EMR

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.

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.

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.

(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…

I use an iPad for many things including access to our NextGen EHR application (see how I connect to NextGen on an iPad). There is no native NextGen app (yet – check my article for information on a third party NextGen iPad app coming soon), and so the program is not designed for touch input. Using a stylus is a better solution than your finger in many cases.

I have been using the Griffin iPad stylus.

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It has a good thickness (similar to most pens), and is a good length. It is shorter than most traditional pens, but not so short that it is difficult to hold and write.

The most common use of the stylus is to select radio buttons or check-boxes within the NextGen templates. This way the small stylus can easily get the box you are going for without inadvertently checking the surrounding boxes. Even still I often unpinch (reverse pinch) to expand the area to make the buttons a little easier to hit with the stylus.

Plus when using a capacitive stylus there are fewer finger prints on the screen.

Another solution is to allow patients to sign their consents on the iPad. You have to have a stylus to sign your name on the iPad, it’s just to difficult to have patients try to sign their name using their finger (it’s not natural).
FYI – there’s no way to allow patient’s to sign their name on an iPad in the NextGen application. In an upcoming post I’ll show you how we allow patients to sign their consents on the iPad.

Recently I saw this post about a new stylus that is a bit longer (more like a regular pen), but it is unavailable for purchase at this time.

Every time you create a document in NextGen, it pulls a file and inserts it into the header, and pulls another file and inserts it into the footer.

Of course the default is the header includes a NextGen logo image, and the footer includes NextGen’s address.

One of the first things you will want to do is get rid of this stuff and setup your documents with your own brand.

In the EHR, you can click tools -> document builder.
A window pops up and there is a file folder called Sub_documents. browse these files to find both the sub_footer.NGN file or the sub_header.NGN file. Edit and Save these two documents to include the new information in all your new documents.

Most dermatologists draw a picture of a body, or body part in the chart, and then make a dot, or an “x” to indicate that certain lesions exist on the patient. Sometimes we use a form, with pre-printed body parts. Then we indicate that all the “x” marks are Actinic Keratosis, or that the “x” is a Basal Cell Carcinoma.

The NextGen solution is to be able to pull up body images into a patient encounter. You then have a toolbar at the top of this image window that has a few colored dots that correspond to different lesion types.

When you select a colored dot, you can then click on the body map and the dot shows up in that location on the body map. You can keep clicking on the body map to indicate additional lesions.

You can then select a different colored dot and click on the body map to indicate locations of different types of lesions.

The problem is that this isn’t ready to go out the door. The body images included in NextGen are of various sizes. They do include pictures of what looks like real body parts with colored skin tone, muscle definition and shadowing, but most dermatologists would not be used to mapping on these types of images.

The NextGen trainers have a “how to setup” document written on an old version of NextGen back in 2008. The trainers also can e-mail you their four colored dots. This document teaches you how to create the toolbar embedded into the image window that allows you to select the different colored dots.

I found the colored dots to be of poor image creation, with some areas of transparency and some areas of white surrounding the colored dot.

I also think it would be easier to have many many different colored dots, even some labeled with text to indicate different lesion types. There could be a plain red dot, a red with ?BCC, a red with ?SCC, a red with ?NMSC (non-melanoma skin cancer). Then you could map on the body image a more accurate assessment.

These are the current images in NextGen, including some of our own images, and the colored dots supplied to us by NextGen trainers.

Of course I’m going to revamp this feature!
See my updated post on what I did to streamline lesion mapping in NextGen.