Technology Solutions Any Neurology Practice Can Afford

APRIL 28, 2009
Todd Kunkler
The late-day “Guidelines, Practice, and Advocacy Open House Featuring Digital Demos” session at the 61st Annual Meeting of the American Academy of Neurology had two things going for it that made it an easy choice for us to attend the and cover it for MDNG readers: 1) the tagline “Technology Solutions that You Can Afford” and 2) the triple bill of David Kibbe, MD; former MDNG: Neurology Edition Physician Editor-in-Chief Daniel Hier, MD, MBA, FAAN; and current MDNG: Neurology Edition Health IT Advisory Board member and columnist Steven Zuckerman, MD. The good doctors (and their colleagues) did not disappoint.

Kibbe started by providing a brief overview of the general provisions of the HITECH Act, reiterating the importance of the “meaningful use” standard, which, although not yet fully defined by the National Coordinator for HIT and the head of HHS, will in all likelihood require the use of e-prescribing and the electronic collection and exchange of quality data, among other requirements. Then, in the first of several assumption-challenging statements made by presenters at this session, Kibbe noted that although the general consensus is that the HITECH Act promotes the adoption of integrated EHR technologies, neurologists and other physicians can currently achieve many (if not all) of the meaningful use goals using what he termed “products that are less than EHRs;” by mixing and matching from among HIT products and applications offered by multiple vendors, according to Kibbe, physicians can achieve the outcomes envisioned by HITECH and get paid the bonuses for meaningful use, without resorting to the use of CCHIT-certified EHRs.

Kibbe called these technologies—smartphones, document scanning, e-prescribing, patient provider secure communications, and voice-activated software—“clinical groupware,” and defined them as Web-based, software-as-service tools that promote collaboration and communication between and among patients and providers.

Neil Busis, MD, AAN Practice and Technology Editor, in his discussion on the use of smartphones in practice, noted that the big deal about these devices is not voice; it’s data. Their utility lies in the “ability to think, synch, and link,” he said. They have applications that are unique to their particular operating system and platform that can exchange data with “the cloud” (a buzzword that refers to a computing model that relies on shared resources and applications over the Internet, rather than locally housed servers and devices—think Google Docs vs. Microsoft Office) and link to the Internet.

Busis said there are currently three domains of information for which the smartphone is particularly suited: patient data, clinical decision support (including drug alerts, adverse event alerts, etc), and practice management. The iPhone alone supports hundreds, if not thousands, of applications that support one or more of these areas (Epocrates, the EyePhone eye exam tool, ICD-9 and E&M coding apps, neuroanatomy and neuroimaging atlases, an “iTunes” for medical references, etc). Smartphones in their current configurations cannot yet support a fully integrated EHR, said Busis. Nor do they have the capacity to support viewing of full patient imaging results. Other drawbacks include awkward data input (those tiny keyboards!), limited battery life, and limited screen size, which Busis likened to peering at the Internet through a keyhole. He concluded by contrasting the success and popularity of the iPhone among physicians with the low rate of EHR implementation, noting that nobody is forcing or incenting physicians to use iPhones. This, he said, is due in part to the iPhone’s openness to third-party applications and vendors, whereas EHR vendors’ notorious reluctance to open systems up to other vendors continues to hold back progress.

Next, William S. Henderson, FACMPE, a practice manager with a neurology group, spoke about the benefits of document scanning. He cited a study that found an average cost of $5.25 per chart (supplies and labor) to set up a paper chart. Another study found costs of $11.00-16.00 to pull a chart (up from $8.25 only five years ago). When the cost of renting space to store all of this paper is added to the income lost due to inefficient use of practice space (that chart room can’t be used as an exam room), the practical benefits of document scanning become clear (and that’s just figuring in patient records; when the mountain of business records associated with each patient is factored in, the economic benefits are even more pronounced).

A business-grade scanner can be purchased for about $1,000. Admittedly, many of these low-end models feature less-than-satisfactory software, but they can do the job. A high-quality scanner and software will cost about $5,000, plus IT support, said Henderson. By way of example, he offered his practice’s experiences as a guide. By using an integrated scanning system for all patient and business records, Henderson said his practice saved $27,000 per year, with zero costs for chart pulls. They also were able to turn 400 square feet previously used for record storage into clinical and business space, increasing productivity. Finally, Henderson’s group now rents out space in its storage unit to other practices that have not gone digital and need space to store files.

Dan Hier, MD, MBA, FAAN, noted that e-prescribing is currently the only form of HIT that the government is paying physicians merely for using. Physicians eager to capitalize on the proven benefits of e-prescribing (among them reduced medication errors, reduced fraud, and availability of pricing information, patient medical history, and payer coverage and formulary status) have several low-cast options that they can adopt in lieu of implementing a full-featured EHR system that offers e-prescribing capabilities. The National E-prescribing Safety Initiative is a free, standalone system that exists entirely online; practices don’t have to install software on their systems.

The NEPSI system provides patients’ up-to-date formulary and insurance information, features alerts for a variety of adverse events (allergies, drug–drug interactions, dosing errors, etc), and makes it easy to electronically process prescription refill requests (in fact, physicians who use the network to send three prescriptions to participating pharmacies are “certified providers,” enabling all network pharmacies to electronically send refill requests to that practice).

Like all standalone systems, NEPSI does not integrate with a practice’s EHR system, which can require duplicate entry of some patient demographic data. All e-prescribing systems are currently prohibited from processing schedule 2 drug prescriptions (which, due to the DEA’s onerous security demands will likely remain the case for the foreseeable future). Several attendees also reported workflow disruptions with e-prescribing.

Patient-provider secure messaging is not merely encrypted e-mail, Steven Zuckerman, MD, asserted. It is a HIPAA-compliant means by which practices can securely and efficiently interact with patients. Call them patient portals, full-function practice websites, or something else—patients want their physicians to use them, said Zuckerman. One study found that fully 90% of patients want their physicians to adopt such a system; many said that the availability of this tool would influence their choice of physician. These systems, by allowing patients to do things like schedule appointments online, check labs, and perform other administrative tasks, can reduce the volume of calls handled by office staff by up to 30%.

Fears that patients would abuse these systems by overwhelming practices with trivial requests and communications have proven unfounded. Patients generally respect their physician’s time. Care must be taken to dissuade patients from relying on the system in emergency situations; clearly-defined instructions and guidelines for use that explain when and how the practice will respond to queries of a non-emergent nature (coupled with instructions patients should follow if they are experiencing an emergency) should suffice.

Full-function systems (eg, Medem, Medfusion, and RelayHealth) are expensive, but offer front office capabilities (online bill pay, insurance and credit verification, etc), back office support (appointment and prescription refill requests, etc), the ability to post educational materials and links for patients, online visits, and electronic prescribing capabilities. Mid-range systems (AskMedica, Medem’s iHealth) are cheaper but offer fewer capabilities and functionality. Simple solutions (such as Zix Mail) offer encrypted, HIPAA-compliant, simple e-mail capabilities.

Kenneth Gaines, MD, MBA, FAAN, said that voice-recognition software fulfilled the three most important requirements of HIT: it makes workflow faster, more accurate, and more economical.

Using voice-recognition software (such as the Dragon Naturally Speaking product suite) to dictate and transcribe notes is up to 50% faster than typing, is more accurate than handwriting, and reduces transcription delays. Voice-recognition software also enables real-time editing of notes. The combination of quality, portability, and versatility ensures return on initial investment (a one-time software purchase and set-up cost) in 3-6 months.

The downside of voice-recognition software lies mainly in the need to train the system to adapt and respond to the individual physician’s voice and speech patterns. Physicians are advised to develop their own templates for notes, letters, and other forms, to ensure maximum efficiency, and to ensure their PC boasts sufficient RAM to smoothly run the software.

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