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EMR Templates – A topic of heated discussion keeps on popping up in meetings and blogs, and rightly so. Studies have been published and we have also heard of CMS audits revealing how templates are sometimes used mindlessly.
There are various issues pushing and pulling in opposite directions.

Here’s an interesting post from the Society of Teachers of Family Medicine – “Are we teaching Template-based Medicine?”

• You want speed of charting but you don’t want each to look similar as the previous one.
• You want to code ‘just right’ but you don’t want to over-code.
• You want to automate charting as much as you can, but you don’t want to order tests and procedure where not required.
• You want to give enough attention to the patient and you want to document their ‘story’ and ‘narrative’.

Where is the balance?

You need to understand what a template really is. Every vendor has their own definition of ‘template’. It could mean anything from a single button template for a condition to sub-templates of every part of a SOAP note. You can have sub-templates for HPI, ROS, Physical Exams, Assessments, Plans, Orders and Procedures, and Medications. There cannot be one-size-fits-all templates.

The first step is to understand your own office workflow. What happens when a patient comes in? Who does the initial triage? Who does what part of the patient encounter? For example, your MA could be collecting initial data such as:

• Chief complaint
• Asking related questions and getting answers that could go into the HPI section
• Review of Systems and Medical history
• Current medications
• Vitals

When you see the patient, you must have quick access to previous notes as well as what the MA collected so far. This was easy in a paper-based system because you just flipped the pages in the patients’ folder – assuming everything was there. Then you engage the patient and elaborate on the ‘narrative’. Then you do the physical exam. At that time, you are ready to chart assessment, plan, order, procedures, and medication.

If you examine closely, the single element that is most difficult to ‘templatize’ is the HPI Narrative.

Trying to build a template that can capture every patient’s unique narrative, is extremely difficult if not impossible. Technologists will tell you it is possible and perhaps it is, but as a provider, you also want to say it in your (and the patient’s) words. My personal opinion is that this is best done by typing or dictation.

Use various forms of templates your vendor offers for everything else.

This guideline will make things easy, keep the workflow smooth, speed up your process, and most importantly, avoid audits because your templates look exactly the same. Ask your vendor how you can do all this and do it fast.

People love Free Stuff. There is nothing not to like about it, of course, barring some catches, strings, and so on. We like the idea of Free but remain skeptical – ‘Why is it free; what is the catch?’

• Why is it Free?
• What’s in it for them?
• Is there a hidden catch?
• Is it really Free at all?
• What’s in it for me?

That last question is really important. Let me repeat – What’s in it for ME?

Forget Marketers – let’s look at Buyers. What is the main difference between people who say –

• I want EMR Free and
• I will Pay for EMR, perhaps even a bit more

Payers: Value their time more than their money.

Non-Payers: Often don’t think of their time as something of value.

As Doctors, Physicians, and Providers consider EMR, each of them will base a decision on their fundamental value of time. I don’t need to tell you what your time is worth, you will make your own determination. The value of time is not just the time spent at the clinic, but also quality time for yourself and/or your family.

I have met providers of both kinds. Those who don’t mind sitting for hours in front of the screen modifying, customizing (or trying to) their ‘Free’ EMR. Sure, they would have saved a few hundred dollars per month, but if you just add the total number of hours spent multiplied by your ‘value of time’, you will quickly come to the conclusion – assuming you value your time.

On the other hand, I see providers paying a little bit more for peace of mind.

I conducted an informal survey of some provider friends with a pricing model that offers unique value. I carved out three distinct models.

(These are fictitious numbers – to illustrate a point)

1. Free EMR, but you just get a ‘shell’ – you set it up yourself, you customize your templates, you watch videos to learn, you teach your staff. You don’t get phone support, just email support, and ‘maybe’ someone will respond.
2. $525 per month per provider, plus $3000 upfront fees that include training, setup, and project management.
3. $700 per month per provider, No Upfront Fees. But this also includes Unlimited training, a Dedicated ‘hot-line’ for support, and unlimited template customization.
4. $1250 per month per provider. Everything in no. 2 Plus Practice analysis, billing review and analysis on an ongoing basis, Marketing consulting, on-site training, and so on.

I knew these people beforehand, and I had a good idea of who valued their time more, just as predicted, it was split exactly as I predicted between those who chose the Free option and those who chose the paid option. But what surprised me was an unusually large percentage chose option 3.

The logic was simple – I can make up the incremental in just one or two additional patients per month, or if I can go home even 1/2 hour early per day, it is certainly worth much more than $175 per month.

You decide where you stand. Share your thoughts with me at Info@Avetalive.com (I will not publish them to protect your privacy).

 

Imagine my surprise when yesterday, September 27th, 2013, a few years after the EHR Incentive program was launched with tremendous fanfare, two (not one, two) Specialists told me “Oh, but I’m a Specialist”, when I asked them why they are not signing up for EHR before October 1?
I was talking to two specialists who have done their homework and finalized the vendor and their EHR system. But they said they would sign soon. Both are starting a new practice on October 1.

So, I asked, ‘If you have decided and it is just a matter of signing the agreement, why aren’t you signing before October 1? Don’t you want the benefit of EHR incentive?’

Even after so much education, information published, and even vendors trying to ‘educate’ providers of the incentive benefits, somehow, somewhere, misinformation seems to have crept in.

Microsoft just unveiled the next iteration in its Surface Pro lineup of tablet computers called Surface 2.
The tech buffs know about this, but I am sure the majority of doctors and providers did not know Microsoft has a Tablet. But it is time the Healthcare IT world takes notice. For the first time, this fantastic device will allow you to do everything you wanted to do with an iPad, i.e. be a great data consumption device (view movies, read emails, catch up on Facebook, and post an occasional status update), and create content just like a laptop without the added bulk.

I think Microsoft is actually pushing the future. Who wants to carry a phone, a tablet, and a laptop only to use a desktop or other laptop at work and then have another computer at home? It looks to me like they are trying to kill off the laptop and possibly replace your home computer as well. It could be all wrong, I’m no analyst, but it makes sense. With this tablet, you get portability and flexibility in your exam room and outside of the exam room. It also doubles up as your ‘watch video’ device.

The Surface ALSO includes Office, on top of everything else it delivers, including Adobe Flash, which the iPad cannot and never will deliver. There are others who may think that they do not need Office, without realizing that they do, especially when they encounter “Excel or Word documents that tablets can’t open”. This is especially true in healthcare, which will be one of the greatest growth areas for tablets.

This is a serious Enterprise Tablet that lets you get things done in a Medical Office. You can hook it up to a large monitor and share screens with patients so that you can ‘engage’ with them rather than isolate them with you focusing on a computer screen and patients wondering why you are not looking at them.

Surface is a Powerful machine in and out. Tablets have to be portable, easy to handle, and install apps and full-fledged software. Surface scores on each of these areas. Tablets should look elegant, The Surface is elegant too, and extremely easy to hold in your palm. I would definitely say, we need to grow out of the Apple, and Samsung fads and stop comparing all things digital to Apple. So give it a chance. I certainly am.

Marketers analyze internet activity with respect to how you search. What terms are being searched to look for your first or next web EMR or web EHR?
Here are the steps you may take:

1. Search online – see keyword terms popularly used below.
2. Ask your peers for their opinions of the systems they use.
3. Use a third party (online, like Software Advice, or a consultant you may know) for recommendations.
4. Narrow down your search to your top 5.
5. Organize Demonstrations – online or offline.
6. Call References of systems you like.
7. Negotiate pricing.
8. Sign and implement.
9. Don’t Start over.

Search Online

Let me show you what most providers – you – are looking for and searching. I have found most providers using the word EMR but you may substitute it for EHR.

• <your specialty> EMR
• EMR software companies
• Electronic Medical records software companies (or some combination thereof, based on if you really want to type everything)
• Web-based EMR
• Free-based EMR (you know you are looking for alternatives to Practice Fusion and don’t want to pay anything)
• Best web-based emr
• Web EMR reviews
• Cloud EMR
• Top EMR vendors
• … you get the idea

All EMR companies – yes, all of them – know this and they try to manipulate their sites so that when you search, their websites appear on the first page of Google, Bing, or any such search engine.

The second method they use is Advertising. Search engine advertising is a huge business. How does Google make its Billions? When you search online, a lot of providers are not aware that the top three ‘search results’ and the ones that seem very relevant are on the right side of your screen. These are really advertisements that are sponsored by EMR vendors. Nothing wrong with that, but you should be aware.

When you search online, what should you be looking for? A well-designed website is no guarantee of a good product. It just says this company has good marketing and design folks. Look for these four things:

1. Does the company list its top executives? Is it easy to contact them?
2. Does the company have customer testimonials? How many are there? Are they listed by Specialty? Are these real providers and practices, or just anonymous quotes? How old are these?
3. What are their products and services?
4. Is this an independent company? Who are the owners? Do they have other businesses? Do the founders/owners have a deep background and knowledge of the healthcare space – more importantly, experience that is relevant to your business?

Peer Opinions

Asking your colleagues and peers is an extremely important ‘tool’ in your search. However, there is a big caveat. Let me explain.

If I ask what car you drive and whether or not you are happy with it – what is the likelihood of you saying you’re not happy? Slim to None.

What I am really trying to say is, that if you simply ask someone their opinion about their software, they will generally say ‘Good’ – unless they are considering switching.

Instead, here is how you SHOULD ask.

‘I am considering getting the system you are using. Can you share your lessons learned (from using it?) What can go wrong? What worked well? How is their support and services etc?’

Now you are engaging them in a conversation rather than a simple – are you happy? If they have any reservations, it will come out at this time. Some vendors offer incentives to their clients if they recommend the system to their colleagues, so be aware of that.

Using a Third Party

Online third-party aggregators – When you search online, I am sure you will run across sites like these – Software Advice.  Don’t get me wrong, they are a great resource. You should just be aware of how they work. Most sites like these get their money from vendors when they recommend vendors that match your needs. The good thing is, that they have a lot of top vendors as clients. They get the same amount of fixed fee from vendors irrespective of who they recommend. I just want you to be aware of this, so that you can use this as one resource, and not be entirely dependent on it.

Individual Consultants – if you personally know anyone, by all means, use their help. These may be your hardware or network vendor, your suppliers, etc. Just make sure that they do not have a vested interest and that there is no ‘insider trading’ involved.

Narrowing your list

Your final list should not be more than 5. Before you narrow down your list, make sure you talk with representatives of those companies. Don’t do demonstrations yet. Ask them all kinds of questions (see the four things to look for on a website). This must be almost as if you are conducting an interview to hire them.

You must have very clear goals and criteria for selection. Unfortunately, too many people go by their ‘feelings’ of what looks good, and who sounds better. Buy with:

• Product (features, functionality)
• People (behind the product, support, services)
• Processes (Do they have well-defined processes for implementation, training, and support?)

Apply the 80-20 rule. Nothing is perfect, nothing is 100%. Be ready to make compromises.

Demonstrations

Online or offline demonstrations? If a vendor has a local representative who is willing to stop by for a demonstration, by all means, do it. But you don’t need to hold it against vendors that do remote demonstrations.

Again, the only way to get the maximum out of demonstrations is preparation. I have seen too many demonstrations where they are all over the place. In the previous section, I mentioned you must know what you want. Write it down. Here is a simple guideline.

1. Write your current workflow. Office workflow, from patient calling for appt, check-in to check-out. List your staff, and write down who does what and in what order.

2. Identify ‘gaps’ or ‘areas of improvement’ in your workflow map.

3. Potential pitfalls and fears in implementing technology.

Now, Prepare a Demonstration Script.

1. Take your most common encounter/patient visit. Look at a few finished visit notes.

2. De-identify the set of note(s) so that patient information is removed.

3. Send it to the demo person(s) – at the time of the demo, or just before so that they have enough time to review it, but not enough to ‘fudge’ their system. Also, send them or tell them your workflow.

4. Ask them to stick to the script. Only after that is done, they can show off their system with other ‘features’. But tell them what you care about and what you don’t.

5. Finally, ask them – ‘What would you do to improve my workflow and make my practice more efficient’? This is one of the most important questions, don’t skip it. It will tell you a lot about how this vendor approaches things.

References

I have written about checking references. Read this.

1. How to check – who to call.
2. Also, Check out your salesperson.

Negotiate Pricing

How Much?

Is this the most important question? And also, when should you ask the pricing question – before or after the demonstration?

I will split the pricing issue into two parts. First, before you engage the vendor with a demonstration, you must have an idea of the approximate price range – you don’t need a final quote. That way, you know whether or not you can afford this solution and it falls within your budget. (This means, as a part of your preparation, you MUST) decide on an approximate budget.

Part two is where you negotiate with the top 2 vendors. I don’t need to tell you about negotiation here, you probably are an expert at that.

Sign and Implement

Signing is the easy part, but make no mistake about Implementation. This is where everything begins. Just because you, the provider have signed the dotted line, your job is not done. You must either take control and become your internal project manager, or assign someone that can stay on top of the entire implementation process. Don’t leave it just to the vendor. The vendor will do a great job, but they need your help. It is a two-way street. If you and your practice do not cooperate 100%, it will fail. Cooperation does not mean just providing information on vendor needs but being an active participant with your vendor implementation team.

Finally – Don’t Start Over.

Barring unforeseen situations, you should not have to do this all over again. EMR is a paradigm shift for your practice and you certainly do not want to go through the process again.

Good Luck!

This is one of the most relevant topics today. I see an ever-increasing number of ‘switchers’.
John Lynn talked about EMR switching and noted three drivers of this phenomenon. But there are more.

Besides the ones that join a hospital or merge with larger groups, the rest of them are from the following camps.

1. Those that were skeptical about EMR initially, did not want to spend money and went with the Free EMR systems. They got their first year’s Incentive money and realized they needed to ‘grow up’ because the free emr just did not cut it and meet their needs. So, they start looking for something better.

2. Switchers from ‘older technologies’. Under this umbrella, you have those that are a) moving from old client-server technology to Cloud EMR, because their IT costs are going up, their servers are aging, and so is the EMR system itself. Even if the software is certified, they want a Cloud system for various reasons – access, not having to deal with VPN, remote access, speed, etc.

3. Switchers because of ‘service and support’ issues. I see this also forming a large group. The reason is, that market pressures are showing on Vendors. Costs rising, competition rising, and it is becoming difficult to continue providing the same level of support as they did when they had fewer clients.

4. And, finally, Provides are Maturing. They are more knowledgeable. When they bought their first system, very few providers knew what they really wanted and what to expect. Having used technology for some time, they have a better understanding of their needs. So, if their current system can’t do it, they start looking for something that matches their needs.

Once you’ve decided to switch, then comes another hurdle which John and Sean talk about here – very important and relevant topics of contract and data conversion costs.

The sad state of EMRs: How they are doing more harm than good

This was a post I read on kevinmd.com, by Val Jones, MD.

Very thought provoking article. I tend to agree with his views particularly when it pertains to hospital settings because there are so many moving parts. Unfortunately, these tend to be islands of automation. Technology with ‘bridges’ tend to breakdown, because true integration is not there. Transcription, is one case of a disjointed system, and as Dr. Jones points out, it is one area where things can and will go wrong.

In an ambulatory setting however, things are slightly different.

I was with a Cardiologist in Delaware last Friday, and I saw how he was using technology. Here is a synopsis of what I saw.

1. Patient comes in, MA updates medical history, takes vitals, initial review of system including the reason why patient is here (Chief Complaint). All of this is done in the EMR.
2. When Dr. is ready to see patient, with one click, he sees what MA has done, as well as prior visit notes ( if this is a repeat patient).
3. In the Exam room, he has a computer with a dual screen. The second screen is a large monitor attached to the wall. As he is talking to the patient, he is pulling up relevant parts of the chart so that the Physician and Patient are seeing the same thing. So, the actual interaction was a mix of eye contact and both the provider and patient looking at the screen while talking. He said the entire objection of ‘doctor looks at the screen and not at me’ is gone because doctor is sharing the screen on which he is charting. This, according to him, had a side benefit of patients sometimes pointing out that they are no longer taking a medication that was on the chart, or pointing out something else and asking questions. Increase patient involvement makes them happier. Therefore, he is able to finish most of the charting accurately while in the exam room with patient.
4. Once he was done with the patient in the exam room, he walked the patient out, gave instructions to his staff if any, and went to his office. Being that his was a ‘cloud’ system, the same patient chart was accessible in his office. So, he did something interesting. In his office, he clicks on the HPI area and starts talking to the computer (using Dragon Dictation) about the patient’s ‘story’. Then, another click and he dictated the plan for his assessment and diagnosis. This took 2 1/2 minutes only! He actually signed off the note right there.
5. He goes to the next exam room for the next patient.
6. Just 1/2 an hour after his last patient, he was done, and he leaves for home, all his notes for the day are done and signed.
7. Because of this, his billers are able to submit claims the same day and helps with better billing efficiency.

I have to say that for this scenario to happen, he worked with the vendor to get a well oiled machine in place. In his words, “You can’t get this efficiency with a free EMR”, work with your vendor as a partner.

A very expensive EHR installation crashed with major implications as reported by HealthcareIT News.
These are huge systems for large Organizations such as Sutter Health of Northern California. But there is a lesson for small practices, even solo docs.

It is, that don’t try to do everything in-house, don’t try to be technologists, and don’t buy a ‘Client-Server’ system. Fortunately, there is a really good Web-based EMR system.

If you are concerned about ‘what if my internet connection goes down’, I can tell you, there are plenty of backup options out there, but if your server goes down, you are sc#$@%^.

Getting a new EMR system is a tedious process, to put it mildly. A lot has been written about ‘how to select EMR systems’. Some of it is sponsored by vendors, and some is written by consultants.
Most of the advice is about picking the system with the right system for your needs. The big concern always is, do you really know what your needs are? I don’t mean to say you don’t know what you are doing, but rather, EMR is a paradigm shift and therefore, you may not realize the effect it will have on your practice in terms of productivity and workflow.

Even if you are impressed with a system that you have seen and you have done your ‘due diligence’ ( checked references – read my earlier blog on this ). All seems well.

Yet, I see this happening over and over. Something goes wrong, and within 6 months, I see so many practices looking to switch EMRs or change their EMR vendor and EMR system.

Why do Practices want to switch EMR Systems when they did all the right things in the beginning to select the system?

If there is a single factor that contributes to this, it is service and support. It starts with your salesperson. Does the salesperson consummate the sale and move on? Of course, there are many factors, but a very prominent indicator shown by surveys has been that if the salesperson stays engaged and in touch, approachable to you for help after sales, it has a better chance of success.

How do you find out if that is indeed the case?

Here is one simple thing you need to do.

Ask your salesperson for References of clients that this salesperson has sold to. When you call, ask the following questions:

1. Was this salesperson honest?
2. Did he/she make any ‘claims’ about the EMR system that were not true?
3. Was the salesperson available and accessible post-sales – say, after 3 months, if you had some questions or concerns, you called the salesperson, did he/she pick up your phone or return your call immediately and help you get your concern resolved?
4. Does your salesperson call on you to check how things are?

If the answers to these questions are positive, it is an indication of how the entire organization works and that they care about you.