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A physician friend has asked me to look into creating a very simple EMR system for her solo practice of 50 patients at a nursing home.She is not interested in billing or other administrative functions (she already has a system in place for that); she only wants a note-taking system which will be accessible to her alone.I have looked into OpenEMR and other open-source applications, but these look far too complicated for what she wants to accomplish.Here is my idea:One laptop, that only she has access to, with a password-protected user account that will be used only for EMRs.One folder per patient, labeled according to this convention: Lastname, FirstnameInside each folder, all scans / electronic copies of lab results, X-rays, etc. can be placed, with the date in the name following this convention: Year-Month-Date Scanname.png/jpg/bmp/etc(This will make it easy to sort all files chronologically, just by sorting all files by name within a folder.)For annual physicals, histories, and other medical notes that are only used occasionally, I will create a basic template in a Notepad .txt file, which she can then copy over as many times as she likes following this naming convention:Lastname, Firstname Year-Month-Date.txtFor ongoing daily rounds' notes, I will create a single Notepad .LOG file per patient, following this convention:Lastname, Firstname.txtIn these files, I will put ".LOG" (minus quotes) in the first line of the file, so that Notepad will automatically append a time-date stamp to the file each time it is accessed. As an added bonus, I can install Launchy and have it index the entire EMR folder. Then all she has to do is hit the hotkey, start typing the surname of the patient, and right away all the pertinent files will be made available to her!Essentially I am using File Explorer (and optionally, Launchy) as the EMR system, and Notepad (with its .LOG function) as the note-taking application. Since she is the only physician in her practice and nobody else needs access to these files, I see no need to complicate things further. This system should also be extremely small in size, and trivial to back-up.Is this sufficient, and is it HIPAA-compliant?
Who knows what HIPAA compliant might be. Every EMR I have seen claims to be HIPAA compliant, but many of them recommend using Windows Server without any security or virus protection. That said, this sounds like a reasonably secure system, but not very useful. Your friend would be better served with a paper chart with this level of simplicity. Who will scan her labs, etc into that one computer? How will data be searchable when most of it is just scanned images? How will the system accomplish even the most basic task of noting drug interactions or providing reminders for preventive care, sch as colonoscopies?
If she has her heart set on the $44k promised by the HITECH act, then she probably will need something more in depth. WorldVISTA is another free EMR, derived from the VA's VISTA system. It was CCHIT certified in 2006 and may qualify for the HITECH reimbursement when (and if) it is ever available.
If she wants something very simple and turnkey, then the $995 AmazingCharts might be pretty good - it involves free typing or using Dragon. There is also a MS Office-based EMR talked about here. I think Al Borges created it.
Dawn,
please check out www.trigramtech.com and the "MedTemps" program. we have many users in the nursing home setting using our program and it's very affordable.
> she only wants a note-taking system which will be accessible to her alone.
That, strictly speaking, is not HIPAA compliant. She must be able to furnish copies of patient records to patients at least. There are several situations where a doctor has a legal responsibility to deliver all or most of her/his records on a patient to.. some person or entity. Over the next decade you can expect that reporting that was at one time merely necessary to get "incentives" will be simply "requirements". Your system will be incapable of even the most rudementary reporting.
> One laptop,
You would be crazy not to use whole disk encryption in this environment. You must also have reasonable backup strategies.
> Since she is the only physician in her practice and nobody else needs access to these files
This is a pretty arrogant assumption, on both of your parts.
> Is this sufficient?
No. For the love of all that is good. No.
What you are talking about is a system that is designed to make -your- doctor more effective, at the express cost of the ability to have information sent to or from other healthcare providers. The notion that this is acceptable is tragic. Your doctor is simply considering rendering her note into a format that would have maximal use for herself, at minimal cost, both in dollars and effort. Because she has so few patients, there will never be enough financial incentive to justify porting this data into a form that can be merged with other patient data. In short, you are considering creating a kind of super-silo.What happens to this data when your doctor retires? What happens to this data if you are not around to support the solution? Neither of you has thought this through, or even taken the time to consider that you to not even have the needed tools to properly think it through. I would encourage you to play a long game of "what-if" sprinkled with some "what-happens-when?" so that you can fully appreciate that you have not thought this through.
In twenty years people will talk about projects like this in the same terms as people do now about doctors participating in blood-letting and refusing to wash their hands because they were "gentlemen". Your doctor is considering excusing herself from the responsibility to participate in Science and you are enabling her. The informatics community does not have that much figured out (sadly) but we know enough to say that this plan is a bad one.
Do not feel too bad. Yours is just an especially bad version of the bad decision that most doctors are making to use any proprietary EHR system. The problems that you will face will happen to most doctors in America, just a little later.
Please reconsider going down this path. I would recommend ClearHealth or OpenMRS as other simple and cheap EHR systems that you can use in your environment. But really you should look into VistA, either Astronaut or OpenVistA (which both have good licenses and OK installers) b/c the VA runs many nursing homes and VistA has a reputation of handling that use-case well.
-FT
Q: How good a typer is this physician ?
50 patients at a nursing home.
Won't the nurses want access to the Physician's notes ?
For annual physicals, histories, and other medical notes that are only used occasionally, I will create a basic template in a Notepad .txt file
For this function, you might just want to have a "Macro" program spit out the text. I use my own Macro program I made with AutoHotKey. AsUType is a good macro program. Microsoft Word has it's own macro like ability: AutoCorrect. Works great.
Windows Explorer + Notepad + Launchy
As opposed to separate .txt files per encounter, I would use Microsoft Word 2003 (which has internal document versioning). If the doctor can't type, maybe use Windows Journal with remote online versioning (say. Dropbox). Text Files are easily edited without opening, and are probably not valid "Legal" digital documents.
Issues:
Billing integration ?
For Physician Notes, was your plan to print them ? (to put in the nurse's charts ?)
I wonder if we have been overthinking this problem. Increasingly, nursing homes are being drawn towards EHR for the same reasons that physicians have. I think that nursing homes have the same grants available to them for implementing an EMR that physicians have (also the decreased revenues for not using an EMR). Already several of our local (rural central Illinois) nursing homes have taken up EMRs.
Maybe your friend should just make physician notes on the nursing home's EMR. I am sure that the NH EMR is capable of physician documentation. You friend would probably then have access to all sorts of data about the patients (vitals, weights, meds, labs) without reentering data or scanning anything.
If the NH is not using an EMR then your friend can advocate the the NH acquire one. If she is just practicing at the NH, then she will have saved herself a bundle of money and a bundle of time.
Dawn:Is this sufficient, and is it HIPAA-compliant?
Are you doing this for free? If so, then anything that works will be a good start.
If you're charging your friend, then no.
If your friend is seeking a low cost system that works .. then there are many.
Graham http://www.synapse-ehr.com/ Synapse - the EMR for the superior physicianhttp://www.onhealthtech.com/Health Tech Discussion Board
I haven't read everyone's responses, so forgive me if this is redundant, but I think the system has to be CCHIT certified... think. I'm not sure if the rules are changing on that. As far as a simple EMR, have you looked at Practice Fusion? I have a friend that has just started to try and implement it. It probably IS more complicated than she wants, but it's free, web based, and from what I've seen so far, their support is amazing. Will it do everything she wants? Probably. Will it do it in a format that SHE wants? Probably not. Still, you can't beat free with a stick, and it's the most user friendly open source I've seen.
Web based is very nice, but does she have Internet access at the Nursing Home?
Margalit Gur-Arie
On Healthcare TechnologyHealth Tech & Policy Bloghttp://www.onhealthtech.com/Health Tech Discussion Board
JenniferJ: I haven't read everyone's responses, so forgive me if this is redundant, but I think the system has to be CCHIT certified... think. I'm not sure if the rules are changing on that. As far as a simple EMR, have you looked at Practice Fusion? I have a friend that has just started to try and implement it. It probably IS more complicated than she wants, but it's free, web based, and from what I've seen so far, their support is amazing. Will it do everything she wants? Probably. Will it do it in a format that SHE wants? Probably not. Still, you can't beat free with a stick, and it's the most user friendly open source I've seen.
It is very expensive to get CCHIT certified so I doubt any free EMR is going to have that certification. The system you outlined above is definitely not CCHIT certified. Search on the site for threads about Practice Fusion.
Bryan D. Uslick, MD CFCDD (Gastroenterologist) eMDs user since 3/3/2006. Currently using version 6.1 (Prior Praxis user.)
Provation MD endoscopy report writer
Well, here's the difference. PF is actually not free. It's free to the end-user, but they are essentially using google apps profile to embed advertising in the software. Whether or not you (in the figurative sense) are ok with that, is one thing, but if you are looking for an inexpensive option that doesn't require extra hardware... there it is. As far as them being certified, they are not currently, but I did find this on their website. Take if for what it's worth.
I'm actually wondering if the lack of certification will matter in the long run if meaningful use can be displayed in all other respects. It will be interesting to see how they follow through with their guarantee.
The facility that handles her labs sends her paper copies now, but they can also send her electronic copies if she requests them. Therefore no one actually has to scan her files into a computer -- it's a matter of dragging and dropping into the appropriate folder.
I'm not sure what you mean by 'searchable data'. True, she won't be able to search within files for specific items like blood pressure, cholesterol levels, etc., but every test will be labeled by date, time, and patient, which is how her paper files are organized now. I brought up your point about drug interactions with her, and she said that's a nice feature, but her pharmacy's software automatically takes care of that already.
To answer other questions, no, I'm not being paid for this. Cost is an issue -- we are trying to do this for as little money as possible and she's not doing this to qualify for government money, just to get away from hand writing everything.
I had the same questions about whether nurses will need access to the files, but she assures me that they won't. She will issue orders to them separately.
Likewise, she has a system in place with her biller that neither are willing to change at this time.
She can type moderately well. She is not the most computer-savvy person, but I am working with her on this. The important thing is I don't want to overwhelm her with too much at once.
The nursing home does not have an EMR of its own -- everything is done with paper charts. She is not the only doctor on staff, and each doctor's system is separate from the others. I will mention asking the administration to adopt a facility-wide EMR to her, but this will probably take some doing.
The nursing home does have internet access and she *thinks* there's a server about somewhere but she's not sure so I'm not counting on that.
"For this function, you might just want to have a "Macro" program spit out the text. I use my own Macro program I made with AutoHotKey. AsUType is a good macro program. Microsoft Word has it's own macro like ability: AutoCorrect. Works great."
Thanks for this suggestion. Templates are clumsy and this looks like a more elegant solution.
"Your system will be incapable of even the most rudementary [sic] reporting."
How so? With her files organized by patient and chronologically, she can very easily zip up all of a patient's records and send them to the patient or the required government entity, or find a specific record and print it out for her patient or their family.
She is not a huge fully-staffed research hospital who might benefit from automatic reporting or the other elaborate features you describe. She just has a small practice with a manageable number of patients and files.
"... doctors participating in blood-letting and refusing to wash their hands because they were "gentlemen". Your doctor is considering excusing herself from the responsibility to participate in Science and you are enabling her"
Thank you for this ridiculous hyperbole. Now I can safely disregard your post as little more than elitist trolling. Frankly, it's this all-or-nothing attitude that's slowing the adoption of EMRs among small practices. Not everyone needs a Ferrari when an Accord will do.
To the rest of you, thank you for your courteous input.
I played around with Practice Fusion today. It is a pretty rudimentary EMR. Its template system is one of the worst I have seen in an EMR. You would either need to be good at typing or use Dragon Dictate to enter data. The good thing is that it is free. Have her try it out to see if it will fit her needs. You will likely need to create some templates for her specific to nursing home notes. You may be able to combine a macro program with their template system to speed up note entry.
There's no need for CCHIT - and CCHIT certication actually means nothing in the new order. All EMRs will need to re-certify if they want access to the incentives.
I'm biased of course but Synapse would work well here ... with the server hosted on Amazon's EC2. This way she could access the records at home or at the nursing home. And Synapse works better if you're an adequate typist.
I took a look at the Medtemps website, and it does seem like a pretty good, inexpensive product. Has anyone tried this? Take a look at the website and let me know what you think of the program.
They are going to set up an account to allow me to demo the program.
http://www.trigramtech.com/MedTemps4Video.htm