Welcome to EMR and HIPAA

If you are implementing an EMR you need to understand the difference in types of interfaces. Unfortunately I bet this is a significant misunderstanding that occurs when discussing interfaces in an EMR purchase. Maybe this opinion is biased because that is what happened to my clinic. After a few long discussions we finally understood the questions we should have asked rather than assuming we knew how an interface works.

The assumption that was made by my clinic(thankfull not me since I hadn’t been hired) was that the interface would be bi-directional. What does that mean? That means that when a Pharmacy is ordered by a Doctor the script would automatically be available in the Pharmacy program(one direction). Then, when the script was filled it would post the charge back to your EMR(second direction). The assumption was made that this would just happen without considering a few questions. First, what happens when someone doesn’t want to fill their script at our pharmacy? Then, the Pharmacy database is filled with a ton of scripts that they never needed to fill. Also, what happens when a drug is filled in your EMR that isn’t available in your Pharmacy program? How does your HL7 interface match a prescribed drug with the drug in the pharmacy database which has enough inventory? How does the interface pass the charge back when someone brings in a pharmacy from another doctor?

For those of you familiar with HL7 interfaces you know that many of these things can be solved. In fact, I hope that somebody will post some ideas on the best ways to accomplish this. However, these are important things to consider and discuss when purchasing an interface. In many cases the “mythical” concept of it all just working may leave you with a uni directional interface.

Not that a uni-directional interface is bad. The fact is that my clinic currently have two uni-directional interfaces. One direction patient information and insurance eligibility is passed. The other direction charges get passed back. This has worked out quite well even though we expected a bi-directional interface.

The moral of the story is to Ask Questions and then Ask MORE Questions! You aren’t an expert on HL7 and you have the right to know what your vendor means by an HL7 interface.

I imagine there are other options than HL7, but so far I haven’t seen any. So, I’ll assume for now that there aren’t any until someone corrects me.

Google should make a Medical Information Portal. I came across a fabolous idea that was discussed at Health IT World. I couldn’t think of a better application for Google technologies. Ok, so I’m still sitting in an idealistic world that evaluates decisions based on merit and not just $$. Either way, I think that having a medical portal on google would be fantastic. You could tie your EMR directly to the medical portal to get the latest and greatest medical information that you could give to your patient. Then, let’s take it one step further. Your EHR could be tied to the google search which would allow patients to see more information without wasting the doctors time. Doctors will probably hate this idea, but in the end patients are and will use this feature if google was to come out with it.

I think the best detail from the article besides the idea is that if it were something easy to accomplish then it would have been done 2 years ago.

In an EMR I think there are really two options for documenting your EMR. One is using a tablet(or laptop or a convertible) with a wireless connection to your EMR. The second is having workstations in each of the rooms. I got a good list from NYFP on emrupdate that gave a pretty good list to start evaluating which soltion works best for you. Here’s the information he posted:

Pros of Hardwired Desktops:
* More comfortable to use
* Won’t lose wireless connections
* No Batteries to change
* Upgraded Microphone
* Larger Monitor
* Regular Keyboard
* Regular Mouse

Cons of Hardwired Desktops:
* Kids can break them
* Must log out/log in when leaving or entering treatment room
* You have to stay in treatment Room to finish note which will prolong the visit, furthermore, the nurse may also come back into the room to draw blood or give immunizations, all while you’re writing your progress note. (NOT ME! As soon as the visit is over I need to disappear!)

* If I want to finish my progress note outside of the treatment room, than I’ll have to go to my private office and use that Desktop, as well as log in again, all in between patients, and this will ultimately take longer.
* Does not work in hallway or up at reception desk
* Expensive to run internal wiring to treatment rooms
* Patients may see what you’re writing

Pros of Tablet PC:
* Integrated Handwriting Recognition
* Touch Screen for faster clicking on templates
* Integrated Microphone for Voice Recognition
* Can easily look at patient while taking history
* Very Mobile
* You can leave the treatment room and finish your progress note in the hallway or in an empty room, and an additional benefit will be that you have ended the visit sooner, thereby saving yourself time with the patient, and you can now go directly to the next patient treatment room
* You can easily write a prescription at the front desk with Tablet PC in hand
* It can function as a Desktop in an emergency, if a Desktop should Crash.
* You can throw it at someone!

Cons of Tablet PC:
* Lose the wireless connection and your F****d
* Poorer microphone quality
* You can drop it
* Can be stolen
* Must charge and change batteries
* Smaller screen
* More difficult to type on
* Must carry it around with you
* Difficult for Medical Assistant to carry, while maneuvering EKG machine, carrying urinalysis sample or blood tubes.
* More expensive per unit

Modifications for Tablet PC:
* You can have a Port-Replicator/Docking Station for the Tablet PC (hooked up to an AC-Line) in each treatment room with options for an; external keyboard and mouse, larger monitor if desired, better microphone, and hardwired Ethernet connection.
This will make it more difficult to use handwriting recognition

Modifications for Hardwired Desktop:
* May be setup with wireless technology, to save on expensive internal wiring to treatment rooms.
May add a Handwriting Pad to it
Fingerprint reader for faster login.

In my opinion, the 2 major issues are:
Wired
The constant logging in and out of the EMR. What if you forget and how much time does it take to log in and out.

Wireless
Dropped wireless connections

All the rest is interesting, but deciding which of the 2 evils you can handle is what I consider the most important question.

The Healthcare IT Guy gives some good food for thought when looking at your database administrator and the security of your database. Database administrators often have access to all of the medical information by looking directly at the database. This is often gone unaudited and unmanaged. As part of any HIPAA policy this issue should be addressed and documented. The best way I know how to do this is through implementing a strict policy with stiff penalties if it is ever breached. I think it would be hard to prove that they breached it, but at least it can insulate you from the “HIPAA police”. I’ll continue my research on the subject and post them here as I find them. Unfortunately, I expect that many of them will be database vendor specific.

More importantly, you should seriously consider who you’re hiring as your database administrator. They really have power to do all sorts of bad if they wanted.

One of the possible advantages of an EMR system is that you can have your EMR tell you of potential interactions between drugs prescribed to a patient or even Drugs that can’t be given because of certain allergies. This is a great feature, but there are cases where the suggestion needs to be ignored. How do you handle that in an EMR is an important question and what liability does a clinic have if a doctor decides to ignore it?

A recent article described a good study that was done and gave some good ideas. Here some important points I found from the study:

-Quality alerts will be used by Doctors, espescially when they are specific
-Doctors often have to ignore the alert since the patient needs the medication

I also really like how they did the study by forcing doctors to give a reason why they are ignoring the alert. I think that could significantly help with liability problems.

I was just browsing an EMR company’s website(which I shall keep nameless) and I clicked on a link that I thought would be interesting. Here’s what I found:

Appointment Scheduler
Automatic Call&Confirm Phone Appt. Reminder.
Electronic Medical Records (EMR)
Complete Billing
Web Access and Security
Call Center (Document Calls)
Transcription Integration

Electronic Prescription Writer
Electronic Orders (Labs, X-Rays)
Image/Document Management
Wireless Enabled
Secure Internal Email
HIPAA compliant security
Solo/Group Features
FREE Customization

I’ve put in bold a few of the features that actually sound pretty nice. Having the Automatic Call and Confirm built into your EMR is great. Web Access to your EMR could be great if that means you could access it remotely. There are some security questions there, but they could be dealt with appropriately. Web access also is nice if you can avoid managing client installs. Secure Internet Email could be a nice thing, but unfortunately that requires your patients to have a secure messaging system too. There are ways around it, but that’s a topic for a different post.

When I took a look at the rest of the list I couldn’t help but laugh. Appointment Scheduler, EMR and complete billing seems a bit vague. Isn’t that what the page is suppose to describe? I was hoping to see a list of how they implemented appointments, EMR, and billing. They did at least tell us that their billing is complete.

It is nice that they told us that their EMR has security. Although I still don’t know what that really means. Is there such a thing as an EMR that doesn’t have security? None that would claim that as a feature.

The rest of the features are pretty vague, but the one that killed me most was “Wireless Enabled.” Amazing!! Maybe someone can point me to an EMR that isn’t.

At least you can feel comfortable with buying this EMR because if you don’t like something there is FREE customization. I’d get that one in writing!

My point is that if an EMR vendor wants to have a website then they should offer some worthwhile information and not just put up junk because “They Have to have a website.”

A recent article said that Blogs lead Top e-health trends. I’ve tried my entire life to not be trendy and now I’ve found out that starting this EMR and HIPAA blog makes me trendy.

I guess if you’re reading this post then the article seems to be correct. I think it is a great thing that seems a bit overdue. I designed a website quite a few years ago with mixed success. I’ve been amazed at how many people have been visiting my EMR and HIPAA blog. Thanks to all of you who come and read my ramblings. My only wish is that more people would post their feelings on my posts. All you have to do is click on comments and make up your name and email if you don’t feel comfortable posting your personal information. In fact, I’d be happy to involve other people in creating posts since there is so much to know and so much to post that by myself I can only start to address some of the important issues related to EMR and HIPAA.

Either way, you are always welcome to read all you want. I don’t see myself stopping this for a while. It’s pretty much become an addiction that I can’t stop.

Thanks for reading.

When implementing an EMR we really wanted the ability to pull up patient’s record with the swipe of the card. Not to mention being able to allow patient’s to check in using their card. I understand that this situation may be unique to a Student Health Center at a University since you know that each person has a university ID card. However, this was an important request for a College Health Center. Not to mention it illustrates a perfect example of a miscommunication that could occur during an EMR sales discussion.

In the discussion the EMR vendor was excited to point out the ability to be able to swipe a student ID card and pull up a patient’s account. Everyone was excited until we found out how the swipe worked. Basically it would match the strip on the card with one of the ID’s stored in the EMR. No problem, until we found out that the Student ID wasn’t actually what was encoded on the strip of the ID card. Instead it was some ISO number that was only used by the proprietary campus card reader system. We could have uploaded the ISO number instead of the Student ID, but then that complicates pulling up patients that don’t have a card and we really didn’t want to expose the ISO number to anyone. Oh the details of implementation.

I don’t think the EMR vendor lied or did anything wrong. It’s just that we didn’t ask the right questions or have the information we needed to understand what is really possible. To our vendor’s credit they have since implemented a hidden field in the database that can use our super secret ISO number.

I found an apt description of what happens in a paper chart:

And as far as that stack of filing - too often it went undone. It would pile up for a month at a time, despite my constant admonitions. When they finally got around to filing, they would just stick the papers in the chart thinking that when the patient came in for the next appointment the papers could be placed in the correct slot within the chart. But that often didn’t get done, either. I would see a patient and discover lab results and letters just loosely adrift within the chart.

And although it seems like filing would be an easy task, for some reason, very few people can perform it well. When my staff did take the time to actually file the papers, they often put them in the wrong spots. Correspondence would be in the lab results sections, x-rays would be in correspondence, and just about any combination possible
-medpundit’s post

I’m not sure why this is the case, but tomorrow I must show this description to my dear friend in HIM(medical records). The post does also describe some of the downsides of EMR’s and scanning. However, I think a lot of the problems that she describes can be avoided with a proper implementation of an EMR. Not to mention that scanner prices have come way down. Automatic feed scanners are relatively cheap these days.

I found an article that is a little dated, but could just as accurately be written today. It is by a Dr. who developed his own EMR. I can’t imagine how he managed to do this and still stay married(since his blog says he has been married 30 years). Regardless, he makes some interesting points about why an EMR isn’t everything that is dreamed to be even if “he couldn’t get by without it.” EMR’s have pluses and minuses and this article gives some concise reasons why EMR’s still have their cons. Here’s a summary:

• Data Entry-Pen scribbling is quicker than EMR entry
• Depersonalization-Computer between you and the patient
• What about the paper?-Paperless Office isn’t possible. You still must scan into an EMR
• What about the old charts?-He suggests you must scan these charts
• Legacy Software-Cost to convert(even if it’s just billing software)
• Design Issues-EMR developed by programmers and not Doctors
• Cost-Need I say more?

He ends with this assertion: “the results will be well worth the wait”.

I agree with him whole heartedly! EMR is still an infant in the software development cycle and has a ways to go. However, if you wait think how many more charts you’ll have to scan in.