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Electronic Medical Records

Lesion Mapping for NextGen EHR Dermatology: UPDATE!

In order to optimize the process of making digital body maps we have created our own images and legends.
Read the first post that I wrote on this explaining the problems of NextGen bodymaps we encountered with the original proposed method by NextGen trainers.

We ultimately created 19 hand drawn body map templates with our legend system embedded into the template.

The 19 different body maps are:
Adult Body Front and Back (no head)
Adult Body Right and Left (no head)
Adult Head Front and Back
Adult Head Right and Left
Baby Body Front and Back (with head)
Baby Body Right and Left (with head)
Baby Head Front and Back
Baby Head Left and Right
Toddler Front and Back (with head)
Toddler Head Front and Back
Toddler Head Right and Left
Ears Detail Left and Right, Front and Back
Eyes Detail
Feet Detail top and Bottom
Hands Detail Front and Back
Lips and Mouth Detail
Nose Detail Right, Center, Left
Everything Body Map
Everything Body Map with Genitalia

Our legend includes 10 colored circles:
Red – Squamous Cell Carcinoma
Blue – Basal Cell Carcinoma
Green – Non Melanoma Skin Cancer
Brown – Nevus
Grey – Wart
Purple – Vascular
Outer Red Inner Black – Atypical Pigmented Lesion
Yellow with AK – Actinic Keratosis
Yellow with SKR – Seborrheic Keratosis
Orange – Other

We also created letters A, B, C, D, E, F, and a few other markings.

Users can pull up the most appropriate body map. These body maps were hand drawn and sized to fill the entire NextGen Imaging window.
The user can then select the color of the dot they would like to add to the body map.
Clicking on the body map will then add that colored item to the bodymap. The user can easily add as many of these they want. We have sized the images and the colored circles so that they are an acceptable size ratio across all the different body maps, minimizing the amount of editing the user has to do.

If you would like to purchase our images and the instructions on how to setup, please contact me.

Physician Assistant (or NP) sign off in NextGen with Supervisor

The NextGen workflow for submitting PA encounters to supervising physicians for signoff has been modified. This modification was done to include appropriate documentation in the note, as well as simplify the process for the signoff by the supervising physicians.

First, let’s see how a standard sign off works.

This shows that the providers name is in the drop down list next to the location.
None of the checkboxes at the bottom of the template are selected.

This results in the document being generated showing who the provider was for that encounter.


This document must be signed, which can be achieved by clicking on the check mark as seen here, or by clicking “Accept” in the PAQ.


The electronic signature is added to the bottom of the document.

Now for a Physician Assistant Sign Off with request for review by the supervising Physician…
NOTE: This is for documentation purposes only. This does not send the note to the supervising physician, and it does not effect how the encounter is billed.

The first scenario is for PA signoff with request for supervising review, where the supervising physician was “available”. This is probably the most common encounter.

This documents that the PA was the provider, it was signed by the PA and requested review by the supervising Physician. It documents, who the supervising physician is, and that they were available at the time of service.
This document should be generated “offline” so that it shows up in the PA’s PAQ.

Once in the PAQ, the PA can “Reassign” the document to the supervising physician’s PAQ. Once in the supervising physician’s PAQ, the supervising physician can click “Accept” to co-sign the document.

The next scenario is for PA signoff with request for supervising physician review, where the supervising physician met with the patient.

The next scenario is for PA signoff with request for supervising physician review, where the supervising physician was off-site.

Physician Assistant Meaningful Use Criteria – Restrictive

The EHR incentive program is designed to reward physicians who use an EHR. Those physicians also must see Medicare patients to receive the incentive payments. The criteria and restrictions on who can receive Medicare Meaningful Use EHR incentive payments is acceptable. I can look at those requirements and say, “Ok, that’s what they are trying to accomplish, and so they are going to reward those physicians”.

When I look at the Medicaid eligible professionals though, I immediately see unfair flags. How can you be eligible for the Medicare incentive payments but not even be eligible for the Medicaid incentive payments (Chiropractors). This doesn’t make sense to me. Then I see the Physician Assistant criteria that must be met in order to be eligible.

The only explanation I can come up with to explain this is lobbying. When “they” were coming up with the list of eligible professionals did someone whisper in their ear, advocating certain professionals to be on the list. Did the Chiropractors not have enough political power to influence the decision to be on the list (I don’t even know, maybe chiropractors don’t bill for Medicaid at all, which would explain why they aren’t on this list.)

What I do know, is that this list includes Nurse Practitioner and Certified Nurse-Midwife, without restriction. But in order for a PA to be eligible the PA must work in a qualified health center or rural clinic and the clinic has to be run by a PA.

Looks like the PA’s didn’t have enough political power/money to pull this one off. We aren’t as important as other fields to incentives us to use EHR.

Someone realized that PAs are dependent practitioners, we always work with a supervising physician. If the physician moved the practice to EHR, the PA would also be using the EHR, and therefor there is no extra need to pay the PA for the cost and work associated with implementing an EHR.
(What if there is a group practice of physicians and the owner decides to use EHR, do you not allow the other physicians to receive EHR incentive payments?)

Many of the EHR companies view PAs as a provider, and when you pay for the software, you pay per provider. – Cost to implement the EHR

Many times the PA becomes the office staff person responsible for handling a good portion of the EHR implementation. – Work to implement the EHR

In future legislation, I hope to see Physician Assistant’s names along with other eligible providers, without additional restrictions.

NextGen Version convention

I’m confused about how NextGen does their version numbers. In addition to a number scheme they also have UD2 (update 2), UD3, SP1 (service pack 1), and then they have separate version control for templates (KBM 7.9, KBM 8.0).

When you login to NextGen, the version number appears at the top right of the login screen.

We are currently on version 5.6.5.73, but you’ll notice something about this… there is no mention of UD1, SP1, or KBM 7.9.

Todd Zantow offered this solution, which I agree would be a much better system than what NextGen is currently using.

In my opinion, the schema should be: V.SP.UD.P where:

V = MAJOR version, such as the change from 3.x to 5.x (Fusion) and/or a new look and feel like 5.6

SP = Significant revision – many new features and/or service pack level

UD = Regular revision – some new features

P = patch/build/hotfix level – no new features

In that model, you normally wouldn’t upgrade even from 5.6.5.73 to 5.6.5.82 unless you needed something that needed to be fixed.

5.6 should have been 6.0.x.x. Service Pack 1 should have been 6.1.x.x and the Updates (UD) should be 6.1.2.x.

I urge NextGen to drop the confusing practice of telling users that they need to upgrade to a SPy UDx, when internally and on their website use the x.x.x.x format! We have enough confusion with the HIPAA/ARRA/MU/5010/ICD-10 requirements, we don’t need more confusion.

Todd Zantow

Prairie Clinic

So how can you tell what version you are on, and how the different codes relate to each other…

SP is a service pack with significant bug fixes and new features, whereas UD is an update with just bug fixes.

5.6.5.73 is considered 5.6 SP1 UD2, but you could also have other similar version numbers that would also be considered 5.6 SP1 UD2.

KBM refers to the NextGen EHR templates and has its own versioning system separately from the NextGen application.

You can run this SQL query:

select * from btu_version

order by create_timestamp desc

Or, per the NextGen knowledgebase follow these steps below. In my case I get “7.8” but the SQL query gives me a more detailed result: “7.8.2.6 – Service Pack”

Every KBM template has a hidden version label. To determine which version is currently being utilized in the host database:

1. Log into Template Editor.
2. Open any KBM template (for example, ABN).
3. The version number appears in the upper, left-hand corner of the template.

Which means that you can be using templates from different KBM versions at the same time. The dermatology templates weren’t upgraded with the KBM 7.9 look, and remain at 7.8, but when you access a vital sign template you get the newer 7.9 template.

In addition to all of this, you also have to pay attention to see if certain versions are released as beta versions, or as general release versions.

Uggh

Know how NextGen Prescriptions were given to the patient.

When you are giving a patient a prescription for a medication, you go into the Medication Module, select the medication, and your directions, then click “Accept”.
This puts the medication into the patient’s medical record, but you have to take another step and prescribe the medication. You can print the prescription, fax the prescription, or e-prescribe the prescription. The problem is, after each of these steps NextGen doesn’t really give you any sort of confirmation that you did what you just did, and when reviewing medications in the past you don’t know which method of delivery was done for those medications.

By adding the “Last Audit” column into your Medication View, you will see one of several things.
Nothing – means the prescription wasn’t given to the patient (maybe it was prescribed by someone else)
P – means the prescription was printed
F – means the prescription was faxed
E – means the prescription was sent via eRX

Now when prescribing medications, you can view this “Last Audit” column and see how that prescription was delivered.

See the “E” in the Last Audit Column

Get this column by right clicking in the Medication View bar and selecting “custom”“Set Columns to Display”.

Now move “Last Audit” from the left list to the right list and move it to the position you want it.

Hardware devices for NextGen Documentation during the visit

Most of our offices and Physicians will be using an iPad to walk around the office with, see who is in an exam room, and view their history. They will be able to enter information into the EHR with the iPad during the visit. But the general idea is that they would then chart most of the visit at their desk, using a desktop computer with a keyboard and mouse.

Currently there is no native application for the iPad. We would be connecting to the windows environment through the iPad. Because the software isn’t made for the iPad, there may be things that will be frustrating trying to use the system in this manner.

The iPad is the future, with a native application allowing complete access to the EHR in a way that is easy to view and enter information, but this app doesn’t exist yet (maybe a year out…?)

The new iPad2 is light, uses touch input and has a very good battery life (reported 10 hours), which makes it ideal in many ways.

We cannot, at this time, install desktop computers in each exam room. Besides the cost, the practitioner/medical assistant would have their back partially turned to patients when dealing with the EHR.

The other option, is to have a laptop computer. I see other offices go with this route. A laptop will allow for much better use of the EHR when in the room. (some use convertible tablets that allow pen input as well). The problem with this, is that they are heavy, difficult to use, unless you set it down somewhere (makes it really difficult to use in the hallway), and their battery life is generally poor. We would have to have extra batteries, and sometime during the day we would have to plug it in, or switch the battery (hoping that the backup was properly charged).

What about an iPad case with a real key board?
What about a tablet PC or a netbook?

I have the first gen iPad, and I have a case with a real key board (the battery is separate and has to be charged via usb – I’m not certain of it’s battery life). I’ll have to do some research to see if they have come out with cases with key boards for the new iPad. The new iPad is thinner, and may not fit in the old cases, and we would have to wait for a manufacturer to sell an iPad2 keyboard case.

Adding a key board does add a bit of weight, and then makes the iPad a little more difficult to use, (more like a laptop, but without a mouse or fingerpad). But it would be fairly inexpensive, and if after using it for a while we decided to abandon it, we would still have the iPads to use.

The tablet PC is what I originally thought would work best.
Most of the new competitors to the iPad run android, and it would be exactly like the iPad, except more expensive and not as good a battery life, and less likely that an app would be released for android before apple.

There are a few Windows tablets. One of the first new lower cost tablets available is the HP slate. I actually purchased an HP slate tablet thinking it would work best. It has a five hour batter life and the battery is not swappable, so we would have to dock it occasionally throughout the day to charge it. You can use your fingers to navigate it, but it works best with its stylus. It is a little bit smaller than the iPad, which makes it easier to carry around and hold (although it is probably slightly heavier than the new iPad). If you docked it in the room the dock could have a keyboard and mouse attached making it more of a desktop, but a very small screen. (It has a usb port). And you would then have your back to the patient again.

There are other larger windows tablets available at more cost ($1900 plus peripherals (battery, docks etc) versus iPad at $630. I think battery is still an issue. I would suggest one from motion computing. They have one with a swappable battery. It weights 3lbs, versus the new ipad at about half that weight 1.6lbs. Both have integrated cameras, but I caution that they won’t work seamlessly with our EMR. We have a better chance that a native iPad app will come out and the camera will work with the EMR, than getting a windows tablet camera to integrate.

Of note, the iPad I was going to order would have a 3G radio. If we lost our internet connection (our T1 went down), we could activate the subscription for the 3G, which would cost $25 for a one month no contract wireless connection. We could then still connect to our hosting provider via 3G. Again, this would take some configuring of a VPN to get working properly, but I think it would be a viable option to allow us to still use the EMR off our network.

I think a netbook would be a poor option. Most of them have pretty slow processors, but this is really just a thin client because we are using Remote Desktop via VPN into our hosting company. So I don’t think the speed will suffer any. It would be small and easier to carry than a laptop, but still difficult to hold and chart (especially with the small screen). The EHR templates have a lot of information on them and are both hard to see and click on boxes on the smaller screens. Battery life issues come up again, and most don’t have swappable batteries like the laptops do.

In light of the above, we have decided to order iPads for our providers and medical assistants.

NextGen in the Cloud – the real cloud

When I was looking for a EHR system, I was originally looking at SAAS systems. That’s Software As A Service. Basically you log in to a website, managed by the company, and you use the software and all your data is there. When the company has a new version, it automatically gets upgraded on everyone’s account, so the next time you log in everything is suddenly on the next version. It’s completely hands off, so you can focus on practicing medicine, and not dealing with your EHR software.

I didn’t find an EHR that matched all my criteria as well as available in the SAAS model.

We found NextGen and found we could have it hosted off site by a third party that was familiar with and regularly manages updates etc.

Having the software hosted off site allowed us to avoid dealing with hardware completely. We also knew that it would be easier to configure a connection from each of our five locations to this third party hosting site. (We are using a mesh network via AT&T – MPLS)

But let me tell you what I really wanted to do with NextGen. I wanted to run it in the cloud.

Most people think of the cloud as anything that is available via the Internet, but actually there is another definition of cloud computing. Cloud computing means that the software runs on a virtual server. Most applications that run via the Internet are loaded on real servers in some server farm somewhere. You purchase/lease three (how ever many you need) servers, configure them, load your web software, and then allow access from the outside world. If all of a sudden you get massive growth, your servers get overloaded, and they crash. You then have to get more servers, and configure those to handle the additional load. Everything is done manually. Disk space is also managed in the same manner.

A virtual server isn’t a physical box limited by it’s internal guts. A virtual server is setup in a manner that allows the server to contract and expand based on the need. Everything is done automatically. It never gets overloaded and slow, or crashes. Additionally, you only pay for the current state of use. You can also get virtual storage, that does the same thing.

I setup a conference call with NextGen engineers to explain my plan. I was going to use Amazon EC2, and Amazon S3 (Microsoft was just announcing their release of Azure). Several issues were brought up by NextGen. First, they didn’t think NextGen could be installed to a server in this manner. (I still don’t see why not, but maybe I’m missing something). Second, there were concerns of HIPAA security compliance. (? I don’t know).

If anyone is successful at getting NextGen running in this environment, let me know, because I would consider moving it over given the many advantages.

NextGen has no plans to release a native iPad app

Based on multiple answers given by NextGen staff, it seems that NextGen has not started development on a native iPad app, nor does it intend to. This comes from inquiries to NextGen sales members, trainers, project managers, and engineers. No one knows of an iPad app in development.

What NextGen may be developing is a more complete version of their NextGen mobile, which allows web access to the NextGen database in a device optimized format. Currently NextGen mobile has limited functionality.

The advantages of this format is that it will be developed once, but available on an iPhone, iPad, any Android phone or tablet, and any windows based hardware. This disadvantage is that you would have to pay NextGen monthly access fees, as NextGen mobile is software as a service and resides on their servers.

I would prefer a native iPad app. The other devices they are tailoring to be compatible with, do not have the battery life to make them usable, and so far are not really any less expensive than an iPad.

There are talks of third parties developing a native iPad app, and I’ll keep you up to date on those developments. If anyone knows of a native NextGen app (not NextGen mobile), then please let me and everyone else know in the comments.

Things we need to know how to do using NextGen

(We already use NextGen for scheduling and billing, so those tasks have already been worked out. Now that we are adding EHR, we have a few things to tweak with check in and billing, but these things are mostly pertaining to the electronic health record.)

Chart Abstraction

Scan Insurance Card
Sign policies/consents
Input information from the Health Questionnaire
MA to room patient
MA document Biopsies / Procedures
MA document Excisions
MA document Mohs

Provider to review history (abstraction information)
Provider to review Health Questionnaire info
Pathology review
Standard patient exam
Manage “my phrases”
Biopsies & Requisitions
Destructions pre-malignant and benign
Excision & Requisitions
Excision with Frozen Section Margin Control
Mohs
KOH and other in office labs
Injections
Body map (mark lesion locations) – supplemental documentation
Pictures in chart
Order labs & Requisitions
Order studies (MRI/CT/PET) & Requisitions
Prescribe to internal pharmacy
Document medication given as sample
Prescribe to Pharmacy
Prescription refills and matching refill requests
Input medication prescribed by outside MD
Pathology input
Pathology manage
Tasking
Signing Documents
PAQ (provider approval queue)
Billing E/M
Billing Procedures
Billing Cosmetics
Cosmetic Quotes
Self pay patients
HMO patients – authorization allowed
Diagnosis – lookup/custom favorites
Send referral thank you letter general derm
Send referral thank you letter excision/mohs/etc.
Request Authorization
Request Authorization procedure
Laser General documentation
EVLT documentation
Cosmetic documentation (injectables)
Consent – Sign and input into chart
Printing
Faxing
Patient Education
Wound Care Instructions
Schedule Follow Up
Check out

Billing to take over charges submitted by EHR

Run reports
Track Meaningful Use Measures
Copy chart for chart request
Give Patient exam summary sheet

Let me know what I missed…

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