Monday, 1 October 2012

EMR Use cases

In this category, let us see some common use cases in the doctor office.

Regardless of what you read, two common themes emerge: the first is "speed, speed, speed" of the performance of your overall IT solution; the second is "focus on workflow." You need to address both so that your EMR does not slow you down while you work toward the ultimate goal of a chartless office.

New Patient Visit use case.

Use case No: 1

The following is very basic work flow in the doctor office.

1. Patient Robert want to meet Doctor John Smith in the practice xxx|
2. Patient calls doctor office and reception desk user picks the call.
3. Reception desk user confirms that Patient Robert is a new patient and then we need to register as new patient.
4. Reception desks register the patient information such as first name, last name, etc..
5. Also reception collect the patient insurance information both primary and secondary insurance.
6. Reception looks the appointment schedule for Doctor John Smith for the patient preferred date and time and books an appointment.
7. Patient visit the practice on the specified date and time.
8. Reception desks check in patient and confirm that insurance verification has been done.
9. And also reception desk select the patient case which to be billed after the visit.
10. Reception also updates the other necessary patient demographics information such as patient preferred pharmacy, etc..
11. Reception desks get the HIPPA Signed form from the patient and scan and attach in the patient demographics.
12. Reception desk scan the insurance card back and forth and attached in the patient demographics.

A patient's statistical information may change between visits. The front desk staff verifies the patient's current address, phone number and allergy information. Regular insurance verification may also be necessary. Front desk staff will need to locate, review and update paper and computer files for the physician. Some other duties are collecting electronic medical records and laboratory results.

13. Reception desk put the patient in the waiting room.
14. Medical assistant pulls the patient from the waiting room and put in her room.
15. Medical assistant collects the following information from the patient as follows

a) Chief Complaint.
b) Vital Signs
c) HPI.
d) ROS
e) Allergy
f) Problem List
g) Current medication.
h) Past Medical history.
i) Past treatments, etc.

16. After collecting all the information, Medical assistant put back the patient in the waiting room again.
17. Once the doctor John smith finished the current patient and then he identify that patient Robert is waiting in the room and the patient already met the medical assistant.
18. Then doctor pull the patient from the waiting room and put in his room.
19. Doctor just quickly goes thru information collected from the medical assistant and if necessary he can add/remove any of the information collected by the medical assistant.
20. Doctor will conduct the Physical examination with the patient.
21. According the patient problem, doctor will do any of these or combined.

a) New Prescription electronically
b) New Lab Order
c) Instruction to the patient.
d) Billing codes (ICD and CPT) for the current visit which needs to be billed.
e) Information about the follow up visit.
f) Finally Sign out the Encounter.


22. Patient comes out the of the doctor room and contact the reception desk for any of the following or all.

  • a) Copy of the current encounter.
    b) Copy of the New Prescription.  (Please note, in some US State, prescription has to print in the specified format.)
    c) Copy of the doctor instruction for the current problem.
    d) Book appointment for the follow up visit.

    23. According to the insurance verification or the patient insurance card, reception desk collects the copay amount and gives the receipt to the user. Some medical businesses collect up front while others collect fees after the services are rendered.

     

    EMR Adoption challenges in Use case 1:

    1. Since the patient is waiting in the call, so reception desk user must act quickly and the software should help her to achieve the process very quickly without too many clicks. I remember there is an exclusive website in the name of toomanyclicks which loudly talks about EMR usability issues.

    Now let us go in detail and look at the problems and recommended solutions.

    1. For the reception desk, (actually not only for reception desk, for any user in the system), system should provide the patient search  window/screen where user can enter one or multiple identifiers to locate the patient such as  last name, first name, DOB, mobile no, home phone no, internal patient code , Medical record number, etc. Surprisingly some time patient may remember system defined patient code and may inform the user in the phone, in such cases, system should simply allow the user to type the patient code and should retrieve the corresponding patient records.

    2. Ok, now assume that user search by last name and hit the search button. In all most all the EMR, shows the list of records that matches with last name entered by the user. So what happens if there are 5 patients under the same name?. Instead of again enter some more identifier and hit the search, the list should provide more columns to choose the correct patient. Please remember, very frequent mistake done by the EMR users is selecting the wrong patient, nothing else.

    [In my experience, lot of time I involved moving the data from one patient to another patient from billing to encounter thru the backend scripts which is very complex job in my experience. I remember, in one of the practice, they have selected wrong patient, all the parts of the soap note filled and claim is generated and statement sent to the patient. After the call from the patient only, all the users realized they have selected wrong the patient.  Then they forwarded the task to my desk, it took more than a day for me to move the correct patient account all the information all thru the back end scripts. ]

    CCHIT came know that this  is a repeated mistake in the survey, and included in their test process to show the software vendor how to move the visit, billing information from one patient to another patient . But MU doesn't care about this.

    So coming back, the list should provide more additional identifier to select the correct patient such as DOB, Home and Mobile No. Even though, the software should give the quick look info for the patient in the list to confirm more details from the patient demographics.  Click here for an example patient search and see how they are showing more information on the selected patient.

    3. Now what is the next challenge, since the patient is waiting on the call, reception desk user need to register the patient if not found in the system. Here is the big challenge, every EMR software, has a big screen with many fields in their patient demographics screen and also contains more tabs to enter other information. And each EMR system will mark the fields as mandatory which are required for their internal purpose, which are marked as per MU Certification and some are marked for billing, and many more.

    Some software's are crazy, such as they will show the mandatory fields information as missing from the other tabs, how the user will know which tab and which field is missing ?!!!!!. The whole problem is developer does not think about the end user and writing numerous code to achieve some thing which user never want it.

    Now, how we can quickly register a patient without going thru all the fields/tabs ? . I have seen in some software, they have a option called “Quick Patient register” which will contain only few fields to register a patient. But the back end implementation is bad, they will have two different tables to for this option, which always a risky one and will give problem.

    So what is the solution ? . In my last EMR project, we handled this by “Incomplete Patient Profile”. Yes we will also have “Quick Patient Register” option, it will go and save the record in the original table only with a flag marking as “Incomplete”. This is the trick, whenever such patient are selected, system will always prompt this information. So now the reception desk can quickly save the information, when the patient actually visit the practice, and the same patient is selected in the patient sign in module, then the system will clearly prompt this message to take further action.

    Use case No: 2

    Let us take an example, Patient Robert Primary Care Physician is Doctor Allen Smith and Doctor John Smith is a specialist. Patient Robert meets the Allen Smith and after diagnosis, Allen asks the patient to go and meet Doctor John Smith along with referring letter.

    1. Patient Robert want to meet Doctor John Smith in the practice xxx.
    2. Patient calls doctor office and reception desk user picks the call.
    3. Reception desk user confirms that Patient Robert is a new patient and then we need to register as new patient.
    4. Reception desks register the patient information such as first name, last name, etc.
    5. Also reception collect the patient insurance information both primary and secondary insurance.
    6. Reception looks the appointment schedule for Doctor John Smith for the patient preferred date and time and books an appointment.
    7. Patient visit the practice on the specified date and time.
    8. Reception desks check in patient and confirm that insurance verification has been done.
    9. And also reception desk select the patient case which to be billed after the visit.
    10. Reception also updates the other necessary patient demographics information such as patient preferred pharmacy, etc.
    11. Since the patient is referred by doctor Allen smith, so reception desk update or create new referring physician information in the system and scan the referring letter from the patient and attach to the patient demographics.
    12. Reception desks get the HIPPA Signed form from the patient and scan and attach in the patient demographics.
    13. Reception desk scans the insurance card back and forth and attached in the patient demographics.
    14. Reception desk put the patient in the waiting room.
    15. Medical assistant pulls the patient from the waiting room and put in her room.
    16. Medical assistant collects the following information from the patient as follows

      • a) Chief Complaint.
      • b) HPI.
      • c) ROS
      • d) Allergy
      • e) Problem List
      • f) Current medication.
      • g) Past Medical history.
      • h) Past treatments, etc.

    17. After collecting all the information, Medical assistant put back the patient in the waiting room and again.
    18. Once the doctor John smith finished the current patient and then he identify that patient Robert is waiting in the room and the patient already met the medical assistant.
    19. Then doctor pull the patient from the waiting room and put in his room.
    20. Doctor just quickly goes thru information collected from the medical assistant and if necessary he can add/remove any of the information collected by the medical assistant. And also he reviewed the letter from the referring physician.
    21. Doctor will conduct the Physical examination with the patient.
    22. According the patient problem, doctor will do any of these or combined.

    • a) New Prescription electronically
    • b) New Lab Order
    • c) Instruction to the patient.
    • d) Billing codes (ICD and CPT) for the current visit which needs to be billed.
    • e) Information about the follow up visit.
    • f) Finally Sign out the Encounter.

    23. Patient comes out the of the doctor room and contact the reception desk for any of the following or all.

    • a) Copy of the current encounter.
    • b) Copy of the New Prescription.
    • c) Copy of the doctor instruction for the current problem.
    • d) Letter to the Primary Care Physician.
      e) Book appointment for the follow up visit.

    24. According to the insurance verification or the patient insurance card, reception desk collects the copay amount and gives the receipt to the user.

    Use case No: 3

    The following use case has 70 % chance in the doctor office. Something doctor will not use the computer system; instead they will use the super bill to complete the patient encounter.

    1. In the above use case, after medical assistant finish the job, she will print the encounter copy and super bill form and stick in the doctor room.
    2. Doctor quickly go thru the information of the information collected by the medical assistant and fill up the super bill with the following information

    • a) New Prescription
    • b) New Lab Order
    • c) Instruction to the patient.
    • d) Billing codes (ICD and CPT) for the current visit which needs to be billed.
    • e) Information about the follow up visit.
    • f) Finally Sign out the Encounter.

    3. Medical assistant enter the information from the super bill into the system.

     
    Use case No: 4
    Life cycle of a Claim.  This flowchart explains life cycle of a claim in doctor office.

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