Working with HIT Systems: HIT System Planning, Acquisition, Installation, and Training: Practices to Support & Pitfalls to Avoid

Audio Transcript

Interviewer:Good morning Dr. Green. I’m really happy that you are able to take some time out of your busy schedule today to let me talk to you about your office practice. I know you are part of the initiative to adopt electronic health records, and my job, as a member of the Regional Extension Center, is to come to your officeand help you bring this system to life.Part of what I need to do is to spend some time with you and your colleagues to determine what your needs are and how we can work together to best help you successfully install and implement an EHR in your office.

Dr. Green:Well thanks, I’m looking forward to talking with you. I’m a little nervous about these systems because I hear from some of my friends they can really be extremely disruptive to the office practice. If there’s anything we can do to make that easier, I’d really appreciate it.

Interviewer:Mm-hmm. Well I have to tell you there is some truth to that. Bringing an EHR into your office is going to require some degree of change; some of it is technological, but a lot of it is related to communication pattern change and the social aspects of change—sometimes referred to as the “people part.” The people part cansometimes present us with the biggest challenge. Many providers are surprised at that, thinking that the technology—the hardware and the software—are going to be the most difficult aspect.My team is here to work with you as best we can, to help you with all aspects of the change process from hardware and software to “peopleware.”Our goal is to make this as least disruptive to your office, your personnel, and to your patients as possible.

There is an awful lot to do and we will do this in stages. Together we will come up with a project plan and a timeline for the integration of health IT into your office. We are going to start today with a component of the user needs analysis. I am sure you are thinking that there are many needs—today we will start with an analysis of something we will call the “provider visit.” Because a provider involves many users and is rather complex when you really think about all the steps and linkages and information flows that occur, we are just going to talk about patient flow today. An easy way to do this will be for you to walk me through the process. I want you to help me understand what happens when a patient comes in, processes through your office, sees aprovider, what information is collected, and where it goes. Then we will examine what happens when apatient pays the bill, schedules an appointment, and goes out the door. How does this sound? Do you have any questions?

Dr. Green:It sounds fine—–although I may have to pull in other members of our office to help me answer some of those questions. Frankly, I am not really sure exactly how bills are generated and the details of scheduling followups and referrals is a bit of a mystery to me.

Interviewer:No worries! Our goal is to talk to other members of the team—because for us to really understand your process and to make sure that we represent all users’ needs, we have to talk with them too. Today however, we are focused on your perspectives. Let’s get started—ok?

Dr. GreenSure.

Interviewer:To begin, let’s play an imagination game here where I will be a mock patient and you will guide me through the office visit process as you see it. I will actually come and verify this later by observing the real process, to make sure that we got this right. As an adult—I can say that I have a reasonable idea of what happens when I walk into my doctor’s office. When I walk into my doctor’s office, I check in. I walk to the desk, and either am greeted by a receptionist or I sign in on a log sheet with my name and time of arrival.What happens in your office when a patient walks in the door? Is it similar?

Dr. Green:Yes it is. When somebody comes in, he signs in with his name and time of arrival on a clipboard. We try to have the desk manned so that patients are greeted by someone, but if not, they sign in and have a seat. If it’s the first time we’ve seen the patient, there is a lot of extra information that we collect. If it is a returning patient, we just ask for any updates to his info that we already have in the chart. We need to verify the patient’s identity and we do ask to see a driver’s license. The receptionist then makesa copy of his insurance card and driver’s license (if we don’t already have it). The receptionist is also responsible for contacting the insurance company to get a quick verification that he’s covered. I think the receptionist also checks to make sure the HIPPA forms are filled in.

Interviewer:Let’s say it is a new patient and you’re going to create a new office record for him. Let’s focus on demographics.For example, the name and address. Do patientsuse a standardized form?

Dr. Green:At the present time, we give the patient a clipboard with lots of papers on it and he or she fillsthemout. They are standard forms that we have on hand for every patient. We try to send the formsto the patient ahead of time, so that he doesn’t have to spend the time in the office doing it. But, either we don’t send it out or the patient forgets it, so oftentimes the paperworkis completed in the office waiting room. The receptionist checks the papers to make sure they are filled out completely, and then we file that in the medical record folder and eventually it gets entered into our patient management system.

Interviewer:I think I understand all of that. I have a question though about the insurance verification step. How do you actually verify the insurance? Does that require a phone call to the insurance company?

Dr. Green:No, our patient management system does that automatically when we enter the insurance number.

Interviewer:Got it.

Dr. Green:It does a quick check, and that saves us time.

Interviewer:OK, very good. I have made a note about your patient management system, and we will be studying that as well to determine how it interacts with your current workflow and what, if any, impact the new system will have on it.

Dr. Green:We’ve had that system for a long time—and we have really grown to like it a lot. It won’t be easy having to move on to something new...

One of the things we’re concerned about in our selection of an EHR is we really like the patient management system. We’ve been using it for a long time. We want to make sure that we don’t have to double enter the things, but that the two systems will work together—right? Or are you saying we will have to replace the old system entirely?

Interviewer:You are making such an important point! We never want to encourage double data entry for the obvious reason becausethat’s inefficient, andalso encourages error. The system you are acquiring is an all-in-one system that includes patient management, billing, the electronic health record, etc. But before I comment on whether this is a total replacement of your old system or not, let me discuss with other members of our team. Regardless,we will work with you to see how we can enable a one-time entry of data.

Back to the patient who has just signed in. I suppose he sits down and waits to be called to the desk, is that correct?

Dr. Green:Yes that’s usually the case. Did I mention that we also have patients update the information if they’ve been here before, or give us the information about what’s been happening recentlyany changes in health or new symptoms.

Interviewer:Yes, you did mention that briefly. Are all of these activities actually all handled by your reception clerk or your check-in person—whoever is sitting at the desk?

Dr. Green:Yes. The clerk makes sure that the patient has the clipboard and the forms to fill out.

Interviewer:Right, and what if the person is unable to fill out theinfo? Maybe he has a vision problem, or English is a second language or…

Dr. Green:We do the best we can. Our clerk will work with the patient. If a family member’s there, we ask the family member to help the patient, but obviously, it’s important to accommodate whatever limitations the patient has.

Interviewer:I also heard you say that you try to, in advance, mail the patient forms so that he can actually fill them out at home and bring them in.

Dr. Green:If he’s a new patient, yes.

Interviewer:What happens if the form is sent out in advance and the patient brings it in or mails it back to you—how is that processed? Is it reviewed with him when he shows up, or does the reception clerk just take it and enter it into your system?

Dr. Green:The clerk just checks to see if the all the forms are there, and that they are completed fully. She will put them in the chart. I’m the one who reviews health datainformation with the patient.The clerk is responsible for the demographics and insurance information verification.

Interviewer:OK got it, very good. Do you collect co-pays at check-in?

Dr. Green:We do that at the time that the patient finishes the visit.

Interviewer:What would happen if you had a patient who came in who was very delinquent on a bill or a payment? Would the person at the desk actually see that or be notified in any way?

Dr. Green:That’s something that I don’t put on the shoulders of my receptionist. That’s something that I would take up with the person. So I don’t ask my clerks to have to deal with that. I have a small practice and I know all of my patients—so I prefer it that way.

Interviewer:Very good, but would you expect your clerk to let you know of that issue then?

Dr. Green:Yes, if the clerk seesthat there is an overdue bill - she flags it very discretely on the chart, I will see that when it comes to me.

Interviewer:Thanks, that is helpful clarification. Some of the physician practices we work with have multiple providers and very large patient loads—therefore they often have a billing clerk or business manager that deals with all of that so that the clinician is focused on the patient and not the billing aspect. I like that personal touch of yours Dr. Green!

Back to the process—if you’re in your exam rooms, how do you know that your next patient has arrived and is ready for you?

Dr. Green:The chart is pulled by the receptionist and it’s put in a little bin at the end of the desk in the hall. My office nurse can see it down the hallway and knows that there’s a new patient who isready to come back to the exam rooms.

Interviewer:Terrific.This is a good overall description of the process of checking a patient in—at least from your perspective. Of course, I will actually observe the check-in process and talk to others, but before we move on is there anything I might have missed?

Dr. Green:No, I think that covers the basics.

Interviewer:Oh—wait—I just thought of something! Do you ever offer any kind of education in your office? Sometimes when I go into my doctor’s office, there is aDVD player and it may play something about diabetes care, or how to live with hypertension, or something like that. I was just curious if you have any sort of educational intervention that you use prior to bringing the patient back in the office?

Dr. Green:No, not right now.

Interviewer:Returning to talking about this check-in process—are there any aspects of this that you wish went more smoothly or more efficiently?

Dr. Green:Well, I understand that there’s this push to get rid of the clipboard. I can understand that. When I am a patient I don’t like having to fill it out all the time either. I think it would be great if we can make it easier for the people coming in so that they can either do it at home or make it easier and quicker for them when they come in to the office. Getting it last minute and rushed ends up in error, and lots of time the patient doesn’t have the information that is needed for the best visit. I need to have up-to-date information and I know that most of the time data from the lab or data from the patient’s last hospitalization may be missing. If there was a way that all of the data related to my patient was in one place and not scattered all over pages and pages of paper—that would be great. My understanding is,however, that the systems out there don’t yet talk to one another—which to me doesn’t make sense. If it is in the hospital system, why can’t I see it? WhenI am unable to getthe patient’s data all in one place, then the burden often falls to the patient.We ask patients to bring in as much information as they have so that I can try to patchwork together their medical story. So, to answer the question—Ijust want to make it easier for them. I think that’s one thing that I’d like the patients to get out of my having a new electronic health record system.

Interviewer:Thanks for that additional information. I know what you are talking about. I cannot tell you how much time I have spent trying to round up my own medical record from all of the places that I receive care.Next question—who actually escorts the patient back to the exam room? Is it you? Is it a nurse? Is it a medical assistant? Is it the reception clerk or somebody else?

Dr. Green:The nurse comes up to the desk, takes the chart, and walks the patient back to the exam room. She will take the vital signs, and looks over the data that has been collected so far. She may question the patient about the symptoms, or new medications and the like. She will then alert me if there’s anything happening acutely, or marked changes. It helps me to focus.

Interviewer:OK. Where does the nurse record that data?

Dr. Green:She records it in the chart.

Interviewer:All right, and how—if something has changed with that patient, how does your nurse communicate that information to you? Does she just write it on the record and hope you find it, or does she pull you aside? Does she use a stickie note?

Dr. Green:She makes just a brief note and we have a little stickie that she puts on the chart if I need to actually talk to her. Otherwise, I review the note before I walk in to see the patient.

Interviewer:I see.

Dr. Green:And that works most of the time.

Interviewer:OK, very good. Can you tell me about some of the information that is gathered before you actually physically interact withthis patient?Besides the vital signs, what other sort of information is gathered?

Dr. Green:Well, if it’s the nurse, she does the vital signs and checks on the medications and sees if they’re any new medications. She will also ask the patient if hehas any new ailments or things that are concerning him. If a family member is there, and the patient permits, she will ask the family member if theyhave anything that they think the doctor should address.The rest of the things I do myself. I need to hear certain things myself, in the way that the patient describes it. I may repeat similar questions. My nurse colleague is a great listener and has years of experience; sometimes she picks up things that I wouldn’t have noticed. When we work as a team we find that the patient visit is better—plus we get more work done this way.

Interviewer:Do your patients, in general, have any tests done before you come into see them?

Dr. Green:Not usually. If it’s a patient with a chronic condition, I may arrange for him to have a lab test before I see him. Sometimes I may ask the nurse to do a finger stick to test blood sugar or to run a screening EKG. For the most part, I usually wait until after I’ve examined the patient to order any of the more complex labs or tests.

Interviewer:OK, I see. If you do order some lab tests, do you do any of these lab tests in your office? Like a quick cholesterol check, or a sugar check, or something of that nature?

Dr. Green:Well, we occasionally do the finger sticks or a urine dipstick test, or maybe a rapid strep test or EKG, but most of the more complex stuff is done in a lab.

Interviewer:OK. Do you do the EKG or does someone else?

Dr. Green:The nurse will do the EKG and then I’ll get the results before the patient walks out.

Interviewer:If there is an EKG that is done by your nurse and it appearsabnormal, how does she communicate that to you?

Dr. Green:She will bring the strip from the machine right to me, and let me know what she sees.If I am with another patient, she will make a note on the front of the patient’s chart with a stickie note so I don’t miss it.

Interviewer:OK. Let’s see, do you have forms that are specific to a particular type of visit? For example, maybe a guideline for the things that you want to remember to check—like, if your patient is diabetic, or if he is a congestive heart failure patient, or something similar.