1. Copyright Primetime Medical Software 2007 May be reused if acknowledged Introduction to Workflow Using an EMR Allen R. Wenner, M.D.

2. Copyright Primetime Medical Software 2007 May be reused if acknowledged What is the biggest problem with an EMR? Data Entry, Data Entry

3. Copyright Primetime Medical Software 2007 May be reused if acknowledged Where Does Data Entry to the Ambulatory Care Office Start? Let’s Look at Your Office

4. Copyright Primetime Medical Software 2007 May be reused if acknowledged Permission The following slides contain pictures of real patients who have given their permission for their images to be used for medical teaching purposes. The illnesses associated with their images have been changed to protect their privacy.

5. Copyright Primetime Medical Software 2007 May be reused if acknowledged Visit Typical Medical Clinic

6. Copyright Primetime Medical Software 2007 May be reused if acknowledged Check in and Registration

7. Copyright Primetime Medical Software 2007 May be reused if acknowledged Where Does Data Entry to the Ambulatory Care Office Start? Let’s Look at My Office

8. Copyright Primetime Medical Software 2007 May be reused if acknowledged Patients Come to the Office

9. Copyright Primetime Medical Software 2007 May be reused if acknowledged Wireless Waiting Room

10. Copyright Primetime Medical Software 2007 May be reused if acknowledged How does the new patient register?

11. Copyright Primetime Medical Software 2007 May be reused if acknowledged What COULD be entered by patients before the visit? Demographics Eligibility Payment guarantee HEDIS standards Guidelines considered Tests pre-ordered Reduced waiting time

12. Copyright Primetime Medical Software 2007 May be reused if acknowledged Going to the Back How does it happen in your office?

13. Copyright Primetime Medical Software 2007 May be reused if acknowledged

14. Copyright Primetime Medical Software 2007 May be reused if acknowledged Clinical Exam with Paper Who enters the data?

15. Copyright Primetime Medical Software 2007 May be reused if acknowledged Clinical Exam with Paper

16. Copyright Primetime Medical Software 2007 May be reused if acknowledged Going to the Back How does it happen in my office?

17. Copyright Primetime Medical Software 2007 May be reused if acknowledged Leaving the Waiting Room

18. Copyright Primetime Medical Software 2007 May be reused if acknowledged 5 Options for Data Entry to EMR 1.Handwriting recognition 2.Typing 3.Templates (by staff) 4.Dictation 5.Voice recognition 6.Patient entered data with editing

19. Copyright Primetime Medical Software 2007 May be reused if acknowledged Cost of MD Documenting Hand Writing 30 words per minute Typing 60 words per minute Dictating 180 words per minute Editing 7200 words per minute $$$$$$ $$$$$ $$$$ $ $$$$$$ $$$$$$

20. Copyright Primetime Medical Software 2007 May be reused if acknowledged 1.Doctor using Handwriting Recognition Slow, but seems great until have more than 6 words or misrecognition occurs

21. Copyright Primetime Medical Software 2007 May be reused if acknowledged

22. Copyright Primetime Medical Software 2007 May be reused if acknowledged Vitals Check-in 2 1 1 5 12 = $32 Doctor for Data Entry Handwriting or Handwriting Recognition Physician Documentation EMR and 15 Minute Office Visit Doctor Handwriting Checkout Escort Physician Exam Nursing Documentation Escort 4 Graphic derived from Dan Russler, MD, McKesson, Making Money Wasting Money Money Spent

23. Copyright Primetime Medical Software 2007 May be reused if acknowledged 2. Doctor Types the Data Patients don’t like the loss of eye contact. “All he did was type in the computer during my visit.”

24. Copyright Primetime Medical Software 2007 May be reused if acknowledged Productivity Drop with Doctors Typing Kaiser Northwest, Portland, OR Time of Office Visit

25. Copyright Primetime Medical Software 2007 May be reused if acknowledged Revenue Drop with Doctors Typing Carilion Health Care – Roanoke, VA

26. Copyright Primetime Medical Software 2007 May be reused if acknowledged 1 3 Vitals Check-in 2 1 4 12 = $42 Doctor for Data Entry EMR and the 15 Minute OV Doctor Typing Checkout Escort Physician Exam Nursing Documentation Escort 2 Making Money Wasting Money Money Spent 8

27. Copyright Primetime Medical Software 2007 May be reused if acknowledged 3. Let the Nurse do a template

28. Copyright Primetime Medical Software 2007 May be reused if acknowledged Nurse Using Templates

29. Copyright Primetime Medical Software 2007 May be reused if acknowledged Templates require more nurse time

30. Copyright Primetime Medical Software 2007 May be reused if acknowledged Vitals Check-in 2 1 1 4 12 = $38 Doctor for Data Entry Physician Dictating The EMR and the 12 Minute Office Visit Compare Nurse for Documentation Checkout EscortPhysician Exam Nursing Documentation Escort Vitals Check-in 2 1 1 12 = $32 Physician Documentation Checkout Escort Physician Exam Nursing Documentation Escort 12 Nurse for Data Entry 3 2

31. Copyright Primetime Medical Software 2007 May be reused if acknowledged 4. We can dictate

32. Copyright Primetime Medical Software 2007 May be reused if acknowledged Dictation is a waste of Time Whether it is Paper or EMR

33. Copyright Primetime Medical Software 2007 May be reused if acknowledged 3 Vitals Check-in 2 1 1 4 12 = $38 Doctor for Data Entry Dictation Physician Dictation EMR and the 15 Minute Office Visit Doctor Dictating Checkout Escort Physician Exam Nursing Documentation Escort 2 Staff management of dictation 1 Inability to answer problems Poor referral management Insurance rejection issues 4 10 2 ? Decreased patient safety & satisfaction Making Money Wasting Money Money Spent 3 Transcription cost

34. Copyright Primetime Medical Software 2007 May be reused if acknowledged Physician Nurse Patient Patient at Home 2 1 1 6 12 = $42 10 Comparison of EHR Data-Entry Workflows 2 1 1 12 = $37 4 Patients are a fast and free way to gather data. 2 1 1 3 12 = $29 4 2 = $9

35. Copyright Primetime Medical Software 2007 May be reused if acknowledged Who Else Could Enter the Subjective History? Hint: Who could do your work for free?

36. Copyright Primetime Medical Software 2007 May be reused if acknowledged Full Service is Expensive

37. Copyright Primetime Medical Software 2007 May be reused if acknowledged It’s Self-Service in 2007

38. Copyright Primetime Medical Software 2007 May be reused if acknowledged “It’s Stupid (for the doctor) to Take a Medical History” Weber, Joe, “Its stupid to take a medical history,” Advance for Health Information Professionals, Vol 73. May 10, 1999

39. Copyright Primetime Medical Software 2007 May be reused if acknowledged The Patient Has the Most Interest in Getting it Right

40. Copyright Primetime Medical Software 2007 May be reused if acknowledged The Patient Will Gladly Enter Data for You

41. Copyright Primetime Medical Software 2007 May be reused if acknowledged Most Patients Can Enter Data From home over the internet - 40% In the office before the Visit - 40% 20% - Must be helped by staff to enter data

42. Copyright Primetime Medical Software 2007 May be reused if acknowledged Exam Room Nurse Instruction

43. Copyright Primetime Medical Software 2007 May be reused if acknowledged Exam Room Patient Interview

44. Copyright Primetime Medical Software 2007 May be reused if acknowledged Clinical Exam What is it like at my office?

45. Copyright Primetime Medical Software 2007 May be reused if acknowledged Patient #1 Notice the Data Quality for Simple Complaint STEP #1 – Take and document the history

46. Copyright Primetime Medical Software 2007 May be reused if acknowledged Exam Room Clinical Interview

47. Copyright Primetime Medical Software 2007 May be reused if acknowledged

48. Copyright Primetime Medical Software 2007 May be reused if acknowledged

49. Copyright Primetime Medical Software 2007 May be reused if acknowledged Patient #2 Diagnoses that are often missed by physicians can be documented and billed at higher levels

50. Copyright Primetime Medical Software 2007 May be reused if acknowledged “Listen to the patient, he’ll tell you what is wrong.”

51. Copyright Primetime Medical Software 2007 May be reused if acknowledged Would charging a CPT code 96103 help your wallet? Would the quality of your care be better? Title: Zung Depression Scale Description: This 14-item scale for depression is a classic in self-rating scales. William Zung at Duke University published this early scale for patient use in 1965. Valued for its brevity, it remains a useful screening tool for depression. Patient Score: 63 - Moderate to Marked Scoring Key and Interpretation: 0 - 50 : Normal 51 - 60 : Minimal to Mild 61 - 69 : Moderate to Marked 70 - 999 : Severe to Extreme Reference: Zung, W.W.K.: A self-rating depression scale. Archives of General Psychiatry, 1965; 12:63-70.

52. Copyright Primetime Medical Software 2007 May be reused if acknowledged Who feels worse…you or the patient? You do Level 4 Work? You document at Level 2. You bill a Level 3 Then, you worry while you wait for: –Medicare Audit –Insurance reimbursement adjustment –“Bounty hunter” to find you –Medicare Fraud and Abuse charges to be filed (the average cost is $100,000+)

53. Copyright Primetime Medical Software 2007 May be reused if acknowledged Patient #3 Complex Patients with multiple medical problems are easy to treat and bill appropriately

54. Copyright Primetime Medical Software 2007 May be reused if acknowledged 4PM Friday Afternoon – “Doctor, I am weak, tired, dizzy and hurt all over” Recognize this

55. Copyright Primetime Medical Software 2007 May be reused if acknowledged Would this documentation help? Why not bill 96103 + 99215? Chief Complaint XXXXX is a 81 year old male. His chief complaint is "dizzy". History of Present Illness #1 "dizzy" Quality She reported: ambulation difficulty, trouble balancing, dizziness described as spinning around, very severe muscular autonomic symptoms, dyssomnia most of the time, lightheadedness, lightheadedness described as spinning around. He denied: dizziness precipitated by bending over, spinning vertigo, tetraparesis (partial). LocationHe denied: hemiparesis, facial paresis, truncal paresis. Severity He reported: mild weakness of arm, mild weakness of hand, mild weakness of leg. Duration He reported: dizziness 2 months to 1 year, lightheadedness 1 day to 7 days. Timing He reported: dizziness, walking difficulty started suddenly and worsened over days, intermittent difficulty walking. She denied: frequently recurring intermittent vertigo. Context She reported: afraid of falling in past year, fallen in past year, fallen 4 or more times in past year, dizziness in certain positions, dizziness with certain activities, vertigo does not occur only with sudden changes in position. //TWO PAGES NOT SHOWN OF DOCUMENTED POSITIVES// Title: Zung Depression Scale Description: This 14-item scale for depression is a classic in self-rating scales. William Zung at Duke University published this early scale for patient use in 1965. Valued for its brevity, it remains a useful screening tool for depression. Patient Score: 74 - Severe to Extreme Depression

56. Copyright Primetime Medical Software 2007 May be reused if acknowledged Documenting the History What is the best way? Only the provider can decide, but it must be completed when you begin the physical exam

57. Copyright Primetime Medical Software 2007 May be reused if acknowledged Documenting the Subjective

58. Copyright Primetime Medical Software 2007 May be reused if acknowledged Documenting the Physical Use of Macros After finishing your exam, document it while the patient dresses STEP #2 – Examine and document the Physical

59. Copyright Primetime Medical Software 2007 May be reused if acknowledged Documentation of Physical

60. Copyright Primetime Medical Software 2007 May be reused if acknowledged Discussing the Diagnosis, Writing the Prescription, and Plan Use the Mouse This part of the exam requires only a few mouse clicks and is not obtrusive. STEP #3 – Discuss and document simultaneously

61. Copyright Primetime Medical Software 2007 May be reused if acknowledged Most Valuable Time You Spend

62. Copyright Primetime Medical Software 2007 May be reused if acknowledged Writing the Prescription

63. Copyright Primetime Medical Software 2007 May be reused if acknowledged Completing the Visit Contrast your workflow. Are you ready to see the next patient or go home?

64. Copyright Primetime Medical Software 2007 May be reused if acknowledged Bachman’s Law Hand the patient a copy of the visit note as they leave the office. Corollary: If you can observe Bachman’s Law, then your EHR is functioning properly.

65. Copyright Primetime Medical Software 2007 May be reused if acknowledged Bachman’s Law

66. Copyright Primetime Medical Software 2007 May be reused if acknowledged The Happy Doctor

67. Copyright Primetime Medical Software 2007 May be reused if acknowledged MD Work Done 1.Prescriptions checked 2.Instructions complete 3.Patient education 4.Referrals done 5.Copy of visit note to the patient

68. Copyright Primetime Medical Software 2007 May be reused if acknowledged What can you do to prepare for the new EMR Workflow? 1.Educate yourself 2.Begin looking at ways to standardize processes 3.Explore new ways to enter data into your medical records 4.Leverage the internet for new practice styles and patient communication 5.Begin making your future

69. Copyright Primetime Medical Software 2007 May be reused if acknowledged 1. Educate yourself Electronic Health Records - Gartee

70. Copyright Primetime Medical Software 2007 May be reused if acknowledged 2. Standardize Your Process What are you doing? What could you do? How will your processes change?

71. Copyright Primetime Medical Software 2007 May be reused if acknowledged Cost of Telephone Medicine (Paper)

72. Copyright Primetime Medical Software 2007 May be reused if acknowledged How much do Med Refills cost?

73. Copyright Primetime Medical Software 2007 May be reused if acknowledged 3. Explore new data entry options Instant Medical History Dr.First Templates Macros Voice Recognition

74. Copyright Primetime Medical Software 2007 May be reused if acknowledged 4. Leverage Internet Practice of Medicine or Surgery Not every patient needs an office visit or surgery; All will pay you for your opinion using CPT Code 0074T

75. Copyright Primetime Medical Software 2007 May be reused if acknowledged If you can sue me, you can pay me. eVisits

76. Copyright Primetime Medical Software 2007 May be reused if acknowledged How do you want to Practice Medicine?

77. Copyright Primetime Medical Software 2007 May be reused if acknowledged 5. You don’t predict the future, you make it Make your future

78. Copyright Primetime Medical Software 2007 May be reused if acknowledged Adopt Technology 1.Study what you are doing the old way 2.Implement the technology but DO NOT do it the old way 3.Use technology to do it a new way –

79. Copyright Primetime Medical Software 2007 May be reused if acknowledged Allen Wenner, M.D. awenner@medicalhistory.com 803-600-5311