EHR – Electronic Health Record – The Latest Industry ‘Buzz’ Word

  By Marilyn K Gard

“I’d love to use a Soap Notes program, but my travel cards are just so quick.  Can you design a Soap Notes program that is as quick to use as my travel cards but gives me all of the fancy reports?”   Using that question posed by a chiropractic practice consultant as a starting point, the quest began to find the right match between speed and ease of use for entering patient encounters.    That is quite the challenge, especially considering that most chiropractors record their travel card notes in fifteen to thirty seconds.   A second obstacle is the fact that many chiropractors are not exactly computer-savvy and have no desire to become so.  The best computer program in the world will fail if people do not like using it.  That fact leads to an inescapable conclusion: the most important aspect of any computer program is design.   Designing a program that quickly captures encounter data is a formidable task.

What enters into design considerations too, is politics.  The acronym SOAP (Subjective, Objective, Assessment, and Plan) has been replaced by the latest buzz word, EHR, Electronic Health Records.  You heard it discussed in campaign speeches; medical records have become a political issue.   There is a growing trend that may eventually require electronic health records so that information can be shared between providers in a timely fashion instead of waiting for paper records to be snail-mailed back and forth.   The HL7 committee is already designing/redesigning messaging standards for the transmission of electronic health records.  The transmission specifications that are currently used to transmit your billing (ANSI 837) already include specifications for transmitting encounter data.

A final design consideration is the all-too-familiar HIPAA.   At this point, everyone is suffering from HIPAA burnout.   People are just plain tired of hearing about HIPAA-compliant transactions, privacy rules and security guidelines.   Unfortunately, HIPAA fatigue is no excuse for lapses in security.   The design must meet HIPAA standards.

Designing for speed and simplicity

Since almost everyone owns a computer, it makes sense to design a desktop application, one that will run on any computer.   The mouse has become the accepted standard for an input design.  Most of the current programs use a dropdown format for entering data.  Of course, a dropdown format requires precise eye-hand coordination and makes it difficult to talk with a patient and record notes at the same time.

Another option for an input device is a Palm Pilot or PDA.  The big advantage is the relative low cost to purchase a PDA.  From a design standpoint, though, they require programming in their own language that is not transferable to a desktop application.   To accommodate the small screen size of the PDA, the program must utilize many different screens to accomplish the task of entering an encounter.   Jumping from screen to screen can become quite inefficient and time-consuming.

Perhaps one of the models to look at for speed is the fast-food industry.  As a McDonald’s clerk takes your order, what happens?  The clerk hits buttons on the computer screen that correspond to your choices.  Once your order is totalled, it appears at the takeout window to be filled.  While a chiropractic office may not want to adopt the total assembly-line approach of McDonalds, the technology behind it is worth a closer look.   Of course, McDonalds doesn’t have to answer to the HIPAA police.  No one cares if you order a Big Mac – except your waistline.

Most restaurants nowadays use touchscreen monitors to record orders.  By using this technology, they avoid costly mistakes that occur in handwritten orders.  Because the process is standardized, orders are filled more quickly.   Touchscreen technology requires minimal eye-hand coordination; the operator can enter information and still maintain eye contact.  Another huge advantage of touchscreen programming is that it can be run on a desktop for those offices that do not want to invest in touchscreen monitors. 

 If the two criteria for creating a great EHR program are speed and efficiency, touchscreen is definitely the preferred input.  From a software developer’s perspective, it is the most expensive to deploy; for that reason, touchscreen programs are usually scarce and expensive.

 Reasons to own an EHR

If you are considering the purchase of an EHR, you may already be familiar with the benefits.  If you are not convinced that electronic records are important, please consider these advantages:

§         Accurate, legible, completed notes.  With an efficient EHR program, progress notes can be produced quickly and efficiently.    Because the notes are computer generated, they will be legible.  In addition, they will be more complete because they are not handwritten or dictated with transcription errors.  By far, the advantage of a good EHR is the free time.  No longer will the doctor have to spend nights and weekends producing the stack of narrative reports or case notes requested.  Everything can stay current.  Imagine having a clean doctor’s desk, no stacks of narratives waiting to be written!

§         Risk management.   Of course, no one wants to be sued.  In the event that a malpractice suit develops, accurate progress notes combat unfounded allegations.   If the patient has filled out assessments such as the Quadruple Visual Analogue Scale (pain scale) or the Oswertry Back Pain Disability Questionnaire, there is documentation of the change in status.  These forms can be built into an EHR program so that the patient completes them during the visit.   Nothing is more powerful than the patient’s own account of improvement.

§         Justification for ongoing chiropractic care.   When you send periodic progress reports with your billing, it keeps the insurance company informed of changes in the patient’s condition.  When the progress notes indicate that the patient is still in corrective care, it is easier to avoid premature termination of benefits.

 

Documenting ongoing medical necessity

In addition to recording patient progress, both in terms of subjective complaints and exam findings, a computerized Soap Notes program documents changes that justify ongoing chiropractic care.  Unfortunately, the insurance industry is built around the medical model where thousands will be spent up front for diagnostic tests.   Then treatment often consists of drugs that are cheap compared to the diagnostic tests.

For chiropractic patients, the majority of the expense is incurred on the back end, the reverse of the medical profession.   After x-rays and exams, the treatment phase begins.   While the diagnostic phase is relatively cheap, the treatment phase may last for months.  There is one important fact that the insurance industry seems to forget:  in the medical arena, a patient may be prescribed a medication for the rest of his/her life.   Isn’t it interesting that the insurance industry balks at lifelong chiropractic care?  

Given the reality that many insurance carriers are predisposed to reject chiropractic claims, it is doubly important that the following scenarios that justify ongoing care are reported to the carrier through the Soap Notes program:

§         New injury to a different area of the spine or re-injury to the same area.   When a new injury is reported by the patient, it should be recorded and documented.  The patient’s description of the injury should be recorded as well as the patient’s indication of symptomatology.  At the least, it may necessitate a new exam.  It may also justify new x-rays.  It certainly signifies the beginning of a new treatment phase.

§         Different condition or symptoms.  Sometimes during the course of care, a patient exhibits different symptoms than what were first presented.  If the original symptom was headaches and the new problem is low back pain, the condition has changed.  This change in condition should be reflected in the progress notes.

§         Exacerbation of symptoms.  Sometimes in the process of chiropractic care, the patient will experience a reversal of the progress that had been made until this point.  At that time, you may choose to perform additional diagnostic tests such as x-rays or exams.

 Finding the Right EHR for your Practice

If you decide to purchase an EHR program, what should you look for?  Here is a list of considerations:

1.           Input method.  If you want speed and ease of use, you would probably lean toward touch screen.   Often a touch screen program can also be run on a pen tablet that can be carried from room to room.   If extreme portability is an issue, you might look at the Palm Pilot offerings.  Be sure to test it and make sure that you can live with the numerous screen changes. 

2.           Customization ability.   It is a fact that no two chiropractors practice exactly the same.  For that reason, it is important to purchase a program that allows you to customize according to your needs and practice methodology.  Because outcome assessment tools can prove invaluable for documentation purposes, you may want to purchase a program that has integrated the common assessment tools.

3.           Reports.  Obviously, the whole purpose of an EHR system is to record patient encounters and be able to produce a report suitable for insurance billing, attorney requests and narratives.   It is an added benefit if you, the user, can control the data that is reproduced on the report.

4.           Trial period.  When you are making the final decision, try the product for a few days.  Record an encounter as if you were processing a new patient and creating a complete narrative.  Then, process an established patient and record an ongoing encounter.

Purchasing an electronic health records program can be the best decision you can make for your practice.  It will speed data entry and give the doctor more time to spend with patients.   Ultimately, a good EHR program should be a practice-building tool because there will be more time available to work with people.

Marilyn Gard is president of Clinic Pro Software.  With over twenty years of experience working with the chiropractic profession, Clinic Pro has designed a touch screen EHR program (Soap Notes) to be released in June 2005.   This new touch screen module will be shipped with standard chiropractic exams and AK templates.  Outcome assessment tools will be optional.   A CD and online demo will be available mid-March.  For more information, visit www.clinicpro.com or call 866-333-2776.