Tuesday, August 25, 2009

EHR Standards and Interoperability

Standards within an electronic health record (EHR) are the necessary building blocks to interoperability. Interoperability is necessary for one system to communicate with another which is one of the main goals of having an EHR. As it stands, most EHR vendors recognize the importance of interoperability and will have to build in and maintain or update these standards as they change to remain competitive. Make sure your EHR vendor has a plan, because as you can see from this excerpt, things will be changing...

WASHINGTON – The federal advisory panel on health IT standards has approved refined recommendations on how providers may electronically record a physician's observations to qualify for federal recovery bonuses.
The HIT Standards Committee endorsed recommendations to call for SNOMED CT for physician's clinical observations by 2015. In 2010, providers must use ICD-9 or SNOMED CT to qualify, and in 2013 they must use ICD-10 or SNOMED CT.

HIPAA Security Rule Standards

If you are looking for the details related to the HIPAA security rules as it relates to technology, administration, and daily operations, this is a great document. It outlines the rules for the various items in each category, providing specific details regarding the HIPAA rules and how to implement these safeguards.
HIPAA Security Rules Standards

Wednesday, August 19, 2009

The Importance of a Successful EMR Implementation

I recently read that more than half of medical information systems fail due to user and staff resistance despite the fact that the technology is sound. This statistic is presented in the book Evaluating the Organizational Impact of Healthcare Information Systems by James G. Anderson and Carolyn E. Aydin. That’s a 50-50 gamble that the significant investment in the system you choose for your medical practice may go belly-up when you try to implement it! If you had the option to purchase “implementation insurance,” wouldn’t you do it? Well, consider this advice a step towards purchase of that insurance plan:
“When selecting an EHR, organizations need to thoroughly investigate the product to insure it can adapt to the changing needs of the services they provide. The clinicians and information management staff should have a clear understanding of all the workflow processes that happen within the organization and spend the time analyzing the system to guarantee the appropriate interaction for all the players involved. Spending greater time investing on enterprise process modeling, coupled with HL7 version 3 and XML provides the necessary flexibility for incorporating a variation of healthcare services.”
It is extremely important that physicians understand what they are investing in when choosing an EMR. Often, software vendors will overpromise and under-deliver, and physicians need to be aware of the level of support EMR vendors provide so they can fill in the gaps where necessary. Often, the gaps appear in the EMR implementation phase of the project, and can sabotage the success of the EMR software, resulting in one of those EMR implementation horror stories we have all heard about.

When implementing an EMR in your practice, it is important to remember that several things must be accomplished in order for the EMR to be successful:

Having a plan. The practice needs to create a project plan and track the progess of each component to ensure everything is on track. There are many factors that can affect the outcome of an EMR implementation and planning is one of the most effective ways to stay focused and ensure success. Here is an example of an EMR Implementation Outline.
High Acceptance Rate among doctors & staff. If everyone isn’t on board, the transition will be tough. A persistent resister can coerce others into joining their side, causing tension in the office. This can escalate to complete office disruption as staff resists and refuses to use the electronic medical record system.
Effective Training Sessions. If the doctors and staff do not retain the information presented during the training, there will be issues using the EMR in their every day routine. The EMR vendor should provide adequate training and support to help ensure your staff will be successful in using their software.
Expectations & Follow Up. The doctors and staff all must understand their job responsibilities related to the EMR, which will take time for everyone to get into their own routine. To ensure everyone is using the software properly and most effectively, follow up on their progress using the EMR and integrating it into their daily routine should be done regularly.

Overcoming Obstacles when Transitioning to EMR

Physicians opening a new practice are readily purchasing EMRs and wouldn’t have it any other way. Physicians who adopt EMRs say they would never go back. Then why are the vast majority of physicians stuck on paper systems…?
Here are some top reasons for why existing practices are holding back and what can be done about it.
I would not lie to you and say that it will be easy. It can take from 6 months to a year to fully transition, and in the meantime, you are operating 2 parallel systems. In a busy clinical environment, this can spell disaster. Besides that, how many have wanted to exclaim, “Dammit Jim, I’m a doctor, not a computer nerd!” To me the argument regarding change is probably the most valid one. People do not like change. We are creatures of habit and we like routine because it is comfortable even if things could be done in a more efficient way. I guess the only thing to say is you can do it willingly or not, but sooner or later we all must venture out of our comfort zone. Healthcare has been the “final frontier” (forgive the StarTerk reference again) in the collaboration with IT. It is high time our industry has embraced the idea and began reaping the benefits. Let’s just take it one step at a time. Get a good project management plan and reevaluate goals often. Never underestimate the value of a good consultant. Going it alone can be a borderline brave/foolish thing to do. Once the preparation and purchase is done, become comfortable with your EMR software and slowly start integrating. Documenting in your EMR will start becoming second nature. EMRs have come a long way and good ones are set up to mimic the common sense clinical flow. The key is not to be in an environment of duplicate check in/out, billing, and documentation processes for too long. It is truly a balancing act.
Well, now with the HITECH Act, the government is trying to incentivize adoption. They are playing nice now, offering the possibility of earning $44,000 under the Medicare plan and $64,000 under the Medicaid plan over 5 years to providers who use qualifying health IT but come 2015 and things will get ugly and penalties will take the place of incentives. The sooner you get on board, the better your incentive will be. This incentive will practically pay for the cost of a correctly implemented system. To me the message is loud and clear: Like it or not, Healthcare IT is a reality. Don’t be stubborn because it will only hurt your pocket more in the long run.
Fear of loss of data
Here’s the scenario…you’re treating patients and then all of a sudden POOF! The internet goes down or the power goes out. Let me begin by saying that the likelihood of that happening once in a year might be correct, and when it does, we have this plan:
battery back ups – in the event of power failure, you will have a back up power supply that will immediately support your office for a couple of hours. Use the time wisely.
Data duplication and back ups – if you are running your software out of a hosted environment, you likely will have the patients on your schedule “checked out” to your system. This means that their record is duplicated on your workstation. You can continue to view history and document notes. When your connection is restored, voila! It’s like it never went away.
Server back ups – your software vendor’s server just exploded. (I got dramatic, but you get my drift…) That server is duplicating real time data on another server located in another part of the country and that one duplicates its data in another part of the country. My point is, you typically have back ups of back ups and the data is safe and sound unless the unthinkable happens.
If you house your information on your own server, be sure to do the same thing! Duplicate your data more than once onsite and take the copy with you offsite when you close your doors.
Security breaches
In several discussions with colleagues, it is inevitably brought up that paper records are in just as much jeopardy of security breach as electronic records. There are steps to ensure that you are doing all you can to protect PHI, such as the use of antivirus software to protect your data from viruses, firewalls to protect from intrusions, etc. Allow only certain people access to certain pieces of the record that they need to do their job by using appropriate permissions. At the end of the day, no system paper or electronic is 100% theft-proof.
Don’t let these barriers prevent you from pursuing an EMR for your practice. Knowledge is power, in this case, empowering you with the knowledge needed to effectively handle the obstacles you could face when transitioning to electronic medical records.

Using Wireless Devices in Healthcare Delivery

Wireless devices have been shown to substantially improve operational performance, clinical workflow and productivity, and quality of care by the promise of real-time point-of-care documentation. This is becoming increasingly important in the increasing adoption of EMR software.
Clinical Documentation at the point-of-care:
Will improve accuracy of entering patient data in conjunction with rules-based, menu-driven EMRs, which will increase patient safety and satisfaction and will eliminate redundant data entry. An exceptionally efficient feature is handwriting recognition capability when free script is necessary to document the plan of care.
Will promote fast access to electronic medical records and reference materials on the go.
Will promote more efficient EMR documentation and higher quality of care by increasing the mobility and productivity of the clinician. This is possible because of no wait times for use of or logins on stationary computers, and there will be a reduced need to clarify information prior to fulfillment of doctor’s orders (tests, prescriptions, etc.)
Will promote security by having one device per user.
Will allow for clinical decision support by quick access to “up-to-the-minute” clinical resources such as drug-drug and drug-allergy contraindications.
Will promote enforcement of the “5 rights”: right drug, recipient, dosage, route, time – which reduces risks to the patient and liability issues.
Increase control and compliance via authentication and electronic time stamps.
To support these statements, I have accessed numerous case studies in support of wireless devices in use for EMR software. A brief excerpt of one of the more powerful studies is summarized here:
Studies have indicated that pharmacist input during the rounding process can decrease the rate of preventable harmful medication errors up to 78% by their consultation in dosing related changes and additional drug therapy recommendations. Their input has also contributed to reducing cost and decreasing length of stay (Kaushal et al., 2001; Kucukarslan et. al, 2003; Leape et. al, 1999; Terceros, Chahine-Chakhtoura, Malinowski, & Rickley, 2007).
Full report available: http://www.motioncomputing.com/about/news/case_study_C5_children_omaha.pdf

Addressing Fears of Malpractice Using CPOE System

Given the state of the current malpractice system as briefly described in the article http://content.healthaffairs.org/cgi/content/full/hlthaff.w4.534/DC1 , there is a legitimate fear of being sued for a medical error that was not entirely the fault of one physician. The largest cause of errors tends to fall on the fact that there is a highly fragmented system of care being delivered to patients by several providers without the ability to effectively communicate between one another. CPOE systems can help bridge the communication gaps that occur and help ensure the safety of the patient by eliminating harmful or fatal consequences due to lack of direct communication.
As an example, “Errors of medication use are among the most common types of medical errors and include mistakes of prescribing, dispensing, administering, or monitoring medications.” http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=aps.section.2364

If using a CPOE system, these mistakes can be eliminated by the functions that the system provides. “CPOE uses clinical decision support systems and links to hospital systems to generate prompts and alerts during the ordering session to notify of potential errors such as contra-indicated medications or routes or duplicate orders.” http://muskie.usm.maine.edu/Publications/ihp/CPOE.pdf
In summary, the potential for the most common medical errors can be significantly decreased by the use of a CPOE system.

Increasing Administrative Efficiency with an EHR

Typically, the administrative role in a health care facility involves billing, transcription, filing and various tasks relating to managing the whereabouts of a patient’s chart. The EHR significantly reduces the time and resources needed to carry out these tasks. The following examples are of ways the EHR accomplishes this, paired with excerpts of case studies supporting the claim.
The EHR eliminates the need for a chart to be pulled and refilled, which saves administrative personnel time. “The average number of chart pulls per day went from 60 in 1995 to zero…three filing clerks were reassigned to other tasks.” 1 The EHR also saves time on searching for lost charts. “We have no more lost charts, and my…physicians are more productive than ever,” said Adams. 2
The EHR enables simultaneous access to various parts of a patient’s record, such as a physician documenting a visit while the office posts a co-payment to the account. Also, through a check-in and check-out process, various clinicians can document within a record. The result is a savings of time with chart “hand offs” to do these types of tasks. “Patient charts…are easily accessible at all times.” 3
Physical storage space and time to archive and retrieve a requested chart is eliminated. “Storage of charts is also no longer an issue.” 4 Transcription is another eliminated burden since the record is automatically populated as the physician keys in information, chooses from a drop down menu, or uses voice recognition features. “After installation of the EHR…my transcriptions costs decreased to zero.” 5
The billing of claims is a more efficient process with an EHR in that procedures are automatically coded properly as well as error checked (“scrubbed”) into interfaced billing systems. “I am charting at the point of care, so I miss nothing and because of that we are billing more accurately…the clinic’s average billing rate has increased more than 30 percent. In addition, Dr. Amos’ clinic has become more efficient. He had previously paid third-party billing companies for years. Now his office manager uses the system to bill electronically, allowing him to reduce his business expenses and add revenue. 6 Claims are also automatically generated and electronically sent in a simple batching process. “Billing code posting has been eliminated.” 7
In conclusion, several tasks can be radically simplified when employing the use of an EHR, specifically in the administrative realm of the healthcare industry. With the main savings of personnel time in the redundancy of duties as well as resources to carry out these duties, it is easy to see how the EHR can claim to be such an efficient tool in health care.
Works Cited:
1 http://www.sunshine-healthcare.org/content/files/davies_2003_primarycare_cooper.pdf
2 http://www.pcc.com/practmgmt/business/CPAcasestudy.lowres.pdf
3, 4 http://www.cchit.org/files/csLanierSurgical.pdf
5, 7 http://www.sunshine-healthcare.org/content/files/davies_2003_primarycare_cooper.pdf
6 http://www.cchit.org/files/csAmos.pdf