I mentioned in my first post that I was going to jump around quite a bit in this blog in order to allow both current EHR users and future EHR users benefit. Today's post will take a look at how the progress note is created in the EHR I am currently using in my practice. As you will no doubt learn, no EHR is perfect and the one I am using is far from it. One must learn to retrain oneself in order to accommodate for the inadequacies associated with whatever EHR you choose. I will go more into detail about specific EHR's and why I chose the one I did in future posts. I will also discuss the various demos and some of the pitfalls to avoid during an EHR demo. However, in this post I wanted to provide a quick overview of one method of creating a progress note - as this really gets down to the nuts and bolts of using an EHR. Remember, I am not providing this information to get you to use the EHR I use. In fact, I would prefer that you don't pick the one I use because then you won't blame me when you get to the "hate" part of the love-hate relationship with your EHR that inevitably develops along the way (you'll see what I mean in a future post).
To start with, any EHR you choose will have some templates available, but I can guarantee that you will need to customize these to your own liking. In fact, many times I will use only a very basic skeleton template and most of my chart note will be dictated using Dragon NaturallySpeaking. I prefer this for many of my notes as this is the method I am accustomed to using, having been a Dragon user for over 10 years. Dictating with Dragon also makes the note easier for me to read on subsequent visits as well as being able to provide a narrative rather than a series of yes and no answers. Each person will have to decide on what works best for them and much of it is trial and error. I have found a combination of Dragon dictation and templates works the best for me. As you will most likely need some templates, here is a link that can help give you some ideas in creating templates Example Templates. Some of the examples are not very good, but I've found the ROS Template useful. In a future post, I will provide a link to download some of the exact templates I use. I would also love to have some readers contribute to this collection as well (hint, hint).
In this demonstration I'm going to show one method of creating a progress note using only a template and no dictation. Almost all EHR's will work in a similar manner providing clickable options as well as pop-up pick lists. What the demos don't usually show is what is involved in creating the clickable options and the pick lists. This can range from a simple editing process to a very complex series of steps. Was the template I used in this EHR easy to make? No. It took several hours to generate the pick-lists and clickable items. Unfortunately, the EHR I use leans more towards the complex side of template development. I have learned to live with this inconvenience and made this compromise in order to achieve several other benefits of the program which I will discuss in one of my next posts where I explain the logic I used in choosing my current EHR. This is all part of weighing the pros and con's of choosing one EHR over another. Am I going to stay with this EHR? Yes, for the time-being. It works fairly well and has many nice features. It also has some attributes that frustrate the heck out of me. I will go more in-depth in a future post about why I love this EHR and why I hate it.
The first video shows a basic ingrown toenail template and its use. As with most EHR programs various data is pulled from other parts of the electronic chart such as vital signs, current medications and allergies, past medical history, etc. and inserted into the current progress note. Some programs may look easier to use than others but it usually has to do with the person doing the demonstration having familiarity with the program. I don't think there is such a thing as the "easiest to use" EHR. They all take effort on the part of the practitioner to learn how to best utilize the strengths and weaknesses inherent to that particular EHR.
This second video is a very brief demonstration of how an image template can be used for examination in diabetic peripheral neuropathy.
As always I welcome your comments, questions and suggestions - let me know what you want to see in these posts.
Upcoming posts include "Show Me The Numbers - How much Did My EHR Cost" and "Where's The Logic - How Did I make My Decision"
Be sure to read my first post below (scroll down) if you missed it.
I used Acrendo for a little over a year. Your intuitions were correct. I missed eRx incentives because they could not qualify for surescripts certification and they kept promising fixes and updates that rolled out to slowly and inadequately to be useful. The system had several flaws making Amazing charts with a Lytec or similar billing program a much better choice. They have had some upgrades in recent years since I stopped using the program, but I do not fully trust them to survive the new regulatory environment with a compliant AND useful product. Their billing is useable, I do not think your claims would be left unsent, but data mining unpaid claims is completely inferior to other well known programs, and this is what separates the wheat from chaff in my opinion. If you own it and it is working for you, I would not throw it away. But there are better choices for someone just about to make a purchase today. My exiting the program was partly due to a new biller that did not feel the program was as effective as other programs. I have since taken over my billing, and agree, Acrendo is not a smooth effective billing program. Unless changes have been made there were very long "hang times" between switching between each patients chart after about a year of data entry despite being an MS SQL database program.
ReplyDeleteI now use e-MDs which is very good. There biggest negative is that They update frequently and this often causes the program to get "buggy" by the time the bugs are worked out it becomes necessary to update again. The billing component is excellent and the EMR is very good.
It is primary care focused, but very customizable. MU may change opinions on this one as it's weak point noted by some users is the patient portal. I don't use it yet so I have no opinion on it. I can say that I like e-MDs enough that I would keep the EMR and take the penalties rather than change for a better patient portal. But I also, am of the opinion that MU 2 and 3 will be more work than the incentive is worth anyway.
Nice Start to the Blog.
Thanks for the great comment. I'm glad to see that my impressions of Acrendo were correct. As I said, I think the program has a lot of potential. It just needs to be developed further. I am also glad to hear that you are happy with e-MD's. I was quite impressed with their screen shots and had it not been for the fact that my biller was very comfortable with using Lytec I would have considered e-MD's more seriously.
DeleteAs to your point about updates, the potential for "bugs" as you put it is exactly why I have not applied any of the updates to my EHR for the past year. None of them were critical and I am waiting until there is a new release which incorporates the previous updates. I also have not started to use the patient portal but would like to consider this in the next 6 months. I am still trying to decide if I want to apply for the second year incentive. As you have noted, it might entail more work than it is worth. I calculated with my current work schedule that the second year incentive would net me an additional $50 per day. I have to decide whether or not the extra time it takes me to comply (which is usually at least one hour and sometimes more per day) makes it worth it. I'm thinking my time is worth much more than that so it probably is not worth it.
I would love to see a video of e-MD's in action such as creating a progress note or something else that you feel represents the program. There is an excellent FREE screen recording utility called BB FlashBack Express that you can download here: http://www.bbsoftware.co.uk/BBFlashBack/Download.aspx (Download the Standard Version). If you create a video you can upload it to YouTube and I can place a link to it on my blog.
Thanks again for the comment.
- Roger
Your blog is fantastic!
ReplyDeleteI think you alluded to what is going to happen in the future: As the incentive shrinks and we head to stage 2 and 3 of MU, less and less doctors are going to participate. Who will find it worth 2K in 2015 to comply with Stage 3?
The government should have just given us the program (ie the VA software called CPRS)and then medical records would be connected and we would really be using the EHR in a "meaningful" way. But they knew the public didn't want their records in a central database because of concerns re: privacy. So CMS decided to give us fairly large incentives just so everyone gets a system, then they will ratchet down the requirements,force everybody to be interconnected and report the information they want. I just don't think it will work when the requirements are so difficult (until the penalties for not having the EMR are high, maybe ~10%). By then, I imagine most companies will merge or go out of business and we will be left with a single EHR that takes over.
Dave -
DeleteThanks for your nice comment. You hit the nail on the head when you said it won't be worth 2K to comply with Stage 3. I'm having a hard time justifying complying with 12 months of Stage 1 for 12K. You also make a great point that it would have made a whole lot more sense (and probably cost less) to get everyone on the same system from the very start.
- Roger