AC Group’s 2007 Annual Report
The Digital Medical Office of the Future
Computer Systems for the Physician’s Office
May 2007
Comprehensive Report on:
Overview of Physician adoption The Six Levels of Physician IT Maturity Practice Management Marketplace Secured Internet Document Image Management PDA and Mobile Healthcare Electronic Medical Record Functionality Electronic Medical Health Marketplace Regional Healthcare Information Organizations
Mark R. Anderson, CPHIMS, FHIMSS Healthcare IT Futurist AC Group, Inc.
(v) 281-413-5572 [email protected]
www.acgroup.org AC Group’s 2007 Annual Report The Digital Medical Office of the Future Computer Systems for the Physician’s Office More about the Author
Mr. Anderson is one of the nation's premier IT research futurists dedicated to health care. He is one of the leading national speakers on healthcare and physician practices and has spoken at more than 350 conferences and meetings since 2000. He has spent the last 30+ years focusing on Healthcare – not just technology questions, but strategic, policy, and organizational considerations. He tracks industry trends, conducts member surveys and case studies, assesses best practices, and performs benchmarking studies.
Besides serving at the CEO of AC Group, Mr. Anderson served as the interim CIO for the Taconic IPA in 2004-05 (a 500 practice, 2,300+ physician IPA located in upper New York). Prior to joining AC Group, Inc. in February of 2000, Mr. Anderson was the worldwide head and VP of healthcare for META Group, Inc., the Chief Information Officer (CIO) with West Tennessee Healthcare, the Corporate CIO for the Sisters of Charity of Nazareth Health System, the Corporate Internal IT Consultant with the Sisters of Providence (SOP) Hospitals, and the Executive Director for Management Services for Denver Health and Hospitals and Harris County Hospital District.
His experience includes 32+ years working with Healthcare organizations, 20+ years working with physician offices, 7 years in the development of physician-based MSO’s, 17 years with multi-facility Health Care organizations, 15 years Administrative Executive Team experience, 6 years as a member of the Corporate Executive Team, and 9 years in healthcare turnaround consulting. Mr. Anderson received his BS in Business, is completing his MBA in Health Care Administration, and is a Fellow with HIMSS. Additionally, he serves on numerous healthcare advisory positions and has developed programs including:
Developer of the Six-levels of Healthcare IT for Hospitals and the Physician Office Researcher and producer of the 2002-2007 EMR Functional rating system Advisory Board and Content Chairman - Healthcare IT Outsourcing Summit, 2002, 2003, 2004, 2005 Advisory Board and Content Chairman - Patient Safety and CPOE Summit, 2002, 2003, 2004, 2005 Advisory Board and Content Chairman – Consumer Driven Healthcare Conference, 2003, 2004 Advisory Board and CPOE Chairman - Reducing Medication Errors, 2003, 2004, 2005 Advisory Board of TETHIC 2003, 2004, 2005 Advisory Board of NMHCC 2000, 2001, 2002, 2003, 2004, 2005 Advisory Board of TCBI Healthcare Conference 2000, 2001, 2002, 2003, 2004, 2005 Advisory Board of TEPR and MRI, 2000, 2001, 2002, 2003, 2004, 2005 Past President of Local HIMSS Boards – Houston, Tennessee, Southwest TX Editorial Board of Healthcare Informatics 2001, 2002, 2003, 2004, 2005 Judge, MSHUG ISA, 1999-2005, TEPR Awards, 2001-2002, TETHIE 2003-05, HDSC 2003-05 National HIMSS Chapters Committee 2001, 2002, 2003, 2004 National HIMSS Fellows Committee 2001, 2002, 2004 National HIMSS Programs Workgroup Committee 2001, 2002, 2003, 2004
More about AC Group:
AC Group, Inc. (ACG), formed in 1996, is a healthcare technology advisory and research firm designed to save participants precious time and resources in their technology decision-making. AC Group is one of the leading companies, specializing in the evaluation, selection, and ranking of vendors in the PMS/EMR/EHR healthcare marketplace. Twice per year, AC Group publishes a detailed report on vendor PMS/EHR functional, usability, and company viability. This evaluation decision tool has been used by more than 5,000 physicians since 2002. Additionally, AC Group has conducted more than 100 PMS/EHR searches, selections, and contract negotiations for small physician offices to large IPA since 2003.
More than 500 healthcare organizations worldwide have approached their most critical IT challenges with the help of trusted advisors from ACG. Since 1972, ACG advisors have been helping healthcare professionals make better strategic and tactical decisions. This unmatched combination of market research and real-world healthcare assessment gives clients the tools they need to eliminate wasteful technology spending, avoid the inefficiency of trial and error, and discover a superior alternative to "guess" decisions. For our healthcare physician clients, ACG provides independent advisory and consultative services designed to assist physicians in evaluating and selecting technology to enable the creation of the “The Digital Medical Office of the Future”.
Please review the attached document, feel free to contact me if you have further questions. Houston office (281) 413-5572 or by e-mail at [email protected] Are You Ready To Embrace Newer Technologies?
AC Group, Inc. (AC Group), formed in 1996, is a healthcare technology advisory and research firm designed to save participants precious time and resources in their technology decision-making. AC Group is one of the leading companies, specializing in the evaluation, selection, and ranking of vendors in the PMS/EMR/EHR healthcare marketplace. For the last three years, AC Group has produced an annual report on the Digital Medical Office and the use of Technology by physicians. This comprehensive report includes detailed reviews of the Mobile Healthcare, Document Imaging, and EMR marketplace. The report also includes the most comprehensive evaluation of vendor EMR functionality to date - more than 5,000 questions. This evaluation decision tool has been used by more than 25,000 physicians since 2002. Additionally, AC Group has conducted more than 100 PMS/EHR searches, selections, and contract negotiations for small physician offices to large IPAs since 2003.
• How do you determine if you are ready to “leap” into the EMR or replace your PMS application? • Can you always believe what the vendor tells you? • Where does a group go to find third-party independent evaluations of vendor’s functionality, financial viability, customer support, and overall best price? • How can you determine if there is a quantified return on investment (ROI)? • How can you leverage the use of an EMR or new PMS to improve reimbursement, improve quantified clinical quality, and reduce malpractice costs? • Who can you turn to for third-party independent advice?
The answer: AC Group’s Physician Technology Evaluations
Our Advisory and Consultative offerings are numerous, and can be customized to your practice’s unique priorities. As you will see later on in this document, the pricing is based on the size of the practice and the number of days selected. Unlike other consultants that represent vendors, AC Group is neutral and we never receive compensation based on the vendor selected – we are third-party advisors to your practice. I believe that to thrive in the healthcare market, every physician group should have interaction with independent Healthcare IT futurists who do not represent any companies. Our proposal gives you the opportunity to interact with one of the top healthcare IT analysts and futurists throughout the project. To assist your organization, we have created five options:
Option 1 – Educational Update – For those organizations that are just starting the process of considering newer Technologies or just need a third-party independent review, AC Group can provide your practice organization with an educational update on the “Digital Medical Office” of the future
Option 2 -Technology Briefing and Readiness Review - AC Group can provide your practice with a technology briefing and readiness review. Under this option, Mark Anderson will come to your practice, meet with members of the practice, will present information on technology and software options and will conduct a brief operational review of your practice’s readiness.
Option 3 - Contract Negotiations – For those practices that have already made up their mind on which application they would like to purchase and install, AC Group can assist with contract review and negotiations. Probably the most tedious and important step of the entire process is contract negotiations.
Option 4 - Vendor Search/Selection and Contract Negotiations – AC Group can become your advisor on the project. Under this option, one of our experienced consultants will be available for conference calls to discuss which vendors you should consider based on 10 operational considerations.
Option 5 - Operational Assessment, Vendor Search/Selection and Contract Negotiations - AC Group can provide your practice with a comprehensive program to ensure that your practice selects the best system(s). Under this option, an experienced consultant will come to your practice, meet with your practice representatives, present information on technology and software options, conduct an operational review of your practice’s readiness, and will assist with the numerous tasks required to select the right system. This option includes all tasks described in Option 4 and, in addition, on-site consulting for operational review and vendor demonstrations.
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AC Group’s 2007 Annual Report The Digital Medical Office of the Future Table of Contents
Section Description Page
1 Overview of the Physician Technology Marketplace 6 – 36
2 Six Levels of Physician IT Maturity 37 – 39
3 Level 1 – Practice Management Systems 40 – 69
4 Level 2 – Secured Internet Connectivity 70 – 77
5 Level 3 – Document Image Management 78 – 97
6 Level 4 – PDA and Mobile Healthcare 98 – 121
7 Level 5 – Electronic Medical Records 122 – 144
8 EMR Spending and Financial Conditions 145 – 152
9 Choosing the Right EMR 153 – 158
Detailed Comprehensive Review of selected Vendor EMR 10 159 – 179 applications
11 EMR Performance Testing And Demo Scripts 180 – 205
12 EMR Pricing and Costs 206 – 210
13 Financial Questions for EMR Application Vendors 211 – 213
14 Listing of Participating EMR Vendors 214 – 231
15 EHR Road Map 232 – 237
16 Practice Protocols 238 – 259
17 Case for Improvement 260 – 261
18 Assessing Your Practice Discoveries and Actions 262 – 263
rd 19 Measure 3 Next Available Appointment 264 – 268
20 EHR Implementation Team 269 – 272
21 Change Management and Quality Improvement Processes 273 – 273
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Section Description Page
22 Implementation Critical Success Factors 274 – 277
23 How to Improve Access 278 – 291
24 Contracting with the IT Vendor 292 – 305
25 Implementation Phased Checklist 306 – 307
26 Common Implementation Issues 308 – 310
27 Redesigning the System 311 - 314
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A. Introduction:
Let’s move past today and imagine that it is January 2007. It is not beyond reason that a visit to a doctor’s office will be as streamlined as connecting through a portal on the Internet to schedule an appointment. Admissions happen via voice command and thumbprint technology. Diagnostics are ordered based on information during admissions. Examination rooms equipped with personal computer stations or wireless tablet computers will enable the physician to view a patient’s medical record with the click of a mouse or an electronic pen. Lab results will be available immediately for viewing during the examination. Prescriptions can be entered in via voice command and filled immediately by your pharmacy. Billings will happen automatically and electronically … and it is not out of the question that electronic payments to the practice’s bank account could happen within 48 hours of an office visit.
Physician practices, like all of healthcare, have been reluctant to spend appropriate dollars on technologies to improve operations. In today’s environment, physicians are being challenged to practice medicine and run a profitable business. Decreasing reimbursements and lower net profits have forced radical changes in practice management and have accelerated the adoption of technology beyond the basic billing office. Many companies have created technological solutions addressing various “pain points” within healthcare. These companies have focused on areas in which they perceived to be inefficient and in need of automation. A staggering myriad of solutions is available to medical practices, making it necessary to wade through the options to find the best solution.
The challenge for now is to find a foundation of technology that will enable you, the physician or healthcare information manager to build a complete solution in the future. The foundation must be based on a strong Practice Management System (PMS) and newer technologies that enable the practice to automate the clinical processing within the practice. Seeking product differentiation, leading PMS vendors are rolling out an ever-widening array of optional modules and are tailoring PMS to meet the rapidly changing needs of the practice management system market. Top EHR vendors and now adding PMS functionality for small, midsize, and large group medical practices and the fast-growing management services organization (MSO) and Independent Physician Associations (IPA) market. This trend will continue through 2008 as group practice consolidation accelerates and the average practice size continues to grow.
For the past 20 years, the healthcare marketplace has used numerous terms to describe the electronic capture of patient specific clinical, financial, and demographic data. In the 1980’s the term Electronic Patient Record (EPR) became popular. The EPR included silos of information collected with hospital departments and in the ambulatory setting. Many times, the EPR included only patient laboratory data. In others, radiology data could be stored in separate EPRs, nursing documentation in others, and physician documentation in a third. EPR did not include comprehensive clinical knowledge based protocols and alerts based on the patient age, sex, and general medical
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history. The industry needed one system that maintained all of the patient’s medical records in one unformed system no matter where the data was collected. The industry needed a patient centered Electronic Medical Record (EMR).
The new EMRs provided all of the functionality of the older EPRs but consolidated the silos of information into one common format. Through this consolidation, clinical decision support, formulary compliance, medical necessity checking, and automated Evaluation and Management (E & M) coding based on Medicare’s 1998 rule set were added. However until 2003, many organizations still maintained separate silos of information, separating hospital data from physician-based clinical data. One reason was the lack of clear data exchange standards. The future of healthcare documentation is now under a new term called community-based Electronic Health Records (EHR).
The EHR includes all components of the EPR and EMR plus the ability to combine data from multiple organizations via a new standard classified as the Continuity of Care Record (CCR). The EHR allows care providers to view information from multiple sources in one common view plus the addition of the patient’s Personal Health Record (PHR). The PHR allows the patient to record “health” related indicators via a personalized web site. This data includes patient’s social and medical history, family history, and daily recording of clinical information between medical visits to the care giver. This new combined EPR, EMR, and PHR all reflect the future of healthcare – the EHR. However, to secure the data, every healthcare provider must ensure that their data system meets all of the new compliance requirements for recording storage, security, and confidentially. Comprehensive community-based EHR solutions enable: • Integrated view of all patient information across multiple patient, clinical, and financial systems. • Improved system security and privacy for adherence to regulatory requirements.
Healthcare in the United States is at the beginning of a technology revolution as previously paper based processes moves online. The challenge for now is to find new delivery technologies that will enable the physician, hospital, or Integrated Delivery Network, to build a complete solution that enables the Digital Medical Office of the Future to become reality. The foundation is likely a clinical information management tool that serves as the connecting point or collection device for all of the technology deployed within the healthcare delivery marketplace. Today, we call this technology “Electronic Medical Records (EMR) and Electronic Health Records (EHR).” This repository of information will enable the care provider access to information that flows into, or out of, a community. Healthcare end users need to ask themselves whether all of this patient information could reside in one system.
The answer is yes.
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However before you run out and purchase such as system, you may want to research the amount of “local support” that each of the vendors provide. We have found that there is a direct correlation between the type and amount of support provided, especially local support, and end-user satisfaction. In fact, 89% of the practices that were very happy or extremely happy with their EMR also indicated that they had local support for the product. Conversely, 76% of the practices that were not satisfied with their product had no local support – the support was provided by a national office located outside of 2-hour driving range.
During the 1990’s companies like Medical Manager (WebMD), Compusence, NDC (Lytec and Medisoft) and Millbrook developed an extension network of local sales and support executives, aka, Value-added resellers (VARs). These VAR’s sold the products locally and provided local support for the applications. Physicians became use to having representatives visiting their offices on a routine schedule to insure that everything was operating effectively. Other healthcare professions like pharmacy detail representatives and office supply store representatives followed the same model. Today however, many of the technology applications are being sold via internet “web casts” and in 38% of the cases, the physicians never meets the technology company’s sales representative until after the sale. This model of sales and support is cost-effective to the software vendor, but we wonder how effective this method will be in the long-term for the physician’s practice.
To insure that a practice makes the right technology decision, we recommend three standard protocols:
1. Obtain advice from outside experts in the healthcare software and technology Field – those with extensive software knowledge and the ability to rank the various vendors based on specific criteria.
2. Look towards vendors that provide local support for their product – within 100 miles of your central office location. If they do not provide local support, clearly understand “how” you will be supported.
3. For small practices with < 10 physicians, consider an ASP options in order to decrease risks and to insure adequate technology overview.
Many companies have created technological solutions addressing various “points of pain” within healthcare. These companies have focused on areas in which they perceived to be inefficient and in need of automation. A staggering myriad of solutions is available to medical practices, making it necessary to wade through the options to find the best solution.
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B. 3rd Party Independent Evaluations
The current pressures in the industry for increased efficiency and better care delivery, coupled with significant advances in technology and applications, have enabled EHRs to take center stage. The challenge with EHRs is that it is very difficult for the average physician practice to effectively evaluate its’ options. Physicians are looking for a 3rd party independent evaluation of the various EMR/EHR offerings in the marketplace today. To evaluate how well and completely each of these offerings meets the real needs of physicians, AC Group, Inc. conducted semi-annual evaluations in Spring of 2002, 2003, 2004, 2005, and 2006 and then again in October of 2003, 2004 and 2005. The AC Group technology functionality report is based on 48 months of research and the cumulative results of a 90- page questionnaire distributed to each participating vendor. The EHR survey includes 2,300 functional questions divided into 47 categories, while the PMS survey includes over 1,000 functionality questions divided into 26 categories.
The 47 functional categories included a section on the Institute of Medicine’s (IOM) requirements for a computerized patient record (CPR), along with functional questions relating to operational areas including prescriptions, charge capture, dictation, interface with laboratories, physician order entry, decision support and alerts, security, personal health records, reporting and documentation. To assist the physician community, the AC Group report quantifies six specific components necessary to ensure that a physician or a group of physicians have made the right choice. The components include:
1. Product Functionality – How well a product meets the basic requirements of a comprehensive EHR based on the guidelines of the Institute of Medicine and the detailed comprehensive survey of functionality based on AC Group’s 2,800+ EHR functionality survey.
2. End-User Satisfaction – How well a company performs in relation to “End-User Satisfaction” surveys conducted by independent analyst firms such as AAFP such as KLAS (http://www.healthcomputing.com/) and AC Group, Inc. (www.acgroup.org)
3. Company Financial Viability – The strength of a company in relationship to their annual revenues, profitability, and percentage of revenues that are placed back into future development.
4. Client Base – The strength of the company’s EHR client base and their ability to understand and meet the needs of their current and future clients.
5. Technology – The strength of the Ear’s use of proven technology that enables a practice to become a digital office of the future.
6. Price – The total price of the solution should be considered when making a decision – not just the price of the software. Practices should determine the “Total Cost of Ownership” (TCO) when evaluating the numerous potential solutions.
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Through AC Group's research, we have learned that, while having the appropriate level of functionality is critical, providers require a vendor that will support and continue to develop the product. Therefore, the 2007 report employs a point system based on a combination of the following major sets of criteria: functionality, company size, client base, end-user satisfaction and price. This point system provides a more comprehensive view of the ability of the end-user to derive benefits from the product. Each set of criteria has been weighted, and each vendor was assigned a “Total Weighted Point Value”. Additionally, in the 2007 report, AC Group divided the rankings based on the following product types:
o EHR Vendors – Full EMR capability, with internet-based Personal Health Records, health maintenance tracking, proven interoperability with other EMR vendors, national clinical standard couplers, and clinical decision support with nationally recognized alerts, etc. The application must have interfaces to multiple Practice Management Systems. We further divided this category between large multi-specialty clinics and stand-alone practices.
o EMR Vendors – Full charting and Document Imaging Management, along with e-Rx with formulary tracking by healthplans, automated E&M coding and verification, medical necessity checking by CPT and Diagnostic codes, comprehensive orders and results reporting, with integrated workflow routing and tracking. The application must have interfaces to multiple Practice Management Systems. o Charting Vendors – Ability to simplify the charting requirements, as specified by many of the medical societies and the IOM. Advanced functionality must include orders and results reporting, problem list and e-Rx tracking. The product does NOT have to have advanced nationally recognized alerts and clinical decision support. The application must have interfaces to multiple Practice Management Systems. o Document Imaging Management (DIM) Vendors – Ability to scan and store paper documents by patient and by sub-folder, along with the ability to electronically receive and file documents that are received either electronically or by fax, including Lab results, transcribed reports, and hospital ADT information. The DIM must have integrated routing and workflow capabilities and interfaces to multiple Practice Management Systems. o Community Health Record (CHR) Vendors – These vendors may not have a full functioning EMR but provide the interoperability functions of an EMR-Light along with the ability to maintain a community health record via a community clinical and demographic data exchange. Advance functionality includes reporting and tracking of orders, results, e-Rx, allergies, and problem lists, among others. The product should maintain a community master patient index, based on numerous inputs, including hospitals, healthplans, and numerous physician practice management systems. The Community Health Record vendor must also be working with various EMR/EHR vendors, to ensure effective clinical data exchange, following national standards like CCR or other recognized future interoperability standards. o FQHC – In May of 2006, AC Group added a new category for Federally Qualified Health Centers (FCHC) since these centers require more government reporting and clinical oversight. o In May of 2005, ACG added also a new category for Integrated PMS and EMR vendors – Our research has shown that more than 72% of the selections in 2005 have been for both Practice Management and EMR/EHR applications. Starting in 2005, ACG started tracking those vendors that provide a tightly interfaced or integrated solution.
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The AC Group selection methodology provides physicians with a simple methodology that they can use to help reduce the number of choices. According to our research, the number of vendors that state that they sell an ambulatory EHR is currently over 250 – too many for any one physician to consider. Through the use of this methodology, practices can reduce the number of potential choices to the top 5 to 10 EHR/PMS products – based on their specific requirements.
Continuing in 2006, AC Group will be “Validating” vendor application. The purpose of the detailed analysis is to determine which vendors meet the functionality to be considered a “Validated EHR” today and to determine which vendors who, with future development, could have a “Validated EHR” in the next couple of years. Vendor Products that receive a minimum rating of 85% are routinely reviewed for validation by AC Group. Other vendors have excellent charting systems and document imaging systems, but in many cases, do not have the necessary clinical alerts, clinical knowledge based databases, and may not have the Clinical Decision Support (CDS) necessary to improve care and to document improvements in clinical outcomes. They still provide excellent benefits, but should NOT be considered a clinically driven EHR.
The 47 functional categories include sections on the Institute of Medicine’s (IOM) requirements for a computerized patient record (CPR), along with functional questions relating to operational areas including prescriptions, charge capture, dictation, interface with laboratories, physician order entry, decision support and alerts, security, Personal Health Records, reporting and documentation. Back in 2005, AC Group added new categories relating to RHIOs, Disease Management, Specialty EMR content, Medical Devices Interfaces, Evidence-based reference content, Practice / Community Portal Capabilities, and Registry Functions. The EMR/EHR evaluation includes a weighted point value for each of the 2,745 questions, based on the following criteria: o The current product doesn’t offer this functionality o The current product provides the functionality for an additional cost o The current product provides the functionality from a third party o A future product enhancement in the next three months will provide the functionality o A future product enhancement in the next six months will provide the functionality o A future product enhancement in the next year will provide the functionality o The product provides the functionality currently
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C. Installation, Training, and Support
As mentioned earlier, the various EMR vendors provide a variety of installation, training and support activities. In 10% of the cases, vendors provide NO on-site support or training – everything is handled via the internet and via phone calls. Of those that do provide on-site training, 32% provide < 10 hours per physician, 33% provide between 10 and 24 hours per physician, 9% provide between 25 and 40 hours per physician, and only 6% provide more than 40 hours of training per physician.
To insure an effective installation, physicians must insure that they receive the required man-hours necessary to maximize the usefulness of the new EMR product. If the practice receives inadequate training, the lost in productivity could cost the practice as much as $50,000 per physician per year. Additionally, practices need help maximizing workflow and reorganizing activities based on the functionality provided by the software application. For many vendors, it’s almost like buying a car. The sales person sells you a car and tells you how to operate the radio and the door locks. The sales person does NOT teach you how to drive and does not provide you with the road map to get from the showroom back to your practice. You are on your own to figure that out. Based on a survey of 69 EMR vendors, < 15% actually work with you and your practice and teach you how to drive – the remaining 85% leave the learning up to the practice.
The EMR marketplace needs more local organizations that can provide local installation, training, configuration, and on-going support. These organizations can be Independent Physician Associations (IPAs), Management Service Organizations (MSOs), Physician/Hospital Organizations (PHO) and Value-added resellers (VARs). This collection of organizations can organize and provide superior market intelligence and technology support for local physician groups. One such group is the Taconic IPA, located in the Hudson Valley, NY.
Under the leadership of John Blair, M.D., the Taconic IPA has established the Taconic Healthcare Information Network and Community (THINC) collaboration. In short, THINC is a collaborative approach that brings together the healthplans, employers, hospitals, and physicians with the single goal of improving clinical quality while reducing the cost of healthcare for all parties. The project involves the capturing of clinical data at the point of care for up to 2,300 physicians who serve more than 1.2 million individuals throughout the Hudson Valley, NY. The program is intended to create a set of standardized quality measures across the plans, making it easier for physicians to participate in the program, and validating the measures. According to Dr Blair, “The Taconic IPA will provide on-site support for newer technologies for any and all of their physicians via collaboration with a company specific designed to provide knowledge and local support - MedAllies”. Under the support model, each physician receives up to 80 hours of installation, configuration, training, and support the first year and between 40-60 hours of on-going support each additional year. The purpose of
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MedAllies is to insure that physician practices maximize the value of their new technology via on-site support and workflow redesign.
Another model being developed is a regional organization call Pro Practica, Inc. located near Cleveland, OH. Pro Practica‘s mission is to enable independent physicians to recapture control of their practice by streamlining administrative functions and clinical documentation, improving compliance with government and payer mandates, and addressing practice liability issues. Their product, StreamlineMD, offers several practice management tools. At its heart is an electronic medical records system (“EMR”), which enables doctors to perform, among others, tasks such as (1) automating the verification of patients’ insurance coverage, (2) ordering and renewing prescriptions online, and (3) keeping patient records in secure and shareable electronic format. Unlike typical EMR vendors, there focus is on service, not on software. Pro Practica is providing access to all of the tools a practice needs via an ASP model.
D. ASP – Application Service Providers
In the acronym-laden world of healthcare, ASP (application service provider) is one of the most frequently heard--being the most popular member of a vocabulary categorizing the various service providers that have come into existence as a result of the Internet. As the tech phenomenon continues to shake out, successful service providers are settling into a role of broader responsibility in their customers' organizations, thereby demonstrating their true value. BSPs (business solution/service providers) are the next step in evolution of the ASP model. These companies let healthcare organizations outsource entire segments of their business, not just one certain aspect, allowing them to concentrate on their core competencies. Examples include, technology support outsourcing, supply tracking and re-ordering, accounting services, and billing and collection services
ASPs offer many advantages, particularly to small practices with fewer than 15 physicians. They allow IT spending to take place in increments rather than in one large licensing and implementation expense. But perhaps their biggest benefit is that they permit tremendous flexibility. Organizations are able to implement solutions quickly; affect plan, privacy and functionality changes fairly quickly; and even change technology providers without delay. An ASP scales one IT professional across three or four companies, depending on the application and the complexity. Another obvious benefit is the total cost of ownership. It’s a lot less costly to run equipment in an ASP model than having to have everything in-house. Another key advantage is you can get work done more quickly. Physicians can make a decision and know it’s going to be done and dealt with right away.
The ASP pricing model, like everything else, varies based on the services that are provided. In most cases, a physician can contract for a flat monthly fee of between $400 and $1,000 per month for a complete EMR application. However, the price varies for installation, training, and initial configuration. Some vendors require “consultative” fees upfront, instead of building into the monthly contract. Of course you still have all of the hardware and networking requirements. These are traditionally included in the monthly software costs, but can be added as a monthly lease cost. In all cases, physicians must look at a 3-year total-cost-of-ownership model when considering either a purchase or an ASP model.
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E. Adoption rates of PMS and EMR
For the past 20 years, physicians have been automating portions of their practice. In the 1980’s through the 1990’s, physicians selected and installed Practice Management Systems (PMS). Although these applications were fundamentally designed to track patient demographic, insurance, and payment information, their real benefit was the electronic printing and subsequent electronic transmission of patient claims to insurers. In 1990, Medicare created new incentives accelerating the adoption of PMS through its policy of reimbursing electronic ahead of paper claims submissions.
From 1985 to 2002 the number of physicians with PMS increased from 10% to almost 95%. (1) Starting in the late 1990’s, physicians searched for additional systems designed to improve the management of their practices. New applications called Electronic Medical Records (EMR), Document Management, Lab Interfaces, Electronic Dictations, and physician Internet access were reviewed and adopted, albeit at a slower pace than PMS. Among these applications EMR appeared to hold the most promise as a breakthrough technology that might improve practice efficiency.
Occurring simultaneously with the increasing sophistication of EMR function was the health care industry’s increasing emphasis on medical error reduction, improved clinical documentation and level of service coding. EMR’s ability to facilitate a typewritten, legible, well-formatted note that is available to all providers within a health care system held the promise of making patients care easier and more efficient. During this early era, affordable office-based EMRs offered a broad range of functionality. At one end of the spectrum were systems that offered little more than a typewritten chart. All the information was present as free "text" with little structure and capacity for searching or sorting clinical information. Free text could be entered by scanning existing documents, routine dictation, or in some cases using voice-recognition to capture the information. The main advantages of this system are the speed of data entry, limited disruption of provider documentation practices and workflow, and often lower cost. In contrast, a number of EMRs require clinical encounter data entry through a series of structured pick lists or templates. Although more time consuming to enter data this way, integration of information into a structured database facilitates subsequent queries and report writing.
In 1995, healthcare IT experts optimistically predicted that more than 50% of physicians would purchase an Electronic Medical Record for their practice by the end of 2000 (2). However, by 2000 a combination of technology issues, reimbursement issues, and the difficulty of justifying the capital costs of the EMR based on the return on investment (ROI) left the estimated percentage of physician users at only 6% across all practice environments. (3)
1 2002-2004 TEPR Report conducted by the Medical Records Institute.
2 2004 Annual Survey of physician adoption rates by AC Group, Inc. (3,935 physician practices)
3 2000 TEPR Survey conducted by the Medical Records Institute.
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This low figure further concealed a significant discrepancy between users in large institutions and multi-specialty clinics and those in small office practice. According to one study, by the summer of 2002, 38% of all university and staff-model (Kaiser, Mayo, etc) physicians were using an EMR compared to less than 1% of community-based physicians. (4)
The authors think that the experts missed their projections primarily because they underestimated how fundamentally EMR adoption changes the way a physician works. In addition, they were overly optimistic on the performance and speed of introduction of the so called “killer applications” (voice recognition, intelligent charge capture, pharmacy formulary management) that were critical to the EMR’s streamlining of workflow and return on investment. Physicians are far more likely to adopt changes that improve either their financial income, practice efficiency, or enhances the quality of patient care. Accordingly, automation of the physician practice is mostly likely to occur if the following principles are a central part of the implementation strategy.
• Create an incremental approach towards office automation • Make sure the EMR integrates with minimal disruption of existing work flow • EMR must either improve efficiency or reduce costs.
The physician market represents over 880,000 individuals in the US market alone. Over 85% of these physicians work in active practices that treat on-going patients in an ambulatory setting. The other +15% is working in non-patient care settings or is primarily involved in education and research. When evaluating physician needs and spending, we first must look at different market segments based on the practice size and the number of physicians within each practice size. As shown below, AC Group has attempted to divide the 206,000 physician practices into eight discrete markets.
Avg No of Total Physicians Total number of % of Total Market Segment Physicians per Market Practices Physicians per Practice Segmentation
A 1 to 2 Physicians 183,434 1.25 229,293 28.3% B 2 to 5 Physicians 10,106 3.30 33,350 4.1% C 6 - 9 Physicians 6,482 7.50 48,615 6.0% D 10 to 49 Physicians 3,834 29.05 111,378 13.8%
E 50 to 99 Physicians 1,235 74.40 91,884 11.3%
F 100 to 249 Physicians 312 143.13 44,657 5.5% Large Practices & Teaching G 754 243.40 183,524 22.7% Organizations
I Non practicing Physicians 67,000 8.3%
Total 206,157 809,699 100.0%
4 2002 Presentation of EMR usage, TEPR conference, Seattle WA, May 10, 2002
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The vendor community traditionally wants to sell to the large practices, those with over 250 physicians. However, the market share is very small, since there is only an estimated 1.3% of the practices with more than 50 physicians. The bulk of the practices are in the 1 – 9 physician practice size. As shown on the table on the next page, 93% of the active practices have less than 6 physicians within the group. Additionally, 96% of the practices have less than 10 active physicians. Therefore, it would appear that the market opportunity for EMR’s would be in the small physician marketplace.
% of Practicing Market Segment % of Total Physicians % of Practices Physicians
1 to 2 Physicians 28.3% 30.9% 89.0%
2 to 5 Physicians 4.1% 4.5% 4.9%
6 - 9 Physicians 6.0% 6.5% 3.1%
10 to 49 Physicians 13.8% 15.0% 1.9%
50 to 99 Physicians 11.3% 12.4% 0.6%
100 to 249 Physicians 5.5% 6.0% 0.2%
Large Practices and Teaching 22.7% 24.7% 0.4% Organizations
Non practicing Physicians 8.3%
Total 100.0% 100.0% 100.0%
However, the vendor community has realized for years that selling to small physician groups was not as profitable as selling to mid-size and large practices. The overall cost of “sales” is relatively the same for a $40,000 sale as a $500,000 sale. The only real difference is in the sales commission, and thus, the sales team would prefer to sell to large practices. But can 50 vendors survive on only 10% of the potential population? The answer is no. The healthcare industry only requires between 5 and 10 vendors in each of the market segments, not the 50 to 150 we have today. Therefore, the market will create winners and the market with crush vendors who have weak functionality, limited marketing funds, and vendors that cannot prove long term financial viability.
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F. Spending Trends:
Spending on technology by physicians has tripled since the 1990’s and is expected to triple again in the next four years. The majority of the increase will incur in the upper three levels of IT Maturity (Physician interaction). We believe that the average physician will be spending upwards to $10,000 for an EMR, $3,000 for other related technology applications, and an average of $4,000 for installation, training, and configuration. Once you add hardware, networks, and mobile devices, the average physician will be spending more than $25,000 on technology. For those practices that are looking for a combined EHR and PMS, the average price will exceed $30,000. However, in an ASP model, the average physician can obtain a complete Digital Medical Office of the Future for around $800.00 per month.
Until 2006, the majority of new technology sales were for internet applications and EMR/EHR applications. However, in 2006 we saw a major change in the belief that a practice’s current practice management system would indeed meet the practice’s future needs. In 2003, less than 9% of practices were looking to replace their older PMS application. In 2006 the ratio increased to 29%. Additionally, 60% of the healthcare EHR vendors have reported major increases in combined EHR and PMS sales in 2006, a 72% increase over 2004. For our clients, we have experience a major change in physician preference in technology. In 2004, only 12% of our clients where interested in a combined PMS and EHR application. In 2006, the ratio increased to over 90%.
So what created the change in physician preference? A study of 2,312 physician showed that 58% of physicians were interested in investing in a comprehensive EHR within the next 24 months – although many barrier to adoption where indicated. Of that 58% of the physicians, 83% indicated that they wanted to replace their current PMS for the following reasons: • 59% indicated that they believed the product no longer met their needs • 74% wanted to have a combined PMS/EHR from the same vendor to reduce the risk of ineffective interfaces. • 63% wanted to have a fully integrated PMS/EHR with one combined database to insure maximum efficiency. • 37% indicated that their current PMS product was no longer being supported by any vendor.
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However, the question is always, “who” will be purchasing. Once again, AC Group has developed their annual market segmentation table on future spending for EMR’s based on the nine market segments. Given the number of practices, and the current EMR penetration rates that vary from 9.4% to 32%, the number of potential sales of new EMR installations is estimated at around 190,000 practices which represents almost 659,000 active physicians.
Estimated EMR Installed EHR Installed EHR Market Segment % of Practices Penetration Physicians Practices
A 1 to 2 Physicians 89.0% 7.10% 16,280 13,024
B 2 to 5 Physicians 4.9% 9.20% 3,068 930
C 6 - 9 Physicians 3.1% 9.70% 4,716 629
D 10 to 49 Physicians 1.9% 14.10% 15,704 541
E 50 to 99 Physicians 0.6% 17.40% 15,988 215
F 100 to 249 Physicians 0.2% 24.80% 11,075 77
Large Practices & Teaching G 0.4% 33.10% 60,746 250 Organizations
Total 100.0% 15.8% 127,577 15,665
Once we understand the market size by segment, we can start estimating the potential revenues for EMR applications over the next 4 years. We estimate that the healthcare industry could spend up to $3.6B on EMR applications in the 4 years plus an additional $3.4B on hardware related products and almost $1.4B on implementation and training. However, this assumes that physician EHR adoption will increase from an average of 18.7% to over 80% by 2009. This is a big assumption since it appears that the adoption rate is increasing by only 32% per year. Therefore, if the current trend continues, the total adoption rate will only be around 52% by 2010. So what will it take to increase EHR adoption? The industry must create financial incentives for physician adoption. Without financial incentives, the US EHR market will never exceed 50%.
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Estimated EMR Estimated EMR Estimated EMR Implementation and Market Segment Software Revenues Hardware/Network Training Revenues 2008 - 12 Revenues 2008-12 2008-12
A 1 to 2 Physicians $ 1,723,092,478 $ 886,132,967 $ 810,867,048
B 2 to 5 Physicians $ 222,684,208 $ 125,971,533 $ 104,792,569
C 6 - 9 Physicians $ 264,130,287 $ 164,359,148 $ 124,296,605
D 10 to 49 Physicians $ 465,164,286 $ 318,401,223 $ 218,900,841
E 50 to 99 Physicians $ 377,393,775 $ 284,155,313 $ 177,597,071
F 100 to 249 Physicians $ 185,539,075 $ 139,700,010 $ 87,312,506
Large Practices & G Teaching $ 814,013,422 $ 612,904,224 $ 383,065,140 Organizations
Total $ 4,052,017,531 $ 2,531,624,416 $ 1,906,831,779
The majority of the expenditures will be in the practices within 10 to 99 physicians followed by the 6-9 physician groups and the large clinics with over 100 physicians. However, this still leaves almost $2.0B being spent by small practices with < 5 physicians. When we add annual support costs, upgrades, and other annual expenditures, the overall market opportunity is closer to $9.0 B over the next 4-5 years.
Along with capital purchases, practices are usually required to pay between 13% to 22% of the software costs each year for product upgrades and product support. Therefore over a six year period, the average practice pays for the entire system again and again. However, without support, the practice has a 73% chance of technology problems. These problems can create operational and clinical issues, which could bankrupt the practice if the corrections are not made within a timely manner. For most established EHR vendors, support fees represent between 35% to 65% of their annual revenues. For Practice Management vendors, support fees represent between 52% to 90% of their annual revenues.
As shown on the next page, support revenues over the next four years could exceed $1B if EHR adoption increases to the 80% range. However, if the adoption rate is below 50%, support revenues will average of $700M per year by 2008.
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Estimated EMR Total New Sales plus Total New Sales Market Market Segment Support Revenues Annual Support 2008 - 2008-12 2008-12 12
A 1 to 2 Physicians $ 682,344,621 $ 3,420,092,493 $ 4,102,437,114
B 2 to 5 Physicians $ 88,182,947 $ 453,448,310 $ 541,631,256
C 6 - 9 Physicians $ 104,595,593 $ 552,786,040 $ 657,381,633
D 10 to 49 Physicians $ 184,205,057 $ 1,002,466,349 $ 1,186,671,407
E 50 to 99 Physicians $ 149,447,935 $ 839,146,158 $ 988,594,093
100 to 249 F $ 73,473,474 $ 412,551,591 $ 486,025,065 Physicians
G 250+ Physicians $ 322,349,315 $ 1,809,982,786 $ 2,132,332,101
Total $ 1,604,598,942 $ 8,490,473,727 $ 10,095,072,669
Based on our projections, we estimate the ambulatory marketplace for New EHR products could exceed $8.1B within the next four years with an 60% adoption rate and less than $4M if the adoption rate maintains the current 32% increase per year. Total spending for new EHR products and support could exceed $11B within the next four years.
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As we mentioned, the industry MUST change, before the adoption rate can exceed 50%. With new Pay-for- Performance (P4P) programs, government incentives, malpractice incentives, and new requirements for clinical reporting, physicians will need to convert to newer technology to stay in business.
Total Ambulatory Technology Spending Assuming a 32% annual increase 2006 2008 2010 2012
EMR $ 347,889,887 $ 477,583,236 $ 655,626,267 $ 900,043,739 PMS $ 195,371,296 $ 242,416,704 $ 300,790,647 $ 373,221,034 Other $ 21,561,980 $ 28,461,813 $ 37,569,594 $ 49,591,864 Hardware $ 270,069,243 $ 367,991,123 $ 500,927,916 $ 681,261,966 Support $ 464,621,437 $ 665,582,955 $ 934,667,552 $ 1,295,408,900 Total $ 1,299,513,843 $ 1,782,035,832 $ 2,429,581,975 $ 3,299,527,503
G. What is happening today in the Health Care Industry and What Is Not Working?
In many practices, a core technology package, such as billing and/or scheduling software, serves as the center of the practice’s management system. Point-of-care technology is not being widely utilized. When there is an attempt by management to add modules to the existing system, the usual process involves calling the company who developed the core technology to see if they offer a module such as prescriptions or patient records software. Many times, the answer is no. Sometime the initial answer is no, but for a large fee, they may develop one. In some cases, when the company does, in fact, offer add-on modules, those modules do not offer the same strength as the original, core technology.
The hope for practices is that there are non-proprietary solutions being built by a variety of companies. The fact that they are not proprietary makes them more powerful for the consumer. It allows a practice the freedom to shop for and choose the best scheduling package, the best billing package, the best patient record package, the best prescription package, and the best diagnostics package. And usually these programs come from different vendors.
The problem today is not so much in the multitude of offerings. The programs are out there. But once you have all of these best-of-breed modules, are they going to integrate and work together, giving you seamless and uninterrupted service that doesn’t require a patient’s name and address to be entered in five different packages?
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H. Setting the Standards for Integration
Over 1,000 companies in the market today provide technology solutions for practices. They are all generating a different type of solution and generating many questions for you, the consumer. Relatively few have the long-term vision of being a complete solution. Advances in hardware and software are bringing technologies focused on patient care to the forefront. Technologies such as Prescription Modules, Diagnostic Programs, Document Imaging Systems, and Computerized Patient Records are more readily available and are being offered by a multitude of companies all touting to be the best.
As technology continues to develop at an exponential rate, how do you know your investments today will still be viable tomorrow? How do you know you won’t wind up with a Beta Recorder in the corner when the rest of the world has embraced the VCR? The questions are numerous: what to buy, when to buy and how to make it all work together. And behind these concerns lies the ultimate question: Who is going go deliver the complete solution? Because of so many options, no one company has provided a complete solution. The solution will come from integrating the best-of-breed packages that serve your individual needs.
And at the heart of the integrated solution will lie the key communication tool of the medical practice: the patient record. In all of the stages in dealing with a patient, from the initial patient encounter to when the insurance company sends the check and everything in between … in all of these stages, there is one communication tool that is present … the patient chart.
That won’t change in 2007. Our method of accessing the chart may change, and, we expect, will become more efficient. But the chart will remain the center of the process, because in healthcare, the patient will always be the center of why we exist.
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I. Government Involvement in the Market
The Office of the National Coordinator for Health Information Technology (ONC) is responsible for coordinating federal activities relating to health information technology. These covered health information technology activities are defined as any effort in the federal government that meets one or more of the following criteria:
1. Efforts that use federal funds to design, develop, standardize, implement, maintain, operate, and/or enhance HIT (e.g., software, hardware or other technology) that is used inside or outside the federal government to deliver, monitor, improve, supply information to, interface with, or use information from a patient care encounter, including financial, clinical, or other information.
2. Efforts that use federal funds for projects or programs that evaluate, research, study, or otherwise assess the use, benefit, cost, consequences, or other aspects of the HIT defined in #1.
3. Efforts that use federal funds to educate, teach, train, or address human factors about or relating to the HIT described in #1.
4. Policies, rules, reports, advisories, or other documents that describe, discuss, or influence the use of the HIT defined in #1.
5. Partnerships, grants, contracts, initiatives, or awards between the federal government and its contractors with non-federal organizations, including state or local governments or agencies, private companies, or other entities that relate to HIT defined in #1.
6. Knowledge management of the experiences gained from HIT implementation across large, distributed health care networks such as DoD, VA, and the IHS will be brought to a central, accessible point.
Many different components of the federal government touch upon health care, so federal leadership in HIT needs to be focused and coordinated. While there is some integration of these efforts, until recently there has been neither a single voice for this effort nor a holistic set of goals for change. The National Coordinator for Health Information Technology has been given the responsibility for coordinating HIT efforts throughout the federal government. As part of the outreach effort, the programs, projects, and policies that involve HIT are being compiled.
According to the FHA initiative and budget documents submitted to the Office of Management and Budget, total federal spending on HIT was over $900 million in FY2004. A list of identified federal HIT programs follows.
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Agency/ Organization Title of HIT Initiative Description of Activities Assistant Secretary for Planning & Evaluation (ASPE) ASPE National Committee on Vital and Policy development and development of standards. Health Statistics (NCVHS) ASPE National Health Information The NHII is an initiative to improve the effectiveness, efficiency, Infrastructure (NHII) and overall quality of health and health care in the United States - - a comprehensive knowledge-based network of interoperable systems of clinical, public health, and personal health information that would improve decision making by making health information available when and where it is needed. (NHII has been incorporated into ONCHIT). ASPE EHRs in Post-Acute and Long- ASPE has contracted with the University of Colorado Health Term Care Sciences Center to evaluate the current status of electronic health information systems (EHIS) and electronic health records (EHRs) in post-acute and long-term care (PAC/LTC) settings. The project team has reviewed literature, conducted telephone interviews, and completed site visits to providers that have implemented EHIS/EHRs in PAC/LTC. The project also contracted with Apelon to conduct a pilot study of the issues of conforming the nursing home minimum data set (MDS v.2) to CHI standards. ASPE Conforming the Nursing Home ASPE and CMS will partner on a project to conform the MDS v.3 Minimum Data Set v.3 to CHI- to CHI-endorsed standards. Endorsed Standards
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Office of the National Coordinator for Health Information Technology (ONC) ONCHIT Consolidated Health Informatics The goal of CHI is to establish federal health information Initiative (CHI) interoperability standards as the basis for electronic health data transfer in all activities and projects and among all agencies and departments. The first phase involved establishing a set of existing clinical vocabularies and messaging standards enabling federal agencies to build interoperable federal health data systems. ONCHIT Federal Health Architecture TheFHA program will define an overarching framework and (FHA) methodology that allows initiatives throughout several federal agencies to proceed coherently, establishing the target and standards for interoperability and communication that will unify the federal health community. The FHA will establish a government-wide road map to achieve the federal health community's mission through optimal performance of its core business processes within an efficient IT environment. Council on the Application of Health Information Technology (CAHIT) CAHIT Coordination HL7 balloting CAHIT staff coordinated the HHS engagement with regard to the HL7 Electronic Health Record Special Interest Group. CAHIT EHR Acceleration Efforts CAHIT staff coordinated a series of planning meetings to best position pertinent departmental HIT activities (either current or future) that hold the promise of accelerating EHR adoption. CAHIT CHI Standards CAHIT staff and membership, via council meetings, activities, and staff briefings ensured the universal integration of CHI standards in HHS agency activities and programs.
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Agency for Healthcare Research and Quality (AHRQ) AHRQ Transforming Healthcare Quality THQIT is a series of three grant programs (RFAs) released in FY04. The Through Information Technology RFAs include the following: 1) demonstrating the value of HIT, 2) (THQIT) planning grants for future HIT implementations, and 3) providing HIT implementation grants for partnerships of three or more entities. AHRQ State and Regional Health IT AHRQ awarded 5 contracts to establish and implement state and Demonstrations regional demonstrations of interoperable health information systems. AHRQ Health Information Technology The Health Information Technology Resource Center (HITRC) will Resource Center (HITRC) provide a state-of-the-art service center for grantees and organizations that are engaged in health IT diffusion activities (e.g., research, diffusion, or adoption). AHRQ Coordination with CMS Medicare AHRQ will be supporting a five-year evaluation of CMS’s MCMP Care Management Performance demonstration project to explore the integration of EHRs in the (MCMP) Demonstration Project ambulatory environment. AHRQ Indian Health Service (IHS) - AHRQ recently provided funding to the IHS to support needed Resource and Patient enhancements to the IHS EHR. This investment will help to create a Management System (RPMS) user-friendly data system that can provide community-specific health care data as well as track the health status of the patient population. AHRQ Patient Safety Health Care This work on health data standards, done in coordination with the ASPE, Information Technology Data will focus of the following four areas: 1) voluntary industry clinical Standards Program: Standards messaging and terminology standards, 2) national standard and Interoperability nomenclature for drugs and biological products, 3) standards related to comprehensive clinical terminology, and 4) nomenclature and research related to accelerating the adoption of interoperable HIT systems. AHRQ Evidence Based Practice Center AHRQ's EPC Program has embarked on a 13-month program to explore (EPC) - Evaluation of the and determine the evidence base associated with certain HIT functions. Evidence Regarding Select Health IT Functions
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Centers for Medicare and Medicaid Services (CMS) CMS Doctors' Office Quality - A special study to develop an approach to promoting adoption and use of Information Technology (DOQ- information technologies in the physician office and reporting of IT) information to Quality Improvement Organizations (QIOs). CMS VistA – Office EHR Modify / repackage VistA (the Veteran's Administration EHR software) for the physician office setting. CMS Medicare Care Management Establish a three-year, pay-for-performance pilot with physicians to Performance Demonstration promote the adoption and effective use of HIT to improve the quality of patient care for chronically ill Medicare patients. CMS will offer financial incentives to physician offices that meet performance standards in delivery systems and outcomes. CMS Medicare Health Care Quality Section 646 of the Medicare Modernization Act (MMA) mandates a 5-year Demonstration Program demonstration program under which CMS will test major changes to improve quality of care while increasing efficiency across an entire health care system. The Demonstration recognizes the use of health IT to improve quality. CMS Physician self-referral exception: Removes the regulatory barrier to allow for the furnishing of technology Phase II of physician self-referral items or services to physicians to enable their participation in community- regulations includes exception wide health information systems. for community-wide health information systems CMS E-prescribing hearings to Participate in NCVHS hearings regarding e-prescribing standards in 2004 develop, adopt, recognize, or and 2005. Develop, adopt, recognize, or modify initial uniform standards modify initial e-prescribing not later than Sept. 1, 2005. During 2006 calendar year, conduct pilot standards. Pilot project to test project to test initial e-prescribing standards, unless the Secretary initial standards. determines the industry has adequate experience with such standards. CMS EHR Focus Groups Pacific Consulting Group, under contract with CMS, will conduct 12 focus groups of providers to identify the issues and barriers that would prevent them from using electronic medical records, and suggestions they may have for addressing these issues. The focus groups will be organized as follows: three Part A, three Part B, three durable medical equipment (DME) providers, two rural providers, and one billing agent. Six of these focus groups will be in person, while six will meet via conference call. Focus groups are planned for the following cities: Boston or New York City, Florida or Atlanta, Chicago, Denver, San Francisco. CMS CMS Virtual Call Center The goal of CMS' Virtual Call Center is to improve beneficiary telephone customer service through the implementation of various initiatives for efficient and effective handling of all types of inquiries. The first phase involves, among other things, improvements in the Web-based application that allows phone representatives to retrieve clinical information about the beneficiary (such as date of last pap smear or colonoscopy). The second phase involves allowing beneficiaries to access clinical information about themselves through a Web-based application.
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Food and Drug Administration (FDA) FDA Structured Product Labeling The SPL provides information found in the approved FDA drug label or (SPL) for prescription products package insert in a computer-readable format for use in electronic (e.g., accessible drug prescribing and decision support. information) FDA Bar Coding for Prescription Standardized labeling. Products
National Institutes of Health NIH National Library of Medicine - Research grants and contracts for advanced computer technologies to Grants for Research, Training, facilitate access, storage, and use of biomedical information, and for the and Access to Informatics value derived from the adoption, diffusion, and utilization of HIT. Resources NIH National Library of Medicine - Support for training of informatics researchers and developers. Grants for Research, Training, and Access to Informatics Resources NIH National Library of Medicine - Support for Integrated Advanced Information Networks (IAIMS), Internet Grants for Research, Training, connections, and access to digital libraries. and Access to Informatics Resources NIH National Library of Medicine - Support for, and development of, selected CHI standard clinical Development and vocabularies to enable ongoing maintenance and free use within the United Implementation of Controlled States. Clinical Vocabularies NIH National Library of Medicine - Uniform distribution and mapping of HIPAA code sets, CHI standard Development and vocabularies, HL7 code sets, and other important vocabularies within the Implementation of Controlled UMLS Metathesaurus. Clinical Vocabularies NIH National Electronic Clinical NIH plans to develop NECTAR, which will link research sites and ultimately Trials and Research (NECTAR) create a “national network of networks,” in coordination with the national Network health information network, by which research information and findings will be shared and scientific collaborations facilitated. NECTAR includes a research workflow model, a common lexicon of standard vocabularies to describe medical and scientific events, and analytical and dissemination tools. NIH Cancer Biomedical Informatics caBIG is a virtual cancer research network of interconnected data, Grid (caBIG) individuals, and organizations that will create a common, widely distributed infrastructure that facilitates the sharing of data and applications and thereby enhances productivity and efficiency of research. caBIG infrastructure is based on HHS CHI standards. caBIG is being pursued as a pilot program that involves NCI’s caCORE central resources, over 40 of NCI’s cancer centers, and the FDA. The NCI has created a standards- supporting infrastructure called caCORE. It is composed of HHS-established controlled vocabularies, standard data elements, and domain models.
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Indian Health Service IHS Integrated Behavioral Health The BH graphical user interface software application that includes the ability System (BH) to track services provided by social work, alcohol/substance abuse counselors, psychologists, and psychiatrists. Application includes suicide tracking system (with bi-directional notification within HIPAA guidelines) as well as embedded guidelines. The requirements determination has been completed and the software development process will begin in FY04. IHS Patient Account Management The PAMS is an enhanced third-party billing system. System (PAMS) IHS Clinical Indicator Reporting The CIRS is a robust reporting system that tracks over 40 indicators in a System (CIRS) standard reporting format. The standards reporting format is a delimited file that exports locally into Excel and can be exported for regional aggregation. IHS Integrated Case Management An integrated case management application is being developed to facilitate System three views of data: patient, provider, and population health. These systems will allow for integration of varied disease case management applications that currently exist (diabetes, asthma, immunizations, etc.). IHS National Data Warehouse This Initiative is developing a data warehouse for use by epidemiologists, as Initiative well as clinical quality in order to enable analyses on quality improvement and interface with the clinical indicator reporting system. IHS Resource and Patient RPMS is the hospital information system utilized by 49 hospitals, 221 health Management System (RPMS) centers, 120 health stations, and 170 Alaska village clinics. IHS IHS - EHR Initiative IHS-EHR provides order entry, results reporting, encounter documentation, and other clinical functionality to IHS, tribal, and urban Indian health care providers. IHS-EHR is a component of the Resource and Patient Management System (RPMS), IHS's enterprise health information system.
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Health Services and Resource Administration HRSA Shared Integrated Management The SIMIS/ICT provides hardware, software, and support services for Information Systems (SIMIS)/ integration of practice management systems among federally supported Information and Communication health centers (SIMIS), and integration of electronic health records with Technology (ICT) practice management systems at consolidated health centers (ICT). HRSA Integrated Services The program supports integration efforts in five areas one of which is Development Initiative (ISDI) information management. HRSA Healthy Communities Access The HCAP is a community-based program to develop or strengthen health Program (HCAP) care safety net delivery systems through providing an infrastructure that will coordinate health care for the uninsured. Development of information systems is fundamental to supporting coordination of efforts that increase access to care. HRSA Sentinel Centers Network The SCN is investing in the information systems of participant health (SCN) centers and networks to provide timely, patient-level data to inform policy decisions and quality improvement activities across all health centers. HRSA Patient Electronic Care System The PECS is a program that is developing patient registry information (PECS) systems for centers participating in the Health Disparities Collaboratives. HRSA Office for the Advancement of Grants support for community-based activities in informatics, electronic Telehealth grants (OAT) medical records, and telemedicine, including telepharmacy. HRSA Office of Rural Health Policy The Network Development Grants are designed to further ongoing Network Development Grants collaborative relationships among health care organizations by funding rural health networks that focus on integrating, clinical, information, administrative, and financial systems across members. HRSA CAREWare CAREWare is a patient, encounter-level software application distributed to HIV/Aids Bureau (HAB) grantees and providers of HIV care to help them manage, monitor, and report on all clinical and supportive care services. The software was originally built in Microsoft Access, but is now being developed in dotNET to enable Internet and wide-area connectivity of care providers and grantees. CAREWare is also being developed for use internationally (in Africa especially) under the President’s Emergency Plan for AIDS Relief.
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Centers for Disease Control and Prevention CDC The CDC is working to advance public health activities through standards- based information systems. These systems need to work with each other and with clinical care systems to support public health needs. Through PHIN, the CDC and its public and private partners have been advancing software components and data and technical specifications that are compatible with federal standards activities such as CHI, NCVHS, and eGov. CDC PHIN: National Electronic NEDSS is an initiative that promotes the use of data and information system Disease Surveillance System standards to advance the development of efficient, integrated, and (NEDSS) interoperable surveillance systems at federal, state, and local levels. CDC PHIN: National HealthCare PHIN is an Internet-based system to collect patient data on measures of Safety Network System health care quality. CDC Public Health Monitoring Most pubic health surveillance and monitoring systems, either directly or indirectly, get some data from clinical care activities. These data are used to facilitate public health surveillance through the timely and efficient transfer and processing of appropriate public health, laboratory, and clinical care data. Vital statistics systems also at times get data that originate in other places in the health system. CDC Clinically Oriented National National Health Care surveys provide a picture of how health care is Center for Health Care delivered in the U.S. by collecting data from hospitals, emergency and Statistics (NCHS) Monitoring outpatient departments, ambulatory surgery centers, nursing homes, office- based physicians, home health agencies, hospices, and others on a periodic basis. These surveys address measurement of diagnosis and treatment, characteristics of health care providers, trends in use of services, characteristics of patients, patterns of disease, use of drugs and other treatments, and emergence of alternative care sites. CDC Public Health Preparedness Preparedness activities such as early event detection, quantification of Systems outbreak or event magnitude, localization of an event, investigation of event etiology, the management of possible cases, the laboratory confirmation of true cases, the tracing of communicable disease contacts, the administration of vaccines, prophylaxis, and isolation all potentially interact with clinical-care data and systems. The PHIN standards have been requirements of the CDC and HRSA preparedness supplements to help see that the over 2 billion in preparedness funds that have gone to state and local health departments and hospitals can meet these information exchange goals. CDC EPI-X EPI-X is the CDC’s Web-based communications solution for public health professionals. Through EPI-X, CDC officials, state and local health departments, poison control centers, and other public health professionals can access and share preliminary health surveillance information quickly and securely. Users can also be actively notified of breaking health events as they occur. Key features of EPI-X include scientific and editorial support, controlled user access, digital credentials and authentication, rapid outbreak reporting, peer-to-peer consultation, and CDC-assisted coordination of investigations.
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Department of Commerce DoC Technology Opportunities Technology Opportunities Program awards matching grants that Program demonstrate how digital networks assist in the delivery of health care, public health services, and a wide variety of other local services. Department of Defense / Veterans Affairs Initiatives DoD/VA Joint Plan for the Electronic The JPEHR will provide interoperability between the two health Health Record (JPEHR) information systems of VA and DoD. The plan provides for the exchange of health data by the departments and development of a health information infrastructure and architecture supported by common data, communications, security, and software standards and high- performance health information systems. The plan will support Healthy People (federal), Federal Health Information Exchange (FHIE), Clinical Data Repository/Health Data Repository (CHDR), Consolidated Mail Outpatient Pharmacy (CMOP), Lab Data Sharing and Interoperability (LDSI), and the Centralized Credentials Quality Assurance System (CCQAS)/VetPro, Scheduling, and E-portal Systems. (Joint DoD and VA funding.) DoD/VA Telehealth Development and adoption of telehealth capabilities within the DoD Military Health System (MHS) and the VA continues to advance. The steady increase in cooperation between the two agencies allows for further leveraging of assets, knowledge, and development of integrated or interoperable programs. There are six joint telehealth initiatives in progress: VA/DoD Imaging Subgroup, Teleradiology, Telepsychiatry, Hawaii Integrated Federal Health Care Partnership, Alaska Federal Health Care Access Network, Case Management (Diabetes), and e- Learning.
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Department of Defense (DoD) Initiatives DoD Clinical Information Technology CITPO is an acquisition office for centrally managed MHS clinical IT Program Office (CITPO) systems that support the delivery of health services throughout the MHS. The following are CITPO projects: Composite Health Care System II (CHCSII), Composite Health Care System Legacy, Clinical Information System (CIS), Preventive Health Care Application (PHCA), Defense Blood Standard System (DBSS), Defense Occupational and Environmental Health Readiness System (DOEHRS), Encoder Grouper (EG), Special Needs Program Management Information System (SNPMIS), TRICARE Online (TOL), Nutrition Management Information System (NMIS), and Veterinary Services Information Management System (VSIMS). DoD Defense Medical Logistics DMLSS replaces aging military departments' (Army, Navy, and Air Force Standard Support (DMLSS) MilDeps) specific legacy medical logistics systems with one standard DoD medical logistics system. DMLSS also manages Joint Medical Asset Repository (JMAR), Customer Support on the Web (CSW), Facility Management (FM), Customer Area Inventory Management (CAIM), Equipment & Technology Management (E&TM), Stockroom/Readiness Inventory Management (SRIM), Assemblage Management (AM), Universal Data Repository (UDR), Prime Vendor Program (PV), DMLSS - Wholesale (DMLSS - W), Customer Demand Management Information Application (CDMIA), National Mail Order Pharmacy (NMOP), Readiness Application (RMA), Medical Electronic Customer Assistance (MECA), Distribution and Pricing (DAPA) Management System (MS), and Electronic Catalog (ECAT). DoD Executive Information/Decision The EI/DS program provides timely, accurate, and appropriate decision Support (EI/DS) information supporting the TRICARE Management Activity (TMA) and DoD MHS mission. The EI/DS program currently consists of a data warehouse and several operational data marts supporting nearly 3,000 system users, providing a robust database and suite of decision support tools to empower the effective management of MHS health care operations. The EI/DS systems support decision making by senior MHS personnel and post-decision monitoring of the effects of decisions. EI/DS products include: MHS Management Analysis and Reporting Tool (MHS MART), Managed Care Forecasting and Analysis System (MCFAS), Population Health Operational Tracking and Optimization (PHOTO), Medical Surveillance, TMA Reporting Tools (TMART), CHAMPUS/TRICARE Medical Information System (CMIS), CHAMPUS/TRICARE Utilization Reporting and Evaluation Systems (CURES), Care Detail Information System (CDIS), and Patient Encounter Processing and Reporting (PEPR). DoD Resources Information The RITPO initiative is a project that consists of a family of capability- Technology Program Office specific applications/systems that support the MHS "Manage the Business" (RITPO) and "Access to Care" and information technology requirements. The RITPO project scope includes providing information technology support for MHS personnel, scheduling, workload forecasting, and patient safety initiatives. The following are RITPO projects: Defense Medical Human Resources System - internet (DMHRSi), Central Credentials Quality Assurance System (CCQAS), Enterprise Wide Scheduling and Registration (EWS-R), Enterprise Wide Workload Forecasting (EWF), Patient Safety Reporting (PSR), and Patient Accounting System (PAS).
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DoD Expense Assignment System IV EAS IV is a standard DoD cost accounting/assignment information (EAS IV) technology system that consists of a cost-assignment application and a data repository. The system receives information electronically from a variety of DoD financial, manpower, and workload systems, and allocates this expense information to Medical Treatment Facility/Dental Treatment Facility (MTF/DTF) direct and indirect work centers. DoD Theater Medical Information TMIP provides a seamless, interoperable medical information system to Program (TMIP) support theater health services during combat or contingency operations within and across all echelons of care. The primary goal is to provide a global capability linking theater medical information databases and integration centers that are accessible to the warfighter anywhere, any time to support the mission. TMIP includes the following programs: Composite Health Care System in the Theater of Operations (CHCS NT), Composite Health Care System II - Theater (CHCS II-T), TRANSCOM Regulating and Command and Control Evacuation System (TRAC2ES), Defense Medical Logistics Standard Support Assemblage Management (DMLSS-AM), Medical Analysis Tool (MAT), Shipboard Non-Tactical Automated Data Processing Program Automated Medical System (SAMS), Medical Surveillance System (MSS), and Defense Blood Standard System (DBSS). DoD Third Party Outpatient Collection TPOCS is the MHS information system used to bill for ambulatory System (TPOCS) services. DoD Telehealth The use of electronic information and telecommunications technologies to provide or support clinical health care, patient and professional health- related education, public health and health administration when distance separates the participants. Current projects include Business cases, e- Learning, Policy, Teleconsultation, Pediatric Consultation, Telecardiology, Teledermatology, TeleENT, Tele Mental Health, Teleneurosurgery, Teleorthopedics, Telepathology, Teleradiology, Telementoring, and Telemonitoring.
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Department of Veterans Affairs Initiatives VA Joint [VA/DoD] Patient Electronic The JPEHR plan will provide interoperability between the two health Health Record (JPEHR) information systems of VA and DoD. The plan provides for the exchange of health data by the departments and development of a health information infrastructure and architecture supported by common data, communications, security and software standards, and high-performance health information systems. (See FHIE.) VA Allocation Resource Center The ARC provides IT services for systems designed to support the VHA (ARC) (Health Resources CFO's ability to develop, implement, and maintain resource allocation Management)* methodologies; gather and report on financial aspects of patient workload and cost; classify patients based on care and diagnosis rendered; and train and provide information to management officials throughout VA. VA Fee Basis Replacement (FBR)* The FBR will replace a claims-processing system used by VA that processes claims made by veterans and providers for non-VA care. The new system will ensure effective and efficient authorization and payment processing for all non-VA care, including state and home health care and community nursing home programs. VA Patient Financial Services The PFSS will create a comprehensive business solution for revenue System (PFSS)* improvement utilizing improved business practices, commercial software, and enhanced VA clinical applications. VA Health Enrollment Health Enrollment includes functionality to accept and process veterans’ applications for enrollment, share veterans’ eligibility and enrollment data with all VA health care facilities involved in veterans' care, manage veterans' enrollment correspondence and telephone inquiries, and support national reporting and analysis of enrollment data. VA Federal Health Information Provides current and historical data feeds electronically from CHCS I to Exchange (FHIE) the FHIE repository node on selected data types for active-duty, retired, and separated service members. VA Health Data Repository (HDR) Defined as a repository of clinical information normally residing on one or more independent platforms for use by clinicians and other personnel in support of patient-centric care. VA Pharmacy Reengineering and IT Facilitates improved VA pharmacy operations, customer service, and Support patient safety, concurrent with pursuit of full re-engineering of VA pharmacy applications. VA Scheduling Replacement Will develop a next-generation appointment application based on business process re-engineering and the Institute for Health Care Improvement guidelines for open and advanced access to care models. VA VistA Imaging Will provide complete online patient data to health care providers, increase clinician productivity, facilitate medical decision making, and improve quality of care. VA VistA Laboratory IS System Will enhance the VA Laboratory Service's information technology system Reengineering and associated business processes to address current deficiencies and meet future needs. VA VistA Legacy (includes staff) The operating system software platform and technical infrastructure (associated with clinical operations) on which VA health care facilities operate their software applications.
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VA Health Infrastructure The health infrastructure is primarily a hardware-refresh project designed to put VA general office automation support servers, workstations, and peripherals on a 4-year replacement schedule. It will consolidate the services of several smaller computer facilities into an existing larger computer facility on newer hardware, providing greater reliability while reducing overall computer space and IT staff. It will establish a working contingency plan for the consolidated site. Department of Homeland Security DHS National Biosurveillance NBIS will combine health data from CDC, agricultural data from the USDA, Integration System (NBIS) food data from a combination of USDA and HHS, and environmental monitoring from BioWatch to improve detection and response.
J. Conclusion:
Technology is only a tool and if used effectively can improve the flow of information and potentially improve the efficiency of the physician’s practice. However in reality, if “change” is not embraced, the probability of success is very low. We learned in the 1980’s that we needed to change the process of billing for services – or we would not be paid in a timely and effective manner. Therefore, the practice of medicine, from the business point of view, changed. Now with newer technologies, government regulations, and the right financial incentive, physicians will begin embracing new levels of technology that were not available just 5 years ago. But where does a physician in a small practice turn to learn about the 100’s of technology choices? The physician can spend hours searching and evaluating all of the opportunities. Or maybe in the near future, physicians will be able to look towards leaders within their own medical specialty for guidance and knowledge.
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A. A New View of Technology
Practices need to divide the implementation of technology into manageable steps or Phases. The concept of an “Incremental” technology approach separates the implementation of Practice Management Systems, Internet capabilities, Document Management, hand-held devices, and the vision of a complete Electronic Medical Record System into easily managed steps.
The original concept, developed by Mr. Mark Anderson, Healthcare IT Futurist with AC Group, Inc., creates a six stage evaluation and implementation plan that rates each provider’s IT maturity level, strengths, weaknesses and critical survival criteria. Mr. Anderson’s research indicates that by 2007 healthcare providers that have not reached at least stage five in the healthcare technology maturity level will begin losing market share because of higher operating costs and inability to clearly document clinical outcomes.
AC Group’s healthcare technology matrix includes six stages that determine a provider’s IT readiness to meet the needs of the patient/member market. The six stages build on one another, beginning with basic IT infrastructure and low-level applications such as billing applications, progressing in a logical series of increasingly advanced IT applications, and culminating in sophisticated clinical outcomes and disease management applications. The first three phases interact more with the front office operations while the last three phases represent a direct interaction by the physician. The six stages are:
General Level Basis Description Description Physician Uses System for Review only Practice 1 Physicians have installed basic billing and accounting applications. Management Secured Physicians have installed Level 1 plus have a basic web site. The web site is usually 2 Internet limited to information regarding the practice. Some physicians will also Capability communication with colleagues via email.
Physicians have installed Level 1 and 2 and have begun receiving lab results, Document dictations, and ER records from hospitals electronically. Since most patient records Image 3 are paper based, level 3 practices have begun scanning paper documents into a Management comprehensive Document Image System. Physicians use the system for viewing of (DIM) records only.
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Physician Uses System for Direct Entry of Patient Data
Levels 1-3 installed. Level 4 is where the physician starts interacting with the computer system. Through the use of hand-held devices like Personal Digital Assistants (PDAs), Hand-Held physicians interact with real-time patient data. The applications include reviewing daily 4 and PDA schedules, formulary look-ups, simple charge capture, e-prescribing, etc. Most the applications data is updated by the physician, the information is uploaded to the practice’s computer system via wireless or cradled connections.
Levels 1 - 4 along with a comprehensive database of the patient’s financial, clinical and Electronic demographic data, tied together by one seamless electronic backbone. The core EMR Medical 5 allows physicians to enter history and physical information, notes, vital signs, etc. Records Allows for Physician Order Entry (POE) with Clinical Decision Support based on (EMR) Knowledge based protocols.
Clinical All applications have been installed (1-5). The physician enhances his/her practice Trails, 6 through the use of clinical outcomes to improve care and implementation of disease Outcomes management programs. Measurement
B. Where are we today?
6-Levels of Healthcare IT Maturity Based on a survey of 3,476 physicians, the majority of
100% Practice physicians (90%) have installed a Practice Management Management 90% System (Level 1). Almost 50% of the physicians have secured 80% Secured Internet internet capability for communication with other colleagues, 70% Connectivity 60% have some form of web site, and in 14% of the practices, the 50% Document Management front office is able to check a patient’s eligibility and benefits 40% Mobile 30% EMR Clinical via an interactive web site with selected payers (Level 2). Only Using Physicians %of 20% Trials 10% 30% of the physicians have access to electronic forms and 0% paper via a document management system (Level 3). The L1 L2 L3 L4 L5 L6 Exhibit 2 mobile healthcare marketplace (Level 4) has been one of the hottest markets in the past three years. However although many physicians have such a device for personal use, less than 21% routinely use it for collecting and reporting of clinical and/or charge capture data. The level that everyone has been talking about since the TEPR conference in Seattle (May 2002) has been the Electronic Medical Record (EMR) application. The EMR incorporates the patient’s demographic and insurance data with the patient’s clinical information (Level 5). The clinical information includes vital signs, history and physical notations, allergies and medications, physician progress notes, ancillary orders and results, etc. Although EMRs have been promoted for over a decade, < 10% of physicians use EMRs in their practice today. The final level (Level 6) incorporates all of the first 5 levels, Clinical Decision Support, Knowledge
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Based Systems for tracking patient clinical outcomes, clinical quality, disease management, and allows the physician to interact electronically and seamlessly with internal or external clinical trials. Today, < 4% of physicians has any seamless electronic interaction for patient clinical outcomes and quality.
C. The Future of Automation?
Based on physician interviews, recent return on investment (ROI) studies, government regulations including HIPAA, insurance payment trends, and the rate of physician adoption of newer technologies is likely to escalate in the next three years. As shown on Exhibit 3, almost 98% of physicians will embrace Practice Management Systems by 2005, almost 80% will communicate with selected patients, their colleagues and 70% of health plans via a secured internet browser, and 73% will have a 6 Levels of IT Maturity
100% Practice Document Image Management System for the sharing Management Secured Internet of paper and electronically generated clinical data. Connectivity y 80% Document Management By 2005, mobile healthcare (Level 4) will be used by 60% Mobile 40% of the physicians for direct entry of prescription EMR 40% Clinical information, intelligent charge capture and coding, Trials % ofPhysicians % usingTechnolog results reporting review and confirmation, and for 20% direct entry of physician notes. EMR (Level 5) adoption 0% L1 L2 L3 L4 L5 L6 has been very slow over the past decade. The main reasons appear to be cost, functionality, and viability of 2003 2005 Exhibit 3 the vendors. We believe that this will change starting in 2003 when more studies were be published that outlines the benefits of EMR, both to the physician and the patients. In addition, health insurance payers may begin subsidizing physicians that use EMRs. In fact one study, conducted by AC Group, showed that on average, physicians that use an EMR had a 9.4% lower Medical Loss Ratio per case mix adjusted DRG and ambulatory ICD-9 than non-users of EMRs. Additionally, another unpublished study by AC Group showed that physicians that used a EMRs improved their documentation and through the use clinical decision support and knowledge based protocols, reduced the number of malpractice claims. This resulted in a reduction in malpractice costs by 16.3%.
To truly understand the physician’s marketplace, we have to explore each of the six levels of technology.
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Overview:
Physician practices, like all of healthcare, have been reluctant to spend appropriate dollars on technologies to improve operations. In today’s environment, physicians are being challenged to practice medicine and run a profitable business. Decreasing reimbursements and lower net profits have forced radical changes in practice management and have accelerated the adoption of technology beyond the basic billing office. Many companies have created technological solutions addressing various “pain points” within healthcare. These companies have focused on areas in which they perceived to be inefficient and in need of automation. A staggering myriad of solutions is available to medical practices, making it necessary to wade through the options to find the best solution.
We are at the beginning of the technology revolution in healthcare. The challenge for now is to find a foundation of technology that will enable you, the physician or healthcare information manager to build a complete solution in the future. The foundation must be based on a strong Practice Management System (PMS). Seeking product differentiation, leading PMS vendors are rolling out an ever-widening array of optional modules and are tailoring PMS to meet the rapidly changing needs of the practice management system market. Top PMS vendors offer multiple versions for small, midsize, and large group medical practices, and the fast-growing management services organization (MSO) market. This trend will continue through 2006 as group practice consolidation accelerates and the average practice size continues to grow.
Practice Management Systems
Many physicians are coming to the realization that their current practice management systems are not performing basic front-office functions as well as they could be. Other factors are also pushing group practices to hunt for new systems: Mergers, consolidations, and IPA’s are causing newly consolidated groups to look for one common practice management system. Some group practices that have been using older, text-heavy Unix-based systems that run on dumb terminals are investigating newer, client/server or web-based systems designed to run on personal computers. These new systems present information more graphically because they use Microsoft Windows. Because many physicians and their support staffs use PCs running Windows at home, these new- generation systems are attractive for their ease of use. However, group practices have to guard against acquiring new technology just because it is new. Other factors should be considered, including company viability, end-user satisfaction, and overall functionality. Once a practice has concluded that its old system no longer can meet its needs, it must determine exactly what functions it must acquire, evaluate vendors' systems and negotiate the best
www.acgroup.org Chapter 3 - Page 40 Last Updated: 5/20/2007 Chapter 3 AC Group’s 2007 Annual Report Computer Systems for the Physician’s Office Level 1 – Practice Management Systems possible deal. By carefully moving through these steps, physicians can avoid paying for-and then having to live with-a system that does not meet their needs.
To make sure they buy the right software, physicians need to develop effective purchasing strategies. According to the CIO of the Taconic IPA (3,000+ physicians), “Today, technology decisions must be based on “knowledge” rather than just guess work. Companies like AC Group, POMIS, and KLAS are conducting independent third party reviews of vendor applications, end-user satisfaction, product functionality, and company viability. These reports take the “guess-work” out of decision-making and streamline the selection process.
Practice Management Systems (PMS) have been widely used by physicians since the late 1990’s when Medicare started paying faster if a physician submitted a patient’s insurance claim electronically. The critical issue today is, “What is the standard functionality of a PMS application. As shown below, a survey of the top 30 PMS vendors indicated that most PMS applications today have the same functionality when it comes to necessary functions.
Standard PMS Functionality Critical issue: What is “standard” functionality?
Necessary Functions Optional Functions Registration 95% HIS linkage 72% Patient Scheduling 95% Enrollment / Eligibility 70% Accounts Receivable 90% Outbound capitation 70% Encounter Tracking 90% Occupational medicine 66% Electronic claim submit 90% Contract management 64% Collections Management 87% MCIS linkage 64% Referrals 87% Encoding support 64% Master Patient Index 85% Rules-based scheduling 59% Resource Scheduling 85% Residency billing 59% Coordination of Benefits 82% DME billing (education) 59% Claims Processing 82% Risk pool management 51% Inbound capitation 82% Medical records 46% Referral Management 82% Electronic funds transfer 24% Paperless Collection 77% Worker’s Compensation 77% Remittance Processing 75%
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Selecting the right PMS application:
Job No. 1 for group practice administrators is determining whether their organization needs a new physician practice management system. This decision should be made with care and expert advice. Consider this: More than 1,500 U.S. vendors sell physician practice management systems, according to Vinson Hudson, president of Jewson Enterprises, a Texas-based research and consulting firm who produce the POMIS report. As a result, group practices need to keep their guard up-and carefully analyze whether the time is right for them to be looking for a new practice management system.
The challenge for most physicians is selecting the right PMS application based on specific functionality by category of functionality. According to the October 2005 report from Healthcare Informatics, there are at least 260 vendors selling Practice Management Systems to small, medium, and large physician practices here in the United States. To assist the physician community, a few studies have been conducted by neutral third parties. The following pages describe the results of the studies.
1. AC Group, Inc. PMS Study – Physician Offices
During May of 2007, Mark R. Anderson from AC Group, Inc. conducted an analysis of the top eleven vendors who sell to practices. The criteria that AC Group, Inc. evaluated included:
• Data security • Accounts payable management • Decision support tools • Accounts receivable management • EDI Claims Processing • Ad Hoc Report Writer • EDI Clearinghouse • Appointment scheduling • Electronic Claims Submission • Appointment Scheduling/Recall • Electronic Posting of Remittance Advices • Audit trails • Electronic claims processing • Billing - Family • Electronic data interchange • Billing - Insurance • Electronic remittance capabilities • Billing - Patient • Electronic signature of reports • Billing/ accounts receivable • Employee Policies Manual Development • Budget Forecasting/Modeling • Encoding support • Call Schedules for Physicians • Encounter tracking • Capitation Rate Setting Development • Enrollment and eligibility • Chart Tracking • Fixed Assets • Claims Adjudication-Managed Care • Fully integrated quality care guidelines with • Clinical data repository compliance tracking • Clinical encounter management • General Ledger • Coding support • HMO roster management • Collections • Hospital Information system links • Contract Management • Hospital-Physician Integration • Coordination of benefits • HR Management • Cost Accounting • Income Distribution
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• Incoming/Outgoing referral tracking • Prescription tracking • Insurance Claim Processing - Paper • Purchase orders • Integrated claims adjudication • Referral Management • Integrated clinical and financial system • Relative Value Scales • Interface to elec. imaging processing • Rules-based scheduling • Inter face to speech recognition • Specialty practice management system • Inter face to wireless/ handheld devices • Spreadsheet • Interfaces with other systems • Supports MPI roll-up functions • Inventory/Purchasing • Transcription • Labor Utilization/Staffing • Treatment authorization • Managed Care Reporting/Prepaid/HMO • Treatment referral authorization • Marketing Analysis/Demographics • Utilization and quality management • Master patient index • Utilization management • Materials Management • Word Processing • Management Reporting • Workers' Compensation • Practice Analysis/Daily Audit • MSO Reporting Other: • Multiple Payor Privileges • Online eligibility • Coding - ICD-9, CPT-4 • Online lab orders/ results reporting • Coding - SNOMED • Online prescribing • Other Coding Support • Open item audit trail listing by line item • Patient Education Features • Order entry • Prescription Assistance • Outcomes measures • Report Generator • Patient demographics • Patient education/ guidelines Technology: • Patient flow tracking • Patient Mix • Encryption Technology • Patient scheduling • Object-oriented Technology • Payroll • Smart Card Technology • Physician Productivity • SQL-based Technology • Prescription assistance
Each of the functional areas (which included over 1,000 functional questions) was assigned a weighted point value based on perceived value to the practice. The 31 applications that were evaluated included: 1. AcerMed EMR 13. HealthMatics 24. OD Professional 2. Allscripts Healthcare 14. McKesson Corporation 25. OmniMD ( A Division of Solutions 15. McKesson Practice Partner Integrated Systems Inc.) 3. Bond Technologies, LLC 16. MCS-Medical 26. PracticeXpert 4. Cerner Communication Systems, 27. Pro Practica, Inc. 5. Company Technologies Inc. 28. PULSE SYSTEMS INC. Corporation 17. MedcomSoft 29. Sage 6. eCast Corporation 18. Medinformatix, Inc 30. SSIMED 7. eClinicalWorks 19. Meditab Software, Inc. 31. SynaMed, LLC 8. e-MDs 20. MedNet Systems 9. Epic Systems Corporation 21. meridianEMR, Inc. 10. GE Practice Solutions 22. Misys plc 11. Greenway Medical 23. NextGen Healthcare 12. Health Highway Information Systems, Inc.
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Total Overall PMS Functionality:
The results of the study (Exhibit 4) showed that McKesson Practice Partner, NextGen Healthcare Information Systems, Inc., HealthMatics; eClinicalWorks, Allscripts Healthcare Solutions, and Epic Systems Corporation. The products offered by GE Healthcare are also very strong. However, GE Healthcare does not want their functionality ratings published in this report. The results were based on the responses of the vendors and do not necessary represent 3rd party certified working functionality.
Total PMS Functions
100% Practice Partner NextGen 95% HealthMatics eCW Allscripts 90% Epic Greenway 85% MCS AcerMed McKesson 80% Misys e-MDs Meditab 75% Sage PracticeXpert 70% MedcomSoft PMS CTC
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Large Multi-Specialty Clinics
The companies that traditionally sell to large multi-specialty clinics are usually different than those who sell to traditional practice practices. For the large groups with more than 100 care-givers, Epic Systems, NextGen and IDX Corporation ( GE Healthcare) appear to have the highest percentage of administrative and billing functionality (Exhibit 5).
Total PMS Functions Large Practice > 100 Providers
100%
95%
NextGen 90% eCW Allscripts 85% Epic McKesson Misys 80% Sage PracticeXpert CTC 75%
70% PMS
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Mid-Sized Practices
The companies that traditionally sell to mid-sized practices are usually different than those who sell to individual physicians or large group practices. For practices with 20-99 Physicians McKesson Practice Partner, NextGen, eClinicalworks, HealthMatics 9Allscripts) and Misys appear to have the highest percentage of administrative and billing functionality (Exhibit 6). Once again GE Healthcare also has strong products but they will not allow us to publish their functionality ratings.
Total PMS Functions Mid-Sized Practice (19 - 99 Providers)
100% Practice Partner 98% NextGen 96% HealthMatics eCW 94% Allscripts 92% Greenway 90% MCS 88% AcerMed McKesson 86% Misys 84% Pro Practica 82% PULSE 80% Cerner PMS OmniMD
2
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Small-Sized Practices
The companies that traditionally sell to small practices are usually different than those who sell to individual physicians or large group practices. For practices with 3-19 Physicians McKesson Practice Partner, NextGen, eClinicalworks, HealthMatics (Allscripts) and Misys appear to have the highest percentage of administrative and billing functionality (Exhibit 7). Once again GE Healthcare also has strong products but they will not allow us to publish their functionality ratings.
Total PMS Functions Small Practice (3-19 Providers)
100% Practice Partner 98% NextGen HealthMatics 96% eCW 94% Bond 92% Greenway MCS 90% AcerMed 88% McKesson 86% Misys Pro Practica 84% PULSE 82% e-MDs 80% Cerner PMS OmniMD
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Individual Physicians
The companies that traditionally sell to individual practices are usually different than those who sell to group practices. For individual physicians (1-2) McKesson Practice Partner, NextGen, eClinicalworks, HealthMatics (Allscripts), Bond Medical, MCS and SynaMed appear to have the highest percentage of administrative and billing functionality (Exhibit 8). There are other small physician PMS applications offered by McKesson (MediSoft and Lytec) but McKesson has not provided us with their specific functionality for testing. Once again GE Healthcare also has strong products but they will not allow us to publish their functionality ratings. Total PMS Functions Individual Providers (1 – 2 Providers)
100% Practice Partner
98% HealthMatics
96% eCW
94% Bond 92% Greenway 90% SynaMed 88% MCS 86% AcerMed 84% Pro Practica 82% PULSE 80% PMS e-MDs
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2. Microsoft/AAFP Study
Of the 3,247 physicians surveyed for the 2005 Leadership Survey conducted by AC Group, Inc. 74 percent indicated that improving operating efficiencies was their primary workplace concern. To help doctors better manage information and, in the process, deliver higher quality care, Microsoft teamed up with the American Academy of Family Physicians (AAFP) to evaluate nine practice-management software programs. "Practice management software" is the term for software developed specifically to increase efficiencies by automating billing, insurance claims, appointments and other office tasks.
The resulting software guide, announced in April of 2002 (therefore now 3 years old) at the AAFP's Annual Leadership Forum in Kansas City, Mo., offered doctors the information they need to determine what software works best for their practice. The vendors' software was subjected to intensive review in the functional, technical and financial/corporate areas. The functional evaluation determined the presence or absence of 57 key functionalities. The technical evaluation included an on-site visit by a team of technical experts from Microsoft to the vendor's premises, detailed discussions with the vendor's technical team, a close examination of the architecture of the product, its design, and the methodology for building and testing it.
Over the course of more than two years and based on the needs and requirements of family physicians, Microsoft and the AAFP evaluated the practice management software on criteria including:
• The quality of software functionality • How well it meets the needs of family physicians • The quality of the software's technical architecture • The reliability of the software • The maker's use of industry technology standards • Customer satisfaction • The financial viability of each vendor.
Vendors evaluated in the guide included Compusense (now owned by A4/Allscripts), e-MDs, Greenway Medical Technologies, InfoSys, MedStar Systems, NextGen Healthcare Information Systems, Millbrook (now owned by GE Healthcare), PerfectPractice.MD and Visionary Medical Systems. Both Microsoft and the AAFP consider the report a buyer's guide rather than an endorsement of specific product.
The practice management software products of these nine vendors were subjected to intensive review in the functional, technical and financial/corporate areas. The functional evaluation determined the presence or absence
www.acgroup.org Chapter 3 - Page 49 Last Updated: 5/20/2007 Chapter 3 AC Group’s 2007 Annual Report Computer Systems for the Physician’s Office Level 1 – Practice Management Systems of 57 key functionalities. The technical evaluation included an on-site visit by a team of technical experts from Microsoft to the vendor's premises, detailed discussions with the vendor's technical team, a close examination of the architecture of the product, its design, and the methodology for building and testing it. The purpose of this detailed examination was to ensure that the technology is reliable, secure, and supportable, that it is capable of working with other modern technologies including the Internet, and that it fits the environment of physician offices. The financial evaluation involved detailed examination of the vendor's financial statements, accounting methods, customer base, growth projections, operating procedures, and potential future liability. The goal of this in-depth review was to measure each vendor’s financial and basic operational sustainability and predictability in a challenging economic environment. Scores on each of these three areas were converted to a 0 to 100 scale. A simple average of these three scaled scores was calculated for the composite rating of each vendor.
All of the vendors offered nearly all of the key functions sought, ranging from 88% to 98%. However, there were large variances between vendors on both the technical and the financial/corporate evaluations. To provide a more comprehensive single measure to compare PMS suites, they developed a composite of the evaluations of the above characteristics by averaging the scores for the individual evaluations. Based on this composite score, four companies scored above 75 on a scale of 0 to 100: A4 (CompuSense), Greenway, GE (Millbrook), and NextGen. The AAFP urged physicians preparing to purchase a practice management software system to consider the relative importance of these three factors to their own situation and needs.
Top 9 Practice Management Systems – According to the AAFP/Microsoft study, AAFP/Microsoft Study investing in practice management Functionality Rating Nextgen software is not the purchase of an GE 100.0 undifferentiated commodity, subject only A4 97.5 to price considerations. If that were the 95.0 Perfect Practice 92.5 Info Sys case, we would not see the vendors 90.0 87.5 Medstar investing in improvements in their 85.0 Visonary 82.5 product’s architecture, design and 80.0 e-MD Exhibit 6 reliability. Quite to the contrary, their Greenway technical evaluations would seem to suggest that this is the arena in which customers are won or lost. But choosing a PMS vendor based solely on the product’s technical merits ignores the question of vendor sustainability in a crowded market. In the end, a careful balancing of risks and trade-offs will point the user to the right PMS vendor to meet his or her needs.
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PMS Case Study:
For the 12-provider Diagnostic Cardiology Associates (DCA), the decision to seek out a replacement system was a relatively easy one to make. According to Dean Rombach, the decision to replace our older text-base PMS, and the sequential selection and installation was very time-consuming, but well worth it. DCA chose one of the up and coming vendors, Microsys Computing, Inc. According to Dean, “Microsys provided a functionality rich product, on-time and on-schedule. For the past five years, Microsys has provided superior service and support and have routinuly customized the PMS application to meet DCA’s ever changing requirements.
Selecting the right PMS application
Job No. 1 for group practice administrators is determining whether their organization needs a new physician practice management system. This decision should be made with care and expert advice. Consider this: More than 1,500 U.S. vendors sell physician practice management systems, according to Vinson Hudson, president of Jewson Enterprises, a Texas-based research and consulting firm who produce the POMIS report. . As a result, group practices need to keep their guard up-and carefully analyze whether the time is right for them to be looking for a new practice management system.
One company that is getting a lot of notice lately is Youngstown, OH based, Microsys Computing, Inc. Microsys has received numerous 3rd party validations and awards during the past year. In the KLAS 2003 PMS report, an organization that measures end-user satifaction, Microsys rated highest for overall performance indicators (60.56) and received first place ratings in:
o Helps Job Performance o -Quality of Custom work o -Implementation within Budget/Cost o -Quality of documentation o -Money’s Worth o -Quality of releases/updates o -Proactive service o -Worth the effort/improved productivity o -Product Quality Rating o -Would buy it again
In regards to product functionality, Microsys was a finalist in the TEPR 2003 awards, and received extremely high marks on the annual POMIS report. Out of a maximum of 10, Microsys received the following rankings:
o Rated Exceptional Cost (9.35), o Overall customer satisfaction (9.28) o Product/Services Maturity (9.40) o Technological Fit (9.55) o Implementation (9.10) o Functionality (9.75) o Customer support (9.75)
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Over the course of more than two years and based on the needs and requirements of physicians, AC Group evaluated various practice management software solutions based on specific criteria including:
• The quality of software functionality • How well it meets the needs of family physicians • The quality of the software's technical architecture • The reliability of the software • The maker's use of industry technology standards • Customer satisfaction • The financial viability of each vendor.
Overall, Microsys received the highest rating (5-Stars) from AC Group, Inc. Microsys’ practice management solution was subjected to intensive review in the functional, technical and financial/corporate areas. The functional evaluation determined the presence or absence of 90 key functionalities. The technical evaluation included detailed reviews of the architecture of the product, its design, and the methodology for building and testing it. The purpose of this detailed examination was to ensure that the technology is reliable, secure, and supportable, that it is capable of working with other modern technologies including the Internet, and that it fits the environment of physician offices. The financial evaluation involved detailed examination of the vendor's financial statements, accounting methods, customer base, growth projections, operating procedures, and potential future liability. The goal of this in-depth review was to measure a vendor’s financial and basic operational sustainability and predictability in a challenging economic environment. During the process, Tom Ferkovic with SS & G Healthcare Services LLC indicated that Microsys provided a great product that allowed his group to support multi-practices from a single location. According to Tom, “Microsys provided an easy to learn and easy to use system with superior functionality and great on-going support.”
Conclusion:
Technology is only a tool and if used effectively can improve the flow of information and potentially improve the efficiency of the physician’s practice. However in reality, if “change” is not embraced, the probability of success is very low. We learned in the 1980’s that we needed to change the process of billing for services – or we would not be paid in a timely and effective manner. Therefore, the practice of medicine, from the business point of view, changed. Now with newer technologies, government regulations, and the right financial incentive, physicians will begin embracing new levels of technology that were not available just 5 years ago. But where does a physician in a small practice turn to learn about the 100’s of technology choices? The physician can spend hours searching and evaluating all of the opportunities. Or maybe in the near future, physicians will be able to look towards leaders within their own medical specialty for guidance and knowledge.
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3. Jewson Enterprises
Founded in August 1973 by Vinson J. Hudson and Jewel C. Hudson, Jewson Enterprises produces an annual report on the PMS marketplace. The company provides market research, industry analyses, and competitive intelligence advice to medical practices and information technology vendors seeking advantage through market knowledge. The company also provides a national and international reputation for excellence, objectivity, and confidentiality in its research analysis, and for identifying market dynamics and strategic visions that is best suited to the development of business and technology needs.
Jewson Enterprises™ (JE) is built on the strategic use of professionals intimately knowledgeable on industry events, trends, and facts. This is reflected in its high quality market research and analyses; products/services, hassle-free customer service; and, most important, timely delivery of reliable knowledge when you need it. JE specializes in the following:
o The POMIS Report© - An seven-chapter subscription database on physician’s office information system solutions (ISS), industry demographics, market analyses, trends, technology utilization, and competitive analysis. o Ambulatory Care Setting Clinical Information Systems Report© - , ambulatory care setting clinical information systems report separated from The POMIS Report that analyzes the market for computer-based patient records systems and associated applications. o The Satisfaction Rating Directory of POMIS Vendors (The SRD©) – An unbiased, primary purchasers source for medical practices who are considering first-time purchase, enhancement, or replacement of an ambulatory care setting ISS. Hundreds of vendors have been give a unique satisfaction rating based on nine essential selection criteria. o POMIS IQ Report – A quarterly digest of pertinent industry dynamics. These dynamics include mini- market analysis, industry analysis, analyst’s strategic visions, and an interesting area called “Hearsay Research.” o Personalized Advisory Services – A customized executive seminar-type presentation to focus corporate planning executives toward existing and emerging opportunities. We perform business/market plan evaluations, due diligence projects, customized market research, organized executive brainstorming, speaking engagements, and brokering acquisition and merger deals.
JE is hub to a successful industry competitive intelligence-gathering network of people and organizations whose intellectual assets are organized in its POMIS Knowledge Base. The flexibility of its business model delivers a
www.acgroup.org Chapter 3 - Page 53 Last Updated: 5/20/2007 Chapter 3 AC Group’s 2007 Annual Report Computer Systems for the Physician’s Office Level 1 – Practice Management Systems kind of market research and analysis firms without walls – a virtual industry knowledge base. JE’s POMIS Knowledge Base is a comprehensive representation of the industry’s competitive intelligence professional.
The POMIS Report has raised its bar of value.
o Presents a scenario analysis of possible futures in the industry. o Presents an industry analysis that expands on physician organization distribution, physician organization expenditures through a 5-year forecast, technological analysis, trends and events, and a strategic group analysis in the Competitors Analysis section. o Presents a separate volume that analyzes only the ambulatory care setting computer-based patient records (or EMR) systems marketplace. o Presents The SRD – the most comprehensive database of POMIS vendors in the U.S. o The POMIS Report is loaded with strategic information to help you refine your goals of market success. o New approach to competitors’ analysis that uses strategic group analysis of POMIS vendors and a scenario analysis that uses specific methodological approaches that looks at how the future POMIS industry could look based on trends, events, and surprises. Strategies of the leading 10 firms in terms of revenue, such as Misys Healthcare Systems, IDX o Systems Corporation, and Medical Manager Health Systems/WebMD, is stressed but sustainable. New companies, such as Amicore and GE Medical Systems, are challenging existing POMIS vendors with large footprints, creating competitive scares.
o Surveys indicate that clinical (e.g., physician CPOE, e-prescribing via the Internet, EMRs/CPRs, etc.) purchases will be significant between 2003 and 2005, dramatic between 2005 and 2007, and widespread after 2007. Practice management systems from new vendors and large established vendors based on Windows-based and ASP-based delivery configurations may significantly begin to enhance legacy systems.
o HIPAA enforcement will drive small and medium-sized physician organizations to seek the help of their information technology solutions vendor.
o POMIS vendor population will continue to decline within a highly competitive marketplace.
o Revenues earned by the vendor population will continue to increase at attractive double-digit compound annual growth rates.
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2006 Edition 2006 Edition 2006 Edition POMIS Vendor POMIS Market POMIS ACS-CPR Database Analysis Analysis Volume 2 Volume 1 Volume 3
Physician’s Office Management Physician’s Office Management Physician’s Office Management & & Medical Information Systems & Medical Information Systems Medical Information Systems Industry report on EMRs/CPRs Industry information technology Industry Essential Knowledge for and related clinical components solutions vendor database. Business and Strategic Planning. for Business and Strategic Planning
Client & Subscriber Profile
Jewson Enterprises (JE) primarily targets POMIS vendors and physician provider organizations. Market demand during 1996 has expanded the client base of companies, executives, and strategic planners into other industries. JE’s clients are described as follows: private physicians, group practices, application software innovators, corporate acquisition seekers, investment bankers, practice management consultants, publishers, drug firms, computer manufacturers, hospitals, health care transaction processing firms, blue cross and blue shield plans, commercial insurers, etc.
The following matrix describes JE’s mix of clients & business:
POMIS POMIS Partnering Advisory Clients Report IQ Assistance Service Application Software Innovators √ √ - √ Blue Cross & Blue Shield Plans √ √ - √ Commercial Insurers √ √ - √ Computer Manufacturers √ √ √ - Corporate Acquisition Seekers √ √ √ √ Drug Firms √ √ √ √ Healthcare Transaction Processing Firms √ √ √ - Hospitals - √ - √ Information System Solutions Vendors √ √ √ √ Investment Bankers √ √ √ √ Medical Practices - √ - √ Practice Management Consultants √ √ √ √ Private Physicians - √ - √ Publishers √ √ - √
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The POMIS Industry
The physician’s office management and medical information systems (POMISSM) industry consists of all ambulatory care settings, medical offices, managed care plans, and the vendors of information system solutions who serve them. The major market segments of physician’s offices are:
• Traditional Solo & 2-physicians • Managed care plans practices • Free-standing ambulatory care centers • Traditional group practices • Integrated Delivery Networks • Hospital-based practices • Academic medical centers
The segments of vendors of information system solutions are:
• Systems vendors – Personal computers, workstations, midranges, and mainframes • Service organizations – Billing services and outsourcing services • Application Service Providers – ASP or Web Services
The POMIS Report History
• The initial POMIS analysis report was called the Computerized Physician's-Office Medical Information Systems (POMIS) database and published in 1968. It was a joint venture with Creative Strategies International and Jewson Enterprises. More than 230 vendors were investigated in an undefined industry; that edition was the first of its kind to furnish in-depth information on a broad range of vendors, healthcare policy makers, and health services institutions within the medical and health care industry. Although the 1968 edition was acknowledged as a qualified success, the one serious shortcoming was that it did not provide answers to data presented.
• By 1985, Jewson Enterprises™’ POMISSM Report was well established. It analyzed facts and numbers that could be used by corporate product development decision-makers. It included discussions by marketing experts, whose professional commentaries address issues that corporate management needed in order to understand how to be successful in their targeted market segments.
• This report included survey results of more than 600 vendors and more than 2,000 medical offices. Information in that study provided value to both the POMIS vendor and medical provider.
TM • In 1990 and 1991, Jewson Enterprises published the POMIS U.S. Analysis Report from its POMIS Knowledge Base. It was designed to assist marketing organizations with growth and penetration into the industry. The report answers three basic questions: (1) What is the size and growth of the market; (2) What is the growth rate of the market in installations and revenues; (3) What are the potential bases by which defined markets might be segmented; and (4) What is the structure of the competitive environment?
• The 1992 base year report, called The POMIS U.S. ANALYSIS REPORT PACKAGE, described strategies and visions on how vendors are selling information systems solutions as a cost-effective way to lower costs and increase revenues. It described what types of medical offices are likely to acquire, enhance, or replace systems; what types of support and services they are likely to buy; where market growth is likely to occur by 1997; how much of each market segment is currently computerized; where expansion possibilities are likely to occur; and how healthcare legislation and reimbursement issues are likely to effect each market segment.
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The SRD©
Included is The Satisfaction Rating Directory of POMIS Vendors (The SRD). The SRD is the unbiased, primary purchaser’s source for medical practices that are considering a first-time purchase, enhancement, or replacement of a medical office ISS. It is a database of U.S. physician practice information system vendors and software publishers. The database has several tables that can be used and is used for analysis.
The SRD features numerous vendors who have withstood an independent Satisfaction Rating process and scored on (1) nine essential selection criteria, (2) an overall satisfaction rating, (3) an overall expectation score, and (4) a satisfaction-to-expectation ratio. Each vendor's profile is presented with the following data elements:
POMIS VENDOR PROFILE AND SATISFACTIONS RATINGS – PUBLISHED REPORT PROFILES DATA ELEMENTS
Company Name • Managed Care Information Systems Parent Name • CPR/EMR/HER Systems Address1 • Other Systems Address2 Company Management Team City, State Satisfaction Rating Summary Postal Code • Overall Customer Satisfaction Rating Voice Number • Expectation Score Toll-free Number • Satisfaction-to-Expectation Score Fax Number • Application Implementation E-Mail • Breadth of Products/Services Website • Cost Ownership • Customer Support Year Entered Business • Functionality Geographical Coverage • Product/Service Maturity Revenue Range • Regional Presence Number of Employees • Technological Fit Number of Sales and Service Offices • Vendor Stability Number of Total Customer Accounts Technology Platforms For Solutions Number of Physicians With Customers General Description of Pricing/Costs Distribution Channels: Type of Customers Targeted • Direct Sales • Value-Added Resellers • Sales Representatives Vendor General Write-up • Telemarketing • Overall Description • Dealers • Alliances • Distributors • Implementation Description • Mail Order • Differentiation Comments • International Sales • Analyst Comments
Products/Services Delivery Types: Products & Applications Descriptions • Computer Systems • Company Name • Billing Services • Product/Service Name • Outsourcing Services • Major Category • Application Service Providers • Method of Delivery Information Technology Solutions Offered: • Product/Service Description • Practice Management Systems
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Physician Practice Database
This database contains more than 11,000 physician organizations from 3-physicians practices and greater. JE uses this database to perform satisfaction ratings on a random basis. The value of this database lies in its potential for business. Few have a database that has qualified contacts. Here is its format:
Data Type Description Field Name practice_tag AutoNumber Medical Office Satisfaction Rating Respondent Identifier practice_name Text Medical office practice name contact_name Text Name of contact and other executives (e.g., CEO, CIO, Administrator, etc.) address1 Text Address1 of Medical Office address2 Text Address2 of Medical Office city Text City of Medical Office state Text State of Medical Office postal_code Text Zip code of medical office voice Text Telephone Number of Medical Office fax Text Fax Number of Medical Office tollfree Text Tollfree Number of Medical Office email Text E_Mail of Medical Office web_address Text Website address of medical office practice practice_type Text Type of medical office practice specialties Text Type of specialties within practice physician_size Number Number of physicians in practice extender_size Number Number of physician extenders (e.g., NPs, PAs) in practice MCPlives_covered Number Number of patient lives covered under managed care plan contract pomis_name Text Name of Vendor's System and/or Solution pomis_vendor Text Name of vendor contract_start Text Month and/or year that practice contracted for system/solution financial_apps Yes/No Financial applications in vendor's system/solution administrative_apps Yes/No Administrative applications in vendor’s system/solution managed_care_apps Yes/No Managed care plan applications in vendor's system/solution medical_apps Yes/No Medical and clinical applications in vendor's system/solution EDI_connectivity Yes/No EDI and communications applications amc Yes/No Is the practice affiliated with an academic medical center? ed Yes/No Is the practice an emergency department? od Yes/No Is the practice an outpatient department? HMO Yes/No Is the practice a Health Maintenance Organization? IPA-HMO Yes/No Is the practice an IPA-HMO PPO Yes/No Is the practice a PPO? ppmc Yes/No Is the practice a physician practice management company? application_detail Memo Any detail descriptions of the applications from the vendor sites Number Number of remote sites comments Memo Additional information to characterize practice
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Competitive Intelligence A Strategic Imperative
During the pre-1990s when POMIS markets were expanding, many vendors could sustain sales growth merely by maintaining constant market share. But the 1990s are different, as will be the next millennium. Many major market segments are declining in number but increasing in the size of individual revenue opportunities.
Vendors today are eagerly eyeing each other’s sales volume and customer accounts to insure their survival. It’s a jungle out there. “It’s a wonder how you keep from going under.” Therefore, the vendor that does not anticipate and effectively plan for increasingly tough competition will become legitimate prey in the medical practice marketplace.
To thwart your competition, market trends indicate that you should develop a strategic competitive intelligence system that uses available information about industry dynamics and competitors to allow you to exploit marketplace weaknesses.
There is nothing sinister with vendors engaged in competitive intelligence. Vendors who implemented a system are not doing anything immoral or illegal. Instead, they are exercising their right to obtain and analyze market information that is publicly available but varying in known sources.
This is not industrial espionage, which JE abhors. Espionage seeks to obtain private, confidential, and/or proprietary information that is not freely available to all; frequently it employs illegal methods to achieve its ends. But the tools of competitive business intelligence consist largely of extracting information from a variety of published, or third party data sources.
To be successful, an intelligence system must have senior management commitment as facilitators. They should delegate one person (item 1 below) with full responsibility for the system. That person could be a marketing or corporate planning executive whose responsibilities could be described in Exhibit 3-2.
The explanation of Exhibit 2 is as follows:
1. The competitive intelligence professional (CIP) is fully responsible for the system. This responsibility will be shared with a Director who assumes operational responsibility. 2. Definition of information requirements – Definition of information requirements could be complex for anyone or company just getting started. JE has been doing it for nearly 30 years. Therefore, this description is organized to show what steps JE performs. Here are the key steps: a. Identify current and potential POMIS vendors. JE has cultivated several reliable sources. But contact with state and local medical societies and associations is a good starting point. When contacting vendors, ask them who their competition is. Lastly, telephone books in large libraries indicate small vendors. b. What analysis offers value to current and prospective clients? JE gets its clients to discuss their concerns and needs. This information is used format The POMIS Report, as well as our research focus. c. Define POMIS industry broadly in terms of major market segments rather than by products. d. Define vendors that make alternative solutions to traditional POMIS, or even emerging industries, such as banking, pharmaceutical, etc. e. Pay attention to the POMIS industry within 2-3 years of the base year. For instance, 2000-2002 indicates reduced profitability and increased competition causing many companies to seek more attractive opportunities. f. Analyze POMIS industry to include vendors of systems and component applications, as well as partners of vendors. Look at internal agreements and/or contracts, competitive product performance (e.g., quality, specifications and delivery methods), R&D (including patients filed,
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new product development, research focus), channels of distribution, sales and marketing regions, sales force analysis, marketing, finance, and personnel. g. Contact knowledgeable executives in charge of planning areas to identify current and potential competitors. Focus on the POMIS 100 vendors (the top ten vendors in revenues) to address the following questions. • What do they want to know about competitors? • What business are you in? • Who are the industry peripheral suppliers and partners? • What do they supply and the extent of goodwill between suppliers and competitors? • What are the competitive product and service performance (e.g., quality specifications, application implementation)? • What is the size of R&D (e.g., patients filed, new product development, research focus)? • What is the state of system integration program (e.g., efficiency of operation)? • What distribution channel is used (e.g., method, number of offices)? • What are the estimated sales and profits by MSA, by system lines, etc.? • What sales force has they (e.g., how many, salary levels, level of expertise, morale, geographic placement)? • What is their marketing level (e.g., number of individuals, media strategy and execution, pricing policy, trade terms and relationships, promotion, historical strategy evolution)? • What is the financial support (e.g., reputation, extent of leverage, ratio analysis, profitability performance, cash flow)? • Who are its personnel (e.g., psychological and performance profiles of key personnel)? 3. Data Search – Primary data is obtained from questionnaires/interviews with vendors and physician organizations. Other data search sources are libraries, SEC, Newspapers, computer databases, specialists, network, and competitors’ products and services descriptions. Current questionnaires are shown in Appendices A and B. 4. Sources Databases – Within the POMIS DATABASE in Microsoft Access format, the following sources are used: a. Table - IDS/N Sources – A source of integrated delivery systems and networks. b. Table – Internet Sources – A source of Internet sources for the POMIS industry. c. Table – PUBLICATIONS – A database of publications that JE uses for information in The POMIS Report. d. Table – Rating Contact – A database of physician organizations that JE uses for surveying ratings and general needs assessments. 5. Data Acquisition –A great deal of useful information is readily available, even though some requires persistent digging. Various disjointed data/information is obtained from competitors, press releases, investment analyses, competing vendors, consultants, customers of competitors, information databases, and trade associations. Competitive information is available from three sources: a. What competitors say about them? b. What third parties say about competitors? c. What individuals within organizations have observed. 6. Data Organization – Organize data acquired into categories based on markets or functional areas. Discard information that is unrelated to need. 7. Information Generation – Preparation for rapid response 8. Tactical Response – Anticipate through query experience what information should be ready for rapid response. 9. Catalog Information – Index information by functional areas. Circulate among clients for review. Their comments will provide the basis to help responding rapidly to competitive information requests. 10. Response to Query – Determine appropriate method to response to query. 11. Competitive Strategy Analysis – Assess competitive weaknesses and make informed estimates of their strategic decisions. Make a strategic review annually. Differentiate between the objectives and strategies of corporate parents and individual business units. www.acgroup.org Chapter 3 - Page 60 Last Updated: 5/20/2007 Chapter 3 AC Group’s 2007 Annual Report Computer Systems for the Physician’s Office Level 1 – Practice Management Systems
12. Business Planning Reports – Prepare planning reports for dissemination to appropriate parties. 13. Customer Satisfaction Index Analysis – Perform an analysis of the customer satisfaction survey and analyze results. 14. Customer Satisfaction Rating Report – Prepare reports. 15. Modification from Early Warning Systems – Review the impact of strategies relative to trends, events, and early warning signs.
Exhibit 2. POMIS Strategic Competitive Information System
CIP & Regional Information 1 Gatherers ¾ The POMIS Report ¾ The SRD ¾ The ACS Clinical Report
Definition of Information 2
Requirements 4 3 Date Search Source Database
5 Data Acquisition
6 Data Organization
7 8
Information Generation Tactical Response
9 10 Catalog Information Response to Inquiry
11 12 Competitive Strategy Analysis Business Planning Reports
13 14 Consumer Satisfaction Index Customer Satisfaction Rating Analysis Reports
15 Modification of Current
Business Strategy
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Jewson Enterprises’ Business and Analyst’s Code of Ethics
Since Mr. Hudson and Jewson Enterprises™ maintain insider knowledge of several organizations through hundreds of non-disclosure agreements, the owners have stipulated the following code of ethics based on Mr. Hudson’s membership in the Society of Professional Intelligence Professionals.
o To continually strive to increase the recognition and respect of the profession. o To comply with all applicable laws, domestic and international. o To accurately disclose all relevant information, including one’s identity and organization, prior to all interviews. o To fully respect all requests for confidentiality of information. o To avoid conflicts of interest in fulfilling one’s duties. o To provide honest and realistic recommendations and conclusions in the execution of one’s duties. o To promote this code of ethics within one’s company, with third-party contractors and within the entire profession. o To faithfully adhere to and abide by one’s company policies, objectives, and guidelines.
More information can be obtained by contacting Vince Hudson at:
6425 South IH-35, Suite 105-177 ♦ Austin, TX 78744 Message Center: 650-368-6570 Direct Voice: 512-445-5050, Ext 505 E-mail: [email protected]
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4. Listing of Practice Management System Vendors:
Code: P = Purchase, L = Lease (ASP), B = Both (Purchase or Lease)
A4 Health Systems • HealthMatics PM (P, L, B) Cary, N.C. • (888) 672-3282 • www.a4healthsystems.com
AcerMed Inc. • MERRIT System (P, L, B) Irvine, Calif. • (800) 841-0008 • www.acermed.com
Advanced Data Systems • MedicsElite (P, B) Maywood, N.J. • (800) 899-4237 • www.adsc.com
American HealthNet Inc. • Multiple products (P, L, B) Omaha, Neb. • (800) 745-4712 • www.americanhealthnet.com
American Medical Software • Practice Management PLUS System (P, B) Edwardsville, Ill. • (800) 423-8836 • www.americanmedical.com
Amicore • Amicore (B) Andover, Mass. • (978) 691-3400 • www.amicore.com athenahealth • athenaNet (L) Waltham, Mass. • (781) 642-8800 • www.athenahealth.com
Avisena Inc. • Avisena Platform for Providers Miami • (305) 446-8599 • www.avisena.com
Axolotl Corp. • Elysium Physician Practice Solutions (L) Mountain View, Calif. • (888) 296-5685 • www.axolotl.com
Berdy Medical Systems Inc. • SmartClinic (L) Saddle Brook, N.J. • (800) 662-3739 • www.BerdyMedical.com
C & S Research Corp. • ProVision (P) King of Prussia, Pa. • (800) 545-8460 • www.csrc.com
CACTUS Software • Visual CACTUS Prairie Village, Kan. • (800) 776-2305 • www.visualcactus.com
CAPCOM Inc. • McKesson Practice Point Manager (P, L, B) Haddonfield, N.J. • (856) 428-0878 • www.capcomnet.com
CereSoft Inc. • EOBAgent (P, L) Silver Spring, Md. • (301) 445-8413 • www.ceresoft.com
Cerner Corp. • PowerChart Office (B) Kansas City, Mo. • (816) 221-1024 • www.cerner.com
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4. Listing of Practice Management System Vendors (Continued)
CHARTCARE Inc. • TotalCare (P, L, B) Lakewood, Wash. • (800) 438-1277 • www.chartcare.com
Clinic Pro Software • Clinic Pro Software (P) Sedona, Ariz. • (866) 333-2776 • www.clinicpro.com
ComChart Medical Software • ComChart EMR (B) Lowell, Mass. • (978) 441-3939 • www.comchart.com
Companion Technologies • MegaWest Practice Management Suite (P, L, B) Columbia, S.C. • (800) 999-0788 • www.companiontechnologies.com
Complete Medical Systems Inc. • Winmed Professional (P, B) Baton Rouge, La. • (800) 256-2803 • www.doctornetwork.com
CPSI • CPSI System (B) Mobile, Ala. • (800) 711-2774 • www.cpsinet.com
CPU Medical Management Systems Inc. • MED/FM (P, L, B) San Diego • (888) 224-4278 • www.cpumms.com
CureMD • CureMD (P, L, B) New York • (877) 362-9549 • www.curemd.com
Dairyland Healthcare Solutions • DHS PPM System (P, L, B) Glenwood, Minn. • (800) 323-6987 • www.dhsnet.com
DataTel Solutions Inc. • M.O.M.S. Medical Office Management System (B) San Antonio • (210) 558-3733 • www.datatel-solutions.com
DeltaWare Systems Inc. • ICore Health (P, L, B) Charlottetown, Prince Edward Island • (877) 201-6771 • www.deltaware.com
Doc-tor.com L.L.C. • Doc-tor.com (L) Oakland, N.J. • (877) 505-1888 • www.Doc-tor.com
Doctor-Driven Systems Inc. • MD Hawkeye (B) Newton, Mass. • (617) 332-3126 • www.doctor-driven.net
DrFirst.com Inc. • NextGen PMIS (P, L, B) Rockville, Md. • (888) 271-9898 • www.drfirst.com
E*HealthLine.com Inc. • Integrated Practice Management System (P, L, B) Sacramento, Calif. • (916) 924-8092 • www.ehealthline.com
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4. Listing of Practice Management System Vendors (Continued) e-MDs • topsBill (P, L, B) Cedar Park, Texas • (888) 344-9836 • www.e-MDs.com
Electronic Healthcare Systems • CareRevolution (P, L, B) Birmingham, Ala. • (888) 879-7302 • www.ehsmed.com
Electroniclaim • Electroniclaim Practice Management 2000 (P) Mequon, Wis. • (888) 240-9985 • www.electroniclaim.com
Epic Systems Corp. • Epic Practice Management Suite (B) Madison, Wis. • (608) 271-9000 • www.epicsystems.com
Experior Corp. • Medical Management System (P, L, B) Fort Wayne, Ind. • (800) 595-2020 • www.experior.com
FemTrack by NC Consulting Inc. • FemTrack (P, B) Chicago • (888) 462-4025 • www.femtrack.com
Greenway Medical Technologies • PrimeSuite (P, L) Carrollton, Ga. • (770) 836-3100 • www.greenwaymedical.com
Health Care Data Systems, An FMT Company • ENTITY (P) Syracuse, N.Y. • (800) 950-7111 • www.hcds.com
Health Care Software Inc. (HCS) • INTERACTANT (P) Farmingdale, N.J. • (800) 524-1038 • www.hcsinteractant.com
Health Data Services • MedLedger (L) Charlottesville, Va. • (800) 800-4021 • www.healthdataservices.com
HealthCentrics • HealthCentrics 3.0 (B) Atlanta • (866) 609-5070 • www.healthcentrics.com
HealthCo Information Systems Inc. • Millbrook Practice Manager (P, L, B) Tualitin, Ore. • (888) 740-7734 • www.healthcois.com
IDX Systems Corp. • Multiple products (P, L, B) Burlington, Vt. • (802) 862-1022 • www.idx.com iLIANT Corp. • The Medical Manager (L) Tampa, Fla. • (813) 855-6880 • www.iliant.com
IMPAC Medical Systems Inc. • Multi-ACCESS (P) Mountain View, Calif. • (888) 464-6722 • www.impac.com
Innovated Medical Corp. • The Patient Advocate (P) South Bend, Ind. • (800) 956-8072 • www.InnovatedMedical.com
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4. Listing of Practice Management System Vendors (Continued)
Insight Mgmt Systems Inc. • OmniTrack-Preventive Care and Disease Management Encino, Calif. • (800) 643-0123 • www.insightmed.com
Intelligent Medical Systems Inc. • SmartDoctor (P, L, B) Alpine, Texas • (800) 747-4154 • www.smartdoctor.com
Internexsys Corp. • Medical InfoManager (P) Walpole, Mass. • (508) 668-7800 • www.internexsys.com
Keane Inc. • Keane Practice Management (P, L) Melville, N.Y. • (800) 699-6773 • www.keane.com/hsd
Matrix Management Solutions • NextGen EPM (P, L, B) Uniontown, Ohio • (330) 899-1275 • www.matrixmso.com
McKesson Information Solutions • Multiple products (P, L, B) Alpharetta, Ga. • (800) 981-8601 • www.infosolutions.mckesson.com
MD/Win Corp. • Millbrook Practice Manager 2002 (P, L, B) Raleigh, N.C. • (800) 849-2750 • www.mdwincorp.com
MDanywhere Technologies Inc. • MDAPRACTICE (P, L, B) Baltimore • (877) 632-4488 • www.mdanywhere.com
MDinteractive • MDinteractive (P, L, B) Brookline, Mass. • (617) 233-6854 • www.mdinteractive.com
MDTechnologies Inc. • MedTopia (L) Baton Rouge, La. • (800) 290-1657 • www.mdtechnologies.com
MedAptus Inc. • In Hand Suite (P, L, B) Boston • (617) 523-1221 • www.MedAptus.com
MedcomSoft • MedcomSoft Record (P, L) Toronto • (416) 443-8788 • www.medcomsoft.com
Medical Central Online • Medical Practice Central & Local (L) Highland Park, Ill. • (847) 266-9404 • www.medicalcentral.com
Medical Information Technology Inc. • Physician Practice Management (P) Westwood, Mass. • (781) 821-3000 • www.meditech.com
Medical Manager Health Systems • The Medical Manager (P) Tampa, Fla. • (800) 222-7701 • www.medicalmanager.com
Medifax-EDI Inc. • MedWare (P) Nashville, Tenn. • (800) 819-5563 • www.medifax.com
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4. Listing of Practice Management System Vendors (Continued)
Medinex Systems Inc. • Medinex Office (L) Celebration, Fla. • (888) 580-1010 • www.medinex.com
HealthCare Data Inc. • Health Probe Professional (P, L, B) Morgantown, Ind. • (765) 342-9947 • www.healthprobe.com
MedStar Systems LLC • MedStar (P, L, B) Coral Springs, Fla. • (866) 775-7779 • www.MedStarSystems.com
MicroFour Inc. • PracticeStudio (P, L, B) Amarillo, Texas • (800) 235-1856 • www.micro4.com
Microsys Computing Inc. • MicroMD (P, L, B) Youngstown, Ohio • (800) 624-8832 • www.micromd.net
Millbrook Corp. • Millbrook Practice Manager (P, L, B) Carrollton, Texas • (800) 645-0985 • www.millbrook.com
Misys Healthcare Systems • Misys Tiger (P, L, B) Raleigh, N.C. • (800) 334-8534 • www.misyshealthcare.com
MMC Inc. • SECUR Practice System (P, L, B) St. Louis • (800) 729-6627 • www.mmcs1.com
NDCHealth • Multiple products (P) Atlanta • (800) 778-6711 • www.ndchealth.com
NextGen Healthcare Information Systems Inc. • NextGen EPM (P, L, B) Horsham, Pa. • (215) 657-7010 • www.nextgen.com
NOVASOFT SANIDAD • Multiple products (B) Rincon de la Victoria (malaga), Spain • +34 951 066 500 • www.gruponovasoft.com
OpTx Corp. • optxTOOLS (P) Englewood, Colo. • (303) 623-7700 • www.healthierpractices.com
PDM Productive Data Management Inc. • Patient Information Management Solution (P) Los Angeles • (323) 725-2904 • www.pdmsoftware.com
PenRad • MAMMOGRAPHY INFORMATION SYSTEM (MIS) (P) Plymouth, Minn. • (763) 475-3388 • www.penrad.com
Per-Se Technologies • MedAxxis (P, L, B) Atlanta • (877) 737-3773 • www.per-se.com
PerfectPractice MD • PracticeManager.MD (P, L, B) Sandy, Utah • (800) 825-0224 • www.perfectpractice.md
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4. Listing of Practice Management System Vendors (Continued)
Physician Micro Systems Inc. • Practice Partner (P, L, B) Seattle • (800) 770-7674 • www.pmsi.com
Physician’s Computer Company (PCC) • Partner (P, L, B) Winooski, Vt. • (800) 722-7708 • www.pcc.com
Point and Click Solutions Inc. • OpenSuite (P) Burlington, Mass. • (781) 272-9800 • www.pointandclicksolutions.com
PracticeOne • PracticeOne Business Manager (P, L, B) Vienna, Va. • (888) 294-0012 • www.practiceone.com
Precisely Write Corp. • DictationNet (L) Brooklyn, Mich. • (800) 630-0076 • www.preciselywritecorp.com
Prodata Systems Inc. • Webselect ES (L) Bothell, Wash. • (866) 487-8346 • www.prodata.com
PSIMED • PSIMED Medical Management System (P, L, B) Santa Ana, Calif. • (714) 979-7653 • www.psimed-ambs.com
Pulse Systems Inc. • PulsePro Practice Management System (P, L, B) Wichita, Kan. • (800) 444-0882 • www.pulseinc.com
QRS Inc. Healthcare Solutions • PARADIGM (P, L, B) Knoxville, Tenn. • (800) 251-3188 • www.qrsparadigm.com
QuadaX Inc. • HARP Healthcare Accounts Receivable Processor (P, L, B) Cleveland • (800) 929-3775 • www.quadax.com
Quick Notes Inc. • Multiple products (P, L, B) Cooper City, Fla. • (800) 899-2468 • www.qnotes.com
RIS Logic Inc. • RIS Logic CS (P) Solon, Ohio • (866) 747-5644 • www.rislogic.com
Riverview Software • PARADIGM (P, L, B) Kittanning, Pa. • (724) 545-1317 • www.riverview-software.com
Scheye Group Ltd., The • Practice Value Enhancer Chicago • (773) 989-9315
SECUREHEALTH • SECUREHEALTH PMS (P, L, B) Burlington, Vt. • (802) 658-3860 • www.securehealth.cc
Soft-Aid Inc. • Multiple products (P, L, B) Miami • (877) 763-8243 • www.soft-aid.com
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4. Listing of Practice Management System Vendors (Continued)
Source Medical Solutions Inc. • Multiple products (B) Birmingham, Ala. • (877) 687-2300 • www.sourcemed.net
SpectraSoft Inc. • AppointmentsPRO (P) Tempe, Ariz. • (800) 889-0450 • www.ssoft.com
STI Computer Services Inc. • Perfect Care for Windows (P) Norristown, Pa. • (800) 487-9135 • www.sticomputer.com
SynergyWare Data Management Systems • SYNERGYWARE DATA MANAGMENT SYSTEM Philadelphia • (215) 284-1600 • www.synergyware.net
Third Millennium Healthcare Systems Inc. • i.suite (L) Decatur, Ga. • (404) 687-2830 • www.tmhsi.com
Trellis Health Partners • Vera Practice Control (P) Schaumburg, Ill. • (877) 778-8372 • www.trellishealth.com
Tricare Medical Resources Inc. • CompuMedic (P, L, B) Tyler, Texas • (903) 592-0562 • www.tricare.com
TriZetto Group, The • Multiple products (L) Newport Beach, Calif. • (949) 719-2200 • www.trizetto.com
Universal Medical Records • Virtual Medical Navigator (L) Cortlandt Manor, N.Y. • (914) 737-7499 • www.universalmedicalrecord.com
VantageMed • Multiple products (P, L, B) Rancho Cordova, Calif. • (877) 879-8633 • www.vantagemed.com
Virtual Clinician Inc. • Virtual Clinician Product Suite (L) Chicago • (312) 829-1779 • www.virtualclinician.com
VitalWorks • VitalWorks Practice Manager Products (B) Ridgefield, Conn. • (800) 278-0037 • www.vitalworks.com
WELLINX • WELLINX (P, L) St. Louis • (866) 935-5269 • www.wellinx.com
Westland Medical Systems Inc. • e-Medsys (P, L, B) Calabasas, Calif. • (877) 636-3797 • www.westlandmedical.com
Zybex Inc. • CyberMed (P, L, B) San Diego • (800) 266-6334 • www.zybex.com
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Connectivity – The Internet opens new doors… and may threaten old ones.
Currently, one of healthcare’s biggest challenges is the excessive cost, time and error relating to administration and the exchange of basic information, which drives up the cost of patient care. From our research, approximately 33% of each healthcare dollar or over $400 billion in the aggregate, are spent on non-clinical patient care expenses such as determining patient eligibility, approving referrals, reporting test results, and paying claims.
Healthcare communications are unusually inefficient partly because the nation’s 610,000 practicing physicians tend to practice in groups that are very small, geographically dispersed, and unconnected by data lines. Most healthcare participants currently rely on paper and phone-based methods to Information Exchange Patterns - Present exchange critical information, which results in errors and information bottlenecks and
LAB EMPLOYER causes delays in treating patients. If INSURANCE COMPANY HOSPITAL healthcare communications can be improved, many kinds of administrative
CREDIT CARD SPECIALIST DOCTOR expenses can be reduced. PATIENT COMPANY
In the highly connected world of e-business, BANK OTHER INSURANCE PHARMACY healthcare success will hinge on how well COMPANY & GOVT. healthcare entities are able to collaborate Page 28 with other health-related organizations. Market pressures—including time-to-market, market efficiencies, and rapidly emerging new business models—will reward those companies that are able to create, and automate, tightly integrated business processes. The Internet is the key to effecting these inter-business application collaborations. Over the past five years, the Internet has quickly evolved from a browser-based information tool (1st generation) to a business-to-consumer (B2C) e-commerce enabled (2nd generation). Now the Internet is entering its third and most important generation, business-to-business integration (B2Bi). This generation offers significant potential that can be realized only when organizations achieve deep integration, seamlessly integrating care chain processes deep inside one company with those inside another. As businesses move into the third generation of the Internet (B2Bi), the World Wide Web begins to look more and more like an old technology whose day has come and gone. The new age of the Internet is all about integrating businesses electronically, rather than about HTML and browsers. In this generation, as in earlier generations, companies are faced with the opportunity of distinguishing themselves leaders in the industry, and with the threat of falling quickly behind their competition. Companies that move decisively into the B2Bi era will, in all likelihood, be paving their way to long- term survival and success.
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Perhaps no other industry places more demands on its practitioners and constituencies than healthcare. Clinicians are asked to see more patients, improve care quality and control costs. And all healthcare organizations are trying to manage risk through cost-effective point of care tools that actually work and can be easily implemented. The key to addressing these issues is real time access to critical patient data, clinical knowledge resources, practice rules and payer constraints. For decades, traditional system architectures have been unable to deliver this information in real time.
Organizations today have a substantial investment in their information systems and packaged applications, such as Managed care Information Systems (MCIS), Practice Management Systems (PMS), and Hospital Information Systems (HIS). The landscape is one of disconnected and disparate information technology infrastructures— residing on different hardware platforms, and utilizing a variety of data methods and communications formats— that were never intended or designed to communicate externally with systems of other companies. To enable the emerging B2Bi business model, isolated systems and applications must be integrated not only within an enterprise, but also externally with strategic partners and customers.
EDI vendors provide two basic functions: format translation and electronic routing. The open Internet network, by definition, performs electronic routing. Electronic formats for healthcare transactions are supposed to be standardized by the government by 2002; after a several year phase in, if each end of a transaction uses the government standard, and the Internet can route a transaction, the EDI intermediaries may add little or no value.
Double counting is commonplace in healthcare EDI and it’s basically legit. In the ideal case, a provider sends a transaction to EDI vendor A, who formats and routes it to the appropriate payor. Unfortunately, if EDI vendor A does not have a direct connection to the appropriate payor, they route it to EDI vendor B, who formats and routes it to the appropriate payor. Since the transaction touches both EDI vendors, it is counted by each, and very misleading. Make no mistake in this example, vendor B is in the stronger position; more often than not, vendor B is NDC for pharmacy claims and Envoy for medical claims. No upstart (Internet or no Internet) can rapidly expand direct connections to payors; switching costs are relatively high for payors.
Even the number of direct connections to payors can be misleading. Just as important as the number of payor connections is who the connections are with. Envoy has connections with nearly all state Medicare programs, which represents a huge share of total medical claims volume; since most other EDI vendors don’t have this connection, Envoy would get the transaction from its competitors.
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The 21st century healthcare organization, rather than just managing incidents of illness, must customer- and information-driven, Internet-linked to other healthcare entities and possess a thorough understanding of managing the healthcare of specific populations. By 2002/03, Information technology will become the critical element that will provide healthcare organizations the differentiation necessary to flourish in an increasingly competitive environment. While other industries typically spend 3-7 times more, as a percentage of their revenues on IT, healthcare organizations must understand that this spending gap cannot last long. We believe that as competition heats up, this spending gap will continue to close. During the next 3-5 years, we believe there will be certain healthcare technology mega-trends. They include:
• By 2003/04, healthcare organizations must become knowledge-driven. Like physicians and consumers, healthcare management must become hungry to capture data, ensure its integrity and employ IT throughout the organization to facilitate managing operations and care delivery. We believe IDN spending will increase from 2.8% (% of revenues) in 1999 to > 7% by 2003/04.
• By 2003/04, healthcare organizations will extend their expertise in identifying and understanding their many types of customers. Because the customer can assume many forms, including patient, employer, affiliated provider and insurer, the healthcare organization will use technology to segment those customers and will develop tailored products. Finally, this healthcare organization will implement CRM applications to improve customer’s service and satisfaction. Finally, by 2004, healthcare organizations will establish benchmarks in customer service as other competitive service industries have achieved.
• By 2005, healthcare organizations will transition to a “virtual" care network. These networks will involve a wide range of independent but interconnected individuals and institutions. Today, boundaries among multiple entities, systems and geographies are very apparent to patients and other customers. By 2006 virtual care networks, using conduits such as the Internet will provide a seamless and secure interface for real-time interaction.
• By 2005, payers will embrace comprehensive care management (CM), in which healthcare providers will assume more risk and responsibility for the health of specific populations. CM will create demand for tools to manage the risk, demand and cost-effectiveness of healthcare delivery. This model of healthcare delivery assesses the risk of each patient as that person enters the network; characterizes patients by their needs; tailors treatments for patients; helps create clinical pathways and protocols and tracks caregiver compliance; and measures the efficacy and quality of care delivered. Spending on CM will increase from $100M in 1999 to $2.1B by 2002/03.
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• While having the data, maintaining its integrity and performing analyses are critical, ultimately the success or failure of an organization is its willingness to actually use the data. While changing an organization's hardware and software might take months, changing its culture is an ongoing process requires an almost single-minded dedication by the healthcare organization.
• The current patchwork of information systems will continue until better-integrated systems become available.
• The current applications of managed care information technology include claims management, contract management, case management, risk management, outcomes reporting, member services, and benefits management. However, HMOs now want to add provider profiling, provider credentialing, decision support, EDI claims linkages, customer service, clinical protocols, data warehouse, case management, EDI eligibility links, and automated medical records, to their information capabilities.
Connectivity - 2002 through 2005 What Do Physicians Do Based on a survey of 257 physicians conducted Online Today? during this year’s TEPR conference in Seattle, Learning about a drug or other medical products 75% over 75% of the physicians surveyed indicated Learning about 68% disease treatments that they use the internet for learning about drugs Reading medical 48% and medical products. However, only 13% publications Taking CME courses 45% currently use the internet for filing insurance Patient communication 20% claims directly to the various healthplans. It Using the PDR 20% appears that the normal billing concept of Consulting with 19% submitting via a clearinghouse or via direct colleagues Participating in/ computer to computer is still the preferred method running clinical trials 16% today. Moreover, we believe that direct secured Filing insurance claims 12% internet connectivity will increase to > 60% by Percent total of 257 MDs surveyed 2004 once the HIPAA regulations are enforced. Page 42
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Case Studies:
Success Stories from Elysium Physicians,
By Dr. David Bales
While vacations are supposed to be a way to get away from it all, physicians may have those nagging medical cases that pop into their minds—"Did Mrs. Jones's biopsy show anything? And, if so, did my colleagues pick up on it and do something about it?" Those nagging questions never really leave my mind until I can personally do something about it. With web-based clinical messaging™, those questions can be put to rest very rapidly.
My wife and I were cruising in the Caribbean when I discovered that the ship had a business center with an Internet connection via satellite. The rates were very reasonable, so I checked some labs and forwarded them to colleagues just to be able to say I had done it! This was about 20 miles off the coast of Cuba!
Later in the year, we had the opportunity to travel to China, and I found that the hotels also had business centers. I was able to check on a biopsy—probably before the surgeon had seen it—and forward the information to not only my colleague who was covering my practice, but to the specialist that I wanted the patient to see.
Most large hotels throughout the world have Internet access, and many airports have a "Laptop Lane." With the time we now spend in airports after going through all of the security, it is very convenient to use your own laptop or use their computers to catch up on various clinical messages. If your patients have access via a secure web site (available from multiple sources including a benefit of AMA membership), you can check labs and notify them of results. Or even fill prescriptions via the Web from thousands of miles away!
By Robert Keet, MD
For the 30 years the holy grail of medical informatics has been the "electronic medical record." Yet, despite the advance of widespread computer technology with automation across most other industries, medical care remains largely a paper process. The failure of the EMR is based on the fact that physicians receive data from diverse sources, that data is not digitized, and there is no common index to unify the data into a single database. EMRs have had to rely on solutions where all of the clinic data is entered into the system as part of the clinical encounter. This is time consuming and interferes with the normal encounter process which is largely one of personal interaction with the patient.
Physicians in Elysium Communities get a large part of their data electronically and uniquely identified by patient across the data sources. While Elysium is sold to the data providers to automate their process of data delivery,
www.acgroup.org Chapter 4 - Page 74 Last Updated: 5/20/2007 Chapter 4 AC Group’s 2007 Annual Report Computer Systems for the Physician’s Office Level 2 – Secured Internet Connectivity the physicians and their staff can use the Elysium data to begin to automate the process of data management and lookup. If physicians add transcription to the Elysium data set they can create an electronic record that is complete with encounter, laboratory and radiology data. Adding prescription, allergies, and problems completes the key clinical data elements.
Scanning and indexing solutions are still too expensive to be practically utilized to store non-digitized data. However, data access and data storage do not necessarily need to be combined and physician offices can take advantage of significant workflow improvement by using the computer to access clinical data in the office, at the hospital and at home. Starting with the management of the clinical inbox, physicians can progress to "chartless" management of patient calls, prescription renewals, records transfer, and intra-office communication. A single internet terminal in the physician workspace can allow significant improvement in the medical record process with more ready access to data and fewer chart pulls. Adding terminals to examination areas will further improve efficiency with less dependence on the paper chart.
The latest version of Elysium is designed to access patient data quickly and efficiently. From any clinical document, physicians and their staff can navigate directly to:
1. All of that patient's other clinical documents.
2. All of the prescriptions written for that patient.
3. Detailed patient demographics with a short list of medications, allergies, and problems.
4. A cumulative view of the data currently viewed.
From any web location, physician and their staff can access all of the patients' clinical data quickly and efficiently. In offices where the data elements are electronically annotated and managed, the staff can also access the status of results including the associated instructions (e.g. "Advise patient of normal result") and annotations (e.g. "Results normal").
Moving to an "EMR" using Elysium can proceed in a step wise fashion. First incoming data can be managed electronically in a process akin to email. Intra-office electronic communication can be added and encounter data included by signing up for an Elysium transcription service. Once the bulk of clinical data is Elysium based the office can begin to use the "Electronic Chart" in lieu of the traditional chart pull. Committed offices can they add the electronic delivery of prescription and orders and add allergies and problems to complete the electronic database.
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The digital delivery of clinical data that is uniquely patient identified along with the tools to manage that data gives physicians EMR functionality at minimal cost. The holy grail might be within reach.
By Dr. Mark Rosen
My staff and I are saving considerable time with the Elysium automatic prescription refill feature. Fielding prescription-related phone calls used to be very time consuming. With the prescription management system my staff simply looks up the patient and their prescription in Elysium and clicks refill—the system automatically checks for interactions and duplications with current drugs, checks that the refill is not premature and sends the online prescription to me for approval. I click an "Electronic Signature" button and it gets sent automatically via fax to the patients' pharmacy. The prescription is logged in the patients' online record and can be printed the next time the chart has to be pulled.
Elysium maintains a log of my patient's prescriptions allowing me to better prescribe for my patients. As many patients take multiple drugs and most drugs being to difficult for patients to remember by name, a complete list is critical. Elysium tracks what prescriptions my patients take and cautions me of interactions.
Elysium can be accessed from any computer or handheld with Web access, anytime—from my office, home, hospital, a hotel room etc. Anytime access to patient prescription information has allowed me to better care for my patients. When I am on call, I can easily look up patient information from my computer at home and effectively prescribe for our group's patients. Elysium Prescription has integrated with Elysium Workstation, a product that we have been using for several years to manage our clinical results. These two products are enabling us to build an online patient record in an easy step-by-step approach.
Broad initiative
Clinical messaging and automation efficiency depends on the involvement and participation of all the hospitals, labs and physician practices that comprise a healthcare community. As more providers enter the system, the power of the technology must grow accordingly. Getting the system fully implemented in our community has been an ongoing four-year process and part of a broad communitywide initiative.
As we convert more processes from paper to automation (prescription writing is the most recent example), our office efficiency continues to grow. Progress is reflected in our ability to see more patients without increasing clerical staff. We also are improving the patient experience by expediting care and expanding communications.
But for this level of automation to succeed and result in better care at lowercosts, there are three key requirements. www.acgroup.org Chapter 4 - Page 76 Last Updated: 5/20/2007 Chapter 4 AC Group’s 2007 Annual Report Computer Systems for the Physician’s Office Level 2 – Secured Internet Connectivity
First, the system should be viewed and implemented from a communitywide perspective. This requires the cooperation of all entities in the healthcare delivery system and implies the formation of a broadly charted entity to guide the process and assure all interests are being satisfied. While this does not happen overnight, the final results are well worth the effort and the wait.
Second, it's important to educate all the members of the healthcare team about the benefits of the new technology. Healthcare in general has been slow to adopt computers--and the physician's office even slower yet. However, there's no doubt that the future healthcare environment will require these technologies. Organizations preparing for automation should begin an educational campaign for its professionals as soon as the goal is clear.
The final key to success is recognizing that today's information technology moves in a rapid sequence of incremental innovations. Waiting on the sidelines for a final, total solution that integrates everything from the patient record to back-end payer systems will mean missing out on significant benefits available today.
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What is the Biggest Obstacle Facing Today’s Medical Practices?
Many physicians are frustrated in today’s paper-laden world. They are finding it difficult to spend quality time caring for the patient, “doing what they went to medical school to do”, because of overwhelming paperwork. Small- to medium-sized physician practices are smothered by decreasing reimbursements in the face of more demanding services, growing volumes of patient loads, as well as burdensome regulations. Indeed, many practices are finding it difficult to cope with regulations such as HIPAA, backlogs of unpaid claims, and stacks and stacks of Explanations of Benefits.
In the center of the storm lies the simple patient chart that is passed from hand to hand, department to department, oftentimes in a stressful environment. In one scenario alone, 20 to 30 minutes of precious office time can be wasted, leaving a patient dissatisfied and the office staff stressed. Take the chart of “Jane Doe”. Jane sees her doctor for a sore throat. She is given a strep test, and is given a prescription for an antibiotic. The next day she develops an itching sensation in her hands, so she calls her doctor to see if that could possibly be due to the antibiotic. When her call is taken, the staff member answering the telephone has to put Jane on hold so she can find her chart, or in many cases, take a message and go looking for the patient’s record. Jane’s chart could be in a number of locations the day after her office visit. Her file could be in transcription, or in the lab getting strep test results put on it, or waiting to be filed back. It could be in the billing office, if there is an outstanding balance. And then, once the staff member finds that record, she or he calls the patient back and try to answer her question.
Physician’s need to take control of the Paper
Many practices are taking the lead in efforts to better serve their patients, help overcome shrinking reimbursements through better overhead management, and develop computerized audit trails to keep up with regulations. Susan Miller, Administrator for Family Practice Associates in Lexington, Kentucky, is one practice manager who took charge of the situation, and through installation of a computerized patient record system, has seen many benefits for the practice. According to Miller, “The medical record becomes a key communication tool” at every level of the practice. Until 1999, Family Practice Associates’ office was computerized at the billing level only. Miller felt the burdens of endless paperwork and overflowing patient charts that many practices are experiencing and decided to shop for a document imaging module that would interface with her existing billing system and take her office to a “paperless” medical record environment.
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Criterion for Paperless Chart
Miller knew what she was looking for when she started shopping. The physicians needed a system that was flexible and able to work with her existing system. The physicians needed a user-friendly system as easy to use as clicking on mouse. Additionally, the physicians wanted the computerized patient chart to look exactly like the paper chart the physicians were used to seeing. And above all, they wanted the system to have a Windows- based, open architecture that would integrate with other packages for future expansion (One of the key elements for success involved the way doctors would use the computerized patient chart). The doctors wanted to have their patients’ charts look the way they were used to seeing them. In other words, they needed to be an exact replica of the paper chart the physicians had used for years.
The solution – the selection of a document/digital image management (DIM) solution for computerized patient records. DIMs are traditionally Windows-based proprietary application designed specifically for practices of 3 to 99 physicians, yet can be scalable to work for medical organizations of any size. The system scans a patient’s entire record in a matter of seconds regardless of the size and color of the file’s papers. Scans can be two-sided, and can even include insurance cards. The system scan and maintain X-rays, lab results, transcriptions and other important documents into appropriate folders that are easy to locate and retrieve. Searching for information is as simple as entering a patient’s name, account number, or social security number. Patient files are located instantly, eliminating frantic searches for lost charts.
Document/Digital Image Management (DIM) applications enable physicians to incrementally transcend into the world of the paperless medical office using cost-effective technologies. In most practices, growth of medical staff automatically implies higher overhead costs because of the need for hiring additional medical transcriptionists. The added efficiency provided by DIM technology often eliminates these costs. By automating large areas of the record-keeping process, DIM technology gives medical practices the power to leverage staff more effectively, and to grow the business without growing the administrative support staff.
By re-creating the traditional medical chart folder in an electronic, "virtual" form, DIM technology makes chart management easier and more efficient than previously possible. All information found in the traditional folder is still present; only more organized and much easier to handle. Instead of sifting through layers of paperwork trying
Confidential Chapter 5 - Page 79 Last Updated: 5/20/2007 Chapter 5 The ACG 2007 Annual Report Computer Systems in the Physician’s Office Level 3 – Digital Image Management to find a certain piece of information, DIM, with traditional highly organized filing systems, allows the user to quickly click through the patient's history for the desired information.
Also the traditional medical folder, in its physical form, has a tendency to get misplaced. With several different people in an office all looking for the same file that was inadvertently placed in the closet or left at the doctor's home, the efficiency of an office is hindered and less work gets done. DIM technology can be used to find, research, or change any patient's chart from one or multiple PC stations in an office. And there's even an option that allows remote access to data -- for example by a doctor working from home.
Physicians that have deployed DIM applications have found that speed is perhaps its finest feature. By dramatically slashing the staff time necessary to transcribe, file and manage charts, the office frees up large blocks of time for other responsibilities -- like seeing more patients. By eliminating the entire manual filing process all together, proficient transcriptionists can double or triple the amount of information processed in a normal day.
There are many generic imaging solutions available for general use, but they cost anywhere from $80,000 to $100,000. And then with the added customizations necessary for precise application in the Medical field, they may cost an additional $20,000 to $30,000. Under those cost conditions, imaging solutions are out of reach for the typical medical practice.
Some practices use a more traditional Electronic Medical Record system. While achieving a portion of the tasks fulfilled by DIM technology, they fall short in the ease-of-use category. An EMR is essentially an input program into which a physician enters the patient's symptoms as they go along. However, since most doctors are not inclined to change the way they record patient information, these systems are not usually as successful or efficient as expected. By contrast, DIM technology is a highly affordable, industry-specific alternative to the expensive scanning systems. By combining the attributes of high-end generic mass-scanning equipment with the benefits of EMR applications, DIM vendors have created an unrivaled entity in the Medical field.
DIM applications are designed to allow the user to include a wide range of materials in any DIM technology chart - - including all paperwork related to that patient, x-rays, photos, insurance cards, related journal or periodical articles or research information pertaining to a given patient's ailment. Not only is this information securely archived in DIM technology, it is also accessible to all appropriate personnel.
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DIM technology is uniquely compatible to almost everything. Too often, medical scanning software packages limit you to simply looking at the scanned document. After that the user is stuck. We have written the software in such a way that not only is the information in DIM technology more manageable and efficient, it can also be imported to other software applications. Users are not chained to the DIM technology system and always retain the rights and ability to utilize their information elsewhere.
We should also stress the non-proprietary nature of DIM technology in relation to its compatibility. DIM technology is based on Microsoft SQL software, which is very stable -- and widely used. Users do not need an DIM technology -specific technician to save or rebuild their data in case of a dramatic problem. Patient data can almost always be retrieved by virtually any SQL programmer.
DIM applications allow you to:
• Effortlessly setup and expand customized patient charts • Instantaneously locate documents and file charts • Reduce or eliminate the need to search for charts • Eliminate courier costs related to transporting charts • Reduce the expense of chart supplies • Access a single chart by multiple people in multiple locations • Save transcription time and cost • Improve staff efficiency and morale • Save office space and storage costs; and • Begin use with minimal installation and training
DIM can be successfully connected with many of the most popular productivity programs. Microsoft products, WordPerfect and Lotus products can all be launched within the DIM applications. A user doesn't have to switch from application to application to get all the correct information into the chart. The appropriate applications are available at the click of a mouse from inside most DIM applications. What's more, word processing, spreadsheet or other documents created can be automatically saved in their proper place in the patient's chart -- saving additional time and keeping things perfectly organized.
For health-care providers, the patient chart lies at the center of an operational storm. It is both the repository for diverse types of information and the trigger for billing. Within a Healthcare Organization, many people may need access to information in a chart at any given time to carry out clinical, administrative or billing functions. Yet the
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patient chart has traditionally existed in the form of a single folder, accessible to one person in one place at one time. Furthermore, because the medical record has been paper-based, functions such as information retrieval, HIPAA compliance tracking and organization of tasks become administratively burdensome. In addition, the potential for error, such as lost or misfiled information, remains a significant concern without automated access to information.
By making data traditionally found in the medical record available in an electronic, “virtual” form, DIM technology makes patient information management easier and more efficient than was previously possible. With DIM, all information kept in the traditional folder is still present, only in a more organized and easily accessible fashion. Instead of sifting through layers of paperwork for the needed document, medical office personnel can quickly click through DIM’s highly organized electronic filing system. Multiple people can access the information at the same time – on-site or remotely via a secure web connection. This feature will become more critical as web technologies become more widely adopted and information more easily shared.
Hospitals who have deployed DIM applications have found that speed is perhaps the finest feature. DIMs dramatically reduce the staff time needed to retrieve and manage information. For the administrative staff, improved workflows and efficiencies on this scale result in lower labor costs and increased productivity.
Document management succeeds where EMRs may fall short
Some Healthcare Organizations use a more traditional EMR system to achieve the same document management objective. However, these generally fall short in the ease-of-use category. An EMR is essentially an input program into which a clinician enters the patient’s symptoms on an ongoing basis. Because most doctors are not inclined to change the way they record patient information, EMR systems are typically not as successful or efficient as expected. In contrast, DIM technology is a highly affordable, industry-specific alternative to addressing the access issue without introducing significant changes in the way a healthcare organization operates.
DIM applications are designed to allow the user to include a wide range of materials in any electronic chart, including all paperwork related to the patient’s care, clinical images, insurance cards, EOBs and related journal or periodical articles and research. Not only is this information securely archived in DIM technology, it is also accessible to all appropriate personnel in a secure, password-protected environment.
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Case Study: Parkview Health System, Fort Wayne, IN
The executive team at Parkview Health System in Fort Wayne Indiana understands the need for technologies. According to Maria Stolze, Director of HIM, “Parkview health recognizes the value and role of “information” in achieving our mission and vision. We will provide quality health services and improve the health of our communities, only when, we can get the right information to the right place at the right time”. One business and clinical issue that Parkview took a leading role in solving was related to problems with days in accounts receivables (A/R).
As all executives know, days in accounts receivables adversely affects an organization’s bottom-line. The higher the days in A/R, the higher the percentage of write-offs that are required. If a healthcare organization can reduce A/R days by a minimum of 5%, a typical 300-bed hospital can improve cash flow by as much as $500,000. However to reduce days in A/R, management must attach the problem from two fronts: the ability of the business office to collect billable charges; and the ability of the Health Information Management (HIM) department to complete the necessary coding and abstracting of each patient’s medical record in a minimal amount of time.
Studies conducted by AC Group, based in Spring Texas, have shown that the use of a comprehensive DIM application, with the appropriate workflow in the Business Office, can help reduce A/R days by as much as 10%. In the case of Parkview Health System, the executive team decided to tackle A/R days by providing a comprehensive technology that would enable the organization’s HIM staff to code and abstract each patient’s medical records from any location at any time. According to JCAHO, the hospital accreditation organization, patient charts must be completed and signed off by every clinician involved in the case before a claim for payment can be submitted. Additionally, JCAHO has established a threshold that states that a maximum of 50% of an organization's patient charts must be completed within XX days of discharge from the hospital. Every day the patient’s record is not complete, the hospital cannot bill for the services, and thus, adds days in A/R. Based on a study of 3,421 hospitals during the summer of 2003, 42% of the hospitals experienced over 5 days in A/R relating to the non-completion of patient records while only 18% of the hospitals have less than 3 days in A/R.
To help reduce the number of days in A/R, Parkview selected LanVision’s codingANYware solution. The codingANYware solution allows the HIM staff to access patient paper charts electronically from any location and from their homes with the appropriate security passwords. Ms. Stolze knew that it was becoming very difficult to find and retain good coders. She also wanted to allow coders to work remotely from home, thus, improving employee satisfaction and productivity. Finally, she wanted a system that would allow the organization to centralize the coding departments across multi-facility healthcare organizations. Parkview’s overall goals were to:
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• Improved patient care through electronic access of other hospital patient records • Physician convenience and efficiency with automated chart completion • Convenience and efficiencies to high volume record review customers (QM). • Improved chart delinquency rate • Timely dictation of discharge summaries!!! • Reduction of AR
The LanVision codingANYware solution:
o .Allows coding professionals to work at home efficiently: codingANYware provides efficient modes of operation for both high speed and traditional dial-up connections.
o Reduced reimbursement delays due to record contention: Patient medical record images are online; therefore, codingANYware encourages movement away from the traditional serial processing environment to a more parallel processing system which allows coding to continue regardless of all the other whom else the paper needs chart.
o Provides HIPAA compliant security. All codingANYware connections are encrypted and HIPAA compliant. codingANYware provided Parkview with the beginnings of a totally HIPAA compliant patient information repository.
o Allowed Parkview to significantly reduce the travel and living expenses associated with outsourcing of their coding backlog.
o Provided direct integration with the organization’s 3M encoder and abstracting systems, thus providing the HIM staff with full, integrated use of the encoder while viewing records online. Once the coding is completed, the codes are uploaded to the 3M abstracting system.
LanVision offered Parkview a flexible workflow processing and management reporting system that provides them an opportunity to streamline and maximize efficiency of the coding and abstracting functions. Based on user defined criteria, such as financial class or patient type, work can now be automatically routed to specific coders. For example Inpatient Medicare records are now routed to Parkview’s most experienced inpatient coders while their Emergency Room charts can be routed to Parkview’s outpatient coders automatically. The LanVision's codingANYware product provides Parkview with a central user interface from which the coder works cases. From this central point, the Parkview coders can launch not only the imaged documents but also the coding system with the necessary patient data already displaying. The coder can then code the chart without signing in and out of
Confidential Chapter 5 - Page 84 Last Updated: 5/20/2007 Chapter 5 The ACG 2007 Annual Report Computer Systems in the Physician’s Office Level 3 – Digital Image Management multiple applications and searching for patients in two different systems, thus providing a streamlined more efficient way of completing the coding and abstracting process.
The HIPAA compliant security solution automatically imports codes to the hospital’s abstracting system and allows for remote abstracting capability, thus eliminating the need to have a third person enter the codes into the abstract system. The solution also enables Parkview to design custom work lists that automatically route cases to specific coders allowing them to customize the application to the way they do business. Additionally, the QA work queue allows Parkview to review and monitor coded caseloads based on their specific defined criteria. Finally, LanVision supplies a powerful suite of management reports that will help you monitor performance in order to maximize the efficiency of your department. As a result of implementing LanVision’s codingANYware solution, Parkview has seen:
• $5.8M reduction in Accounts Receivables
• 95% decrease coding backlogs
• 48% decrease Accounts Receivable Days relating to Medical Record delinquencies
• Improve coder productivity by 30%
• Significantly reduce outsourced coding costs by 100%
• Reduced chart delinquency rates by 36%
• Improved recruitment and retention of qualified coding professionals
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Medical Document Management – The Key to Building an EMR
During the Spring of 2003, AC Group, Inc. evaluated the top Document/Digital Management Software vendors that were being sold to physician practices that ranged in size from 2 to 100 healthcare providers. The survey included 1,538 functional questions and was sent to 87 vendors that stated that they sold DIM applications to physician practices. The results of the survey indicated that only 2 vendors meet more than 80% of the functionally requirements. These two vendors are Advanced Imaging Concepts (AIC), based in Louisville, Ky. and a new product, labeled Smart DIM, located near Pittsburg, PA. The other vendors either decided not to participate because they were two busy, or in most cases, the product did not meet the majority of the DIM requirements.
One of the major functionally requirement relates to the ease of indexing a complete chart, or individual pieces of paper. Companies like AIC provide 1-click indexing which improves indexing quality and allows office staff to index a 50 page chart in less than 1 minute. Another major functional requirement is sophisticated workflow which automatically routes individual electronically stored documents to the appropriate care giver based on an office’s workflow. Without this type of functionality, the DIM only provides scanning, viewing, and printing capability – NOT what a practice needs.
AIC’s Medical Document Management Solution
IMPACT.MD® is a medical document management solution that provides a cost-effective way to automate the patient chart without requiring a paradigm shift for the way physicians practice medicine. IMPACT.MD accesses patient data from the practice management system and serves as a single, flexible repository for all of the patient- related paper that flows around the office, whether it is generated from within the office, such as office notes, or outside the office, such as lab results and referral letters.
Perhaps most importantly, because it is an image and not text, the electronic chart looks exactly like the paper chart the doctor currently uses. Office and clinical staff don’t have to change the way they work. Document imaging systems are normally customized to fit the way the practice works … they aren’t templates that require the practice to change its ways to suit the program. So there is no need for drastic behavior changes. Automation is incremental, allowing clinical and office staff to gradually build their system to a full-fledged EMR as they are ready.
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IMPACT.MD also addresses many workflow issues. The imaged patient records can be simultaneously accessed by multiple users and are fully portable and fully legible. The patient chart will never be lost because it sits in a computer, not in a doctor’s trunk or on the billing clerk’s desk. It is easier to ensure the privacy of patient records, because document imaging provides built-in safety and security measures that restrict user access as well as the opportunity to create an automated audit trail of who accesses the records and when.
IMPACT.MD handles extraneous paper such as telephone message notes, outsourced diagnostics results, consults, Explanation of Benefits (EOBs), and charts from other practices. Paper that isn’t generated in the adopting organization’s system still has to reside somewhere. If EOBs are stuffed in boxes stacked in a file room, the practice really isn’t paperless. But if the practice has a way to get labs, x-ray reports, EOBs and so forth into its electronic medical record, it can eliminate the paper. IMPACT.MD uses high- speed scanning to get these documents into the computer system and make them part of the permanent record. It does away with the extra boxes piled up in a file room. Many practices using IMPACT.MD have put their chart rooms to more productive use.
Once a practice has firmly established a paperless record, it is ready to integrate additional modules to the system. In many cases, the next step is automating prescriptions. Some practices want to be able to see an insurance company’s drug formulary, and see listings for alternative drugs, etc. Some practices simply want to write a prescription electronically and have it reside in the electronic chart for easy access. Thanks to the communications standards of HL7 and the open-architecture programs now available, practices can purchase a prescription module that meets their specific needs. By adding a prescription module incrementally, a practice has the freedom to buy the application it wants when it wants.
The pyramid reflects the order of the steps taken by most practices who automate. But prescriptions don’t have to be the next module added after medical document imaging. A practice could move right into Physician Order Entry. In other words, individual modules don’t depend upon each other to work. They can integrate back into the practice management and document imaging systems and be added in any order the practice wants to add them.
Any size practice can take advantage of technological efficiencies according to its own terms. While practice managers are still dealing with a few resistant physicians, they don’t have to get bogged down into a major system conversion. Adding components incrementally, as the practice is ready, allows smaller upfront capital expense, a chance to evaluate results throughout the process, and a much better chance at overall success.
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DIM Case Study: Living Happily After the Installation by Janet M. Connell, CMPE
Unexpected benefits results when a private group practice uses its medical document management system to get rid of paper patient charts. When Nephrology Associates of Kentuckiana, PSC, purchased a medical document management system in 1999, we were literally drowning in paper. We are one of the only practices in the Louisville, Kentucky area specializing in problems exclusive to kidneys. We had two specific issues that were a nightmare for us: filing our hospital consult paperwork and dealing with EOBs.
We serve 12 area hospitals and see as many as 300 patient consults a week. Many of these patients never even came into our office. It was too costly to make an individual paper chart for each of those consults, so we filed (or rather crammed) each consult patient’s paperwork alphabetically into accordion folders that filled seven, 10-feet- wide office shelves.
Added to that were onslaughts of EOBs that we received by the thousands per month. Because one EOB may list 20 or more patients, we had to copy these and file them individually in the appropriate patient files. We receive an average of 20 pended or rejected claims daily. It took us approximately 20 minutes to check and respond to each rejected claim, and we checked every single one. That was at least 400 minutes (almost seven hours) a day just spent on addressing rejected claims.
Satisfactory First Steps
In 1999, when we found IMPACT.MD, a medical document management system that lets authorized users scan in paper and access it from a desktop, we were so grateful that it corrected those two situations that we coasted with it for three years, satisfied with the filing improvements and increase in billings received. Without using the system for anything else, we realized the following monetary benefits: o July 1999 added a physician: no additional administrative staff o In 2000 increased the amount of billings by 7% o Increased collection of fees by 9.2% (a 2.2 % overall increase in collections resulting in $91,000 extra income). o Decreased the amount of time spent responding to pended or rejected claims by 80%. (With IMPACT.MD, it only takes four to five minutes to deal with a rejected claim instead of 20 minutes.) o Saved several hours a day in EOB handling, resulting in an annual savings of at least $4,000.
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o Eliminated seven, 10-ft. shelves that housed the accordion folders for hospital consults. Also eliminated six, 5-drawer filing cabinets from the billing office. o The entire system paid for itself in under a year.
Pushing Away the Paper
After three years, the staff and I decided that we weren’t using our medical document imaging system to its fullest capacity. IMPACT.MD is designed to hold all of the patient-related paper that flows around an organization, whether it is generated from within the office, such as phone messages and office notes, or outside the office, such as lab results and referral letters. The electronic chart can be accessed by authorized users instantly with the click of a mouse from any workstation, which eliminates the need for paper records.
We did a study of our expenses. Our paper charts had six dividers and were custom-made in the factory. We paid $25.00 per patient chart just for materials. That did not include the staff time spent creating the chart, filing the chart, pulling the chart, re-filing the chart, and worrying about what went in which divider. With approximately 1,300 new patients a year, we are saving $32,500 in materials alone, not counting staff time. In 10 months we have saved $60,000 on printed forms, letterhead, etc., that we sent to a professional printer.
We decided to eliminate paper charts by starting with new patients only. Our plan at first was simply to help our office workload and decrease a few more expenses. However, the physicians started noticing the front desk using the system to access charts. They were amazed at the increase in employee morale and the decrease in the time that they had to wait for information. Soon the doctors suggested that we take the entire practice paperless and get rid of all of the paper charts.
We started scanning in our 14,000 charts into the system and quickly realized there was much more information in the chart to be scanned in than we originally thought because we have many long-term patients with very large files. For example, our prescription refill requests were shingled (small pieces of paper taped in layers to one piece of paper), and we would have to take those apart and scan in each individual refill request. That might mean eight individual scanning efforts for one shingled piece of paper in one of the 14,000 charts. There was no way we could realistically get every single archived item into the electronic system in a cost-effective manner.
I went back to the physicians and said: “Tell me what is essential to the chart and we will create a boilerplate of the information to be scanned into the system. In return, we will put the paper charts in storage. If we need to retrieve a chart for any reason, we will scan that entire chart into the system.” They agreed to this, and requested all renal ultrasound results, lab reports within one year’s time, hospital admissions, dishcarges or consults within
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one year’s time, all office notes, the drug list, and a vital signs flow sheet be contained in the electronic chart. Everything else remained archived in the paper version and was sent to outside storage. We literally emptied our office of every single paper chart and only retrieved six paper charts from storage in one year, and those were due to legal inquiries.
Maximizing Empty Medical Records Space
Once we got rid of our paper charts, we had an empty 10 x 12 medical records room. We decided to embark upon a major renovation project that would shuffle our space around and utilize it to the utmost, as well as maximize the efficiencies of being paperless and expand services to patients.
Many pre-End-Stage Renal Disease patients become anemic and normally make a time-consuming trip to the hospital for an injection to treat the anemia. We had a nurse who gave those injections in our office in a limited fashion because it was cumbersome and we were in tight quarters. We wanted to offer that to every patient who needed it right in our office. In our renovation plans we created space for a full-time nurse to administer that injection. In addition, we added two new exam rooms and a check-out window.
Because we are a nephrology practice and specialize in kidneys, many of our patients are seriously ill. Our physicians did not feel it was appropriate to have a computer in the exam room under those circumstances. They wanted to maintain the “personal touch” that we had always had, yet reap the benefits of a paperless environment. IMPACT.MD, allowed us to do both. We set up PC workstations outside of the exam rooms and assigned four physicians to each station. We also added two PCs in the lab area. The providers can view a patient’s entire chart at any of those workstations.
In addition, each physician designed a mini chart within IMPACT.MD. A mini chart is a printable, stripped-down version of the entire patient chart that can be customized to each individual’s preference for seeing certain information from the chart. Each physician carries the patient’s mini chart into the exam room and makes notes directly onto it, as well as taping dictation. The paper mini chart and the dictation tape, along with the appointment log, goes to transcription. Our transcriptionists type up the taped notes, scan in the mini chart and the log, and are responsible for shredding the mini charts after everything has been entered into the system electronically. This system is a good compromise for us, especially due to the serious illnesses of our patients. It allows our physicians to rely on paper during the encounter, something they weren’t willing to give up, and we got rid of our paper charts.
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3 New Doctors – No Additional Support Staff
When we started with IMPACT.MD in 1999, we had 11 physicians and 15 FTEs. We were already running an efficient practice with a ratio of 1.5 support staff per physician. Many practices use an average of 4 to 5 FTEs for every physician. Today, we have 13 physicians and the 14th is signed-on to join us in 2004, with no additional support staff. While our staff has grown to 19 FTEs, none are physician support, but rather hold billing, check-in, and managerial positions. The bottom line is we have not added any support staff for the extra physicians and this is due to the administrative efficiencies we are gleaning from utilizing IMPACT.MD as a paperless patient chart system.
We back up our system on tape every night without fail, and this tape is taken off-site. We also have a redundant power system in the server. Whether by luck or providence, we have never been down with IMPACT.MD. We have had great success with this system and are still looking for ways to use it to save time and money.
Janet Connell is the administrator for Nephrology Associates of Kentuckiana, PSC and can be reached at [email protected].
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Case Study Getting Rid of Paper Charts and Saving a Million by John Somers
We started out with a mission to reduce our dependence on paper. We will end up with no paper patient charts and an average annual savings of at least $300,000 a year.
When I joined Bristol Park Medical Management in 2001 as Chief Operating Officer, part of my responsibilities included improving operating efficiencies for a medical practice that had over 800 employees, 525 of which were full-time. Bristol Park has been in business for 42 years, providing primary care services for hundreds of thousands of patients in Orange County, California. The 85 primary care physicians work from 11 medical office and one business center, which include two urgent care centers. We have a constant need for access to a medical record of any given patient at any given time. Handpicking a chart from 250,000 paper records was way too cumbersome for practicing medicine in this millennium.
Overwhelmed with Paper
If I had to use one word to describe the paper flow of our Bristol Park Medical, it would be “constant”. We need instant access to patient information resulting in constant pulling of charts, re-filing of charts, purging of charts. The activity surrounding just one chart included a message to medical records that the chart was needed, pulling the chart, logging it out, couriering it back and forth between locations and then back to the patient’s primary location for service.
We have 65 doctors working per day. Each physician in the office sees about 25 patients a day. All of the charts need to be pulled for each of those patients. Most of our physicians get at least 15 messages and refills each a day, minimum. By conservative estimates, we had a minimum of 2,600 charts floating around the Bristol Park campus on any given day. When you think about the constant paper movement with that much paper, you can imagine the many opportunities for error. We had too many occurrences of lost charts and less than satisfactory accessibility to the patient information.
Too Much Wasted Time
Then we had the wasted time spent handling charts. In prescription refills alone, we were in a constant state of pushing paper. When we had an incoming prescription refill we would pull the incoming fax from the pharmacy. We would then find the patient’s chart, make decisions on the refill, fax the information back to the pharmacy, two-
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hole punch the piece of paper so it could be put in the paper chart, and put the chart back in the chart shelf. This took 10 minutes at the very least, per chart, with as much as 20 to 30 minutes if a chart was in flux and not so easy to find.
When a telephone message came in to the office, it would be typed in, message would be printed in the records room, a person would tear the message off the printer, take the message and pull the chart, take the chart to the appropriate nurse or doctor, the provider would utilize the chart, make notes, forming yet another piece of paper, file the paper into the chart, route the chart back to the records room and place the chart back on the shelf. Another 10 – 20 minutes total (not counting the hours or days that the chart was truly floating around) of time spent taking care of paper rather than patients.
Medical Document Imaging Replaced our Paper System
Our workflow in general needed to improve. I wanted to make sure that we always had access to patient information, whether it was after hours, on weekends, during the lunch hour, during morning rounds, whenever. Authorized users needed immediate access to crucial patient information regardless of their location in relation to a paper chart. It was time to utilize technology and automate our paper records. We were ready to be rid of paper.
We searched for a flexible computer system that would automate our patient records within the confines our unique needs. We selected IMPACT.MD , a Windows-based, medical document imaging solution developed by AIC for healthcare organizations. Using high-speed scanning, IMPACT.MD serves as a single repository for all of the patient-related paper in an organization, such as phone messages, office notes, lab results and referral letters. Once scanned in the system, the data, (that was once paper, but is now an exact replica on the computer screen) can be organized and indexed just like a paper medical record. Authorized users can access patient records instantly with the click of a mouse from any workstation, eliminating paper charts. The system was flexible: the computerized charts could look exactly like our paper charts had, with the same tabs and format. It also included extra features like one-click indexing, mini-charts, tasking, full annotations, electronic signatures, HIPAA-friendly audit trails, and importing of transcription documents that made it attractive to Bristol Park.
Implementation in Phases
On March 1, 2003, we began our implementation and planning phases utilizing a team approach. The Implementation Team decided to go live site by site the first week of June 2003. Our goal was to create no new paper charts for any new patient. Every new patient would become part of the computerized system. We aimed
Confidential Chapter 5 - Page 93 Last Updated: 5/20/2007 Chapter 5 The ACG 2007 Annual Report Computer Systems in the Physician’s Office Level 3 – Digital Image Management for scanning records on existing patients at a rate of four charts per doctor per day for scheduled patients, two to three days ahead of the scheduled visit. Some of our smaller offices achieved as many as eight charts per physician per day. And some of our offices with thick charts for each patient struggled just to get the four charts scanned in.
We put PCs in every examination room that operate from one central network. Many doctors chose a flat panel touchscreen to access patient charts. Others prefer a keyboard and mouse. In addition to the exam rooms, we have workstations for nurses. Of course, the front office and medical records have access as well. Every patient’s record is secure and only accessible by an authorized user. We set up Security Groups to determine authorization levels. The system provides automatic audit trails that would be useful in the event of a HIPAA audit. We could easily see who accessed a chart, when, and what part of the chart they accessed.
High-Speed Scanning
We purchased two types of high-speed Fujitsu scanners for the IMPACT.MD system: 25-page and 40-page scanners. The large, 40-page scanners are used exclusively for chart conversion. Our average chart had 60 pieces of paper in it. It takes just two minutes to scan the entire chart into a main batch file in IMPACT.MD. From there, a medical records person assigns the individual pages to their appropriate electronic tabs. The smaller scanners deal with the day-to-day records maintenance: in-take records, insurance cards, drivers’ licenses, lab results, or any paper generated that needs to be put into a patient’s file.
For the first 60 days, we brought in two additional people at each of our sites to help with the scanning workload, to work on the chart conversions and to help keep the flow moving. In addition, we purchased a VRS-Co-fax filter. We use many different colored forms. Purple and blue pages don’t scan well in a normal setting. If you got to a purple page in the middle of a patient’s chart, you had to stop and adjust the setting on the scanner, scan in that page, then change the setting back to the white papers. It became cumbersome and tedious. The VRS Co- fax filter automatically sees the purple form, adjusts the setting, straightens out the paper and allows continuous scanning. We don’t have to stop in the middle of a chart conversion to adjust anything. The VRS does it for us.
When we started this project, we were rolling out a site a week, and were scanning in approximately 350 charts per day. At this rate, we estimated it would take 18 months to totally convert all of our charts. Very quickly, our earliest conversion sites started to see results. When a patient who was seen on June 10 came back into the office in August and no one had to pull a paper chart, yet the entire chart was accessed with the click of a mouse and they never had to leave their workstation, they really began to like and appreciate the system and became very enthused.
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Return on Investment
The benefits and return on investment with this system have wildly surpassed our original expectations. The practice spent $690,000 for the entire system with $350,000 for hardware, including server, equipment for communications, exam rooms and nurses stations, faxing hardware, scanners, etc., plus $28,000 for annual T-1 costs; $272,000 for software, including IMPACT.MD licenses, faxing and other software, and $40,000 for software maintenance.
For year one we realized $250,000 in savings using conservative numbers: $330,000 in staff savings and $150,000 in not creating any new paper charts, less $230,000 of amortized costs (one time equipment and licensing costs of $690,000 were amortized over 3 years). As we move into year two, I estimate we will show $550,000 in total savings, once all the charts are in and the practice is no longer using paper charts at all. Over a period of three years, we will have saved at least $1million.
We will enjoy a complete return on investment within two years of implementing the system, and will begin to realize significant annual savings thereafter.
We are saving in key areas such as: • $150,000 annually in no new charts. • $450,000 annually in staff time saved handling paper records.
John Somers is Chief Operating Officer for Bristol Park Medical Management, LP
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How does a physician record, store, and manage diagnostic tests.
One company, Brentwood by Midmark, (TEPR award winner for Document Image Management) offers an innovative solution that electronically acquires and digitally stores diagnostic back office tests for the medical professional. For example, approximately 38 million ECGs are performed each year in the US. The IQmark Diagnostic Workstation stores ECG data in 18Kb vs. 600Kb for scanned reports. Workstation incorporates the latest in diagnostic hardware and software technology (ECG, Spirometry, Holter, Vital Signs) that offers the medical professional a giant leap forward towards a paperless office.
The IQmark Diagnostic Workstation enables the user to digitally acquire diagnostic data from ECG, Spirometry, Holter, and Vital Signs monitors and store the data electronically. The patient’s demographics are entered, the patient is connected to the device, the program activates the device, and data is digitally transferred to the database. For example, connect to a vital signs monitor to transfer blood pressure, pulse rate, temperature and pulse oximetry results without manually entering the results.
Brentwood by Midmark’s Diagnostic Workstation Software offers a complete Patient Data Management Software System that digitally stores many different diagnostic tests. Brentwood’s software is designed with Microsoft’s open-architecture products in mind, offering capabilities such as EMR integration (using ActiveX controls), networking, central database (MS SQL Server) and Access database options. The storage of physiological measurements include: ECG, Spirometry, Holter, and connections to Welch Allyn diagnostic equipment.
As an entry level EMR, the Workstation allows the physician to store, review, edit and delete all diagnostic tests acquired through the Workstation. In addition, the doctor can store patient demographics for quick retrieval for re-testing or analysis. If the doctor has a network in place, the Workstation will enable her to review tests in the comfort of her office while the staff is acquiring data in examination rooms. If they only want to test and have someone else over-read and analyze the results, they can email the tests to a colleague. The interfaces to additional modalities will make the Workstation a central, necessary software package in the physician’s office.
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Vital Signs Workstation
For users that already have a Welch Allyn vital signs monitor (temperature, blood pressure, pulse rate, and pulse oximetry), the Workstation enables them to digitally acquire, store and display the monitor’s results. Weight can also be digitally acquired from Tanita ™ or seca ™ scales. The Workstation can be defined as the following:
1. Entry-level EMR for diagnostic tests — All users have the same privileges 2. Storage and management software for patient demographics and test results 3. Network capability — Multi-users each with full access to patient data records 4. Patient report transfer capability — Email, send to file, archive, delete, etc. 5. Allows interface to multiple modalities:
a. ECG b. Spirometry c. Holter d. NiBP - Noninvasive Blood Pressure e. Temperature f. SpO2 - Pulse Oximetry g. Static Pulse Rate h. Weight
Brentwood used technology to reduce device weight from 15 lbs to less than 1 and eliminated A/C power requirements. Connect to a pen-based computer for portability. Add a wireless network to enable network testing for central storage and office-wide access to the results. Data is acquired through serial and USB ports. Scalability is provided using Access, SQL or ActiveX interfaces. The program uses the latest development software to maximize program efficiency and versatility (Windows 95/98/2000/NT/XP/Me).
For additional Information, contact
Brentwood by Midmark 3300 Fujita Street, Torrance, CA 90505 (800) 624-8950
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A. Executive Summary:
Is the Medical Industry Ready for Wireless Devices, PDAs and PC Tablets? We contend the use of Wireless Device, Personal Digital Assistants (PDAs), and PC Tablets by physicians at the point of care will become standard over the next few years, potentially saving the healthcare industry > $50B per year.
The implications of the Wireless Internet for physicians are easy to imagine. Physicians are on the move all the time and they have an intense and constant need for data to make decisions. Add to that, doctors’ proven acceptance of new mobile technology.
On the other hand, physicians are only beginning to take advantage of the Internet to assist them with their clinical practice. According to a recent Harris Interactive study entitled “Computing in the Physician’s Practice,” an overwhelming majority of physicians are online an average of six hours per week, but mostly from home and for personal use. Relatively little time is spent looking for general clinical information or on clinical work related to their patients.
Harris Interactive Survey Some 18% of physicians responding to a recent survey Key Findings • 89% of physicians use the said they use a hand-held computing device as an "integral" part of their daily Internet at the office or at home, with the average online practice. Another 8% of physician respondents said they use hand-helds, but physician using it six hours per mostly for personal activities, according to the survey of 834 practicing week. • 86% of physicians use cell physicians from the polling firm Harris Interactive, Rochester, N.Y. Two years phones, and 15% use handheld ago, a similar Harris survey showed 10% of physicians used hand-held devices appliances, e.g. personal data assistants (PDAs), like Palm in their practice and an additional 5% primarily used them for personal activities. Pilots. • 52% of physicians sometimes use computers to receive the The survey does not specifically ask what work-related functions physicians results of laboratory tests. perform on hand-held devices. However, only 3% of responding physicians use hand-helds to track clinical work for billing purposes, according to the survey. Some 49% of respondent’s record billing codes on cards or notes and 27% record codes on a computer. Another 15% of responding physicians said billing codes are automatically generated as part of a computerized clinical record taking process.
Overall use of hand-held devices is more common among physicians under age 45 (33% use rate) than among older physicians (21% use rate), according to the survey. Wholly or partly hospital-based physicians use the devices more
www.acgroup.org Chapter 6 - Page 98 Last Updated: 5/20/2007 Chapter 6 The ACG 2007 Annual Report Computer Systems in the Physician’s Office Level 4 – Mobile and Hand-Held Technology than office-based physicians. The size of a physician practice also plays a role in determining how many physicians use the device. Only 11% of responding physicians in a solo practice used hand-held devices in the course of their work, while 25% of physicians in a practice of at least 25 members used them, according to the survey.
Some 11% of responding physicians who record notes manually or Dictation on to tapes expect to use a hand-held device for recording within 18 months, according to the survey. Another 22% expect to use hand-helds for recording notes within five years. "Given these expectations and the current rate of growth in the use of hand-helds over the last two years, one can reasonably estimate that about half of all doctors will be using hand-held devices by 2004 or 2005," according to Harris Interactive. "However, this rate could be greatly increased if payers, hospitals or group practices mandated their use." The polling firm notes that pressure on providers to reduce medical errors could accelerate the adoption of hand-held computing devices.
B. PDA Handheld Market Overview:
During the early 2000’s numerous technology vendors entered the healthcare PDA market. Each of these vendors provided one or two of the functions list above. Only Allscripts Healthcare Solutions marketed a “complete” solution. However, the majority of these PDA applications were not integrated with the various practice management systems Intergrated
(PMS) and electronic medical record (EMR) applications. 100% Therefore, a physician was required to re-enter all of the 90% 80% information that was already captured by their office staff. 70% After the initial wave of adoption, the actual % of physician 60% 50% using one of these systems decreased. A number of vendors 40% that were highly rated like ParkStone went out of business 30% within two years of their initial release. 20% 10% 0% 2000 2001 2002 2003 2004 2005 One major factor that drove many of the stand alone vendors Integrating with EMR and PMS Applications out of the market was the transition of the leading PMS and Page 68 EMR vendors that developed and launched integrated PDA applications. In 2001, only 12% of the leading EMR and/or PMS vendors offered integrated PDA application. By 2003, over 50% had integrated PDA applications. Based on future plans, over 90% of the top EMR/PMS vendors will have integrated PDA applications by 2005. Therefore, PDA applications that are not offered by PMS/EMR vendors or are not tightly integrated will fail, and will be replaced throughout the market.
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Today, there are two basic operating systems for PDA devices – Palm OS, and Windows CE for the PC Pocket. During the 1990’s PALM ruled the handheld and PDA market with a 90% share of the healthcare PDA market. However, in 2001 when Compaq released their new PDA device labeled “Pocket PC IPAQ”, the market economics began to change. In 2002, Palm’s new sales market decreased to 50% while IPAQ increased from almost nothing in 2000 to 30%. Based on a survey of 48 healthcare IT vendors, 46 or 95% have elected to build all of their new PDA applications using Windows CE and the IPAQ product line. Based on this and other projections, we expect the IPAQ to dominate the healthcare PDA market by 2004/05. Three of the main reasons are memory and processing speed, color, and IPAC’s ability to record electronic dictations. As shown on the exhibit, the IPAQ increased their healthcare market share from 1% in 1999 to 30% in 2002. Based on all projections from the various healthcare solution vendors, we estimate that IPAQ will exceed PALM by 2003 with a 47.1% share, and the IPAQ could capture as much as 70% of the healthcare marketplace by 2006.
90%
80%
70%
60% 2000 50% 2002 40% 2004 30% 2006 20% 10% 0% Palm IPAQ Other
So while is IPAQ capturing the healthcare marketplace? Mostly because the top 40 healthcare IT applications vendors have already switch their development plans to the Microsoft PC Pocket applications and that 90% of this top healthcare application vendors have selected IPAQ as the device of choice.
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C. Device Selection
In choosing devices for mission critical applications, consider scalability and robustness. If you purchase an underpowered handheld simply because of the attractive hardware price, you may sacrifice the return on your much larger infrastructure investment. Many organizations will find that different departments and divisions require different devices. As stated earlier, start with the high-level business objectives, move to application requirements, and then consider the most appropriate hardware platform. And still, there is the deployment of handhelds as companions to laptop and notebook PCs. Handheld devices are increasingly augmenting, not replacing, portable PCs. Certain functions such as serious document editing require mobile PCs.
The advent of handheld devices will further differentiate between luggable versus portable technology. Handheld devices are often application specific devices. They may be extending a specific application, almost becoming an appliance or utility. The burgeoning consumer handheld market has flourished largely as an extension of personal information management. Today, organizations are looking to these same devices to extend supply chain management, sales force automation, inventory management, facilities management, and point of care applications, law enforcement, scientific data collection and production data collection.
Despite all being called PDAs, devices in the handheld computer category cover a very broad range of functionality, from simple devices that are basically electronic organizers, to high-power products that rival the functionality of laptops. And to make matters even more interesting, mobile technology is evolving so quickly that newer, more advanced options are being introduced with amazing frequency.
To decide which device is best for you, there are a number of factors to consider, the outcome of which should help you narrow down the field of candidates for your PDA dollar. As you begin to make choices as to which features are important and which are optional, you will find the selection process becoming increasingly simple.
• Color - Historically, color was one of those features that often dictated choice of device. Pocket PC’s were color, Palm OS devices were not. Time has changed this though and manufactures have moved to more common ground. Palm, Handspring, and Sony make color devices using the Palm OS while Compaq makes a monochrome version of its Pocket PC device. People choosing color screens find the clearer display and enhanced readability in low light environments to be the key benefits. Taking advantage of color displays as well, although aside from games, color doesn't really change the performance. The noticeable disadvantages of color are decreased battery life, and added size and weight of the device.
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• Memory - On the surface, this seems to be a pretty straightforward comparison. Pocket PC devices generally come with more memory that their Palm OS counterparts (32MB is common for Pocket PC devices compared to 8MB for most Palm OS devices). While this may not sound like much compared to the amount of memory on the average desktop, it is important to note that all memory is not equal. For example, a reference work that may need 10MB on a desktop may function perfectly well using only 1MB on a PDA. What is much more important than the amount of memory that comes with the device is whether or not you can add more. Most Pocket PC devices accommodate Compact Flash cards (the same kind of memory used in digital cameras) as do PDAs made by TRGpro (which uses the Palm OS). Handspring devices can accept more memory through Springboard modules (Handspring's propertary expansion port) and the new line of Palm devices incorporate the ability to add memory as well.
• Operating system - The most important aspect of the operating system is not who makes it, but what kinds of software have been written to run on it (which is discussed next). If you are accustomed to using Windows on a desktop, you may find the Pocket PC interface more familiar. However, it is not as efficient as the Palm OS as it takes more processing power to run. This means faster processors are required which are more expensive.
• Battery life - As has always been the case with portable computing, a device is only good if it has the power to run. The monochrome Palm OS PDAs has a distinct advantage with a pair of batteries lasting the better part of a month with fairly regular use. A Pocket PC or Palm OS with color screens will exhaust the batteries in a matter of days, if not hours with similar use. Most higher end PDA's and all color devices have rechargeable batteries that help alleviate this issue. Provided the device is placed in its cradle regularly, it will be a very rare occurrence that the device goes dead. The only downside of this system is that if you don't have access to a cradle, there is no way to recharge the device (as opposed to those where the batteries are replaced, which can be done anywhere).
• Speed - One of the benefits the streamlined design of the Palm OS provides is quick response time. Because the operating system is quite simple and does not need to process colors (color models excluded of course), Palm OS devices are very fast. Pocket PC devices on the other hand tend to be more sluggish as the processing required to produce full-color, graphic intensive images is high. The speed on the newer models of Pocket PC devices is dramatically improved over the older models and will likely continue to get even better.
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• Data input - Almost without exception, handheld computers use a stylus for data input. If an integrated keyboard is a must, your options are pretty limited. However, both Palm OS and Pocket PC devices have detachable keyboards, which can be used for data entry. These add-ons generally cost between $50-$100 and can dramatically increase the speed of data entry. For the more adventurous there are also a number of more esoteric options such as software that is somewhat better at handwriting recognition and on handed keypads to experiment with.
• Screen size - PDAs generally come with two basic screen sizes depending on whether you are interested in a handheld PDA or a palmtop PDA. Handheld PDAs (Pocket PC, Palm, Handspring, etc.) have screens in the range of 2.5 x 3 inches. Palmtop PDAs on the other hand have larger screens; with dimensions starting at 2.5 x 6 inches up to 10-inch screens (a typical laptop screen averages around 12 inches). If the larger screen is a deciding factor, your choices are going to be limited to a small selection of devices. It is also very important to note that most manufacturers have stopped making palmtop sized devices due to the lack of demand so future product support and software choices could be severely limited.
• Expandability – The expandability of the newer PDAs is important to insure that your device will not become obsolete too quickly. Expansion slots allow the addition of memory and accessories, thereby increasing the device’s functionality without replacing it. Fortunately, almost every manufacturer makes a device with an expansion slot meaning the choices are no longer limited to just one or two brands. The important factor to consider with respect to expandability is the cost and selection of expansion modules. Make sure the device you select has the choices you require and that the cost of those modules is not going to break your pocket book.
• Price - PDAs range anywhere in price from $150 to $1,000 with physical size, memory and color being the most influential factors in pricing. Devices based on the Palm OS tend to be at the low to mid range of this spectrum with Pocket PC devices at the middle to higher end (this is primarily due to the extra memory and added functions that come standard on a Pocket PC). If you are comfortable spending between $250 and $500, you will find a good selection of PDAs using each of the three operating systems
The proliferation of PDAs within the medical profession will become the norm, in our view by 2003/04, especially as other applications such as dictation, charge capture and lab ordering are added to software suites. We estimate that > 45% of the Physicians and > 50% of other medical professionals will be utilizing PDA’s by 2005. This equates to > 3M devices by 2005. For the medical professional, here are just a few of the things that can be done with a PDA: • Patient tracking • Simple organizational tasks • Billing, Charge Capture and • Dictation • Internet access Correct Coding • Receiving Alerts • Electronic prescription writing • Mobile ECG’s • Reviewing Lab Data • Renewing Prescriptions • Drug Reference
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The following pages describe each of these applications Patient Tracking
It is possible to keep simple profiles of patients including personal and demographic information. Or choose one of the more advanced packages that allow for much more sophisticated tracking such as lab data, medical history and prescriptions. Once entered in the PDA, patient information can be exchanged with other handheld users using infrared beaming, ensuring all members of the care team have completed and up-to-date data. And by synchronizing the PDA with a desktop computer, notes from the device can be immediately transferred to a comprehensive medical software package. • View and manage office schedules from any Internet-enabled PC • Customize appointment types • Schedule multiple providers in the same practice • Use either as a standalone scheduling system or port over data from your existing scheduler
Dictation
Dictation restores mobility and convenience to the physician. Dictation provides the functionality of a handheld digital recorder, incorporating advanced capabilities such as Patient List information and Dictation Templates. By setting new standards for medical dictation software, Dictation has become an industry leader and "must have" tool for doctors in hospitals, clinics and private practice.
Dictation uses the latest in Windows Pocket PC technology to record up to three hours of digital voice files and forward them to the appropriate voice server for transcription. This enables a doctor to complete his dictations without being tied to a telephone for dictation and dictation ID entry. This efficiency also lowers the cost for administrators by streamlining workflow and intelligently processing voice files by flagging incomplete dictations or dictations with invalid medical record numbers.
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Reviewing lab results
Healthcare providers can receive lab results at the point of care. Working seamlessly with an integrated Mobile Patient Index, a lab retrieval system represents a significant opportunity to make workflow more efficient. No more logging on to a computer to view labs, or sifting through paper records in a chart to find pertinent information. Oftentimes, labs may be drawn at different times, run on different machines, and reported in different areas, such as coagulation or bleeding lab tests. By customizing the application, healthcare providers can bring together, on one screen, all labs for a particular patient's clinical condition. Also, users will be alerted to abnormal lab values, and these abnormalities can be fed into a Mobile Patient Index and an Alert so that the user is alerted to this abnormal value when viewing his or her patient list.
Lab will save you time by allowing you to access patient lab data efficiently, improve your quality of care by being able to act immediately on critical lab results, and make clinical decisions quicker, leading to more efficient care and the potential of decreased lengths of stay. Similar to the idea of receiving an alert, physicians can also receive an alert about an urgent lab result. This enables the physician to make an immediate decision about any action required. In addition, having access to this information on the fly can help avoid additional or repetitive tests, saving both time and money.
Decision Support
Amongst the most popular uses of PDAs in maintaining a comprehensive and complete, drug reference. Rather than carrying a cumbersome book, or making a side trip to the nearest nurse’s station, drug guides on handheld computers provide up to date information on dosages, interactions, contraindications and cost. • The most widely accessed source of drug content used by over 200,000 healthcare professionals • Unbiased information provided by trusted third party resource • The number one source of drug reference information for pharmacists across the U.S. • Offers simplicity with an intuitive, menu-driven interface • Provides immediate access to critical drug reference information on your mobile handheld device • Ensures ease of use for busy physicians and healthcare professionals Includes regularly updated information for over 3,000 drugs across 26 therapeutic classes • Search drug content by generic or brand name, or by therapeutic class • View dosing, contraindications, adverse reactions, mechanism of action and more • Reduces risk of drug-drug interactions and other related medical errors • Provides you with the critical information you need, when you need it • Integrates seamlessly with the prescribing module for easy access
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Internet access
Virtually all PDAs offer the ability to access the Internet using either wired or wireless connections. This feature provides the ability to access a virtually limitless amount of information from online archives, newsgroups and other websites. There is also an increasing amount of content available on the Internet designed specifically for PDAs (such as AvantGo, which provides updated content such as newspaper and magazine articles specifically formatted for handheld devices). While the small size and screen resolution of PDAs does not make them ideal for general web browsing, for quick trips to find relevant information they can prove extremely convenient.
Electronic Prescription
Prescription errors not only put patients at risk, they result in time consuming callbacks. Using a PDA, prescriptions can be written electronically and then sent to a printer or directly to the pharmacy. More advanced prescription programs even check formulary and drug interactions information.
• Prescription automatically checked for insurance formulary compliance • Prescription automatically checked for prior adverse reactions and potential drug interactions. • Claim handled automatically on-line • Medication is pre-packaged with a tamper proof safety seal • Automated inventory management process • Time spent on process is time saved from answering pharmacy calls • Only most commonly prescribed medications kept in stock (size requirement is the size of typical sample closet) • Add new patients to your handheld on the fly while doing rounds • Analyze your prescribing patterns • Customize your own drug list and create a favorites list of your most commonly prescribed drugs • Decreases pharmacy waiting time for your patients • Easily manage medication recalls • Eliminates medical errors resulting from misinterpreted handwriting • Lowers incidence of in-pharmacy drug switching • Maintain electronic and/or printed transaction records automatically • Maintain patient's preferred pharmacies • Order prescription refills from the prescription history reports
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• Physicians using this tool typically save one to two hours each day by reducing pharmacy callbacks and administrative tasks. • Record and track patient allergies • Reduces pharmacy-related phone calls to your office • Send signed prescriptions wirelessly to any pharmacy in the continental U.S.¹ • The formulary lists, programmed into the system, are displayed in a format that encourages physicians to choose the lowest cost medications. • The practice is notified in advance of pending prescription renewals. • The printed or electronically transferred prescription is legible. • The referral module customizes the referral generation process to managed care organization- specific networks. • The system keeps a record of prescriptions and prints an updated medication sheet for the patient chart. • The system prompts physicians to prescribe on-formulary for each individual patient. • View, sort and print medication histories • Write multiple prescriptions at the same time • Write prescriptions in as little as 3 seconds
Renewing a Prescription
One of the most time-consuming and frustrating endeavors for physicians is refilling prescriptions. A patient calls a physician’s office with the request, which begins the string of phone calls, time on hold, relaying the same information time and again to each person in the chain. If the physician is away from her office, there is an added concern about making treatment decisions without complete information about patient allergies, other medications, and history.
Imagine this scenario as told by Dr. Anderson, “I was driving in my car, and I received an alert on my cell phone. A patient that I know needed a refill on his antibiotic. By pressing one button, I instantly faxed the renewal to his retail pharmacy, updated his online medical record, and notified him by email that his request had been filled. It was so fast and easy that I felt safe doing it while driving my car.”
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Key Characteristics of an Electronic Prescription Writer By Robert Keet, MD FACP
Healthcare practitioners have a professional mandate to prescribe the most appropriate, disease-specific medication in a safe and efficacious manner. Each year, though, this becomes more complex. The number of new medications increases exponentially each year with new entries for each class and new classes for each disease. Each drug has its unique indications, contraindications, cross reactivity, complications, and costs. Increasingly, drug-drug interactions present a major problem, reportedly occurring in 12% to 22% of prescribed medications.1
Providers can no longer rely on memory for necessary details about familiar medications. They must prescribe in the context of all medications a patient takes, including those prescribed by other physicians in the community. In addition to indications, contraindications, and potential side effects, they must be aware of drug-drug, drug-age, drug-allergy interactions, and which medications are covered by the patient's insurance. The cost of managing the plethora of often-modified, insurance-specific formularies is rapidly driving up the cost of care.
Several studies have shown that applying computing technology to prescription writing significantly reduces the cost of medications while increasing the adherence to specific protocols.2 3 Computerized prescription writing can provide tremendous benefit to both the healthcare provider and the patient.4 Despite the obvious benefits, the use of computerized prescription writers is not widespread.
My healthcare community, which includes 135 physician offices, is implementing an electronic prescription writer. The prescription writer is part of a project to automate the flow of clinical data between physicians and their affiliated healthcare partners. The first stage of the project involved managing the flow of incoming clinical data such as laboratory results, radiology results, and transcriptions. The data was digitized and delivered to physicians' "inboxes," and tools were provided to manage those messages. The second stage of the project automates the management of outgoing messages including authorizations, laboratory orders, and prescriptions. Lessons learned during this effort provide insight into specific issues that must be addressed by architects of automated prescription systems for healthcare providers.
A variety of papers and articles have addressed the design issues faced when implementing physician automation in a single economic entity.5 This paper addresses the myriad of issues that must be considered when designing a prescription writing system to meet the needs of physicians in multiple economic entities linked only by a common community of patients.
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Cross-Community Implementation
The typical patient sees a primary care physician and several specialists each year. An effective electronic prescription writer must track all drugs prescribed by all physicians in the community and must perform duplicate and interaction checking based on all drugs prescribed for that patient by multiple providers. The prescription writer must provide adequate security, for example, to assure that physicians do not have access to drug information for patients they are not managing. Finally, each prescription must be linked to a unique patient identifier so that data can be appropriately transmitted across the system.
Our healthcare community created a "master patient index" (MPI) that identifies each patient and provides up- to-date patient demographics, eligibility status, health plan, co-pay, and eligibility information. It also has the capability to carry key clinical information including prescribed medications and allergies. The MPI database entries are automatically generated and maintained from data included in incoming clinical messages, such as laboratory results, and from outgoing messages, such as laboratory orders and prescriptions. The database is replicated across the community and allows for rapid demographic look-up and unique identification of clinical data (including prescriptions) and for checking for duplicate and interacting medications.
Although we implemented a wide area network across the entire community to maintain the patient index and to distribute clinical messages, healthcare communities today can take advantage of the Internet and Web browser technology, thereby avoiding the high costs associated with the development of a community-wide network. Using the Internet and Web browser technology, physicians and their staffs can easily access the tools necessary to facilitate writing prescriptions. This includes linkages to expert databases, patient demographic data, and medication history. Using an e-mail metaphor familiar to physicians and their staff, prescriptions can be generated and delivered to the appropriate pharmacy.
Web technology faces two special considerations: security and speed. The U.S. Federal Government via the Health Care Financing Administration (HCFA) is currently setting standards for the Web-based delivery of clinical data.6 With encryption and appropriate authentication or identification, Web transmittal of clinical prescription data should not be a problem.
Quick Response Time
Each day the average primary care physician writes 10 to 20 prescriptions and processes a similar number of refills. Prescription writing generally occurs at the end of a patient encounter and must be done very rapidly.
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Because of this, response time is critical in any point-of-service system. Since the speed of a browser-based prescription writer is dependent on the data transfer bandwidth and the speed of the loading of pages, the prescription writer must be designed with an eye to rapid loading and transfer of data, even if this requires compromising on the quality of graphics.
In addition, physicians are very sensitive to the number of "mouse clicks" and text entry required to complete a task. The physician must be able to quickly choose the appropriate drug and create the "Sig" (directions for use). Effortless, Intelligent Medication Choice
We found that physicians generally wish to choose a medication by name but appreciate the ability to find medications by diagnosis and cost. Often physicians remember only the brand name, yet wish to prescribe the generic alternative when available. Sometimes they do not know if the drug name is brand or generic, so they must be able to choose drugs from one master list. Spelling is also often a problem; physicians may remember only the first several letters of a drug name. Finally, physicians need guidance regarding the specific strengths available for a medication.
For new medications, physicians often remember that a new drug is available in a specific class or for a specific diagnosis but do not remember the specific name. Presenting the physician with drugs sorted by FDA-approved diagnoses solves this problem. In short, choosing a medication should require minimal data entry and not be dependent on knowledge of the drug's exact name or whether the name is a generic or brand name. Once chosen, the physician should be presented with available strengths and guided to the appropriate direction for use.
Formulary Linkage
Managed care has introduced a new dimension to prescribing a medication—selecting one that is covered by the patient's insurance. Because formulary management directly impacts patient satisfaction and office efficiency, it is of increasing concern to clinicians. Healthcare providers now spend more money on medications than they do for primary medical care. This is an issue of significant economic importance.
Unfortunately, there is no single formulary of medications to use for a specific diagnosis. Instead, the physician usually has several possible choices with costs related to the insurance carrier's contracted rates. The appropriate drug choice thus depends on the patient's insurance and that company's current contracts— a rapidly moving target. Providers should be warned when they prescribe a drug not on the patient's
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Physicians tend to prescribe a subset of medications repeatedly. In addition, they usually prescribe the same number of tablets with the same directions and number of refills. The electronic prescription writer should allow rapid completion of the prescription form for each physician's frequently prescribed drugs.
Expert Database Linkage
The complexity of prescription writing requires that clinicians have rapid access to expert knowledge. The prescription writer should automatically check for drug duplicates and interactions as prescriptions are written. Duplicate checking includes checking for the same drug as well as for similar drugs in the same class. We have found that physicians wish to be warned but do not want that process to interfere with the completion of the prescription. Often they are aware of the potential problem and do not want more details. When interested, the physician would like the complete detail of the potential interaction including scientific reference.
Prescription writers linked to expert databases such as Medi-Span allow this checking. Expert drug databases can also provide physicians with specific prescribing details including the usual dosage, route of administration, relationship to food, contraindications, and potential reactions. Average wholesale price data is useful for choosing among otherwise equivalent drugs. Providing physicians with details of drug cost leads to cost-effective improvement in prescribing patterns.7
Directions for Use and Patient Education
The ideal prescription writer provides defaults for appropriate usage directions. These defaults can come from the physician's personal list for frequently prescribed drugs or from an expert database and can be easily changed. The directions for use should drive other automation within the prescription process. For example, the prescription writer can use the dose, strength, units prescribed, number of refills, and the directions for use to calculate the date that the drug would normally require renewal. This date can drive other processes including the renewal process and the tracking of patient compliance.
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Finally, drug databases can provide drug-specific patient education in multiple languages. This includes information about proper usage of the drug, contraindications, warnings, and precautions and can be printed before the patient leaves the office.
Renewal Process
Our workflow analysis showed that the refill process is one of the most cumbersome and expensive processes in a primary care physician's office. A typical primary care physician may receive 20 or more requests for refills each day. These requests come from patients and pharmacies via phone, fax, and mail.
For each request, the office staff must obtain the chart, check and update the medication list, confirm the dose, and present the data to the physician for approval. Once approved, the staff must update the chart and transmit the refill approval to the patient or pharmacy by fax, phone, or mail. In a paper-based system, it is cumbersome to determine if the drug is being refilled too soon and impossible to determine if it isn't being refilled soon enough. Medication lists often become outdated or contain incorrect information regarding dose or directions for use. For critical drugs such as Coumadin, this can lead to significant risk to the patient.
An automated prescription process must allow the staff to enter renewal requests for approval by the physician. By choosing a drug from the prescribed list, a staff member should be able to initiate a renewal with a single mouse click. The original dose, number, refills, and directions for use should be carried forward to a new prescription with the date modified. This preliminary renewal request can then be deposited in the physician's electronic inbox for approval.
If the system can calculate the expected renewal date based on the dose, strength, number, refills, and directions for use, the staff and physician can quickly determine if the refill is occurring too soon or there if evidence of non-compliance. If the dates of the patient's last visit and laboratory tests are also available, refill checking can be even more comprehensive.
Provider Workgroups
Provider groups often centralize the process of prescription management and refills. An automated prescription writer must function in the context of a group of healthcare providers and staff who work together to manage this complex task. Provider workgroups can simply be call groups or may comprise all the clinicians in an economic entity. Thus, the prescription process must take into account the fact that providers often act clinically on behalf of each other. One clinician may write a prescription for another clinician's patient
www.acgroup.org Chapter 6 - Page 112 Last Updated: 5/20/2007 Chapter 6 The ACG 2007 Annual Report Computer Systems in the Physician’s Office Level 4 – Mobile and Hand-Held Technology or may refill medications on behalf of a colleague who is out of town. While prescriptions must be signed by the generating provider, the regularly treating provider must have information about all drugs prescribed for his patients. It is this provider who takes responsibility for the ongoing management of the patient's medication.
Because staff members generally work with multiple providers, the refill process must allow staff to generate prescriptions with direction to a specific provider for approval. Legally, an automated prescription writer should allow only physicians or, where legal, mid-level providers to complete (sign) prescriptions; however normal workflow mandates that prescriptions be prepared by the office staff.
Linking All Players
In an ideal world, physicians, pharmacies, and patients would all be electronically linked. While pharmacies often have automated systems to track drugs and refills, clinicians typically deal with multiple pharmacies with dissimilar systems. In recent years, online pharmacies have been proliferating on the Web, yet no simple technology exists to link these services to provider or patient.
An automated prescription writer should have the ability to link to a variety of other computer systems. Refill requests from the pharmacy should be delivered electronically to the responsible provider. Even the patient could be brought into the loop with standard e-mail and Web tools. However, electronic prescriptions must also easily interface with the world of paper, fax and e-mail. Incorporating prescription writing into a standard communication infrastructure allows for maximum functionality now, with a growth path for the future. Electronic prescriptions can easily be converted to fax and paper, thereby meeting the general needs of the current work environment. Implementation Process
The critical success factor for any new system is that it can be adopted in a gradual, non-disruptive manner. In our healthcare community, we found that, wherever possible, it is best to introduce automation first with the office staff. Once time savings are demonstrated, providers can gradually adapt to the new process. Automating the time-consuming and expensive refill process first provides the most obvious gain for the effort. A few key staff can be trained to enter refill requests from pharmacies and patients into the system. The physicians can approve or reject these requests "online" in a process that requires minimal adjustment from current procedures.
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Once the system has been primed with most of the drugs for each of the patients, clinicians can gradually transform their prescription writing practice to one that is online. Providing automated alerts for drug duplicates, interactions, and formulary non-compliance will encourage clinicians to use the system.
Conclusions
Prescription writing is one of the most complex tasks performed by physicians, demanding both detailed knowledge of the patient's care and of drug usage. Treatment protocols are increasingly complex, and providers are responsible for assuring that medications are prescribed appropriately and without adverse interactions.
Several factors are coming together that will move physicians to more automated systems. First, the complexity of medical care is increasing, making it difficult for physicians to maintain the knowledge base necessary to provide quality care to their patients. Second, as computers have become more common and less expensive, clinicians have begun to use them in their day-to-day work. A recent Gartner Group survey found that 78% of physicians use the Internet. Finally, Internet and e-mail technologies are increasingly sophisticated, and complex management tools can be built within this familiar environment to assist in the delivery of healthcare.
Systems that give physicians immediate and direct feedback during the prescription process are most effective in changing behavior and improving quality.8 Using tools built on communication platforms, professionals can work together across a community to care for patients. Combining systems that generate prescriptions, track medications, provide communication between providers, and link to expert databases allows providers and their staffs to automate this process in the context of their usual workflow.
Dr. Keet has practiced Internal Medicine and Geriatrics in Santa Cruz, California for more than 20 years. During the last four years, he served as chairman of the Steering Committee of physicians overseeing the development of an automated clinical messaging network in his community. He consults with Axolotl Corp. where he assists in the company's ongoing effort to provide clinical automation tools. 1. Linnarsson R, Drug interactions in primary health care. A retrospective database study and its implications for the design of a computerized decision support system, Scand J Prim Health Care 1993 Sep 11:3 181-6 2. Grams RR, A primary care application of an integrated computer-based pharmacy system; J Med Syst 1996 Dec; 20(6) : 413-22
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3. Donald JB, Prescribing costs when computers are used to issue all prescriptions; BMJ 1989 Jul 1;299 (6990) : 28-30 4. Schiff GD, Computerized prescribing: building the electronic infrastructure for better medication usage, JAMA 1998 Apr 1;279(13) : 1024-9 5. Chin HL, Implementation of a comprehensive computer-based patient record system in Kaiser Permanente's Northwest Region, MD Comput 1997 Jan-Feb 14:1 41-5 6. HCFA Internet Security Policy, Nov 24, 1998 7. Donald JB, Prescribing costs when computers are used to issue all prescriptions, BMJ 1989 Jul 1 299:6690 28-30 8. Soumerai SB, McLaughlin TJ, Avorn J, Quality assurance for drug prescribing, Qual Assur Health Care 1990 2:1 37-58
Billing and Charge Capture
Outside of solutions that assist decision-making processes directly related to patient care, charge capture is one of the more popular solutions. Particularly in this evolving era of healthcare reform and insurance regulations, efficient and accurate billing is a necessity. The most basic of these types of solutions allow you to reference ICD- 9 (International Classification of Diseases, 9th Edition) and CPT (Current Procedural Terminology) codes so you can complete your paper-based superbills more quickly.
The hottest and best received application on the market today in classified as “Intelligent Charge Capture”. Unlike traditional charge capture systems that allow a physician to record daily charges, intelligent charge capture provide the physician with undated “knowledge” on what individual healthplan require for proper coding and charge reimbursement. Companies like MedAptus and Allscripts Healthcare Solutions are the two leaders in developing and deploying intelligent charge capture systems.
• HCFA data indicates practicing physicians are losing $25+billion per year in denied or reduced claims, a direct result in inadequate documentation, while administrative expenses exceed 40% of gross physician revenues. • Lost billings average $60,000 per year for each of the roughly 450,000 practicing physicians in the US.
When evaluating charge capture systems, there are numerous functions that should be examined. Theses include: • Does the system have prefigured superbills by specialty?
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• Does the system customize the application to match the way you capture charges? • Does the system use in any care setting, including office or hospital? • Does the system display user-selected ICD-9, CPT and HCPCS codes? • Does the system add modifiers, visit notes, and return visit requests? • Does the system assign charges to CPT/HCPCS codes? • Does the system add new patients to the handheld when doing consultations? • Does the system reconcile today's patient list to make sure charges have been captured for each one? • Does the system automatically sends charges to your billing/practice management system to be processed the same day • Does the system check and confirm patient's insurance and co pay information? • Does the system track referral information? • Does the system view or print superbills (including physician's notes and return visit instructions)? • Does the system provide a calculator to help ensure your coding is in compliance with the newer E&M (Evaluation and Management) coding recommendations? • Does the system prompt the physician for missing information required to meet specific level of service? • Does the system suggest additional data that needs to be captured in order to meet the requirements for the next level of service?
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Which Vendors provide the best Charge Capture Application? - Healthcare IT Application vendors provide PDA functionality in many ways. A few companies, like MedAptus, MDeverywhere, PatientKeeper, and MDanywhere provide stand alone Charge Capture systems that can be interfaced with any Practice Management System (PMS) and Electronic Medical Record (EMR) vendor applications. Other companies like Allscripts Healthcare Solution, NextGen, and WebMD, provide integrated PDA applications with there own PMS and EMR applications. However, which vendors have the best Charge Capture System? Based on a recent survey of 56 healthcare IT vendors (self reported data, verified via demonstrations and site visits) that sell applications to physician offices, the vendors with best Charge Capture systems are shown below:
Although the variations are limited in some cases, MedAptus and Nextgen are the clear leaders in Charge Capture systems today. However the up and coming vendors, based on future functionality, will be Allscripts Healthcare Solutions, MDeverywhere, and PatientKeeper. Finally, when selecting a Charge Capture Vendor, organizations must also consider the financial viability of the company and additional functionality that might be considered at a latter time.
100%
98%
95%
93%
90% % of Requirements 88%
85% Charge Capture & Coding
Nextgen MD Anywhere eClinical Works PMSI Allscripts Medaptus Patient Keeper MD Everyw
Management and Financial Viability - When evaluating company management and financial stability, healthcare organizations must consider numerous sources of information. In particular, most PDA application vendors are not publicly traded, and therefore, financial and management strategies are hard to come by. In most cases, company evaluations are based on industry and financial analysts, and are more based on opinion than
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real concrete data. However, as most will state, the various industry and financial analysts track the industry closely, and although their judgments are not always correct, their influence over the industry creates visibility for those vendors who stand out in regards in functionality, management capability, marketing and sales capability, and vision to survive and thrive in the future.
100%
90%
80%
70%
60%
50% % of Requirements of % 40%
30% Management and Company
Nextgen MD Anywhere eClinical Works PMSI Allscripts Medaptus Patient Keeper MD Everywhere
Management and Company Rating:
Using this rating system, companies like NextGen, Allscripts Healthcare Solutions, MedAptus and PMSI are recognized leaders in the Charge Capture Marketplace. Other companies may have strong functionality, but without nationwide name recognition, companies like eClinicalworks, PatientKeeper, and MDeverywhere become acquisition candidate for larger-national known companies. Already, PatientKeeper has a direct relationship with Cerner Corporation. This direct ownership relationship create great opportunities for Cerner sites (over 1,000 hospitals), but creates conflicts with the other large healthcare IT vendor organizations like McKesson, IDX, Siemens, Meditech, Nextgen, GE Medical, etc.
MedAptus and MDeverywhere are neutral Charge Capture vendors with numerous relationships with IDX, Siemens, McKesson, and GE Medical (Milbrook). This relationship benefits their companies and their clients since they have already tested the required interfaces between the Charge Capture system and the healthcare organization’s practice management system(s).
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Total Combine Charge Capture Rating System - When you combine ratings for functionality, management, company, and PDA and Wireless Synchronization, the top vendors rating change slightly, but the top functional applications remain at the top. As shown on the next page, the top vendors for charge capture remain NextGen, Allscripts Healthcare Solutions and MedAptus. However, based on an organization’s willingness to accept minimal risk and depending on their future Practice Management Vendor, companies like MDeverywhere and Patient Keeper would still make good choice for certain organizations.
Overall rating of Charge Capture Functionality, Management,
95% 93% 90% 88% 85% 83% 80% 78% % of Requirements of % 75% 73% 70% Total Charge Capture
Nextgen MD Anywhere eClinical Works PMSI Allscripts Medaptus Patient Keeper MD Everywhere
Company, and PDA and Wireless Synchronization.
Charge Capture offers automated alternative to the traditionally cumbersome manual capture of charges for both inpatient and ambulatory services. Physicians can efficiently capture charges for all services at the point of care. Integration with practice management systems is essential. Physicians should be vary of “bolt on” or stand alone PDA software applications that do not integrate with either the physician’s current EMR or PMS applications.
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PDAs provide an ideal way to keep track of procedures to ensure proper billing. Not only do they replace 3 X 5 cards and napkins as a medium for recording billing information, the electronic data can be transferred directly to a desktop or hospital mainframe so all changes are accounted for and transcription errors are minimized
• Get started faster with pre-configured superbills by specialty • Customize the application to match the way you capture charges • Use in any care setting, including office or hospital • Display user-selected ICD-9, CPT and HCPCS codes on your handheld • Add modifiers, visit notes, and return visit requests • Assign charges to CPT/HCPCS codes • ·Reduce lost charge slips and superbills with mobile, electronic data capture • Add new patients on the fly to your handheld when doing consultations • Reconcile today's patient list to make sure charges have been captured for each one • Instantly send charges to your billing team to be processed the same day • Check and confirm patient's insurance and co pay information • Track referral information • View or print superbills (including physician's notes and return visit instructions) • Generate reports (no-show list, day's charges and cash receipts) • Helps you reduce lost revenue associated with unrecorded patient visits • Streamlines billing so that charges can be processed immediately • Assists your staff with managing office receipts and patient billing
Mobile ECG’s
The latest software product in the IQmark family elevates your ECG capabilities to a new, more efficient level of portability, cost-savings and efficient patient care. When used in conjunction with the IQmark™ Digital ECG, the new IQmark PDA lets you run hundreds of ECGs on a Pocket PC-based device - like the Compaq iPAQ® - without the need and expense of transporting a large ECG cart from room to room.
The IQmark PDA is perfect for use in the office, clinics and medical centers as well as for remote and emergency situations. You can evaluate live ECGs on the LCD screen, then simply click on “Save” to automatically store the ECGs.
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Managing the ECG is very easy. Simply connect the PDA device to its docking station and the IQmark Sync will automatically transfer the stored ECGs from the PDA device to the IQmark Diagnostic Workstation for interpretation, measurements, editing and printing. IQmark Sync also works with Infrared (IR) or wireless network connectivity.
Advantages
• Capable of storing hundreds of patient ECGs • Works on Microsoft® Pocket PC 2002 platform • Small pocket size PDA (Personal Digital Assistant) • Download tests via standard docking station, IR or wireless network to the IQmark Diagnostic Workstation for interpretation, editing, storage and management
Summary:
PDA devices are just that – another device to help the physician improve their effectiveness. However, we do believe that the PDA has limited functionality given the screen size. Information reviewing, charge capture, dictation, vital signs, and prescription writing are applications that work well on a PDA. We do not believe that PDAs will be used for clinical charting of physician notes, H & P, and template driven collection of detailed patient information. Numerous studies have shown that the screen is too small for routine collection of detailed clinical information.
Additionally, the majority of the vendors plan on porting their clinical capture applications to a new device labeled the Microsoft PC Tablet. The PC Tablet is expected to have built in wireless capability, integrated voice and hand writing recognition, touch point technology like the PDA, full integrated digital dictation, and the device will be light weight, have a full active matrix color screen, a longer battery life than the PDA and will be able to maintain 5,000 patient records on the expanded hard drive.
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