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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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.

Watch as Software as a Service (SAAS) for EMR / EHR becomes Cloud Computing: And Cloud Computing becomes a Valid EMR Choice

By Sheldon Needle

A few years ago, the idea of SAAS computing services for the medical EMR / EHR industry was still on the vanguard, a little risky: a kind of out-there medical solution for medical groups who wanted a cheap, automated solution.

Today, many large Practice Management Vendors are offering cloud-based Practice management software alongside their client hosted EMR – and sometimes instead of client hosted EMR.

After all, if we do so much of our IT work on notebooks that don’t have much in the way of a hard drive, and are writing our personal papers on Google Docs that are out there in the ether world, why would we not consider similar solutions for our practice management software? Even client hosted software has its own mini-version of cloud computing when it offers physicians tablet-based drug prescription software (tied in to their own remote server) or patient portals that can be logged into remotely.

The difference between cloud-based EMR and client hosted EMR is really this: Who is doing the system maintenance? In the case of client hosted EMR, it is your own employees; in the case of cloud-based EMR, it is a contracted IT team. The question becomes one of reliability, and that is a hard question to answer.

If you are large enough to hire your own full time IT people to be available 24/7, well and good. It might make dollars and (good) sense to have your own client hosted server; if you are a smaller practice, or a large practice that doesn’t want to get involved in IT management, cloud computer based EMR / EHR begins to make more and more sense as medical software management application get more sophisticated.

Some of the risks associated with cloud computing for EMR need to be discussed and evaluated. Most are valid, but are equally applicable to client hosted systems as well:

1) Who controls the data?

If your secure data is in a cloud, it means that someone else has access to your data. But companies that offer software as a service are likelier to have more secure encryption and control of the data than you are in house with a personal server, because security is such a large part of their business. In-house ignorance of data control rules, even in data associated with patient billing, or lack of enforcement thereof, is just as likely to be part of the company culture. Benign neglect of rules because you trust your fellow employees makes a system even more vulnerable than leaving security issues to a third-party whose integrity and reputation will be based on careful security maintenance.

2) Poor training and associated data vulnerability:

Poor training in the use of patient-related data is a risk in any EMR environment. Ignorance of security procedures is a more likely culprit in confidentiality breakdowns than is deliberate security violations. Most providers of quality EMR software will provide enhanced training, either as part of their regular contract, or as an enhanced feature option available with your contract for a software package, whether it is SAAS or client hosted. Don’t skimp on training, because it can make the difference between a relatively easy migration to new software and a nightmare situation. IT can also make the difference between security slips due to ignorance and a safe and secure data situation.

3) Catastrophe and backup procedures:

Isn’t it wonderful to have someone else worry about backup procedures? This is something that must be part of any cloud computing contract. If it is not, you are not dealing with a provider who is aboveboard.

If you are managing your own backup and catastrophe procedures, be vigilant: no one wants to dream of the worst-case scenario, but as we have seen in the macrocosm, and in the microcosm, such things happen readily enough. Assign this critical catastrophe management and precaution role as an integral part of your daily workload, and assign it to one person or group; the buck must stop somewhere on security issues.

In summary, we are not preaching the virtues of cloud computing, but we are saying that cloud computing is a very valid and reliable choice for some practices today. Security and flexibility of design are issues in any system. Ultimately, someone is hosting your system, whether your server sits in your back office or half a world away. The real issue is responsibility for your data. Someone has to be in charge. And you had better know who that is.

How do I know whether the EMR and EHR products I am considering are truly certified by the US government as Certified Health IT products? And, if I am not confident of receiving incentive payments for my practice, why should I care whether they are certified? Isn’t it most important to have a system that digitizes my information well and makes it easily retrievable for diagnostics, information, and billing purposes?

As most medical providers understand by now, the purchase of and /or implementation of EMR and EHR software is becoming a necessity. Not everyone is convinced of immediate efficacy of EMR and EHR systems in each of their individual practices, but it is the way the medical industry is headed. So for most of us, this means biting the medical software bullet and choosing an EMR / EHR system sometime very soon making sure that it will work with the specs of your practice or medical group.

Certified EMR and EHR systems, and submitting proof of their meaningful use, can bring financial incentives and payments for medical practices. Conversely, by 2016, lack of implementation, may result in penalties for practices.

How do you know which Software Products are certified Health IT Products, and qualify for incentive payments?

The US Government maintains a Certified Health IT Product list at: http://onc-chpl.force.com/ehrcert/CHPLHome.

According to the site, “The Certified HIT Product List (CHPL) provides the authoritative, comprehensive listing of Complete EHRs and EHR Modules that have been tested and certified under the Temporary Certification Program maintained by the Office of the National Coordinator for Health IT (ONC). Each Complete EHR and EHR Module listed below has been certified by an ONC-Authorized Testing and Certification Body (ONC-ATCB) and reported to ONC. Only the product versions that are included on the CHPL are certified under the ONC Temporary Certification Program.”

It should be noted that different modules of different packages can be certified independently. One should not assume that a brand name of X means that every module of product X is EMR certified. Excellent medical software reviews by companies such as CTS, Inc. online from reputable companies to review different modules of EMR packages.

Using the online listing of the Certified Health IT Product list, which is maintained by HHS should offer an authoritative listing of products. Even if you are not particularly excited by the financial incentives because you do not believe they will bring you great return, or if you feel that because of your patient base you would not qualify for many incentive payments (very few Medicare or Medicaid patients, for instance) there are other reasons you might want to buy a Certified Health IT product:

1. Because companies that want to compete for this large audience of buyers are eager to sell the quality of their product, they are often more aggressive about good training and problem rectification. They are eager not to have complaints lodged against them, or to receive bad reviews for their products.
2. Because EHR certified systems are eager to be able to upload their material to CMS, they are eager to have good reporting capabilities and interactive modules that communicate information with each other and with of EHR systems easily.
3. Because standards and rules for certification are still in flux, certified packages and their various modules need to be responsive to changes in rules and in the law. So if your practice buys into an EMR / EHR that is certified, you are likely buying into a product that will stay current and be reviewed and regularly updated.

The big news in EMR Software as a Service right now (June 2010) is the Dell/Practice Fusion offering of  “cloud-based” free EMR software from Practice Fusion when you buy it bundled with Dell hardware to support it.  This would allow small practices that would not think of making the large initial investment in a traditional EMR or even a medium-price SAAS EMR to contemplate the great leap from paper-based offices to an EMR.

What’s more, Practice Fusion claims that its EMR  software will be certified by the right organizations and available to all medical practices that want to qualify for 2011 HITECH payments.

This means that if a medical practice is willing to jump in and make the transition to an EMR , the ramp up time will be shorter  and the money investment  much smaller than it would be using more traditional EMR systems.

Practice Fusion has a set of suggested Dell hardware support requirements for a solo practice, smaller practice, and medium small practice.  This is an extremely interesting development for a small practice, and will certainly not come free, but will still be reasonable. And since the software and hardware suppliers will be working in tandem, a practice ordering this package will probably get good guidance on their hardware purchases.

This medical software/hardware bundling will certainly be the first among many such offerings from other suppliers.   It will offer a small practice the opportunity to get its feet wet in the world of EMR with decent hardware and technical support promised from the vendors.

Of course, the cloud-based free software will not be as customized and tailored as “bespoke” EMR built for a proprietary server.  But since cloud based computing is becoming such a popular, if not dominant way to go in the industry, a potential user can be confident that cloud-based software, and its ingenious promoters, will find ways to become more customized as time goes on and as competition for this very large market segment, small to medium sized practices, becomes stiffer.

What about CCHIT certification and “meaningful use?” Must every small practice worry about that?

If your practice is small enough that you would not otherwise consider purchasing or leasing an EMR, or if your only other option is to install open-source software, a bundled offering like this one is probably a good bet and an excellent risk: both the hardware and software manufacturers want this bundled offering to succeed, and they are promising good technical support.

Watch for competing offers from other companies.

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