Gopher was able to keep track of information about every book in the entire Oregon College/University system and put it at my fingertips. Using gopher to search through the librariesdatabase made my life a lot easier.

Today you interface with databases everyday. If you log into a website, use your ATM card or navigate a telephone menu you are working with a database. A database is a set of structured data that is presented to an end user by a server. The server is like a very, very fast and efficient librarian. Think of me doing my entire research at the library in the blink of an eye and that would be me without any coffee.

Sharing data using servers and databases is very easy too. By knowing how to ask the server a question you can find anything in your database lightning fast. The is where your electronic health record software comes in.

Every person you see has a completely different story. Information such as first and last names, insurance companies and e-mail address are straight forward and easy to define. When classifying information such as cause of injury on a certain date of service or treatments performed during a patient encounter the software company has to be more creative with how they will store that data.

The goal of an electronic health record developer is to make it simple and intuitive to put information about your patients in the database as well as recall and present the information. Currently there are over 300 EHRs on the market all of which use a database to help you simplify your practice and make your transition to a paperless office possible.

Dragon Medical uses the most advanced technology and forward thinking programming to create an interface so intuitive that you will be surprised when your computer doesn’t talk back to you. With Dragon, a microphone and your computer you can dictate  directly to your computer. I’ve talked to many doctors at trade shows and in their offices who have said they used Dragon years ago and were not satisfied with the results. Ten years ago I said I would never own a cell phone but changes in technology make that thought ridiculous now. To those doctors I say give it another chance, you will be amazed.

Dictation allows you to document your patient encounter by telling the story of the visit. There are as many methods of reporting your patient encounters as there are practitioners. Speech recognition allows you to easily document the specifics of your patient visit without relying on a third party interpreting your words for you. Details such as medical necessity, patient progress, affected activities of daily living can be easily and accurately reported and stored as fast as you can talk.

Improve quality, safety, efficiency, and reduce health disparities

The term ‘Meaningful Use’ implies a clinician using their software in a meaningful way.   The list put out by CCHIT is extensive in its requirements for what can qualify as a meaningful use certified software, many of the requirements are features that are not utilized by practitioners of different specialties.  Does this mean to be eligible for the government stimulus money you need to implement a system that isn’t designed for your type of practice?

Standards of interoperability are being finalized now.  CCHIT is one EHR certifying body and others, like the Drummond Group, are entering the arena as well.  The standards are being set by the Healthcare Information Technology Standards Panel (HITSP). HDM reports that the Department of Health and Human Services will now be the body to set the criteria for meaningful use.

David Hunt, M.D., chief medical officer in the Office of the National Coordinator for Health Information Technology had this to say at the Health Data Management’s Health IT Stimulus Summit in Boston.

“You have to be able to send data and CMS has to be able to receive it,” Hunt said. “The big thing for 2011 is that you actually acquire this equipment and start using it.”

It’s a good place to start.  Look at your practice and decide how you want to implement your EHR.  Stay aware of the current standards of in the quality of documentation expected, software interoperability and make sure your software provider is dedicated to growing with the standards as they are implemented.

Standards are not in place regarding how different portions of an EHR should operate with each other, how or if an EHR should interface with health information exchanges, how an EHR can demonstrate that it is being used in a meaningful way or establish a measurement of an EHRs effectiveness.  Big moves are being made with how these definitions will be finalized and we can only hope that the overall goal will remain the improvement of quality, safety, efficiency, and reduction of health disparities.

References:

Meaningful use Matrix Tagged for CCHIT Reference Link

HITSP Website Link

Health Information Technology and Federal Stimulus; October 7, 20009 Newsletter PDF

HDM Breaking News,Certification Recommendations OK’d, August 14, 2009 Link