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How EMR Process Issues Screwed Up One Small Practice

Posted on January 31, 2011 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Here’s a story which I’m sure could be retold in practices around the U.S.  It’s a tale of how EMR process issues slowed down care to a crawl.

I recently visited small OB/GYN practice — a busy and seemingly prosperous one in a wealthy suburb — which had just implemented a popular EMR package. Knowing how small practices are struggling to make EMRs/EHRs work, I took a suspicious look around.

From the looks of things, everything was in place:  the EMR was available at every workstation used by clinicians and nurses, doctors had carts to roll their e-charts into exam rooms, and the use of paper was minimal.

Then, it was my turn to be seen, and the EMR (in theory) came into the picture. Whoops!  Things went downhill pretty fast.

First, I had my vitals taken by a medical assistant, all of which went onto a piece of paper.  Couldn’t she have had access to one of those carts?   Was the practice too cheap to buy enough terminals to make this not-so-cheap EMR a success? Process failure #1.

Then, I was moved along to a nurse to be asked some additional questions. Though the nurse seemed patient and careful, she had to ask me about my medications three times, because something about the system interface led her to dump the data over and over.  I’m not blaming the nurse (I blame the vendor and their UI) but that was definitely process issue #2.

Then, I finally had a talk with the doctor.  She didn’t make use of  the EMR at all!  She did look at some of the paper I turned in during my waiting room stay, and clearly listened carefully to my concerns, but didn’t take notes during the whole conversation, EMR or no.

I thought one of the great things about an EMR was to normalize how notes were taken and preserve the value of them from the point of care on.  Process issue #3 and the EMR is outta there!  (Well, I wanted to pitch it anyway.) Just how much clinical value could they be getting from this fractured way of doing things?

Folks, I have no idea how long the EMR had been in place there. This could have just been growing pains.  But my instinct is that more likely, the place is going to keep running its EMR in a hodgepodge style until it  begins losing clients or gets punished harshly for its inefficiency. Which do you think will happen first?

Longings for the future: what I still can’t do on my EMR

Posted on January 29, 2011 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

As much as I’d like to say my EMR is perfect, and I’m always the happy EMR doctor, its’t actually not the case yet.  There are several things I still can’t do on it, despite the logic that would dictate that I should be able to do such things on it.  So I thought I would here put together a wish-list of things I hope the future holds for EMR software development.  Most of them deal with me being still bound to printing or handwriting orders on paper that I need to give to patients.  Now, I’m sure that many, if not all, of these are planned for future programming projects, but currently they don’t exist on many EMR systems.

1.  Medical supplies for diabetes or any other condition.

As an endocrinologist, I have a box of preprinted prescriptions for orders of diabetes supplies, including alcohol pads, lancets, and test strips.  I give out at least two or more of these pieces of paper daily.  The patient then hand carries these slips, if they don’t lose them first, to the pharmacy of their choice.  Why don’t I call the orders in?  To answer that would require knowledge of the number of seconds it takes to scribble a patient’s name and a few X marks on the paper slip vs. calling into a pharmacy automated voice mail system.  In short, it’s all about saving time.

2.  Orders for radiology and nuclear medicine tests.

Ditto for the above, when it comes to CT scans, sestamibi parathyroid scans, neck ultrasounds with thyroid biopsies, etc.  If I could only open a templated window, type a few quick words for the test details, enter a fax number of click  facility name, and then click a “send” button, it would save a huge amount of time over a given day and eventually a year.  Oh, then I could go back to being perpetually happy and blissful!

3.  Integrated receipt and organization of faxes into patient charts.

This one would help the front desk staff more than me, but I still end up pitching in when we are getting swamped with work.  And I can pitch in easily from my desk in the back of the office because my practice is 98% paperless and fully networked.  (Oh, let’s get it to be 100% already!)  I envision opening up a window within the software that would access my fax folder, open up a quick view of the faxes, and allow me to assign a patient’s name to the fax.  Then it would be click and done.

These days, I think twice when I hear comments like, “We need it to do this,” with which I no longer always agree.  Clearly, some intermediate functionalities are needed before we should ask for the cherries on top.

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.  He can be reached at doctorwestindc@gmail.com.

Health IT And Cloud Computing: A Promising Start

Posted on January 28, 2011 I Written By

Priya Ramachandran is a Maryland based freelance writer. In a former life, she wrote software code and managed Sarbanes Oxley related audits for IT departments. She now enjoys writing about healthcare, science and technology.

Note: This piece was written by Priya Ramachandran, a former IT auditor and freelance writer who blogs at www.pramwriter.com. We’d like to welcome her to EMRandEHR.com.

You gotta hand it to the IT folks.    Once they come up with a catchy phrase like cloud computing, it spreads like crazy, and now it’s come to mean just about any architecture you can imagine. This Wikipedia entry explains how “cloud” might mean anything from software and services available on the web, to virtual servers created off of physical servers. Adding to the confusion, some leading names in IT willfully obfuscate the terms.

I really like Rob Pegoraro’s definition of the term and that’s all cloud computing is going to mean for the purposes of this post:  cloud computing is “having an Internet site host your data and the programs you use instead of keeping them on your computer.”

Some benefits to putting health data in the cloud:

Now in the case of health IT, there are compelling reasons why a cloud may benefit your organization:

— Increased processing power:  If you leave it to the folks who provide these services, you won’t have to administer/upgrade your own hardware

— Pay as you go:  Pay for only those services that you end up using

— Data portability:  If you keep your customers’ health IT records online, it’s a lot easier for you and your customers to access said data

— Freedom from the IT department guys:  Yeah, it might be a pipe dream, but when you’re with a good cloud service, IT is really your vendor’s headache

— Security:  Which, as we will see later, can be something of a double edged sword

Some models of cloud computing have evolved to better address data integrity. The costlier and most robust solution would be to create a private cloud. Open source cloud solutions such as osCloud allow healthcare organizations with some IT muscle to design their own.

Third party vendors often work with healthcare providers to create a secure version of the cloud for private use. The costs of this approach are significantly higher than investing in a public solution, where all your patient data is on a nebulous cloud. Pragmatic hybrid cloud solutions abound too, fixing the security concerns of a public cloud, and with costs cheaper than a private cloud solution.

Use cases in healthcare:

For health IT, there are several uses cases where cloud computing is probably a great option. Some of the more interesting ones I’ve come across:

— For hospital surveillance and security – Awarepoint, a fully managed service, provides GPS style RTLS (Real Time Location Systems) tracking of patients, personnel, equipment for reducing hospital theft prevention; Denver Children’s Specialists is utilizing ControlByNet’s cloud-based, hosted video security surveillance solutions, to monitor six locations on the cloud. The group moved from separate DVRs to ControlByNet’s solution to monitor its six locations throughout Colorado.

— Cheaper and better transcription services –  Details courtesy of Lauren Richman, healthcare marketing director at Nuance Healthcare: “The doctor dictates a patient record (via phone or into an electronic health record system), the voice file is sent to the cloud where it runs through a speech recognition engine, a draft medical record is created and sent to a transcriptionist for review/editing and then sent back to the doctor for final sign off. Leveraging this cloud-based technology saves time on documentation for doctors and transcriptionists, which speeds efficiency and significantly reduces costs.” A whitepaper published by Nuance shows that 39 customers saved over a million dollar each for a total savings of 93 million dollars.

— Access and collaboration between specialists: ClickCare, a HIPAA compliant SaaS and iPhone application combines pictures, text, sounds, and videos to improve collaboration between healthcare providers. In one instance, at the Wound Institute in PA, 70 patients were treated solely over ClickCare with an overall healing rate of 93% and an estimated savings of $24,000 in transportation costs.

— Other business activities: SuccessFactors is a vendor that works with several hospitals to streamline their HR processes. Presidio Health, a service created by a former ER physician, helps hospitals enables hospitals, health systems and urgent care centers to efficiently collect patient payments at the point of service. (Interesting statistic provided by Presidio: once a patient leaves the ER, the facility only has a 20% chance of collecting any amounts due from the patients)

If you live next door to a mafia don, you’re more likely to get shot:

All these success stories in the media must make everyone else in the healthcare field salivate. But, moving to the cloud shouldn’t cloud one’s judgment about this relatively new IT paradigm. When you’re housed in some cloudy barracks, you have little say over what services you receive, as pharmaceutical giant Eli Lilly found in its experience with Amazon web services. Eli Lilly had long been promoted by Amazon as its poster (client) child, but found that it could ask (and receive) few guarantees from Amazon about power outages, security breaches and other unsavory aspects.

Also as in real life, the ‘hood you decide to live in might very well affect how secure your data is. Amazon Web Services found itself having to boot Wikileaks after it (Amazon) was targeted by groups intent on bringing Wikileaks down. Even though Amazon might be better able to protect itself against a DOS (Denial of Service) attack, its visibility might mean it is attacked more than an average client.

Bottom line:

I’m excited by the services that are now available on the cloud, and even more excited about how much they can revolutionize healthcare. But given my background as an IT auditor, I’m wary of getting too excited about cloud computing just yet.  Let’s see what the next year or two brings.

EMR and EHR Reader Survey

Posted on January 27, 2011 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Time for my first ever EMR and EHR reader survey. I’d really like to get a feel for who reads EMR and EHR and how I can make the content on EMR and EHR better. So, don’t be shy in your comments. It’s a simple 13 question anonymous survey and none of the questions are required so just answer the ones you feel comfortable answering.

The survey is embedded below, but if you’re getting this by email then here’s a link to fill out the EMR and HIPAA Survey.

My apologies to those of you who read EMRandHIPAA.com and have already done the EMR and HIPAA survey. If you have, I’d still appreciate you spending 30 seconds to answer the multiple choice questions in the survey for EMRandEHR.com below as well. It’s nice to at least know who’s reading the site.

A Process for Replacing CPT Codes

Posted on I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

Those of you who have been kind enough to read my blog know I criticize CPT coding on a regular basis.  Finally after my last tirade, a comment from John finally said what I have been dreading to hear:  “I’d love to hear more about what you think a good replacement to the current CPT system would look like.”

That is the question, isn’t it?   I’ve been criticizing long enough.  Time to put up or shut up.  A brief Internet search does not reveal any significant activity regarding a replacement for CPT except for vague “pay for performance” concepts that would pay for results rather than the care itself.  I must confess that despite thinking about CPT replacement for the past few months I don’t have any bright ideas either.

But since I raised the question in the first place I’m willing to take a shot at it.  Ignorance has never stopped me before…

I would like to begin a 4 step brainstorming process with you:

  1. Outline the shortcomings of CPT coding
  2. Translate those shortcomings into desired characteristics for a replacement system
  3. Explore applicable technologies that allow us to leverage the use of EMR to create an IT-based payment system with the desired characteristics
  4. Formulate proposals to replace CPT

I’m going to resist the urge to write my usual 1000 word post and stop here.  Please share your thoughts regarding the wisdom of this project and whether or not these 4 steps are the best way to approach the question of a replacement for CPT.

Happy EMR Doctor Meets Unhappy EMR Patient

Posted on January 26, 2011 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Twice in the past year I’ve had patients comment that they thought I was spending more time facing the computer than them. Now, granted, I’m still under the impression that the first guy, a thirtysomething techie guy who must have been facing some personal inner demons, (since he also later  told me I was saying things during our visit that I would never in my right mind tell anyone), but the second patient had a more understandable issue.  She asked me why I couldn’t just give her the lab results over the phone when all I did during our interaction was type the results into the computer notes and talk with the back of my head to her.

After I explained that I couldn’t get paid like that, compliments of her insurance company requirements, she felt more reassured and voiced understanding.  However, it was also a jaw-dropping, very important, lightbulb, ding-ding! moment for me.  Was this how I was actually coming across to other patients?  When I thought about it, I realized that in my rush to get into the room and not “be late” to the patient’s appointment time with me, I was not understanding that I spent most of the time staring at the computer screen reviewing results and then documenting the results in the note, which of course, took additional typing time.  I thought the patients valued an on-time doctor more than my face time, literally.

Later that week, I had dinner with a good friend who happens to be an orthopedic surgeon.  He recalled reading a study that showed that doctors who sat down and faced the patient were rated by patients as having spent more time with them, even when, for the purposes of the study, they had spent only half as much time (in minutes) in the room with the patient compared with another group of doctors who stood up during their interaction.  Human psychology is an amazing thing! and one I now use more often.  Since the time of my interaction with that second patient, I now usually spend at least 5-10 minutes reviewing documents and “pre-charting” in my office before I ever enter the patient room.  Do I spend about half the time (or less!) with the patients face to face?  Typically.  Do I touch the computer in the patient’s room anymore?  Not typcally.  Are the patient’s happier?  I haven’t had a complaint yet …

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.

How Smart Chart Abstraction Can Speed EHR Deployment

Posted on I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Caught an interesting analysis this week from the California HealthCare Foundation, which has been studying EHR deployment within community clinics and health centers since 2006.

In most cases, chart abstraction creates a major bottleneck which can slow the transition to EHR use to a crawl, while cratering caregiver productivity in the process.  But if it’s done thoughtfully, you can avoid some of the chaos, the study suggests.

In its new paper, the foundation shares chart abstraction techiques that used by members of its California Networks for EHR Adoption initiative.

Here’s some strategies CHCF has identified which seem to speed  up the process — and in turn, streamline EHR deployment. (This is just a small sample; I highly recommend you check out the paper itself for detailed case studies and advice.)

Some of the research group’s suggestions:

* Start with a strategy: Decide in advance what information will be entered, when, and by whom — and decide how closely the EHR data should resemble the paper version.  Just as importantly, decide whether any given piece of data is really worth entering at all.

Don’t abandon paper too quickly: How do you abstract paper chart data?  Usually, you consider scanning charts, migrating data from legacy systems, entering data manually or going for a mix of all of the above.  While each can work, the key is not to drop paper charts too quickly.  To reassure staff, the clinics in CHCF’s initiative typically kept paper on hand all the way through the EHR go-live period — and sometimes for a while afterwards.

Fine-tune your abstraction approach: Clinics that did well with the abstraction process had make near-constant adjustments to their process.  For example, one clinic had to move quickly from traditional scanning to a software solution which gave the docs smart headers, after staff wasted countless hours poring over cryptically-named scans. Then, when that wasn’t enough, it had to develop a hierarchical naming system for scans not long after.

Readers, are you struggling with chart abstraction process as you prepare for EHR deployment?  Has staff productivity taken a big  hit?  Perhaps most importantly, how long do you think it will be before the paper-to-electronic- data process stops being an issue?

Many Hospitals May Not Meet MU Goals By 2015

Posted on January 25, 2011 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

John’s Note: I’d like to welcome accomplished healthcare journalist, Anne Zieger, to EMR and EHR. Anne has a long history in the healthcare IT space and I’m really looking forward to her contributions to EMR and EHR. I’ll still be posting on EMR and EHR as well and of course on EMR and HIPAA. However, I’m excited to bring another voice to EMR and EHR. Welcome Anne!

Nobody said that meeting Meaningful Use standards for EMRs would be easy, but if a new Accenture study is any indication, things are even worse than they seem out there.

Accenture argues that hospitals have a a staggering amount of work to do, and that few are ready. If they hope to get to MU compliance by 2015, hospitals going to have to think differently about change management, plan for a long, tough project, spend heavily and find qualified new personnel.

According to the study, less than 1 percent of health systems were mature EMR users in 2009.  What’s more troubling is that if Accenture is right, only half of U.S. hospitals will meet MU criteria by  2015. That could mean penalties of $3 million to $4 million per year for a 500-bed hospital, the consulting firm estimates.

Why are hospitals and health systems lagging behind?  They’re underestimating how hard the MU compliance job is — and getting blindsided what can be an 80% jump in costs during the transition.

My question:  are these massive transformation headaches and eye-popping costs are inevitable if you want to prove Meaningful Use of an EMR?  Or will hospitals that run lean IT and plan well enjoy a smoother ride?

Screwed Up Meaningful Use (at least for specialists)

Posted on January 24, 2011 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I regularly get passionate emails from readers of EMR and EHR (and of course my other site EMR and HIPAA. I don’t always agree with the emails, but I almost always find them interesting. The following is one such email. It wasn’t intended to be published, so excuse the format. However, I find much of the comments about ONC’s approach to specialists spot on. The hard part is that I think ONC realizes this as well. The question is whether ONC in meaningful use stage 2 is going to do anything to address the specialist problem. I think this is a topic we need to voice to ONC.

The EMR’s basically started with certification requirements from CCHIT…ONC took that starting point…and moved to MU from it…without regard to specialty. Properly done, they should have started with MU by specialty…then figured out what the product certification requirements should be from there—for that specialty: Orthopedic guys see lots of patients (50-70 per day, and lose two days/week to surgery), mostly NEW patients with specific problems (broken bones or joint replacements)…no big longitudinal charts…and need to dictate complex notes; Dermatologists have lots of lab/biopsy tests, need to draw pictures and annotate them, not dictate; Pediatricians need growth charts and long medical histories and trends; Oncologists need detailed treatment histories, dosages, outcomes; Ophthalmologists need lots of technical data, measurements and interfaces to optic devices. Yet ONC made a set of rules that really only apply to Primary Care…which is where much of the CHRONIC conditions (and a large portion of the medical cost issues) are quarterbacked…and have the best chance of prevention.

Besides…all the data from specialists should flow back to the PriCare docs anyway…why try to keep it coordinated in both places? I think we have a long way to go to get all healthcare “communitized”…and powers that be need to recognize how different things are for various specialties…and define MU from each specialty’s point of view…and find out that the current certification standards are WAY overkill for most of them…unnecessary complexity and, thereby, cost….to do the irrelevant things to qualify for incentives. After five years, they will stop doing those things anyway, when incentives run out. Having a data pathway between in-patient and out-patient (ambulatory) is a great goal…that should come first..the ability to share data…even if via documents. That could be done today. Trying to devise interoperability standards for 400 EHR’s, a dozen or so major Hospital-based vendors…and registries, labs and other participants….that is a LONG way from being reality

Will be interesting to see how the “success stories” pan out this year starting in May for EP’s. Thank goodness ONC has made it almost impossibly easy for specialists in Stage I….they can opt out of almost everything required and get incentives the first 2 years($30k)…is that a good use of taxpayer money?

Welcome to the Happy EMR Doctor!

Posted on January 21, 2011 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This is the new home of the Happy EMR Doctor. We’re just rearranging things right now, but soon you’ll be able to read great content from a real doctor who’s using and loving the EMR in his practice. Of course, that’s not to say that he won’t have things that could make his EMR better, but you’re going to get real life experiences of a doctor using an EMR in his practice.

This blog originally started as some guest posts on the popular EMR and EHR blog. Now it’s graduated to its very own blog where Dr. West can share his good and bad experiences with EMR.

More coming soon!!