What does EMR mean to you ?

[ozzie]

I learned many years ago thats the best description of a problem is from the mouth of babes so to speak. So I would ask describe "the PC is not working"
So I ask you what you think know or guess and EMR system to be..

No cliche`s I can get than from any sales blurbs..


I see it as a digital system to replace paper and phone records.
So thats the gross description.

Then it breaks down into subsets

Patient management Dr management Office Management Billing Management.

am i on the right track so far ??

[Scroggie]

What does EMR mean to me?

A system for generating notes at its simplist.

A method for consoladating and tracking patient lab, x-ray and clincal data.

A way to track needed diagnostic/preventative and follow testing (flu shots, eye exams, diabetes tests, colonoscopies et cetera)

Monitor therapies and prescriptions/drug interactions.

Practice management
-scheduling
-billing
-time managment
-work delegation

Patient education
-links to sites, handouts for relevant diseases

As the technology improves more to come.

[ozzie]

now see the most important in note generation..
It seem thats many docs use that as a deciding factor..
A short answer is learn to touch type and or train your voice recogition system well.
\(grin)
However I think that the data input focus varies a lot from DR to DR.. So that facet is really more a personal choice than an engineering feature..
But looking at the greater picture from patient calling to make an appointment to getting paid . The dr notes are a very small part of the total cycle.. an important part but a small part..
Granted I am looking at small private practice and not for rounding and or institution type care where you just see an endless stream of patients..
Then the situation is reversed..

But it comes down to 4 choices
Typing input static (keystroke)
Typing input dynamic ( tablet writing /screen capture etc )
Voice Input Static ( transcription )
Voice Input Dynamic ( what you speak is what it types hopefully! )
Any others ???
The lets look at all the pros and cons

oz






What does EMR mean to me?

A system for generating notes at its simplist.

.

[Scroggie]

There are other inputs methods.
Templates (preprinted version of the most common related physical findings or history) alter as needed for the particular patient
-These tend to be static (hard in most EMR's to customize or Doc doesn't take time to customize
-Usually are made by someone else, maybe a non-Doc or in a different speciality
-Tend to "feel" artificial and forced

Picklists
-Like mini-templates: short phrases selectible from a list
e.g. Click on PIP (hand joints) and select from a list: bouchard's nodes, swan neck deformity, Boutinnerre deformity, tender, red, swollen, limited motion, et cetera. click on all that apply for that patient

There are some EMR's that have "concept processor" (I won't mention Praxis by name)
-This will let you pick a diagnosis (assessment) and the CP will go backwards from there to pick the most common physical exam and history related to that diagnosis and then go forward to fill in the most common plan related to that diagnosis (based on what you have done in the past.
-Them thats used it like it. Outsiders are dubious of its value (where are you Al)

[Scroggie]

Also, although many other functions are the mechanics of remuneration: scheduling/billing/claims filing; payment really depends on what is DOCUMENTED in the note (not what was actually done or how long it took). So generating a comprehensive note that better reflects what we do it key. Because even if all the other parts work great, a poorly document note will be "downcoded" if audited.

[ozzie]

I am looking more so at taxonomy as a starting point..
Typing input static is the genus so to speak templates and picklists become a sub species of Typing input static . Somepoint in time it may be that you can speak the commands of a pick list .When that becomes available typing input hybrid has evolved and the genus created with the sub species variants that I cannot think of right now would be next..
Once the taxonomy is resolved then we can see where all the apps out there fit into the big picture which give us the DNA to build a better widget..
As many Dr don't know where fits what how and why and app adverse reaction is problematic and pervasive oh it is expensive too..
Lets keep this going as we are heading in the right direction..
More Dr's need to input.. The less you know the better..

innocence is always truthfull excep when discussing spandex tensile strength.

[Tim2]

When a patient arrives in my office, I want the scheduling system to alert an event system, and expect an answer or note entry. That is, there should be a forward looking system anticipating my work to help me along. If a patient doesn't sign in, I want that system to send them a letter automatically. When a number of appointments have been missed, The thing should count them up and ask me for an action. When a patient calls in I'd like to see an event screen recording the pertainents. It should be identifying forms I fogot to do. And lastly, It would be nice for it to have a dating sevice for my secretary.

[Kursk]

Scroggs touched on this but I will emphasize a few points:
1. Reuse what has already been input
2. Customization that mimics my workflow - I don't need to pull 10000 meds in a query as I use less than 100 routinely, and use those 100 in a specific way (IE dose, formulation, days of treatment). My pick list is 81 members and on a frequency curve most after #40 fall way off.
3. HD is on the money with anticipation - as the handspring inventor (Hawkins?) has said "intelligence is the anticipation of input". If an organism (program) can anticipate what is coming it can focus the majority of its resources getting ready to meet that need. So many EMRs fail to allow enough custimization or are incapable of being changed to do this workflow mimicing. Some are so all inclusive that it takes forever or actually the effort is asymptotic - you work harder and harder to customize the app and never quite get to where you want to be. Which is expensive.
4. Lastly, as Dr. Zellman has been fond of pointing out in the past, paperless is not necessarily the goal. If you look at what crucial functions need to be present in EMR and computerize them what is left is an amazing stack of crap that offers little to decision support, patient safety and office efficiency but each must be knocked off to achieve the nirvana of an electronic office. The effort/return curve starts peeling upwards like an F18 on takeoff.

IMHO, from the trenches, seeing adults for over 10 years and wondering why it has to be so hard and why I am the one expected to pay for all this wondorous transformation.

[ozzie]

Scroggs touched on this but I will emphasize a few points:
1. Reuse what has already been input
thats what relational databases do very well

2. Customization that mimics my workflow - I don't need to pull 10000 meds in a query as I use less than 100 routinely, and use those 100 in a specific way (IE dose, formulation, days of treatment). My pick list is 81 members and on a frequency curve most after #40 fall way off.
This is why I am detailing the input methods to explore all the options and try to get the best input methods. As the best result would be the input method that suits your work habits and logistics..

3. HD is on the money with anticipation - as the handspring inventor (Hawkins?) has said "intelligence is the anticipation of input". If an organism (program) can anticipate what is coming it can focus the majority of its resources getting ready to meet that need. So many EMRs fail to allow enough custimization or are incapable of being changed to do this workflow mimicing. Some are so all inclusive that it takes forever or actually the effort is asymptotic - you work harder and harder to customize the app and never quite get to where you want to be. Which is expensive.
hawkins is a pitch man too I can easily say that "intelligence is the anticipation of disease" Does not mean we can cure cancer quite yet ..
You could say that XP has predictive capapability the way it caches stuff. But in the end when the time saved is in the millisecond range and is eclipsed by CPU power and cheap fast RAM ...its sales jive..
Customization is problematic in many ways. when you look at how apps evolve. Dr A builds the custom app then goes to market with it . So the core app is based on Dr A needs . Then other Dr may have to modify their work behavior to suite the app. So at best you have compromise .. Now the sales department says dont leave the app un locked cause then we wont sell as many copies and then we can't after-sell changes etc . So now change is up the the whims and financial needs of the company more than the needs and wishes of the clients or another approach is to cobble another app to solve some issues but in some cases this compounds the problem as now the app is going in two directions.. Dr A is FP Dr B is Surgeon. The needs are far different.
So the initial design needs to be modular , platform independant so this allows the maximun flexability and reduces the dependence on both hardware and operating systems.. Note some times this is a altruistic goal and must be compromised and it like drug therapy it's a balance of result versus side affect. A great example is using a Microsoft application . Works good if on total MS world but you ugrade an email client and Access gets funky because some DLL gets mangled. Kinda like HMO's if Dr get too deep into the HMO system it can be hard to define a good patient outcome versus a good financial outcome for the HMO ..


4. Lastly, as Dr. Zellman has been fond of pointing out in the past, paperless is not necessarily the goal. If you look at what crucial functions need to be present in EMR and computerize them what is left is an amazing stack of crap that offers little to decision support, patient safety and office efficiency but each must be knocked off to achieve the nirvana of an electronic office. The effort/return curve starts peeling upwards like an F18 on takeoff.
I see the paperless as a direction more so than a goal. I consider any software to be in a addition to rather than replace of. The human mind(s) in the end is the greatest tool in the world. Humans can always just turn the computer off. 911 is great example of how humans can bounce back into the caring beings, as the buildinge were collapsing folks were looking for ways to solve the pain of other humans. I was with a bunch of folks watching the dram unfold on TV in New Jersey and it was great how people just transformed in mother teresa's . Computer had no roles and I was training a bunch of geeks. As in life it's a balance and rather adopt a mantra the best route is the path that suits your needs and only you and your fellow Dr know that best.. To me as a patient I like to see the human side of my Dr, otherewise I would go to webMD . As geeky as I am I still prefer to go to the bank and deposit my money rather than the ATM. If I saw my doctor punch in a bunch of co-ordinates then a paper spat out and that was the fix I would change my doctor in a heartbeat..
I can still remeber Dr Satchel who was my childhood MD, a wonderful man and sitting in the surgury holding a 8 x 4 index card waiting my turn. Looking at all the hieroglyphics and asking myself what the heck does all this mean and other the other side was the running balance of how much mum owed. After all these years I still remeber his name don't remember one school teacher of that era.. So thats show how important the human experience is to me anyhow.
So a goal for me is to retain the human experience , more of the Dr Patch Adams aproach than an AMA aproach.
It's the patients stupid !
And thats why I am asking..[/QUOTE]

IMHO, from the trenches, seeing adults for over 10 years and wondering why it has to be so hard and why I am the one expected to pay for all this wondorous transformation.
Because you are special and that funky space suit shows you can afford stuff.

[ozzie]

baisc info for patients which is filled in one time unless changed
#primary Information#
Last Name
First Name
Middle Name
Address Line 1
Address Line 2
City, State, Zip
Date of Birth
Sex
#Physician info#
In House Doctor
Referring Doctor
Primary Care Physician
Number of Other Physicians

#medical#
Blood Type

#Personal#
Gender
Marital Status
Employment Status
Patient Status
Social Security Number
Internal Practice ID #
Driver's License
Type of Billing
Monthly Budget Amount
*Notes#
anything else needed here ...
insurance billing and visit info is on another page this really core info

[ozzie]

Allergies
Chronic Problems
Current Problems
Episode of Care
Insurance Authorizations
Letters
Medications
Patient Coverage
Payments
Prescription
Previous Operations
Procedures
Progress Notes
Scanned Documents
Statement
this is all the stuff that would be considered demographics and some parts would have subsets for instance
#episode of care#
Description
Related to Pregnancy
Date of First Occurance
Related to Employment
Date of Current Onset
Related to Automobile
Referring Physicia
Related to Other Cause No Yes
Facility
Diagnosis Family
Episode Type
Disability Type
Disability From Date
Hospitial Admission
Disability To Date
Hospitial Discharge Date
Disability Back to Work Date