Welcome to EMR and HIPAA

From MSNBC:
Electronic health records don’t aid patient care – MSNBC (Reuters)

Electronic health records — touted by policymakers as a way to improve the quality of health care — failed to boost care delivered in routine doctor visits, U.S. researchers said on Monday. Of 17 measures of quality assessed, electronic health records made no difference in 14 measures, according to a study published in the Archives of Internal Medicine. The study by researchers at Stanford and Harvard Universities was based on a survey of 1.8 billion physician visits in 2003 and 2004. Electronic health records were used in 18% of them. In 2 areas, better quality was associated with electronic records, while worse quality was found in one area, they said. Many experts believe electronic records can help prevent costly medical mistakes, but few studies have evaluated whether the records actually improve the level of care when compared with paper records. “Our findings were a bit of a surprise. We did expect practices (with electronic medical records) would have better quality of care,” said Dr. Randall Stafford of Stanford University. “They really performed about the same,” he said in a telephone interview.

Who said that EMRs were about increasing patients’ care? Ok, that looks nice for government work and it’s a great theory about saving lives. However, most of the EMR sales presentations I’ve seen talk about the bottom line. Sure, if I can cover my bottom line, then it’s great if I can offer better care also. However, I would guess that for 90% of the people choosing an EMR 90% of the decision is about dollars and cents.

Granted were not looking at all the details of this study. It would be interesting to take a look at how they quantified quality of care. That sounds like a rather subjective measure to me. I’d also be very interested to see how long most of the doctors in the study had been using an EHR. I can certainly see how at the beginning of an EHR implementation the patient care could be less than with paper. It takes time to mold a system and to implement all of the features that make an EHR work efficiently. However, once implemented a whole new world of patient care comes into focus.

What an EMR can eventually do for you is more interesting and powerful than the immediate impact of implementing an EMR.

I personally have a theory on doctors selecting an EMR system. I call it “My Theory of 5.” It goes like this.

I believe that after a short discussion with a doctor’s office, I could give them a list of 5 EMR systems to evaluate. My guarantee is that Any of the 5 suggested systems can work for their doctor’s office. Furthermore, I also guarantee that every one of those 5 EMR systems will cause them a certain number of headaches and challenges. However, in the end if they are willing to adapt and learn the new system, they will be happy they decided to use an EMR.

It’s a pretty simple system that I’ve only used one time. That’s why I call it a theory. It worked well for the doctor that used it. I gave him a list of 5 systems to evaluate. We talked a couple times about the advantages and disadvantages of each system and he selected the system that he liked best. I didn’t personally care which system he chose, because I knew people who had successfully implemented all 5 systems. Therefore, he was just choosing which system he thought would best fit his style of practice.

Many people may note that this isn’t revolutionary. These people aren’t the ones that are just starting to evaluate the 1000s of EMR vendors out there. I guess the other option is to spend a year and countless hours evaluating hundreds of EMR systems just to have most of those people probably end up choosing one of the 5 EMR systems I would have recommended in the first place.

One Final Note: The theory of 5 will not work if a doctor isn’t fully committed to implementing an EMR. I’ve told a couple doctors that they weren’t ready for an EMR and so I wouldn’t work with them. Thankfully I have the luxury to do so. I could tell their hearts weren’t in it and so it wasn’t worth my time and effort to drag them kicking and screaming through the EMR process.

As I pointed out in my previous post on patients filling out forms electronically, it is absolutely essential that your EMR software supports a robust set of preferences for determining which forms a patient should fill out.

Let’s take three example forms to illustrate most of the needed options: HIPAA privacy form, Health History form, Consent for Pap Smear. All of these forms need to be filled out in different intervals.

HIPAA Privacy Form
I think that in most cases, the HIPAA privacy form is something that just has to be filled out one time. Once I’ve filled it out, then I don’t want to have to ever see that form again. What does this mean for the EMR self check in kiosk? That means the computer has to check my account and know if that form has been filled out already or not. Easy enough right. I check in for my appointment, the EMR checks to see if I’ve filled out a privacy form and presents the form to me if one doesn’t exist. No sweat…or is it.

Of course, you can’t forget about the case where the government decides to change HIPAA laws and so now you have to change your HIPAA privacy forms. Let’s assume you change this form on January 1, 2007. This now means that your EMR self check in kiosk needs to now provide the new HIPAA privacy form to anyone who has not filled one out since January 1, 2007. Can this be done? Of course, and it really isn’t that hard. However, it’s an important difference that must be planned for.

Health History Form
How often do you make your patients fill out a health history form? Some may only do it once and then never ask again. If that’s the case, then you can see my comments above on HIPAA privacy form. In our clinic (and I think most others), a health history form should be filled out every year [Emphasis Added]. My clinicians tell me it’s just good practice to get the history if it’s been more than a year, because you never know what else might have happened to them or their family in that time. Is this really possible with a paper chart? Not very easily. However, with a computer it’s no problem.

When a patient checks in for the appointment, the EMR self check in kiosk checks the patient’s notes for the last time they filled out the form called “Health History.” If the form is more than a year old, then the patient is prompted to fill out a new health history form. Of course, we’ve previously set a preference that the Health History form should have be filled out every year. Again, it’s not rocket science, but an important difference from the HIPAA privacy form.

Consent for Pap Smear
This form is even more difficult. Unless of course your EMR is like ours and requires you to use specific appointment reasons when scheduling an appointment. When scheduling an appointment our front desk will choose appointment reasons like Pap Smear, Wart Removal, etc. This makes it easy for the EMR self check in kiosk to quickly check the reason for the patient visit and require patients to fill out forms like the Consent for Pap Smear.

A few other points of note:

Minors: I could easily see an EMR self check in kiosk determining a patient’s age and displaying special minor consent forms for those that are under 18. We’ve solved this problem using conditional questions on our forms which I think I’ll leave for a future post if people are interested. Minors is another good reason to capture the electronic signature as opposed to just using some sort of individually identified login for a signature.

The Unseen Procedure: Often you won’t know if a patient needs to fill out a consent for treatment form until after they’ve seen the doctor. This is obviously a problem since they can’t just fill this form out when they check in for their appointment. We’re still working through this problem, but we’re either going to go with scanning a paper form or possibly some sort of portable workstation with signature pad. I sure wish that UMPC’s were a little farther along. I’ll let you know how it turns out. This could also apply to forms like birth control and the unplanned pap smear.

One thing that’s important to understand is just because you could sign the form electronically doesn’t mean that it’s always beneficial. Does it really matter if you have your consent for treatment or HIPAA privacy form in your EMR immediately? It’s certainly nice, but it’s not like someone’s going to go looking for it in the EMR the next day to see what was done. The EMR notes contain the time sensitive information. As long as it’s eventually scanned into the EMR, then some forms can wait. Of course, don’t forget to weigh the cost of scanning to the cost of signing it electronically.

In the end, there are a bunch of business and operational decisions that are required to make using an EMR self check in kiosk work properly.

It looks like my previous post about Digital Signatures in an EMR drew quite a bit of interest looking at the stats. Really this isn’t surprising. How long have we been signing things electronically at Walmart. Longer than I can remember honestly. Sure, Walmart is worth billions of dollars, but the technology isn’t that expensive. The real advantage that Walmart has is a great legal team.

Setting the legal items aside, the technology of a digital signature is not rocket science by any means. In fact, it’s the legal questions that are harder mostly because there just hasn’t been much case law that has dealt with it. Just as a thought, I would highly suggest that whoever reads about this talks with a good legal team before implementing it.

Of course, reading the comments from my previous post made me realize that what we’re doing is really quite innovative. I’m not just talking about digital signatures. For more than two years now we’ve been collecting patients health history form in our Health Center and intake questionnaire in our counseling center electronically. These forms don’t require the patient or client to leave a signature. It’s basically just capturing information. I think most people can see why it’s valuable to have a health history form captured electronically. In our case it makes all of the necessary clinical information available in one place without dealing with the time consuming and inaccurate scanning. Even more significant for us as a state institution was the ability to do aggregate reporting on the type of patients we were seeing. How many other people can find out things like 20% of your patients have a family history of heart disease (not our actual number)?

I know there are a number of EMR companies out there that have a whole patient portal where this kind of stuff is done, but I’ve never seen any that use a kiosk at the doctor’s office to collect this information. If you are an EMR vendor that has this feature, please leave a comment. I think we’d all love to know who else does it.

Looking at it now, capturing digital signatures for HIPAA privacy forms, consents, etc is just the next step in ridding ourselves of paper. In fact, this addition means that our patients can bypass the front desk completely. They check in on the computer, fill out their necessary forms and then are directed to have a seat. This notifies the nurse that they have arrived and they are ready to be seen. No face to face contact. Privacy at its best.

Well, I got a few questions and comments in my digital signature post that prompted this post. I’ll do my best to answer them here.

Chris Kozloski said, “I like the idea. A kiosk for registration that they could fill out the paperwork online and sign the blocks on the screen would be really neat.”

See my notes above. It’s not just an idea. We’ve been having them fill out the paperwork for two years now. We also have the technology to do the signatures. Just waiting for the other signature pads to arrive and we’ll be implementing it.

One thing I’m not sure most people think about is how the computer will know which forms need to be filled out by the patient. I think that’ll have to be the topic for my next post.

Craig Briars asked, “What software are you using to do this with?”

This is a good question. We are using Medicat EMR. It’s an EMR that is focused on the College Health community, but could be used in a general practice if needed. I’m not sure how it is in a general practice, but I know that they have a ton of features that make it a solid choice for College Health offices interested in EMR.

Medicat has integrated it’s software with topaz signature pads. Medicat uses the Topaz software to capture the signature. It’s actually quite neat how the signature is captured and stored in the database. We did find that the LCD signature pads with the back light were the best. The cheap $100 topaz signature pads just wouldn’t capture my signature if I did it quickly. Plus, if it isn’t LCD, then I don’t know which part of the signature it missed so that I can correct it.