If you’ve been reading me for a while, you know that I have a few hundred draft posts (basically ideas) for future posts. However, the news about meaningful use is coming out so quickly that it’s not that often that I have to go back and use those draft posts. I probably should do it more. Well, when I was working on my soon to be released e-Book on EMR selection, I ran across this comment about two different ways of documenting in an EMR. It’s written by Matt Chase from Medtuity and likely was originally posted on EMRUpdate (sadly, I don’t have the original link).

I’m a total Matt Chase fan boy, and this type of information is what makes him so good. Plus, if you’ve ever received a 10 page note with about 1 small paragraph or relevant information, then you’ll find this information VERY interesting.

There are two methods of documenting with templates: documentation by exception, or DBE, where the template is pre-answered, and documenation by veracity (where you actually gather a history and examine the pt before documenting).

The first (documentation by exception) usually puts into the chart a huge number of normal items and the physician’s duty is to change what does not apply. The “change what does not apply” becomes too burdensome because there is so much fluff on each patient, that it is simply easier to forego the editing. This contributes to the not so unusual findings of “normal clinical *** exam” in a 7 year old boy and “normal descended testes bilaterally” in a 12 yr old girl. Think of it as every 80-yr old male appears on paper identical to every 20 yr old, strapping young man– no abnormalities.

The VA is probably using documentation by exception. The easy way to tell if a system uses DOE is by simply printing an encounter. If it exceeds 1-2 pages, it’s probably DOE.

In contrast, the better method of documenting is for the EMR to present a template with all of the relevant findings, both normal and abnormal but allow the physician to click the findings. For example, a sore throat encounter would have all those things important to a sore throat, including history of fever, difficulty swallowing……through a good neck and throat exam. You would not expect it to document a *** exam, digital rectal exam, or exam of the genetalia. IT’S A SORE THROAT! The documentation would be relevant and short.

With the proper mix of “input controls”, such as checkboxes, right-left-bilateral, positive/negative, multiple choice text controls, calendars, number control, and dozens of other types, it is possible to rapidly enter truthful information. Many EMR’s have only several types of controls (either checked or unchecked), making it easier for the designer of the system to simply put in paragraphs of text (hence the DBE).

Obviously, my disdain for padding the chart with meaningless information is a strong indicator that at Medtuity, we provide a system where the physician clicks to enter truthful information. We take the step of allowing information to be entered quickly.

The local hospital’s emergency department uses one of the “big boy” EMRs that performs documentation by exception. For example, every ankle sprain has a full neurological exam placed in the chart, by default. It does not matter that few ankle sprains receive a full neuro exam. For EMRs designed for DOE, they usually generates a high billing code because including 30 normal findins in the chart is easier than documenting a couple of abnormals.

Selling our product locally always generates the same question: “My documentation won’t look like the ER’s, will it?”. Nobody wants a multi-page report of meaningless normal findings.

One reason, I believe, that there is a lower penetration of EMRs among specialists is this problem of padding a chart with a single click. The charts produced by specialists are actually read by the referring primary care physician. When anticipating a colleague reading the chart, they may hold themselves to a higher standard.

On the other hand, we feel that the scores of questions that are asked by the specialists again and again, with every patient, should be easily responded to with just a few clicks to set many responses to negative. For example, a *** surgeon will ask about *** self-exam findings including lumps, nipple discharge, skin dimpling…through weight loss, bone pain, etc, etc, many times a day. Most of these are negative.

Our profession may blame the insurers and Federal Govt for documentation by exception, but the reality is, it is a design defect. It is very easy to design an EMR for DOE. It is much harder to design an EMR that allows pertinent positives and negatives to be quickly entered.

Probably the easiest method for determining whether an EMR depends on DBE is to ask how many control types they have for entering data. We have over 40 in MedtuityEMR, and counting. I simply cannot fathom how EMRs can get along with just a couple, IMHO.

I asked for a demo of a common peds and family practice complaint (otitis) from “big boy” EMR user. Perhaps this problem has been remedied, but for such a common complaint, there was no means in his template to show:
ear canal occluded with cerumen
bulging TM
erythematous TM
tympannostomy tube present
perforation of TM
location of perforation
retraction of TM
normal TM
scarring of TM
TM motion on pneumotoscopy
………and about 10 other findings that you may wish to show, whether positive or negative) on your ear exam. He couldn’t even click right or left but had to rely on “the affected side”.

There was but one selection available for ear exam (normal/abnormal). That was perhaps two years ago and things may have changed.

So if you are shopping for an EMR and this matters, just ask the demo’er to show you a bunch of abnormal tympannic findings for a screaming 4 yr old. That will tell lots.

Matt Chase
www.medtuity.com
“Practice medicine, not paperwork” ™

Imagine a world without HIPAA
Imagine a world without 100 zillion insurance companies (each with different policies)
Imagine a world where people didn’t shop for drugs
Imagine a world where patient care was the only reason for health care

Never going to happen. However, I can’t help but wonder the type of EMR software we could create if we didn’t have to worry about the above items.

As always, on the weekend I write a little less focused and intense content. Well, I’d say that writing about the US Airways pilot “Sully” Sullenberger on an EMR site is way out there. However, he’ll be a keynote speaker at HIMSS and the guy is a hero. So of course I find the guy incredibly interesting. Plus, someone sent me this video rendering of “Sully” landing Flight 1549 in the Hudson and I gained even more respect.

The first few minutes of the video are slow, but then it’s absolutely intense hearing the radio communication and the communication between the pilot and co-pilot. Wow!

More of my HIMSS plans and meetup info on Monday.

In a move of more transparency the government (CMS) has made the comments on meaningful use public. You can find the comments on the Regulations.gov site. So far there have only been 24 comments made. Granted, there’s still a month available for people to comment.

CMIO has done a summary of the EHR comments:

• I find myself discouraged that we will ever be able to comply with this meaningful use definition. I also reflect on the last eight years of using the EHR and wonder how a new user of an EHR would qualify as well. Just installing and getting everyone using electronic records is a difficult task. So I believe that this version of meaningful use is too aggressive for the first year.
• We have been using a specialized EHR in our endoscopy center for eight years…I find it distressing, under the current requirements for meaningful use, ambulatory surgery center (ASC) specific EHRs may not be eligible for consideration. I strongly urge you to include these essential information systems for their unique contributions to meaningful use in the ASC environment.
• Regarding requirement to patient access to EHR within 48 hours, patients may have multiple encounters with a hospital prior to the development and implementation of an EHR. There should be no requirement to provide an EHR prior to the implementation of the EHR system … Hospitals should not be expected to provide EHRs to non-covered organizations or to those who do not have the capability of receiving the information. This should be covered by separate regulation that impacts these facilities

CMIO also have some comments on the CPOE and HL7 components of meaningful use at the link above. I love this sort of transparency and we’ll be keeping an eye on the comments made. I wonder if the people submitting the comments realized that they’d be made public. Maybe it should be understood, but still feels a little off to just make them public when they weren’t previously. Hopefully we have more than 24 comments a month from now. I’m thinking that I’ll make a bunch of individual comments (maybe I’ll do 24 myself). I’m all about transparency and so I think I’ll post them on here as I send them to the government. I think my first submission will be these thoughts on Meaningful Use and then follow it with my own thoughts on the harmful effects of meaningful use.

Looks like HHS and ONC have been hearing less than rave reviews about the ARRA EMR stimulus program. About a week ago, HHS posted a presolicitation asking to evaluate the “potential harmful unintended consequences” of the EMR Stimulus. Here’s a few excerpts from the notice that describe the problem:

“While we expect for these programs to help achieve the many desirable outcomes envisioned by Congress,” the notice said, “a sense of responsibility for activities we support, historical experience, as well as mounting evidence of unexpected problems, demand that we consider potential downsides,” the notice said.

“By ‘unintended consequences’ we mean outcomes that are not intended, even though, upon investigation and reflection, they are, at least in part, a natural consequence of the activities. While some unintended consequences are desirable, the purpose of this contract is to identify and address those that are undesirable and potentially harmful.”

I don’t completely understand the government process, but I wonder if this request isn’t a means to an end. For example, maybe HHS and ONC want to modify the requirements for meaningful use and certified EHR, but are strapped because of the details of the legislation. By doing a study that shows major unintended consequences to the legislation, maybe it will open the door for them to be able to make changes to how you gain access to the stimulus money even if it doesn’t match the initial legislation perfectly.

I could be all wrong here, but otherwise why would you do a study of the harmful unintended consequences? So, you can say we told you so after those harmful events happen?

The always interesting Evan Steele, CEO of SRSsoft, has taken this idea and listed his top three unintended consequences of the HITECH Act on his blog (Side Note: Evan and I are going to be on a bloggers panel together at HIMSS. That will be a lively panel.):

• There will be more EMR failures than successes, particularly among high-performance specialists.
• “Certification” will stifle innovation.
• Alternatives such as hybrid EMRs will lead the market among high-performance physicians.

I agree with the first 2 items. I’d just clarify the first one to say, “more EMR failures by those trying to get EMR stimulus money” For those not going after the EMR stimulus money “windfall,” I predict we’ll have an increase in successful EMR adoption. Of course, Evan’s final point is a little self serving since he’s the CEO of a “hybrid EMR.” Although, I do think the EMR software companies (hybrid or otherwise) that stay focused on a physician’s productivity and reimbursement will be the big winners in the long run.

Back to the study by ONC, I’ll be interested to hear who wins the contract for this work, if we’ll ever be a part of the study and if we’ll get to see the results of the work that’s done. Looking through the list of interested vendors, I wonder if any of them really have any expertise in EMR or healthcare.

Many EMR vendors have been announcing all sorts of guarantees about the EMR stimulus money. I think this is probably a smart move for many of these EMR vendors. It’s one more tool in the belt of their EMR salespeople. However, I think it’s worth considering an instance where someone thinks that their stimulus money is guaranteed and they end up with Nothing.

Let’s say a doctor’s office submits proof of meaningful use (however this will actually be done) and CMS comes back with a rejection letter. Who knows, maybe they didn’t record the preferred language or ethnicity of each patient. Maybe they weren’t able to report immunizations to the immunization registry properly. Whatever it is, they get a notification that they’ve been denied the EMR stimulus money.

Of course, this doctor isn’t worried, because their EMR vendor guaranteed them the stimulus money. So, they turn to their EMR vendor to collect the money.

What the doctor didn’t make note of was that in the guarantee of the EMR vendor, it says something about the doctor’s responsibility versus the EMR vendor. Basically, the EMR vendor just has to provide the capability to receive the stimulus money. They can’t guarantee that you’ll actually use their software the way they want you to and be able to get the stimulus money.

Using the examples above, the EMR vendor wouldn’t be responsible if the feature for tracking preferred language and ethnicity is available in the software and you just chose not to record it. At least that will likely be their argument. It’s also not their responsibility if you didn’t record the immunizations in the granular format that was needed to be able to report it to the immunization registry.

Point being that the EMR vendor is guaranteeing that the software is capable of getting the EMR stimulus money. They’re not guaranteeing that YOU will get the money. You are still responsible for understanding the 692 pages of Meaningful Use documentation to make sure you’re using all your EMR’s features that will get you the EMR stimulus money.

Just don’t be surprised if you ask your EMR vendor to make good on their guarantee and you get blamed for not getting the EMR stimulus money and end up with nothing.

A few days ago, I took a few moments and attended a Greenway presentation on the EMR stimulus money. They did a pretty good job on most aspects of the EMR stimulus money. For someone who didn’t know anything about ARRA, it would have been a decent start. Only a few comments that had a nice EMR vendor bias.

One thing that did kind of bother me was the list of EMR resources that they listed to help people searching for an EMR. Here’s the list of sites they suggested:
cchit.org
klasresearch.com
ihe.net
mgma.com
himssehra.org
ehrdecisions.com

Interestingly, I don’t think any of the above sites would make my list of great EMR resources. I think I might have to do a future post with my list of resources. Sure, I know that Greenway is a large EMR vendor with a certain agenda. Maybe I’m just offended since I wasn’t on the list (my own personal agenda). It’s just unfortunate with so many good EMR resources out there that the above websites were the ones listed. I mention Greenway, since they provided this list. No doubt many other of the large EMR vendors would have provided a similar biased list.

Feel free to provide your list of great EMR resources in the comments.

An EMR vendor saw my question, “Has EMR helped?” and they sent it to one of their EMR users to get some feedback. Here’s their response:

I am absolutely in the camp where this transition to EMR has been helpful. Long and steep learning curve but the benefits of accessing readable notes and histories and helping patients off hours has all been great. I believe I am writing better notes and noticing HCM issues more, and I hope the drug interactiion piece will be helpful down the road also.

SO, yes, this has been great.

I’d love to hear more people’s response to the question: “Has EMR helped?”

A lot of people have been asking me lately about the readership of EMR and HIPAA. In a few months, I’d like to do a full survey to get some feedback from the readers of EMR and HIPAA. Until then, I thought I’d just do a quick poll to get an idea of who reads EMR and HIPAA:

Thanks for voting. Hopefully this will also help me to tailor the content towards the topics readers would like me to cover.

EMR and HIPAA Reader Submitted Question:
Is there a way for a provider to get stimulus money for EMR if not currently a Medicare provider?

Besides Medicare, there is also stimulus money available through Medicaid. In fact, Medicaid has more money per provider available than Medicare, but also has different requirements to obtain the EMR stimulus money. Outside of that, ONC has a number of grants that might be available for organizations that qualify and want to go through the grant writing process. Otherwise, NO there is no stimulus money if you don’t take Medicare, Medicaid or qualify for some special grants.

Check out all of EMR and HIPAA’s EMR Stimulus Questions and Answers.