Welcome to EMR and HIPAA

A while back I wrote something about why having an EMR or EHR consultant could be beneficial to a doctor looking to implement an EHR. Here’s the first part of a five part series on reasons why I think a well qualified, experienced EMR or EHR consultant is valuable. The first part is how an EMR or EHR consultant helps with the selection process.

EHR Selection Process

By first evaluating a doctor’s needs and preferences EHR consultants are able to eliminate a majority of the EHR companies and provide doctors with a short list of high quality EHR vendors to evaluate. By providing a smaller pool of EHR vendors, doctors are more comfortable with the selection process and don’t get discouraged seeing hundreds of EHR vendors that don’t meet their needs. EHR consultants also help doctors through the evaluation process. EHR consultants often provide a list of questions that can be used to evaluate EHR vendors. These questions have been designed to tease out information which will better enable doctors to select the right software. EHR consultants also assist doctors that need help negotiating with EHR vendors. These services include requesting enhancements to meet doctor specific needs or even ensuring that EHR vendor pricing is comparable to other EHR implementations.

When it comes down to it, a good EHR consultant can save a doctor large amounts of time and money that would have been wasted looking amongst the hundreds of EHR companies. It’s not hard to say that doctor’s most precious commodity is time.

See other parts of Benefits of using an EMR/EHR Consultant:
Benefits of Using an EMR/EHR Consultant - Selection Process
Benefits of Using an EMR/EHR Consultant - EMR Training
Benefits of Using an EMR/EHR Consultant - Clinical Process Mapping
Benefits of Using an EMR/EHR Consultant - Comprehensive Technology Support
Benefits of Using an EMR/EHR Consultant - Improved Clinical Buy-in

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.

In my recent post about EMR site visits, I got a comment from prakash about what questions a doctor should ask an EMR vendor. He gave me the following list of preliminary questions:

What is the cost per physician license?
Do you have any existing clients in our specialty?
Does your system come pre-loaded with templates for my specialty?
Is your company the developers of the software or is it re-branded from another vendor?
Is your system client/server based or ASP based?
Does your system include practice management software?
How many clients does your company have?
Is your system HL7 compliant?
How long has your company been in business?
Is your development done overseas?
Is support done overseas?
Is your software CCHIT certified? If not, why?
How often is the software updated?

I don’t think this is nearly a comprehensive list of questions. In fact, I think it just is the tip of the iceberg. I also would consider changing some of the way the questions are phrased. However, I thought it was a good starting point that could be built out over time. In fact, I think I’m going to make a static page on this website for these type of questions.

Hopefully, my valuable readers will continue to point me to other good resources that might have a nice list of questions that I can continue to compile into a valuable resource for those searching for an EMR. Just post a comment if you have other questions you think should be asked or know of other resources and I’ll continue to compile questions for EMR vendors.

Thanks Prakash.

It was very nice to see a well written article that documented 5 cases of users implementing an EMR system. I think there are hundreds of more stories that need to be told. They laid out the stories into 5 phases as follows:
Phase 1: The Spark
Phase 2: The Vendor Search
Phase 3: The Installation
Phase 4: The Payoff
Phase 5: The Future

I love the idea of the 5 phases, but some of the stories didn’t seem to fit the phases described above. Looking at the phases above it does seem like they left out a nice gap between installation until payoff. Thankfully the stories didn’t leave the hard work of implementing an EMR out. Therefore I loved the article from Health Leaders Media. Here’s a little play by play of the 5 stories:

Phase 1: The Spark
This woman is courageous. Running a solo practice by herself with one part time medical assistant. Talk about thinking outside the box and managing costs. I was super impressed by this ladies thought process. I imagine this type of gyn practice allows her a lot of freedom. More importantly for this site was that she sunk $70,000 into an EMR system. I hope those reading this will know that you don’t need to spend that much money. EMR programs shouldn’t cost nearly that much money. Espescially for a solo practice. She does point out an important point to remember with an EMR program. Buy the upgrade package. You don’t want your EMR stagnant. Stay with the latest and greatest in EMR development. Don’t get left behind on an old EMR system where a few years down the road you’ll have to upgrade again.

Phase 2: The Vendor Search
Excellent story of EMR vendor selection failure but eventual EMR implementation success. It really makes me sad that an EMR vendor the size of NextGen couldn’t deliver in this story. I guess kudos go out to Companion’s EMR software (which I’ve never heard of) for helping them be a success. I still think the story needs more detail on what happened with the second EMR vendor. It’s only fair to compare the differences between the EMR failure and EMR success.

Phase 3: The Installation
This story seemed quite off target. Why would they use a home grown EMR system to Illustrate the installation phase of an EMR? Programming and implementing your own EMR system, besides being a crazy idea, is not a good example for those implementing an EMR package. I’ll push that aside and say that there were some good points in the story.
-Katrina proved that EMR’s are essential
-Continuing testing and reworking your EMR processes
-Have physician champions
I loved that they actually payed an IT salary to a few of the doctors who helped test their EMR system. That’s thinking outside the box.

Phase 4: The Payoff
Be careful comparing financial rewards of one clinic with another. They are too hard to compare. I think it is important to see the clinical outcomes he is able to show because of an EMR. If your EMR breaks you even and provides your patients better care then I call that a Win. This should be the hope and expectation when starting an EMR implementation. Isn’t healthier patients payoff enough?

Phase 5: The Future
The Quote of the article:
“For six months, I lived EMR.”
This pretty much describes most implementation and the reason I got the job I did. They needed me to live EMR. Now you see why I call it the EMR experience. I think a lot more could be said about what EMR will allow a doctor to do in the future. This fifth EMR story doesn’t even do the future justice. It does point out one great monetary key to EMR implementation. Transcription cost savings can be a key driver for purchasing an EMR program.

I’ve been reading quite a bit of discussion about a new CCHIT certification that is being created for EMR companies. I really think these medical certifications are interesting since you really have no requirement to be certified and certification really doesn’t mean you are necessarily better. However, with the number of EMR companies out there a consumer certainly will be looking at certification as some means of proof that an EMR has features that they will need or want. Too bad this isn’t necessarily the case. Either way, the CCHIT certification is coming whether you like it or not. Here’s a link to the CCHIT certification requirements. You have until March 31st for public comments.

Many of the smaller/free EMR companies out there are really frustrated with the certification process proposed by CCHIT and they’ve been making their frustration clear in an EMR forum called EMRUpdate. Theit frustration from my point of view lies mainly in the enormous cost to be CCHIT certified including a large yearly royalty fee and the requirement to code a bunch of useless enhancements just for certifications sake. I can’t say I disagree with these 2 items.

I also think the certification process is wrong because it is an all or nothing certification. That means if you are missing one feature then you would not be certified. This really doesn’t make sense. An EMR company should receive a grade instead of a certification. This would allow each EMR vendor the ability to justify why they got the grade that they did. Not only would this be fairer, but it would also give more information to doctors evaluatin an EMR.

A group at EMRUpdate have put together a letter that they are sending to CCHIT about flaws found in the CCHIT certification process. Any of those interested in participating in these recommendations can sign their name at EMRUpdate Draft Letter to Dr. Mark Leavitt, MD, Ph.D. You can see the thread that created this letter here.

Depending on the response to this letter, many of the people who participated in creating the content for this letter have talked about creating a new Certification sponsored by EMRUpdate.com. They’ve termed it SHOVEL - Software for Healthcare Organizations EMR Voluntary Ligitamacy and I better give some props to AlBorg who has done a significant amount of work on this idea. I like the idea, but as stated in the thread creating the idea, I think it will probably take 30-40 EMR vendors coming on board to make it work.

I guess we’ll see how much power an online group of vendors, consultants, doctors and EMR lovers are able to do. Let me know what you think of the certification process and SHOVEL.

No one really likes dealing with sales people. There is just a general feeling of mistrust that usually exists around salespeople. However, it is important that you create a good relationship of trust with that person so you can ask good questions. During an EMR demo you will see a lot of great features on the ideal system. Unfortunately, it is often the ideal system for a specific office for which it was designed. If your office is ideal then there isn’t a problem.

Since you are still reading I assume that you don’t have the ideal office(not to mention it doesn’t exist). This means that your office is going to have to adapt to the EMR software. Don’t expect the EMR software to adapt to you. Even with the most reactive customer service friendly EMR(which I consider mine to be at the top in this area), it just takes time to make changes to software, test them and then deliver them to the customer. So, the ease or difficulty in implementing a software depends on how close the software mimics your method of doing business.

Let me give an example for those visual learners. One of my evaluating clinicians asked, “Can your EMR handle a walk in ONLY system?” The EMR vendor had some great features to handle walk ins and intermix them into a clinicians schedule. However, somehow the ONLY was missed in a sales communication. It would have been much better to ask the EMR vendor, “How can your EMR handle a walk in ONLY system?” Then, follow it up with the question, “Can I see it?” Now you can actually envision what this EMR vendor would be like in your “ideal office” and what you would need to adapt to use that EMR in your environment.

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.

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.”

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.

When purchasing our EMR we were told that you could get a lab interface with the EMR system. All sounded great, but there was so much information that we found out later. Here’s a few things we wished we’d asked when talking about a Lab Interface.

First, how much does it cost us for our EMR vendor to implement a lab interface. This is important, because usually the lab interface has to be customized to each client and often incurs a cost to the emr user. There are some possibilities that the EMR vendor will provide it at no cost. However, you must check it out. During the sales process the EMR vendor will most certainly say that they have built a lab interface with and that they shouldn’t have a problem doing it. This is great, but you need to know how much it costs.

Second, how much does it cost for your Lab vendor(or software program for in house labs) to interface with your specific EMR. Many labs may already have an interface with a certain vendor and offer this service for free. Also, if you are a large enough customer they may do it for free also. However, it all has to be negotiated and you don’t want to learn down the road that they want another $5k for their part because you chose a certain EMR vendor that they have never interfaced with before.

Third, you need to ask your EMR and lab if they can interface together. Usually this isn’t a problem because most people will use a standard HL7 interface. However, you don’t want to find out later they don’t.

Fourth, will your interface be able to run on your EMR server or do you need to purchase another server(or workstation) to host your interface? Many times the answer will be you could run it on the same machine. Anytime they say could that means you need to look at the pros and cons and decide for yourself whether you want them on the same machine. I personally reccomend having a redundant server for your EMR system and using that as the interface server. Kills 2 birds with one stone.

These are the major factors that we didn’t understand about an interface. In another post I’ll discuss bi-directional interfaces vs. uni-directional interfaces and why interface with a lab and costs to implement.