Re: Information Technology in health care

[Guest guest]

Gordon: The work is always a work in progress. EMRs seek to perform steps of work, but often don't create a flow until a useer asks for a set of functions and the vendor responds. Each new version gets closer to optimal. I did not design each step of my work, because literally thousands of permutations exist, but I did pick an EMR that supported the main conponent. I still could spend most of my time on the process and flow, tweeking things closer to ideal, but I need to make a living and each provider often has a unique method of performing each task. My EMR has had two major revisions and each time major improvements in keystrokes and flow improved without my direct imput. I trust others have asked for these changes or the vendor has taken his own initiative. The next level of EMR "care" will be a major change in

the way doctors provide care to the patients. I really believe patients health can be driven by an emr designed around guidlines which can be individually modified by the provider and consented by the patient. This modified practice guidline and healthcare engine would drive future visitis, track down orders, refill medications, send patient reminderd and generate reports of compliance to guidelines and adherence by patients to a doctor suggested and patient selected plan for each persons health. Results from the assessment and plan from one visit will automatically populate the HPI of thew next visit with guidline interval focused options presented for physician and patient to select based on current findings at the visit. The plan would change incrementally from visit to visit without the need to retype or copy/paste the entire plan of care. From visitt to visit the history of care would be efficiently documented. I envision JNC VII with functionallity embeded in a patients plan of care with the patient and data moving along an electronic flow chart modifiable by physician and patient based on additional data and choice. For 1 million and spare time, I think it is the next reality in the EMR evelution. "L. Gordon " wrote: Hi folksMost IMPs bailed from typical practices and started

fresh with IT (Information Technology) from the start.I'm curious if anyone out there started by redesigning the work and then went in search of IT to support new work processes?Gordon

Stay in the know. Pulse on the new Yahoo.com. Check it out.

[Guest guest]

From Joanne in Drain Gordon, I had planned this system prior to going into medical school in 1995 at age 50. And, yes, I did look for the IT systems later. This what why I went back to school...I thought they were crazy to say there was no way to run a rural practice "in today's health care market.." And I thought I should put my money where my mouth was, so studied up for the MCAT and applied into med school, in order to find a needy rural area and open a medical practice based on what I had done as a veterinarian. "Come on," I thought, "if I can make a rural practice work in Whitehorse ,Yukon Territory, I can do that anywhere." I think I am in the minority, though. This practice is now making my income and its own overhead at one year out. Not enough to pay back my loan,

yet, but it clearly will; and later it will repay me for my investment. The best part is that I really can help people, and that I am completely a part of this community. This happened almost instantly when I opened (which is not usually the case in moving to an older rural area.) It would be impossible to be lonely here as an MD, unless you wanted to be. Everyone knows you, and everyone wants to help. Heck, there are volunteers all the time. Someone will come over and mow my lawn, and later I will find out I answered his aunt's question some Sunday, made her less worried and he wanted to do me a favor back. I have lots of fun; not like I saw at my residency or in my externships. There is really no reason that MDs should be miserable in their practice environment. The system can not work without us, and we should not cooperate in unpleasant

systems. Rather than keeping your head down, keep your overhead low. Joanne "L. Gordon " wrote: Hi folksMost IMPs bailed from typical practices and started fresh with IT (Information Technology) from the start.I'm curious if anyone out there started by redesigning the

work and then went in search of IT to support new work processes?Gordon

Get your email and more, right on the new Yahoo.com

[Guest guest]

Yes, I was bitten with the IHI bug in 2000-2002 (thanks to you also)

and decided to combine this thinking with information technology. I

was especially enamored of the Toyota production system, lean

thinking etc. and still am. My goal with my new small office

starting in 2002 (still a part of a larger hospital system) was to

establish continuous flow of information to the point of care as well

as have all of the examination rooms standardized and have all the

information available within the examination room (which of course is

a necessary thing if you only have one exam room-we have four). We

have 1.5 physicians and accomplish seeing 15-20 patients per day each

with three FTE.

My belief is that using the conceptual tools, almost all electronic

health record that are decent can accomplish this goal. The issue is

not so much the electronic health record as the connectivity to

outside resources and interoperability. Additionally, if you have

any staff they need to have at some point a gut level understanding

of what you're trying to accomplish. (I went through a number of

staff to get at the good ones!)

I would also invite anyone on this list serv to check out the new

health information technology continuing medical education that is

being posted on the Center for health information technology website-

www.centerforhit.org click on the CME link.

The first module is about hardware and network basics and is already

on the site and the second module about workflow should be posted on

Monday. You do not have to be a member of the Academy of family

physicians to access the information but you do have to be a member

to obtain CME. Any comments/criticism about the CME would be welcome

as I have high regard for the members of this listserv.

Regards,

Lou Spikol

Louis Spikol M.D.

Senior Healthcare Information Technology Consultant

Center for Health Information Technology

American Academy of Family Physicians

lspikol@...

lspikol@...

mobile:

>

> Hi folks

> Most IMPs bailed from typical practices and started fresh with IT

> (Information Technology) from the start.

>

> I'm curious if anyone out there started by redesigning the work and

> then went in search of IT to support new work processes?

> Gordon

>

[Guest guest]

Lou,

Your message just jogged my memory. Didn’t

you want some people to video (digitally) their office in action, using IT? I

think I dropped the ball on it, but am willing to give it a try (assuming I’m

not mixing you up with someone else, and it’s not too late)

A. Eads, M.D.

Pinnacle Family Medicine, PLLC

phone fax

P.O.

Box 7275

Woodland

Park, CO 80863

From:

[mailto: ] On

Behalf Of l_spikol

Sent: Friday, August 18, 2006 6:56

PM

To:

Subject:

Re: Information Technology in health care

Yes, I was bitten with the IHI bug in 2000-2002

(thanks to you also)

and decided to combine this thinking with information technology. I

was especially enamored of the Toyota

production system, lean

thinking etc. and still am. My goal with my new small office

starting in 2002 (still a part of a larger hospital system) was to

establish continuous flow of information to the point of care as well

as have all of the examination rooms standardized and have all the

information available within the examination room (which of course is

a necessary thing if you only have one exam room-we have four). We

have 1.5 physicians and accomplish seeing 15-20 patients per day each

with three FTE.

My belief is that using the conceptual tools, almost all electronic

health record that are decent can accomplish this goal. The issue is

not so much the electronic health record as the connectivity to

outside resources and interoperability. Additionally, if you have

any staff they need to have at some point a gut level understanding

of what you're trying to accomplish. (I went through a number of

staff to get at the good ones!)

I would also invite anyone on this list serv to check out the new

health information technology continuing medical education that is

being posted on the Center for health information technology website-

www.centerforhit.org click on the CME link.

The first module is about hardware and network basics and is already

on the site and the second module about workflow should be posted on

Monday. You do not have to be a member of the Academy of family

physicians to access the information but you do have to be a member

to obtain CME. Any comments/criticism about the CME would be welcome

as I have high regard for the members of this listserv.

Regards,

Lou Spikol

Louis Spikol M.D.

Senior Healthcare Information Technology Consultant

Center for Health Information Technology

American Academy of Family Physicians

lspikolptd (DOT) net

lspikolaafp (DOT) org

mobile:

>

> Hi folks

> Most IMPs bailed from typical practices and started fresh with IT

> (Information Technology) from the start.

>

> I'm curious if anyone out there started by redesigning the work and

> then went in search of IT to support new work processes?

> Gordon

>

[Guest guest]

, yes I am presenting a talk at the annual Academy meeting in

Washington, DC entitled Health Information Technology-Real Doctors in

Real Time. I would be very interested in you or anyone else

interested in this group getting a few minutes of video as to how you

use health information technology to make it possible to run an

efficient, personal, reliable family medicine office. I would leave

the exact content of the video completely up to you. (Although I can

get some guidance). I would need the video in a DV format-that is

you would send me a DV tape. I would certainly reimburse you for

it. If you do not have a digital video camcorder I would even be

willing to send you one (you do need to send it back of course!).

Lou Spikol

> >

> > Hi folks

> > Most IMPs bailed from typical practices and started fresh with IT

> > (Information Technology) from the start.

> >

> > I'm curious if anyone out there started by redesigning the work

and

> > then went in search of IT to support new work processes?

> > Gordon

> >

>

[Guest guest]

Gordon

I wanted to get my sources correct.

Yes, i did do it this way.

From 1999-2002 I studied Medical Informatics part-time at UC while in full-time practice in Willows, CA.

the hospital based clinic I worked at was a wonder of waste, inefficiency and redundancy in all processes.

At TEPR 2002 in Seattle I heard Hultman DPM, MBA speak and he nailed all the points I was thinking of:

The Principles of Reengineering

Operations and Automation Together

Capture data one time, when it is first created

Work in parallel, then integrate results

Focus on results, not tasks

Locate equipment where it makes sense

Deliver information, training, authority

Focus on bottlenecks, variation and waste

I took his suggestion and read and re-read The Goal by E. Goldhatt

and I set out to find an EMR that would allow an improved workflow.

I settled on Alteer Office and opened my office in Gig Harbor in April 2003.

I continue to work at speeding and smoothing the workflow: specifically,

i still take too long to document a visit using the Alteer EMR.

In other ways Alteer is great: billing, internal communications, recalls, faxing, pharmacy fax backs and messaging.

But I welcome any suggestions to streamline documentation of encounters.

I still do too much free typing - yes I have reworked my encounters but they must be general to fit various patients yet I want to include specifics for each patient.

Anyone willing to share some of their Alteer encounter templates?

thanks

Dennis Galvon

Information Technology in health care

Hi folksMost IMPs bailed from typical practices and started fresh with IT (Information Technology) from the start.I'm curious if anyone out there started by redesigning the work and then went in search of IT to support new work processes?Gordon

[Guest guest]

I too have some bottlenecks in the Alteer medical record. My way

around that is run Asutype since I do not do well with the

templates. They only work for me on routine physicals and pap

smear.

Asutype works kind of like soapware , you can type just a small

amount of text and it will type a lot.

For example.

Procedure: the affected toe was scrubbed with Betadine. The toe was

then infiltrated with 1 percent plain lidocaine in a digital block

pattern. After adequate anesthesia, the nail was split and rolled

out of the nail sulcus all the way to the base. The excess tissue

was removed. The toe was covered with antibiotic ointment, non

stick gauze and light pressure applied with coban.

Instructions: they are to soak the toe 2-3 times a day in warm soapy

water and pat dr

Notify doctor of increasing pain, fever, bleeding, pus, redness or

any problems

Note: nail care reviewed.

took me 1 second to type.

problem list and chart updated,see face sheet for complete list, it

may not be reflected in the note

sooner if worsens

medication list updated

Usual coarse for dx discussed, if changes or symptoms suggestive of

something else is to return or if seems out of the ordinary.

Took 2 seconds to type

risks and benefits discussed

prescription provided

Took one second.

The patient is in no acute distress, speaking clearly, cooperative,

friendly

HEAD: atraumatic, normocephalic

EYES: sclera white, extraocular movements intact

EARS: tympanic membranes without lesions, canal patent

CV: regular rate, rhythm, no rub, no ectopy

LUNGS: clear to auscultation, equal breath sounds bilaterally

ABD: soft, benign, non tender

EXT: no clubbing, cyanosis or edema

Took one second

Brent

>

> Gordon

>

> I wanted to get my sources correct.

> Yes, i did do it this way.

> From 1999-2002 I studied Medical Informatics part-time at UC

while in

> full-time practice in Willows, CA.

> the hospital based clinic I worked at was a wonder of waste,

inefficiency

> and redundancy in all processes.

>

> At TEPR 2002 in Seattle I heard Hultman DPM, MBA speak and he

nailed

> all the points I was thinking of:

> The Principles of Reengineering

>

> Operations and Automation Together

>

> Capture data one time, when it is first created

>

> Work in parallel, then integrate results

>

> Focus on results, not tasks

>

> Locate equipment where it makes sense

>

> Deliver information, training, authority

>

> Focus on bottlenecks, variation and waste

>

> I took his suggestion and read and re-read The Goal by E. Goldhatt

>

> and I set out to find an EMR that would allow an improved workflow.

> I settled on Alteer Office and opened my office in Gig Harbor in

April 2003.

> I continue to work at speeding and smoothing the workflow:

specifically,

> i still take too long to document a visit using the Alteer EMR.

> In other ways Alteer is great: billing, internal communications,

recalls,

> faxing, pharmacy fax backs and messaging.

> But I welcome any suggestions to streamline documentation of

encounters.

>

> I still do too much free typing - yes I have reworked my

encounters but

> they must be general to fit various patients yet I want to include

specifics

> for each patient.

> Anyone willing to share some of their Alteer encounter templates?

>

> thanks

> Dennis Galvon

>

>

> Information Technology in health

care

>

>

> Hi folks

> Most IMPs bailed from typical practices and started fresh with IT

> (Information Technology) from the start.

>

> I'm curious if anyone out there started by redesigning the work

and

> then went in search of IT to support new work processes?

> Gordon

>

[Guest guest]

In addition to a lot of templates in my emr i use voice recognition. It's hard to get all of the subjective in a template. In my voice recognition I have a lot of macros. If I say "normal ent exam" the entire ent exam pops up. I do the same for a normal gyne exam. This speeds up my dictations. I use about 1/2 templates and 1/2 voice recognition.Larry LindemanI too have some bottlenecks in the Alteer medical record. My way around that is run Asutype since I do not do well with the templates. They only work for me on routine physicals and pap smear. Asutype works kind of like soapware , you can type just a small amount of text and it will type a lot. For example. Procedure: the affected toe was scrubbed with Betadine. The toe was then infiltrated with 1 percent plain lidocaine in a digital block pattern. After adequate anesthesia, the nail was split and rolled out of the nail sulcus all the way to the base. The excess tissue was removed. The toe was covered with antibiotic ointment, non stick gauze and light pressure applied with coban. Instructions: they are to soak the toe 2-3 times a day in warm soapy water and pat drNotify doctor of increasing pain, fever, bleeding, pus, redness or any problemsNote: nail care reviewed.took me 1 second to type. problem list and chart updated,see face sheet for complete list, it may not be reflected in the note sooner if worsens medication list updated Usual coarse for dx discussed, if changes or symptoms suggestive of something else is to return or if seems out of the ordinary. Took 2 seconds to typerisks and benefits discussed prescription provided Took one second. The patient is in no acute distress, speaking clearly, cooperative, friendlyHEAD: atraumatic, normocephalicEYES: sclera white, extraocular movements intactEARS: tympanic membranes without lesions, canal patentCV: regular rate, rhythm, no rub, no ectopyLUNGS: clear to auscultation, equal breath sounds bilaterallyABD: soft, benign, non tenderEXT: no clubbing, cyanosis or edema Took one secondBrent>> Gordon> > I wanted to get my sources correct.> Yes, i did do it this way.> From 1999-2002 I studied Medical Informatics part-time at UC while in> full-time practice in Willows, CA.> the hospital based clinic I worked at was a wonder of waste, inefficiency> and redundancy in all processes.> > At TEPR 2002 in Seattle I heard Hultman DPM, MBA speak and he nailed> all the points I was thinking of:> The Principles of Reengineering> > Operations and Automation Together> > Capture data one time, when it is first created> > Work in parallel, then integrate results> > Focus on results, not tasks> > Locate equipment where it makes sense> > Deliver information, training, authority> > Focus on bottlenecks, variation and waste> > I took his suggestion and read and re-read The Goal by E. Goldhatt> > and I set out to find an EMR that would allow an improved workflow.> I settled on Alteer Office and opened my office in Gig Harbor in April 2003.> I continue to work at speeding and smoothing the workflow: specifically,> i still take too long to document a visit using the Alteer EMR.> In other ways Alteer is great: billing, internal communications, recalls,> faxing, pharmacy fax backs and messaging.> But I welcome any suggestions to streamline documentation of encounters.> > I still do too much free typing - yes I have reworked my encounters but> they must be general to fit various patients yet I want to include specifics> for each patient.> Anyone willing to share some of their Alteer encounter templates?> > thanks> Dennis Galvon> > > Information Technology in health care> > > Hi folks> Most IMPs bailed from typical practices and started fresh with IT> (Information Technology) from the start.> > I'm curious if anyone out there started by redesigning the work and> then went in search of IT to support new work processes?> Gordon>

[Guest guest]

I

agree. I use Alteer & a combination of a generic template & voice

recognition. I do not see how the HPI/narrative can be accurately templated

by an EMR. In the end, there is no good equivalent to a free text

narrative in the physician’s own words (medico-legally especially). A

template based HPI may print out nice & clean & “look nice”

but really says nothing of substance medico-legally. Also, I do not use

macros/commands for something like a “normal ENT exam.”

Rather, my template has a normal physical exam & I quickly cut out or add

text as needed.

Information Technology in health

care

>

>

> Hi folks

> Most IMPs bailed from typical practices and

started fresh with IT

> (Information Technology) from the start.

>

> I'm curious i! f anyone out there started by

redesigning the work

and

> then went in search of IT to support new work

processes?

> Gordon

>

[Guest guest]

I

agree. I use Alteer & a combination of a generic template & voice

recognition. I do not see how the HPI/narrative can be accurately templated

by an EMR. In the end, there is no good equivalent to a free text

narrative in the physician’s own words (medico-legally especially). A

template based HPI may print out nice & clean & “look nice”

but really says nothing of substance medico-legally. Also, I do not use

macros/commands for something like a “normal ENT exam.”

Rather, my template has a normal physical exam & I quickly cut out or add

text as needed.

Information Technology in health

care

>

>

> Hi folks

> Most IMPs bailed from typical practices and

started fresh with IT

> (Information Technology) from the start.

>

> I'm curious i! f anyone out there started by

redesigning the work

and

> then went in search of IT to support new work

processes?

> Gordon

>

[Guest guest]

I am having the same problem with accurate charting. What can I use for voice recognition ? I have a digital recorder. Do you use anything like that ?I agree.  I use Alteer & a combination of a generic template & voice recognition.  I do not see how the HPI/narrative can be accurately templated by an EMR.  In the end, there is no good equivalent to a free text narrative in the physician’s own words (medico-legally especially).  A template based HPI may print out nice & clean & “look nice” but really says nothing of substance medico-legally. Also,  I do not use macros/commands for something like a “normal ENT exam.”  Rather, my template has a normal physical exam & I quickly cut out or add text as needed.   Information Technology in health care> > > Hi folks> Most IMPs bailed from typical practices and started fresh with IT> (Information Technology) from the start.> > I'm curious i! f anyone out there started by redesigning the work and> then went in search of IT to support new work processes?> Gordon> 

[Guest guest]

I use

Dragon Naturally Speaking version 8 (medical). I know you can use a digital

recorder with Dragon though I do not. I use an aftermarket Sennheiser

microphone & try my best to complete the notes between & after

patients. I just do not like being distracted with charting in the room with a

patient (I scribble brief notes, vitals etc during the actual face to face

encounter).

Information Technology in health

care

>

>

> Hi folks

> Most IMPs bailed from typical practices and

started fresh with IT

> (Information Technology) from the start.

>

> I'm curious i! f anyone out there started by

redesigning the work

and

> then went in search of IT to support new work

processes?

> Gordon

>

[Guest guest]

I use

Dragon Naturally Speaking version 8 (medical). I know you can use a digital

recorder with Dragon though I do not. I use an aftermarket Sennheiser

microphone & try my best to complete the notes between & after

patients. I just do not like being distracted with charting in the room with a

patient (I scribble brief notes, vitals etc during the actual face to face

encounter).

Information Technology in health

care

>

>

> Hi folks

> Most IMPs bailed from typical practices and

started fresh with IT

> (Information Technology) from the start.

>

> I'm curious i! f anyone out there started by

redesigning the work

and

> then went in search of IT to support new work

processes?

> Gordon

>

[Guest guest]

Thank you, I will try to find it.I use Dragon Naturally Speaking version 8 (medical).  I know you can use a digital recorder with Dragon though I do not.  I use an aftermarket Sennheiser microphone & try my best to complete the notes between & after patients.  I just do not like being distracted with charting in the room with a patient (I scribble brief notes, vitals etc during the actual face to face encounter).   Information Technology in health care> > > Hi folks> Most IMPs bailed from typical practices and started fresh with IT> (Information Technology) from the start.> > I'm curious i! f anyone out there started by redesigning the work and> then went in search of IT to support new work processes?> Gordon>    

[Guest guest]

Thank you, I will try to find it.I use Dragon Naturally Speaking version 8 (medical).  I know you can use a digital recorder with Dragon though I do not.  I use an aftermarket Sennheiser microphone & try my best to complete the notes between & after patients.  I just do not like being distracted with charting in the room with a patient (I scribble brief notes, vitals etc during the actual face to face encounter).   Information Technology in health care> > > Hi folks> Most IMPs bailed from typical practices and started fresh with IT> (Information Technology) from the start.> > I'm curious i! f anyone out there started by redesigning the work and> then went in search of IT to support new work processes?> Gordon>    

[Guest guest]

I use viavoice medical but I don't think that they sell the medical vocabulary any more. I would recommend Dragon with the medical vocabulary. I tried initially to be cheap and teach the program every medical term but it was taking forever. When I bought the medical vocabulary it was much easier. LarryI use Dragon Naturally Speaking version 8 (medical).  I know you can use a digital recorder with Dragon though I do not.  I use an aftermarket Sennheiser microphone & try my best to complete the notes between & after patients.  I just do not like being distracted with charting in the room with a patient (I scribble brief notes, vitals etc during the actual face to face encounter).   Information Technology in health care> > > Hi folks> Most IMPs bailed from typical practices and started fresh with IT> (Information Technology) from the start.> > I'm curious i! f anyone out there started by redesigning the work and> then went in search of IT to support new work processes?> Gordon>    

[Guest guest]

Dennis, I too have been working in Alteer since April 2003! Like most office management systems, it seems more dedicated to the business side than the clinical side, but I have been able to create workarounds that are satisfactory. The medicine list needs an archiving function, I believe. And the problem list needs to be sortable for faxing and printing (when sending info to consultants), not just on-screen. Anyway . . . I have the same problem with taking too much time for documentation. I do as much of it as possible in the room with the patient or right after the visit. I have a laptop on a cart that I can position so as not to create a barrier. But still I am way behind on completing visits so I can bill them. Being in Family Medicine, and seeing a wide variety of patient ages and problems, I ended up not using any of the Alteer templates, which I regard as much too

wordy and not clinically sound and efficient. I have two templates in Word, one for ordinary visits, and one (actually two - one for each gender) for complete exams. I developed the complete exam templates in the olden days when I was dictating and my paper matched the template in the dictation tank. I have the complete exam templates printed out for visits so I can make quick handwritten notes while I am with the patient - sometimes that is needed rather than industriously typing while interacting. I'll attach them here - these may not be my most up-to-date version but close enough. I document a lot by exception, putting a comma after the boilerplate and typing in what is different. Other times I delete and add as appropriate for the specific visit. The templates help me quickly determine the CPT code also. I'm sending this to you

direct, as well as here, because attachments don't always come through in this system. If anyone else wants an attachment and can't get to it, email me direct. Do you have any templates to share? Terry Merrifield, Andover KS

[Guest guest]

Dennis, I too have been working in Alteer since April 2003! Like most office management systems, it seems more dedicated to the business side than the clinical side, but I have been able to create workarounds that are satisfactory. The medicine list needs an archiving function, I believe. And the problem list needs to be sortable for faxing and printing (when sending info to consultants), not just on-screen. Anyway . . . I have the same problem with taking too much time for documentation. I do as much of it as possible in the room with the patient or right after the visit. I have a laptop on a cart that I can position so as not to create a barrier. But still I am way behind on completing visits so I can bill them. Being in Family Medicine, and seeing a wide variety of patient ages and problems, I ended up not using any of the Alteer templates, which I regard as much too

wordy and not clinically sound and efficient. I have two templates in Word, one for ordinary visits, and one (actually two - one for each gender) for complete exams. I developed the complete exam templates in the olden days when I was dictating and my paper matched the template in the dictation tank. I have the complete exam templates printed out for visits so I can make quick handwritten notes while I am with the patient - sometimes that is needed rather than industriously typing while interacting. I'll attach them here - these may not be my most up-to-date version but close enough. I document a lot by exception, putting a comma after the boilerplate and typing in what is different. Other times I delete and add as appropriate for the specific visit. The templates help me quickly determine the CPT code also. I'm sending this to you

direct, as well as here, because attachments don't always come through in this system. If anyone else wants an attachment and can't get to it, email me direct. Do you have any templates to share? Terry Merrifield, Andover KS

[Guest guest]

Yes I

agree that Alteer is much better at the business side than the clinical

documentation side. I have mentioned it here several times but few seemed

to agree with me. Glad to hear that I’m not the only one that

thinks the charting in Alteer is cumbersome. I use my own template,

usually the same for all visits except peds well checks. Occasionally I

will just free text the whole note if it sounds like a brief 99213 or 99213.

Your templates look similar to mine, except I would recommend creating a

separate section that lists out pertinent ROS rather than saying “as

above”. I know these are included in your HPI & referenced, but

by not distinctly separating them an auditor could still say those were

actually “modifying factors” when counting the HPI bullets &

not count them towards your ROS part. I assume you just free text the HPI

section? I can attach my generic template. I cut & type the

pertinent positives/negatives in the ROS & PE sections. I use the

discussion section in Alteer rather than have an A/P section in my

template. Do you not use that part of Alteer?

Re: Information Technology in health care

Dennis, I too have been working in Alteer since April

2003! Like most office management systems, it seems more dedicated to the

business side than the clinical side, but I have been able to create

workarounds that are satisfactory. The medicine list needs an archiving

function, I believe. And the problem list needs to be sortable for faxing

and printing (when sending info to consultants), not just on-screen.

Anyway . . . I have the same problem with taking too

much time for documentation. I do as much of it as possible in the room

with the patient or right after the visit. I have a laptop on a cart that

I can position so as not to create a barrier. But still I am way behind

on completing visits so I can bill them.

Being in Family Medicine, and seeing a wide variety of

patient ages and problems, I ended up not using any of the Alteer templates,

which I re! gard as much too wordy and not clinically sound and

efficient.

I have two templates in Word, one for ordinary visits,

and one (actually two - one for each gender) for complete exams. I

developed the complete exam templates in the olden days when I was

dictating and my paper matched the template in the dictation tank. I have

the complete exam templates printed out for visits so I can make quick

handwritten notes while I am with the patient - sometimes that is needed

rather than industriously typing while interacting. I'll attach them here

- these may not be my most up-to-date version but close enough. I

document a lot by exception, putting a comma after the boilerplate

and typing in what is different. Other times I delete and add as

appropriate for the specific visit. The templates help me quickly

determine the CPT code also.

I'm sending this to you direct, as well as here, because

attachments don't always come through in this system. If anyone else

wants an attachment and can't get to it, email me direct.

Do you have any templates to share?

Terry Merrifield, Andover KS

[Guest guest]

Yes I

agree that Alteer is much better at the business side than the clinical

documentation side. I have mentioned it here several times but few seemed

to agree with me. Glad to hear that I’m not the only one that

thinks the charting in Alteer is cumbersome. I use my own template,

usually the same for all visits except peds well checks. Occasionally I

will just free text the whole note if it sounds like a brief 99213 or 99213.

Your templates look similar to mine, except I would recommend creating a

separate section that lists out pertinent ROS rather than saying “as

above”. I know these are included in your HPI & referenced, but

by not distinctly separating them an auditor could still say those were

actually “modifying factors” when counting the HPI bullets &

not count them towards your ROS part. I assume you just free text the HPI

section? I can attach my generic template. I cut & type the

pertinent positives/negatives in the ROS & PE sections. I use the

discussion section in Alteer rather than have an A/P section in my

template. Do you not use that part of Alteer?

Re: Information Technology in health care

Dennis, I too have been working in Alteer since April

2003! Like most office management systems, it seems more dedicated to the

business side than the clinical side, but I have been able to create

workarounds that are satisfactory. The medicine list needs an archiving

function, I believe. And the problem list needs to be sortable for faxing

and printing (when sending info to consultants), not just on-screen.

Anyway . . . I have the same problem with taking too

much time for documentation. I do as much of it as possible in the room

with the patient or right after the visit. I have a laptop on a cart that

I can position so as not to create a barrier. But still I am way behind

on completing visits so I can bill them.

Being in Family Medicine, and seeing a wide variety of

patient ages and problems, I ended up not using any of the Alteer templates,

which I re! gard as much too wordy and not clinically sound and

efficient.

I have two templates in Word, one for ordinary visits,

and one (actually two - one for each gender) for complete exams. I

developed the complete exam templates in the olden days when I was

dictating and my paper matched the template in the dictation tank. I have

the complete exam templates printed out for visits so I can make quick

handwritten notes while I am with the patient - sometimes that is needed

rather than industriously typing while interacting. I'll attach them here

- these may not be my most up-to-date version but close enough. I

document a lot by exception, putting a comma after the boilerplate

and typing in what is different. Other times I delete and add as

appropriate for the specific visit. The templates help me quickly

determine the CPT code also.

I'm sending this to you direct, as well as here, because

attachments don't always come through in this system. If anyone else

wants an attachment and can't get to it, email me direct.

Do you have any templates to share?

Terry Merrifield, Andover KS

[Guest guest]

Terry,

My husband Rian has had Alteer since July of 03 and I am his office manager.

It's great, as you say, for the business end of the practice. I also do all our billing and it is easy. However, Rian, as others, is really frustrated with the EMR portion - he falls terribly behind on documentation (he tends to write very detailed notes) - he doesn't like the templates so he uses a combination of free typing and an older version of Dragon (medical). Because I need to know the charges, he codes and does that portion after reviewing his hand-written notes so I can get the claims out but his unfinished charts "stack up", so to speak.

First thing we'll do is upgrade to the Dragon 8 version. However, we are both hopelessly ignorant when it comes to using Word templates and the technical end of EMRs, etc. After you use your own Word template, are you printing it out from Word and scanning it into the chart or can you open a Word template right inside of an Alteer encounter note?

Thanks so much for the attachments.

a Mintek

office manager

Allegan, MI

PS If anyone has Alteer billing questions, I think I finally fully understand the system and I'd be glad to help someone else

Re: Information Technology in health care

Dennis, I too have been working in Alteer since April 2003! Like most office management systems, it seems more dedicated to the business side than the clinical side, but I have been able to create workarounds that are satisfactory. The medicine list needs an archiving function, I believe. And the problem list needs to be sortable for faxing and printing (when sending info to consultants), not just on-screen.

Anyway . . . I have the same problem with taking too much time for documentation. I do as much of it as possible in the room with the patient or right after the visit. I have a laptop on a cart that I can position so as not to create a barrier. But still I am way behind on completing visits so I can bill them.

Being in Family Medicine, and seeing a wide variety of patient ages and problems, I ended up not using any of the Alteer templates, which I re! gard as much too wordy and not clinically sound and efficient.

I have two templates in Word, one for ordinary visits, and one (actually two - one for each gender) for complete exams. I developed the complete exam templates in the olden days when I was dictating and my paper matched the template in the dictation tank. I have the complete exam templates printed out for visits so I can make quick handwritten notes while I am with the patient - sometimes that is needed rather than industriously typing while interacting. I'll attach them here - these may not be my most up-to-date version but close enough. I document a lot by exception, putting a comma after the boilerplate and typing in what is different. Other times I delete and add as appropriate for the specific visit. The templates help me quickly determine the CPT code also.

I'm sending this to you direct, as well as here, because attachments don't always come through in this system. If anyone else wants an attachment and can't get to it, email me direct.

Do you have any templates to share?

Terry Merrifield, Andover KS

No virus found in this incoming message.Checked by AVG Free Edition.Version: 7.1.405 / Virus Database: 268.11.7/434 - Release Date: 08/30/2006

[Guest guest]

You can “import”

the word template into the “alteer office” file so it can be opened

right in Alteer, but I think it has to be converted into RTF (rich text format)

to work. I think it is explained in the Alteer manual, but my wife helped

me do it. I don’t recall it being very hard to do. I now type

in “HPI” into the template box on Alteer & it opens up (My

template I created & use is saved as “HPI”). When you say

his charts are stacking up, how long do you mean? I have a few to do at

day’s end (usually 2 -8) but almost never let myself leave without

finishing them. I HATE taking work home. Dragon has helped me

immensely. I chart a lot of details too (especially discussion section:

for example, “discussed role of screening colonoscopy in the early

detection of colon CA, talked about polyps, etc & alternative means of

screening & their limitations. Patient has decided to . . . ).

To me, it is not enough to just say: “patient refuses colonoscopy”.

Re:

Re: Information Technology in health care

Terry,

My husband Rian has had Alteer since July of 03 and I

am his office manager.

It's great, as you say, for the business end of the

practice. I also do all our billing and it is easy. However, Rian, as

others, is really frustrated with the EMR portion - he falls terribly

behind on documentation (he tends to write very detailed notes) - he doesn't

like the templates so he uses a combination of free typing and an older version

of Dragon (medical). Because I need to know the charges, he codes and does

that portion after reviewing his hand-written notes so I can get the claims out

but his unfinished charts " stack up " , so to speak.

First thing we'll do is upgrade to the Dragon 8

version. However, we are both hopelessly ignorant when it comes to using Word

templates and the technical end of EMRs, etc. After you use your own Word

template, are you printing it out from Word and scanning it into the chart or

can you open a Word template right inside of an Alteer encounter note?

Thanks so much for the attachments.

a Mintek

office manager

Allegan, MI

PS If anyone has Alteer billing

questions, I think I finally fully understand the system and I'd be glad to

help someone else

Re: Information Technology in health care

Dennis, I too have been working in Alteer since April

2003! Like most office management systems, it seems more dedicated to the

business side than the clinical side, but I have been able to create

workarounds that are satisfactory. The medicine list needs an archiving

function, I believe. And the problem list needs to be sortable for faxing

and printing (when sending info to consultants), not just on-screen.

Anyway . . . I have the same problem with taking too

much time for documentation. I do as much of it as possible in the room

with the patient or right after the visit. I have a laptop on a cart that

I can position so as not to create a barrier. But still I am way behind

on completing visits so I can bill them.

Being in Family Medicine, and seeing a wide variety of

patient ages and problems, I ended up not using any of the Alteer templates,

which I re! gard as much too wordy and not clinically sound and

efficient.

I have two templates in Word, one for ordinary visits,

and one (actually two - one for each gender) for complete exams. I

developed the complete exam templates in the olden days when I was

dictating and my paper matched the template in the dictation tank. I have

the complete exam templates printed out for visits so I can make quick

handwritten notes while I am with the patient - sometimes that is needed

rather than industriously typing while interacting. I'll attach them here

- these may not be my most up-to-date version but close enough. I

document a lot by exception, putting a comma after the boilerplate

and typing in what is different. Other times I delete and add as

appropriate for the specific visit. The templates help me quickly

determine the CPT code also.

I'm sending this to you direct, as well as here,

because attachments don't always come through in this system. If anyone

else wants an attachment and can't get to it, email me direct.

Do you have any templates to share?

Terry Merrifield, Andover KS

No virus found in this incoming message.

Checked by AVG Free Edition.

Version: 7.1.405 / Virus Database: 268.11.7/434 - Release Date: 08/30/2006

[Guest guest]

You can “import”

the word template into the “alteer office” file so it can be opened

right in Alteer, but I think it has to be converted into RTF (rich text format)

to work. I think it is explained in the Alteer manual, but my wife helped

me do it. I don’t recall it being very hard to do. I now type

in “HPI” into the template box on Alteer & it opens up (My

template I created & use is saved as “HPI”). When you say

his charts are stacking up, how long do you mean? I have a few to do at

day’s end (usually 2 -8) but almost never let myself leave without

finishing them. I HATE taking work home. Dragon has helped me

immensely. I chart a lot of details too (especially discussion section:

for example, “discussed role of screening colonoscopy in the early

detection of colon CA, talked about polyps, etc & alternative means of

screening & their limitations. Patient has decided to . . . ).

To me, it is not enough to just say: “patient refuses colonoscopy”.

Re:

Re: Information Technology in health care

Terry,

My husband Rian has had Alteer since July of 03 and I

am his office manager.

It's great, as you say, for the business end of the

practice. I also do all our billing and it is easy. However, Rian, as

others, is really frustrated with the EMR portion - he falls terribly

behind on documentation (he tends to write very detailed notes) - he doesn't

like the templates so he uses a combination of free typing and an older version

of Dragon (medical). Because I need to know the charges, he codes and does

that portion after reviewing his hand-written notes so I can get the claims out

but his unfinished charts " stack up " , so to speak.

First thing we'll do is upgrade to the Dragon 8

version. However, we are both hopelessly ignorant when it comes to using Word

templates and the technical end of EMRs, etc. After you use your own Word

template, are you printing it out from Word and scanning it into the chart or

can you open a Word template right inside of an Alteer encounter note?

Thanks so much for the attachments.

a Mintek

office manager

Allegan, MI

PS If anyone has Alteer billing

questions, I think I finally fully understand the system and I'd be glad to

help someone else

Re: Information Technology in health care

Dennis, I too have been working in Alteer since April

2003! Like most office management systems, it seems more dedicated to the

business side than the clinical side, but I have been able to create

workarounds that are satisfactory. The medicine list needs an archiving

function, I believe. And the problem list needs to be sortable for faxing

and printing (when sending info to consultants), not just on-screen.

Anyway . . . I have the same problem with taking too

much time for documentation. I do as much of it as possible in the room

with the patient or right after the visit. I have a laptop on a cart that

I can position so as not to create a barrier. But still I am way behind

on completing visits so I can bill them.

Being in Family Medicine, and seeing a wide variety of

patient ages and problems, I ended up not using any of the Alteer templates,

which I re! gard as much too wordy and not clinically sound and

efficient.

I have two templates in Word, one for ordinary visits,

and one (actually two - one for each gender) for complete exams. I

developed the complete exam templates in the olden days when I was

dictating and my paper matched the template in the dictation tank. I have

the complete exam templates printed out for visits so I can make quick

handwritten notes while I am with the patient - sometimes that is needed

rather than industriously typing while interacting. I'll attach them here

- these may not be my most up-to-date version but close enough. I

document a lot by exception, putting a comma after the boilerplate

and typing in what is different. Other times I delete and add as

appropriate for the specific visit. The templates help me quickly

determine the CPT code also.

I'm sending this to you direct, as well as here,

because attachments don't always come through in this system. If anyone

else wants an attachment and can't get to it, email me direct.

Do you have any templates to share?

Terry Merrifield, Andover KS

No virus found in this incoming message.

Checked by AVG Free Edition.

Version: 7.1.405 / Virus Database: 268.11.7/434 - Release Date: 08/30/2006

[Guest guest]

I have seen the same issue on comparing business vs clinical programs (Practice Management Systems vs EHRs). After looking at many PMSs & EHRs, I strongly recommend looking at separate vendors rather than trying for a combined PMS/EHR from the same vendor. (You might still do that, looking for a more efficient separate EHR to interface with your business program.)

I've found that producing the best of breed of PMSs and of EHRs requires very different competencies and different vendors. I haven't seen any combinations of the two from the same vendor that do both functions well, if either one. The best EHR vendors should be able to tell you which PMS vendors they have proven interfaces with. Interface standardization seems to be improving now, but verify this important characteristic before you buy, and ask for a guarantee.

Also, be sure to enter your new patients and all demographic and scheduling data into the PMS first, and then import whatever subgroup of data fields you need (name, gender, birthdate) into your EHR (not in the reverse direction, to avoid duplicate and possibly conflicting data fields). The service and diagnostic codes are generated in the EHR and exported to the PMS. This data flow should be seamless with a good interface, without having to resort to the lowest common denominator from a common vendor of both types of programs.

I use the Praxis EHR and I think its awesome, but its vendor wisely doesn't pretend to be an expert on PMSs, so it includes interfaces with the following programs (with others pending):

PMS: Accumedic, AdvancedMD, Athena Health, Calmed, Compumedic, Discus Dental, Eclipse by Galatek, EZ Health Care Systems, EZ Office, G.E./Centricity (Millbrook), Immtrac (Immunization Registry), Lytec, MD Office, Medbilltech, Medent, Medical Manager, Medics Elite, Medisoft, Medware, Micro MD, MOMS-AT, On Staff, PCN, PDS, Perfect Care, PPM, Practice Plus, Raintree, SoftAid, Ultramed, VitalWorks, Yorkmed

Lab Systems: Dynacare Laboratories, Dianon (Labcorp), Labcorp, Labtrak, Meditech, Quest, Schuylab, Sunquist, Westcliff

Patient Demographics: Paradigm Consulting Inc, X-Link

Pharmacy Systems: Allscripts, Omnicare

EKG, Spirometry, Holter Monitoring: Brentwood by Midmark, Cardio Control NV (Welch Allyn), Cardio Card ECG

Patient Medical History: Instant Medical History

Wes Bradford

Rancho Palos Verdes, CA

From: [mailto: ] On Behalf Of Terry Stryker Merrifield, MDSent: Thursday, August 31, 2006 6:10 PMTo: Subject: Re: Information Technology in health care

Dennis, I too have been working in Alteer since April 2003! Like most office management systems, it seems more dedicated to the business side than the clinical side, but I have been able to create workarounds that are satisfactory. The medicine list needs an archiving function, I believe. And the problem list needs to be sortable for faxing and printing (when sending info to consultants), not just on-screen.

Anyway . . . I have the same problem with taking too much time for documentation. I do as much of it as possible in the room with the patient or right after the visit. I have a laptop on a cart that I can position so as not to create a barrier. But still I am way behind on completing visits so I can bill them.

Being in Family Medicine, and seeing a wide variety of patient ages and problems, I ended up not using any of the Alteer templates, which I regard as much too wordy and not clinically sound and efficient.

I have two templates in Word, one for ordinary visits, and one (actually two - one for each gender) for complete exams. I developed the complete exam templates in the olden days when I was dictating and my paper matched the template in the dictation tank. I have the complete exam templates printed out for visits so I can make quick handwritten notes while I am with the patient - sometimes that is needed rather than industriously typing while interacting. I'll attach them here - these may not be my most up-to-date version but close enough. I document a lot by exception, putting a comma after the boilerplate and typing in what is different. Other times I delete and add as appropriate for the specific visit. The templates help me quickly determine the CPT code also.

I'm sending this to you direct, as well as here, because attachments don't always come through in this system. If anyone else wants an attachment and can't get to it, email me direct.

Do you have any templates to share?

Terry Merrifield, Andover KS

[Guest guest]

, thanks for your response. I would like to see your template,

and the additional info Gordon provided, but I don't know how to

access attachments (or maybe I can't with my system). Any pointers?

WRT the ROS - in the full exam templates it is itemized. In the

shorter visits, I often have the patient fill out a symptom check

sheet and scan that in. Then I delete " as above " in the ROS section

and type in " see attached symptom list. " I covers a lot of

positives and negatives that way. Also the symptom list makes it

easy to free text the HPI very specifically to the individual. I

can make that available if you are interested.

Initially I used the Discussion section in Alteer, but I found there

were enough times I wanted to zip back to the HPI to make sure I was

covering everything, that I decided to put it all in one section

where I can page or slide up and down rather than having to change

sections. Also free-texting the Assessment allows me to document my

thinking process, DDx, etc.

>

> Yes I agree that Alteer is much better at the business side than

the

> clinical documentation side. I have mentioned it here several

times but few

> seemed to agree with me. Glad to hear that I'm not the only one

that thinks

> the charting in Alteer is cumbersome. I use my own template,

usually the

> same for all visits except peds well checks. Occasionally I will

just free

> text the whole note if it sounds like a brief 99213 or 99213. Your

> templates look similar to mine, except I would recommend creating

a separate

> section that lists out pertinent ROS rather than saying " as

above " . I know

> these are included in your HPI & referenced, but by not distinctly

> separating them an auditor could still say those were

actually " modifying

> factors " when counting the HPI bullets & not count them towards

your ROS

> part. I assume you just free text the HPI section? I can attach

my generic

> template. I cut & type the pertinent positives/negatives in the

ROS & PE

> sections. I use the discussion section in Alteer rather than have

an A/P

> section in my template. Do you not use that part of Alteer?

>

>

>

>

>

>

>

> Re: Information Technology in

health care

>

>

>

> Dennis, I too have been working in Alteer since April 2003! Like

most

> office management systems, it seems more dedicated to the business

side than

> the clinical side, but I have been able to create workarounds that

are

> satisfactory. The medicine list needs an archiving function, I

believe.

> And the problem list needs to be sortable for faxing and printing

(when

> sending info to consultants), not just on-screen.

>

>

>

> Anyway . . . I have the same problem with taking too much time for

> documentation. I do as much of it as possible in the room with

the patient

> or right after the visit. I have a laptop on a cart that I can

position so

> as not to create a barrier. But still I am way behind on

completing visits

> so I can bill them.

>

>

>

> Being in Family Medicine, and seeing a wide variety of patient

ages and

> problems, I ended up not using any of the Alteer templates, which

I re! gard

> as much too wordy and not clinically sound and efficient.

>

>

>

> I have two templates in Word, one for ordinary visits, and one

(actually two

> - one for each gender) for complete exams. I developed the

complete exam

> templates in the olden days when I was dictating and my paper

matched the

> template in the dictation tank. I have the complete exam

templates printed

> out for visits so I can make quick handwritten notes while I am

with the

> patient - sometimes that is needed rather than industriously

typing while

> interacting. I'll attach them here - these may not be my most up-

to-date

> version but close enough. I document a lot by exception, putting

a comma

> after the boilerplate and typing in what is different. Other

times I delete

> and add as appropriate for the specific visit. The templates help

me

> quickly determine the CPT code also.

>

>

>

> I'm sending this to you direct, as well as here, because

attachments don't

> always come through in this system. If anyone else wants an

attachment and

> can't get to it, email me direct.

>

>

>

> Do you have any templates to share?

>

>

>

> Terry Merrifield, Andover KS

>