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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.

I was asked to evaluate a ‘request for proposal’. One of the questions was – ‘Is The Integration To Other Internal Systems Seamless Or Integrated Bolt-Ons From Acquisitions?’

Most EMR systems claim they are fully integrated. On the surface, what this means is – you can do everything from within the same platform. You don’t need to buy different modules to do different things.

EMR, Scheduling, Practice Management, billing, and patient portal are all offered by the same vendor.

As the title suggests, these modules may have been purchased from a third-party vendor, or developed as separate products and then ‘bolted’ to provide a semblance of seamlessness.

What is wrong with that?

Nothing superficially, but anything that has ‘seams’ can break.

From the software perspective, not being on the same ‘database’ and platform means that data integrity can be compromised. Something can go wrong somewhere.

When upgrades and updates are made to the software, connectivity between these bolted products can break. This can happen more with stringent regulatory compliance and the need for interoperability between different vendors.

I read a fantastic piece written by Dr. Daniel Essin, MA, MD, FAAP, FCCP for Physician’s Practice.

With EHR, Two Heads Are Not Better than One

He discusses the push and pull between the need to analyze discrete data versus providers’ need to ‘articulate’ the patient’s condition without getting to the SMD (Slow Me Down) factor.

Most practices adopt EHR motivated by Meaningful Use Incentives. The goal is interoperability and data analytics. However, at the point of care providers struggle with improving productivity and they look at alternatives such as dictation, which in turn is against the objective of capturing discrete data.

Dr. Essin said it well:

“Today’s EHRs collect many informational elements twice, once in the narrative and again as “data.” Until narrative and data are united, using an EHR will require too much effort, create too much risk, and provide too little benefit to justify imposing them on medicine by fiat.

I believe that that computer technology, if used correctly, does hold great promise to improve healthcare. Unfortunately, as people have debated EHR over the years, the discussion has been framed as if the benefits of EHR are real, not potential. Irrational exuberance on the part of the EHR policy wonks and government officials not only spread this notion but lend credence to it. The reality is that EHRs have yet to deliver most of the promised benefit. Perhaps, giving more weight to the hype than to reality explains why poor decisions about EHR are so common.”

For many years I struggled with a simple problem – Getting things done.

Symptoms of this problem:

• Going home late
• Not finishing tasks on time
• Unread emails
• Stacks of paper on my desk
• Incomplete or improper responses to clients
• … and the list goes on.

A little over a year ago, it became unbearable. I had tried everything, read many ‘self-help’ books, tried to improve my time management, and attended seminars. Nothing seemed to work. I just did not have the ‘details’ gene.

It dawned on me that I was so much better at other things than writing emails, sending replies, answering and making follow-up phone calls, and doing paperwork. I would get into the nitty-gritty of installing software, doing excel spreadsheets, and lose focus of the ‘big-picture’. I was penny-wise and pound-foolish.

What did I do about it?

I hired a personal assistant. Something I would never have dreamed of doing earlier. How can I afford to hire someone? I did some analysis and math. Quickly I realized I could not afford not to hire help. I was scared.

It has been a year and a half since I made that decision. I must say, I have never been happier. My quality of life has become so much better, I am focusing on things I love doing and my revenue has actually gone up. My Productive senses are on full alert all the time, and I don’t get tired.

Wow, such a simple thing changed my life.

I am seeing a similar pattern with a lot of Doctors I speak with. In order to save money, they compromise on some critical elements of running a successful business. Running a Medical Practice is a serious business. I just don’t understand why they cut corners.

Doctors want to install modern EHR software systems but don’t want to pay for training. They are smart – granted, but then that is not where their efficiency should be used. EHR software systems are a paradigm shift not just for themselves, but for the entire practice. If not done well, it can make or break a practice. Revenues can suffer, and employee morale can suffer.

I just want to let them know – don’t be penny-wise and pound-foolish like I was.

An important element of a medical practice workflow is Order Tracking.

When Providers order labs, radiology, etc, a practice must follow up at least twice to ensure that results are received or there is some follow-up action taken.

In a technology solution that drives a practice, I frequently see questions related to the ability to ‘task’ someone with a responsibility to take some action.

This is where the process versus technology debate comes in.

When you ‘task’ or message someone to do something, that is like walking over to your staff and saying, ‘Can you take care of this’?

Let me illustrate this. There may be an eFax queue where lab results come in, or they come in electronically via lab connection. Someone needs to look at these results. Someone needs to determine if the doctor should be looking at these or if they are normal. Next comes the determination to call or inform the patient and whether or not the patient must be called in for a visit. Finally, any comments must be entered to close out the test.

All Doctors, Office Managers, Practice Manager looking for EMR systems should read this blog – Courtesy The Healthcare Blog.

It will open your eyes; at least make you think – and take all the online reviews with a pinch of salt. How influenced and flavored are these reviews?

Having worked with many vendors, I will say that most sites do not allow vendors to post reviews directly. However, they may certainly be influenced. Read past the ‘blandly positive’ reviews as the writer of the blog says, and focus on those that appear original. If possible, find and try to talk to the provider or practice that wrote this review.