Occupational Health Research

Transcription

1 Occupational Health Research White Papers Occupational Health Research 28 Research Drive Skowhegan, Maine December 2010

2 Table of Contents The Advantages of Leasing Software... 5 William L. Newkirk, MD, FACPM Operational Strategies: Five Steps for Demonstrating Your Value & Fiscal Contributions... 7 Meg Flanagan, Consultant Operational Impact Analysis...11 David Nicewonger, MHA SYSTOC Cloud Computing: The Accessible, Reliable IT Solution for Clinics...13 Staff Report The Wireless Electronic Healthcare Record...14 William L. Newkirk, MD, FACPM The Road to a Paperless Office: Begin with the End in Mind...16 Scott Bressette, BA and Wynne Keller, BA Implementing SYSTOC EHR...19 Cristine V. Amurao, MD, MPH EHR Equipment Overview for Clinic Managers...21 Staff Report Using EHR to Integrate Occupational Medicine and Physical Therapy...25 Larry Briscoe, ATC, MPT, CEA SYSTOC EHR: Can a Software Program Give your Clinic a Competitive Edge?...27 Anthony Richey, BSW, MPA

3 The Advantages of Leasing Software William L. Newkirk, MD, FACPM When Occupational Health Research was established to develop occupational health software, the original group of clinics using SYSTOC decided that a lease arrangement was better for them than a purchase. In 2002, when OHR acquired StolaSystem, a lease option was soon offered to new and existing clients. Today, for almost every occupational medicine clinic, a lease is still a better option than buying. Here are four reasons why: 1. Better cash management When you lease your practice management software, you can expense the cost of your software system each tax year. Purchasing a software system, on the other hand, requires that you depreciate your purchase cost, typically over five years. Purchasing software often creates a negative cash situation where you have spent money that you can t immediately expense a scenario most financial managers want to avoid. Leasing provides better cash management. 2. Reduction of financial risks Leasing generally puts less capital at risk. If you do not like the software or your practice does not succeed as planned, your losses are lower with a lease. Advocates of purchasing occupational medicine software counter this point by arguing that purchasing software creates an asset that you own. Although this is theoretically true, this advantage of purchase is deceptive. Occupational medicine software is different from other assets. To be able to recover money from an asset, there must be a market for it. When you buy office equipment, for example, and aren t using it anymore, you can sell it and recover part of your investment. There is no market for secondhand occupational medicine software. So you have purchased an asset with no real way to recover your investment. Leasing is less risky. 3. Better budgeting with automatic upgrades Occupational medicine is different from other areas of medicine in that it is heavily affected by governmental regulations. Drug testing, employee screening, OSHA surveillance, and workers compensation dictate rules that a clinic must follow. To be useful, occupational medicine software must continually be upgraded. Leasing makes it much easier to budget for these upgrades. With a SYSTOC or StolaSystem lease, all upgrades are included. If an unexpected regulatory change occurs that requires an upgrade, the upgrade is provided at no additional charge. For clinics that have purchased their software systems, obtaining an upgrade normally requires additional funds. Occasionally, clinics pay a support fee that then entitles them to minor upgrades this is essentially a lease by a different name. Usually, the clinic must purchase a new version of the software, investing further money and tossing away their previous version. Software vendors often have to find a way to persuade you to buy upgrades so that they can continue their revenue stream. Typically they announce they will no longer support the product you bought from them. When that happens, you own software that is out-of-date; you can neither sell nor receive support for it certainly not an advantageous situation. Leasing enables better budgeting and more predictable upgrades. 4. Stable, long-term focus on customer support The initial group of clinics using SYSTOC clearly told us: We need an organization whose success depends primarily on supporting us, not on generating new sales at new clinics. The lease structure for SYSTOC and StolaSystem enables OHR to concentrate on existing customers because revenues depend more on keeping existing users happy than generating new sales. Not surprisingly, OHR provides a comprehensive list of support features for both SYSTOC and StolaSystem lease customers at no additional cost. In order to survive, vendors that rely on selling software must continually aim their resources toward new users. As a result, they emphasize sales over support. Unfortunately, as markets mature, as occupational medicine is now, there are fewer new clinics and new sales. As the sales base weakens, these vendors can go out of business, leaving clinics to fend for themselves. Leasing provides stable support SYSTOC White Papers Dec

4 Summary: Leasing vs. Purchasing Software Advantages to Leasing Lower initial cost Predictable fees Annual expense fully tax-deductible Software automatically kept up-to-date Necessary adjunct services included Greater likelihood that vendor will stay in business Advantages to Purchasing Lower annual cost in non-upgrade years About the author: WILLIAM L. NEWKIRK, md, facpm, is a board-certified occupational medicine specialist. He is Director of Occupational Medicine at Redington-Fairview General Hospital in Skowhegan, Maine, and Director of Research at Occupational Health Research. Dr. Newkirk may be reached via bill. newkirk@systoc.com. 4 SYSTOC White Papers Dec

5 Operational Strategies: Five Steps for Demonstrating Your Value & Fiscal Contributions Demonstrating the fiscal impact of an occupational health program can be one of the most difficult challenges for the Program Director. After all, occupational health programs direct revenues to other cost centers, but carry the overhead to drive those downstream dollars. Some of the more common remarks heard from Senior Administrators are, We would have gotten those ER visits anyway! or Rehab grew 20%, why didn t occupational health meet its budget? or What do you mean, occupational health generated ancillary and physician referrals? If occupational health is to get the respect and rewards it so rightly deserves, you should ask who is evaluating the program s performance and how does the evaluator measure success? It is important to provide relevant data that emphasize the factors that administrators value. For example, a midwestern occupational health program had three levels of administration: Medical Director, Vice President, and CFO. The Medical Director valued client satisfaction. The Vice President valued growth in client base and revenues. The CFO wanted to see an increase in the workers compensation payer mix. All of these success factors are valid; however, the Medical Director and the Vice President reported to the CFO, thus determining what would be valued most highly. Armed with this information, the Program Director can provide relevant management reports to the key stakeholders. Other programs have valued bottom line profitability, physician or ancillary referrals, client retention and growth, occupational health as a practice builder, or decreasing an organization s own workers compensation costs. The following steps can be used to analyze and potentially improve a program s fiscal impact on an organization. Meg Flanagan, Consultant market. Using your program s practice patterns you can calculate the number of follow-up visits and ancillary utilization with their associated revenues. The chart on the next page represents an example of this methodology. It uses injury rate projections determined by industry and assumes 2.5 visits per injury at an average visit charge of $160. (Average visit charge is determined by dividing the number of injury visits into the total injury-related revenues.) Once the total market potential is defined you can determine your current market share. Next, make three-year projections based on an incremental increase in market share or a percent of revenue increase over the break-even point. By determining total market potential, your projections will establish what is attainable, based on realistic calculations. Step 2: Monitor your key indicators It is important to conduct a monthly audit of data to determine if the actual numbers are on track to meet the targeted goals; if not, you can make necessary midcourse corrections. Several key indicators to monitor: Company utilization. Monthly auditing of visits by company helps you to spot any attrition and allow timely intervention to save the account. If growth is demonstrated, boost customer service to retain that account and look for cross-selling opportunities. Physician/practitioner practice patterns. Productivity goals should be established for your practitioners. Do the majority of your ancillary referrals come from a single practitioner? Does this mean under utilization by the other practitioners or over utilization by this one practitioner? Sales activity tied to goals. Is the sales staff meeting the program s revenue goals? Is more time being spent on customer service for operational Originally published in the Occupational Health Tracker, Spring, 2001, and lightly edited in 2010 to update. Step 1: Develop annual projections Calculate the total potential within the program s defined market. To accomplish this, purchase an employer database that lists the actual number of employees per company. By sorting companies/employees by NAICS or SIC codes and using the Department of Labor injury rates you can project the number of injuries in the SYSTOC White Papers Dec

6 Projected Projected Avg. Revenues Industry # Employees Injuries Injury Visits ($160/visit) Develop Annual Projections in Your Market Agriculture 3, $102,080 Construction 1, $65,120 Transportation 1, $57,280 Retail 17,666 1,148 2,871 $459,360 Service 26,68 1,388 3,469 $555,040 Projected Projected Avg. Revenues Industry # Employees Injuries Injury Visits ($160/visit) Mining $1,760 Manufacturing 8, ,999 $319,840 Wholesale 6, ,031 $164,960 Finance 2, $17,920 Public Admin. 7, ,015 $162,400 Demonstrating the fiscal impact of an occupational health program can be one of the most difficult challenges for the Program Director. After all, occupational health programs direct revenues to other cost centers, but carry the overhead to drive those downstream dollars. Some of the more common remarks heard from Senior Administrators are, We would have gotten those ER visits anyway! or Rehab grew 20%, why didn t occupational health meet its budget? or What do you mean, occupational health generated ancillary and physician referrals? If occupational health is to get the respect and rewards it so rightly deserves, you should ask who is evaluating the program s performance and how does the evaluator measure success? It is important to provide relevant data that emphasize the factors that administrators value. For example, a midwestern occupational health program had three levels of administration: Medical Director, Vice President, and CFO. The Medical Director valued client satisfaction. The Vice President valued growth in client base and revenues. The CFO wanted to see an increase in the workers compensation payer mix. All of these success factors are valid; however, the Medical Director and the Vice President reported to the CFO, thus determining what would be valued most highly. Armed with this information, the Program Director can provide relevant management reports to the key stakeholders. Other programs have valued bottom line profitability, physician or ancillary referrals, client retention and growth, occupational health as a practice builder, or decreasing an organization s own workers compensation costs. The following steps can be used to analyze and potentially improve a program s fiscal impact on an organization. Step 1: Develop annual projections Calculate the total potential within the program s defined market. To accomplish this, purchase an employer database that lists the actual number of employees per company. By sorting companies/employees by SIC and using the Department of Labor injury rates you can project the number of injuries in the market. Using your program s practice patterns you can calculate the number of follow-up visits and ancillary utilization with their associated revenues. The chart on the next page represents an example of this methodology. It uses injury rate projections determined by SIC code and assumes 2.5 visits per injury at an average visit charge of $160. (Average visit charge is determined by dividing the number of injury visits into the total injury-related 6 SYSTOC White Papers Dec

7 revenues.) Once the total market potential is defined you can determine your current market share. Next, make three-year projections based on an incremental increase in market share or a percent of revenue increase over the break-even point. By determining total market potential, your projections will establish what is attainable, based on realistic calculations. Step 2: Monitor your key indicators It is important to conduct a monthly audit of data to determine if the actual numbers are on track to meet the targeted goals; if not, you can make necessary midcourse corrections. Several key indicators to monitor: Company utilization. Monthly auditing of visits by company helps you to spot any attrition and allow timely intervention to save the account. If growth is demonstrated, boost customer service to retain that account and look for cross-selling opportunities. Physician/practitioner practice patterns. Productivity goals should be established for your practitioners. Do the majority of your ancillary referrals come from a single practitioner? Does this mean under utilization by the other practitioners or over utilization by this one practitioner? Sales activity tied to goals. Is the sales staff meeting the program s revenue goals? Is more time being spent on customer service for operational complaints than on selling? Are you cross-selling and up-selling other services to current clients? If your goal is to increase workers compensation payer mix, then evaluate and/or provide sales incentives accordingly. Ratios. What is your ratio of work injury to non-injury visits? Typically 65 70% of the business should be higher paying injury visits. Drug screens. Drug and alcohol screens can represent as much as 80% of your non-injury business. Consider using medical assistant staff instead of nursing staff for specimen collections to make better use of personnel and keep expenses low. Leaving money on the table. Many programs bill through the hospital s billing department with historically low reimbursement rates and poor practices relative to workers compensation rules. Often payments are not applied by line item, causing balances to grow. Many organizations must write off outstanding amounts at year end, since they cannot provide workers comp payers or clients with an accurate accounting. This makes the occupational health program appear less profitable. Nationally, most hospital organizations using the hospital s billing department (and hospital/patientbased billing software) realize between 50 80% reimbursement rates. However, occupational health programs that control billing and collections using occupational/account-based software realize reimbursement rates in the 90+% range. Step 3: Track referrals outside occupational health Occupational health programs provide referrals to other departments and medical staff but have difficulty tracking these revenues. At issue is tracking the data while the revenues remain in each service line s cost center. This can be accomplished by applying a tracking code at patient registration using medical service, patient type, insurance plan, or a mix of several customized codes that allow for end of month sorting. Referrals to specialists can be tracked via case management software, but this process often requires some manual tracking efforts. Step 4: Eliminate loss leaders Certain services are promoted as loss leaders in an effort to attract new customers. Change loss leaders into revenue-generating services by offering an annual Health Maintenance Program that charges its clients a set rate per employee per year. By repackaging wellness, education, and prevention services into an annual client package you can get paid for what used to be freebies SYSTOC White Papers Dec

8 Step 5: Don t wait to be asked You have to demonstrate the program s contribution to the organization as a whole, not just the program s bottom line. By providing quarterly summary reports to administration you arm them with data that show the program s value in supporting other organizational initiatives, like physician referrals. If you are not on target for projections, troubleshoot and provide your game plan to administration. If you can demonstrate that improvements are in progress, you may buy more time before budget cuts are considered. If budget cuts are inevitable for your program, create options for scaling back rather than being forced to deal with ultimatums. For instance, if there is too much overhead, achieve cost savings by relocating the program site or sharing staff with other departments. Don t wait until they are ready to make cuts to act. Be proactive and control the program s destiny. Finally, make sure the occupational health program is on the organization s radar screen. It is your responsibility to demonstrate how the program impacts other departments and service lines. By providing relevant data on a regular basis you can reposition occupational health from a clinical service to its rightful position as an employer/provider strategy that drives organizational referrals while building strong, long-term client relationships. About the author: Meg Flanagan, BS, is an occupational health consultant specializing in employer/provider programs and sales. Ms. Flanagan may be reached at or by at megfchg@aol.com. 8 SYSTOC White Papers Dec

9 Operational Impact Analysis David Nicewonger, MHA As a clinical management tool, SYSTOC can have a significant impact on the efficiency of an occupational health clinic. In many cases, a close assessment of the actual cost benefit reveals that the savings exceed the annual cost of the software the investment returns more than it costs. The following provides a brief summary of those segments of clinical operation that can be improved through the use of SYSTOC. Front Desk Operations The front desk is the key to efficiency in any occupational health clinic. The patient visit originates there and all of the work done at that first point of contact sets the stage and the tone for the rest of the encounter. Any inefficiencies or errors that occur at this point are carried through and sometimes magnified during the rest of the treatment process. The impact of SYSTOC in this area is twofold. First of all, the use of SYSTOC greatly reduces the risk of errors being made in the scheduling of services and the preparation of patient charts because company profile information is tied directly into scheduling, and the front desk person can easily see what needs to be done for each visit and how that visit will impact the clinic. Those same profiles provide a map for preparing the chart so that all of the appropriate forms and documentation are pulled together according to the specifications of each individual employer. This eliminates the need to reference inefficient systems of card files or notebooks for profile information for each patient. SYSTOC can also impact the efficiency of the receptionist job itself. Effective implementation of SYSTOC at the front desk makes it possible to automate many functions. For paper-based offices, preparing a patient chart can be as simple as printing a report and pulling all of the necessary paperwork and forms from the printer and placing them in the chart. For paperless offices, forms don t need to be printed and are completed on the computer. Searching for information is easy using special tools for viewing schedules or finding specific items in a schedule. It is not expected that implementing SYSTOC will result in a reduction of full-time employees at the front desk, since most clinics operate with minimal staff in that position. It will, however, make the staff more effective and accurate in their jobs. The use of SYSTOC results in less chaos at the front desk and fewer problems throughout the rest of the patient visit. PROVIDER OPERATIONS SYSTOC s impact on nursing and physicians is similar to its impact on the front desk in that the use of company profiles, patient-specific flow sheets, and preprinted or computerized forms makes the entire patient encounter less confusing and less prone to error. If the program setup is done correctly, errors associated with the execution of company-specific services and instructions are greatly reduced. This, of course, translates into higher customer satisfaction, and fewer services that need to be repeated or credited due to staff error. In a busy to moderately busy office, the improved organization and easy access to patient information increases the number of patients that can be seen before additional staff is needed. The exact impact depends upon the degree of implementation and how accessible SYSTOC is to the provider staff. The busier the clinic, the more of an impact SYSTOC can have on these job functions. A busy clinic can feel chaotic, with many different activities occurring at one time, and an incredible burden of paperwork, telephone communication, and other tasks to be completed. SYSTOC brings order to the chaos by structuring the work that needs to be done, tracking orders to insure completion, and grouping tasks into blocks of related work, rather than random activities. There are documented cases showing that the use of SYSTOC made it possible to reduce the nursing staff from three to two for a daily volume of patients. If the medical providers use the tap2chart utility to create the medical record, the visit information is available much sooner than would be possible with transcription, and the cost of transcription is eliminated. With any form, information that has not changed from prior visits can easily be carried forward and a comprehensive medical chart is created in a few minutes SYSTOC White Papers Dec

10 Case Management For the clinic that provides case management or worker tracking as a value-added or additional-fee service, SYSTOC injury management can have a considerable impact upon the efficiency of the case management staff. It is estimated that a case manager who takes full advantage of the tracking tools in SYSTOC can handle three four times the number of open injury cases compared to a case manager who must rely upon maintaining individual physical files. The efficiency comes from automated organization of the work to focus time and energy on only those cases that require attention rather than relying on manual monitoring of each file to catch work that needs to be done. Computerized injury management results in significantly reduced costs and greatly improved quality because computerized tracking tools make it almost impossible to lose patients for more than a day. Billing When used to its fullest potential, SYSTOC probably provides its greatest impact on billing functions. Increased efficiency actually starts at the front desk, where the use of company profiles during scheduling results in the creation of orders that are later used for billing. Fewer staff are needed to complete the billing and there is less opportunity for errors from multiple data entry. This leads to fewer customer complaints and followup credits and corrections. One large clinical system was able to reduce their billing staff from 11 full time employees to six through implementation of SYSTOC. In a smaller clinic, or one that is just getting started, SYSTOC makes it possible to share job duties, so that a single person may be able to complete the billing and provide other support services such as data entry or patient registration. SYSTOC_EDI is the electronic billing utility for SYSTOC. This tool sends invoices to the clearinghouse of your choice, and can even return the remittance advice for those clearinghouses that support it. The electronic bills can include the medical record. This utility removes the expense of paper bills and provides faster payment. SYSTOC LabLink Another benefit of using SYSTOC is automatic eligibility to use LabLink, a tool that provides electronic reporting of results from the testing laboratory. Some laboratories offer a discount when a clinic uses LabLink. Discounted testing fees have a variable impact on financials, depending on testing volumes and the fees that a clinic can negotiate with labs outside of the LabLink group. In one case, a clinic saved over $9000 in their annual drug test program costs. Other clinics have seen a financial impact that is considerably higher. Additional savings can be realized through the electronic downloading of test results directly into SYSTOC. This feature minimizes manual data entry and results in improved accuracy. Customer Satisfaction Customer satisfaction is a hidden benefit that should not be underestimated. Occupational health is about handling each and every company as if it were the only client being served. This becomes challenging when employers demand services or packages of services that are specific to their operations. With SYSTOC, a client profile and all aspects of the client relationship are recorded, ensuring that the clinic staff provides services to each patient according to the specific protocols of each company. There are fewer patient-care errors, fewer reporting errors, and fewer billing errors. That translates into happier customers, fewer customer complaints, and ultimately, less work for staff. These are only a few of the areas where using SYS- TOC has resulted in improved operational performance and cost savings. SYSTOC covers a wide range of clinic functions, and the more SYSTOC functionality implemented, the greater the potential for savings. About the author: David Nicewonger, MHA, is the Administrator of MultiCare Health System s Regional Cancer Center in Tacoma, Washington. At the time this article was written, he worked at OHR, helping clinics improve operational efficiency. This article was edited by OHR staff to update it. 10 SYSTOC White Papers Dec

11 SYSTOC Cloud Computing: The Accessible, Reliable IT Solution for Clinics Only a few short years ago, most businesses wouldn t think of keeping their data anywhere but at their own offices, in their own computers. IT Departments or contract IT service companies were responsible for installing, configuring, and maintaining diverse software applications about which they knew very little. Few options were available for handling computer technology any other way, until the advent of cloud computing. In its broadest sense, cloud computing is an infrastructure that provides software services and data storage over the Internet. An early example of cloud computing is software such as Yahoo Mail. Mail is kept somewhere on a server that is available to you anytime using an Internet connection and a login. Today cloud computing is a viable software option as individuals, businesses, and IT departments become comfortable with advances in the technology that supports the cloud. Consider the three components that are needed to run an application such as SYSTOC: Software (operating system, application, database, networking) Hardware (application server, database server, workstations) Service and expertise (networking, database, application, connectivity, backup, disaster recovery, HIPAA compliance) IT Departments can become burdened with purchasing and maintaining the infrastructure that supports a software application that potentially only a relatively small number of their total network users require. Clinics without an IT Department must pay for IT service companies who do their best, but cannot reasonably become experts in supporting the clinics needs. In both situations, cloud computing can provide welcome relief. With SYSTOC Cloud Computing, Occupational Health Research provides a solution that completely manages the installation and maintenance of SYSTOC. The computer network in your office and an Internet connection are your only responsibilities. Everything else is left to OHR s team of experts, who configures the software and hardware components to keep SYS- TOC running smoothly. The software maintained under a cloud computing arrangement includes SYSTOC, the SQL Server Staff Report database, the Windows Server operating system, virus protection, and data security over the network. Each of those software components involves software updates and monitoring, all handled by the OHR team. Hardware needs are also covered under the cloud computing arrangement. OHR makes sure you never run out of server disk space or memory. Equipment is monitored for performance, and the data center that houses the servers is in a secure, climate-controlled facility with backup power and backup servers. OHR recognizes that access to your data is critical to your business and makes it available 24 hours a day, seven days a week via your workstations and an Internet connection. The name cloud computing was inspired by Internet diagrams that use a cloud symbol to represent the underlying complexities of the Internet. All data communication takes place over a secure Internet connection and multiple Internet providers service the data center to ensure you can always reach your data. Backup systems and procedures are established and tested to handle all potential points of failure, from a loss of electrical power to a virus attack to a natural disaster. The OHR cloud computing team is skilled in maintaining the infrastructure components needed to support SYSTOC. Your data is stored on a dedicated virtual server with regular, secure backups, and all data is encrypted to meet HIPAA requirements. When a new version of SYSTOC is released, the cloud computing team performs the upgrade and installs any necessary non-systoc supporting software. When an application that is at the heart of your business requires a range of supporting software and hardware, making sure that each of those supporting elements work together reliably is vital. Cloud computing places that responsibility in the hands of experts, allowing you to focus on using the application and operating your business. Originally published in the Occupational Health Tracker, Winter, SYSTOC White Papers Dec

12 The Wireless Electronic Healthcare Record William L. Newkirk, MD, FACPM Yesterday, I treated a 45 year-old man for a recurrence of low back pain. He told me that a particular muscle relaxant had worked well for him in the past. I asked him what pharmacy he used and tapped the screen of my tablet PC a few times. The computer automatically created a typed prescription, added my signature, entered the details of the prescription in the patient s medical record, and faxed the prescription to his pharmacy. As we continued talking, I told him that the prescription was already at the pharmacy. He looked at me and the tablet PC and shook his head. That thing s amazing, he said. I feel that way every day. I ve been in occupational medicine for 27 years. During that time, nothing has changed my daily clinical activities more than the wireless electronic healthcare record (W-EHR). W-EHR improves the way I document, prescribe, transcribe, schedule, and bill. I anticipate W-EHR will be adopted by many, if not most, practitioners over the next few years. Unraveling a Paradox In my job as Director of Research for Occupational Health Research, I oversee the development of computer systems for almost 60% of the nation s occupational medicine providers. It has puzzled me for years that even though computer systems get better and more reliable, occupational medicine clinics do not seem to become more productive as a result. Working on W-EHR, I began to see the reason. Clinics repeatedly convert information from paper to computer and back. The reason clinics use paper is that the computer system s effectiveness is usually limited to back office functions like billing and quality assurance. The doctorpatient interaction is largely paper-driven. Moving back and forth between the paper and non-paper world saps much of the advantage of computerization. Regaining that advantage requires eliminating paper. Eliminating paper requires computerizing clinical personnel. Years ago, when I was a surgical resident and was lecturing at Surgical Grand Rounds about using computer models in making surgical diagnoses, one of the older surgeons stopped me and said: But Dr. Newkirk, if you are right, we ll need computers in every emergency department. His colleagues nodded and smiled condescendingly. I agree it did seem preposterous then; but it is standard today. Similarly, we are now at a point where it seems likely that in the not-too-distant future, doctors will be walking around with tablet PCs in their hands. To eliminate paper, we need to computerize and un-wire doctors. Un-Wiring Doctors For a wireless electronic healthcare record system to work, doctors must be willing to use it. Historically, doctors have been unwilling to use computer systems. It s easy to blame this on doctors being techno-phobic. Some older ones certainly are; but younger Nintendogeneration doctors certainly aren t. I think the real reason for the unwillingness is that computer systems don t work the way doctors need them to. This flaw goes back almost three decades. Here s the problem in a nutshell: medical computer systems have generally had two components databases, which store information, and reports, which output information. These limit what the computer system can do. A software developer can make a computer system more flexible by allowing the user to define how some data fields are used, and more powerful by incorporating flexible report writing software. But that s about it. Doctors don t work that way. Doctors fill in forms medical record forms, physical examination forms, insurance forms, physical therapy authorization forms, etc. There are hundreds of different types of forms. A doctor needs the computer system to be flexible enough to handle them all. A well-designed W-EHR allows the physician to integrate an infinite array of physician-customized forms into the system by merely plugging them in. The databases and reports still exist, but operate in the background. [Originally printed in the Winter issue of the Occupational Health Tracker.] 12 SYSTOC White Papers Dec

13 The Benefits of Wireless My clinic has only been using W-EHR for three months. I will never go back. W-EHR has made me a fan because it helps me do many things with less work and hassle. In addition to electronic prescribing, here are six of my favorite features: Not having to ask for charts The tablet PC contains access to the medical records. If I am working on one patient and a question about another comes up, I merely click on the new patient s chart. The tall stacks of charts on my desk are gone. Work seems less chaotic. Automatic transcription When I see a patient, I complete a template form for my evaluation. I click on the screen and the form transforms into a typed medical record. If I don t like the way the record looks or see that I ve forgotten to document something, I click back to the template, add the new information and instantly transcribe it again. When I leave the patient, the record is done. I sign it and move on. I have no dictations to review the next day. Automatic ICD-9 coding When I select a diagnosis, the computer codes it. I no longer have to wait for coders to review my chart and code my diagnoses. Easy appointment scheduling In less time that it would take me to find a support person and tell them a patient needs another appointment, the computer has the appointment made. It takes only a few seconds. I give patients an appointment time as I talk with them. Getting help filling out forms If I have to fill out a form for an employer or insurer, the computer fills out as much of the form as it can from the stored data. I no longer have to re-write the same information on numerous forms. In addition, I can computerize absolutely any form on any topic easily. Carrying my inbox with me If I get a few seconds between patients, I can sit or lean against the wall and use my tablet PC to clean out my inbox. I can sign authorizations, review lab and x-ray reports, and answer phone messages. The Repercussions of Seeking Perfection W-EHR creates both freedom and fear. If the W-EHR lets you have any form you want because you are no longer constrained by the decisions of the software developer, then you are free to create a form for the ideal shoulder examination, for example. But what exactly does that examination look like? What should the restrictions for carpal tunnel be, exactly? What medications and dosages will you provide in your prescriptions? What diagnoses and ICD-9 codes will you allow? Multiply these questions by a thousand and you get some idea of the self-examination you must perform on your medical practice as you implement W-EHR. It made me very nervous. What we have found, however, is that the process of moving though these questions improves clinic operations and upgrades the level of our medical care. But implementing W-EHR has an emotional price as well. Because it entirely eliminates some clinic functions (such as managing and filing paper charts) and dramatically reduces others (such as transcription), certain clinic jobs vanish seemingly overnight. This takes a toll on the staff as we see co-workers lose their jobs. But the competition in the occupational medicine marketplace is relentless. Unless we seek the highest levels of perfection and efficiency, our clinic will cease to exist and we will all lose our jobs. In that battle, I think the wireless electronic healthcare record will give us a significant edge. It has puzzled me for years that even though computer systems get better and more reliable, occupational medicine clinics do not seem to become more productive as a result. Working on W-EHR, I began to see the reason. William L. Newkirk, MD, FACPM SYSTOC White Papers Dec

14 The Road to a Paperless Office: Begin with the End in Mind Scott Bressette, BA and Wynne Keller, BA Increasingly, the medical community is implementing Electronic Health Records (EHR) because of its potential to save time and money and, lately, because the government encourages its use. Transitioning to this technology can be challenging. This paper identifies issues that are crucial to the successful implementation and use of electronic health records. The goal of EHR A paperless office is not an office without paper! It is simply an office in which most records are created, stored, and retrieved on the computer in real-time, then disseminated securely to other interested parties, without paper at any stage. The main inefficiency in paper environments is the process of converting information from paper to digital and back. For example, in a paper-based office, the patient will complete forms which are then entered into the computer so that visit-related information can be printed for clinical staff. The staff writes on paper while treating the patient, then hands it to someone for data and charge entry into the computer. A report of the visit and invoices are then printed and distributed appropriately. Each step at which information is placed on paper and then typed into the computer by someone else costs money and time. The goal of EHR is to remove every stage at which paper is used to store or present information. Is paperless right for you? The first step is to determine what you hope to accomplish with electronic health records. Some possible goals are: Reducing office staff without reducing patient volume Reducing/eliminating transcription Reducing errors Eliminating searching for charts Making information more readily accessible Improving communication (among staff, between patient and doctor, between doctor and company, between staff and insurer) Improving clinic/patient/work flow These goals, if achieved, will make the clinic much more efficient, and therefore potentially more profitable. Feasibility planning should take the following issues into consideration: Hardware and software Physical layout of the clinic Training Security Cost Hardware and Software Your current equipment is probably not adequate for EHR. You can elect to use cloud computing, which means you log in remotely from your local network and someone else provides the server hardware, software and backups. Or you can handle all IT requirements internally. Either way, you ll need expert advice and careful planning. This list provides a starting point for discussion of your information technology needs: a wireless network or a (wired) computer with highresolution monitor in every exam room; a well-designed and fast tablet computer for each physician (if wireless); one or more (depending on clinic size) spare tablet computers as backup for the physician units; a computer with high-resolution monitor for each nurses station and for support staff, typically one per person; equipment that allows patients to sign electronic documents; multiple scanners/fax machine, printers enough to prevent bottlenecks; a backup server; some form of auxiliary power or battery backup that can provide a minimum of four hours of operation time; sufficient disk space on the server to handle the added storage needs for the paperless approach; a tested, reliable backup system, with media stored offsite. 14 SYSTOC White Papers Dec

15 Physical layout of the clinic Your facility must accommodate patients privacy at all stages of their care, with a computer either in the room or in the hand of the interviewer. If using the completely paperless approach, the patients won t be sitting in the waiting room filling out forms; they will either be talking to a staff person who fills out the form for them on the computer in real-time or using a computer themselves to answer simple questions directly on screen and sign consents. Of course, you can always start out partially paperless and move to fully paperless in stages. One compromise is to have patients complete some forms on paper and use a scanner to convert the paper forms to electronic format. Training In the paperless office, everyone must use the computer. The medical staff will have to give up their reliance on paper for both data entry and data retrieval. Will your medical staff adopt technology readily? Assuming you are computerized now, how many people use the computers often? If your personnel resist using the computer, what are you willing (or able) to do about it? The current staff will have different levels of computer expertise. Inexperienced users may need instruction on how to operate in the Microsoft Windows environment, send faxes from the network, scan paper documents, fill out an electronic form, use digital signatures, passwords, , and similar tasks that have become commonplace in computerized environments. You will need several key people who have a complete understanding of the hardware configuration and can deal with computer lockups, network connections, and peripheral devices. If you have an IT department that normally handles such things, consider how long it takes them to respond to a request for help. No one remembers everything the first time they are trained. Follow up training can improve efficiency as employees learn time-saving shortcuts for the processes they use most often. Security Some security issues specifically relating to EHR include the following: there must be privacy when medical issues are being discussed; wireless networks must be properly configured to prevent someone with a laptop in the lobby or parking lot from accessing your data; who has rights to edit or view the various software screens and the forms?; what method will you use to ensure that an approved medical record cannot be altered?; how will electronic documents be signed?; encryption is required when transmitting electronic documents to an outside recipient; pen tablet computers are so portable they are easily misplaced or stolen, either of which is a HIPAA violation and dangerous security breach; when patients are in exam rooms unattended, computer access must be locked; every person at the clinic needs to always be thinking about computer security, and all processes should be tested for security. Cost Cost estimates will depend on your evaluation of all the preceding factors. When budgeting for EHR, be sure you consider the costs of all the following: hardware, including all the factors discussed under equipment; software licenses, including all software needed for the new machines; cloud computing, if used. Cloud computing typically reduces some hardware and software costs; staff training; physical plant changes; lower patient volume initially until you work problems out. Preparation Implementing EHR requires a tremendous amount of setup work. You will need to review all your current processes and determine whether they fit into the new paradigm. This means evaluating every single task; many processes may need to be changed, or eliminated entirely. Form design Good form design is paramount. A bad form will stop the work flow completely, and cannot be remedied on the fly. All forms must be tested in a patient workflow process before they are used! You may need to devote considerable time to form design if you want computer SYSTOC White Papers Dec

16 forms that correspond to the paper ones you already have. A good form will: gather all the data you need; have easy-to-pick defaults that eliminate repetitive data entry; display all the pertinent data available, eliminating re-entry of known information; A bad form: is an exact replica of a paper form, with no attempt made to streamline data entry or consolidate forms; wasn t tested and won t accept a perfectly valid answer; was created by someone who doesn t understand the database, so key information does not upload automatically in the form, requiring the medical staff to enter it again and patients to repeat themselves to each person filling out a form. Work flow Developing an efficient work flow in the paperless environment is essential to success. Without a paper chart on your desk, you need to have other clues that there is work to be done. Tracking work electronically requires that all workers have access to a computer so they can retrieve information, and that the available information is specific enough to identify the work that needs to be done. SYSTOC has a system for moving orders from one person or group s to-do list to another. The sequence is pre-defined by the clinic manager, but may be modified during the visit if needed. Careful analysis of how work should flow through the clinic makes it possible to prevent many common data-related errors. For example, you can ensure that a patient visit form is signed by the physician before it moves on to be faxed to the company or billed to the insurer. You also need to consider the total workload for each staff person. What will each person do in the new paradigm? Will people need different skills? Is too much work going to flow to a few people, creating a bottleneck? When an employee leaves or is sick, who will find his or her electronic to do list and take care of it? Being paperless in a paper world The process that will take the most time is the conversion of paper documents into paperless. Paper that enters the clinic must be scanned and attached to the applicable patient s record. Scanners are slow and the attaching process requires multiple steps, such as examining the scan to make sure it is legible, finding the right patient record, naming the document appropriately, attaching it to the record, and so on. The fewer items you need to scan, the better. Using sophisticated fax and scanner software can greatly facilitate the transition from paper to paperless. If possible, arrange flow so information leaving the clinic will be encrypted and travel electronically. But when you must send paper to the recipient, you can either print a report or print the form that was used to gather data. Final thoughts Going paperless will not solve problems in other areas of clinic operation. If your hardware doesn t work right can you get IT to fix it promptly? Is the staff apprehensive of using the computers or resentful of necessary data entry? The more smoothly your clinic operates now, the smoother the transition is likely to be. If there are major problems at your clinic, they should be addressed before the paperless approach is attempted. 16 SYSTOC White Papers Dec

17 Implementing SYSTOC EHR Cristine V. Amurao, MD, MPH Clinics are used to having paper documentation for everything. Cutting the paper umbilical cord may be traumatic and stressful for the entire staff. Here are some tips on making the transition as smooth and painless as possible. Are you ready to make the change? Before shifting to EHR, discuss the system changes with the clinic staff. Make sure that there is open dialogue about this major step. Set your goals; for example, do you plan to downsize your staff and eliminate positions after implementation or are you using EHR to handle increased patient workload without adding employees? Explore different scenarios, talk about difficulties you might encounter and plan ahead for possible solutions. Knowing your process and endpoint will help you evaluate the success or failure of your system. Assess the willingness of the staff (doctors, physician assistants, nurses, and non-medical staff). Some employees will be affected more than others. Most of the front office personnel probably deal with digital data entry already. The nurses, PAs, MAs or physicians might have to adjust the most since they are least likely to have used the computer for clinic operations in the past, and SYSTOC s Clinical Work Area is designed to be used by clinical staff. Firm clinic administrator and medical director support is needed. State your expectations, stress the need for everyone s patience, and assess each person s current level of computer experience as well as adaptability. Review your equipment to determine if it is suitable to the new environment. While it is not necessary to buy handheld computers for every provider, it IS necessary to have a tested and reliable backup system that copies your files frequently (more than once a day) or, depending on clinic size and comfort level, even continuously. Detailed equipment information is available; contact OHR or visit the User Forum to obtain additional articles on this topic. Training and preparation is the key SYSTOC Application Specialists are always ready to help. SYSTOC clients can schedule on-line or on-site training visits from their designated specialist. Another option is to attend on-line training classes at OHRuniversity.com. Make sure that there is adequate training time for all clinic job functions. Remember that different staff members need to learn different aspects of the software. Let them assess their own competencies aside from the supervisor evaluations and give them the opportunity and time to get additional training if they feel uncertain about some modules before going live. For existing SYSTOC users, set aside time for regular training/refresher courses. Be sure to check out the Users forum for more information or to ask questions. Set your sights on achievable goals Discuss and set targets for your implementation plan. Decide if you will do a full or a phased implementation and if so, what kind. There are several options available for phased implementation. For example, you can implement one clinic location at a time (for multi-site clinics), or by job function, or by procedure. Assess which will fit your clinic the best. Immediate implementation might be appropriate if the clinic has been storing data in SYSTOC via Orders. There will be little need to scan old paper records if you have used SYSTOC correctly in the past! If SYSTOC was used for data storage only occasionally, or data entry was not done via Orders, you need to load some information by scanning old paper records into an electronic file and attach them to the patient s record. If you are a new SYSTOC client or haven t used SYSTOC to store patient data via Orders, more work will be needed. You ll have to limit your conversion. Set a cut-off date for when new patients will be entered in the EHR system. For old patients, load only important/useful records for future visits. Do not try to scan in ALL the records for an old (longstanding) patient because it will get too overwhelming and you might not need all that data anyway. Decide what needs to be transformed into an electronic format and attached to the new electronic record. Prioritize patient record conversion; start the full EHR on new patients first, followed by old patients already scheduled for followup, then lastly old patients not recently seen, but still considered active. Analyze: What data do you really need? What can you live without? What can go into storage? SYSTOC White Papers Dec

18 Once your basic priorities are set, review the forms that are provided with SYSTOC and decide if modifications are needed. Compare them to paper forms you currently use, and determine which paper forms will need to be converted to electronic versions. Be ready to tweak the form because you may get ideas for improvements as you go. Keep in mind which fields on the forms write back to SYSTOC (available on each form s help screen). Think about the available reports as well, and which fields are needed to generate reports that you want. The transition workload The clinic workload may not decrease initially. For SYSTOC clients already using Orders, EHR implementation will be easier. However for others users or new clients a lot of effort may be needed to do the correct setup and convert old files into electronic records. Nevertheless, if preparation is done properly, EHR implementation should not slow down the office, although scheduling a light patient load on the first day or two may help reduce stress for everyone. How long the transition period will be is determined by how much data you need or want to transform, how big your practice is, and how efficient and motivated your staffs are. Once it is up and running: Successful use of EHR If everything works out as it should, efficiency increases and quality of work improves because of fewer errors and less repetitive data entry. The staff can be more responsive to patients, client companies and insurance companies. It is much easier to provide required information or paperwork promptly. Most patients love EHR, even those with no technological savvy. The key is to maintain the patient-medical provider rapport. For example, it is important to keep eye contact while talking to the patient and enter the data without turning your back. Position workstations appropriately and try them out among yourselves before deciding on the best setup. Patients find the system very efficient; when they come out of the clinic, they have everything they need and they have the security that if they need more information or forms, the office can provide them faster than before. Patient education as well as provider education can be enhanced. For example, during the history and physical examination the provider can access the web or any program in the computer to show patient diagrams to help Things to remember when implementing SYSTOC Orders can be easily added during the actual visit as long as the prototype tasks have been set up in advance. Access rights are set by the clinic administrator and can always be adjusted as needed. Sending results by through SYSTOC is safe. Data are encrypted and the receiving party needs the right password to open the file. A specific PDF form can be opened by just one user at a time and the system tells you who has it open. Plan for the inevitable equipment failure. Maintenance should be done regularly and always make regular back-ups. To avoid panic when the system is down, do a disaster drill to test your plan. Try to have someone knowledgeable inhouse to get your system up quickly, or arrange in advance for expert help on-call. There is always the option of backing up your data with paper printouts for a limited period of time after going live if the fear of being paperless is the only thing keeping you from trying out EHR. explain the disease or treatment. Patient monographs from medical information websites such as the NLM /NIH Medline Plus can be accessed, printed out and given to patients at the end of the consultation. Keep open lines of communication among the management, medical, and non-medical staff members. Continue gathering job function information from the persons handling the work, to look for ways to improve efficiency. For example, if you decide that a standard form is not adequate after using it live and evaluating it, send in a request to OHR to customize the form. The most successful clinics will continuously evolve to take advantage of staff ideas, changing circumstances, and technology. 18 SYSTOC White Papers Dec

19 EHR Equipment Overview for Clinic Managers Staff Report Introduction This document is intended to be a resource guide for the components commonly used to implement SYSTOC 7.2x EHR (Electronic Healthcare Records). Links to vendor sites are provided throughout. Your clinic s IT staff should be involved in the process of researching and reviewing necessary components and helping you find the items that offer the best fit for your network. In the table below, the column labeled Ideal shows the equipment configuration we recommend to support enhanced network performance and growth; the column labeled Budget shows a minimalist approach to setting up SYSTOC within your network. Both lists are simply starting points that will need to be modified when taking into account clinic-specific factors, such as the physical layout of the network, the number of employees, and how SYSTOC will be utilized. Server EQUIPMENT IDEAL BUDGET 2 Servers 2 drives RAID1 3 drives RAID5 OS and swap file on RAID1 Application, MSSQL, and db on RAID5 2 Servers 3 drives RAID5 Partition for OS/Application Power Generator/UPS UPS Backup/Disaster Recovery SAN/NAS/Virtual Server NAS/LTO/Tape Tablet PC Tablet PC in wireless environment - largest view screen - fastest CPU - RAM 1GB Laptop or workstation - RAM 512MB minimum Workstation Signature Pad Scanner 3GHz P4-17 monitor - RAM 1GB Topaz SigLite - varies by version of SYSTOC - must use Topaz SigLite T-S460-B if running SYSTOC in a Citrix/ Terminal Server environment (check SYSTOC version for compatibility) Networked document center - Page Feeder/scan multiple - Software that allow scan to PDF format P4-17 monitor - RAM 512 MB Topaz SigLite - varies by version of SYSTOC - must use Topaz SigLite T-S460-B if running SYSTOC in a Citrix/ Terminal Server environment (check SYSTOC version for compatibility) Local scanner Remote Redundancy T-3/Terminal Services DSL/PC Anywhere Fax Solution Printer Fax server /document center Fax machine/software print SYSTOC White Papers Dec

20 Recommended Components Tablet PCs Tablet PCs eliminate the need for workstations in every room and provide clinicians the necessary mobility to move throughout the clinic in the course of patient care. Dual form factor (can function as either a tablet PC or a notebook) Wireless Access Points Wireless access points allow your tablet PC to connect to the network without a network cable. Many companies manufacture wireless access points. Linksys Cisco Systems Tablet PC Fujitsu Toshiba UPS (Uninterruptible Power Supply) A UPS device provides temporary battery power (typically about 15 minutes) to handle an abrupt loss of power and allow technicians to shut down the network in a controlled manner if power is not restored promptly. The UPS wattage must be capable of supporting the server, and should oversize the equipment s wattage. The more money you spend on this device, the more time you buy before the system has to be shut down. Virtual Server A virtual server is a powerful server that runs virtual server software. This software enables multiple versions of an operating system like Microsoft Windows, Linux, or Novell NetWare and associated applications to run simultaneously on the same piece of hardware, or to be moved between physical systems while the server software is running. Virtual server software consolidates applications and infrastructure services running on diverse operating systems onto fewer highly-scalable, reliable, enterprise-class servers, including blade servers. Virtual server software provides flexibility and redundancy to keep server downtime to a minimum if your application/database server goes down, you simply switch to another virtual server that has SYSTOC already installed. APC Tripp-Lite VMWare ESX Server SWSoft Virtuozzo Microsoft 20 SYSTOC White Papers Dec