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Moving A Cardiology Practice Into The Information Age

By James VanTassel, M.D., F.A.C.C.

182 office-based patients. 15 exam rooms. A 35-bed hospital-based cardiovascular care unit. 28 outreach clinics. One cath lab. And only 14 hours to work them all in.

Welcome to consult day.

Constantly on the move, cardiologists put in miles of "travel" each day as they move among exam rooms, procedure rooms, hospitals, outreach clinics and cath labs. At each stop, they gather, collect, review and disseminate patient data. Constantly flipping through reams of paper in flat files, searching handwritten hieroglyphics on everything from family history to vital signs, they try to piece together the entire puzzle of clinical data needed to evaluate a patient's progress.

Yet while they use state-of-the-art machines to diagnose and treat their patients, many physicians are still in the dark ages when it comes to utilizing computer technology.

For all its medical technology innovations, health care is an anomaly. It is one of the nation's last major industries to rely heavily on paper records. Let's be honest: A primary reason the medical industry's information "transformation" is moving at a snail's pace is because of the physicians themselves. Issues of denial, applicability, utilization, resistance and basic mistrust are concerns which lead many practices to live by the mantra of "if it ain't broke, don't fix it."

But while a practice's existing information system may not be broken, it can cause the group to be less competitive and productive. And that can spell doom in today's unforgiving health care environment.

Moving Forward, One Group's Journey to the Information Revolution

Nasser, Smith and Pinkerton Cardiology (NSP) is one of the nation's largest cardiology practices. With more than 140 physicians, 800 authorized computer users, 28 locations and a main office in Indianapolis housed in a steel reinforced concrete building, it poses an information systems logistical nightmare.

As physicians, we were not interested in falling behind the information technology curve when we began looking at computerization issues in 1997. "Denial" wasn't an issue in this instance. As a leader in cardiology innovation, NSP, which is now part of The Care Group, understoods the importance of bringing its enterprise into the information age through proactive health care management. But where to start?

While the marketplace offered many products touting the ability to provide our practice with an electronic medical record (EMR) or a computerized patient record (CPR) system, there were no cardiology-specific systems designed to enhance a cardiology practice's workflow.

To computerize our practice, we knew we needed a single information system that would streamline our system's administration; provide clinical support by reducing variances and enhancing patient care; as well as unify our registration, ordering and scheduling systems.

To accomplish these goals, we commissioned Gateway Electronic Medical Management Systems (GEMMS) in 1997 to work hand-in-hand with our physicians to develop a state-of-the-art cardiology-specific integrated health care information system.

Understanding Is The Key

"The GEMMS approach is very consultative and customized by nature," explains John Slack, M.D., clinical director of The Care Group. "There are no off-the-shelf products here. Instead, GEMMS spent time with us to determine our needs and specific information requirements. Then, they designed and installed the system to meet those unique needs."

Through its initial assessment, GEMMS learned NSP wanted to go beyond the basic electronic medical record and manage both its care and costs during the actual patient encounter. This led to the concept of a point-of-service electronic clinical information system (ECIS) that would be used seamlessly by everyone who interacts with patients.

ECIS technology goes beyond existing EMR and CPR systems. EMR systems -- the first level of electronic record keeping -- offer multiple user access, documentation repository and transcription replacement features. At the next level, CPR systems duplicate EMR features, but also offer users patient ordering capabilities, a limited patient database, electronic data interchange and standardized patient protocols.

"We are continually addressing the challenges associated with the business of medicine, says Slack. "We know we must seek to increase our operational efficiencies, lower our overhead and operating costs, cope with managed care issues, and provide superior services."

One solution for meeting and exceeding these challenges is to organize and utilize existing practice information. By doing so, a practice can report the cost of doing business, as well as manage the cost of doing business. Electronic clinical information systems can be the answer.

Through ECIS, cardiology practices can obtain all the features of a CPR system. Yet with ECIS, physicians and clinicians can also:

• Conduct longitudinal tracking of patient problem lists, medications, clinic visits and vital signs
• Access remote information
• Coordinate patient scheduling and messaging
• Document clinical encounters
• Evaluate workflow
• Order and write prescriptions and refills
• Integrate insurance coding (ICD-9 and CPT), as well as documentation and billing
• Create confidentiality and audit trails
• Analyze practice costs and create quality assurance measurements
• Access a full clinical database at the patient encounter level

"ECIS represents the new information age for cardiology clinical practice management," says Rodger P. Pinto, Ph.D., chief executive officer of GEMMS. "Through ECIS, cardiology practices can analyze diagnostic test results more efficiently, write prescriptions and refills faster, code insurance forms more accurately, and make faster decisions. It all adds up to saving time and money for a practice, as well as enhancing its ability to deliver more effective health care services to patients."

Practice Requirements as a Starting Point

At NSP, we felt a successful ECIS application would need to perform 80 percent of the tasks necessary for interacting with a patient. For our practice, the system would have to be capable of patient registration, scheduling, ordering, communication among professionals regarding a patient's chart, and patient flow monitoring. The system also needed to hold documents in repositories so they could be viewed, evaluated, stored and archived.

"We required an extensive demographic and encounter database that allowed for longitudinal evaluation of a patient's disease management process," explains Slack. "Finally, we needed decision support services and pathways, as well as a system that would integrate billing codes with the proper documentation in a cohesive manner. "

Pinto adds that "it became clear very early on that in order for this concept to become reality, physicians and providers would have to use the technology while they were seeing patients."

GEMMS answered with a hardware/software-integrated system designed for pen-based computing. This engine creates "decision trees" and action properties that allow for clinical workflow construction. This workflow can be used and modified for any clinical operation.

At the heart of GEMMS' ECIS is a point-of-service, wireless data collection and documentation system. The communication network uses radio frequency transmission to transmit data between handheld pen-top computers and the main data repository. The information is managed through easy-to-follow "trees" that guide the user through the system.

By utilizing this type of information system, clinical, management and fiscal information can be integrated into one virtual database available to the entire practice, regardless of its size. With ECIS, a practice can capture the true cost of doing medicine. It gives the practice the ability to create and manage a standard of care and identify which procedures led to which outcome. It allows for an integrated long-term and linear patient record, thus allowing physicians to more effectively track a patient's medical progress.

According to Slack: "Through these enhanced operational efficiencies, we can provide high-quality services to more patients with fewer resources and in less time. And it's possible simply because we have all the necessary information at our fingertips."

System Designed With Clinical Emphasis

To truly provide a practice with the "clinical" aspect of an electronic clinical information system, the system has to do more than provide electronic storage of discrete clinical data drawn from medical records. It must also enhance the practice of medicine by providing decision support.

"The GEMMS system is unique in many ways, but underlying its development is the fact that it was designed and implemented by clinicians. As clinicians, we understand the information challenges facing physicians and their practices. We used our clinical experience to create the system," says Pinto.

Because physicians are always on the move among exam rooms other medical campus buildings, any practice system must be highly mobile and non-intrusive.

"We understand the need for a state-of-the-art information system, " says Slack. "However, the system could not physically or psychologically interfere with the provider-patient relationship. GEMMS' pen-based, wireless technology system allows us to move into the information age, without altering our practice patterns."

The pen-based, electronic clinical information system developed by GEMMS utilizes emerging information technologies, including wireless radio frequency applications for sending and receiving data. The radio frequency technology provides the necessary flexibility, mobility and speed for data flow throughout the entire NSP enterprise. The software/hardware combination automates the entire patient encounter; alleviating the need for handheld clipboards, fat paper files and data entry functions.

"There are many benefits associated with wireless technology," says Slack. "First and foremost, you don't have the cost of running miles of cable between an entire network of expensive PC's. It allows us to utilize our pen-tops similar to how we carried paper files in the past. And, since the wireless technology provides us with real-time data entry, we can speed up the data recording and retrieval processes."

Cardiology Practice Computerization, Just Point and Click

When physicians begin a patient encounter using the GEMMS ECIS system, they simply click on the "Physician Tree" icon on the handheld computer and immediately see a current patient information summary collected by a medical assistant or nurse. This information could include the patient's chief complaint, an active problem list with appropriate ICD-9 coding, allergies, current medication and a list of all vital signs. The physician can review any clinical information collected in previous patient encounters and update the patient record as needed. This is the electronic equivalent of the transcription and dictation process.

Once the physician completes the encounter documentation, the patient's problem list can be updated. The system offers a problem specific short-list, with the ability to search the entire ICD-9 table. With a simple point-and-click, the physician adds this to the patient's problem list. Problems may be assigned a ranking of primary, concurrent, secondary or additional secondary diagnosis and they may also be assigned a status, which reflects the patient's progress in a historical fashion.

Through ECIS, clinicians can also order patient tests. GEMMS installs these tests into the tree-based system according to the practice's specific needs. By selecting the necessary study from the tree, users receive an order screen that allows them to choose an appropriate billable diagnosis. The ECIS system then routes these orders to the correct department within the practice. When placing the order, the provider also has the option to enter the test's charges, which are then automatically posted on the patient's billing ledger.

The physician may now determine and enter a service level based upon the documentation's complexity. Through ECIS, an E&M calculator automatically reviews the electronic document that has been created and recommends a service level. The document is matched against HCFA guidelines and if the physician accepts this level, he or she clicks on "OK" and the level automatically posts on the patient's ledger.

Once physicians perform the level of service entry, they place the document in a chart section. The ECIS system provides a number of discrete chart sections, with the ability to customize a short list of the most frequently used sections that allows for quicker chart posting. With the document placed in the repository, it can be signed with either a pen-based technology or electronic signature. Once signed, the document becomes encrypted and no further changes can be made.

Finally, the physician can generate patient prescriptions for all new medications added to the patient regimes during that visit. The physician will sign the prescription, which may be printed for the patient or sent electronically to the patient's pharmacy.

But the technology does have its flaws. The system, according to Slack, does have one major drawback: "Now the nurses know just how bad we spell!"

Story Side Bar:

Questions Which Should Be Addressed When Evaluating A Computerized Record System

1) In terms of security how does the computerized record system handle:

• Access control: (i.e, User Profile Script, Secured Password)
• Levels of security: (Operating system, Database, Front End Application)
• Physician signatures: Pen, Electronic (pin number)
• User auditing (Does the program allow you to audit users?)
• Documentation security (Can you alter signed documents?)

2) How does the system handle availability:

• Is the system designed to be available 24 hours a day, 7 days a week?
• Does the system work over an enterprise (Wide Area Network, Local Area Network, and Radio Frequency Network)?
• How does it handle remote access (i.e, from home, out of town, out of country) in a secured manner?

3) How does the system handle Clinical Work Flow Issues:

• Does the system's Medication Management module include updated drug selections, and who does it?
• How are prescriptions generated?
• Do you order tests, labs, procedures, etc. from the system?
• How does the system handle lab and diagnostic information?
• Does the system support alerts, reminders, and messages?
• Is the clinical encounter documentation generated by the system in compliance with federal regulations and guidelines?
• How are phone prescription refills and encounters documented in the system?
• Does patient scheduling occur in the system or is a work list generated from another scheduling system?
• Can you track patient flow through the practice (i.e., time it takes to get from the waiting room to the exam room, who is in the exam rooms, when do they check out etc.)?

4) Describe the retrieval database that the system generates:

• Does the system store discrete data elements for:
  • Patient demographics
  • Patient scheduling
  • Past medical history
  • Review of systems
  • History of present illness
  • Physical examination
  • Treatment Orders
  • Medication
  • Treatment plans
  • Treatment results
  • Diagnosis
  • CPT codes
• What data are obtained for a point in time only (snap shot outcome)?
• What data are obtained longitudinally?
• What type of indicators are followed (NCQA, JCAHO, ACC or others)?
• Is there a functional status tool used (Quality of Life Tool in the system, SF 36 etc.)?

5) Describe The Database

• Is it proprietary?
• Does it allow for off-the-shelf data mining tools (Access, SAS, SPSS, Crystal Reports etc.)?
• Is it relational?
• What platform does it require?

6) Electronic Data Interchange (EDI) capabilities:

• Does the system comply with known standards for interconnectivity (i.e., HL7, ASTM etc.)?
• Are there interfaces written for other types of systems (laboratory, practice management systems, etc.? If so, what are they?

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