Monday, May 23, 2016

Surviving “Migration” To a New System

Many Practices are faced with the necessity of changing their Electronic Health Records vendor for a variety of reasons. These may include hospital buy-outs, marginal usability and/or poor performance of present EHR, political reasons, interoperability problems, cost, support, expansion, consolidation, and ownership personal preferences.
Commonly, the administrators, clinicians, and technicians involved do not understand the vast complexity and huge potential costs of mid-stream changes trigger. Often, a major issue that arises is the generally encountered requirement that providers maintain records for at least 7 years.      

The Strategies for Switching or Merging EHRs by Shannon Firth makes many reasonable suggestions on how to approach this transition with wisdom. Here are some essentials that the author suggests you think about:

·         Ask: What data do you absolutely have to have in your new system and what's negotiable? One has to decide what data to mine actively and what just to store. You might decide to input data on active patients only, while placing the rest in an accessible database. While you do not want to load up the new system with data you will never use, you also want access to historical data in some cases, should patients reappear (which of course they often tend to do).

·         Consider: Will you choose to load data manually or digitally? Digital loading is extremely expensive. A commonly employed solution is to scan potentially needed old data into a server from which the new system can retrieve. A provider can then access and utilize the previous data. This tends to work for both paper and digital records. You might be safer trying to resist any urge to move all the data all at once. That becomes a mountainous task. Instead, you might be able scan key documents for regular patients when it gets closer to their next appointment. What should you do about problem lists and medications? One approach is to treat patient as if new to the practice, and update the system with a clean slate using the scanned documents as the basis for doing so. This may sound onerous at first, but consider a) problem lists and medication lists frequently become outdated and need a regular “spring cleaning” anyway, 2) you would do this for any new patient anyway and probably correct many erroneous data points in the process.

·         Think About: What data will be archived and how will you find it in a timely way? Have a coherent plan to archive all the data but do not use unless needed. You can then decide what to scan into the new EHR. Medication lists, problem lists, last complete history and physical, and pertinent lab and x-ray data are high on the list, especially for current active patients. Routine follow-up checks can be accessed through the database if necessary.

·         Ponder: Will you maintain your old system? If so, for how long and how much will it cost? What will be the cost to maintain access?  Will you have to pay your old vendor support and updates?.  All this will depend on your changed contract with the previous vendor, and and the price to maintain it on a server, yours (preferably) or theirs. Remember that sever costs are based on amount of data. The author recommended a year.

·         Give thought to: How will new data (laboratory tests, consults etc.) be received? In most cases, this should be done by accepting data into the new EHR automatically using HL7 standard interfaces.

·         Spend time considering: What forms looked like in the old system (especially those for each visit) and how will they look in the new one. This will affect workflow dramatically. Too much change at one time, even if perceived by you as an improvement, is rarely well received. Gradual change is better. Try to pick an EHR that is end-user oriented, with excellent graphic interfaces, and easy navigation. The end-user will reward such efforts with increased satisfaction and potentially increased productivity.

·         Think through: What is the workflow for each type of visit and what forms are used? You might find it best to use a template driven system for quality control and consistency.

A transition of this sort is in no way an easy task, even in the slightest. An important goal, naturally, is to minimize pain and cost. Remember what we have discusses so far does not even begin to examine what many consider to be the more important, and trickier, transitions of practice management and billing.

Monday, May 16, 2016

The One-Two Punch of Ill-Considered EHR Decisions

Many articles published lately like “Dissatisfaction” leading to EHR replacement trend, discuss the chronic unhappiness and dissatisfaction of Electronic Health Record users. Weeping and gnashing of teeth over electronic record systems is pervasive, and the sources of pain are common and recurrent. 

Still, most every EHR issue that appears or re-appears can be boiled down to one of two root sources. Systems are unusable because of either absence of realistically usable clinical support, or lack of real-time billing functionality. Or both.

Key points from this article include:

·       Practice management has grown as a focus for systems. Whereas in the more distant past, documentation-even CPOE have held sway, the nitty-gritty of running the operation is now the number one priority for systems.

·       The number clinicians replacing their EHRs in any one year has increased 59 percent since 2014

·       Billing functionality is a strong need for EHR buyers. It is the top-requested functionality (45 percent) ahead of claims support (27 percent) and patient scheduling (23 percent).

·       Practice management includes, not surprisingly, management of a facility’s patient population.  Hence, 28 percent of buyers are looking for patient tracking capabilities: monitoring assessments, treatment plans, progress notes, etc.

A parallel and significant problem arises when a facility decides to replace their EHR: the replacement becomes a new bombshell that can bankrupt the facility doing the change.  Buyer’s “remorse” from Electronic Health Records replacement ranks up with car purchases and marriage. Well, maybe not marriage. But in all cases, an unfortunate and costly initial mistake is often compounded by a second mistake.

The key question to ask is whether the EHR can support both the provider and the business side of the practice. Either alone won’t work, and the absence of any one key part creates a vicious cycle. For example, even though the financial side may be given priority, but chronic dissatisfaction of the provider team leads to decreased productivity and further exacerbates any lingering financial woes.

Find an Electronic Health Record System that can support everyone.

Wednesday, May 11, 2016

Meditation (et al) May Help Slow Down Dementia

A recent article the Benefits of Yoga and Meditation for Alzheimer’s and Dementia stated that meditation may delay the onset of dementia by 7 years. (Note: Be careful not to drop the first “t” in meditation, as a co-author did, because the result, mediation, will actually accelerate dementia for an equivalent period of time.) Now 7 years does not seem like a lot unless you are already in the senior citizen group. Any reprieve from Alzheimer’s disease and dementia is well worth the effort.

Dementia, according to Wikipedia, is a broad category of brain diseases that cause long term, usually gradual, decrease in the ability to think and remember, of a degree great enough to affect a person's daily functioning. Alzheimer’s disease accounts for 60% to 70% of cases of dementia.[1][2] It is a chronic neurodegenerative disease that usually starts slowly and gets worse over time.[1][2]The most common early symptom is difficulty in remembering recent events (short-term memory loss). If you do not remember why you started reading this blog, you may be a candidate.

The article extolls the virtues of yoga and meditation for both the individual and caregiver to make life less stressful and more fulfilling. Basically it is saying that you have to exercise your brain and body to maintain your “youth”.

Practicing Yoga is an easy solution to avoid the sedentary state that will eventually kill you. There are many forms of exercise but you have to perform them religiously. Meditation is a way to control anger, compulsions, and exercise your brain. There is a role for puzzles, games and focused mindfulness.

Take a class and find out whether these strategies will work for you. Medical science allows us to live longer, but preferably in an awake and aware state.

Keep in mind that causes and cures for Alzheimer’s are popping up daily. In the exercise category Pilates or TRX is likely as effective as yoga.  Not to mention swimming, surfing, sailing, and other activities conducive to meditative presence.

And if you get into the supplement category, there are far too many, from omega oils, to various roots and herbs.  And then there are the toxins, take aluminum salts in some antacids.

It is sufficient to say that if you read this blog, and you remember any of it, you don’t have to worry for a while.

Monday, May 2, 2016

“Uberizing” Pre-Hospital Care

Medical Costs keep rising and are under a great deal of government, societal, and insurance company scrutiny. Rarely discussed in the medical cost debate the true cost versus effectiveness of prehospital care.

The entire fire-rescue paradigm has broad support from most constituents but there probably could be some evidence-based cuts. The article above gives some guidelines how this can be attempted.
An interesting phenomenon occurs every time a rescue is dispatched: a fire crew is simultaneously sent out to act as first responders. The rationale four quick response is to arrive within 4 minutes, start CPR, and defibrillate someone with reversible V-fib. Yet, the majority of calls do not need CPR, defibrillation, our even treatment; but at the same time, they cannot be simply left where they are, and therefore need transportation to a care facility. 

Such transports are not only extremely expensive, but also take valuable paramedics out of service to act pretty much as a taxi. Municipalities commonly encounter fire-rescue budget constraints, and many cities now instruct their paramedics to call for a private ambulance themselves when the need is strictly for transport. Of course, such vehicle and personnel shuffling is time-consuming and potentially more expensive.

A potential “out-of-the-box” solution is to take advantage of the Internet, social media, and companies like Uber and Lyft. In the future “Uber” may be used as the generic name for Internet driven transportation services.

Potential applications are:

1.      When a patient needs just transportation, “Uber” can be called by the fire rescue, paramedics, and or dispatch. A patient may even initiate the call.

2.      Cities and Fire Rescues can contract with “Uber” to send specific taxis with CPR-trained our even ACLS-trained drivers to transport patients who do not need a stretcher for transport.

3.      Certain cities are studying paging anybody within 6 blocks of a cardiac arrest victim who has volunteered as a CPR first responder. Specially trained “Uber” drivers that can commence CPR and attach and use the AED can extend this first level of care. Having backup of this type would gou a long way to alleviate community concern, and generally assure that every victim is reached in under 4 minutes

There is considerable potential for cost saving. Think of reductions in fire station construction, personnel, and equipment. All of this could be achieved with little reduction in quality. It’s time to take advantage of social media and include private infrastructure to aid the public good. Perhaps in the future, stories ouf babies being delivered by taxi-drivers will be replaced by a stories of heroic Uber drivers in that honored role.