CIS Physician Advisory Group

Back in 2004, Peter Lindenauer gave me a call and asked that I join a group he was convening that would help develop the vision for CIS. If you know your paleontolgy, you'll know that this was during the Jurassic era when internists saw their patients through the course of their care, whether in the office or the hospital.

We now know through carbon dating (however contested by the Kansas state board of education) that since 2004, there was a dramatic evolutionary shift of the punctuated equilibrium sort*. This shift yielded two subspecies of physicians, homo ambulatorus and homo hospitalus. I don't want to launch into a potentially divisive debate nor forget that there are vast populations of geographically versatile species (phylogentically speaking homo medicoversatilus, with innumerable subspecies). Rather, I'd like to call attention to the vast lands that this variegated collection of creatures roam outside of the hospital.

As I've mentioned in a previous post, 2010 promises to be a very productive year, particularly in the ambulatory environment. Not wanting to review these goals again (see post from 12-14-09), I just want to let folks know that I will be convening a group of about 20 docs from the five major departments (med, OBGYN, peds, psych, surg) with the primary intention of keeping a larger audience up to date. The meeting will be on a quarterly basis and will provide a high level overview of current developments and future projects.

One could say that "advisory group" is a misnomer. I'm choosing it because I am interested in the feedback I expect to receive and am also hopeful that this group will bring back information to a wider audience of colleagues. I don't expect that to be done on an official basis, but rather by generating some excitement by word of mouth. I will also try to post agendas and minutes for those meetings. Stay tuned.




(*Eldredge, Niles, and S. J. Gould (1972). "Punctuated equilibria: an alternative to phyletic gradualism". In T.J.M. Schopf, ed., Models in Paleobiology. San Francisco: Freeman, Cooper and Company, pp. 82-115. )

Medication Not Effective

Med Not Effective

Filing Documents and the Folder Structure

I've been speaking with folks from HIM who are concerned about the filing of a variety of inpatient documents, including those of your service. To give you some background, the so-called folder hierarchy was designed, tested and retested over about 2 ½ years before it was put into the live environment a number of months ago. While it might seem confusing to some, there is an overarching logic to its build that accounts for the filing of documents of all types and from all sources. This is to say that, implicit in its design is consideration of the type of document (dictation, PowerForm, PowerNote), the author of the document (physician, nursing, social work, ancillary service), the document's associated department/division, and, most importantly, the venue of origin. This last determinant is the crucial one to keep in mind.

So, if a patient is seen in the hospital, there are a limited number of folders to place a document. In the case of a consultation, the initial document, whether dictated or done by PowerNote, must be placed in the Consult Notes folder. Those notes created on follow-up visits in the hospital are Progress Notes and so should be filed in that folder. The easiest way to think about this is to consider the design of the paper hospital chart: the initial consult note is placed under the Consultation tab and all subsequent notes are placed along with all others under the Progress Notes tab. Other hospital-based folders include Admission/History and Physical and Discharge/Transfer Notes.



Other folders designed for physician use, i.e. those that are labeled by specialty, are for the ambulatory world. So if a patient comes in to your office for a pre-operative evaluation, this note should be filed in the Medical Consultation Program folder. Were you to see that same patient for a follow-up visit, that document should also be filed into the same folder. That folder is essentially the office chart for the program/division.



Additionally, operative and procedure reports will be filed in the Operative Notes and Procedure Notes folders, respectively, and without consideration of whether the event occurred during a hospital, daystay or ambulatory encounter. Associated consult, progress and follow-up notes, though, are filed in folders as described above (Consult & Progress Notes folders for inpatients and Specialty Office Notes folder for ambulatory patients).



We are working to educate folks about the proper filing of documents, particularly in the inpatient setting. When notes get placed in specialty folders designed for the ambulatory environment, there is a great risk of those notes not being found on review by colleagues, consultants, ancillary services and administration, e.g. HIM coders.



I hope this clarifies a murky subject.

Happy New Year!

On the evening of December 30th, the Office of the National Coordinator of Health Information Technology (ONC HIT), led by Dr. David Blumenthal, released the "Interim Final Rules" regarding Meaningful Use of the electronic health record. Apart from a world filled with acronyms, (CIS, ONC, HITECH, ARRA, MU, EMR, EHR to name an elementary few), it appears that health care reform is integrally linked to HIT. While we've been blanketed by media impressions of the federal wranglings towards reform, it seems to many that the path set by the separately signed congressional bills are better understood as health insurance reform. On the other hand, the ONC is setting an agenda that has its origins in the ARRA (the American Recovery and Reinvestment Act) which earmarked as much as $36B to invest in and incentivize for improvements in health care delivery in the United States. In large part, these improvements will be facilitated by the institution of robust electronic technology that will not only create the building blocks for information input and storage, but will streamline the exchange of health information across local, state and federal boundaries.

The Interim Final Rules that were released on Wednesday night is actually a 556 page document that details the criteria for "eligible professionals" and hospitals to receive reimbursement for the implementation of electronic health records. Also outlined are regulations for quality reporting via PQRI and the need to create the means for interoperability between systems and institutions. As with any hefty document, operations and accounting regulations take up a chunk of weight as well.

After reviewing this document, I am proud to say that Baystate's CIS implementation has anticipated much of what it takes to achieve Meaningful Use status. As I posted a couple of weeks ago, a number of our FY10 projects will further advance our efforts to achieve MU as well as other institutional goals that will improve the quality and depth of care we provide to our patients.

Check out David Blumenthal's NEJM discussion released shortly after the publication of the mega-document. He does a nice job of distilling the essential elements of the ONC's efforts and defining some of the more commonly used terms in this ever-growing sector of medicine.

Launching HITECH