Active Forum Topics | Getting Started | Interviews | EMR Forum | Medical | Billings | Press & News | Voice Recognition | The Water Cooler
We are a Pulmonary and Critical Care office with 4 physician. The physicians want to "create" all of the pathways/decision trees for office visits from Apnea to XRays and Sleep Medicine. They want to build these to be a duplicate of their thought process they would go through with a patient. Our question is: This is going to be a hefty amount of work (which they are okay with) but they don't want to give this work to an EMR company to turn around and sell and make a profit off of their work. Currently there is no Pulm/Crit Care specific EMR out there. So when this work is finished it would truly be a jewel for for all programers to use and call their own. We are working with QRS Medical in Knoxville Tenn. who have a producted called "Progression". The base system is nice and will work great but the "trees" are basic and need the specific Pulmonary/Critical Care design. What can the physician do to protect his work yet allow the EMR company to build this for us? I briefly mentioned this to the EMR company and was politely told: This is a shared process. Without our existing database and programming abilities your "tweeking" of our system would go nowhere. In some respects that is true but if your a Honda dealer and can only sell me a new car in partially assembled parts and I have the knowledge to make it drivable for everyone I should benefit. Correct or Not? Please share your ideas on this topic.
The only way is to hire your own programmers and that way you retain copyright.
I don't understand your position though. You get something you want ( who even knows if it is something anyone else would want?? ) ..what skin off your nose is it if the company that does the work uses it to help themselves and other physicians.
Medicine has changed ...
Graham http://www.synapse-ehr.com/ Synapse - the EMR for the superior physician
Here's a clinical pathways editor I wrote http://www.emrupdate.com/forums/t/15862.aspx
Feel free to use it to model your pathways.
I don't think a group of doctors should be worried that their customizations of Company X's EMR will just be used to make Company X rich .... if you actually like your customized EMR from the company .. you'd better hope the company does well so it can continue to update your EMR !
In all likelihood, your vendor's chance of survival over the next 5 years is well under 50%.
Try paying for a customized EMR where the company just goes belly up ! Now you have a customized defunct EMR !
Choosing an EMR Vendor is not like buying a TV, it's more like a marriage.
(but with more screwing ?)
http://www.synapsemgmt.com/Progression.pdf
http://www.qrsparadigm.com/web/index.html
more here:
email:
>>Choosing an EMR Vendor is not like buying a TV, it's more like a marriage.
(but with more screwing ?)<<
How true. I hope Al Borges runs a pictorial on this one!
Chris Wilkerson, D.C. Carson Doctors Group TabletPCs in Medicine Editor-in-Chief www.MedicalTabletPC.com Home: www.Digital-Doc.com
Couldn't you just get them to agree to some sort of design services agreement? That's pretty common. If you are paying them to design your software then you should share in the profits if they turn around and sell it to another group. I totally understand your logic. Get them to agree to some workable arrangement where you can all benefit.
Eric
http://fastercharts.com
I have 2 perspectives on this:
I understand the physicians view point. Having sat with them in a conference room listening to the application of their Medical School logic as we begin the "tree" process, it is going to be alot of work for them, (alot of work!). None of the systems I looked at are plug and play at least for a specialist. They know this and that is where this question has arisen from. As they meet to go over these trees the subject always gets brought up about protecting their work. I'm more concerned about getting this whole thing up than who hold's what part. But they are not letting this go and Im concerned they will hit the brakes and then back to quare one.
The EMR Co. perspective obviously would be, without our system you have nothing to work with etc. etc. Which is true enough. As for 5 years out, who knows what mess Obama will have created by then that we all have to wade through. I can not speak for who will survive and who will not survive. It may just boil down to a coin toss. What will medicine look like in 5 years? That's anybodies guess.
My perspective is to get this ugly job done. As with any medical office, you have two types of staff. 1. Those who don't know were the ON switch is, And 2. Those who think they know more than they actually do and are truly dangerous to not only their pc but in giving advice to other staff around them. The ages vary from 21 to 58. That in itself is challenging. I compare this process to launching an aircraft carrier by myself.
Design service agreement? Will have to look into that. Sounds sensible. That may be the avenue that allows much more speed to this process without the fear of falling off of a cliff.
"We are a Pulmonary and Critical Care office with 4 physician. The physicians want to "create" all of the pathways/decision trees for office visits from Apnea to XRays and Sleep Medicine. They want to build these to be a duplicate of their thought process they would go through with a patient. Our question is: This is going to be a hefty amount of work (which they are okay with) but they don't want to give this work to an EMR company to turn around and sell and make a profit off of their work. Currently there is no Pulm/Crit Care specific EMR out there. So when this work is finished it would truly be a jewel for for all programers to use and call their own."
The truth is, the group may add great content, and that content may have value, but the next pulmonary group will have their own idea on what is great content. That is why it is most important that the system has not only clinical content, but also the ability to edit and add to that content.
Which is why most places have their own "best practice guides" instead of everyone using the same ones.
We experienced a similar situation for our dermatology practice. As others have stated, there are simply no good EMRs that are ideal for specialties "out of the box."
What worked for us (or let me say, what worked for my bosses!) is to utilize a computer-literate member of the practice to make the templates and customizations. In our practice, I was that employee. I work as a Physician Assistant, and after doing what I've done, I cannot see how any programmer with no clinical experience will ever begin to get it done correctly. I have spent hours on any given "template", only to find during actual use in seeing a patient that something needs to tweaked or streamlined. You simply will not be able to fully convey your thought process effectively to a programmer. If you try that route, you will either find yourself going back and forth with them, having them redo or tweak the templates many times over (at your expense), or you will find yourself "settling" for a number of templates that work well for the most part, but aren't quite where you want them.
So, I have a few suggestions. First, like someone else mentioned, please look at the overall likelihood of this particular company being around in 5 years. It's true- many smaller IT companies dabbling in the market will not be around too long, and it will RUIN YOUR DAY YEAR if they go under and you are left with an unserviceable product.
Secondly if/when you do finalize which EMR to go with, make sure it's easily customizable. We use e-MDs, and I naively thought all EMRs were just as customizable. I've since learned that template customization is not an easy task in a number of other EMRs.
Third, consider hiring a computer-savvy clinician as an employee whose job duties include the building of those templates. I say clinician, because to really understand how to make the templates "flow" like they should, the person creating the choices, etc., in the templates needs to know what it's like to "think" like a doctor. This can be a PA, NP, or even an MD (although the cost of an MD as a quasi-programmer could be a bit prohibitive). But even a good nurse or MA still doesn't think like a doctor. He/She must know what it's like to diagnose, think of differentials, treatment options, etc. A PA or NP could come on, see patients 2-3 days/week, and work on the computer the rest. The average PA or NP will make his/her supervising doc a fair profit seeing patients full-time. This one may not, since he/she would only see patients part-time, but at least they'd likely break even.
Finally, with regard to either recouping or even profiting from the work put into the templates....good luck. I suppose if you do build a great set-up, there could be the option to work with a clinic on some sort of reimbursement for any templates they use. But how much $$ and who is to keep them from simply "pirating" the templates somehow? It all gets sort of sticky and you'd likely pull your hair out trying to keep tabs on all of it.
In the end, believe me, it's worth it just having an EMR which is customized to your practice the way you want it.
Tim
Tim,
Another consideration is to trade templates with peers. For example, we have a function in Medtuity where you can right click on the template name and email the template to a colleague. As EMR adoption rates increase, this should become more popular.
Yes, that would definitely be the smartest way to go....if 1) you can find someone willing to share them with you and 2) your EMR is able to use these shared templates. I'm glad to hear Medtuity has the capability to do this.
In checking out the popular eClinicalWorks, it came to be my understanding that changing or customizing the templates is virtually impossible. I tried to contact a few derm users when we were getting set up, but got no response. Also, as someone else mentioned, no matter how well you think something may be set up, you're still going to want to customize it even more.
If the original poster of this thread can find out if any peers are successfully using EMR, then finding out which one they're using and borrowing their templates is without a doubt the easiest way to go. That being said, anyone who has spent hours upon hours customizing and creating templates likely isn't in the mood to give them away for free. But even to sell them for a nominal fee still is going to be a lot cheaper and a lot less hassle than starting from scratch.
The hard part is convincing someone of that when they first get started. How many of us have ever started a home-improvement project which looked "easy" only to say in the end that "had I known it was going to be this difficult I never would have done it myself!". That pretty much summarizes exactly how I felt once I got knee deep into doing it for our office's EMR.
Currently, no one is using them in our specialty that I am aware of. That is what is making this such a big task. The existing format is at best generic.
I have looked at a number of systems, tell me, they all appear to have been built on the same concept. Is there a central design that most emr companies pull from to build theirs? Just curious. I went to a demonstration for Greenway (may not have the name correct but it was Green something) and it looked very similar to other systems. Problem is is that they like many others they push the use of a "Dragon" device when text entries are needed. That is not an option here, which puts me back onto the logic tree format with drop down boxes where indicated.
I am beginning to think that the reason we have not come across a pulmonary design is that no one (physician) has taken the time to perform the work that we are now undertaking.
Another question I have is how compatible are all of the designs for EMR's. Example if Dr. X want to send a report to Dr. W, will both systems be compatible as to sharing data when prompted to. I am assuming that is some of the push here "compatability".
OLCC,
Most EMRs are designed and built by programmers. Many are remarkebly similar because when a programmer has a lack of expertise in the field of medicine, they have little choice but to copy what already exists.
Additionally, documentation is typically slow using the "logic treee format with drop down boxes" (as you described it). To speed documentation, programmers typically use "documentation by exception". That is, you pick a template (sinusitis) and and a sinusitis note is generated. Your responsibility is to change or delete what does not apply to the current patient. Each time you generate a sinusitis note, you find some content as superfluous or even dumb, but you have little choice but to remove it each time, or simply ignore it. Four pages of documentation is not unusual with such a design. Relevant facts are often hidden among the meaningless drivel. "The EMR made me do it!" is an oft repeated phrase.
Dragon is often used to add "color" to a history, but to also overcome the limitations of poor clinical content and a slow user interface.
Many EMRs have either no template construction tools, or are so difficult to use as to make template building available only to those with an advanced EMR degree.
But I digress..........To answer your questions, there is no uniform method of storing information in an EMR database, especially the clinical details of a visit. There is a method of transmitting this information to another physician in a digital and computable form-- it's called the CCR, or Continuity of Care Record. It is based on a format called XML which allows the trading of data in quite a robust way. The CCR is an ANSI standard and quite detailed. Unfortunately, while very good a transferring "the lists" (problem, meds, allergies, SH, FH, encounter dates, surgical hx,etc), it has no features for transferring the actaul encounter note ("Mary comes to the office today with a 24-hr hx of burning on urination...").
Similarly, there is no uniform way to trade the clinical store information (or the logic tree that you alluded to). It is not terribly difficult to design, but to trade such information, you need trading partners. There is no agreement on the logic tree. Personally, I think what physicians have u sed for decades (the H-and-P format) would work very well because physicians are immediately familiar with that design.
One of the most important features you should require in an EMR are:
- ability to add new signs and symptoms to the clinical store, even while documenting on a patient
- ability to edit templates on-the-fly, even while documenting on a patient
These two features will allow you to control what is printed in the encounter, not the programmer who designed the system.
Our system includes the tools to do your own customization. If you do your own customization we will not re-use your work without your permission. However, we will also do the customization for you at no extra charge. If we do the customization we reserve the right to re-use it. I wish I could count how many times we have been told how valuable the customization would be to other practices but rarely found that to be the case. That is one reason why the ability to easily customize the EHR is so important.
C Huddle VP, Market Development www.Sevocity.com