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Electronic Medical Records
Dr. Stephen Pittenger

January 19, 2003

Copyright

LindaShell: Good evening. Welcome to another monthly Practice Management Rounds. Tonight Dr. Stephen Pittenger will be telling us more about using electronic medical records. GA Dr. Pittenger!

StephenPittenger: Thanks Linda, Good Evening.

A little about myself before we begin. I earned my DVM from Texas A&M University in 1995 and started practice as an associate at Memorial-610 Hospital for Animals in Houston, Texas. Since 1997, I have lectured and written about technology issues in Veterinary Medicine. That same year, I began planning the transition in our practice from traditional record keeping to an Electronic Health Record. Now as a co-owner of that same practice, I continue to tweak and improve upon our system that was put into place in 1998.

I have a strong interest in finding ways to utilize technology to better our patient care, as well as improve the quality of life for the veterinarian and his/her staff. I can go about 19 different ways with this discussion tonight.

Let me poll the folks here and see which way we should go . . POLL: How many are currently utilizing Electronic Medical Records in their practice? Y or N

AlexSherer: N
SheilaChisholm: n
NickNail: N
JayNaylor: n
ChickNewman: n
KennethKaucic: Y
MargaretRoberts: n
KatharineLunn: y
JamesScott: y
SidLehr: y
JoyFoxBeaudet: N
GregUpton: n
LindaCochran: y
LindaShell: n
CelestinaDiazdeValdez: n
SuannHosie: y

StephenPittenger: More N than Y from the group . . . .

StephenPittenger: Of those of you that ansered No, is it something that you sincerely wish to do in the near future Y or N?

JayNaylor: y
AlexSherer: y
MargaretRoberts: y
SheilaChisholm: y
NickNail: Y
CelestinaDiazdeValdez: y
GregUpton: Y
ChickNewman: n

StephenPittenger: IF I may open up the can of worms and ask . . . what is holding you back now?

NoreenLanza: y
JayNaylor: just switched to Avimark and adding bits and pieces of the program as I go
JoyFoxBeaudet: y
AlexSherer: Poor user interfaces to medical records
MargaretRoberts: knowing which software package to use. Afraid that it will be either too complicated to use or too time consuming
JoyFoxBeaudet: I do not own the practice yet and I need more information.

StephenPittenger: Medicine may well be the most information-intensive of all the professions and it is time to take advantage of the technology available to us. The transition to an electronic health record may be the most important step a practice can make, because it will directly affect patient care. A successful transition will significantly improve the administrative efficiency of a practice. A failure can be both frustrating and expensive.

For many years, veterinarians have had practice management systems that contained ""electronic client records"" or ECR's. This was the database of the clients that was used for billing, etc. As time went on, more and more patient data was filtered into the system until a hybrid existed, part ECR and part Electronic Patient Record (EPR). In the beginning, almost all of the data in the ECR/EPR was also kept in paper format, called the ""medical record"". Clinicians kept the things on the computer that it was designed to handle - like reminders, etc. The material was input during the ""billing"" process, but was supposed to be recorded in the paper medical record as well. The Electronic health record (EHR) is just what the name implies. It is a complete, accurate account of the medical diagnoses and treatments of the patient. The EHR contains everything the paper records used to, but in a different format. This format allows you to create, store and retrieve the charts on the computer. They should allow the veterinarian to input information as before, but empowers you to view the information in many more different and exciting ways.

For our purposes, we tend to think of the EHR as containing the ECR and EPR as well - basically an integrated program that ties the medical records processing directly into the billing/accounting section for the clients. I may slip up a few times tonight and use EMR or EHR and mean the same thing . . . we have changed to using EHR on the human side . . . .

AlexSherer: That is the problem. Most systems seem to be legacy invoicing/reminder systems with add-on medical records. I want something where the process of care is the core of the design and invoices are just a by product, not vice versa.

StephenPittenger: Good point - many are still built this old fashioned way. The emphasis has always been on the bottom line :) Here are some advantages of the EHR:
Cost Reduction through Greater Efficiency
Efficiency and increased productivity of the staff reduces the eventual overhead cost of the practice.

Gains may be seen with reduction of the "paper shuffle" allowing fewer staff to handle more records and patients per day. There are fewer "chart pulls" and dramatically less filing. Universal access to the chart means less searching and less lost charts and the improved productivity of allowing more than one individual to have access to the chart at a time. This, in turn, leads to a reduction in "phone tag" and improved internal communication.

AlexSherer: Perhaps such a design with the process of care at the core would have a greater bottom line!

StephenPittenger: I agree that one creates the other
Enhancement of Revenue

The EHR increases the accuracy of documentation and can lend to better fee capture and more complete reminder program for routine preventative health services.

Improved clinical efficiency and patient care
High quality documentation in the medical record (legible, organized, more complete) reduces errors and improves the care process. Enhanced productivity is possible through automation of some of the routine processes of medical records input.

Now that we have a few more folks that have joined us lets take another poll . What practice management software are you using currently? GA Everyone with your answers.

JayNaylor: avimark
JocRawls: Petware
MargaretRoberts: Visual
JoyFoxBeaudet: psi
DougWeeks: Softvet
NickNail: Avimark
GregUpton: Avimark
SidLehr: avimark
JamesScott: intravet
LarryNieman: AVI mark
JamesJorgensen: avimark
SuannHosie: AIS
CarolHillhouse: avs
AlexSherer: IMS
KennethKaucic: E-Friends
SuannHosie: !
DeborahEasterlingCharles: Avimark
NoreenLanza: impromed system

StephenPittenger: Now everyone can ""look around the room"" and see what other folks are doing the same thing they are and bonuce ideas of one another on the boards . . .

SuannHosie: You asked re: practice management software, but management of accounting is with Quickbooks. AIS has reports (income, mostly) I see practice management as separate from EHR

StephenPittenger: Thanks - I understand your division of those two tasks. How do I make the transition?
Use the EHR as the primary means of clinical documentation.
Start using the computer to record the progress notes, prescriptions, vital signs, and all other handwritten or transcribed documentation into the patient record.
Establish interfaces
Utilize existing interfaces and create new ones to gather data (especially lab data) into the patient record to reduce transcription errors and improve efficiency. Lab data capture can be utilized for both in-house and referral lab data collection.
Establish protocols for scanning - It is unavoidable that some of the clinically relevant data for the patient will arrive on paper. These documents can be scanned and converted to text (Optical Character Recognition) and placed into the EHR. Successful EHR practices are careful only to scan the information that is truly relevant to the patient record. Some materials may need to be entered by hand - this is an inevitable by-product of the transition.
Utilize clinical tools that support an EHR environment
Utilization of computer-based products, such as computerized ECG, digital capture of ultrasound and endoscopy images to avoid having to scan these items to capture them into the EHR.
Methodically retiring your paper charts in a steady fashion. It is not practical to convert all the paper charts in a practice at once. It will be necessary to at least summarize the salient points of a patient's history in the new system. This usually encompasses allergies, master problem lists, current medications, selective lab results and perhaps a recent progress note. Some practices choose to do this as the patients present for treatment; others choose to tackle the most frequent client/patients during idle hours. This process occurs over the first 6-18 months.

StephenPittenger: How many folks are using digital cameras to capture images in their practice?

MargaretRoberts: n
SidLehr: y
AlexSherer: n
LarryNieman: n
GregUpton: y
KennethKaucic: Y
CarolHillhouse: y
JamesScott: y
NickNail: n
SheilaChisholm: y
JayNaylor: y
JoyFoxBeaudet: n
SuannHosie: y
JocRawls: n
JamesJorgensen: y
CelestinaDiazdeValdez: y
DeborahEasterlingCharles: N
DianeOlszowy: y
NoreenLanza: y

StephenPittenger: This seems to be one of the first technological advances that veterinarians are making in the imaging department. Anyone using the camera to store images of radiographs and/or telemedicince with radiologist to read them?

JayNaylor: y
GregUpton: n
DeborahEasterlingCharles: N
NickNail: n
CarolHillhouse: y
SidLehr: n
DianeOlszowy: y
AlexSherer: We use a radiograph scanner that came with our telemedicine system.
JamesJorgensen: y
CelestinaDiazdeValdez: y
JoyFoxBeaudet: we also use the radiiograph scanner with our telemedicine system
SuannHosie: n
SuannHosie: (but will soon)

SidLehr: Is there any physical limit to the amount of data one can store about one's patient? Imagining takes up a lot of space

StephenPittenger: Only limited by the means that you employ to store it. Hard drives are relatively cheap these days you can store a bunch of images before it becomes a problem.

AlejandroGarcia: could you tell about your experience with telemedicine, Alex and Joy?
AlexSherer: We haven't run out of space after over a year of ultrasounds and radiograph scans. If we do. We'll just get a bigger hard drive!
JoyFoxBeaudet: We use Sound Technologies, I love it except for when the computer crashed which it did one week ago and we are still not back on line.

StephenPittenger: We are in a unique position when compared to the human medical field. The vast majority of our ""data"" stays within the confines of our hospitals. There is not an overwhelming need to share data amongst numerous systems (insurance companies, pharmacies, hospitals, etc.) We do not write/telephone as many prescriptions as our MD/DO counterparts do, so the information exchange problems there are not as great. There are, however, a few issues that need to be taken seriously in veterinary medicine. Standards in diagnosis and treatments need to be established so that we would be able to report the true incidence of diseases and research which treatments are most effective. The ability to screen our patients for drug interaction problems would be highly useful. We are a highly fragmented industry, with each hospital largely ""doing its own thing"". There is a general lack of standards at this time, but we are moving in the right direction and I do not feel that the lack of standards should be an impediment to starting this process.

The Business Side of Things
Making the transition to an electronic health record (EHR) is a major undertaking for any doctor, clinic, or hospital. It not only involves as expenditure of both human and financial capital, but it also requires a fundamental change in the way that healthcare procedures are conducted. Does it make sense from a business perspective? There is strong evidence that suggests that making the transition to an electronic health record is one of the most intelligent business decisions that a practice can make. Determining whether an electronic health record makes sense in a medical office is not strictly a numbers game. It is a function not only of finance, but also of the quality of services provided and the effect it will have on the clinical and administrative staff. In our profession, the relative cost associated with the hardware and software systems on the market today make this a viable alternative to the traditional record-keeping methods. In the human medical sector, the slowest to change is the solo and small practices. This is due mostly to economies of scale and the fact that large software vendors in the human market may employ up to 6 sales consultants and one technical consultant to make a single sale - this dramatically elevates the cost of their systems. Our systems are a relative bargain compared to other industries :)

Avoiding Crashes
Okay - what if your network goes down? Yep, you guessed it, you need safeguards for that as well. This is the hardware/software side of things - you probably cannot over-prepare for a disaster such as this, but you can definitely under-prepare. Technology exists to prevent ANY downtime; it just requires more money to achieve this state. In the computer industry, this is called fault-tolerance. You can guard against a hard drive crash with a ""mirrored"" hard-drive. You can also mirror the data to other machines on your hospital network. Battery backups/surge protectors can provide power during brief outages and protect against spikes in electricity. Veterinarians usually need simple networking systems, with a few needs for data safeguards. One word of advice for anyone who ever touches a computer: BACK-UP! Okay, so it is really two words and a hyphen - just do it - you'll thank me later. You can never back up too often.

Let me throw in one off the wall subject here. It ties into communication with the client and technology. Has anyone tried the language tools that are available on the web to facilitate better communication with your clients? One example of such a service is on the Google search page, called Language tools. This allows you to translate text from one language to another on the fly. Here is an example of a few lines of a discharge instruction:

English: Please observe the surgical site for any swelling, drainage, redness or discoloration. Please call the hospital immediately if you see any of these signs.
Spanish: Observe por favor el sitio quirúrgico para cualquier hinchazón, drenaje, rojez o descoloración. Llame por favor el hospital inmediatamente si usted ve cualesquiera de estas muestras.
French: Veuillez observer l'emplacement chirurgical pour n'importe quelle gonflement, drainage, rougeur ou décoloration. Veuillez appeler l'hôpital immédiatement si vous voyez un quelconque de ces signes.
Italian: Osservi prego il luogo chirurgico per tutto il gonfiamento, drenaggio, rossore o sbiadimento. Denomini prego immediatamente l'ospedale se vedete c'è ne di questi segni.
German: Beobachten Sie bitte den chirurgischen Aufstellungsort für jeden möglichen Swelling, Entwässerung, Rötung oder Entfärbung. Benennen Sie bitte das Krankenhaus sofort, wenn Sie irgendwelche dieser Zeichen sehen.

Although these are never going to be 100% accurate all of the time, it sure does break down that communication barrier that sometimes exists. I utilize these tools several times per year as I have a large Spanish speaking population here in Houston and I am quite rusty at speaking, reading and writing it these days. This allows me to present the instructions in both English and Spanish. I have also translated treatment plans, estimates and other client education pieces using these tools.

AlexSherer: I tried one of these tools with German and sent the result to a German friend. He said he understood what I meant, but it was a pretty rough translation and don't bother. But I guess that's better than nothing

StephenPittenger: Well - certainly if someone understood English - yes don't bother. But if it the only way to get a point across, that translation (albeit not 100%) can be a livesaver.

AlejandroGarcia: but can also lead to confusion

StephenPittenger: Absolutely - but so can my Spanish :)

AlexSherer: We just need to realize that all the meaning may not be getting through.

StephenPittenger: Lets talk about the security of your records - Alterability of them or prevention of that very same thing. Lets see about the protection from alteration of the data. We need some way to prove that what is contained in Fluffy's record at 8:30pm this evening is the exact same thing when viewed in January of 2005. Here is just one way to do that. At the end of July your data and program were backed up onto a CD. That disc was stored off-site with a company in a records warehouse in bonded storage. A courier came and pickup up the disc at your hospital, you signed it in on the log and the courier logged it in at the warehouse. The warehouse maintains security of their establishment and they vouch for the fact that you have not touched that disc since it left your office in July of 2000. The State Board asks to see your records about a dispute the client has about Fluffy's care back in July of 2000. You print out the records in your system at the office and present them to the Board. They want to be sure that you didn't ""doctor"" the record. You give them written permission for the investigator to obtain the CD from the storage facility (you do not go get it yourself!) as evidence you have not altered the record - it contains the exact same data regarding the incident. This is the safest way I know possible and involves a neutral, bonded, third-party. As far as ""inalterability"" of most programs on the market for us today - the data could probably be altered in some way. The above scenario would be a good safeguard. The money you used to spend on printing costs now goes into CD storage.

AlexSherer: Authentication is another weak spot with veterinary EHRs. You can't recognize people's handwriting in an EHR and many systems allow entries without timing out users or forcing repeat log ins with passwords. This could also lead to legal problems

StephenPittenger: Yes - problems exist with authentication at this point because it costs more money to place more safeguards into the programs. Digital signatures are now making their way into the human medical world . . .

AlexSherer: I don't think timing out inactive users or asking users to repeat log in every 5 minutes would cost much. It's just a hassle.

StephenPittenger: If the users of the program do not want a feature (ie. they see it as a hassle), the programmer is not going to hassle with it either. Too many people look at those of use who are ""paperless"" with glassy eyes and wonder what magic occurs in our offices. We still provide patient care and have the need to document that care - we just do it on the computer. We can type it in, scan it in, speak it in, import the text in, save the pictures within, etc

AlexSherer: The authentication technology won't matter if you don't make it hard for different people to assume your identity after you authenticate.

StephenPittenger: - we can even print it out on PAPER! In fact, we go through lots of paper. There are times, when viewing an extended history that reading things chronologically on paper is easier than navigating the EHR. Those times are greatly outweighed by the number of times the computer can give you the information faster than you could look it up on paper. If this tool will allow us to improve efficiency (and thus $), reduce errors and improve patient care, then the focus is right.

StephenPittenger: Let me be quiet for a little bit and see what questions you guys have - I'll see what answers we can come up with.

JayNaylor: Stephen, can you comment on how much of the canned software you use for exam findings and how much you rely on self made ""macros""

StephenPittenger: Canned as in it came with the program and self made macros meaning I created the template?

JayNaylor: yes

StephenPittenger: I use only self-made information - my style of medicine mandates that I practice it MY way :) I use templates for some common presentations . . . .

StephenPittenger: Let me touch on data entry for a moment. One key concept is data entry. As shown in the graphic to the right, there is often a trade off: speed vs. flexibility. Although some may type much faster than the write, it is assumed in this model that the doctor is not a proficient typist. Dictation or transcription is not a usual and standard mode of data entry in veterinary medicine at present, but voice recognition systems are now readily available and do represent an additional choice. Expert systems involve the use of complex prompting algorithms and are usually set up by the programmer. Although this may speed data entry, you may be forced to practice medicine and document your cases in a style that does not agree with your philosophy. Template driven records are the most common implementation in veterinary electronic health records. There is wide variation in the speed and flexibility here due to the inherent simplicity or complexity of the presenting case. Your template designed for the typical fleabite dermatitis may serve you well in a typical case, but you may compromise a little speed or flexibility when using it for a slightly atypical presentation.

AlexSherer: Do you know anybody who uses an Application Service Provider type of software and if so, how it is working out.

StephenPittenger: Very few using ASP technology - it is only good as the last mile of telephone cable to your practice :) Anyone using ASP technology in the room tonight?

AlexSherer: Some providers are providing local buffer that can last quite a while if the DSL goes down.

TerillUdenberg: how about wireless conections at your clinic?

StephenPittenger: To the internet or amongst the terminals in house?

TerillUdenberg: terminal

StephenPittenger: Problems arise with the solid walls that we tend to build to reduce noise levels in hospitals. Some of the newer technology is making it easier, but many hopsitals have ""dead spots"" in the building where the signal just won't go there. There are quite a few folks who are taking advantage of this technology for a few workstations (laptops usually) as it is easy to bring them online and off (like in the case of a laptop that goes home with the doctor at night). Avoids needing to pull all that cable - I love crawling up in the ceiling in the fiberglass :)

JoyFoxBeaudet: Could you describe the overall flow of how this would work? Are there laptops in exam rooms and the treatment areas? Which system do you recommend? How fast are the programs changing and improving?

StephenPittenger: Computer needs to be anywhere data entry should and can occur. As far as recommendations, the best resource is probably the AAHA Trends survey, published every 2 years in June/July - this is a survey of practices across the US - what software they use and how they rate it. I personally use AVImark. Some of the programs are evolving rapidly (like whitewater rapids), some more like stagnant pond water. It depends on the development process in place - a few programmers getting their hands dirty vs. a committee that sit at a table and talks forever before actually deciding on a new feature.

Overall - I like terminals in the exam rooms - I use mine every day - some prefer not to have them in their - I see it as a tool to help me be more efficient. I can do data entry during the history taking and examination - when I leave the room, I'm done.

SidLehr: Speaking of backups, as you were before, how important is it to have an off-site back-up? With the size of the systems and data files today back-ups are done in the middle of the night.

StephenPittenger: If you do not take your backup off site, it is worthless. Fire and flood are not kind to data.

SidLehr: How often do you do that?

StephenPittenger: Every evening, the core data is taken outside. Non-essential data is done once monthly

JayNaylor: My clients love having the terminals in the room (a lot are Dell employees) Also,it is important to orient your terminal to still face clients

TerillUdenberg: dvm manager-we use digital pictures to follow surgery orRx etc right in their file (skin cases and their progression)

StephenPittenger: Yes - Good point Jay - my clients are always to the left of me in my exam rooms - my back is never to them.

StephenPittenger: Thanks Terill - my favorite is a corneal stain progression for the owner to see the healing process. And a bonus if another doctor has to see the case for you along the way - drawing the lesion in the record is so old fashioned :)

StephenPittenger: It is a little past 11 EST - any last minute questions? Post anything to the Boards - Computers or Practice Management and we will try to get you an answer :)

JoyFoxBeaudet: Do you recommend any other sources for information on this topic?

StephenPittenger: There is not a lot of information out there geared towards the Veterinarian . . . .

TerillUdenberg: Western states Vet conference is a fantastic source of info

StephenPittenger: the Texas Veterinary Medical Association is presenting a whole three day seminar on these issues Feb28-March2nd

NoreenLanza: Can you recommend an emergency protocal for the staff when the computer does go down? Do you print anything , like schedule or prices every day or appointment etc, or health record just in case? What other forms of protection do you use besides backing up, mirroring etc.

StephenPittenger: An appointment schedule is nice to have if the lights go out :) So is a current listing of prices - so you can still get paid for what you do. Everything else just transitions back to good 'ol paper until you are up and running again.

NoreenLanza: how often does that happen in your practice, and how long are you down for?

StephenPittenger: Clean out your machines every 6 months - the amount of hair and dust will kill the fan motors and power supplys - need to do preventative maintenance. Happens every once in a blue moon - longest time down has been about 7 hours. Be Prepared is a good motto. Any other questions before we call it a night?

JayNaylor: If all power is out...can't exactly practice anyway
NoreenLanza: thanks, I will ask more specifics on the boards, we are in the process of trying to make an emergency protocal for the staff and I wanted to get some ideas. thanks and goodnight
LindaShell: Thank you Dr. Pittenger! It was a very informative session!
NickNail: Great Session Stephen
JoyFoxBeaudet: Thank you for the great session - good night.

StephenPittenger: Thanks for having me tonight - hope you leave with some good thoughts :)

JayNaylor: Thanks Stephen, I will be in College Station late Feb. at TVMA winter conf. and hope to meet you there.
GregUpton: Thanks Stephen. Great session.
SheilaChisholm: Thanks a lot!
JeffreyKubinec: thanks
SuannHosie: thanks, Stephen
AlexSherer: Thank you.
TerillUdenberg: thanks
SusanGatto: thanks


Conference Room participants: LeslieRoss EricGriesshaber VINGUEST2 StephenPittenger RobertWeiner VINGUEST2 VINGUEST3 TedSchulz SheilaChisholm ScottErickson AlejandroGarcia RobertLukas JeffreyKubinec AlexSherer JayNaylor JamesScott JocRawls MargaretRoberts WSteveWhitaker SidLehr LindaShell KathKlassen KathyJames KatharineLunn PhyllisWebster GregUpton JoyFoxBeaudet NickNail BeckyLundgren NoreenLanza LindaCochran KennethKaucic SuannHosie CelestinaDiazdeValdez ChickNewman SusanStrattman JamesJorgensen ColeenHarman KarenKommes CarolHillhouse LarryNieman DougWeeks DeborahEasterlingCharles SusanTarver LJMcdaniel DianeOlszowy GingerSanders MargaretRoberts SusanGatto KathleenCavanagh KennethKaucic ChaimLitwin TerillUdenberg RandallUlrich NoreenLanza MichaelBosilevac RonScharf DawnPerri BruceBauersfeld AlexSherer



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