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:

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.

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!

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!

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.

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.

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

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.

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.

This report summarizes the results of a recent CTS Software Selection Survey, and reflects the opinions of 150 survey participants who visited www.CTSGuides.com, and registered for our free distribution, construction or manufacturing Software Selection Kits. Each kit includes software reviews, ratings and selection tools, along with a 10-minute Smart Shortlist™ consult with software expert and CTS President, Sheldon Needle, designed to help identify the best software options for the registrant’s shortlist. Under Needle’s leadership, CTS has been publishing business software evaluation materials since l983.

The results of the CTS Software Selection Survey are surprising at times and reaffirm that, despite the challenges in our economy, many companies are implementing new software. A summary of the survey results follows.

Why Software Buyers Choose a Particular Product

In the CTS Survey, 78% of respondents bought new software in 2010. When asking respondents why they chose a particular product, our survey listed four possibilities: Best Function, Best Price, Brand Recognition and Sales Presentation.

As Exhibit A illustrates, 60% of the respondents cited Best Functionality as a reason for choosing a particular product. (We were extremely happy to discover this because our CTS comparative ratings charts help direct buyers toward the products that have the best functionality for their needs.)

Price was the second most mentioned reason for choosing a solution. However, while 44% of the respondents cited Best Price as one of their software selection factors, only 9% chose a solution based on price alone. These price-driven buyers were generally less happy with their purchase than other software buyers we surveyed. In fact, one-third of the price-alone respondents reported being Very Dissatisfied with their software choice. This finding demonstrates that, while it’s important to consider price when choosing software, buying on price alone is certainly not the best approach.

Our survey indicates that a solid sales presentation was often an important factor in the buyer’s decision: 27% of respondents cited this as a factor in their decision-making process. Interestingly, 19% of respondents claimed that their choice was made based on Sales Presentation alone – and every one of these respondents report that they are generally happy with their decision. The takeaway here is that a well-informed sales presenter carries a lot of weight with buyers. Brand Recognition only played a role in 9% of the software selection decisions.

Exhibit A

What’s to Like (and not Like) About New Software

While pre-defined response choices, such as Somewhat Helpful and Very Happy, helped us spot trends and establish percentages, the free-form pick-list comments gave us a deeper understanding of why a company was happy or unhappy with their software purchase.

Comments like “flexibility” and “user friendly” were fairly common among happy buyers. Good support and training, and the ability to customize the software, were other factors that routinely lead to happy buyers. Also on the positive side, integration capabilities and technology platform were mentioned as reasons for choosing a solution and reasons why a company reported being happy with their choice.

Some of the happy software buyers reported struggling with complex implementation or functionality issues. But with strong vendor support, these issues seemed to get resolved over time.
Among the unhappy buyers, “We should have done more research,” was a fairly common response. In addition, poor training and support were contributors to overall dissatisfaction. Also on the minus side, a number of respondents were surprised by the complexity of setup and use of the system they chose, and felt that more testing should have been done before the purchase. Several respondents commented that having an internal champion to manage the evaluation process and software implementation would have improved their company’s outcome.

Exhibit B

A Note about the Non-Buyers

Our survey revealed that 22% of the respondents haven’t purchased software. While 15% of these respondents reported that economic reasons put their purchases on hold, 40% indicated that lack of interest or lost momentum among upper management stalled their technology initiative. This confirms that buy-in from top management is vital to the successful execution of a technology initiative.

CTS: A Valuable Software Selection Resource

A cautious and thorough approach to evaluating software products and vendors is the best recipe for a successful software purchase. While it is the software buyer’s responsibility to perform the necessary due diligence to make an intelligent purchase, expert guidance and quality research materials are valuable tools that lessen the chance of choosing a solution that doesn’t fit your organization’s needs and expectations. Utilizing CTS’ free published information and Smart Shortlist consult to narrow your company’s choices is an excellent step toward a positive outcome.