Author: Chandresh Shah

Practice Fusion Violates some Physicians’ Trust in Sending Millions of Emails to their Patient
You cannot imagine my outrage when I saw this posted by John in the above post.

But then again, I’m not surprised at all. If you have been reading some of my posts about Free EMR software, you will know what I mean. Mitochon, another Free EMR software shut down, perhaps because they were not ‘smart’ enough to steal your data and trust.

One user pointed out, ‘… Why can’t we use the emails we enter [into] the system but you can…’, tells you Practice Fusion has been deliberately leaving out functionality so that they can control and manipulate what doctors can and cannot do.

I don’t mind repeating it again and again. It is about making money from YOUR data docs, be aware.

My problem is not with Free EMR per se – you can use any web-based EMR system or any client server EMR software. As long as the EMR company and EMR vendor treat you with respect and dignity, and protect your data, I have absolutely no issues.

Patient data is yours, and you decide what you can do with it; no one else.

Practice Fusion may just have sent out innocent emails, asking your patients to grade you (by the way, it is not that innocent). The next step is more dangerous.

They know what you have diagnosed and what meds you have prescribed to patients. So, the next move will be to include directly targeted Ads and blurbs from Pharma companies promoting and pushing their drugs. Pharmas have been waiting just for this opportunity, to market directly to your patients. They have tried DTC (Direct to Consumer) ads in TV and Print media, with reasonable success, but FDA is cracking down on them.

So, Practice Fusion provides an elegant avenue to market directly to the people who need those drugs.

Wake up guys, please, for heaven’s sake, don’t sell your vital trust with Patients. I personally will never go to a physician that uses Practice Fusion.

Here is a statistic that should make you cringe: The data-mining industry, which buys the information and resells it to medical companies, will top $10 billion in revenue by 2020, McKinsey estimates. This is according to a report from Bloomberg Businessweek.
Read the Full Report here.

This article talks primarily about data being shared by state health agencies and sold to private data-mining companies.

What I am concerned about is that there are some EMR companies that see ‘big money’ in data. We have seen the new healthcare IT buzz around ‘big data’. What do you think this is about?

Everyone from Free EMR companies to others that charge money is eyeing the model of being able to sell ‘de-identified’ data. Why else would even large companies like ADS which had no business in the healthcare world buy an EMR company?

My worry is about implications for healthcare providers and doctors. What is their liability when there is a breach that is outside of their control? Perhaps, nothing to fear from a legal perspective, (I’m not a lawyer and I have no idea), but what happens to the ‘trust’ between patient and provider in case of such a breach?

How will patients perceive you even though there may not be a straight connection between the provider and the breach?

Today’s post by Seth Godin has implications across the spectrum, but couldn’t be more true for EMR and Healthcare.
Here it is, word for word – (credit goes to Seth – but I’m sure you will relate to it)

Photography is a cheat, the death of painting

Photoshop is a hack, the death of photography

Instagram filters are crap, the death of Photoshop

Typing is mechanical, the deathknell for organic handwriting

Word processors are a cheat, the end of linear writing via the typewriter

eBooks are for losers, stealing the magic and majesty of the printed book

Blogging is impermanent, the end of thoughtful word processing

Tweeting is stupid, the end of intelligent blogging

Video is too easy, a cheap shortcut that destroys the essence of film

YouTube has no curators, the end of quality video

Wikipedia is an unproven shortcut, true scholarship is threatened

Selling by phone is for losers, closers show up in person…

Technology almost always democratizes art, because it gives us better tools, better access and a quicker route to mediocrity. It’s significantly easier to be a mediocre (almost very good) setter of type today than it was to be a pretty good oil painter two hundred years ago.

And so, when technology shows up, it’s easy to imagine that along with the old school becoming obsolete, the new school will be populated by nothing but lazy poseurs.

Don’t tell that to Jill Greenberg, Sasha Dichter or Jenny Holzer.

… all this ending is leading to more and more beginnings, isn’t it? It’s not ruined, it’s merely different.

Who is not struggling with finding a balance between using technology to research and document versus the perception that ‘I’m not listening’? The problem that all providers face is not how good they are at handling technology, but how patients react.
Technology is a double-edged sword. You want it (other than CMS mandating it) because it is supposed to make you more efficient, you don’t want to take charts home. On the other hand, it can be a distraction if you don’t pay attention to patients. Even worse, you are paying attention, but patients feel they are not being heard. Consequently, you don’t want these patients to stop coming to you.

Let me first focus on the technology itself. There are multiple ways of using technology to chart in an EMR.

1. Templates – point and click
2. Typing
3. Dictation
4. Transcription services

Every individual is different. Some are good typists, some are fluent with ‘point-n-click’, and some just love dictation. The majority of you fall somewhere in between. You must find your own sweet spot. Find a method that works well for you.

When I interact with providers, I actually help them find a way that works well for them. For example, here’s a scenario:

“Dr. Smith is an OK technology user. She can google, use the internet to search, use email quite effectively, and overall use a Windows system quite well. On the other hand, her typing skills are not good. She actually hates typing. When she emails, she hunts and pecks the keyboard.”

Armed with this information, the first thing I did was have her take a test of dictation software like Dragon Medical. She did pretty well. Achieved almost 98% accuracy without any training at all.

After discussing a bit more, here is what we concluded. For Dr. Smith, the recommendation was –

Use templates (point and click) to chart important elements of the note while in the exam room with the patient.

• Diagnosis
• Orders/Procedures
• Meds ePrescription

As soon as the patient leaves the exam room, she dictates her findings in detail under HPI and/or Plan.

Regarding other parts of documentation such as the review of systems, and physical findings, she chose to point and click after the patient left.

So, we found that in her case, this was the most effective method. It took her less than 5 minutes between patients to finish the encounter completely.

Will this work for you also? Maybe, maybe not. We have to figure out a way that works for you. But I know for sure that there are ways that will make YOU more efficient and effective.

Now, the second part. Managing Patient Perception and Expectation.

There are a few things you can do to make sure that patients know you are paying full attention to what they are saying, including their body language.

1. Let me ‘show’ you. Immediately involve patients in the use of technology. Sharing a screen with past results, and past prescriptions, and then asking them about it, engages them right away. Asking questions – ‘Is that clear?’, etc. makes them comfortable with the new you – you and technology together.
2. You know you can multitask, but patients think they deserve and want your full attention. So, after that initial encounter with technology, turn around, face the patient, and give them 100% of your attention. Let them know you care with thoughtful words and a compassionate attitude.
3. Now is the time to ‘document’, and so with the patient’s consent – ‘let me make sure I document that’ – turn your attention back to the computer while talking all the time with the patient. If you are ‘clicking’ on a template and documenting a diagnosis code, say what you are doing, relating to and repeating what the patient told you. That way, as you are clicking, you are doing what good listeners do – feed it back – ‘let me make sure I heard that right’.

Just this 1-2-3 step approach takes the fear of technology from your mind as well as that of your patients. If your software allows, use diagrams to draw and show patients what is going on. In other words, anything that you can do to make the computer part of the conversation rather than an adversary.

By examining your use of technology, we can ensure an even more professional human bond with your patients and increase efficiency for you at the same time.

You have ‘heard’ ICD-10 is complex. You really don’t know because I don’t think you have the time or inclination to dive into it, yet. Most of you will depend on your support system to help you – your Academy, your EHR vendor, your Biller, and so on.
It is a dual-edged sword. One of the promises of ICD-10 is the potential for enhanced granularity, laterality, and overall reporting accuracy. This is particularly important to providers because insurers use ICD to determine reimbursements based on the medical condition of the patient and the procedure(s) used for treatment. What granularity does for CMS and insurers, i.e. provide better reporting, can become a nightmare for providers because more granularity means more work for you. You are doing the heavy lifting on their behalf.

Your first concern should be to ensure that the codes correspond one-on-one with your current reimbursement structure. You do not want to choose a ‘wrong’ code that causes underpayment. Sure, I think it will perhaps be difficult to find exact one-on-one matches for all codes from a treatment and reimbursement perspective for each encounter and claim, but perhaps on an aggregate level, your goal is to ensure your overall reimbursement level remains the same.

ICD-10 and Reimbursement

Improper and incomplete coding can increase denial rates, causing significant revenue loss. Migration to ICD-10 could result in significant over- or underpayment when using DRG-based reimbursement. Here’s a real example I found at Edifec’s website.

ICD-9 Code 6149 is categorized under MS-DRG 759. When converting to ICD-10, ICD-9 Code 6149 can be mapped to two different ICD-10 codes: N735 or B3749. These map to DRG 759 (same as ICD-9) and 690, respectively. The resulting payment in the second case is about $6,000 more than what would have been paid before the ICD-10 transition.

This example shows that payment variation under ICD-10 can be cut both ways. If a provider organization can’t quantify its risks, it may end up dealing with unfavorable payer contracts, longer collection cycles, and uncertain financials.

Of course, this type of analysis can be very time- and labor-intensive. Providers and payers should work together to identify and prioritize areas of risk, based on actual historical data. Analyzing a provider’s own data based on reality-based ICD-9 to ICD-10 mapping scenarios delivers the “street-level view” of the real operational and financial risks posed by ICD-10 to the organization, rather than just a list of every possible risk.

Your EHR / PM system should allow you to generate reports that analyze the reimbursement by codes so that you can use these when you talk to payers and when you map out ICD-10 codes.

Make it Work

Therefore, while there is a lot of fear, you can make it work for you. Your EHR/PM system should help you ease some of the pain by providing proper mapping tools. Talk to your vendor and make sure they know what they are doing.

I was intrigued by a guest post from Jon Fox, MD (founder of HealthApp Connect) at EMR and HIPAA Blog.
The biggest benefit will come from integration with EMR systems in a way that allows providers to maintain eye contact with patients rather than constantly staring at a screen.

The simplest form of integration would be in a ‘read-only’ or ‘view patient chart’ mode so that while talking to the patient, providers can view the previous charts, look at test results, past prescriptions, medical history, and so on.

The second would be a good integration with the EMR using a dictation system.

I would envision the encounter to be one where the doctor is talking to the patient, viewing the charts, results, etc on Glass, and dictating HPI and other findings straight into the interfaced EMR. I would still imagine some amount of interaction with the computer for things like ePrescription, and basic ‘templates’, including diagnosis and procedures.

“I was able to customize my EMR to the exact way that I practice”
Almost every EMR company that publishes testimonials from their clients has a version of the above statement. Not only that, when you talk to referrals, almost everyone asks – how easy is it to customize.

A few years ago when I bought my new home in NY, my neighbor told me something I still remember – ‘when you buy a house, you’re either a handyman or you have money…’

Customizing EMR is not too different from working in your house fixing things, doing small repairs, additions, etc.

You are a trained physician, you are good at treating patients, that’s what you excel at. While Practice systems, EMR, etc. may be flexible and designed to be customized, that is not how you would want to spend your time. Of course, for some of us like being ‘handy’ around the house, that’s a different story.

How many of us have tried to be handy to ‘save money’, messed up, and then called the handyman to not only undo our work but pay more to get it done right? (Nagging can be an added bonus :-))

Don’t be penny-wise and pound foolish

Unless you have time, and are an expert at technology, don’t try to customize your templates and application yourself. If you have a staff member that is smart and tech savvy, have him/her do it. If not, get the vendor to do the customization for you. In the long run, it is not about saving money, it is about using all resources wisely. However, if you attempt to do your own work, make sure you’re properly trained to do so (that may cost money too).

Don’t get me wrong – I’m not implying that EMR software is not good at customizing templates – they’re pretty good – I mean some of them are really good at the ease and simplicity of allowing customization.

It all boils down to you, and the cost-benefit of doing your own customization.

Accessing EMR data via mobile devices is gaining popularity, at least in theory. I have seen almost every EMR inquiry include a question – ‘does it support tablet/iPad/iPhone/smartphone/android’ or some version of this?
In the latest study reported by FierceMobileHealthcare, they say ‘these (mobile) apps can be unsafe in a clinical setting’.

While this study focuses on CIOs and hospital environments, it is easy to say this does not or may not apply to a small clinic in an ambulatory setting. Not necessarily true.

Let me play this scenario and you will see what I mean.

You are using a tablet in the exam room and you get called to another exam room. You immediately rush there, but forget to take your tablet with you. Now, you’ve exposed all PHI to breach. Breach does not necessarily mean someone stealing data, or a device, although this has been reported commonly.

You can argue that this can happen even if you have a regular desktop and you walk away without logging out or locking the computer. The fact is, that tablets and mobile devices are more fascinating and more accessible to patients and others.

Of course, there are other reasons why you don’t want to use tablets and mobile devices in the exam room, such as smaller screens, and not easy to ‘create’ content – even if it is point and click. In reality, all charting is a combination of point-click, typing, and dictation (e.g. Dragon). There is no single method that is most efficient for data entry.

Therefore, in conclusion, I feel mobile devices are okay in a private setting such as your private office or home where accessing data is important, but definitely in an exam room, I would use tremendous caution; and perhaps avoid them altogether.

Another thought-provoking article by my friend John – here.
E&M Coding guidelines are so old. They’re from 1995 and 1997. If we look at what the guidelines say, it starts with the basics – whether the patient encounter was Brief (1-3 elements)or Extended (4 or more elements). This is just for the History of the Present illness, where HPI Elements include: location, quality, severity, during, timing, context, modifying factors, and associated signs/symptoms.

This is the easy part.

Then you look into ‘complexity’, data reviewed, and ‘risk of complications’.

We are not at a point where ‘systems’ can evaluate risk and complexity. Also, as doctors frequently tell me, it may not be a complex case or may not be that high of a risk, but if the patient is talkative, and I spend more than 30 minutes with the patient, my level of coding may jump up.

Secondly and more importantly, these guidelines may be rendered totally obsolete if healthcare reform progresses where reimbursements would be tied to a ‘continuum of care’ rather than pure ‘episodic’.

Just additional food for thought.