Every
workday, the typical cardiologist will be continually on the move,
going from his or her office to exam rooms, procedure rooms, to
the hospital and back, to outreach clinics, and catheterization
labs. At each stop, the cardiologist will gather, review, and disseminate
patient data. Flipping through reams of paper in flat files, the
cardiologist will search through handwritten notes on everything
from family history to vital signs, trying 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 patients,
many physicians are still in the Dark Ages when it comes to using
computer technology to help them manage the data they generate and
review each day. For all its innovations in medical technology,
health care is an anomaly. It is one of the nation’s last major
industries to rely heavily on paper records. Physician groups that
continue to limp along with outdated systems may be doomed to fail
in today’s unforgiving health care environment.
Moving
Forward
Nasser,
Smith and Pinkerton Cardiology (NSP), in Indianapolis, is one of
the nation’s largest cardiology practices with more than 70 physicians
and 400 authorized computer users in 28 locations. As physicians,
we were not interested in falling behind the information technology
curve when we began considering computerization issues in 1994.
As a leader in cardiology innovation, NSP, which is now part of
The Care Group, a large cardiology group in Indianapolis, understood
the importance of bringing the enterprise into the information age
through active health care management. The question for the physicians
was: Where should we start? The Care Group is an organization of
140 physicians and 800 authorized computer users in 36 locations
that resulted from the merger last year of NSP, Northside Cardiology,
and Store-Schmidt.
While
the marketplace offered many products touting the ability of 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 work flow. To computerize our
practice, we needed a single information system that would streamline
our system’s administration and provide clinical support by reducing
variance in practice and enhancing patient care. But we also wanted
the computer to simplify our registration, ordering, and patient
scheduling systems.
In
1995, we commissioned Gateway Electronic Medical Management Systems
(GEMMS), a company in Indianapolis that builds specialty-specific
information systems for physicians, to work with our physicians
to develop a state-of-the-art cardiology-specific integrated health
care information system.
“The
GEMMS approach is very consultative,” explains John Slack, MD, clinical
director of The Care Group. “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 the physician group wanted
to go beyond the basic electronic medical record and manage both
the care and costs during actual patient encounters. This process
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
offer access for multiple users, a documentation repository, and
transcription features. CPR systems duplicate EMR features, but
also offer users the ability to order patient tests, a limited patient
database, electronic data interchange, and standardized patient
protocols.
“We
are continually addressing the challenges associated with the business
of medicine,” Slack says. “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 these challenges is to organize and use existing
practice information. By doing so, a practice can manage the cost
of doing business.
Through an ECIS, cardiology practices can obtain all the features
of a CPR system and also:
• Track patient problem lists, medications, clinic visits, and vital
signs
• Access remote information
• Coordinate patient scheduling
• Document clinical encounters
• Evaluate work flow
• Write prescriptions and refills
• Integrate insurance coding (for ICD-9 and CPT-4), documentation,
and billing
• Create confidentiality and audit trails
• Analyze practice costs
• 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, CEO 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, and enhancing its ability to deliver
more effective health care services to patients.”
Patient
Interaction
The
physicians in the group believed that an ECIS application would
need to perform 80% 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,”
Slack explains. “Finally, we needed decision support services and
pathways, and a system that would integrate billing codes with the
proper documentation in a cohesive manner.”
To
meet the group’s needs, GEMMS developed a system using integrated
hardware and software that is designed for pen-based computing.
The system creates algorithms that physicians meeting with patients
can use and modify 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 send data between handheld computers and the main
data repository. The information is managed through easy-to-follow
“trees” that guide the user through the system.
Using
this type of information system, the physicians can integrate clinical,
management, and fiscal information into one database available to
the entire practice. With ECIS, the practice can capture the true
cost of providing patient care because the practice can identify
which procedures led to which outcome. It allows the physicians
to develop an integrated long-term and linear patient record, thus
allowing physicians to track each patient’s medical progress.
A Clinical
Emphasis
To
provide a practice with the clinical aspect of an ECIS, the system
must do more than store discrete clinical data drawn from medical
records. It also must enhance the practice of medicine by providing
decision support.
Since
physicians move frequently among exam rooms and other medical campus
buildings, any practice system must be highly mobile and nonintrusive,
Slack explains. “We understand the need for a state-of-the-art information
system,” he says. “The system could not physically or psychologically
interfere with the provider-patient relationship, however. GEMMS’
pen-based, wireless technology system allows us to move into the
information age without altering our practice patterns.”
The
pen-based ECIS automates the entire patient encounter, alleviating
the need for handheld clipboards, paper files, and separate data-entry
functions.
“There are many benefits associated with wireless technology,” Slack
says. “First and foremost, you don’t have the cost of running miles
of cable among an entire network of expensive PCs. It allows us
to use our handheld computers just as 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.”
Point
and Click Documentation
When
physicians begin a patient encounter using the ECIS, they 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. The physician can review any clinical information
collected in previous patient encounters and update the patient
record as needed. This system 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 short, problem-specific
list and the ability to search the entire ICD-9 table. With a simple
point and click, the physician can add a problem to the patient’s
problem list.
With
the ECIS, clinicians also can order patient tests. GEMMS installs
these tests into the tree-based system according to the practice’s
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 physician
or other provider can 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 on the
documentation’s complexity. The ECIS uses an evaluation and management
calculator to review the electronic document and recommend a service
level. The document is matched against guidelines from the federal
Health Care Financing Administration.
Once
a physician enters the level of service, he or she can place the
document in a chart section. The ECIS system provides a number of
discrete chart sections and the ability to customize a short list
of the most frequently used sections. 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’s prescription regimen during the visit. The
physician will sign the prescription, which may be printed for the
patient or sent electronically to the patient’s pharmacy.
Given
that many industries are moving quickly to use a wide variety of
computer technologies, it is only a matter of time before all physician
practices have electronic systems for managing the significant volume
of patient data we generate every day. Groups that adopt these technologies
now will go through a transition from paper-based records to handheld
computers that may be difficult for many physicians. But, as the
experience at the Care Group shows, the end result is well worth
the effort.
Copyright © 2000 Premier
Healthcare Resource, Inc. All Rights Reserved.
