50% of the patient visits, I needed to change the templates since I had not, in fact, taken into consideration every possible mechanism of injury.

So, what did I do? Like any physician who knows that he can make the system work, I modified the templates each and every time that I found it necessary to do so. I figured that after seeing ‘enough’ patients, the percentage of new patients who didn’t fit into the predetermined potential mechanisms of injury would diminish, and when it was below 10%, I’d stop customizing it. One flaw persisted; the number of new patients who didn’t fit into the mold never went below 50%. It just stayed there. No matter how many different options I placed into the template, my patients just hadn’t reviewed my EMR before having their accidents, and therefore hadn’t complied with my predetermined mechanisms of injury!

I either needed to choose a different patient population – one that was more considerate of the templates that I was using – or I needed to discontinue the use of the templates. I didn’t like either option, and I quickly determined that the middle ground was best. I kept my patients, and I kept my templates. However, I utilized the templates only for the portions of the reports for which they are most appropriate. I need to test the range of motion of the spine on all of my patients who complain of spinal pain. The AMA published a book which tells me what the ‘Normal Values’ are. I made templates out of the MS Word macros I had been using for years, and in just a few short clicks, the entire range of motion was documented.

But what did I do for the pesky history that was so difficult to document properly? I resorted to the state of the art of the 1990’s and implemented Dragon Medical speech recognition software. I dictated the history using Dragon, and used templates for the rest of the medical report. It worked perfectly.

Therefore, I recommend to any physician that he or she integrate Dragon Medical speech recognition software into their EMR system to produce the best and most complete patient health record. This is because the pre-determined templates of most EMRs simply cannot anticipate the full spectrum of facts presented by the patient which must be incorporated into the historical portion of their health record. The historical portion of the patient medical record should not be truncated to fit a narrow range of template options and speech recognition technology enables the physician to dictate the entire patient history and any other patient data into the EMR.

One of the advantages of an EMR is that it allows physicians, hospitals, insurance companies, pharmaceutical companies, medical societies, and other parties entitled to view the patient data for legitimate, permissible purposes, to do so. Legitimate, permissible purposes include coordinating patient treatment, accessing diagnostic procedures and results, preventing adverse drug reactions, and ensuring medical practice within clinical practice guidelines. One particularly high priority purpose from the physician’s standpoint is that the data be accessed by third party payors to streamline reimbursement for services.

An issue that arises with the integration and use of speech recognition software in an EMR system is that the voice dictated text may not be maintained adequately as ‘data’ and therefore may not be appropriately parsed with current technology. It is therefore not easily accessed by third parties, and may not be able to be utilized, for instance, for E/M coding. However, the dictated text is generally not information that third parties require. For example, in the context of the particular facts of an automobile accident, I do not believe that the E/M code will be different for a front-end, 1 car collision than it is for a 2 car rear-end collision. Similarly, it is highly unlikely that there is any difference in medical care for a patient who develops chest pain at their favorite local restaurant, as opposed to developing it while they were at the fair. Again, if the child’s earache started after they swam in their backyard pool, as opposed to the local municipal swimming pool, the treatment provided is likely to be similar.

Even though the historical portion of the medical record which is dictated does not constitute ‘data’ that can be captured by third parties, given the current state-of-the-art, this is a slight disadvantage with no substantive impact. Any perceived disadvantage is significantly outweighed by the benefits to the treating physician and the patient of having a complete patient history on file which the physician can access and utilize in rendering proper medical care.

There is a trend towards utilizing artificial intelligence to parse the dictated historical portion of the record so that the EMR can capture it as data. However, I do not believe that there are any reasonably priced, commercially available products which do this with sufficient accuracy at this point in time as to be practical. However, in the not too distant future, this is likely the direction that dictated text will take.

One of the limitations of speech recognition technology in the past was that the level of accuracy only reached 96 or so percent. However, the latest versions of the software, combined with modern hardware configurations, has resulted in a 99% accuracy rate except for those physicians who speak with particularly unusual and heavy accents. It is generally accepted that a 98% accuracy rate for a human medical transcriptionist is the standard. Most physicians should be able to obtain at least 98% accuracy without any significant difficulty, and 99% accuracy is more and more common using the current version of Dragon Medical. In fact, I have seen published reports of physicians with accuracy rates of over 99.5%.

Another factor which may concern a physician is the need to wear a headset microphone which is physically attached to a computer. While this is the ‘standard’ mechanism of utilizing voice recognition software, there are a variety of options. One is the use of a wireless headset, or even an array microphone which can be attached to the computer, but not to the physician. A more and more common alternative is the use of a high-end digital recorder, such as those by SONY®, Philips®, or Olympus® to capture the spoken voice, which can then be ported to a computer that then analyzes and transcribes the dictated text. In situations such as this, the medical office will frequently utilize the services of a ‘revisionist’, to review the text, as opposed to a transcriptionist who classically types it from scratch.

In step with hardware that permits computing in a mobile environment by means of a tablet PC or laptop, the newest release of Dragon Medical includes a roaming user profile. This allows physicians to dictate, using their own personalized user profile, from any of a variety of networked computers, PCs, tablets, etc.

The need to integrate speech recognition technology into EMRs has not escaped the notice of the EMR manufacturers. It is no longer the exception but has become one of the standards by which EMR products are evaluated. Does the EMR have a speech recognition feature? Is it compatible with Dragon Medical?

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Timing of Dragon Medical Implementation

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By Eric Fishman, MD
President
EMRConsultant.com
info@emrconsultant.com

Should you Purchase Dragon Medical Before, During or After an EMR Implementation?

We are frequently asked the question “If a physician is going to eventually use Dragon Medical with an EMR, is it preferable to purchase Dragon before, during or after the EMR is acquired?”.

Fortunately, there is no one right answer to this question, just as when operating I found that ‘one size fits none’ was an appropriate expression when it came to gloves in the operating room. In other words, it is necessary to determine your particular workflow, operating environment and goals, and to then make a decision. Hopefully, the parameters discussed below will allow you to make a more educated decision about this issue.

Having said that, please understand that the parent company of EMRConsultant is 1450, Inc., the county’s largest distributor of Dragon Medical. This provides us with both a substantial amount of information from which to draw conclusions, as well as a vested interest in encouraging you to utilize Dragon Medical in your office. We thought that you should understand both of those inclinations of ours from the beginning.

Now, let’s make an assumption that in the not too distant future you will, in fact, be using a state of the art EMR, and whether it is a client/server or ASP (SaaS) EMR is a decision which is rather tangential to this question. I bring that up because Dragon will work very well in both of those environments.

From the federal government down, there has been a significant push to ensure that essentially all physicians adopt an EMR by 2014, but in reality, I believe that there are a number of compelling reasons to acquire this technology significantly earlier than this self-imposed deadline provided by governmental entities. Furthermore, let’s make a reasonable assumption that you, like most physicians who do utilize EMRs will find them to be more palatable when used with a speech recognition software system such as Dragon Medical. To support this, it has been found that physician adoption of EMRs is substantially enhanced by the proper utilization of speech recognition technology.

The purpose of this paper is to provide some guidance concerning the respective timing of the acquisition of Dragon Medical and the EMR software. As you will see, there are advantages and disadvantages to each of the 3 possible scenarios.

Advantages of Purchasing Dragon Medical Before an EMR

There are some rather compelling reasons to acquire Dragon Medical prior to starting to use your EMR.

First, let’s dispel a potential obstacle which is that Dragon will end up either being incompatible with or not necessary with your chosen EMR. While the possibility does exist that you will end up purchasing or otherwise acquiring a strictly MAC compatible EMR, the probability of this being the case is extremely low. Personally, I happen to like Apple products. However, their penetration of the EMR market is, at this time, unfortunately extremely low, and therefore the probability of your soon to be chosen EMR being incompatible with Dragon is also extremely low. I guess I need to explain this by stating, rather straightforwardly, that if you are going to use a Windows compatible EMR, that there is an overwhelmingly high probability that it will be to some extent or another, and probably to a great extent, very compatible with Dragon Medical. This is not to state that there will be no integration issues whatsoever. However, this potential to have minor integration issues is in fact one of the more compelling reasons to acquire Dragon early in the process of automating your office – namely that by the time you do acquire an EMR, you will have enough familiarity with Dragon to be able to assist with the integration yourself, thereby minimizing the significant workflow disruptions that are going to inevitably occur with implementation of an EMR. While we’ve acknowledged that the majority of EMRs work very well with Dragon, if you try hard enough it is possible to find one that doesn’t work as well as you would want it to, in a Dragon environment. We can’t overstate the emphasis we give to having a complete system which includes an EMR and speech recognition software. If you acquire Dragon first, you will try to use any prospective EMR with Dragon, and you will thereby minimize the potential of acquiring an EMR that is not adequately compatible with Dragon.

Other compelling reasons for implementing Dragon first exist. For instance, it is rather self-evident that there is a phenomenal ROI (return on investment) when a practice begins dictating and transcribing their notes using Dragon Medical. The ROI begins essentially immediately, and there really are no compelling reasons to delay taking advantage of the monetary savings afforded by using Dragon. Since it is clear that there is a much wider variety of choices when it comes to EMR technology, and that the best choice is not always self-evident, there are frequently substantial delays both in choosing and implementing an EMR. These delays are frequently many months, and not infrequently can be a year or more in large institutions. Since Dragon Medical usually pays for itself in significantly less than 6 months (unless you are currently handwriting your notes, in which case the payback is quality of care more than monetary), it is rather common that if you acquire Dragon when you start your EMR search, that you will have already paid for the Dragon component in full with your transcription savings by the time you purchase the EMR.

Another advantage of purchasing and using Dragon Medical before implementing an EMR may be considered to be psychological. Implementing an EMRs is a major event in one’s life. For those of us who are not particularly sophisticated when it comes to computers, getting ready for the big plunge by learning a new computer skill can significantly increase your readiness for the substantially more involved process of learning an EMR. In essence you are sowing fertile ground by learning a new, but relatively less complicated yet still related computer skill, readying you for the task of learning an EMR.

There are still other advantages of learning Dragon first. I will take it as a given that at the end of the process you will be using Dragon and an EMR together, since that is, overwhelmingly, the most logical choice of technology to run your medical office and produce your medical records. Having said that, there are significant customization steps that are required for essentially every EMR in every specific medical office. It is best to undertake those customization steps once, rather than twice. Therefore, if you do not use Dragon first, and customize the workflow, templates and macros within the EMR to a non-Dragon enabled methodology, you will need to redo many of those customizations when you do implement Dragon. Thus, learning and using Dragon first will allow you to make one set of customizations to the EMR, rather than 2 sets. This is also true if you implement Dragon at the same time as the EMR, but to a significantly lesser extent.

Dragon is easy to learn, but a bit of attention must be paid to the effort. If it is done prior to the EMR training, the Dragon training will be maximized and you will have the best possible experience with Dragon, both with and without the EMR.

A more subtle reason for leading with Dragon is that many physicians are likely to have a generalized disbelief that technology will be able to assist them in running their office. However the ease with which a physician should be able to be trained in the use of Dragon, and the ease of creating documents, immediately, just by voice, is likely to increase their enthusiasm for the use of even more sophisticated EMR technology.

Finally, learning some of the basic macro features of Dragon Medical may increase a physician’s ability to intuitively understand how some of these features can be utilized within an EMR.

Disadvantages of Purchasing Dragon Medical Before an EMR

If you have a limited amount of time during which you will want to learn all of the technology, purchasing Dragon first may prolong the total learning time. This is most appropriate as a consideration in situations such as during the opening of a new office, in which you may wish to have all of your technology available to you simultaneously.

Learning various macros that will be utilized within MS Word, but not within a new EMR can be considered an extra step on the way to a combined system.

Also, it is conceivable that the hardware requirements of the EMR and Dragon will be meaningfully different, and when you purchase hardware for Dragon you may end up with hardware that is not perfect for the EMR. This is unlikely, particularly since Dragon is admittedly a very resource intensive program. However, you may find the need to add additional RAM into a CPU, for instance, when starting to use an EMR.

Advantages of Purchasing Dragon Medical at the Same Time as an EMR

The major advantage of purchasing both Dragon Medical and an EMR together is the streamlined process of implementation which can occur in this instance. The most classic example of this is when a physician is starting a new office. In that case, implementing both technologies simultaneously can be advantageous.

Another advantage of acquiring both of them together is that the total number of weeks during implementation may be minimized. I don’t believe that the total number of hours is likely to be diminished, but the number of calendar days between starting and finishing may be lessened by one or two.

There are workflow changes that are required whenever the method of charting is changed. When you implement Dragon and an EMR simultaneously, there is only one set of workflow changes which are needed, rather than a series of changes.

Finally, while the financial differences may be rather trivial, in part because of the disproportionate cost of Dragon in comparison to the cost of most EMRs, there is sometimes a modest discount available when purchased simultaneously.

Disadvantages of Purchasing Dragon Medical at the Same Time as an EMR

Learning the new workflow and technology of an EMR is an extraordinarily complicated task. The stories of 3 month implementations in small offices, and multi-year implementations in enterprise situations is not an exaggeration. The efforts can well be worth it, but it can be, and in fact in most instances is quite disruptive. Adding to this disruption with an additional task, no matter how trivial, can lead to more of an overwhelming sense of frustration.

Another disadvantage can be cash flow. The cost of Dragon Medical and all associated training is rather trivial in comparison to the cost of most EMR systems. However, when added to the cost of the system the timing can be unfortunate.

Advantages of Purchasing Dragon Medical after an EMR

The physician will understand exactly where within the EMR, and where within their daily workflow their use of Dragon will be helpful, and they can restrict their usage to exactly those specific locations, thereby, possibly, avoiding learning certain features of Dragon that might not be required of them in their daily workflow.

Disadvantages of Purchasing Dragon Medical after an EMR

First, and most obviously, all of the advantages of purchasing Dragon before or during the EMR implementation are lost if you purchase it after the fact. Possibly non-obvious disadvantages also include that the Dragon training, which is in fact the easiest part of learning a Dragon enabled EMR system, will be given less attention, and the user may never become as adept at using Dragon and the combined system as they otherwise would.

By Eric Fishman, MD. © 2009. All Rights Reserved

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