As many of you know, when an EMR or EHR vendor wants to show me their system, instead of getting a full demo of their EMR I instead ask them to show me the unique features of their EMR. Basically, I’m interested in seeing the features, functions, approach, etc that makes an EMR or EHR vendor unique from the 300+ other EMR companies in the market today. This was my approach when EPOWERdoc approached me with a request to take a look at what they’ve created with their EMRDoc software.

Turns out that EPOWERdoc has been around for 12 years and is already in 250 hospitals in 40 states. That’s a pretty good footprint for an Emergency Department comnpany. In fact, I read that they’ve done 17 million Emergency Department visits in North America in their 12 year ED EHR history. Of course, these numbers come from EPOWERdoc and we know how good EMR install counts are from EMR vendors. However, even if that numbers bloated it’s a decent sized install base. Update from EPOWERdoc: The client numbers and ED visits are correct, we started out as a Paper Template system from software printing and that is where the large client base is predominantly. We are 36 months into the EDIS market with the product you looked at and have 18 live and another 9 by first qtr 2012.

During the short demo, EPOWERdoc showed me 3 or 4 interesting things about their Drummond Group modularly certified EHR. However, the feature that hit me most was the EMRDoc prose generator. In fact, this demo was one of the reasons that I’ve started predicting an EMR documentation revolution against hard to read, bulky, clinical notes.

I wish EPOWERdoc had a video of their EMR notes prose generator to demo it. If they create a video, I’ll post it to my EMR, EHR and Healthcare IT videos website. Until then, here are before and after screenshots of the EPOWERdoc interface which shows the granular data entry and the note that was created (click on the image to see the full image).

And now the image of the outputted documentation:

We could certainly debate the finer points of the user interface for inputting the data. Plus, a screenshot doesn’t show some of the other elements they’ve created to be able to quickly handle the input of the granular data elements. What hit me was how much the second image read like a clinical note. To be honest, as I read it I felt like I was hearing someone dictating a clinical note. Are their subtle differences where dictation is better, definitely. However, they seem to have done a good job of taking the granular data and turning it into clinical prose. I’ll be interested to hear some doctors thoughts on the above to see if they agree or disagree.

There were a few other interesting EMRDoc features that stood out to me in my short EMR demo.
-As an ED EMR, you have a different workflow than an ambulatory practice. As such, you need the ability to manage multiple open records at the same time. What I think EMRDoc does really well is switching between patients, but then also tracking your last documentation location for that patient.
-Related to seeing multiple patients, EMRDoc documentation feedback tool provides the user (doctor, nurse, etc) with a real time feedback as to the status of the level of documentation for medical coding as well as what has been completed in the note. In the ED where you’re regularly pulled away to deal with a pressing problem, the feedback statuses are a great little feature.
-EMRDoc has a feature that forwards clinical information and data from the Nursing Record to the Physician Record and from various sections of the Physician Record to other sections. Pretty slick implementation that reduces having to document that same thing multiple times.
-One of the big questions for an ED EHR like EPOWERdoc is how they deal with the hospitals large HIS system. EPOWERdoc’s answer was a partnership with Iatric who uses technology allowing data insertion into non accepting systems such as Epic, Cerner, McKesson or Meditech. I’d seen Iatric (They had the amazing trick shot pool table guy at HIMSS), but it sound like I should get to know them a little more. Maybe I can get Katherine Rourke to cover them over on Hospital EMR and EHR as well.

As I said, I didn’t do a full scale top to bottom demo of the EMRDoc ED EHR system, but I thought these were some interesting features of their EHR that were worth sharing. I’d love to hear some first hand experiences from any EPOWERdoc users. Let’s hear what you think in the comments.

Ever since HIMSS (still seems like yesterday, but was really a month and a half ago), I’ve been wanting to do a writeup about the company Shareable Ink. A number of people asked me at the show what the most innovative thing I’d seen at HIMSS was and my most common answer was Shareable Ink.

The interesting thing about Shareable Ink is that they provide such an interesting middle ground between a technical solution and continuation of paper. I remember about 5 years ago when I heard someone describe the perfect clinical documentation system. It was completely flexible. Required little to no training. Supported every possible documentation style. etc etc etc. Then, they acknowledged that what was being described was the paper chart. It was then that I recognized that while EMR can provide some benefits that paper charts can’t provide, paper charts also had some advantages that would be difficult to provide using an EMR. (See also this post about EMR’s being designed as more than a paper chart).

I think this background is why I found the Shareable Ink approach to documentation so fascinating. I really see it as an interesting way to try and capture the benefits of granular data elements and electronic capture of the data while still enjoying the benefits of paper.

My simplified explanation of the Shareable Ink technology is as follows. You print out a form that you want to use for the patient visit. Each page that’s printed out has a unique background (although it just looks like a colored page to the naked eye). When you use the Shareable Ink pen to write on the printed out page, the pen uses a camera to record what you wrote on that page and where you wrote it. Then, once you sync the pen it recreates the document you wrote on in the system.

It also has some really interesting advanced functionality as far as being able to do check boxes on the printed out form and even will convert your handwriting into text on the electronic document if you wish. I’m certainly not doing all of the features justice in this description, but I think you get the general idea. It’s a pretty cool demo if you get a chance to see it. I wish they had some videos on their website of it in action so I could show you. (UPDATE: Stephen from Shareable Ink sent my this link to a YouTube video of it in action. I’d like to see a few more specific examples of it in action like I saw at HIMSS, but it does do a pretty good job of showing some of what I described above.)

I think they’re also taking a smart approach to the market. Their strategy was to focus on areas of healthcare that were slow to go electronic: Anestheiologists, Emergency Room, Hospitalists and ambulatory Physicians. A smart plan since this hybrid paper/electronic system might get those that love their paper off the fence and into the digital world.

I do have some concern about how well this would do over the arc of the day. How often would there be issues with a pen that frustrates the providers? How much work is it to print off the sheets for each patient? How well could this integrate with an EMR (although, I’d love to see it used with a number of the “Hybrid” EHR vendors out there)? Not to mention, how will the syncing of the pen work? Will it sync flawlessly every time or will you have a bunch of doctors wondering where the documents are/were since the pen didn’t synch for some reason?

I’ll be keeping an eye on Shareable Ink and how well they do. There’s certainly an existing market of users that love their paper and so I’ll be interested to see how these doctors like Shareable Ink’s technology.

An interesting side note is that I find it interesting that Shareable Ink left the Boston area and moved their headquarters to Nashville, TN. Very interesting move I think.

This will be a bit simplified, but I think you’ll get the idea. If you consider a doctor’s training. Doctors are trained in an incredible volume of information and then how to use that information along with a lot of other variables to be able to evaluate patients conditions, provide care and at the end of the day solve problems.

On the other hand, transcriptionists are trained to do repetitive tasks very well with high accuracy. Certainly they have to have some skills with the medical terminology. Also, many have moved beyond transcription into helping with the clinical documentation and ensuring that it’s documented properly.

None of this should be news to anyone. Now for the big finish…

Which training is more suited for someone doing a million clicks on an EMR?

Is it any wonder that scribes and other creative models for documenting a patient visit in an EMR are becoming an important part of the discussion? Watch for many more creative models using people to come out in the next year.

Back in March 2006, I had this great idea about synchronizing video with the EMR. Essentially instead of having to do all these pick lists of information, you’d just record the whole visit with the doctor and that would be all the documentation you’d need. Ok, so that won’t quite work, because you need some things recorded granularly, but the idea of a video EMR was and is really interesting.

Thus, you can imagine my interest when I saw this article about a company, CareCam, that’s developing a video based EMR. Here’s a quote from the article:

CareCam is developing an EMR system based on video. The idea came to founder and president Shannon Pierce from her days working as a nurse. Data entry distracts clinicians from patient care, she said.
…
But the based in Greenville, S,C.-based company’s 2009 patent on the method of documenting health records describes the technology as an electronic documentation system consisting of “documentation devices having a digital video recorder directed towards the patient.”

The device will record video and audio information about the care of the patient, categorizing the data and logging it for future reference. That would be a different tack from most EMR offerings on the market, which aim to move paper records to the digital world, but without the audio and video that CareCam proposes.

EMR may eventually replace paper records altogether, but doctors, and likely their patients, will ultimately decide whether a video record is preferable to other formats. CareCam completed its first pilot in December, according to Pierce.

As I look at their website, there’s not much information. However, it seems to me more like the cameras are for virtual office visits and not for recording visits in the doctor’s office like it described in the quote above. Of course, these type of video cam visits from home are a popular topic and I can definitely see them becoming very popular. Especially as more and more devices start coming built in with a camera like the iPad (the iPad 2 has 2 cameras).

I’m still really intrigued by the idea of integrating an EMR with video. Video is becoming more and more popular on the web and I can see integrating video into an EMR being a very interesting next step. Most EMR systems can actually support some video today. I can easily see a dermatologist taking a video of a person’s skin and uploading it to the EMR. There wouldn’t be the seamless playback that would make it really cool, but it’s certainly possible today. Hardest part today is getting it off the camera and into the EMR. A nice iPad or smart phone app could easily solve that problem.

Looks like I should have patented my video EMR idea back in 2006.

One of the biggest complaints surrounding the implementation of an EMR is the way the EMR software handles the documentation method. Beyond just the learning curve, there are plenty of EMR software that have a terrible user experience.

While I don’t want to totally let EMR vendors off the hook, I do think it’s worth noting that EMR vendors aren’t completely to blame for the unwieldy interfaces. I believe one of the biggest reasons that the EMR documentation interfaces are so terrible is thanks to the crazy insurance billing and documentation requirements.

Seriously, it’s a total mess. Everyone that’s involved with insurance billing in healthcare knows what I’m talking about. Trying to code an application that’s easy to use, works well for the doctors and still handles all the insurance billing and documentation requirements is a serious challenge and so it’s not surprising why so many EMR software fails to deliver a great user experience.

That’s not to say that all EMR software have terrible user experiences. Although, let’s be honest that they’re taking on a nearly impossible task. I guess I compare the insurance documentation and billing requirements to cleaning a toilet. Nobody really likes to do either. Yet, they’re absolutely necessary jobs. Certainly there are some tools that can make cleaning a toilet easier (gloves, wands, cleaning solutions, etc). However, it’s still a task that isn’t fun to do no matter how you slice it (unless you pay someone else to do it, but the pain of the expense is still there). The billing and documentation parts of an EMR software are trying to do the same thing: make a task that no one likes easier. Unfortunately, using an EMR isn’t going to change a task that no one likes into something fun.

I hope that EMR vendors don’t use this as an excuse to not focus on creating usable software. It’s NOT! However, I think it’s important to consider the true impact of the EMR. Is it really the EMR software that is so bad or did you hate these parts of practicing medicine before having an EMR as well?

If you find that it’s the EMR software that’s so bad, then hopefully you were smart in the contract you signed with your EMR vendor (see the EMR contract section of my Free EMR Selection e-Book). You won’t be the first or the last practice to switch EMR vendors.

Of course, if the complicated insurance billing and documentation is the problem. Maybe Obamacare’s single payer insurance plan will help to solve that issue. At least there would only be one organization to deal with.

In continuation of my posts about RAC auditors and other audit issues that EMR software can help or hurt, the following comment was sent to me by an EMR and HIPAA reader. Maybe all of you have heard of “The Impossible Day” but I found the concept interesting and it seems like EMR software could be well positioned to control this issue. Is this a major problem or only a problem for a few people that like to code too high?

The RAC audits are an interesting and mindful subject. Some practices have been getting into trouble with the “impossible day” which their EMR’s seem to help perpetuate. Some seem to end up with more documentation in files, but when RAC auditors do the math on how long the docs are supposed to be legitemately spending, its not adding up… Thereby “The Impossible Day” emerges.

I’ve asked some EMR vendors if there is some sort of a control feature with a warning on the total time based on visits/notes for a day. Most are not familiar with this. Just like anything else, if we hear more about it from the RAC audits, more will pay attention.

Yesterday I addressed the possible caustic demeanor of insurance companies towards template based EMR documentation methods. Definitely something worth considering when you choose an EMR. How they document and the type of note that it creates matters to the insurance company, matters to you reading the note later, and to some extent the doctors who receive your notes on a referral.

Today let’s look at another possible problem with the ugly template note that many EMR systems like to employ (Note: The Jabba the Hut EMR vendors LOVE this type of note). This was sent to me by another reader (Yes, I have the best readers).

I know that Medicare RAC auditors apparently love the EMR systems as practices seem to be hanging themselves with poorly maintained patient notes; (ie. “sutures healing nicely “ in a current note for a surgery that is 2 years old). I guess some insurance payers are jumping on that same wagon of EMR note distrust as the RAC auditors.

Now I’m sure that none of those reading this blog would have poorly maintained patient notes. At least not intentionally. The problem with many of the template approaches to EMR documentation is that the above scenario easily happens in a busy clinical practice. Luckily there are a number of EMR software which don’t use this poorly designed template note systems.

As they say, Buyer Beware. It’s never been more true than when selecting and purchasing an EMR.

I recently got an email from someone who told of a practice manager that was concerned with the insurance companies demeanor when it came to EMR. Here’s a short description of their concern:

He [A practice manager] mentioned he’s noticed and heard from many physician colleagues that the insurance payers really seem to be getting more of a caustic demeanor and approach with their subscribers. In particular, they don’t seem to care that an EMR is being used. If anything, they seem to challenge the notes saying the physicians are just using a template and not doing what they say. My caller wanted to know if we were seeing more of this. I think some payers are changing demeanor in preparation for upcoming cuts due to health reform.

This type of reaction is something to definitely be concerned about. Back in Feburary of this year I posted about the difference in an EMR that does Documentation by Exception versus Documentation by Veracity. In that post, Matt Chase from Medtuity does a great job describing the difference in documentation methods.

It’s really kind of interesting to see that the insurance companies becoming caustic towards this template based EMR notes that basically post a bunch of junk in the note that may or may not have been done. I don’t know a single doctor who likes those types of notes. In fact, most people hate them. Well, I guess I have seen many doctors who liked this type of note because it allowed them to bill the insurance companies at a higher level than they were documenting previously.

As I write that last line, I guess it’s no wonder that the insurance companies are kicking against this type of documentation. Especially since they’re always looking for ways to save money. Although this spells trouble for many of the large EMR vendors that are designed to document using this type of method.

I guess we can give credit to the insurance payers for something if they can help to end the long, useless, hard to read, templated based notes that are just designed for reimbursement and not better patient care.

I’ve seen a number of side comments on the challenges of Copy and Paste functions in an EMR. However, I’ve seen very few people really address the challenge that is copy and paste functions that are built into almost every program in the world.

Before I talk about the challenges, of copy and paste with an EMR I will first profess my amazing love for these 2 functions. I use them probably 100+ times a day. On a good day it’s probably a few hundred times and on a bad day it might only be 50 or so. I can’t imagine doing what i do without copy and paste. Even in this post I’ll likely using copy and paste a dozen or so times.

I’ll admit that I probably use it more than most. However, it’s amazing how many people use copy and paste. It’s really become a major part of computer use. The fact that it is almost automatically integrated with every application is a testament to this fact. When used right, those two functions are an amazing utility.

Of course, when used wrong it can cause some really ugly problems. In your personal life it might just be an email sent to someone with someone else’s name on it. Usually not a major problem, but a minor annoyance. Now apply that same situation to an EMR.

Let’s say you copy a nice physical exam assessment. Despite the very best of intentions, many times you’re going to forget to change something after you paste it. Yes, it happens all too often. Not purposefully of course. Usually something happens to distract you right after you paste it. Maybe the phone rings, your cell buzzes, you get an IM, the nurse comes to talk to you, etc etc etc. Each of these distractions often lead you to forget to change/add something that you just copy and pasted. I don’t need to describe why it’s a problem to have it say “normal rhythm” when it’s not normal or why having other pertinent positives missing is a major problem.

Now, this is just the most obvious case. It’s pretty easy to see how it’s easy to miss things when you start copying and pasting into an EMR. However, the EMR copy and paste challenges don’t stop there. However, the problems might not be as obvious.

One example, is how the length of EMR notes BALLOON with the use of copy and paste. Yes, that means that you might have more robust notes, but that also means that we’re missing out on the “minimum necessary” documentation which makes those notes really useful and functional. Sure, insurance billing has ruined notes in this regard, but copy and paste hasn’t helped either.

I also haven’t talked about the potential HIPAA issues related to copy and paste. I’ll save that for the lawyers out there.

It’s amazing how a function which can be so useful can also be so dangerous. Although, I guess this is true of most tools.

Many of you might remember my post about EMR documentation by exception. Today I came across the best description of the problem with this form of documentation:

When a consultant sends you an EMR note, you are reading his Billing Justification.

Seems like this post is appropriate for President’s Day. Imagine the founding fathers wrote the constitution or bill of rights in order to justify their billing. We’d have 100 amendments, but only 10 of them that other people needed to read. Luckily our founding fathers had the good sense to only pen what was needed. Maybe we should take a lesson from these amazing men.