EHR Guru

Hello Everyone,

When shopping for an EHR system there are many key points you need to evaluate when shopping for an EHR. These will help you identify which of the EHR solution is the best match for your budget and your specific needs. I have developed a set of ten points, which will help put any practice on track for partnering with the absolute best product/company for your needs.

This list of evaluation points will apply in some way to everyone shopping. You might consider keeping a note book for taking notes on each point so you can remember them in the future as you narrow your decision.

This week let’s talk about specialty cost.

Price /Budget:

Most DCs are small business owners and have to be acutely conscious of the bottom line. Before you begin shopping and doing demos, properly evaluate the maximum upfront or monthly (as most vendors have monthly financing plans available) which you can comfortably invest in your EHR system. In our market the typical range of cost on CERTIFIED EHR is $4,500 to $14,000.

Remember to include hardware costs. Get middle of the line hardware, meaning not the cheapest, but also not the $3,700 gamer machine.

This will give you an overall picture of cost. If your EHR system is $5,000 and hardware is another $5,000 then you know what to budget for the project.

If you decide to buy these in shifts to keep costs down (meaning you will buy the hardware then the software at different time periods) get the software first. Hardware gets slower with time and you don’t want to buy hardware, take a year to pay it off, and then buy software. Best case would be to buy the software, become proficient, trained and customize it on 1 computer then buy the new hardware for the whole practice and you will be in a much better position.

IMPORTANT: Don’t buy a system based on a possible government incentive rebate promises. Be smart and buy based on your current needs and budget as if you were not receiving an incentive.

Please stay tuned!

Thank you,

Alex Niswander

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Author, Alex Niswander, is a soap notes expert with over 10 years focusing on clinical charting and proper noting procedures.  He has reviewed charts in hundreds of clinics throughout the country and continually reviews new requirements by Medicare and major insurance carriers.

To learn more about Alex’s products, please visit the company website:

Chiro QuickCharts – billing/scheduling/ehr/emr

515-967-3002

www.quick-charts.com

Hello Everyone,

When shopping for an EHR system there are many key points you need to evaluate when shopping for an EHR. These will help you identify which of the EHR solution is the best match for your budget and your specific needs. I have developed a set of ten points, which will help put any practice on track for partnering with the absolute best product/company for your needs.

This list of evaluation points will apply in some way to everyone shopping. You might consider keeping a note book for taking notes on each point so you can remember them in the future as you narrow your decision.

This week let’s talk about specialty specific content.

Specialty Specific Content:

Every specialty in healthcare has what is called ‘custom content’. This means that you see the things you routinely do like Low Back Pain, Neck, Shoulder, etc. (as having Podiatry or Optometry content wouldn’t really do you any good for patient documentation). During your demo keep an eye out for the things you do every day. I would encourage you to have a list of the top 5 or 10 things you do handy and ask to see them during your demo. If you are reviewing a Chiropractic specific system, you should easily see these items. If you are demoing a medical based system with a Chiropractic ‘module’ you will be less likely to see these things which means a lot more time customizing the system and in all reality could mean you end up shelving the system.

IMPORTANT: Be careful when considering a non-Chiropractic specific system. This means quite a bit of more time customizing upfront and may not work well for your work flow.

Please stay tuned!

Thank you,

Alex Niswander

__________________________________________________________________________________

Author, Alex Niswander, is a soap notes expert with over 10 years focusing on clinical charting and proper noting procedures.  He has reviewed charts in hundreds of clinics throughout the country and continually reviews new requirements by Medicare and major insurance carriers.

To learn more about Alex’s products, please visit the company website:

Chiro QuickCharts – billing/scheduling/ehr/emr

515-967-3002

www.quick-charts.com

Hello Everyone,

When shopping for an EHR system there are many key points you need to evaluate when shopping for an EHR. These will help you identify which of the EHR solution is the best match for your budget and your specific needs. I have developed a set of ten points, which will help put any practice on track for partnering with the absolute best product/company for your needs.

This list of evaluation points will apply in some way to everyone shopping. You might consider keeping a note book for taking notes on each point so you can remember them in the future as you narrow your decision.

This week let’s talk about product customization. What that means and how to evaluate and why it is important.

Product Customization:

With today’s technology an EHR system should offer a great level of what is called ‘end user customization’. This means once installed you can modify the software to have the wording and items you wish to use for your daily notes without the software’s programming staff having to make the changes (which translates to added costs).

My best advice here is to ask your sales person to add /modify an entry during your demo. This will give you an idea of how easy it is to modify and if your sales person struggles, or shrugs off your request it should be taken as a red-flag for difficulty or non-ability to customize after the sale.

Please stay tuned!

Thank you,

Alex Niswander

__________________________________________________________________________________

Author, Alex Niswander, is a soap notes expert with over 10 years focusing on clinical charting and proper noting procedures.  He has reviewed charts in hundreds of clinics throughout the country and continually reviews new requirements by Medicare and major insurance carriers.

To learn more about Alex’s products, please visit the company website:

Chiro QuickCharts – billing/scheduling/ehr/emr

515-967-3002

www.quick-charts.com

Hello Everyone,

When shopping for an EHR system there are many key points you need to evaluate when shopping for an EHR. These will help you identify which of the EHR solution is the best match for your budget and your specific needs. I have developed a set of ten points, which will help put any practice on track for partnering with the absolute best product/company for your needs.

Although there are no two Chiropractic offices the same, this list of evaluation points will apply in some way to all of them. Keep a note book for notes on each point on the systems that you are reviewing so you can remember them in the future as you narrow your decision.

Each week moving forward I will send one major point to consider when shopping for your EHR system.

Compatibility /Interfacing:

It is very important that your systems “link up”. This means your new EHR software must be able to send and receive data from your existing billing system. The ability to interface with other software has been around almost since the beginning, so if a company cannot interface to your system, one of the two is outdated and one or the other (or both) should be replaced.

Imagine having to manually type in every active patient from your billing system into your new EHR software? It would take weeks and maybe months of un-needed data entry. I have seen program imports process 25,000 patients in just 5 or 10 minutes. It would take a person 6 months.

Another important item with interfacing is the ability to export the billing codes from the EHR system to your billing system.  If automating billing coding is a need, please ensure the systems can do this with each other.

Last, it should go without saying, but ask to SPEAK with someone using the 2 systems together!

Please stay tuned!

Thank you,

Alex Niswander

Hello Everyone,

When shopping for an EHR system there are many key points you need to evaluate when shopping for an EHR. These will help you identify which of the EHR solution is the best match for your budget and your specific needs. I have developed a set of ten points, which will help put any practice on track for partnering with the absolute best product/company for your needs.

Although there are no two Chiropractic offices the same, this list of evaluation points will apply in some way to all of them. Keep a note book for notes on each point on the systems that you are reviewing so you can remember them in the future as you narrow your decision.

Each week moving forward I will send one major point to consider when shopping for your EHR system.

Software Platform, Web VS Local Client-Server:

Web based software means it runs on a web-server, meaning you can access the software through a web-page from anywhere online. The advantage to web-based is lower hardware costs (you wouldn’t need a server) and lower “buy-in” cost. You can begin using for a small down payment and so much per month based on which features you are using. The other advantage is you won’t require any extra software to login from anywhere on the internet. If you have many offices, or work from many places, this could be the best option.

The downside to web-based software is generally a higher long-term cost of ownership as you are ‘renting’ instead of owning the software. This could still be a good fit, but something to consider. Compare this to office space, sometimes renting is a better fit than buying. The other potential downside is that the web-based software has to function within an Internet browser which means the software may be more difficult to use compared to a like client-server system. Internet up-time has become very reliable, however if your internet is down, so is your EHR system. The last item to consider with web-based is what happens in the event you wish to stop using the system. Are you walking away with nothing or a text file of your patient demographics and billing? This is an important item to clarify with your sales person if you are leaning toward a web-based system.

Client-Server software means the software is physically installed in your office and you must have one ‘main’ computer (also called ‘server’). The main advantages here is costs long term could be less and the software is likely easier to maneuver.  Another advantage is that you own the software and can usually still use an older version if you stop paying the annual maintenance fees.

One downside is higher upfront costs and could require additional costs with ‘remote control’ (Gotomypc, Logmein or PCAnywhere) software to access your system from anywhere. Another downside is that you would need to keep updated hardware in your office to keep up with the demands of the software.

Please stay tuned!

Thank you,

Alex Niswander

Hello Everyone,

This is the introduction to a 10 week newsletter we are doing to help you quantify many of the most important aspects of selecting the right EHR for your practice. The series is mostly based on an article I wrote which was recently published in Chiropractic Economics.

When shopping for an EHR system there are many key factors every doctor must consider in order to best evaluate which solution is the best fit for his/her unique practice. Imagine going to buy a new car, but not knowing yet how to drive. You would be buying based on what looks cool, but not which brand, style, size, features, and budget suited you the best. In this comparison a sports car doesn’t exactly meet the needs of a family man (or woman). This would be a recipe for disaster when put into daily practice. You would end up trading, selling or suffering for your mistake. It is because of this we usually have a pretty good idea of what style, size budget and time line for a vehicle purchase. The same is true for your EHR system; you have to have a basic understand of what you need, before you start shopping.

When just starting out we learn from family, friends and even a good sales person will help us discover which car is be the best fit for our needs. EHR is quite different because the vendor typically has just one product to offer and their job is to sell it to you. That is why you must be cautious, take your time and do your homework!

Over the last decade I have been involved in over 5,000 EHR implementations. During this time I have seen too many systems shelved after frustration, lost investment and huge amounts of valuable lost time. With time as our most precious resource, it is so important that you select the best fit EHR system the first time and avoid following the same ugly path.  (For information on planning your successful EHR implementation, please review our article on Implementing and Training on an EHR System)

There are many key points you need to evaluate when shopping for an EHR. These will help you identify which of the EHR solution is the best match for your budget and your specific needs. I have developed a set of ten points, which will help put any practice on track for partnering with the absolute best product/company for your needs.

Although there are no two Chiropractic offices the same, this list of evaluation points will apply in some way to all of them. Keep a note book for notes on each point on the systems that you are reviewing so you can remember them in the future as you narrow your decision.

Each week moving forward I will send one major point to consider when shopping for your EHR system.

My disclaimer is I do own the company that created & develops Chiro QuickCharts and my goal is for every practice to use and love our product.

Please stay tuned!

Thank you,

Alex Niswander

__________________________________________________________________________________

Author, Alex Niswander, is a soap notes expert with over 10 years focusing on clinical charting and proper noting procedures.  He has reviewed charts in hundreds of clinics throughout the country and continually reviews new requirements by Medicare and major insurance carriers.

To learn more about Alex’s products, please visit the company website:

Chiro QuickCharts – billing/scheduling/ehr/emr

515-967-3002

www.quick-charts.com

I recently put together a short webinar presentation concerning the hesitancy to take the plunge from paper soap notes to electronic health records.

There are 3 good reasons doctors hold off from making the change and understanding the fear.

Please consider watching this excellent 5-minute presentation.

Here is the video, I hope you can take a few minutes to watch:

http://www.quick-charts.com/paperless/

The procedure section of your daily soap is very simple. Don’t over think or over document. It only confuses the issue and makes a trained reviewer roll their eyes when they see a paragraph explaining how great Electrical Stimulation is for healing a sprained low back.

There is a lot of confusion on what must be documented per procedure performed. Your procedures should simply be a cut and dry list of what was performed with the patient during their office visit. There is no reason to write a book about the success or validity of a specific procedure. It simply boils down to what you already probably know.

Here are a few things to consider about documenting procedures (in no particular order):

1. Does insurance commonly pay for this type of procedure, and are you using the code that you should be?
2. Does your subjective and objective note prove that the location you are doing the procedure on is valid?
3. Are you doing more procedures than really needed for this visit?

Let me break down each point above.

First, does insurance commonly pay for an item? This one is pretty common sense, but if insurance doesn’t pay for a laser treatment for fertility, then why try to get them to pay you?

Second, are you using the proper code? This is important because if you are trying to bill low level laser as a neuromuscular or manual therapy code, you are just asking for trouble. Make sure you are using the right code, and if there is no code, you should be billing as a cash procedure directly to the patient and not submitting this to insurance.

Third, the rest of your note should backup what you are doing. Your Objective section needs to mention pain or discomfort in every area if you are documenting that you did a procedure on it. A most basic medical documentation example is that if you do a strep test, you better have ‘my throat hurts’ as a subjective complaint. I like to use medical documentation examples as much as I can because in Chiropractic we seem to document completely different, and we shouldn’t. Do you think you would see a detailed description of why a strep test was performed in a medical note? Nope, this would be assumed that anyone in medical field or insurance can look up the test if they are questioning it.

Last, are you doing more than you should be doing for the patient? Let’s talk about someone going into an Emergency room. The most important thing is to find out what the problem is ASAP. That is why we spend a quick $1,000 and learn we were just dehydrated and we can return home. Stick with this idea for a moment because it applies to your patients as well. When the patient first comes in, that is when it is more ‘acceptable’ to run the most tests and have the highest patient dollar visit.

It makes “insurance sense” to focus on just one major complaint at a time.  This will of course reduce your per visit number of procedures, however, it will be more likely to get paid and will extend your patient life span of visits to your practice.

Below is an example of a simple, yet well documented daily procedures section. Keep in mind the title of your section really doesn’t matter. It could be daily treatments, treatments today, treatments, procedures, etc.

Treatments

CMT 1‑2 Spinal Regions (98940) was performed on thoracic and lumbar regions.

Neuromuscular Reeducation (97110) for 8 to 15 minutes was performed on the thoracic and lumbar regions.

Remember, keep it simple for procedures!

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The plan section of your daily soap consists of quite a few components (or it should contain a number of important aspects).  Years ago a plan was likely to just read “return as needed” with no more details. Now that just doesn’t meet documentation standards.

While your plan doesn’t have to be complicated, it does need to have a few parts to it:

1. How often are we seeing them and what are we doing?
2. Are we doing any home therapies or home instructions?
3. What are the goals for improvement (this one is a big one today).

Ensure you cover 1 & 3 for your plan. Below is good example of how to quickly cover all three.

Plan:

• Spinal manipulation to lumbar spine 2x times per week for 3-6 weeks.
• Hot packs to lumbar region as needed to reduce swelling and improve blood circulation.

Home Therapies

To continue the use of cold and heat and the proper application of alternating cold/heat as needed for lumbar pain.

Short Term Goals

Improving low back pain to improve ability to do housework and go shopping 50% within 10 weeks.

Your assessment is where you cover your true functional improvements; however your plan should contain the goals that match the things you are also documenting in your assessment.

Make sure to match up plan items to the given condition when you are working with more than one condition. For example, if you are doing electrical stimulation for the low back, make sure you indicate that in your plan. If you just have one primary condition, this is not critical since a reviewer can see that you just have neck pain or LBP or a single condition.

Remember: plan your work and work your plan. Without a good plan your entire span of patient visits could be in jeopardy if you were to have them reviewed/auditied.

Once our soap note series is complete, we will cover re-exams, follow ups and new conditions.

Our 5th part of this series: What’s in a soap note – Part 5 – Plan – will be sent in our newsletter in a week or two.  I will also send the entire series  in one large lesson once completed.

Please stay tuned!

Thank you,

Alex Niswander

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Sources: http://www.cms.gov/  http://www.acatoday.org/

Author, Alex Niswander, is a soap notes expert with over 10 years focusing on clinical charting and proper noting procedures.  He has reviewed charts in hundreds of clinics throughout the country and continually reviews new requirements by Medicare and major insurance carriers.

To learn more about Alex’s products, please visit the company website:

Chiro QuickCharts – billing/scheduling/ehr/emr

515-967-3002

www.quick-charts.com

It’s important to understand and properly document all aspects of a patient encounter. More and more of the insurance companies and Medicare are moving towards strongly reviewing the assessment part of the documentation in order to see how the patient is improving, which confirms they should be continuing to pay you.

The days of better/same/worse are gone folks. We can no longer get by with the basics and this includes the daily assessment. What needs to be documented in order to show medical necessity in the assessment? Let’s find out.

Here is an example of a well documented daily assessment:

Diagnoses

• Lumbar Subluxation (839.20)
• Dizziness, vertigo (780.4)
• Headache (784.0)
• Neck pain (723.1)

After today’s assessment Alex’s overall condition is progressing slow, but steady.

Headaches:  Patient’s progress is noted as evidence by decreasing pain and increased ROM in the cervical region. Additionally Alex neck spasms and swelling are reduced.

Low Back Pain: Low back pain has been aggravated because of working longer hours on the line at work last week.

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Your assessment must contain the information below every time you see the patient:

• Patient diagnosis codes.

• General daily assessment.
• Per complaint daily assessment.

I call these daily assessments because you need to change/update them each time you see the patient.

Remember the general and per complaint assessments shouldn’t be the same for every note in the patient file. Yes, changing these each time is a pain when you just saw the patient 2 days ago, however, it is the right thing to do if you want to be as compliant as possible. You need to setup your forms or software to make these quick changes. For example you should be able to change each assessment in less than 5 seconds. For my example above you would spend less than 15 seconds changing your assessment. Let’s say you see 30 patients, so it could equal 7 minutes of your time.

Now if I can help you get all your notes for that day done in just 35 minutes, I think I would make your Christmas card list.  Am I right? It can be done, however, you have to remove the extra fluff and get just the facts on progress. We will put these lessons together to share how you can accomplish a great note in less time.

Once our soap note series is complete, we will cover re-exams, follow ups and new conditions.

Our 4th part of this series: What’s in a soap note – Part 4 –Plan and Procedures – will be sent in our newsletter in a week or two.  I will also send the entire series  in one large lesson once completed.

Please stay tuned!

Thank you,

Alex Niswander

It’s important to understand and properly document all aspects of a patient encounter. The bottom line is that you must show medical necessity. That is the Medicare way and all other carriers follow suit.

My goal with this lesson will be to show what basic aspects of the visit should clearly be documented. Anything additional you would like to include is typically alright, however I caution you to be careful when documenting exams not widely accepted and understood by all flavors of healthcare.

The Objective exam can consist of many types of testing and retesting to check for differences and improvements. In this lesson I am focusing on what exams to check in a typical follow up visit.

This is a difficult lesson to teach because everyone does exams and follow-ups differently.  I will attempt to stick with the general approach to Objective exam. Objective exam is also difficult because there is no cut and dry number of items you must document to be compliant. Essentially it is very subjective since some could say simply listing ‘cervical shows stiffness’ would be the same as ‘C1, C2 and C3 on the right show stiffness today’.

Generally speaking we want to be consistent with the items we check and document here. If a patient has neck pain, we want to check ROM, swelling, stiffness, muscle tension, etc. We also want to make notes of differences for each visit and approach the documentation slightly different each time. The nature of Chiropractic is repetitive, however your job is to change this up so you don’t have 10 soap notes that all look like this: Swelling and stiffness in C1, C2 – The end.

Keep in mind that every day your notes should show medical necessity for the services you provide. There are some gray areas and you can push the envelope on extra services, however, those of you that do this often should pay extra attention to the medical necessity side of your documentation.

I want you to take away that Medicare wants you to check muscle findings along with your typical segmental areas checked. The choice is yours of course; however, briefly discussing muscles found close to a problem area of the spine is a quick and easy way to expand this area of your daily notes and improve your documentation.

Let’s see an example of a proper documented Objective below. Keep in mind I am covering just a standard follow up visit as we will cover initial exam findings in another lesson.

Palpation Exam:

Asymmetry, edema and hypertonicity were found in the upper cervical region (specifically C2 and C3 on the right side). Swelling, tautness and tenderness were also noted in right C2, C3. Motion palpable fixation, muscle spasm, weakness was found in left trapezoid muscles.

The daily Objective doesn’t have to be complicated. The challenge, as I already hit on, is how does this compare side by side against the 10 or 20 follow up visits you have between the exams? Do they all say the same thing? Are they simply a copy of the prior note? In the software notes world this can sometimes happen automatically for speed, however, you MUST change every day’s visit objective so they are not identical.

Once our soap note series is complete, we will cover re-exams, follow ups and new conditions.

Our 3^rd part of this series: What’s in a soap note – Part 3 – Assessment – will be sent in our newsletter in a week or two.  I will also send the entire series once complete in one large lesson.