Introduction
“Project Introduction: A physician’s office hired you as a consultant to provide recommendations for an efficient information system that will: 1) minimize patient waiting time, 2) decrease paper work between the office and other healthcare entities such as hospitals, labs, and imaging companies
3) increase quality of patient care, and 4) optimize billing and coding process. Your recommendations should reflect an overview of the key technologies that are important in today’s business environment and introduce organization and management concepts relating to information technology function. Problem Description: “The current processes are not efficient,” the physician stated. With the current system a new patient has to fill paper work that might take 15 to 20 minutes at their first visit. The nurse will verify new patient information; take the temperature, the pressure, the weight and the height in an additional 30 minutes. The physician will see the patient after almost 50 minutes of their arrival time, which is irritating to the patient and stressing to the physician himself, not only that but some patients might have a serious disease and faint while waiting. With old patients, the Check‐in nurse is required to get all labs and imaging results from other healthcare entities.
These results will be faxed by these entities scanned by the nurse and saved within the system.
Waiting for the fax and scanning the results will create another delay in providing the proper service for incoming patients. The third delay comes as a result of the insurance verification process, where the biller has to make sure that insurance information are correct and that the patient has the proper authorization. Constraints: Information security is an important issue to consider when dealing with patient sensitive information actually it provides a huge burden of liability. Not to forget the ethical issues associated this type of practice. Although there are lots of policies, rules and guidelines provided by governmental and nonprofit organizations it is very important for the physician and the staff to have high ethics and morals while providing their service. Other issues to consider are more related to technology such as data backup, system login, levels of access to patient data. Going digital will require having electronic approval by the physician on prescriptions, hacking to the system might result a major problem in prescription abuse, all these issues need to be addressed when recommending a new information system. Billing and coding limits the terminologies approved to be paid by the insurance. All terminologies should follow the ICD9, ICD10 codes published by insurance companies. Codes are another issue that needs to be considered in that type of a system.”
3 | P a g e
Current Business Process (New Patient Flow Chart) Schedule visit 24 hours prior, unless a walk‐in/urgent (Patient given option of filling out paperwork online, sent via email initially) Patient arrives and signs in at front desk. (Consent signed for examination)
Patient provided with any additional forms/info needed
(Collect copay)
(Driver’s license, Insurance cards)
(Physician and nurse notified)
Nurse notified patient has completed necessary paperwork and is ready to be seen.
Nurse takes patient to exam room
Nurse takes patient to exam room and collects vitals
(height/weight/HR/RR/blood
pressure)
Nurse begins patient notes, takes history and prepares note for the
Physician
Physician notified patient ready to be seen Physician meet patient and completes history and exam
Physician completes note and orders in EMR
Patient discharged
Patient taken to front desk to schedule follow‐up visit and pay final bill if (if needed)
Patient is sent home.
(billers receive charges to bill insurance company
4 | P a g e
Data Collection and Analysis Data collection plays a crucial role in a physician’s office. From personal contact information to insurance ID numbers to past health information multiple pieces of private patient information need to be collected. These pieces of information need to be collected in an efficient manner and capable of being organized into an effective electronic medical record.
Prior to each new patient visit the patient will be electronically sent via email an interactive form to complete. This form once completed will be submitted electronically and the information provided (see attachment 1) will be incorporated into each corresponding section of the EMR. For those patients who walk‐in or are not capable of completing documentation over the internet ahead of time (ie: computer illiterate, no internet connection), an iPad will be provided at the time of patient registration on which the same form may be completed prior to the patient being brought back into the office.
Data and System Security
Multiple security measures must be integrated into an electronic medical record.
Proper unique usernames need to be setup for each employee that will have access to the EMR.
Passwords that require alphanumeric and symbol values should be required with bi‐annual change of password reminders. The EMR administrator will have the highest level of security clearance and thus have unlimited access to the entire EMR system so that they may program and manage the EMR in its entirety. Physicians and other providers (PA’s, ARNPs) treating patients will need access to all areas of the EMR without programming access. Nurses will have similar access as providers, but will require electronic provider co‐signature/authorization when placing orders in the system such as medications, labs, studies, etc. Front desk and office administrative staff will primarily need access to the patient’s demographic and insurance information, as well as the scheduling system. They will be unavailable to access clinical date on the patient given they are not clinical staff.
Ethical Issues
Each new employee will be required to complete an online course regarding HIPPA.
HIPPA stands for “Health Insurance Portability and Accountability Act” and was implemented in to ensure the confidentiality and security of all healthcare information as it pertains to a patient. Many offices source this out to 3rd party companies that specialize in this training and are able to offer short online courses, during which the employee can watch a lecture with slides, take a posttest and receive a
5 | P a g e
certificate of training completion. This course specifically addresses that any and all use of a patient’s personal identifying information (name, date of birth, social security number, etc) and clinical information (medications, medical problems, family history) must only be used in a private clinical setting as it pertains to the patient’s medical care and billing. For example, an employee is forbidden to lookup a patient’s (whom they find attractive) past medical history to find out if they are free of sexually transmitted disease. This would be a HIPPA violation. Improperly disposing of pieces of paper with a patient’s personal or clinical information printed on them also constitutes a HIPPA violation. There are many examples of HIPPA violations and the aforementioned online training videos efficiently provide a complete and adequate summary of HIPPA.
System Requirements and Recommendations A basic EMR must incorporate the following: an electronic means to share provider notes between consultants in different offices, e‐prescribing, an organized chart which allows the physician to easily find different sections and different items in each section efficiently, notes that are easy to complete in a short period of time with optional note templates, tables to track chronic disease recommendations, tables to track health maintenance items, tables to track medical problems, tables to track drug allergies, tables to track current and past medication use, tables to track surgical history, tables to track family history, tables to track immunization history, integrated billing, integrated patient scheduling with schedule appointment reminders that are automated through phone and email, a way of tracking important reminders that the doctor needs to see at each patient visit and a way of organizing
(usually through chart sections) scanned patient documents from other offices which may not provide electronic document or interface with the office’s EMR.
An adequate networking system needs to be in place with either a computer in each clinical setting or a portable device such as a laptop or iPad that the provider can bring with them to each room. VDI (virtual desktop access) using IR badges can be very useful in the clinical setting allowing the doctor to move from room to room and quickly access the same screen they were on in the previous room without having to re‐login to the computer and EMR between each patient visit. There are two main types of EMR, locally based or those which use cloud servers. A cloud based EMR provides additional benefit in that one can easily have access to the EMR from multiple locations. The patient’s medical records are kept safe on the “cloud” through a 3rd party company which automatically provides backup of all of the records and maintains the servers. One does not have to worry about needing to manage their own EMR server.
6 | P a g e
Attachment 1‐ New Patient Intake Form OFFICE LOGO
Name:
First
Today's Date:
Address:
Telephone Number:
Home‐ (
Middle
Date of Birth:
)
Cell‐ ( )
Last
GENERAL HEALTH
1. Why did you make this appointment? (Check all that apply.) regular checkup first appointment to start care with a new doctor switching doctors (from:
) have a specific health problem (if so, explain:
2. How would you describe your health? Excellent Very Good Good Fair Poor 3. Are you taking any prescription medicines? Yes. (please list your medicines below) No, I do not take any prescription medicines. (If no, go to question #5.)
Name of medicine
Amount / How many pills or doses do you take at size of pill
morning noon dinner bed
morning noon dinner bed 4. What over‐the‐counter medicines do you take regularly? Pain reliever (for example: Tylenol, Advil, Motrin, Aleve, aspirin) Vitamins Antacid (for example: Tums, Prilosec)
Herbal medicine (please list)
Other (please list)
None ‐ I do not take any over‐the‐counter medicines regularly. 5. Have you ever had any allergic reaction (bad effects) to a medicine or a shot? Yes. (Please write the name of the medicine and the effect you had.) No, I am not allergic to any medicines.
)
7 | P a g e
Medicine I am allergic to
What happens when I take that medicine
6. Do you get an allergic reaction (bad effect) from any of the following? (Check all that apply) latex (rubber gloves) grass or pollen eggs shellfish Other (please describe)
No ‐ I have no allergies that I know of. 7. Have you ever been a patient in a hospital overnight? Yes. (If yes, explain EACH reason and when.) No, I have never been a patient in a hospital. (If no, go to question #9)
I was in the hospital because:
When
FOR WOMEN ONLY
10. Have you ever been pregnant? Yes No
How many times?
How many children have you given birth to? 11. Have you had a PAP smear? Yes No
Result and Date of last one
12. Have you ever had a PAP smear that was not normal? Yes No 13. Have you had a mammogram? Yes No
Result and Date of last one
SHOTS
14. When was your last Tetanus shot? Year
15. When was your last Pneumonia shot? Year 16. When was your last Flu shot? Year
never never don’t know
don’t know
never
don’t know
SOCIAL HISTORY
17. Circle the highest grade you finished in school?
1 2 3 4 5 6 7 8 9 10 11 12 GED 1 2 3 1 2 3 4+ Grade School High School Vocational School College
8 | P a g e
18. What language do you prefer to speak? English Spanish Other
19. How well can you read? Very well Well Not well I can not read 20. What do you do during the day? Work full‐time Work part‐time Attend school Take care of children at home Go out most days (shop, visit, appointments) Stay home most days Other
21. Have you ever smoked cigarettes, cigars, used snuff, or chewed tobacco? No (if no, go to question #23.) Yes a. When did you start?
b. How much per week?
c. Have you quit? No Yes, when
_ d. Do you want to quit? No Yes Already Quit 22. Do you drink alcohol? No (if no, go to question #24.) Yes a. Have you ever felt you ought to cut down on your drinking? Yes No b. Have people ever annoyed you by criticizing your drinking? Yes No c. Have you ever felt bad or guilty about your drinking? Yes No d. Have you ever had a drink first thing in the morning? Yes No 23. Are you Single Married Partnered Divorced or Separated Widowed? 24. Do you have sex with: men women both neither 25. In the past year, have you been emotionally or physically abused by your partner or someone important to you? Yes No
FAMILY HISTORY
What medical problems do people in your family have?
Family Member
Medical Problems
9 | P a g e
Diabetes (sugar)
Mother:
Cancer
Father:
other:
Diabetes (sugar) Cancer
Siblings:
Children:
Other:
Cancer
Heart problems
High blood pressure
other:
Heart problems
High blood pressure
Heart problems
High blood pressure
other:
Diabetes (sugar)
Heart problems
High blood pressure
other:
Diabetes (sugar) Cancer
other:
Diabetes (sugar) Cancer
High blood pressure
Heart problems
PAST/CURRENT MEDICAL HISTORY
Have you ever had any of the following conditions? (Check all that apply) Anemia (low iron blood)
Asthma (wheezing)
Diabetes (sugar)
Heart Trouble
Hemorrhoids (piles)
Cancer
Hepatitis (yellow jaundice)
Tuberculosis (TB)
Liver Trouble
Pneumonia
Rheumatic fever
Ulcers
Stroke
High Blood Pressure
Depression (feeling down or blue)
Anxiety (nerves, panic attacks)
Skin problems
Epilepsy (fits, seizures)
VD, STD (syphilis, gonorrhea, chlamydia, HIV) Other
REVIEW OF SYMPTOMS
Sleeping
Do you feel tired a lot?
Do you have trouble falling or staying asleep?
Do you have other problems with sleep?
Eating
Have you lost your appetite recently?
Have you lost weight in the last year without trying?
Do you eat too much or have you gained weight recently?
Do you have other problems with eating?
Throat
Do you have sore throats a lot?
Do you have other problems with your throat?
yes yes yes yes yes yes
no no no no no no
yes yes yes
no no no
10 | P a g e
Ears
Back
Eyes
Nose and
Sinuses
Teeth and
Mouth
Heart or
Breathing
Bowel movements Peeing and
Kidney Stones
Joints
Head, Balance,
Fever and
Weakness
Emotional
Health
Do you have trouble hearing?
Do you wear a hearing aid?
Do you have constant ringing or noises in your ears?
Do you have other problems with your ears?
Do you have back pain?
Do you have any other problems with your back?
Do you have trouble with your vision or seeing?
Do you wear glasses or contacts?
Do you have other problems with your eyes?
Do you have a runny or stopped up nose a lot?
Do you have other problems with your nose or sinuses?
yes yes yes yes yes yes yes yes yes yes yes
no no no no no no no no no no no
Do you have sore or bleeding gums?
Do you wear plates or false teeth?
Do you have other problems with your teeth and mouth?
Do you ever have pain/tightness in your chest when working or exercising?
Do you wake up at night with trouble breathing?
Do you have a racing or skipping heartbeat at times?
Do you have other heart or breathing problems?
Do you have bowel movements (poop) that are black, like tar, or bloody?
Do you have any other problems with your bowel movements (poop)?
Do you have trouble passing your urine (peeing)?
Does it burn when you pass urine (pee)?
Do you have to pee more than 2 times a night?
Do you leak urine (pee)?
Have you ever passed kidney stones?
Do you have any other problems with your peeing?
Do you have swollen or painful joints?
Do you have any other problems with your joints?
Do you have frequent or severe headaches?
Have you ever fainted (passed out)?
Have you lost your balance and fallen recently?
Do you have weakness in any part of your body?
Have you had a fever within the past month?
Do you have any other problems with your head or balance? Do you get upset easily?
Do frightening thoughts keep coming into your mind?
Have you ever been hospitalized for nerves, thoughts or moods? During the past 2 weeks, have you often been bothered by having little interest or pleasure in doing things?
During the past 2 weeks, have you often been bothered by feeling down, depressed, or hopeless?
Do you have any other problems with your emotional health? Have you ever had prostate trouble?
Do you have any other male problems?
Do you have pain or lumps in your breast?
Do you have unusual vaginal discharge or itching?
Do you have any other female problems?
yes
no
yes
no
yes
no
yes yes yes yes yes yes
no no no no no no
12 | P a g e
References
**All of the above information was personally obtained by me through interview with and a day spent shadowing Dr. Christopher Riccard at the Tallahassee Memorial Healthcare Family
Medicine Residency Program. His help with this project is greatly appreciated.
