Welcome to EMR and HIPAA

Today I ran across what I considered a very new term for me: Biofeedback Here’s a definition and description of biofeedback I found:

What is Biofeedback?

Biofeedback is a learning process in which people are taught to improve their health and performance by observing signals generated by their own bodies. It is scientifically based and validated by studies and clinical practice. It is a highly effective way to control stress, realize true relaxation and help achieve important personal goals.

Fear, over-eating, smoking, anxiety and other problems are actually linked to, or aggravated by, stress. For some, stress is a stimulant to effective action, but for others it’s a barrier to self-fulfillment. The secret is knowing your reaction to stress, and using this new awareness as a springboard to a life in control. A life where you can release the powers of the mind for greater achievement and better health.

Biofeedback is the widely-used and medically-accepted technique for teaching us to control stress, achieve relaxation, and channel talents and energies toward realizing our full potential. Our home biofeedback devices make you aware of your unconscious “involuntary” physical reactions to stress – “feeding back” subtle changes in stress levels. You’ll be able to hear or see changes in your stress level!

Even more interesting was a list of biofeedback devices that you can purchase:

Skin resistance biofeedback (GSR Galvanic Skin Response) is a measure of how relaxed you are, which changes based on your overall mood and emotions.

A sensor is placed on your hand, you hear a tone that increases in pitch when your emotions or mood becomes more tense, and decreases when you are relaxing.

Muscle tension biofeedback measures how tight a particular muscle is. Relaxing your forehead can help reduce headaches, release jaw tension, and upper shoulder tightness. You wear a pair of headphones with a band containing sensors that goes across your forehead. When the muscles in your forehead let go, then the tone that you are listening to decreases.

Brainwave biofeedback measures the quality of your brainwaves. Improving the quality of your brainwaves helps people with learning and concentration, reduce mental clutter, reach deeper states of relaxation faster, and to improve the quality of sleep.

Two electrodes are placed on your scalp. Using a computer interface, you can see your brainwaves on the screen, which appear as wavy lines, much like ocean waves. When the waves are close together, it means that you are alert. When they are further apart (slower), that means you are relaxing into deeper states of alpha, or creative visualization (theta).

When you see irregular waves, the quality of that particular brainwave state is not very good. When the waves become smooth and regular, you are able to sustain focus within that particular brainwave state.

Heart Rate Variability biofeedback measures how your heart responds to emotional, mental, and physical stresses, and its ability to bounce back to a relaxed and better functioning state. It helps for general relaxation, and cardio vascular distress.

You wear a finger sensor, and a computer interface allows you to see your heart rhythms on the screen, which appear like ocean waves, or lines that move up and down. Irregular, ever-changing waves mean that things easily upset you, whereas smooth waves mean that you are able to stay calm in stressful situations.

Skin temperature biofeedback measures the amount of blood flow beneath the skin. The warmer the temperature, the greater the degree of relaxation in that area which improves circulation for healing.

I find the science of it all quite interesting. I’m interested in hearing people’s opinions on biofeedback. How is it accepted in the medical community? Would it be beneficial to have it integrated with an EMR system. Then, you could track a person’s change in stress level for example. I think this could be espescially intrigueing in a counseling center setting. Integrated with an EMR, I think if the biofeedback works you could get some really interesting data on how a client with stress in their life improves their stress level over time. Could be very interesting.

As you may have noticed, my blog hasn’t been nearly as active over the past 2 weeks. You can blame it all on my wife since I spend almost all of my vacation days from work over the past 2 weeks. That’s not completely true since the state actually gives a fair number of vacation days. However, it is true that I was on vacation and therefore this blog got transgressed.

Don’t worry, I haven’t fallen off the planet and I have a number of good posts waiting in the wings. I think it is good for me to have some breaks sometimes. Maybe I need to find someone else to contribute to my blog too. That way my absence won’t be so noticeable. Any takers?

I also have been dreaming lately about presenting at some conference somewhere. I think I have some decent content and could do a pretty good job. I’m just not sure how to really get started. Not to mention figuring out the funding mechanism for getting to those conferences. I’m seriously considering going to HIMSS, but I’m not sure that’s the right play for me. I think I would get an interesting taste of what hospitals are doing and probably be pretty disappointed with what I could take away. I’m not sure what other conferences there are around, but if anyone has any connections and wants to hook me up then please let me know.

Can you believe that real doctors will answer your questions unpaid? The concept still kind of floors me, but when you look at their website you can see how it works. I’ve considered making a website like this before because I think I’m benefitted greatly by my access to doctors who I work with who can answer my detailed questions. My family doctor does his job, but when you get home you always have 2 or 3 more questions that you forgot to ask your primary care physician. This free service from OurHealthNetwork.com (http://www.OurHealthNetwork.com/) might just be the solution for many people interested in getting more information from an actual doctor.

Here’s a description of their service:

For millions of Americans who do not have health insurance, seeing a doctor is not an option. However one unique Web site allows visitors to ask its board-certified physicians questions - absolutely free. Since 1999 OurHealthNetwork.com (http://www.OurHealthNetwork.com) has provided the public with accurate and up-to-date information about a variety of medical conditions. This information includes causes, symptoms, and self-help treatments that are written in terms that the general public can understand

OurHealthNetwork.com is a “network” of specialty-trained physicans who have joined together to create Web sites that furnish information about each of their specialties. Each Web site covers a specialist’s field, and all of the information on the site is written and maintained by that physician.

“What makes these sites unique is the fact that the doctors will answer questions that are submitted to them through their Web sites, free of charge,” said Dr. Lowell Weil, Jr., a medical director of OurHealthNetwork.com. “Of course the doctors cannot make diagnoses, but they can clarify an individual’s medical problem, answering that person’s specific questions. Our goal is to offer people in pain accurate medical information and peace of mind.” OurHealthNetwork.com’s doctors have personally responded to tens of thousands of questions every year since 1999. Another unique feature of OurHealthNetwork.com is the fact that it does not allow advertising on any of its sites. This permits its physicians to provide truly unbiased information. “We do not need to tailor our information to please ‘Corporate America,’” Dr. Weil, Jr. added. “Having no ads or pop-up windows helps to keep our Web sites from being cluttered, and allows for easy and hassle-free navigation.”

OurHealthNetwork.com finances its efforts by allowing visitors to purchase the exact same products its doctors recommend and use in their private practices. Visitors benefit from purchasing these products through the physician’s Web site because they get the correct medical-grade products that they need at discounted prices.

But Dr. Paul R. Kasdan, the network’s founder, emphasized that visitors do not need to purchase anything in order to use OurHealthNetwork.com’s informational services or to have their questions answered. “Purchasing products is just another convenience we offer the public.”

Millions of visitors from every U.S. state and more than 30 different countries around the world now turn to OurHealthNetwork.com every year. The specialty Web sites that are currently available include arthritis; the back; hand, wrist, and elbow; the knee; and the foot and ankle. According to Dr. Kasdan, “New specialty sites are added when we find a specialist who is dedicated to practicing medicine ‘the old fashion way’ - helping individuals in need and not worrying about a fee for their service.”

There website also seems like a good source of information for those doctors interested in linking their main website to other online medical resources. I personally took a look at the carpal tunnel syndrome page since I think I’m headed down that road since I spend so much time on the computer. Some good information.

I also wonder how many doctors should start doing something like this in their own web portal. Patients would love it. It could be integrated with your EMR and provide a great service to patients. Maybe OurHealthNetwork.com (http://www.OurHealthNetwork.com/) could provide an affiliate program to doctors who want to integrate OurHealthNetwork into their own patient portal. This would give doctors a funding mechanism for answering questions online while also increasing the knowledgebase of OurHealthNetwork.com (http://www.OurHealthNetwork.com/).

I finally made the time to finish installing a fax server for a Doctor who I’ve helped implement a new EMR system. I don’t know why I took so long to install the fax server. A fax server is so much better to have when you have an EMR system. I think that a fax server should be a required purchase with every EMR on the market.

Why is that?

Having a fax server means that you can fax a document from any computer on your network with just a few clicks of a mouse. You don’t even have to get out of your chair and walk over to the fax machine. If you can print it then you can fax it. That should be reason enough in and of itself. However, there’s a much more important reason than that.

Incoming faxes are all stored electronically and can be stored in a shared folder that can be accessed throughout the network. No more hanging out at medical records waiting for a fax to arrive. Just keep refreshing the shared folder until the fax arrives. Another way to not have to get out of your chair. However, more important you can just upload the file electronically straight into your EMR system. No need to print it out and then scan it back into your EMR. Plus, from what I saw, the quality was better than a scan with a smaller file size.

You can also have digital cover pages that people can actually read built right into your fax server. This saves paper, money, time and makes your cover pages look that much more professional

Add the history of all your faxes in and out and there is no reason someone shouldn’t go out and buy a fax server today.

Look forward to a post about some instructions on setting up a fax server after I get back from my vacation to Utah this week.

A recent article in PC World(Australia) claims that Nuance claims breakthrough on speech recognition. It looks like Nuance is trying to continue their lead in the voice recognition market in their latest version of Dragon Naturally Speaking 9. The article says it will ship to Australia in August, but it is available immediately through Nuance’s global network of reseller partners, software retailers and professional sales organizations according to their recent press release.

Here’s the good information from the article.

Nuance Communications says the latest version of its speech-recognition software can achieve — with some speakers — 99 percent accuracy out of the box, without a “training” session to familiarize the software with how a particular person talks.
…
The accuracy rate, or what percentage of words the software spells correctly by itself, varies depending on sound quality and how a person talks, Revis said. But Nuance has improved it by 80 percent since NaturallySpeaking 8 was introduced in 2004, according to the company.

Version 8 could reach 99 percent, but only after the user read a prepared script, Revis said. Now users can get that level of accuracy right after installing the software and starting it up, though a script is still available if a user isn’t satisfied with the results on the first try. In any case, the software can continue learning on its own just through normal use, Revis added.

The out-of-the-box 99 percent accuracy figure is for the American English version, but the new Dragon releases for other languages get similar boosts in accuracy, Revis said. The software is available for Dutch, French, German, Italian, Japanese and Spanish, as well as for Australian, Asian, Indian and U.K. English. Also with NaturallySpeaking 9, Nuance is certifying two Bluetooth wireless headsets for use with the software.

Nice to expand the product internationally. I can only imagine what new technology Nuance has come up with to be able to recognize out of the box this many languages. It would make sense if they only had listed latin languages. Howevever, Japanese, Asian(what language is that) and Indian is definitely not anything like latin languages.

A few other interesting notes:

-Dragon Naturally Speaking 9 can be used anywhere on the network including at thin clients
-New support for Nuance-approved Bluetooth headsets
-The Upgrade cost is usually a know brainer if you use Dragon Naturally Speaking 8
-The RAM and CPU requirements are of course higher
-Still requires Windows XP

Call me a skeptic, but my feeling is that despite the increase in accuracy available out of the box with Dragon Naturally Speaking 9, you are still going to want to do the “training” or “enrollment.”.

A recent comment on my list of EMR vendors post told such a good story that I had to get permission to post it as its very own post. I think this is only the beginning of what an EMR will be able to do.

Enjoy the story.

ComChart EMR: An experience from the exam room

I was in the exam room talking to a patient, who I am treating for hyperthyroidism. The patient complained of profound fatigue, of several months duration. It was unclear if the problem was being addressed by the PCP. While talking to the patient, I reviewed all his labs which were in ComChart EMR. There was nothing obviously wrong.

From within the exam room, and while still talking to the patient, I connected to my hospital’s computer and download all his labs which were less than 1 year old. I then had ComChart file the labs into his ComChart chart. I then had ComChart EMR create a chart of all his CBCs by clicking the “Chart… CBC” button in the labs. It was obvious that his hematocrit had dropped precipitously sometime between January and March.

The PC computer I was using had Skype installed (a free program which allows you to make free telephone calls from your computer.) I also have a headset attached to this computer, which I use with Dragon NaturalSpeech Medical. While still in the exam room, and from within ComChart EMR, I clicked the “PCP” button in the patient’s Progress Note and a dialog box popped up and asked “Do you want to go to the Dr. XXX’s Addresses file?” I selected “yes.” I then clicked on the label “private,” which is in front of the physician’s “private” phone number. ComChart opened Skype and connected the call. I spoke with the PCP and I arranged for the patient to see the PCP the following day.

I then click the “orders” button and selected my “anemia work-up” panel. This created a lab order slip which included all the necessary blood tests. I choose the option “Send copy of results to… PCP” and then clicked the button “Fax order slip” to lab.

Finally, in front of the patient, I dictated a Progress Note, using Dragon NaturalSpeech 8 Medical. The resultant Progress Note included the chart of the patient’s CBCs. I then selected the PCP as the recipient, and clicked the button “Create queued fax.” In my office, I have one computer which continually sends out the “queued faxes” as soon as they are created. Thus, the PCP had received a copy of the Progress Note and the lab had received the lab order slip even before the patient left my exam room. The entire process occurred within a few minutes.

Needless to say, that patient was impressed that my office was able to use technology in order to efficiently advance their healthcare. And, the fact that it all happened in front of the patient, seem to reassure the patient and de-mistify the healthcare delivery process.

True story. It occurred on 7/7/06. Score one for ComChart EMR.

Hayward Zwerling, M.D., FACP, FACE
ComChart Medical Software
275 Varnum Avenue, Suite 102
Lowell, MA USA 01854
978/441-3939
HZMD@comchart.com
www.comchart.com

I espescially liked this story because it tied in so many different technologies into an office visit. Skype in the exam room is great. Voice recognition in front of the patient is gutsy. Faxing notes is such a paper and time saver. Charting lab results is the essence of lab interfaces and granular data in your EMR.

Can your EMR do all that?

60,000 visits to EMR and HIPAA!!

That is really quite exciting and astounding for me. I’m even more impressed because looking at my statistics it seems like people are returning again and again. For example, yesterday I had 56 referrals(not including my.yahoo.com which I think is just an RSS reader) to the website. However, I had EMR and HIPAA visitors with the following operatings systems:
Windows XP - 193
Windows 2000 - 55
Windows NT - 21 (who’s still using NT?)
Linux - 8 (this seems lower than usual for one day)
Mac - 5
Windows 98 - 2
Total: 284 Visitors
That means that just yesterday I had 228 people return to EMR and HIPAA. Pretty cool I’d say.

Of course I wondered what my top pages were. I’m sure many of you can guess. Although these numbers aren’t completely fair since many of the pages have been up longer and so will of course have more hits. Either way, it is interesting to look at my top 10 EMR and HIPAA web pages:

1. EMR and HIPAA Feed - I guess people like to read this through an RSS reader
2. Main EMR and HIPAA Page - This is pretty obvious
3. Overwhelming List of EMR Companies - If you click on this link and see the list you can see why the search engines love this page. However, I also think that it is significant that the list of EMR companies is so large. Which is why I posted it in the first place.
4. EMR and EHR Vendors - I really need to work on this some more and start reviewing EMR companies. I think it would be a lot of fun(and possibly get people to start commenting more).
5. Biometric Facial Recognition for Continuous Computer Access Control and Authentication - This facial recognition software is still the very best. I couldn’t live without it on my computer. Right now I’m helping them integrate single sign on. Then, I might have to quit my current job and go work for SensibleVision since I love their product so much.
6. EMR and HIPAA Archive - I’m a little surprised this page made it to the top 10. However, I guess search engines probably like it a lot.
7. EMR Category - I guess this means I like EMR more than HIPAA. That would be correct.
8. Securing Your Desktops - Pod Slurping - What an interesting topic. I think the name pod slurping just attracts people to click it to find out what it is.
9. EMR Implementation Category - Nice to see this one on the list. Implementation is the my favorite part of an EMR. It makes or breaks everything.
10. Open Source EMR’s - Free EMR? - I think this ones on the list because people love to search the internet using the term “Free EMR”. I can’t imagine why!?
Honorable Mention: HIPAA Lawsuits Category - I had to add this one to the list because I think over the next 3 months this is going to make it into the top 5 most visited pages on my site. I’m also going to be looking for some more content on HIPAA lawsuits. It is of interest to me and EMR and HIPAA readers.

A few quick stats:
9.7% of visitors stay at EMR and HIPAA for 30 minutes - 1 hour and 15.7% stay for 1hour+. Sweet!!

Wednesday is by far the most popular day to visit.

10 AM is the busiest time with spikes at 6pm and 10pm.

EMR and HIPAA is overwhelmingly read by Americans - with “Unknown” beating out every other country.

I wanted to put my top 10 list of funniest searches, but there were too many to go through. Therefore, I decided to copy and paste all of them below. In order to not uglify(I made that word up) my main page, I am adding a link that says more below. If you click on it you will see the long list of all the search terms and which search engine sent something to EMR and HIPAA. No I can’t format it better for you so don’t ask. Yes, it does feel like I’m exposing myself to you, but I think that is fun. So, enjoy the list and let me know which searches were your favorite.
Read more…

Here we go with the final installment from 50 reasons to get an EMR or EHR. What a ride. Reading through these reasons you can see why there is so much to think about when deciding to implement an EMR in your practice.

In this post, I’ll cover reasons number 42-50 to implement an EHR or EMR. These reasons talk about higher income and a more robust practice because of an EMR.

Higher Income

42. Qualify for “pay for performance” bonuses by tracking the care you provide and the outcomes you achieve for various groups of patients.

43. Capture all your charges automatically as you record what you do.

44. Reassign your transcriptionist and file clerk to help collect accounts receivable.

45. Confidently code for higher levels of service based on thorough documentation.

46. Get automatic suggestions for E&M coding based on your documentation.

Pay for performance seems like a bad reason since to my knowledge it hasn’t been implemented yet. It is still just an idea. Correct me if I’m wrong.

Capturing the charges automatically could be a great reason, but that assumes that charges are being missed because of documentation. Also, many people don’t actually chart in an EMR in the room. I think documenting in an EMR is best in the exam room, but since not all people do that there’s still a high probability that charges could be missed.

Do you really want a transcriptionist and file clerk collecting accounts receivable? Seems like very different job descriptions to me. Plus, it seems like this saving has already been covered in a previous point.

The potential to code higher levels is great. This is a great reason for an EMR. In the recent implementation I did of an EMR for a new office, this was his favorite part of the EMR he chose.

Not all EMR’s offer E&M coding suggestions. Plus, from what I’ve read and seen you have to be careful how much you trust it. You still need to verify that it coded it correctly. The algorithms for this coding are just too difficult to implement. It needs a little brain power still and even then it’s still quite subjective.

A More Robust Practice

47. Convert your file room into an extra exam room.

48. Gain an edge in recruiting doctors fresh out of residency who’ve grown up using computers.

49. Retain topnotch staffers who otherwise would be burned out by the chaos of paper charts.

50. Impress patients by demonstrating that you run a modern, cutting-edge practice.

Finally they got the file room savings on the list. I posted about this in a previous post. I guess I should have finished reading the list before I commented.

Do you really want a doctor that’s fresh out of residency? I think there are pros and cons to this one and so I consider it a wash.

While I wish that I could say that topnotch staffers love computers and EMR, it is just not always the case. While I think it is a serious oversight for people to not use an EMR and gain its advantages, it is also true that some of the most qualified and caring staff don’t want to use an EMR. Plus, computer problems can burn people out almost as quickly as paper charts. I think this is a wash too.

Do patients really care if you are a cutting edge practice? I know that when I went to my doctor 10 years ago he used a computer. He documented while I talked and I was a little disappointed that he didn’t give me more attention. I did know he was listening, but in some respects I felt like I was talking to a wall. I think this was specific to my physician and can be overcome. Not to mention I loved the patient education he printed out for me. That was great. Now I definitely want my doctor to have an EMR. More importantly, I want to have a patient portal where I can do and ask whatever I want of my doctor.

Here’s the other reasons I’ve commented on so far in case you missed it:
13 reasons to get an EHR or EMR
12 reasons to get an EHR or EMR
14 reasons to get an EHR or EMR

There we go!! My review of 50 Reasons to Implement an EMR or EHR is complete. If life doesn’t get too busy I think I might takes these 50 reasons and narrow them down and merge them down to what I think’s important. We’ll see how that goes.

Maybe the moral of this set of posts is this:

“There are enough reasons to choose from. If you don’t implement an EMR is just because you don’t want to and not because it’s not a good idea.”

I should really thank Medical Economics for creating the original 50 reasons to get an EMR or EHR. It is a great list to work off. Someone put in a lot of work to put this together. Thank you.

In this post, I’ll cover reasons number 14-26 to implement an EHR or EMR. These reasons talk about greater efficiency and lower costs because of an EMR.

Greater Efficiency

27. Review a summary of the patient’s health information at a glance instead of flipping through pages.

28. Stay on top of your work with an electronic to-do list that includes incoming lab, radiology, and pathology reports as well as in-office messages and telephone calls.

29. Reduce phone tag: When patients call, answer their questions immediately instead of pulling the paper chart and calling them back.

30. Produce referral letters, school and work excuses, and other documents with a few clicks.

31. Send messages to your nurse without leaving the exam room or hollering down the hallway.

32. Reduce staff downtime at the copy machine: When you need to share records with someone, transmit them electronically.

33. Automate the way you report childhood immunizations to state-mandated registries.

34. Order lab tests and diagnostic imaging with a few mouse clicks.

35. Get claims out the door faster by sending encounter information, including diagnostic and CPT codes, straight to your practice-management software.

This list of efficiencies have to be some of the best reasons on the list. The ability to quickly access, create and communicate data is what EMR’s are all about. This list summarizes well a number of good efficiencies that can be gained.

My major problem with this list is that these reasons describe the ideal EMR system. Not all EMR systems have built in messaging and to do lists. Plus, just because an EMR program has these features doesn’t mean that it is the most effective way to handle things. How many times have you used your to do list that come with many email programs? I know I haven’t. Also, sometimes the yell down the hall is more effective than electronic orders. I think the lab orders is a great example if you have an in house lab like we do. I guess I’m just suggesting to take this list with a grain of salt. A lot of this depends on your EMR system and your implementation of it.

I also think that this list should have something about the efficiencies of charting that are gained. I think it’s covered elsewhere, but it would fit well here too.

Lower Costs

36. Save $10,000 or more per doctor per year on dictation and transcription costs.

37. Eliminate positions for file clerks and transcriptionists.

38. Save several thousand dollars a year on paper-chart supplies.

39. Download ECG readings directly into the patient chart and save even more on paper.

40. Spend less on postage by transmitting charts electronically.

41. Build a satellite office without a file room.

Transcription costs are a great way to save money. However, that assumes you currently use transcription services.

I personally haven’t found a descrease in file clerks and trascriptionists. There is still a lot of scanning and other things that must be done with medical records.

The savings on paper chart supplies can be a huge benefit. Add in the good green feelings you get for saving trees and you have something of great value.

I didn’t know that ECG paper was so expensive. It doesn’t seem like that paper would be that great of a savings. However, if you apply this same principle to a nice lab interface then you have some real savings. It amazes me how many labs are done and how much paper adds up with all the lab results. Doing that electronically is an excellent way to save money.

Postage savings won’t be a benefit until their is a standard for transmitting charts electronically. You could possibly fax a chart to someone from your EMR. Otherwise, there is no good way to transfer the chart electronically and save on postage at this point.

Not only does your satellite office not need a file room, but if you do an EMR properly then you don’t need a file room in your main office either. I implemented a new doctors office recently and he doesn’t even have a file area in his office. There was no need for it. Too bad he only gave me about 2 weeks to implement everything. Either way, he’s good to go now. No paper charts anywhere. I better check and make sure he’s doing his backup properly.

There you go. 15 more reasons to get an EHR or EMR.

Here’s the other reasons I’ve commented on so far on my way to 50 Reasons to Implement an EMR or EHR:
13 reasons to get an EHR or EMR
12 reasons to get an EHR or EMR