Hi to all my pediatrician colleagues who are EHR users, or EHR seekers, or EHR avoiders. As the newly appointed Medical Director of Connexin Software, I plan to use this space weekly to comment on many different topics relevant to those of us who practice pediatrics. From the frustrations of negotiating with insurance companies, to the ever-changing ACIP immunization schedule, to HIT initiatives across the country, and the inadequate representation of pediatricians and pediatrics surrounding many health care topics, there is so much to say!

I had an INCREDIBLE experience this week. I was asked to represent the PA chapter of the AAP standing behind President Obabma as he gave his speech about health care at Arcadia University on Monday. The room was electric, and no matter what you think about health care reform, it is totally cool to be able to tell my patients that I stood 20 feet away from the President of the United States.

I have LOTS of thoughts and opinions on the health care reform topic, as do most of us. As someone who runs her own small business/pediatric office and is a consumer of health care as well as a pediatrician who often experiences the first-hand inequities of health care to children, how can I NOT have passionate thoughts on this topic. I won't bore or inflame you with my personal philosophies except to say that I believe there is a medical parallel to the current debate. There are many times in medicine when we don't know exactly what is wrong with the patient or how to heal them. However, sometimes we have to start somewhere, and act quickly or the patient's condition will decline precisely by our inaction. I believe this is also true for the current debate: we must start somewhere. Yes, the devil will be in the details but if we don't act, even a multi-organ transplant won't save the current health care system.

Connexin Software is pleased to announce Susan Kressly, MD, FAAP as the newest addition to the team. Dr. Kressly has joined us in an official capacity as Medical Director. Many of you may know her from her involvement with the Council on Clinical Information Technology and the Section on Administration and Practice Management of the American Academy of Pediatrics. She testified in DC on behalf of the AAP regarding implications for HIT adoption/ARRA funding for pediatrics, and before the CDC regarding physician use of immunization registries. In addition she serves on the Child Health work group of CCHIT and is on the executive board of the PA Chapter of the AAP. We welcome her input and expertise as we continue our commitment to the pediatric-focus of Office Practicum. She has much to say regarding HIT in pediatrics as well as other topics which impact pediatric practice. We look forward to hearing from her with regular updates on relevant issues on our Blog.

Office Practicum user Sue Kressly, MD has the opportunity to help define "meaningful use" for Pennsylvania Pediatricians.  As many states are now trying to determine who will qualify for ARRA funding under the Medicaid program and are defining what they think meaningful use "should" look like, pediatricians should take every opportunity to help shape these programs.

If you are interested in helping to shape these programs, Dr. Kressly suggests you contact your state AAP chapter and/or your state Medicaid program and ask whether there is an opportunity for pediatricians to get involved. In addition, she is willing to share testimony and ideas with any interested parties. Dr. Kressly can be reached at skressly@kresslypediatrics.com

GIVING 145 flu shots to 114 patients in less than three hours. That's right, after last week's successful flu clinic experience, Kressly Pediatrics doubled down and scheduled patients at a rate of 42 per hour. We still ran ahead. It being Halloween, the staff was in a good mood. (That's Sue in the middle, with nurses Colleen and Sija.) There had been a few anxious moments during the week, because we were running out of needles and syringes. Did you know there's a nationwide shortage? Apparently distributors were forced to give much of their stockpiles to the Federal government, which is having trouble coordinating distribution to sites like ours that got multi-dose vials. In the meantime, we had dipped into our own office stockpile, which was exhausted by last weekend's clinic. Imagine Jane's relief when UPS delivered that box on Thursday. In the nick of time, everything was carefully prepped -- insurance confirmed, doses drawn the night before, bandaids at the ready:
Even the patients came prepared, presumably because this was the scariest activity on their personal calendars today:
We followed the same workflow as last week, with Sue doing the front end medical work, me acting as her scribe, and the nurses alternating on shot duty. The last vaccine was given at 11:15, claims were sent at 11:24, and Frank Caniglia at the PA SIIS in Harrisburg confirmed receipt of the whole group shortly thereafter.

We have started receiving EOBs for administration of the vaccines given last Saturday. A few payers are covering the full $22.64 that Medicare says this service is worth in our area, but many are paying less than half of that amount. So anyone who thinks this is just a big scam for doctors to make more money should reconsider. Given the total work I have documented that goes into providing and accounting for a single vaccination, I hope it rings loud and clear that this valuable public health service is a labor of love and necessity for pediatricians, not a way to get rich. Without an EMR, it has all the makings of a financial disaster, which is why some pediatric practices have elected not to participate in distributing this vaccine.

I hate to say this is becoming old hat -- and I'm certainly not looking for another job -- but it was one of those awesome experiences where you get in a zone and everyone is in sync and three hours just fly by. You look up, everyone is gone, and you feel the satisfaction of a good job well done. Kudos to everyone who made this happen.

Late update: the Bucks County Courier Times sent a reporter and photographer to watch all the action. These appeared on the front page of the Sunday edition. Some great quotes from parents and a nice recap of the overall distribution issues that are facing everyone.

From HealthLeaders Media

"The House of Representatives unanimously passed a bill Tuesday, October 22, that would exempt a healthcare practice with 20 or fewer employees from the FTC's identity theft Red Flags Rule requirement."

Link

[If just joining us, read the previous article first. That way this one will make more sense.]

I'm not really a morning person. (Brief pause for family and friends to chuckle knowingly.) But duty -- and those 150 dead soldiers lying in state in the fridge -- called, so there I was with a cup of coffee in the reception area of Kressly Pediatrics bright and early at 8:00am this morning. Based on the panic-laden cable news reports, I half expected a line to have begun forming in advance of our scheduled 8:30 start. But no: only Colleen and Jane greeted us upon arrival. We fired up the computers and took our positions.

The plan was that Sue and I would greet the patients in alternating fashion. We would confirm names, open encounters, ask the flu ROS questions to affirm readiness, and add seasonal flu to the order upon patient request. (We had prepared a list of patients already in today's schedule who were due for seasonal, so we could offer the dose. We also had question lists hanging in the waiting room so patients could read ahead.) The patient would proceed to the next available nurse in an exam room, who would take and record a temperature on the Vital Signs screen, then administer and document the vaccine. Since we only have one lot in inventory, everything on the Vaccine Entry screen -- manufacturer, lot #, expiration date, VIS, route, vaccinator -- would be pre-populated, except the body site.

The first patient showed up at 8:12. We quickly learned why some practices use scribes. In very high volumes, it turned out that the best approach was for Sue to do just medical work (take temps, ask ROS questions, propose adding the seasonal) while I recorded it. The nurses thus took back patients who were fully vetted and ready to roll up their sleeves or slide down their pants.

Not only did we run on time, we were always ahead. Sue's patients are well attuned to the practice's "fine German engineering" and they showed up early. Everyone seemed grateful that our litle practice has maintained its dignity and composure in the face of the "Greatest Public Health Threat Since The Founding Of The Republic!! Details At 11!"

Of the 120 patients scheduled, 2 were no-shows and 10 cancelled for a variety of reasons (sickness overnight, fear of thimerosal, etc). A few showed up who weren't in the schedule and got squeezed in. Ultimately we gave 112 H1N1s and 28 seasonals, a total of 140 fully documented vaccinations in 4 hours. We easily could have wedged in 50 more throughout the morning without breaking a sweat. We'll keep that in mind when scheduling next weekend's clinic.

The last patient was vaccinated at 12:26. I had been keeping up with the superbills during my "down time," so I transferred everything to the claims queue and sent it out the door at 12:38. We turned out the lights and locked the back door at 12:43. I'm typing this from home, and we're done. And when I say "done," I mean "DONE." All of the encounter documentation is complete, all of the claims have been filed, and all of the vaccine records are resting comfortably on the PA SIIS server in Harrisburg. (We both report and pull down immunization records in real time. Thanks, Frank Caniglia!)

For the next few weeks, whenever a prospect asks me whether there is really any ROI (return on investment) to be gained by installing an EMR, I will ask them to estimate how long it would take their office to:

- manage inventory (10 minutes)
- identify and contact patients (30 minutes)
- book appointments (20 minutes to setup/test)
- confirm and follow up insurance (20 minutes)
- check-in/check-out (2 people, two hours each)
- document encounters (2 people, two hours each)
- load syringes (2 nurses, 20 minutes each)
- administer vaccines (2 nurses, four hours each)
- create claims (1 check-in person, no extra time)
- report to the state registry (0 minutes)

for 140 flu shots. Our answer: 18 hours of total staff time -- an average of less than 8 minutes per patient for ALL activities combined. If anyone can beat that, I'll buy their next EMR.

The bad news is, I was good enough at my job to be invited back to next Saturday's clinic. "The things we do for love..."

Greg

(PS: "Eating your own dog food" is a phrase computer geeks use to describe the situation when we have to use our own programs to do real work. Surviving that experience is considered the acid test of whether the software is ready to deliver to others.)