Author: Chandresh Shah

I re-read an article in Fast Company that was written 4 years ago to see if it is still relevant given that there is so much emphasis on mHealth software and applications these days. (Here is that article)

This article lists a few iPhone apps that are recommended for Doctors and Providers. Some of these are still around. At that time very few electronic health record systems (EHR systems) were robust enough.

I have seen an evolution of EHR systems that incorporate a lot of functionality that required separate ‘apps’.

With the majority of them now on the Cloud, you can access not just one or two mHealth apps, but the entire system on your mobile device with a browser.

How times have changed?

Kyle wrote a very precise article related to Medicare’s refusal to pay for readmission within 30 days of discharge from a hospital.

He summarizes it well – ‘But this is intrinsically a superficial strategy, not a strategy that addresses the underlying cost problems in healthcare delivery.’

The second problem I see is not addressing the issue from a patient’s perspective. The <30 readmission rule can potentially put patients in harm’s way, just as I have found in my case, it was so difficult to get approval for an MRI when my back hurt.

Reducing costs must be addressed, but not at the expense of patients.

I’m sitting at the Las Vegas McCarran airport returning from a fantastic Healthcare IT Marketing and PR Conference hosted by John Lynn. This is also one of the rare airports that has free wifi.

That’s not what I want to talk about though. I am sitting at the gate waiting for my flight. A young lady sat right next to me. I thought she limped a bit. As soon as she sat down, she plugged in her laptop to charge it, connected to the free wifi, and within 5 minutes, she was on the phone.

‘Hi, is this Dr. Podiatrist? I am looking for an appointment next week. Ok, thank you. This went on for 7 calls. She mentioned on one of the calls that she was looking up her Insurance company’s website for participating podiatrists, and she wanted to see someone close to her office.

Finally, on the 8th call, she did find someone who had an availability.

As each call was made, I could sense her frustration grow and her sighs get louder.

Why is it so difficult to find a doctor and get an appointment? We can book flights, find, review, and book dinner at restaurants without talking to anyone.

Is this the last bastion?

The Number One reason to hate EMR is that it slows down doctors.

The ‘it’ that is being referred to is what happens in the exam room with a patient; the clinical encounter. Doctors are no longer scribbling on paper, they are using computers, and they have to collect data, and click on templates. Worse, they have to type or somehow enter their findings, assessments and plans into the computer.

For some doctors, it is a piece of cake, others hate it with a passion.

EMR has gotten a bad name because of this – SMD (Slow Me Down) Factor I had written earlier about.

Even if all other elements of the Practice Software help improve the office productivity significantly – front-office to back-office workflow, productivity, better collections, efficiency, etc. it doesn’t matter if the doctor is afflicted with SMD Factor.

Do Not Despair – there are choices and options.

There are 6 choices. You will pick the most appropriate choice for you depending on the following factors:

• Technology comfort, savviness, and ability to use computers.
• Number of Patients seen (or you would like to see) per day.
• Relative importance and value of time vs. money.

1. Templates and Keyboard. Standard, out of the box, nothing to add. No additional cost if the system has the templates you need.

• Assumption: You can type reasonably well, you can manipulate templates, and click fast enough to keep pace with your patient volume.
• Cost: No additional cost.

2. Templates and Dictation software like Nuance Dragon. The difference compared to the first option is that you can use the templates reasonably well, but you are not a good typist and you need to enter your findings, plan, and HPI in detail. The use of Dictation software allows you to ‘cut the keyboard’. I recommend this option if you are not a good typist.

• Assumption: You are willing to work with Dragon software for voice recognition. This technology has come a long way. If you tried it a few years ago and found that it did not work well with your accent, try again. A lot has changed, you may be surprised.
• Cost: One-time charge that is approximately $2000 for Dragon Dictation software.

3. Digital Pen and Dictation software. Option 2 was good if you were good with computers and templates in general but not a good typist. If you are generally computer-averse and don’t even like clicking on templates, this is a good option for you.

Digital Pen is a wonderful advanced piece of technology that allows you to use normal paper. When printed with custom paper templates, it takes your markings on paper and maps them to your computer templates as if you are clicking on-screen. The best part is, if well designed they can convert paper to discrete data.

• Assumption: As with the earlier option, you must be willing to use Dragon software for dictation.
• Cost: The cost of preparing custom forms for Digital Pen can vary from $1000 – $2000 per form depending on the complexity of the form. So, if you need 5 custom templates, it can cost up to $10,000. This is generally a one-time fee. The cost of the pen can be up to $500 and perhaps a $60-$70 monthly fee.

If you add total upfront costs when amortized over 3 years, it will be less than $350 per month, but it gives you tremendous peace of mind and productivity gain for yourself.

4. Transcription. Most Doctors are aware of this option and have probably considered this at one time or the other. This option is perhaps the simplest one, but there is now a new twist. The transcriptionist needs to listen to the dictation and not only type a narrative but also work the EMR to select options in the templates for discrete data – physical exam, assessment, etc. In addition, when the provider uses a paper superbill that must be sent to the transcriber to enter in EMR – this expands the role of the traditional transcriptionist.

• Assumption: Expansion of transcriptionist responsibility to be able to work and use EMR.
• Cost: Can vary, but consider $10-$15 per hour.

5. Scribe: The concept of having a scribe do all the work on EMR has been in the news quite a bit and is being widely discussed. There is no doubt that it can completely eliminate the SMD Factor. You must be comfortable with a scribe being present during the encounter with a patient. This is generally not a good practice for certain specialties like Psychiatry, but for others like Pediatrics, Family Practice, or Internal Medicine it may be generally acceptable.

Scribe as an option has two variations: A Remote scribe that can be out of the clinic somewhere else or an in-clinic scribe.

• Assumptions: Willingness on the part of the provider and patient to accept the presence of a scribe during the encounter.
• Cost: Remote scribes can cost an average of $15-$18 per hour, whereas in-clinic Scribes (Medical assistants) can cost anywhere from $25-$30 per hour.

6. Combination: Sometimes a Combination of various options mentioned here can also work.

Conclusion

You need to analyze each option’s Return on Investment, your desired goals, and comfort levels and pick the one that makes the most sense. You should seek an expert’s help to help you analyze your objectives and choose what works for you. There is no single best method when it comes to how you interact with EMR.

Arthur L. Caplan, Ph.D., did a Video Blog on Medscape that has invited almost 250 responses as I am writing this.

Would a Scribe Repair or Destroy the Doctor-Patient Bond?

EMR or EHR has made tremendous strides in bringing workflow efficiency to medical practices and ambulatory clinics. Current EMR Software technology has also partially solved the remote access and data repository problem for patient disease management, but not the data entry obstacle.

Data access and disease management won’t be important if point-of-care data entry is a problem.

EMR and EHR software may not improve efficiency for the doctor if he/she is not a good typist or good with computers and they try to do everything themselves. EMR software has certainly improved workflow and documentation in the service of the healthcare system as a whole. With improper EMR systems clinicians become data entry clerks.

I disagree with Art to some extent. Scribes may work for some types of specialists, as many doctors have noted in their comments.

There are also other methods that can solve the data entry conundrum.

I generally start with evaluating each individual Provider and their clinic to determine their level of comfort with computers, typing speed, speech recognition, comfort with templates, and perhaps a combination thereof.

Usually, I find that the best option is a judicious use of all methods.

• MA/PA/Nurse (you can call them scribes) enter chief complaints, review systems, and even basic HPI, vitals, and refill requests. Before the provider goes into the exam room, the chart is pulled up with lab/pathology/radiology results on the screen.
• Dr. views the note that the MA created before entering the exam room from their own office (like viewing the paper folder before entering the room).
• In the exam room, the Doctor does minimal necessary clicking after spending essential time with the patient one-on-one. The level of ‘clicking’ involves diagnosis, procedures/orders, and medications. After the patient has gone, the Doctor dictates findings (detailed HPI, impression, and plan) with Dragon software or voice dictation for transcription. This should not take more than 2-3 minutes.

This kind of approach results in saving providers time and allows them to go home early. Sounds optimistic? Not necessarily. Involve your vendor or consultant to help you create an efficient workflow for yourself to create a truly rewarding patient engagement without wasting time with computer screens.

1. Is your staff (physician) able to access patient clinical data (EMR) from any computer and any internet/web browser (no Citrix, remote desktop, or terminal service software needed)?
   1. Yes (true SaaS)
   2. No ( either ASP, client/server, or hybrid EMR)
2. Are EMR updates/upgrades from vendors installed at once and immediately available to ALL other SaaS EMR vendor clients?
   1. Yes (true SaaS)
   2. No (either ASP, client/server, or hybrid EMR)

Definitions

• SaaS EMR – Software as a Service electronic medical record (EMR).  EMR product deployed in a practice in which server(s) are owned by the service provider and hosted remotely (off-site).  The only requirement for accessing clinical data stored on the off-site server(s) is an internet connection/internet browser, regardless of the computer’s location.  The service is a multi-tenant offering.  The vendor installs EMR updates/upgrades at once and these are immediately available to all SaaS EMR vendor clients.
• ASP EMR – EMR data is stored on the server(s) which is hosted remotely.  The clinical data stored on the server(s) is accessed through the internet browser and additional remote access software (i.e. Citrix).  Only those computers with Citrix or some other type of remote desktop/terminal service software installed can access the clinical data on remote server(s).
• Client/Server EMR – EMR data is stored on a server(s) that is housed and located within the walls of the physician practice.  System maintenance and updates are conducted in the office.

Other points to consider before buying EMR Software:

• Software updates – Typically, a client/server EMR vendor charges for any major upgrade, such as compliance with Stage II of Meaningful Use.
• Other add-ons (separately they can cost quite a bit) such as
  • integrated eFax, which makes the office workflow very smooth
  • integrated appointment reminder service
  • Practice website for new clients and new patients searching the internet
  • Patient portal for bringing efficiency to patients and practice
  • Integrated insurance eligibility
• Unlimited claims, and true integration with clearing house. Clearinghouse reports must be accessible from within the system without going to the clearing house website to access rejections etc.
• Truly integrated EMR, PM, and Billing systems are developed from the ground up on a single database ensuring data integrity.

As I read (and re-read) this most wonderful article, I suddenly realized there were two important words embedded.

“The Ideal Medical Practice Model: Improving Efficiency, Quality and the Doctor-Patient Relationship” – L. Gordon Moore, MD, and John H. Wasson, MD (Fam Pract Manag. 2007 Sept;1

1. Model

2. System

I mean ‘Modeling’ the practice and building a process-oriented system for the Practice – NOT system as in Information Technology.

Unknowingly, perhaps, you created and perfected a process-oriented system that is efficient for you and your practice and then built or bought technology to make it work.

Many people get it wrong. They expect Tools and Technologies to do the modeling of internal systems for them, which is completely backward, and the reason for failure and immense frustration.

Building an ideal medical practice should start with designing a model that focuses on optimizing the smallest functional work unit capable of delivering excellent care; even for a solo doctor, even without any staff. Too far-fetched? Perhaps.

But, when you mix in good technology around this process and workflow, such model practices can emerge.

We just need to make sure we put the horse before the cart.

High employee turnover hurts every practice. It costs upwards of twice an employee’s salary to find and train a replacement.

What can you do?

• Hire the right people from the start. A lot has been written about the concept of ‘hire slow, fire fast’. Hire slow certainly has its merits. When you hire under pressure and duress, you may overlook something and hire the wrong person. I focus on the three C’s. Character, Commitment, and Competence – in that order. Checking for Character and commitment takes time.
• Right Compensation and benefits are extremely important. Get creative if necessary with benefits – bonus structures, etc.
• Pay attention to employees’ personal needs and offer more flexibility where you can.
• Finally, and most important in my view, is to Develop and Train your people. There is so much going on in healthcare these days. ICD-10, Health Information Technology (EMR, EHR), Meaningful Use, PQRS. This will serve the purpose of developing their careers as well as benefiting your practice by having ‘experts’ around when critically needed.