Monday, August 26, 2013

The "Electronic Health Record Solution"

Comprehensive solutions for medical documentation when a complete Electronic Health Record (enterprise system or niche product) interferes with work-flow and provider satisfaction is suggested:
"Best of Breed" - commonly recommended - combination of an enterprise system with a specific module for the area of work.  This would solve many issues, but will take mutual cooperation between the enterprise and niche system to build efficient interfaces.  This may include the ability for the providers to choose the device (tablet, C.O.W., smart phone, etc.) to interact with the system.
  1. The "Hybrid Approach" - combination of paper templates that are scanned in the EHR.  The Electronic Health Record can provide the database, CPOE, patient education and ePrescribing.  This solves the #1 complaint that the providers are data techs with a 20% decline in performance.
  2. Voice-Activated Technology - same as #2 with dictated charts with no transcription fees.  Dictating from templates can achieve excellent documentation.
  3. Using a user-friendly, area specific electronic charting software that employs minimal "clicks" supplemented by direct access voice activated technology.  This eliminates the cookie-cutter computer speak chart and gives important context to the documentation.
  4. Wait for a major break-through in artificial intelligence that creates and supports a reality based documentation of the encounter.

Wednesday, August 21, 2013

Communique from the Beach - by Jim Tate EMR Advocate

EMR Advocate Newsletter
by Jim Tate
August 2013
Communique from the Beach

Summer is almost gone. My kids start school next week. Time for one last trip to the beach. "The windy beach, far from the twisted reach of crazy sorrow" as Dylan proclaimed. Even here, beneath the diamond skies of Coral Bay on St. John Island, I am not beyond emails informing me of the latest developments pertinent to CMS EHR Incentive audits. 

In between snorkel trips to Trunk Bay and Salt Pond Beach I find disturbing emails lurking through my inbox. Of course, there are the standard inquiries I've received from eligible professionals who are being audited and don't stand the slightest chance of passing an audit. There is the dermatologist who swears he was told there was no minimum number of patients he had to document in his ONC certified EHR to receive an $18,000 incentive in 2011. He received the infamous "audit engagement letter" letter last week. I asked him how many patients he saw during his 2011 meaningful use period and he answered, "Hundreds". I asked him how many patients did he record in his EHR? "Six" was the reply. My advice? Do not pass Go, do not go through the audit, do not appeal. Pay the money back and go and sin no more. Those are the easy, black and white answers. However, I have also be running across some issues with those touchy nuances pertaining to the often foggy "public health" measures.

The Public Health (PH) measures have been slightly off the radar as they swish and sway down there in the Menu Measures for Eligible Professionals (EP) and Eligible Hospitals (EHs). Such Menu Measures as Immunizations, Syndromic Surveillance, and Reportable Lab Resultscontinue to confuse and confound. Wouldn't it be nice to pick one, claim an exclusion, and then be rid of it hopefully for all time? Just throw it over the fence and forget about it. These PH measures and the attestation strategies employed by both EPs and EHs are now starting to bear bitter fruit. I am working with a number of providers undergoing audits for their 2011 attestation in which the core area of concern is focused on the PH measures. Often the person that planned and carried out the 2011 attestations has moved on and there is no paper trail to document the logic behind the decisions as to which Menu Measures were chosen. If that wasn't enough, a thorough audit will want documented proof supporting an exclusion claim. You say your state was unable in 2011 to receive immunizations electronically? Fine, provide that documentation to your auditor and move on. If you can't, well you can see why this is a sticky area. For an EP this could be the tipping point between keeping or giving back that long gone $18,000 incentive. For an EH the stakes are much, much higher. We are talking millions here.


I'm thinking there were a lot of attestations that were just thrown together in 2011. There was so much money on the table. I can imagine the pressure that came from those at The Top to "Get those incentives!" Who wouldn't want to make the boss happy with the news that the attestation was successful and the check was on its way? Tell the CEO, the CFO, and the Board, "It's all good". I haven't talked to too many of those happy folks. The ones that contact me are the ones who are undergoing an audit or have failed one. The ones that are trying to piece together the what, how, and why that occurred two years ago. They ones sent in with mop and bucket to clean up the mess. Contact me here if you need help. Audit and appeal resources can be found here.

Webinar: Meaningful Use, Audits, and Behavioral Health 

I'll be joining Mary Givens on September 12, 2013 at 2 PM EDT for a  

Meaningful Use Audit webinar designed specifically for the Behavioral Health Eligible Professional. Register for free here and send in questions ahead of time and we'll try and cover them.


Monday, August 19, 2013

Ditch, Switch and Migrate!

This article has many interesting statistics on the demand of the provider to find an EHR that works for them.  When and if you switch-we advise you have a "Migration Plan" carefully created with your new vendor to avoid starting from ground zero. 

EHR users ditching systems, trading up - Dissatisfaction with current EHR systems have many providers turning to new vendors 

Erin McCann is Associate Editor at Healthcare IT News. She covers physician practices, ambulatory care and social media in healthcare. Follow Erin on Twitter @EMcCannHITN

2013 has been billed as the year of EHR dissatisfaction, with up to 23 percent of physician practices reporting they were trading in their current EHR system for a new brand altogether, and, according to a new Black Book Rankings report, there were only a handful of vendors that came out on top. 
The survey finds that providers switching to new EHR systems were turning to Practice Fusion, Care360 Quest, Vitera, Cerner, Greenway, ChartLogic, GE Healthcare and athenahealth — all vendors who have risen to the top of the replacement market satisfaction polls, officials note.  
"Regularly, at least two of these eight vendors were on the short lists of 88 percent of the current replacement market buyers surveyed," said Doug Brown, managing Partner of Black Book, in a news release. 

Seven others — Allscripts, AmazingCharts, eClinicalWorks, Kareo, McKesson and NextGen — also received top rankings in six of seven 2013 Black Book client experience surveys, Black Book officials note. 
"EHR system shifters now position to reallocate more than $5 billion in sales as the unstable vendor marketplace begins to get agitated," said Doug Brown, managing partner of Black Book, in a news release. 
Eighty-one percent of survey respondents who indicated they were ditching their current systems said they were on track to replace their EHR within the next year; some 11 percent said they were unsure, according to the report. 
The study is a follow-up assessment on the status of electronic health record users, all of which indicated deal-breaking dissatisfaction with the current vendors.
EHR users polled in the original survey had cited numerous cases of software vendors underperforming enough to lose crucial market share, with vendor solutions often struggling to keep up.
Most concerning to current EHR users were unmet requests for sophisticated interfaces with other practice programs, complex connectivity and networking schemes, pacing with accountable care progresses and the rapid EHR adoption of mobile devices, the original survey found.
Out of those EHR users considering a system switch, 80 percent said the solution does not meet the practices' individual needs; 79 percent indicated that the medical practice had not adequately assessed the group's needs before choosing the EHR; 77 percent of respondents cited solution design as ill-fitted for their medical practice or specialty; and 44 percent said vendors have been unresponsive to requests. 

Monday, August 12, 2013

Decrease the # of Clicks and Improve Navigation

At the present time, the number of clicks necessary to fill out a chart is endlessly time consuming and non-productive.  The cost per click is now being calculated (see my prior blog) and quantified.  The work flow is slowed down and there is a real-not imagined- price to pay.
One solution is to create an auto-flow sequence that is tunable by site or provider and that comfortably guides the clinician from one area of the chart to another in a logical-customary- sequence.  If an out of sequence entry is desired, this should be easily accomplished.  A system with automatic guidance will eliminate the need to figure out where should one go next, especially if one is interrupted.  When it is acknowledged that one area is complete, it then moves to the next area when documentation is continued or resumed.  Once the area is completed, the list shrinks.  Your favorite click might be auto-sequenced.
An example sequence could be...
  • Vital signs
  • Triage sheet
  • Past medical history
  • Nursing notes
  • History and PE in logical order
  • Medical decision making
  • CPOE
  • Lab and x-ray results
  • Clinical course
  • Final diagnosis
  • Disposition
  • e-Prescribing
  • Patient education
  • Follow-up
  • Review nursing notes
  • Sign the chart
Navigation would be significantly simplified.  The provider can always go to any area directly and in any order.  Nursing notes might be reviewed, if easily accessible.  Training would be simplified and hopefully stress-reduced.

Monday, August 5, 2013

Is There a Place for Paper Documentation?

The first question is whether any urgent care, medical office, and/or emergency department can really survive totally without paper.  Second question is whether the documentation portion of the medical record can still be done on paper, and whether it could then serve to support patient care in a manner equally, or perhaps more, effectively than electronic documentation.  These are complex questions, but many are coming to realize that paper may still have a role in modern medicine.

In practices or institutions not quite ready for a full-blown electronic health record, paper can be a very effective part of the workflow.  Well-structured paper charting,  integrated with modest and simple electronic tools (scanning, e-prescribing, patient education and follow-up) can be a beneficial and legitimate solution to the EHR documentation quagmire.

Some benefits-
  1. Predicable provider acceptance and willingness to cooperate- this is a key component for the success of any clinical system.
  2. Storing and retrieving patient records becomes simple by scanning all documents to the patient database.
  3. Prescriptions are quick, managed, and legible.
  4. Patient education and follow-up instructions are legible and rapidly produced.
  5. The need for provider-financed documentation assistants- scribes- virtually disappears, saving $$$!
  6. Template documentation facilitates completeness, and is valuable for medical-legal and financial reasons.  Free-handwriting should be used only to supplement a template, but not to document the entire encounter.
  7. The costs of paper solutions are historically much less than those of EHR implementation and maintenance.
Negatives do exist-
  1. Legibility issues
  2. Potential losses of meaningful use stimulus money.  However, meaningful use criteria is a constantly moving target that many- despite huge expenses for EHR systems- have not received.
  3. Decreased ability to extract data.
  4. Common traditional complaints about paper templates- legibility ad difficulty obtaining a representative narrative.
Paper documentation can be realistic for practices that can structure themselves to be partially electronic.  If you are so inclined, choose a product that has a good database, a scanning solution, and well-written templates.  You may want to implement a system that uses voice-activated EHR technology for certain type of cases.  When the next- future - quantum advance in EHR technology is available to clinicians, it may - if simple and easy to use- actually take us beyond paper.  At the moment, however; that future isn't here yet.