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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.

I’ve been thinking about the reason why doctors and clinics switch to EMR / EHR. Of course, there is no single answer, but in all my interactions with people who have wanted to switch (Providers, Doctors, Administrators, Office Managers, Front Desk personnel, Billers), two things stand out.
1. Customer Service

2. Lack of Functionality

and – a few other reasons, such as – wanting to dump aging old computer servers and client-server EMR in favor of web-based EMR, web-based EHR, Cloud EMR, and other such technologies, etc.

By Far, customer service far outweighs other reasons for wanting to switch. So, as I read Seth Godin’s blog yesterday, it all came together.

Here are some of the cardinal customer service mistakes companies/people make:

1. Making it difficult for clients to reach someone when they have an emergency.
2. Once they reach a human being, failing to acknowledge the problem ‘Nothing wrong with the software, it is the way you’re using it you du#$a%@!’
3. You acknowledge the problem, but then you just turn around and say, ‘Right now, I’m too busy – let’s talk in 29 days’.
4. Company owners and employees treat customer service as a ‘cost center’, as a burden, as a necessary evil you need to have, unfortunately.
5. Favoritism among clients. I hate that client – I’m not going to help them.

Customer Service is not a job, it is not a department, it is an attitude!

I could write a book, but let me just make a point and you’ll get the message. Put yourself in the shoes of a client – next time you have a problem with your CRM software, your Financial Software, your cell phone service, cable service, or internet provider, what are your expectations of the service provider?

Need not say more.

It’s official. Read here.
http://www.emrandhipaa.com/emr-and-hipaa/2013/05/20/mitochon-shuts-down-free-ehr-service/?utm_source=EMR+and+HIPAA&utm_medium=email&utm_campaign=5ca173c3ce-RSS_EMAIL_CAMPAIGN&utm_term=0_d6aa4454b2-5ca173c3ce-57468073

I had written about this in February and it does not surprise me at all.

See my earlier post – ‘writing on the wall prediction’ here.

I got a few phone calls from people that told me I was wrong and these guys knew what they were doing. I don’t question that, but it is all about execution isn’t it?

So then, the next question is, what about Practice Fusion? Why is Practice Fusion still alive, and how is it making money?

Practice Fusion’s free web-based EMR claims it makes money on Ads. I did some math earlier, and based on a pure Ad model, it does not add up. I have to work on the math again, but I am still not convinced.

To me, it is clear – there is something else cooking. That stew is ‘data mining’. For sure, I am not talking about selling patient data but analyzing aggregate intelligence, which is in dire need by Pharma. Today I believe Practice Fusion EMR company is building the mass and momentum. This is why they have billionaires like Peter Theil behind them. They need lots of cash to burn every day.

Why do you think ADS bought AdvancedMD? ADS? A-D-S – Advanced Data Processing. Data is their core business. ADS has nothing to do with healthcare as such. The only thing in common is Data. So, they did the right thing. They bought AdvancedMD, with a ‘Paid’ model rather than free. They are charging money while collecting data. They are spending huge amounts of money marketing, and advertising rather than offering the software free.

So, here’s where I see the long term – five years from now. There will be consolidation for sure. The buyer will be strong in the data space or have a particular interest in data. And because there are huge buyers of this data, there will be money in it.

So, two messages for small EMR software vendors – client-server EMR and web-based EMR.

1. Stick it out, hang on, stay profitable.

2. Don’t fly in the cloud. While you may get bought out, keep your valuations realistic. Forget your 10+ multiple expectations on revenue.

According to Eric McCann, Associate Editor of HealthcareITNews, one of its doctors lost an unencrypted USB drive.
The lost drive had the health information of 537 patients, according to the report. The drive had patients’ names, genders, ages, dates of birth, telephone numbers, medical record numbers, orthopedic physician’s name, dates of service, diagnostic studies, procedures complications, if any, etc. Officials, according to this report, said that the social security number or insurance information of these patients was not compromised.

As I read through the report in terms of what the URMC staff is doing, there’s education involved, but a lot of work is required on the staff’s part.

I just don’t understand why people feel a need to download data. With secure cloud, web-based EMR systems, this need is totally eliminated. Granted that hospitals may not want to trust a traditional cloud provider, but then technologies allow them to host a ‘Private Cloud’ based EMR.

Time for people to grow up.

This is a must Read Blog – Click here.
John is always very inspirational. But this time, he touched on something that just happened yesterday.

A very good client (a Wonderful Physician in Florida) of mine called me couple of days ago. They had been a good EMR user for a couple of years, but thought they can do better. Thought they needed to ‘graduate’. So, we spent half an hour online, and ‘discovered’ he can save at least 45 minutes per day just by tweaking things.

Spot on John –
– Continuous Training
– Continuous Improvement

I’ve seen too many EMR users try to cut corners, cut costs by avoiding one of the most important elements of a successful EMR software implementation.

It is my humble appeal to all EMR users – Web based EMR, or Client Server EMR; Please don’t compromise not only on ample initial training, but also ongoing training.

My friend John has written a very thought provoking blog –
http://www.emrandhipaa.com/emr-and-hipaa/2013/04/30/ehr-benefit-eliminate-staff/

This is not a new topic. It has been beaten around since the advent of EMR. Yet, its relevance is most current.

I remember few years ago when so many vendor sites had an ROI calculator where staff reduction was an important part of the calculation as a justification for EMR.

As I consult with various EMR vendors, I don’t find a single vendor using ROI as a ‘tool’. Of course, there are two reasons – one being that Providers are not trained to think ROI. The second is that experience has shown that even in successful EMR implementations, staff reduction rarely happens exclusively because of EMR. As John rightly says, there may be other reasons for staff to leave.

What Providers should focus on is improving their workflow, reducing inefficiencies and working with staff to improve patient experience.

EMR is, and I keep on repeating this in my talks, just a tool. A tool with a lousy implementation and workflow will make the practice even more inefficient. So, use your staff (and vendor) to introspect, critically examine your practice workflow and try to make it more efficient by using the right tools.

A doctor mentioned – ‘I don’t want to talk to reference names from EMR company’s website’.
A very simple statement but reveals a lot about the current thinking about the EMR buying process.

There were three steps originally involved.

1. Look at a list from your Academy, or some reference site, or ask your peers, or go to your academy meeting.

2. Call some vendors, ask for a demonstration, talk to some of their references.

Now, with the explosion of various review sites and social media, it is easy for doctors to do some homework before they start looking. You still need to do the full demonstration as other ‘due diligence’, but there is a tremendous amount of research done upfront.

Vendors have realized this and therefore encouraging their clients to post positive reviews online. In their eagerness to do so, some vendors ‘implant’ reviews. Vendors have their happy customers they want to nurture and get testimonials from.

Doctors looking to buy EMR from these vendors sometimes are a bit skeptical about talking with those clients of EMR companies since there is a perception that clients whose video testimonials are on the vendor’s website may be on their ‘favorites’ list. Justifiably so, because more and more EMR companies are taking that route – even getting their ‘friends/family’ doctors to do videos.

Not all companies do this. I have talked to so many vendors and I know most of them are genuine.

So, even though you think talking to the vendor’s favorite clients may have a bias, and right fully so, if you craft your questions properly, if you ask genuine questions and engage them in a dialog, you will get honest opinions beyond ‘It’s great, I like it’.

So, I would actually encourage you to go to Vendor’s websites, identify some of their clients that have their testimonials listed, and call them directly yourself.