The Power of Paperless: Understanding EMRs

As the wound care industry adapts to the paperless society and electronic medical records (EMRs), there is hesitation by some professionals to embrace the digital push. A large majority of healthcare transactions in the US still take place on paper. However, our editors Caroline Fife, MD, FAAFP, CWS and Dot Weir, RN, CWON, CWS; and other industry professionals such as N. Blair Hughes, MHS, PT, CWS, director of specialty programs and wound care services for Frederick Memorial Healthcare System (FMHS), Frederick, Md, explain that there are many reasons for wound care facilities to start embracing the technological advantages that are available in EMRs. Fife, chief medical officer at Intellicure, Inc. (The Woodlands, Tex) reviews the company’s option for EMR. Weir, discusses an EMR option that her facility has been using for years, provided by Net Health Systems (Pittsburgh, Pa). Finally, Hughes discusses the EMR option used at her center (FMHS’s Advanced Skin & Wound Care Center) since 2000, provided by Wound Care Strategies (Harrisburg, Pa). Regardless of their affiliations and personal experiences with the three different companies, Fife, Weir, and Hughes raise some very valuable points and are all advocates of adopting an EMR system in a wound care clinic setting. The Complete Electronic Medical Record Option Caroline E. Fife, MD, FAAFP, CWS In 1998, the Memorial Hermann Wound Center in Houston, Tex went live with a prototype version of an electronic medical record (EMR) specific to wound care. In 2006, the system was upgraded to the most current version of IntelliTrak, an EMR from Intellicure, which according to this author meets all of the legal requirements of an EMR. The Healthcare Information and Management Systems Society (HIMSS) defines the essential attributes a system must meet to qualify as an EMR. These requirements include that all data must be collected in real time, that is, at the bedside. HIMSS suggests some other tests to determine whether a system is really an EMR including: 1. It is the official medical record (in other words, a paper chart is optional and the EMR is really the legal chart). 2. It meets HIPAA requirements. 3. The EMR checks information for reasonableness (eg, it warns if the number entered for blood pressure seems too high). 4. It supports electronic signatures. 5. It supports government endorsed message and content standards (eg, HL7). 6. The organization uses EMR data to measure and manage quality. 7. Clinicians perform no extra tasks for medical record coding and reimbursement (in other words, the calculation of the level of service is automatically derived from the documentation in the EMR). How It Works for Memorial Hermann Wound Center The HL7 interface means that when a patient is registered in the hospital’s electronic system (which happens to be Cerner), they are automatically registered in Intellicure, and wound center data in Intellicure can also flow back into Cerner (no scanning paper documents). Computers are present in every exam room and 100% of all clinical information is entered by the nurses and physicians in the exam room. Data entry is facilitated by numerous click and scroll menus, which keep typing to a bare minimum. Nursing assessments such as those for pain, advanced directives, abuse screen, activities of daily living, and so on, can be done in seconds. The same is true for hyperbaric technical documentation. Cameras are cabled to computers, which allows digital photographs to be automatically archived to specific wound locations. All clinical charting is password protected and all data entries are tracked. Numerous other security measures allow Intellicure to be the legal chart. While the legal chart is the electronic one, the program automatically generates all necessary documents after data entry is complete, including prescriptions, home nursing orders, physician correspondence, nursing notes, and so on. For example, copies of physician correspondence or home nursing orders can be given to patients as they leave the clinic. Giving patients a copy of new home nursing orders prevents confusion: patients whose payers require correspondence to authorize certain procedures know that this task has been performed, and family members of elderly patients with complex problems appreciate being able to read over assignments and plans. The ability to hand these documents to patients at the completion of their visit has been one of the most beneficial effects of implementing a true EMR. Evidence Based Medicine As the center has used the system over the past 10 years, it has certainly used all of the benefits of the EMR noted earlier, but the most exciting advance in the last 3 years is the implementation of Evidence Based Medicine guidelines directly in the EMR. By simply charting the patient’s history and physical findings, the EMR helps with live time quality assurance by unobtrusively suggesting appropriate clinical pathways to the clinician, removing the obstacle of out-of-sight, out-of-mind. Billing and Coding EMRs like IntelliTrak qualify as Interoperability Level 4 programs, meaning that the majority of data is not stored as blobs of data in text fields but in discrete, machine interpretable data fields. This empowers the EMR to automatically calculate the level of service based solely on the clinical documentation, which ensures 100% coding compliance. For example, Intellicure calculates facility level of service based on over 100 aspects of nursing documentation according to a system validated on over 5,000 wound care visits (OWM, Jan 2007). The physician level of service also is calculated based on documentation performed in the areas of history, physical examination, and clinical decision making, as specified in the 1997 Medicare Physician Documentation Guidelines. Neither the clinic staff nor the physicians perform any additional work specifically for the purpose of determining the billed level of service, so no staff time is spent to ensure documentation compliance. In addition, the physician and the facility documentation correlate with each other. When staff members sign off using their electronic signature, they are immediately able to see the calculated level of service so feedback as to the relationship between documentation and billing is immediate. The Joint Commission IntelliTrak helps our center comply with The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) regulations with features like an allergy alert each time the electronic record is opened, a patient headshot for a second method of patient identification, and complete medication reconciliation. Data Management Since 100% of all patient data is collected, data can be analyzed and reported in an almost infinite fashion. Reports can be generated on billed revenue, profit loss statements, product utilization, referring physician utilization, patient outcomes, quality assurance, healing rates, marketing effectiveness, and so on. Furthermore, data from one facility can be compared to aggregate data from all clinics using Intellicure, to provide benchmarking services. With the consent of the facility, data which has been de-identified according to HIPAA requirements becomes part of the Intellicure Research Consortium (IRC), now the largest repository of complete medical information on wound care patients in the world. These data are used by the Centers for Medicare and Medicaid Services (CMS), many CMS Fiscal Intermediaries (Fls) and Carriers, the Food and Drug Administration (FDA), as well as numerous individual investigators researching various areas of wound healing. For more information about Intellicure and the IRC, visit the website www.Intellicure.com. The Challenges of Implementing an EMR The data management dividends of implementing an EMR are enormous, but so are its implementation challenges. Every article about EMR implementation emphasizes the critical importance of training for the physicians and clinical staff. With a paper system, documentation errors, which could result in reduced reimbursement, will not be recognized (if ever) until weeks have passed. With an EMR, documentation errors link directly and immediately to problems with billing and coding and can bring clinic operations to a standstill until they are corrected. There is also a fear factor for less technologically sophisticated staff members, but even the most technologically reluctant come on board when improved efficiency becomes apparent. Significant time can be saved by simply not having to hunt for charts anymore. Clinic workflow does change with an EMR, because somewhat more time (about 10% to 15%) is spent in the room with the patient (usually increasing patient satisfaction). In exchange, far less time is spent completing tasks later. Documentation is complete when the staff exits the room. As a result, this author’s clinic has been able to put an end to staff overtime. Not a product but a process What helped us the most was to think of the medical record not as a product, but a set of processes supported by technology. The EMR has become our living operations manual, which helps standardize these functions. Implementing an EMR is inherently a process automation and systems integration task. The goal is not to create the ultimate medical record, but an entirely better clinical process. Caroline Fife, MD, is co-editor of Today's Wound Clinic, Board Member at the Association for the Advancement of Wound Care, and Chief Medical Officer at Intellicure, Inc. Fife is the past Medical Director at the Texas Wound and Lymphedema Center. She can be reached at cfife@intellicure.com. n Get the Facts: Utilizing a Comprehensive Wound Clinic Documentation System Dot Weir, RN, CWON, CWS The comprehensive and ongoing documentation of the patient evaluation, the patient progress, and the events that occurred during each encounter at a center providing wound care is the critical basis of information capturing regardless of the system; electronic or paper. There are those components that one wants to capture, those that must be captured, and the usability of this information that drives one to evaluate the effectiveness of the methodology used and quite frankly, what will actually work for them. As this author entered the world of outpatient wound care, she started in a system where at least eight pages of written forms were filled out at the first visit, and probably five of those on an ongoing basis with each patient visit. Comprehensive it was, but time efficient, it clearly was not. The attempt to gather any usable data was virtually impossible, completion of the charting was most often totally completed the next day, or when the clinicians had time, and everyone was buried in paper. And so it was that in 2003, staff entered the world of semi-electronic data management, and the author’s three centers finally were interconnected via the WoundExpert System, in one of the early versions provided by Net Health Systems. The clinics early use was not a point-of-use system. Alas, the author’s facility continued with the paper charting, and had a person whose role in totality was to enter the data retrospectively. Not ideal, but it gave an excellent start in and appreciation of the usability of the information that a system such as this can provide about centers, patient mix, payer and wound type mix, as well as healing times and rates. It allowed tracking referral sources and trends, and even generated a mailing list for holiday cards. As numbers grew in the system, that data enabled entering the world of clinical trials, providing the sponsors with up to date information of potential numbers of specific patient types that would qualify the center for certain trials. Fast forward to 2006, now at a new center that was designed with efficiency in mind. With computers in every treatment room as well as three out in the clinician work area, the facility launched into the world of a true electronic information system which has revolutionized how to achieve the same gathering of critical information, meeting all regulatory requirements, with the potential now to provide referral sources, home care and long-term care partners, and coding department with the necessary documentation to efficiently and effectively provide care and share the information necessary to keep the patient in a true continuum of care. The WoundExpert system has evolved and is currently used by clinicians and organizations all over the US. It is this author’s opinion that this EMR has passed exquisite scrutiny from a security standpoint, a comforting fact in the era of HIPPA requirements. At this author’s center, utilization of its completely customizable components from scheduling to documentation has grown exponentially, but the facility still does choose to print certain documents and file them in charts for easy access and reference. At this point in time, the center’s Health Information Management Department (HIM) and coding department still require that physician providers continue to dictate a note in the system although WoundExpert will indeed generate a complete physician note. To legally utilize that, however, the physician would need to be the person putting that data into the system. In the flow of the authors clinic it has not gotten to that point yet, though many have. In the context of this article, it would be impossible to thoroughly describe all of the processes that the system provides. For further information, refer to their website WoundExpert.com. However, listed are some the author’s favorite features: Documentation. For the centers choosing to utilize WoundExpert for their physician documentation, it is designed in the familiar Subjective/Objective Assessment Plan (SOAP) format, based on the preferences of the majority of its physician users. It includes a history and review of systems, with tabs identifying sections including chief complaint, history of present illness, past medical and surgical history, allergies, and past family and social history, enabling each section to be updated as needed and as change occurs. The system then allows the physician to add a note related to any positive complaint or past diagnosis. Similarly, the physical exam is divided out into core systems with physician defined templates and systematic flagging of abnormal evaluations to generate an accurate and updatable problem list. As a result, the appropriate ICD-9 codes are automatically identified. For those desiring it, the system also provides complete procedural information with accurate accompanying CPT-4 codes to assure accuracy in coding and billing. Additionally, as decisions are made for diagnostic and medical care, the system will generate a prescription with the accompanying codes required, which simply only then needs to be signed. For the clinic documentation, the system asks for all of the information needed to complete not only a comprehensive wound evaluation, but also all of the necessary components of a patient evaluation, with the critical information needed for compliance and achievement of the national patient safety goals, including patient identification, appropriate hand-off communication, medication safety including continuous reconciliation and recognition of potential allergy issues, duplications, and sound-alike/look-alike medications. Additionally, the system queries the clinic on any changes in fall potential as well as providing three opportunities to document current pain level, changes in pain levels, as well as pre- and post-procedural pain. Many centers have successfully completed Joint Commission surveys with all appropriate documentation parameters present. Reports. The potential reports generated by the system are as numerous as the points of data collection. Through the use of the Dynamic Report Builder, the user is able to custom design reports to meet any number of needs. Additionally, there are very specific reports set up related to commonly tracked procedures such as Negative Pressure Wound Therapy, debridement, multiple reports related to hyperbaric oxygen, and the list is endless. Of particular value is the ability for a center to benchmark healing outcomes with the data from the other more than 250 centers across the US, which the center uses as an ongoing performance improvement report. In the most recent version of WoundExpert, a new feature called The Program Directors Dashboard is available. The Dashboard allows a clinic director to have real time tracking of desired facility specific information related to performance, referral sources, payer mix, volumes, and any number of details without the need to build these reports individually. Patient and Referral Source Satisfaction. Chronic wounds can be a limb-or-life threatening process, which brings about frustration from providers and fear and alterations in quality of life for patients. Of great reassurance is to see visual proof of wound improvement, which added to decreases in actual wound surface area and volume, gives hope in the face of previous despair. One such tool in WoundExpert is the Wound Analysis, patients can view on the computer screen, but also can them to take to their primary or other consulting physicians, as well as to show to concerned family members who are unable to accompany the patient on clinic visits. The last tool, which is very effective from a reporting as well as a marketing perspective is the ability to develop a personalized template from the center to the patients referring and/or primary care physician to provide either a progress letter or closure letter at the time of complete healing. Space does not allow full expansion of what a truly excellent EMR/data system can provide for a busy clinic. There are not dollar values that can be placed on it, but the details provided, which allow one to constantly evaluate care provided for patients is priceless. n Dot Weir, RN, CWON, CWS, is co-editor of Today’s Wound Clinic and the Clinical Director of The Wound Healing Center at Osceola Regional Medical Center in Kissimmee, Florida. Weir can be reached for questions by calling (407) 518-3565 or through her email address: dorothy.weir@hcahealthcare.com. Department Evolution It’s Not Just About a Software; it’s About Your Process N. Blair Hughes, MHS, PT, CWS The Transition Process In the year 2000, a decision was made to transition this author’s existing wound care patient population from the outpatient PT Department at Frederick Memorial Hospital, to a dedicated, hospital-owned, outpatient wound care department. The wound care team managed to arrange four treatment rooms and about 1,500-square-feet of space, and recruited participating physicians from a broad spectrum of specialists. The facility felt that with its design and concept of providing one-stop shopping to meet all of the wound care needs, it needed to focus on processes that would allow it to be coherent and remain patient focused with thorough communication. It was apparent that a paper chart is cumbersome. Valuable information is lost in the volumes of pages—only attorneys take the time to read the full medical chart. The center needed to go electronic and needed to start that way or risk having difficulty convincing the staff (clinicians and physicians) to transition later. The EMR Search The search for the right EMR system for the facility began. Thorough research and tough standards were paramount in the decision-making process. The EMR ultimately selected would have to meet unique requirements—one that would meet the needs of patients, staff, and stakeholders. Any successful program must be based on the particular department’s process. Process is crucial, and pulls documentation, patient care, and payment together. Any lack of coordination would result in an exercise in futility. Patient care outcomes, staff satisfaction, and financial viability would suffer. The search for a comprehensive EMR took the facility down a path with its key players (information services, finance, risk management, quality improvement, billing and coding personnel, and the health information management director). A list of clinical and operational endpoints was created that would meet the vision for the ideal wound care software. Wound care professionals in the facility agreed that to meet needs the system must be a comprehensive medical record and financial system. There should be no duplication of work, and no transcription services needed. The system would have to be compliant with all regulatory agency requirements, have extensive reporting capabilities, and be able to grow with the changing technology capabilities. A system that could be interfaced with other hospital systems (MEDITECH in this case), work without an Internet connection for medical record documentation, store data on the network, yet provides a web interface for reporting and remote inquiries. To ensure financial success, the software would have to allow for maximal efficiency, provide auditing functions, assist in the quantification of work performed by clinicians and physicians, produce multiple clinical and operational reports, benchmarks and outcomes, and capture our spin-off revenues from referrals and tests ordered. The Selection Process For the author’s facility the choice was TriAssess® Premier Software (TPS) from Wound Care Strategies, Inc. It incorporated the key ingredients, processes, and extensive requirements. From the beginning, for this facility, this software has assisted the facility’s workflows, saved time; improved communication processes, increased patient safety, enhanced revenues and operational efficiencies, and assisted increasing patient satisfaction. TPS has allowed the center to manage the entire wound care process for performance and results. The facility was one of the first comprehensive wound programs in the area. One of the largest insurance companies in the area was not quite sure what to think, and put the program on 100% review. This was not difficult for the center due to the ease of processing the EMR reports. It did not take long before the insurance company was overwhelmed by the thorough and complete nature of the records. They removed the review requirement and even decided not to bother with preauthorization requirements. This resulted in extensive cost savings due completely to the software system. Customizing the Software TPS continues to meet this author’s facility’s customized needs. The center’s process modules would ultimately include: • Clinical and Operational Policies and Procedures • Clinical Competency Validation Tools • Continence Assessment Module • Facility-Specific Chargemaster • E/M Calculator Module • Evidence-Based Pathways and Algorithms • Facility Level Mapping Management Module • Hyperbaric Oxygen Therapy Management Module • Order Management Module • Ostomy Management Module • Patient Education Module • Physician/Non-Physician Superbill • Scheduler Module • Skin Assessment Module • Suite of Risk Assessments • Wound Care Module The department has grown into 8000-square-feet with 10 exam rooms and two hyperbaric chambers. This author believes that TPS is dynamic and the software has allowed for meeting clinical and payment requirements. As the hospital has grown with the MEDITECH EMR, and considering the CMS initiatives, it is now engaging a companion management inpatient module for our TriAssess® Premier Software, The Admission Assessment Manager™. This module provides the vessel for documentation of the admission assessment and subsequent follow up care. Advanced practice wound care team members will utilize the inpatient software to identify and document pressure ulcers and catheter associated urinary tract infections upon admission and throughout the hospital stay for high-risk patients. This module will be seamlessly linked to the MEDITECH EMR, allowing all other care providers access to the wound care documentation and photographs. For those wary of switching to an EMR system, this author’s experience was very positive and the provider was available not only during the initial process but throughout the service. N. Blair Hughes, MHS, PT, CWS, is the Director of Specialty Programs and Wound Care Services for Frederick Memorial Health System (FMHS) where she has been employed since 1993. Hughes teaches wound care courses, has published multiple articles, is a contributing editor for various textbooks, and has presented at the national level. FMHS opened its Advanced Skin & Wound Care Center in 2000, which has recently expanded to an 8000 square foot facility for wound and hyperbaric medicine in large part from the talents of. Hughes. The Advanced Skin & Wound Care Center provides evaluation and treatment for wounds of all etiologies and for patients of all ages. Program staff engages in inpatient, outpatient, and SNF levels of care.