Welcome to EMR and HIPAA

If you’ve been reading my blog for any amount of time, then you know that I currently work in College Health at my local University. I started this job about 3 years ago and it has been a great learning experience for me in learning about EMR and healthcare IT.

When I started the job 3 years ago, I took advantage of working at the University and started classes for my Masters in Information Systems. Happily I completed my Masters a few weeks ago. With the completion of my Masters degree, I’ve decided to start looking around for other job opportunities. I already have a few leads, but I thought I’d post my availability to my blog in case any of my readers have potential job openings.

To be completely honest, I’m really jack of all trades when it comes to technology. I’ve done everything from server and database administration to workstation rollouts. I enjoy optimizing processes and analyzing how to revamp a process using technology. I don’t want to be a programmer and will probably avoid doing any hard core system or database administration, but those things are fine as a small part of my job. I much prefer working in a strategic position where I can plan and organize in a way that the company is well positioned for the future.

If anyone has some potential job openings in the EMR or Healthcare IT field, then I’d love to hear about the opportunity and I’ll have my resume handy. You can either leave me a comment or send me an email at john [at] emrandhipaa {.} com

This entire week my EMR vendor had someone in our clinic going over our EMR implementation. Yes, that’s nearly 4 entire days of our health and counseling staff meeting with our EMR vendor. You can imagine after the first few meetings it’s pretty hard to keep things straight. However, this type of EMR vendor site visit is so beneficial.

The biggest benefit is that it almost forces doctors, nurses, front desk staff, lab, pharmacy, etc to sit down and think about our EMR, how it could be made better and which parts of the EMR are just causing them pains, problems, frustrations, or other discomfort. We tried to make sure that each EMR meeting went over: our current EMR challenges, features of the EMR that we aren’t using and finally discuss ideas for enhancements to the EMR software.

We’re lucky that we selected a smaller EMR vendor that’s completely focused on the college health EMR market. That means that we have a strong relationship with the EMR company. In our final meeting the EMR “trainer” said that they really are our “partner” in not just the EMR, but they’re willing to support us beyond just software. The nice thing is that our EMR vendor really does try to do this. They don’t always succeed at it, but they certainly are sincere in their effort.

Another major benefit of having someone from the EMR vendor do a site visit is that they are looking at your clinic with fresh eyes. They can see things about the way your process works that you may not see. Plus, they have usually been to hundreds of other EMR installs and so they are aware of how other clinics are using the EMR software.

Of course, you can’t expect someone from your EMR vendor to come and work miracles. In fact, many of the ideas they have just may not work for the way you practice medicine. It takes a solid filter to be able to see the benefits, problems, and workarounds that will work best for your standards of care, legal regulations, and clinical organization. The biggest problems that an EMR vendor faces is that it’s really hard to build a one size fits all EMR. Different practices act differently. However, there’s something really valuable about discussing the various options of an EMR.

I highly recommend this type of collaborative approach to working with your EMR vendor. I believe it’s paid amazing dividends for our clinic. In the end, your EMR company better be a good partner or you’ll pay the price later.

I’m currently attending the PCCHA conference which is basically the college health association conference for the west coast. The conference has been quite interesting. A few of the sessions ended up being quite useful, but more than anything it was just fun for me to talk to all of the various people working in the college health community. Most of my conversations centered around EHR and EMR implementation, but it was also fun to see these other college health professionals jealous of the really state of the art facilities we have on our campus.

My presentation on EMR went quite well and I think that many of the people in the audience got some useful information. At least that’s my hope. It was fun to present on EMR and the things we’ve learned. The interesting thing for me was that as I talked to people about EMR and EHR and using it in college health, I realized that over the past two years I’ve really learned a lot about what it takes to implement an EHR into a clinic. It can certainly be a daunting task if you look at all the intricacies.

In the end, my message to most of the people that I talked to was that while implementing an EHR can be overwhelming, it’s important to take small bite size pieces of it and accomplish those. Then, move on to the next problem and the next. The reality is that 2.5 years after implementing our EMR system, we’re still adding, modifying and changing our processes to be more effective.

The day is fast approaching for me to present at the Pacific Coast College Health Association conference in Hawaii. In fact, I have less than a month to finish my preparations. I feel pretty good about my ability to present and also my knowledge of EMR, but presenting something always gets my nerves going. I think once I get started talking about EMR, then I won’t be able to stop. My real hope is that the people that attend my session will be interested in what I have to say, find it useful and ask good questions. Honestly, a part of me really wishes that I was a member of a panel where I just answered questions about EMR. I think that would be a lot of fun.

Since it’s not a panel, then I’d love to hear any feedback from people on things I should include in my presentation about “Lessons Learned from EMR Implementation.” I have a ton of things already planned about EMR implementation, but I’m sure there are some important things that I’ve missed. Time has a way of doing that to you.

Either way, I’ll be happy if one person in my session on EMR goes away saying they were better prepared to implement an EMR system, then I’ll be happy.

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.

I think there is a ton of misunderstanding about digital signatures. So, hopefully in this post I can clear up some of the confusion of the various types of digital signatures that can occur. It’s important to understand some of the intricacies since there are a number of choices out there. I’ve been working through some of this digital signature stuff for months now and in the next month we’re finally going to have all of the digital signatures implemented in our office.

The first method of digital signature is basically using your login to sign something. This is the most common digital signature in an EMR and many people don’t even realize that what they are doing is digitally signing their chart. Some EMR programs don’t even ask you to physically sign the chart. Instead, they leave the note open for a certain time period. After that time period, then the note will essentially be locked so that nothing can be changed. Why does this type of signature work? Basically it knows that you were the one that logged in and the EMR logs who enters what piece of data. Essentially, the program is leaving your virtual signature throughout the chart as you enter your information. Pretty neat as long as that EMR has a good audit program so you can see who entered what information on a patient.

The second method is similar to the first in that it uses your username. Often, it may use some of the same principles of the first method by keeping track of who entered what information. However, in this method each electronic note requires you to click a button to “digitally sign” the clinical note. This can also apply to lab or x-ray results. This is the type of digital signature that we use most in our clinic. Each note has a button that lets you sign the note electronically. After clicking the button it imprints your name, credentials and the date and the time of the signature. The date and time is especially useful on lab results so we can know when a doctor may have read the lab results.

The third method is what I call “electronic signature” because it literally takes your physical signature and captures is electronically. Everyone should be familiar with this if they have been to a grocery store or Walmart. Basically all of the major chains are accepting your credit card signature electronically now. I can’t say how much I appreciate the digital signature in stores when I’m holding a baby. Have you ever tried to sign a piece of paper while holding a baby in one arm. It’s nearly impossible, but I digress.

I honestly haven’t heard of many (if any) doctor’s offices that are using a signature pad like Walmart does. However, it really is something that is an essential feature of an EMR that wants to have patients fill our their information electronically. Ok, some larger practices can distribute logins to all their patients. However, even then you’d probably need a physical signature to give them the login. My clinic is currently implementing this technology. The signature pads aren’t cheap, but I think they are well worth the money. It basically allows us to make every patient form electronic. This was never possible before since so many required a signature. Capturing a digital signature is what we’re doing to capture this information.

I hope for the signature pads to all to go live in the middle to end of August so look for more information on this coming soon. Is there anyone else using digital signatures with their EMR?

The past couple weeks I’ve gotten a few emails and phone calls from my EMR vendor about having a few other college health clinics(doctor’s offices) come and take a look at our EMR implementation. I always go into these with a little bit of a mixed bag since I know that my EMR vendor would like me to speak positively to the client. In fact, in many ways it is in my best interest to help make my EMR vendor successful. The more offices my EMR vendor signs up, the more money they’ll have to stay around and continue to develop the product. However, I always wonder if the trade is really a fair one.

In the end, I love to have other people come and take a look at my EMR implementation. My wife just gave birth to our second child. You know I’m that proud daddy carrying around his little princess to show her off to all those around me. My EMR implementation isn’t that much different. It’s my little baby that I want to show off to other people.

Another part of the satisfaction of a site visit is that my EMR vendor is saying that our implementation of EMR is one of their premier implementations(yes, I know that is a run on sentence, but I’m too tired to fix it now). An EMR company wouldn’t send clients to a failed or shoddy implementation. I take real pride in that recognition.

However, the best part of site visits is the time to be able to connect and collaborate with other colleagues from around the country. It’s always fun to get a different perspective on what should be very similar processes. Plus, I just love interacting with people. We have two coming up in the next month. I’ll let you know how they go. If they don’t buy me lunch then you can guarantee they weren’t as good.

Not too long ago I ran accross an article that talked about Ohio University’s server being hacked and in a hackers hands for a long period of time. I honestly don’t think this is really all that common. In fact, after working with a friend of mine in college who was excellent at hacking I think this happens a lot more than we ever realize and definitely more than ever gets published. Not that the practices of this article are acceptable, but I don’t think we should be naive.

Many may be wondering what a University getting hacked is doing on an EMR and HIPAA blog. Well, read this quote from the article:

How a server could be left open to intruders is still under investigation. But this much is known: A server supporting the alumni relations department was supposed to be offline, Sams said. The people responsible for shutting it down thought they had done so. The server continued to be connected to the Internet but didn’t receive security updates. It was the equivalent of leaving a backdoor open for thieves to walk in and seize what they wanted.

The culprits who broke into the other two servers made off with health records belonging to students treated at the university’s health center, as well as Social Security numbers of an additional 60,000 people.

Does this really make sense to any rational person? What is a student’s health record doing on a server supportint the alumni relations department? Not to mention on a server that someone isn’t updating. At the rate that Windows puts out updates I think we are all guilty of sometimes being a bit lazy in our updating policy. However, to forget about the machine and think it is shutdown is ridiculous. That has HIPAA violation and HIPAA lawsuit written all over it.

I’m thrilled to say that we just passed 30,000 visitors to EMR and HIPAA. It really is something else to think that so many people have come to this site to find out about EMR and HIPAA. I’m really happy to see its success. In fact, I didn’t realize how well I was doing at attracting visitors until I looked at a great Healthcare IT blogger recently posted that since tracking his statistics since September 2004 he just hit 10,000 visitors. Pretty amazing that I just started blogging in December 2005.

It’s been a roller coaster getting it started. Now that I’m a little more established with some quality content in place I have been taking a step back to see where I want to take my EMR and HIPAA blog. I definitely want to work on some of my fixed pages:
EMR and EHR Vendors
EMR vs. Paper Charts
EMR Evaluating and Purchasing
EMR Features
EMR Implementation Ideas

I also want to work more on giving details to those interested on implementing an EMR. I want to start doing my initial vision of reviewing various EMR systems. I’ve already started some of the reviews, but I’ve been debating the best way to review an EMR system in an unbiased and professional manner. If you have any ideas please post a comment so I can have your feedback.

Mostly, thanks for helping me reach 30,000. It’s amazing to me that I have gone from 0 to 30,000 so fast. Espescially since this EMR blog was started as a Christmas whim. Who would have thought I’d love EMR so much?

I had someone email me asking me what I thought about a small group of doctors developing their own EMR. Then, I was helping a doctor implement an EMR in a new office and his friend asked me why I didn’t just create my own EMR and make a ton of cash. All I have to say is….Are you CRAZY????

While developing your own EMR is a very nice thing because you are able to customize the process exactly the way you like I honestly think this is a big mistake. You will honestly be spending just as much money developing your own EMR as you will spend purchasing from an EMR vendor. Doing this for a small group of doctors is even worse. Gaining a consensus of these doctors on what is “best” for an EMR is like asking which type of ice cream is best. There are certainly some that are better than others, but it really just depends on a person’s preference. EMR choice is pretty much the same.

One of the biggest problems of creating your own EMR from scratch is what happens once your EMR is “created”. You have to continue paying development to continually create enhancements. If you stop enhancing your EMR program then you get farther and farther behind and lose some of the advantages of an EMR. If you go with an EMR vendor then you continue to benefit from the enhancements that they continue to create. Often there is a small update fee, but much less than you developing all these features yourself over time. An EMR vendor is able to generate a lot more revenue which can be funneled into enhancing your EMR. Do you really think that one programmer can compete with a whole team of programmers? Besides the time factor it is really hard to find a programmer that can do all of the specialized programming for an EMR. They would have to know how to do an HL7 interface, learn CCR, document management, reporting, just to name a few.

Even more important is it is just not realistic for one programmer to be able to build an EMR that has all the feature set of a good EMR system. Sure, I have the technical skill to program an entire EMR. It would just take time. Not a little bit of time, but hordes of time. Individual components of an EMR system really aren’t that complicated. When you pile them all together it would just require a lot of work to develop an EMR from square one. I really think developing your own EMR is a poor strategic decision.

Another point is that there are some great EMR companies that are reasonably priced and will certainly pay for themselves over time. There are even some different pricing models that don’t require an enormous up front fee which allows a doctor to minimize the risk of EMR implementation.

Here’s a few examples you might look at:
Doctors Partner - http://www.doctorspartner.com No up front, just a monthly fee
Medtuity - http://www.medtuity.com/ Charged per visit(does not include a PMS)
I know both of these companies personally and they are quality organizations and people with a unique cost structure.

There are so many EMR vendors to choose from. In fact, look at my enormous list of EMR systems.

Every doctor should be able to find an existing EMR system that meets their needs(pricing and features).

One other quick tip is to choose an established, but smaller EMR. These smaller EMR’s are able to listen and implement your specific requests much more quickly than a larger EMR that receives tons of requests.