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EMR Documentation by Exception or Veracity

Posted on February 8, 2010 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

If you’ve been reading me for a while, you know that I have a few hundred draft posts (basically ideas) for future posts. However, the news about meaningful use is coming out so quickly that it’s not that often that I have to go back and use those draft posts. I probably should do it more. Well, when I was working on my soon to be released e-Book on EMR selection, I ran across this comment about two different ways of documenting in an EMR. It’s written by Matt Chase from Medtuity and likely was originally posted on EMRUpdate (sadly, I don’t have the original link).

I’m a total Matt Chase fan boy, and this type of information is what makes him so good. Plus, if you’ve ever received a 10 page note with about 1 small paragraph or relevant information, then you’ll find this information VERY interesting.

There are two methods of documenting with templates: documentation by exception, or DBE, where the template is pre-answered, and documenation by veracity (where you actually gather a history and examine the pt before documenting).

The first (documentation by exception) usually puts into the chart a huge number of normal items and the physician’s duty is to change what does not apply. The “change what does not apply” becomes too burdensome because there is so much fluff on each patient, that it is simply easier to forego the editing. This contributes to the not so unusual findings of “normal clinical *** exam” in a 7 year old boy and “normal descended testes bilaterally” in a 12 yr old girl. Think of it as every 80-yr old male appears on paper identical to every 20 yr old, strapping young man– no abnormalities.

The VA is probably using documentation by exception. The easy way to tell if a system uses DOE is by simply printing an encounter. If it exceeds 1-2 pages, it’s probably DOE.

In contrast, the better method of documenting is for the EMR to present a template with all of the relevant findings, both normal and abnormal but allow the physician to click the findings. For example, a sore throat encounter would have all those things important to a sore throat, including history of fever, difficulty swallowing……through a good neck and throat exam. You would not expect it to document a *** exam, digital rectal exam, or exam of the genetalia. IT’S A SORE THROAT! The documentation would be relevant and short.

With the proper mix of “input controls”, such as checkboxes, right-left-bilateral, positive/negative, multiple choice text controls, calendars, number control, and dozens of other types, it is possible to rapidly enter truthful information. Many EMR’s have only several types of controls (either checked or unchecked), making it easier for the designer of the system to simply put in paragraphs of text (hence the DBE).

Obviously, my disdain for padding the chart with meaningless information is a strong indicator that at Medtuity, we provide a system where the physician clicks to enter truthful information. We take the step of allowing information to be entered quickly.

The local hospital’s emergency department uses one of the “big boy” EMRs that performs documentation by exception. For example, every ankle sprain has a full neurological exam placed in the chart, by default. It does not matter that few ankle sprains receive a full neuro exam. For EMRs designed for DOE, they usually generates a high billing code because including 30 normal findins in the chart is easier than documenting a couple of abnormals.

Selling our product locally always generates the same question: “My documentation won’t look like the ER’s, will it?”. Nobody wants a multi-page report of meaningless normal findings.

One reason, I believe, that there is a lower penetration of EMRs among specialists is this problem of padding a chart with a single click. The charts produced by specialists are actually read by the referring primary care physician. When anticipating a colleague reading the chart, they may hold themselves to a higher standard.

On the other hand, we feel that the scores of questions that are asked by the specialists again and again, with every patient, should be easily responded to with just a few clicks to set many responses to negative. For example, a *** surgeon will ask about *** self-exam findings including lumps, nipple discharge, skin dimpling…through weight loss, bone pain, etc, etc, many times a day. Most of these are negative.

Our profession may blame the insurers and Federal Govt for documentation by exception, but the reality is, it is a design defect. It is very easy to design an EMR for DOE. It is much harder to design an EMR that allows pertinent positives and negatives to be quickly entered.

Probably the easiest method for determining whether an EMR depends on DBE is to ask how many control types they have for entering data. We have over 40 in MedtuityEMR, and counting. I simply cannot fathom how EMRs can get along with just a couple, IMHO.

I asked for a demo of a common peds and family practice complaint (otitis) from “big boy” EMR user. Perhaps this problem has been remedied, but for such a common complaint, there was no means in his template to show:
ear canal occluded with cerumen
bulging TM
erythematous TM
tympannostomy tube present
perforation of TM
location of perforation
retraction of TM
normal TM
scarring of TM
TM motion on pneumotoscopy
………and about 10 other findings that you may wish to show, whether positive or negative) on your ear exam. He couldn’t even click right or left but had to rely on “the affected side”.

There was but one selection available for ear exam (normal/abnormal). That was perhaps two years ago and things may have changed.

So if you are shopping for an EMR and this matters, just ask the demo’er to show you a bunch of abnormal tympannic findings for a screaming 4 yr old. That will tell lots.

Matt Chase
www.medtuity.com
“Practice medicine, not paperwork” ™

EMR Patient Data Interoperability Between 3 Locations

Posted on December 28, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Another interesting story from EMRUpdate talking about how one EMR vendor, Medtuity EMR, took 3 locations and tied their EMRs together. However, they didn’t just do one centralized database accessed from each location. Instead, they essentially built patient data interoperability between the 3 locations. Check it out:

We just linked 3 sites in October. The docs described what they wanted, including the speed of a separate SQL Server in each facility. They also had a billing office (as the center or hub). They previously used a single server with Remote Desktop as the means of communicating with a central server. They were not entirely happy with that arrangement and so wanted to embark on a SQL Server in each facility. Additionally, they did not want all encounters synched to all facilities daily. Instead, the 3 offices synch to the billing office once daily. Pt demographics get synched from that hub outward to all offices daily just in case a pt should visit another office.

So the underlying theme was speed– each office has its own server; pt encounters originating there are stored there + at the billing office, but pt demographics are synched to the hub and from there back to all 3 facilities. It’s all automated. If a pt visits a different facility than the original, the demographics are already at that alternate site and so the additional encounters can be synch with a button press to insure contemporaneous info.

What they did not want is to have all encounters stored at each site because there is not enough cross visiting among docs to warrant it, but they did want to be able to transfer encounters quickly when the need arose.

Certainly, this problem is much easier since all 3 locations used the same EMR software. However, it seems like there’s something that can be learned from this story in regards to broader interoperability of EMR software.

Type of IT Support You Want for Your EMR

Posted on December 23, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

On my favorite EMR forum, EMR Update, Matt Chase from Medtuity suggested the following pattern for how IT is involved in the EMR implementations he’s been involved in. Here’s what he said (emphasis added):

The characteristic pattern on a new server install is the IT guy comes in, puts the infrastructure in place, comes back in a couple of times over the ensuing 2 weeks and then disappears into the ether for a few years. Once a network is setup properly, it needs surprising little tuning. For example, a facility running Medtuity ~7 years is just now replacing their Windows 200/SQL Server 2000 box (a busy place too. They’ve had their IT people out no more than once per year, I’ll bet, over the last 7 years. Another group with 7 facilities does not even have an IT person on their payroll despite a server at each facility. The important point is to set a server up correctly at the outset.

I’ve seen this pattern first hand with the small clinic implementations I’ve been apart of. Although, I’d say that it’s probably more like 1-2 calls per year and the Merry Christmas phone call in December too. The key really is to make sure the server is setup properly at the outset.

However, what Matt doesn’t highlight is the importance of having the right IT people available for those 1-2 calls per year. It happens so rarely that the clinic goes into a partial state of panic. Having an IT person that can assist you quickly and effectively in that moment of panic is very important.

Does Your EMR Vendor Love You?

Posted on March 4, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

In a recent thread over at EMRUpdate (best EMR forum out there) someone made the assertion that the reason that so many doctors hate EMR is because far too many vendors are focused on making the quick buck rather than providing EMR purchasers TLC (Tender Loving Care). The poster then espoused one EMR vendor has having TLC for purchasers of their EMR.

After espousing other EMR vendors who love their customers, that EMR vendor then posted the following comment about his EMR, loving customers and the EMR industry:

This business is tough and tough for many reasons. Now that the smell of money is permeating the air with Obama’s HIT initiative, it will be like sharks in a feeding frenzy. Anybody and everybody will try to enter the market and makes lots of marketing noise with new venture capital money (if there is any left out there!).

There is no clear cut “best EMR”. We cater more to physicians who expect that there will be work and some level of frustration in going to a paperless record. We attract physicians who are willing to (and frankly want) to put in the infrastructure to have control over their EMR (read: buy a server, put in a network). Our users are those who intuitively understand that there is no software in the world which will replace their paper-filled processes with nary a hint of change. Their intuition also tells them that there is no EMR that can duplicate their level of skill……there will have to be some tweaking of templates and clinical content.

So I love our customers. That is no secret, but I love them because we can work together to build a better solution. They provide lots of feedback, are patient (most of the time), are thoughtful, are goal oriented, are smart, are owners (and managers) of their practice. Their decisions stand (ie, get outta Dodge if you aren’t on-board with an EMR I can hear them saying to a foot-dragging staff member). Others need not apply.

In short, Medtuity is not for the masses of physicians. Our phone rings pretty much non-stop…..and that is also why Obama’s HIT plan will fail. It takes too much caring.

Kind of rare to find such stark honesty in the EMR industry. An EMR vendor who actually tells doctors that there’s going to be “work and some level of frustration in going to a paperless record.” Reminds me of a loving father trying to prepare a child for the future heartache they are sure to experience. Sounds like an EMR vendor love to me.

Does your EMR vendor love you?

IM (Instant Messaging) EMR/EHR Integration

Posted on February 2, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

In my first post on IM in a clinical environment I discussed some of the benefits and options available by having an IM program rolled out in a doctor’s office. IM really is a killer application that can facilitate communication. We all know the benefits good communication can bring to a doctor’s office and the pains bad communication can cause.

I love the idea of IM being integrated into an EMR. In fact, so much so that I asked my vendor if they were going to integrate IM into their EMR when they told me that they were looking to integrate the whole Outlook like messaging and calendaring system into the EMR. The response to my IM question was that it wasn’t on their roadmap and that they weren’t sure they’d want an IM popping up while they were in the middle of a patient visit.

I haven’t thought through all the complexities of integrating IM into an EMR in a way that wouldn’t be obtrusive, but would still facilitate the needed communication. However, I’m confident that with a little thought it could be built so that the communication happens without leaving the doctor in an awkward position and while still protecting the privacy of the patient.

Matt Chase, of Medtuity (one of the more forward thinking EMR companies out there), offered some interesting insights into possible benefits of having IM integrated into an EMR. Here’s a quick summary of some of his thoughts on it with some of my own additions.

IM Direct Link to Patient Chart – If I’m sending a message about a patient to the doctor, then it’s very likely that the doctor will want to look at the patient chart.  Certainly I could send the number or possibly the name, but if the IM is integrated into the EMR, then I could include a link in the IM which would take me directly to the patient chart.  As I’m typing this, why not have the ability to embed a part of the patient’s chart right in the EMR?  You could even direct link to a specific part of the chart or document that was uploaded that the doctor might need to see.

Patients Image Shown in Discussion – Assuming you’ve captured the patients image in your EMR for reference (and many do this), why not show the patient’s image in the IM message when someone mentions the patient.  How much would having the picture of the patient help if you received an IM message that said, “John Doe from last week has an abnormal lab.”  Most doctors are much better with faces than they are with names.  In the name of HIPAA, they probably should be.  Why not jog their memory of the patient by including a picture?

Click To Save to Patient’s Chart – Some IM discussions might be worth saving in a patient’s chart.  Sure copy and paste works from other IM programs, but why not make it one click to save it to the patient chart.  Of course, I suggest making it a one click add, but still let it be editable so that someone can format the IM before saving it completely.

EMR Access = IM Access – No one needs to know where you’re signed into EMR.  As long as you’re accessing EMR, then you’ll get your message.  This could be in a room, in your office, on your cell phone at the hospital, or in the Bahama’s when you were checking your EMR because you missed it so much (hopefully not likely).

EMR Defined Groups – Built intelligently, the EMR could be built to know which staff was on duty.  For example, we have a number of lab techs in our clinic.  Either a flag in the EMR or just by the lab tech’s activity in EMR it could know who to send a lab message to.  Look at it like a virtual IM account that the EMR intelligently knows who is available.

I’m sure there are many more features or benefits that would be only available by having IM integrated with EMR.  Are there any others that I missed?  Are there people using IM in their practice?  Is it integrated with your EMR?  I’d love to hear people’s thoughts and experiences with IM in health care.

Requirements of an Efficient EMR

Posted on January 26, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

While browsing a thread on my favorite EMR forum, I found this intrigueing post by Matt Chase (someone who I deeply respect and the MD behind Medtuity EMR).  Matt created an interesting list of requirements for building an efficient EMR.  He created this list to dispel the notion that the government could create an EMR software and offer it to doctors for free.  I’m sure this isn’t a complete list and I disagree with some of the finer points, but if every EMR was able to do the things on this list, those using EMR would be much happier.  Take a look at the list of EMR requirements:

  • The record must be totally collaborative to allow anyone in the office to open and chart without regard to others having the chart open.
  • There must be security. An audit trail.
  • It must be very customizable for the practice. No EMR company in the world has all the medical expertise to have the latest and greatest templates for every specialty.  Customizing must be simple and intuitive but a template which is customized now, cannot in any way harm the documentation done previously with that template.  Just think of the new procedures, treatments, lab tests, medications and more than arrive daily.
  • It must be capable of collecting that information, slicing and dicing it with great discrimination,  and conveying that information to other health systems software.
  • It must be capable of running client-server or self-contained on a laptop.
  • It must be affordable.  This $25,000 or more per user is ridiculous. A government funded EMR should be affordable out of cash flow– that is, no upfront purchase of the software, but rather, turnstile pricing.
  • It must be intuitive.
  • It must be “graded” in its operational capacity.  A new user can use obvious features but as they mature in their EMR awareness, more features can be accessed.  There is nothing like “need” to inspire to user to learn another step.  That is, filling out a lab form is too slow and so if the user wishes to switch to a bidirectional lab interface, it should be available.  If they don’t care, then at least give them the option of the software filling out the lab request form.
  • It must be easy to assist users who experience difficulty. This is one of the most important items by far. The ease of assisting a user will make or break many EMR installations.  My preference is to have the ability of the user, with a single click, to show their desktop to technical support, whether that technical support is in their large facility or in another prearranged site.
  • It must be easy to update, including all the SQL schema changes,  executable versioning, new clinical content, and so much more without the use of IT staff.  If for every update, someone in the practice must go from computer to computer to update it, updates will never get dispersed. Already the bar is too high.
  • It must be relatively simple to install, not requiring a dedicated IT professional.
  • It must be capable of allowing the practice to be paperless.  To design it short of that would ignore a significant percentage of the market.  That means document management in the many forms of documents– tif, jpg, doc, txt, pdf, Outllook emails, html, and even CCR.  Additionally, it should be capable of outputing all those scripts, excuses, referrals, letters, and more.  It should handle telephone triage (as it’s called in pediatrics) without generating a sticky note for the chart.  It must have a forms feature.
  • It should have alerts, messaging, and reminders for those who wish to use them.
  • It must be fast.  You want no one complaining of speed.
  • Anything else you think should be added to the list?  Anything you see that shouldn’t be on the list?

    Generic Electronic Medical Record Description

    Posted on September 26, 2008 I Written By

    John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

    I get a bunch of email from all sorts of electronic medical record vendors telling me about their software and their company. I don’t mind when people contact me with something innovative and interesting. The problem is that most company press releases are all the same. They all tout the more or less the same feature set of every other emr company out there. I’ll put an example press release I got below so you can see what I mean.

    At the end of the day, reading press releases like the one below I wonder if 1. companies understand what it gets bloggers and media to use their press release and 2. emr companies have really stopped innovating the way they should.

    On the first point, if you want me to write about you or your company then you better tell me something cool and different. Sure, add in the list of standard features at the bottom, but sell me on a feature that makes you better than every other EMR company out there. Otherwise, I’m just going to ignore you as one of the other on the long list of EMR vendors. You’ll notice I didn’t even put a link to the company whose press release is found below, because there’s nothing interesting or unique enough about the company in that press release that makes me want to send people to their website.

    As far as the second point, it’s been a while since I’ve seen some truly creative and innovative thinking from an EMR company. I’m talking about things like Medtuity’s granular method of data entry or Brendon’s beloved eMedRec which is a really interesting hybrid of a scanning/document work flow with some of the EMR features layered on top. I’m sure there are more cool things being done with EMR, but it gets lost in everyone needing the standard boring features.

    So, keep the emails coming, but make them interesting so I don’t just go straight for the delete button.

    WITH MTBC, THE LOCAL DOCTORS OFFICE FINALLY JOINS THE PRESENT AND FUTURE OF HEALTHCARE IT

    New integrated IT system provides patient scheduling, touch-screen check-in, integrated records and billing with mobile access, real-time adjudication of insurance claims and more

    SOMERSET, N.J. Sept. 9, 2008 Unable for years to match the cost-cutting IT advances of deep-pocketed insurance companies and hospitals, private physician practices are now embracing a level playing field with innovator MTBC.
    This playing field extends throughout the patient-physician-insurer continuum, from the Internet to the paperless doctors office, creating enormous efficiency for all involved partieseven the pharmacy and medical laboratory. Through MTBCs integrated system, patients schedule appointments online, receive automated reminders by phone, and check in at the doctors office at a touch-screen kiosk.
    Technology becomes far more dynamic as it enhances the patient-physician relationship, said David Rosenblum, president of MTBC. Our newest services reduce the time the patient spends in the doctors office and increase the care the physician can provide.
    Patients whose physicians use MTBC can schedule appointments privately with their doctors on a secure web site, while viewing available blocks of time. The reason for the appointment and medical symptoms may be entered, along with current insurance information. The patient will receive automated reminder calls prior to the appointment, minimizing no-showsa bane of most doctors offices.
    At the doctors office, the kiosk scans a patients insurance information with a swipe of a card and then conducts a brief survey of medical questions. This information is integrated into MTBCs EMR software for easy access by doctor and staff.
    During and after the appointment, doctor and staff enter notes, diagnoses, and prescriptions into MTBCs EMR software. Prescriptions are transmitted by electronic fax to any pharmacyhandwritten prescriptions are obsolete. Lab reports are also electronic, accessible securely by the doctor on the web.
    Insurance claim data, such as procedure and diagnosis coding, is entered and transferred securely via automated synchronization on a daily basis to MTBCs web-based billing platform, with its real-time financial reporting and array of practice management tools. MTBCs dedicated teams in billing, practice and patient support complement the cutting-edge service package.
    After the patient examination, MTBC will determine exactly how much of the visit is covered, and how much the patient needs to pay out of pocket, thanks to Real-time Adjudication (RTA), a new service spearheaded by certain insurance companies.
    MTBCs system means no more waiting in a doctors office for hours due to poor scheduling practices. It means having the physician know what the problems are the moment the appointment begins. It means no more uncertainty or confusion over insurance payments, avoiding the unpleasantness of an unexpected bill that arrives weeks later.
    And for the physician, MTBC creates a streamlined scheduling and billing system that allows substantially more time to be spent on the patients needs and questions.
    These advances demonstrate that were a nimble technology company that acts quickly on the issues reshaping the entire healthcare industry, said Mr. Rosenblum. We are always committed to maximizing and accelerating our clients collections.
    MTBCs system integrates several advances in healthcare ITpreviously available only at hospitals or insurance companies to revolutionize private practices:
    Doctors migrate to MTBCs free EMR (electronic medical records) software and slash records-related administration.
    MTBC provides access to real-time adjudication (RTA) of insurance claims for patients with UnitedHealthcare insurance, greatly accelerating related payment.
    MTBC recently launched the PDA version of its billing platform so that clients can access their practices financial reporting, claims data, and scheduler through an iPhone, Blackberry and Windows Mobile device.
    MTBC is now rolling out physician web sites that allow patients to schedule appointments online.
    MTBC conducts automated phone reminders to patients.
    MTBC is integrating a detailed survey program that patients can access online when an appointment is made. This survey gives a physician a better sense of the patients symptoms before the appointment even begins. And unlike other companies that have started to offer patient survey services, MTBC does not sell patient information to third parties everything is kept confidential between doctor and patient.
    MTBC is testing patient kiosks that read a patients insurance card, take his or her picture, and conduct brief medical surveys. This will dramatically reduce waiting times and bottlenecks in physician offices.
    Weve always been committed to bringing state-of-the-art technology to private practice physicians and practice administrators, said Mr. Rosenblum. Our business model makes all these innovations easy to use, integrated, and remarkably affordable.