About the Author

Sheldon Needle is President of CTSGUIDES.COM, a free web site offering reviews, ratings, tools, and expert advice to help companies select software. Sheldon is a former CFO, consultant and software designer who has published more than 20 guides on software selection.

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  • Electronic Health Records and the challenge of Unstructured Data
  • Don’t let Poor Planning Make the Migration to EMR/EHR More Difficult
  • EHR for Doctors in 2012: What to Expect, What to Avoid
  • What is the 5010 Standard and What Does it Have to Do with the Electronic Health Record?
  • White House Pushing Hard to get Doctors to embrace EHR

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By Sheldon Needle

The real problem of an established medical practice moving into the realm of EHR is not the cost of the medical software package; it is not the training necessary for staff; and it is not security and backups.

The real problem of moving into EMR/EHR is the problem of unstructured medical data.

If you are involved in a new or relatively new practice, this is a no-brainer. Begin with a serious search to compare medical software vendors who are available to answer your questions honestly. It is not truly so difficult to get on a friendly medical screen to enter your patient’s blood pressure or lab test values. You can get used to that.

Neither is it difficult to take notes on a notebook that upload to the EHR system.

The real problem is taking your notes and dictation on a patient that go back 15 years and finding a way to get his possible symptoms, his worry about IBS, his headache history, and his worries over his children into a metrically available rendition that that does not take you or a member of your practices days to decipher. These notes are usually on dictation, hand written notes, and referral letters.

The concerns are many: this can take what feels to be forever, and the anxiety issues and unclear symptoms may not translate easily into metrics but may be critically important in future diagnoses.

There are two critical questions here:

1. 1) Is it worth it? and
   2) If it is worth it, what to do to make this work efficiently?

In the long run, it doesn’t even matter if it is worth it. It will happen. Medicine as well as the rest of our cultural world, is becoming electronically-based whether we like it or not. But in the long run, it is worth it. Think of a patient going in to the hospital after a car accident, all by himself, and having all his data available to the admitting doctor in an instant: blood type, history, etc.

Think of a patient being referred to you, the specialist, and having all his patient history available in less than a minute. What a time saver! What insight!

Medical informatics has a number of methodologies it is using to translate unstructured data into useful and structured data.

Three basic methodologies exist to accomplish this:

• String matching
• Natural language processing for Medicine (NLP), which uses syntactic rules in extracting data from text documents
• Concept-based indexing which uses data base codes to group and relate medical concepts

These methods will be refined, utilized, and integrated in some way into most decent medical vendor software packages over the next few years. For you the physician or practice manager, this may start to pay off in a while, but you still have to get from hand written records into the database.

The obvious way to proceed makes use of our culture idea of, “going forward”:

1. Start with today’s records being input into the database electronically – this is the easy part.
2. Then get help in moving 1 year of back data scanned and automated. Get someone technically savvy and talk to the support people whose EHR software you are considering about OCR (optical character recognition) software that may be available from vendors.
3. Most vendors of decent repute will have voice recognition software incorporated into their total EHR solutions. Have them demonstrate how well it works in moving data into their files.

The real message to practitioners moving to electronic health records is, don’t look at the top of the mountain when you start climbing, just put one foot in front of the other. Delaying the climb will not get you anywhere, but starting the march will move faster than you think!

Source:

Having recently spent time as an observer in a hospital setting, I was struck by the lack of intelligent planning and forethought made for doctors trying to move into an EMR / EHR environment.

Though I saw a well-known EHR panel on the computer screens within an ICU, and the EHR being used to record certain patient data, doctors were taking their notes in long-hand. Later on the same day I saw the same doctors transcribing their notes onto their computers. The doctors, doing double duty on note taking were not available to their patients because they were acting as secretaries.

When a large clinical environment is incorporating an EHR it has to be done in a modular way that does not impact productivity any more than it has to. The task is hard enough. If you are using an EHR to record point of care patient information, give your doctors a Notebook so they can take their notes electronically. In fact, insist on electronic note-taking. Incorporate change with some forethought to peoples’ time and effort.

This real-life observation just underscores the need to plan for transition to an EMR rather than throwing an institution into the chaos of change for its own sake, or for the sake of Meaningful Use incentive payments. As in all things, the old US Coast Guard motto holds true: Semper Paratus! Always be ready and prepared.

Most good EMR / EHR systems can offer medical clients some guidance as to best practices in incorporating EMR / EHR systems within their practices.

By Sheldon Needle

The prospects for EHR in the coming year are exciting but more than a little daunting.  The issue is really how to find an EMR/EHR system that will organize and centralize the functions of your practice, without bankrupting you and throwing your staff and yourself into turmoil.

If you look at the websites for EMR vendors today, you can see that the functions they describe within their system –the integration of clinical records with practice management data, e-prescription, patient portals — could conceptually do wonderful things for you and for your patients in the way you handle their individual cases, but many of the details are still not working smoothly.

Here are some of the things to be aware of:

1. If you are getting a client/server system, make sure your internet connection has the bandwidth to support the sheer number crunching your system will need.  Otherwise your system may well freeze up on you or move at the speed of molasses.
2. If you are a small practice and getting SAAS software, hurray for you!  This could be just the right way to move towards EMR.  But beware of sticker shock.  The prices quoted to you on-line for monthly subscriptions to SAAS may well not mention additional fees you need to pay for licensing, installation, initial training.  Make sure everything is clearly stated in your contract.
3. Think hard about how you are going to transition your current paper based system to digital records.  Who will do the scanning?  What will you do with your dictation?   The whole issue of free form data (things like scanned documents that need to be OCR’ed in order to get into the database, your dictated notes, etc.).  It is not enough to just get everything on paper scanned.If you can afford to get a service that does transitions like this for a reasonable fee, consider this as a viable strategy.  It may save you lots of headaches.
4. Not everyone can necessarily get the benefit of “Meaningful Use” incentive payments right away.  It will depend on the nature of your practice, your specialty, your patient base, as well as how many Medicare or Medicaid patients you service, just to name a few variables. Do not let “Meaningful Use” be the only criterion you use in evaluating EMR software.
5. Find a company that will do serious training for you and your staff, and will not nickel and dime you for every question you have for them as you move into the implementation and use phase.

Remember, always read the fine print and ask every question you need to. Know that EMR software decisions is a very competitive business. The vendors need you just as much as you need them!

By Sheldon Needle

5010 is not only a date 3,000 years in the future: ANSI 5010 is the newest version of the HIPAA transaction standards regulating electronic transmission of medical and healthcare transactions. The existing standard is called 4010, and 4010 does not support ICD-10 coding.

The current coding standard for diagnosis and procedure coding is the ICD-9, and it has outlived its possibilities –it limits the number of new procedure and diagnostic codes that can be created.

This is how the CMS.gov (center for Medicare and Medicaid services, at: http://www.cms.gov) defines the ICD-10:

About ICD-10
ICD-10-CM/PCS (International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System) consists of two parts:

1. ICD-10-CM for diagnosis coding
2. ICD-10-PCS for inpatient procedure coding

ICD-10-CM is for use in all U.S. health care settings. Diagnosis coding under ICD-10-CM uses 3 to 7 digits instead of the 3 to 5 digits used with ICD-9-CM, but the format of the code sets is similar.

ICD-10-PCS is for use in U.S. inpatient hospital settings only. ICD-10-PCS uses 7 alphanumeric digits instead of the 3 or 4 numeric digits used under ICD-9-CM procedure coding. Coding under ICD-10-PCS is much more specific and substantially different from ICD-9-CM procedure coding.

The transition to 5010 is supposed to happen by January 1, 2012. This means that electronic transmissions including claims, eligibility inquiries and remittance advices must be made in a 5010-compliant format. Healthcare providers, health plans and clearinghouses for transactions are all expected to upgrade their transmissions. Non-compliance may result in claims denied or slower payment.

Systems that are certified as ONC-ATCB for 2011/2012 are already 5010 compliant. If you are contemplating buying a system that is so certified, you do not have to worry about the software compliance, but you do need to educate your staff, including yourself, if you are the physician or the P.A., on what the differences between 4010 and 5010 mean to their everyday work.

If you are using old medical software that has not been updated, or are contemplating installing software that is not certified as ONC-ATCB for 2011/2012, you need to update to a newer version, or face delays and uncertainties in your billing and claims submission. In other words, do some serious upgrading, or else!

By Sheldon Needle

November 30, 2011: Today HHS Secretary Kathleen Sebelius announced incentives to speed the adoption and use of health IT in the form of meaningful-use qualified EHR in doctors’ offices and hospitals nationwide, which will improve health care and create jobs nationwide.

The new administrative actions announced today, which will be made possible by provisions of the HITECH Act, will loosen requirements for doctors and other health care professionals to receive incentive payments for adopting and meaningfully using health IT.

“When doctors and hospitals use health IT, patients get better care and we save money,” said Secretary Sebelius.  “We’re making great progress, but we can’t wait to do more. Too many doctors and hospitals are still using the same record-keeping technology as Hippocrates. Today, we are making it easier for health care providers to use new technology to improve the health care system for all of us and create more jobs.”

The press release continues to state: “HHS also announced its intent to make it easier to adopt health IT.  Under the current requirements, eligible doctors and hospitals that begin participating in the Medicare EHR (electronic health record) Incentive Programs this year would have to meet new standards for the program in 2013.  If they did not participate in the program until 2012, they could wait to meet these new standards until 2014 and still be eligible for the same incentive payment. To encourage faster adoption, the Secretary announced that HHS intends to allow doctors and hospitals to adopt health IT this year, without meeting the new standards until 2014. Doctors who act quickly can also qualify for incentive payments in 2011 as well as 2012.”“ (The italics are ours.)

We need to understand what acting quickly means: buying in 2011? Incorporating EHR within the next month, so that meaningful use occurs in 2011? This is not yet clear.

HHS is redoubling its effort to reach out with information, education, and the possibility of incentive payments to doctors and hospitals and vendors about stepping up the pace of transitioning practices and HER software to meet standards of Meaningful Use. What Meaningful use means to the individual practice depends on size, degree of implementation of the EHR, and the nature of the client base (how many Medicare or Medicaid patients, for instance, figures into the formula of Meaningful Use.

The Obama Administration is working to create a nationwide network of 62 Regional Extension Centers, comprised of local nonprofits, to help eligible health care providers learn how to participate in the Medicare and Medicaid EHR Incentive Programs and meaningfully use health IT.

See the HHS press release, at: http://www.hhs.gov/news/press/2011pres/11/20111130a.html to learn more.

Keep your eyes on the newspapers, government announcements and on this blog to learn about EMR and EHR news and updates.

By Sheldon Needle

You know that your medical practice will have to bite the EMR bullet sooner or later (actually, sooner). The digital handwriting is on the tablet, isn’t it? So what is it stopping you from moving ahead at a planned pace rather than being forced into converting your medical practice to an EMR at the 11th hour?

Here are some of the most common obstacles people face in converting their practices to the use of electronic medical record software, and here are some strategies to deal with them or get the process going:

1. How will we migrate from paper to digital images? Conversion of paper medical records to digital format: If you have your eye on an EMR, learn how tolerant it is of varying formats: does it accept PDF files? JPG format? Ascii text files? Extracts from excel files?

Don’t bit off more than you can chew to begin. If you are practice with reams of folders full of paper files to convert, decide how many years back you need to go in getting your EMR up and running. Perhaps you can start with one year of files via EMR? Or perhaps you need to go much further back?

Look into the possibility of having a consultant specializing in data conversion take charge of your files. There are companies that specialize in just such medical data conversions. If you are really desperate, hire your responsible college students, make the specs clear, and pay her decently!!

2. How will we train everyone in such a new system? Training your self and your staff: Once you have chosen your EMR system, engage the company’s own training staff; that way, you are sure you are being oriented in the current system, using the right documentation. Before you chose your EMR, see what kind of training options the company offers. You might go for a short orientation up front, with a good help desk that is available 24/7. Check reliable Electronic medical records ratings to see which companies provide good in person and on the phone / online support

3. Do we have to set up all the hardware and maintain the software? I don’t think we can manage that. Consider a cloud-based EMR solution: If you are reluctant to invest in a server and commit to the upkeep of hardware and software, consider a Web-based EMR solution, in which you log onto an EMR that worries about security, and updates to hardware and software.

4. How can I compare products so that my practice knows what it is getting into? How much can I trust referrals from other practices? Don’t put all of your EMR decision eggs into one basket: While personal referral are extremely helpful and reassuring, not all are meaningful for your unique EMR practice situation. There are many good EMR products to choose from, and each has its strengths, and its weaknesses.

The right choice will depend as much on the nature of your medical practice and the answers to many questions: What is your medical specialty? How many employees do you have? How expensive is the EMR, per year? How much money can you dedicate to investing in your EMR annually? Can you integrate your medical billing software with your proposed new EMR? Can you afford to hire a dedicated IT employee? How comfortable you and the others in your practice are with using an electronic device as the main source of medical input to your system. These are just a few of the many questions you need to ask yourself.

Talk to people in other practices, yes; but learn to ask the right questions and compare apples to apples and oranges to oranges. Great EMR comparison tools are available to you at no charge, and they can educate you to ask the right questions and maintain a solid baseline for comparison when choosing an EMR.

Many EMR experts — both on the user side and the training side – agree that comprehensive training in the specifics of EMR software — or the absence of it, can be one of the most costly aspects of the transition from a paper based medical practice to an EMR /EHR.

Making the move to an EMR, and failing to train your staff adequately, can sour your entire staff, top to bottom, on the use of the EMR. You certainly need to avoid such a situation.

Here are some considerations and precautions to keep in mind and to discuss with your EMR vendor when evaluation the purchase or leasing of an EMR / EHR: Some of them will surprise you:

1. Your youngest and least academically sophisticated employees will probably have the least trouble learning to use your EMR. That is because they are computer savvy, and are used to texting, apps, and intuitive computer use. Your most sophisticated applications may be used by your least computer-savvy users: older doctors and nurses. Do not assume that they will know what to do without training. Do not allow your vendor to talk away the need to train your most senior employees.
2. Make sure your implementation schedule is reasonable. Do not allow your vendor to move the implementation along too quickly. Allow people time to practice functions before you go live, and don’t forge ahead with the next module’s implementation until most employees achieve a comfort level with the first.
3. Stagger your training schedule to match your implementation schedule. Training in the use of an EMR system is something that cannot be boxed off into a space of time. If you are staggering your implementation into stages (that is, implementing different modules at different times) makes sure that your training schedule is staggered to accommodate the different implementation phases.
4. Training is never one-size-fits-all for a medical practice. There is no point in offering all of your employees the same nature and level of training. Carving up the training pie carefully is critical. Careful implementation planning will, in the end, save you money.
5. If some of your staff needs training in basic computer skills, have someone less expensive than your vendor offer such training. Get a skilled college student to teach a class, or find an adult education class for your computer illiterate employees. Save the expensive training for more sophisticated applications.
6. Never rely on memory to keep track of training lessons. Request formally prepared training material to be distributed to your staff. Record the training sessions – audio and visual — for later use. If there is no prepared training material available, appoint a staff member to gather notes, handouts, etc. in a binder that can be used for reference.

By Sheldon Needle

No one can promise you that Implementing an EMR, however good, can be easy and without false starts and problems. The changes you are planning to make – both in the way your practice does business, the workflow, and the change from paper trail to electronic documentation – are so major. Finding the right intersect between the needs of your medical practice and the features and strengths of a particular EMR/EHR will make this implementation go more smoothly. But it helps to know which EMR implementation problems you can surely anticipate, and which you can hope to avoid .

Here are some ideas to help avoid major disasters within your implementation:

1. Plan to Implement in Phases: no one can hope to integrate all functions and modules of an EMR at once. Identify an easier function for starters — some functions that are close to stand-alone — and implement that first. Think out the order for implementation of modules, so that the successful outputs from one modules can feed another. The nature of your practice or medical group will determine what makes most sense.
2. Flow chart your medical practice functions, as the programmers of old used to do, so that the visual presentation will help you make sense of the order of implementation. Look at your employees – your doctors, your nurses, your technicians, your medical billing specialists. See where their functions intersect and overlap. Look at the modules available, and see how they can be divided up according to your workflow chart.
3. Map staff into your flowchart and implementation plan, so that you know who will be involved in each stage of the EMR implementation and who will need the most extensive training in the use of your EMR.
4. Think about how you will get “free text” into your EMR/EHR– that is, data that is not sitting in a database somewhere. Notes that you take via speech recognition software will not be discrete fields that can easily be picked up and “reported” on by an EMR’s report writing function.. Some EMR’s are beginning to use AI (artificial intelligence functions) to capture free text data, convert it to discrete and “reportable” data to come out of the EMR’s reporting functions.
5. Have end-users involved in the design and implementation phase of the EMR. For instance, the technicians most involved with processing and handing over x-rays need to be involved in the design of the scan and capture of x-rays, MRI results, etc. into the EMR. The end users are the people who will actually use the modules and the reports from the EMR. Design decisions must be reviewed by the end users to make sure interfaces are workable and practical. Make sure that your medical billing specialists are on-board in the use of the system, and the importing of codes from your clinical information to your billing modules.
6. Allocate plenty of time for training your medical end-user staff. That time should be broken up, rather than administered in one serious “gulp”. People need time to assimilate and test out what they have learned about using the EMR. Give staff time and a place to practice methods so that they are not rushed through procedures that they do not feel confident using.
7. Provide good local computer support. Not everything can be resolved using remote help desks. Make sure there is someone physically available for hard/ware software issues on a regular basis. This person does not have to be available 24 / 7 but must be available on a daily basis, even if it is for an hour a day.
8. Keep a close eye on the system interfaces before you commit to using them: This is the likeliest place for gross problems to crop up. Interfaces between different medical software systems must be examined before the EMR/ EHR goes anywhere near live: Have your I T person , whether in-house or hired, investigate the interfaces between your EMR or EHR and any external systems very carefully. Do not make assumptions about system compatibility. Do not believe the vendor literature without testing the interface.

There are so many critical planning and training factors to keep in mind in planning for your EMR/EHR, but these are critical ones. Look at the CTS Demos Scorecard to help you compare EMR/EHR software and find the right fit for your practice. Your practice – and your patients – stand to gain the most from a good EMR/HER fit and a semi-calm implementation.

Come back to this blog for additional EMR implementation and integration ideas and planning issues

By Sheldon Needle

Should you consider integrating your current Medical Practice Management System with a new EMR, or must you shift to an EMR that includes medical practice management functions?

Practices which are relatively new to software as a management tool sometimes do not realize the very different functions that a PMS (medical practice management system) and an EMR system offer:

A PMS is used for managing administrative, billing, scheduling, and budget related (financial) information, and an EMR is used for managing clinical, patient related information How feasible is it to integrate these two functions to produce reliable information for your practice, and to fulfill government reporting requirements.

Let us assume that you are a practice ahead of the wave, and you transitioned long ago to a medical billing software and medical scheduling system. You are very happy with it. It works for you and for your patients. Now the world, and the government, are at your door, and is pushing for a more total solution: an EMR / EHR.

Do you have to ditch the practice management system that you worked so hard to install and to customize to your needs and replace it with a total solution – an EMR that incorporates financial and billing capabilities? Or is there a way to keep you medical Practice Management System and integrate it safely with an EMR minus its billing and scheduling capabilities?

Here are some issues you must consider before you can answer this question:

1. Your Practice Management System is a business system, and your EMR will be essentially a clinical system (although a full EMR will include Practice Management functions). Unless you are looking for hardships, you need the 2 systems to talk to each other in a transparent manner, and you need the possible upgrades to work in tandem. One thing this might suggest: if you are interfacing a PMS with an EMR, you had best be dealing with well known systems that are very regularly upgraded, and whose interaction with other systems are constantly monitored.
2. A single database for financial and clinical patient data would, theoretically, provide the best and most reliable data-mining capabilities for your practice. But what if your Medical PMS is very effective? Perhaps you can live with the two databases, or you have a way to periodically reconcile the two databases. Or perhaps the functional users of your databases are so different that you can live with the minor incompatibilities? Evaluate these issues closely before making a decision. Don’t throw away the baby with the bathwater.

Read the complete article at CTSGuides.com.

By Sheldon Needle

EMR’s come loaded with options, medical practice modules, streamlining techniques. But, unless your employees – physicians included –learn to harness (if not master) most of the modules of the EMR and tailor them to the work-flow of your practice, you will lose the advantages the EMR can bring.

Thus, training in the use and management of the EMR is almost as crucial as your choice of EMR. In fact, when you compare EMR software be sure to investigate the training options the EMR manufacturer, and the consultants who install it offer to a practice like yours. The training and support offered by an EMR vendor is as important as the quality of your EMR software. If you can’t use it correctly, and it doesn’t save you time and effort, it will make your whole practice miserable.

Here are some critical tips to keep in mind regarding training:

1. Understand the workflow of your practice. Chart it out on paper, for starters: who does what? Who follows up on a task. Just charting the progress of a medical prescription from the doctor’s pen to the patient’ pharmacy is a multi-person task. See what tasks may be eliminated or cut short by the use of your prescription module, for instance.

2. Understand who needs to be trained in what: Unless you are a 1-physician doctor’s office, different people generally perform different functions within the practice. Everyone doesn’t do everything, and doesn’t have to be trained in the use of all modules.

If you are dealing with a reputable vendor, the people who are installing your EMR will talk to you first about your workflow and your needs, and tailor and help customize the EMR to meet those needs. They and you will recognize the need to train different people in the use of different modules.

For instance, the people who handle medical practice management and medical insurance claims processing do not need to be expert in the Prescription Drug Tracking Modules. They may need to know how to access the module for reporting purposes, but they do not need to know all of its ins and outs as the doctors and nurses do.

3. Don’t try to implement the whole EMR at once. Virtually all EMR’s are modular, and handle different functions discretely. Since functions are often pretty complex, allow your employees to master a number of critical modules before they move on to others.

Read the complete article at CTSGuides.com.

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