Home Forums Discussions General Discussion Workflow Processes for results, call backs, etc..

I would like to know how others are handling when results come back either interfaced or scanned in. We are thinking there might be a better workflow process then how we are currently doing it.
Our providers have commented (several times I might add) that "signing off" labs, radiology, etc. is a very time consuming process. In order for our MA/nurse staff to be aware that the results are back and that they have been signed off the provider has to send a message to the MA/nurse while in the sign off screen. Our MA's call back all results to patients unless an appointment is coming up or necessary. Is there another way to inform our MA's of results with AC other than sending/attaching a message in the signing off process?

Since this is an area of AC that I don't personally use I don't know what to recommend to them. Thanks.

I don't know why I am chiming in since I know nothing of this. But, I know solo providers who do things similarly so you could do it for multiple doctors.

Do all the triaging up front. One off staff member takes in the faxes and distributes them to the providers via the computers (shortcuts, etc.) The doctor then reads the lab or x-ray and using a sticky note "signs off" and gives directions to his or her nurse. Sticky notes in PDF/Adobe, etc. have names and time stamps so that can be nice.

So, the doctor just reads the lab, comments as to what needs to be done and forwards it again through the computer to his or her MA. The trick is to make your MA a medical student or something high enough so she/he can import the file. License issues sure, but many work around this.

Sadly, I find that I am doing more of the clerical work than I did when the charts were paper. The end result is significantly better medicine, better documentation, and better patient involvement, but there is no getting around the fact that it takes me significantly more time.

UpDox may help you. We have one staff member who reviews the incoming images, and then sends them to the appropriate person by changing the color tag. The recipient filters by color tag and just sees his/her items. The item can be reviewed, signed off, imported to the chart, sent to the patient portal with comment, and staff notified from one screen. But, there is no getting around that it is a number of steps (over 20 mouse clicks and some typing) to do this, and it has to be done by me personally. There are all kinds of combinations and permutations of how UpDox can be used, and my way would probably not work well for you. but, there are so many tools available I'm sure you can find one flow that helps.

I realize a word description of how I do it would be really confusing. This is where an UpDox session at a user's group, or even YouTube videos, would help.

Be that as it may, if you are not using UpDox, I would encourage you to try it out and explore it.

Hi Bert,

A few questions...
I've been charged with the task of finding out what the workflow process is with regards to getting test results into the chart, signing off on them, etc.

Here's what we do at present:
We have an in-house lab (but also use Lab Corp and Quest) as well as x-ray results (we get paper reports from a Radiologist that reads our films). They come in, the MA puts them on the front of the respective chart, and they wait in stacks for us to review. During the course of the day (or more often, after we are done seeing its for the day!) we sit down and sign off on these, usually making notes on the labs if we want the MA to call them back about something.

Can you tell me the nutshell version of how we would do this within AC?

I am under the impression that each paper result (other than those from LabCorp/Quest) would have to be scanned into the patient's chart - after that, what is the process for us to sign off, make notes (I like the "sticky note" idea - where do we get those?) and return the chart to the MA station?

In addition, am I correct in saying that if we scan an in-house lab result into the chart, it is not "searchable" - and that it would have to be entered into the actual body of the chart somewhere to be searchable?

Thanks very much!
Melanie

Hi Melanie,

As you can see, I truly enjoy helping when I can. Unfortunately, our system involves only the importation of labs, x-rays, H & Ps, etc. into a program we made. I can give you some direction, but people like Jon (JBS) could help you more.

Yes, any paper that you want in a patient's chart would need to be scanned in. But, your goal should be doing everything possible to have all "paper" (documents) come in as PDF or other electronic files. The PDF is the de facto application. So, any document faxed to you should come in to a central computer via a fax server (pretty much any fax/computer combo that allows the fax to come in as a fax. Some people use Brother fax machines which will bring the document in as a tiff which can then be converted using special software to a PDF. Finally, maybe your best route is using UpDox where all your documets come there and you mark them up anyway you wish. See JBS about that.

As far as sticky notes, there are literally hundreds of free PDF software mainly for printing to PDF. I can't speak for all of them, but Adobe (which invented the PDF and is Acrobat, while overpriced) can still do more to a file than any other PDF document software. After all, we are talking $395 or more vs $00.00. But, you do get two licenses. Adobe allows you to do many, many things to a document, one of which is the yellow sticky, an electronic sticky note that is date and time stamped with the user's name on it.

It seems as though you said the same thing twice in the last question, but 1) I don't do searches on that, so I probably couldn't help you. I do about one search every two weeks and seem to get by. I guess that's the hard part about starting with AC after it gets more efficient. It's hard to know what you can and can't live with.

As an addendum to Bert's comment about PDF markup. All of you Fujitsu ScanSnap S1500/fi-6130 users should already have a copy of Acrobat Standard. It's worth $300 so it'd be a mistake not to use it. Considering the S1500 is about $400, you're really paying a 100 bucks for the scanner. It's a pretty damn good deal.

Here's the comparison between Pro and Standard: https://www.adobe.com/products/acrobat/matrix.html

Here's a condensed comparison: http://www.softwaremedia.com/acrobat_standard_vs_professional_difference.html

In my opinion, the Standard should be more than enough. If you're considering getting it, think about getting a document scanner while you're at it because it'll probably be way cheaper as a bundle.

Melanie,
In relation to your query on workflow with labs, etc.

We have an all-in-one fax/scanner/copier which takes incoming faxes and converts them directly to PDF. These are routed to a shared folder on the server. Periodically during the day, my staff uses Adobe Acrobat v9 to sort through the faxed documents. They label each file by LastName/FirstInitial/ReportCategory/FileType. ie. SmithR_radiology_CTChest or JonesH_lab_UCx or HarrisonF_consults_ophthalmology.

Periodically during the day either between patients or during a really long and boring office visit, I look at the "Fax Folder". Stuff I don't need to actually read I will move to the sub-folder called "OK_to_File." examples include most walk-in-care visits, optometry visits, PT progress notes. I will read many of the consult reports, DCSummaries, etc.

Stuff that I need to think about and review more carefully when I have time is moved to the sub-folder called "Hold." This includes all labs, radiology reports, and some of the more important consults.

The first filtration process (moving the lesser important items to "OK to file") weeds out about 70% of the incoming faxes. Any file I place in "OK to File" as the name implies has been reviewed by me and the staff has permission to file it. Since they have already labelled it according to name, category, and file type there is no need for them to open it again. They just drag into the corresponding pt's chart.

The secondary filtration process of putting important items in "Hold" allows me to process them thoughtfully. At the beginning of each day when I'm fresh, I look at these files. For example, a normal mammogram is reviewed. I bring up the patient's name in AC, create a message directed to the MA. Using the template I created for normal mammogram, I right click the message field and select "normal mammogram." This states: Please call the patient and inform her that the mammogram was normal, Thank you. Then I click send, and move that file into "OK to file" sub-folder. In another example, I review a lab report from a recent visit, everything is normal. I use Adobe to write the following message: Mr. Smith your cholesterol and liver enzymes are normal. Please continue the current dose of your cholesterol medication, great job! ALauer. (then I print the lab to paper and we mail it to the patient, so they can see the lab numbers and see the message I wrote (highlighted in yellow highlighter pen)). Then I can place in "OK to file."

In the example of abnormal lab, I use Adobe to make a note: cholesterol dangerously high, pt instructed to return for ofv. Then I go to AC, in a message instruct the MA to call the patient to review elevated cholesterol and treatment options. Then I move it to "ok to file."

After my staff has gone through the "ok to file" folder and filed things, I have messages in my in box that there are items to sign off. Since I've already dealt with these files, I hover my cursor over the sign button. Then I click it as quickly as possible until all the files are signed. Done.

No I'm not using all the features of AC by doing this. However it keeps the volume of items in my in box to a minimum (I hate clutter). And keep the workflow rather efficient for us. Perhaps other users have ways that involve fewer mouse movements, but this workflow is very comfortable for us and we work very quickly with this method.

You are correct that scanned items are not searchable. In order to make them searchable, they would have to be imported in the HL7 format as granular data, or created as text in an office visit.

Hope this helps you. Ask others and you will find that for as many AC users there are different ways of creating your workflow. This setup allows me to get done within 15-30 minutes of my last patient so I can get to activities that I enjoy, like swimming in the pool or white water kayaking in my local creek or renovating my old house.

Melanie and Robynne,
Since Bert brought up my name, I will describe our workflow. You already have some good descriptions above, and as David points out there are many ways to do this successfully.

1. Start by making every effort to minimize the paper you receive and maximize the faxes. Call your hospital lab, pathology department, radiology providers, etc. You may get some resistance at first, but ultimately they should do it because faxing is cheaper for them, too. Remember: paper is the enemy; you have to hold it, scan it, process the document, and dispose of it. Faxes are just ?there? in your PC.

2. We use Updox. Hard to describe but easy to use. It has some cost (which there are ways to reduce) but the price will likely be no more than 2-3 hours of staff time each month, and I assure you the program will save you more than that.

3. All faxes come in to the workspace in Updox. The workspace is basically like the pile of faxes in your fax machine, but it is visible to each staffer at their desk. Some docs like to go to the fax machine themselves; I tend to let the staff do the triage. Intermittently through the day they look at the workspace and handle the incoming faxes. Some are trash or junk and are thrown away. Some are auths or referrals or insurance info from patients that the staff deals with and I never see. Most are lab results, xrays, consults?.the things that I need to sign off on. They import them into AC. One of the beauties of Updox is the ease with which this takes place; no renaming of the file, no converting to a pdf?it just appears in the patient?s imported items with a minimum of clicks. More on those in a moment. A few of the faxes don?t really go in a patient?s chart but are important for me to see. They are routed to MY Updox box and I view and deal with them there.

4. Any paper results that come in are scanned into AC directly; from there they are then handled just like the results in #3, by importing into the patient?s chart in AC.

5. All of the results in #3 and #4 are brought into AC. This generates a message to me that they need to be signed off. I look at my message box regularly through the day (incoming phone messages are put there as well). When I click the message, the ?sign off screen? opens. Some require no further action; I sign off, the result is in the chart; end of story. Some require a comment, just for the record. I can put a comment on the result as I sign off on it. Some require action by staff (call and give the result; call and schedule an office visit; etc). Part of the sign off screen is a box to send a message. I select the staffer who is to receive the message, type what I want (very often using a template) and send it. Then click sign off.


We don?t use the colored tag system that David describes; I guess our workflow just doesn?t demand it.

We also don?t have any need for an additional ?sticky? system that Bert and Sandeep mention. I feel like the messages in AC do exactly the same thing for us.

Robynne, you ask ?Is there another way to inform our MA's of results with AC other than sending/attaching a message in the signing off process??. What do you have in mind; what aspect of this do they object to? I guess I don?t see why this is a labor intensive process.

One other general point: I remember hearing someone talk about efficient paper handling and organizational skills. The speaker suggested that a goal is to have each piece of paper (mail, etc) be handled only once. So when a fax comes in, your goal should be to look at it, handle it, ?.and never have to deal with it again. That is obviously not always possible but is a reasonable objective to keep in mind.

We have a few more hiccups than others, but here is our process.

Labs
1) All lab results come through the Quest/Labcorp Interface. This generates a message for Dr C to review the item.
2) Dr C reviews the lab, makes a note on the lab and signs off. The note may say "There are no significant abmormalities" or it may say "You test show you have X problem. You should do the following. If you have additional questions, come infor an appointment." This also automatically generates a letter to the patient in AC.
3)Dr C then sends a message to the "Nursing" mailbox to please send the patient their lab results and a copy of the letter." Any MA can see the Nursing mailbox, which is why we send it there. They then print the labs and letter to PDF and attach it to a templated message via our portal RelayHealth and send it to the patient.

Other Items:

3)With items that come in via hardcopy, like a fax, the MA scans it into the chart in the appropriate area, which then generates the message to Dr C to review the item. Then basically see 2) above.

Myfax:
4) I recently started using an internet fax named Myfax. When I want to insure a fax is done right, i do it myself via Myfax. But i need to print to pdf from the chart, and then upload it to Myfax and send it. Pharmacies do not have this phone number. Only specialist offices or others that I specifically give it to.

5) Some xray results may come in via Myfax or password protected email. These come to me, and I download the pdf and import it into the chart. I do have to rename it when I save it to disk before importing. Then it is like 2) above. And i have to delete the file.

We are considering changing to Updox since the cost of Updox is about the same as the combined cost of RelayHealth + MyFax. Well, actuall I think it is about $100/year more but it has some integration with AC with Myfax and RelayHealth do not. It may be worth the extra cost.

OK, so I am on my 3rd Heineken so if I offend anyone, sorry. Also, there will be some sarcasm.

First....I talked about sticky notes, but we don't always use sticky notes. I hope Jon knows that. This will be the first post as to how WE do things at RVP.

I will have to admit that if my software company hadn't designed File Assistant Pro, I probably would be on the way to UpDox. I had looked at UpDox which had to work with OneBox seven years ago and Andrew Barbash couldn't convince me it worked that well. The latest versions seem very good, and I would highly recommend you look at it closely.

But, our workflow.

We don't have that much of a work flow. It is rather seamless. We send messages in three ways all HIPAA compliant. Instant Message, Outlook and AC messaging.

We never send a chart to someone. We only message. So, when a patient checks in, they are greeted and copays, etc. are taken. They are taken to triage (one area) by our CMA who does the vitals and the subjective. The chart is then sent to me. (OK, the one time we send a chart).

If a referral needs to be made in the room, the orders section is used and it is sent to our referral person. All x-rays and other orders are done by me, printed to the printer on my desk and a label is made using Amazing Labels, which is free and is simply amazing. Ask Steven. The lab sheet is given to the patient or if something needs to be done in house, the lab req and label is given to my MA. If my MA, intuitively knows what the in house lab is, she will print the req and make the label. But, other than that, I do everything once I get the chart including most letters, etc. If a patient needs a letter for school or other excuses, etc. I do it with a template, but if they ignore the 42 inch flat screen TV in the waiting room that asks for those types of things to be done while their chart is open (see 95% of the time), I just ask my receptionist to do it who has templates for all.

Now, if you don't use UpDox and you are a solo practice, then my workflow here is easy and free and very, very, very fast. All incoming faxes which is 98% of our paperwork comes to the server. Since it is on the server it is distributed to everyone's desktop and SharePoint (another day). Since it is in a folder called Inbox, it is automatically in the inbox of F.A.P. File Assistant Pro is a software program designed by our software company which is used by about ten people on here. And, you do have to be a solo practice at this time. Anyway, the fax will be in the inbox of the program and is renamed by the staff. Once named and categorized, I can look at it from any computer and import it. Importing it to the database automatically signs it off at that exam moment in time into the FAP database. These are backed up in multiple ways every night.

Now, this is our only workflow. If I open a PDF, already named by my staff as Smith, John Lab, and it needs some action on it, I click on the email icon which makes it an attachment to an email, I add a subject line, then in the body of the email, I write down what to do. Like: Serum iron is low. Please call patient and put on Niferex and schedule a repeat iron in six weeks. My CMA who functions at a level near a nurse practioner, then does this. It is reflected in Amazing Charts and sent back to me. ALWAYS. She then drags and drops the PDF into Sharepoint and keeps a copy in her email, so we now have three copies with no extra work.

When PDFs are named, sticky notes may be used. Say, it is a transfer, the staff may use a sticky to say, patient had stated last week that they were getting too old, etc.

Anyway, this is basically how it works. It is actually very simple. The instant messages are for things like, so and so is on the phone or I may send a message to get me so and so and call the medical records department for a report we don't have.

Wayne,

Your workflow process sounds very doable and efficient. I am assuming that you send pts messages (about abnormal labs, etc.)by email. For elderly pts. who do not have email, do you just send via snail mail? Since the latter can get pretty expensive, if you have the M.A. just call the patient, is there a way to make a permanent notation in the record that this was done?

Thanks!
Melanie

Bert and Jon (and all of those kind enough to reply with helpful suggestions) - Thank You!!

And Bert - Heineken! A man after my own heart (ever visit the actual brewery? It's pretty cool!)

Ahem...on to all things medical...

I think I am confused a bit on a couple of things. What I am trying to sort out is (since we have a lot of paper generated by our in-office lab) - is this:
Is there ANY way to have a document added to a patient's chart that will enable it to be searchable? By that, I mean if our office lab churns out a sheet with an A1C of 6.5%, is there a way to add that to a pt's chart that will let me: A) Quickly sign off on it B)send a message to the M.A. to tell the pt. by email that the lab is great, etc.etc. recheck in 3 months AND have this message be permanently part of the medical record,and finally C) have the result searchable within the medical record so that if I wanted to view a list of all of my pt's whose A1C is below 7.0%, this pt. would pop up in the list?

If I were to use UpDox, would that do all of the above?

Melanie

Are the sticky notes a permanent part of the patient record?

The sticky note function on AC says that they are NOT. I want a way to do this and have it stay there permanently in case Dewey, Cheatem and Howe come a'knocking...

Melanie

Thanks Melanie.

We don't really have any elderly patients since we don't accept Medicare. We do have a few low-income-but-not-Medicaid patients who are not computer literate and/or don't have access to computers. We typically just call them and have them come in to discuss abnormal labs (yes, it makes them pay another copay). We have one patient who also doesn't have voicemail. That one is a problem. You make a note in the record one of two ways.

1) The MA or I adds an addendum to the chart recounting the telephone conversation.
2) A message can be sent to Dr C telling her of the conversation, and she can save the message to the chart. For this, the chart MUST be attached to the message.

Iff (that's if-and-only-if) the lab is downloaded via the lab interface, the doctor can add a note to the labs when they sign off on it. This note can be automatically generated as a letter to the patient. I dont know exactly how, but Alice does this on all labs. She then just sends a message to the MA asking them to send the letter to the patient.

On those downloaded labs, you can run a report searching for testname=hemoglobin a1c and value < 7.

Now, this works on labs downloaded via our lab interfaces. I don't know if it is possible otherwise.

Melanie, it sounds like you are trending towards Wayne's workflow, so I will let him handle some of this, but a couple of points:
In answer to your set of questions that Wayne quotes immediately above...
1. As he says, labs downloaded via interface can have a note added and are searchable
2. When signing off all other labs, yes the provider can quickly sign off and send a message to the MA which is part of the permanent record.
3. No, the labs imported in other ways (not via an interface) are not automatically searchable, but you can enter them in a way that they are. If you go to the patient's summary sheet, on the right is a section called "tracked data". You can enter the labs there (a1c's in your example) and they are then searchable. Entering the data is a bit of work, but it is easy to run a report and identify all above a certain cut-off.
There are different types of messages in AC. "Stickies" are designed to be temporary reminders that are not permanent parts of the record. On the other hand, "messages" can be saved to the chart and are then part of the permanent record. Not to create confusion, but "addenda" are another type of "message" that is designed to be made a part of the record.

OK, as difficult as it was, the above is both accurate and confusing. Simply because what you are asking for is somewhat difficult and some things aren't specified. For instance, when you say churns out a page, do you mean paper or an electronic document?

Pretty much searchable items are going to be those that are entered into the chart. Imported items would be difficult, especially since it is difficult to search plain documents and because the II are in an entirely different folder.

While UpDox seems more and more incredible the more I hear about it, you will (I believe) still be limited by the fax coming in.

So, yes, if all your HbA1Cs were in the charts, you could, as Wayne said, do a search on them.

Now, if you wanted to search for certain words or phrases throughout your II, you could. One way would be to have your Adobe PDF software change the PDF from plain to OCR or Optical Character Recognition. Doing so, allows you to search through the document or documents.

So, it is possible, as we have done, to convert all of our files (> 6GB) to OCR. Now, we can't search for all potassiums under two, but we can say, "Who was it that had that glucose of 672," and search the entire database and find it. We have needed that maybe ten times in five years, so probably not worth it.

Now, there are fax machines which will import the PDF files as OCR PDFs. Next MFC I get I will get this.

Adobe also allows you to publish to the cloud and send a PDF to the cloud with a message to the email recipient. Sending plain email to patients is not HIPAA compliant, but your patients can sign a waiver. But, web portals such as with UpDox, allow you to do this. Adobe, allows the document to go securely to your Adobe site, and an email to be generated to the recipient.

You can certainly add sticky notes, but I have never been able to make them "stick" or even make them auditable.

Bottom line is this. To be honest, I think you have been very diligent about this, but I think one can also overthink it. Just come up with a workflow and see how it goes. It isn't etched in stone. I don't even think we had one to start.

Bert,

I hear you about the over thinking part....but before we make the leap to an EMR, my Med Director wants to know how AC works with incoming faxes, and how labs that come in can be sent back and forth through the system, how that works when we sign off on a lab, and more importantly, how it works when we put a message on the lab and then the M.A. has to read it, and possibly reply to our question. An example of what I am talking about is this: Say there is confusion about exactly what dose of a statin a pt. was on when his lipids were done; as it is now, we jot a note on the lab (which is paper clipped to the front of the chart), the M.A. takes it, calls the pt., makes her note as to what the pt. says, and it comes back around to us again. We have lots of circulating labs this way. It is not efficient in the least, but there you have it. My MD wanted to know how all of this would be accomplished within AC.

In addition, there is the issue of how to manage the paper reports our in-house lab generates. We have the ability to do CBC (w/diff), chem, lipid panels, TSH, PSA....and all of these results are reported on separate sheets of paper. Again - really poor efficiency, because one lab may come in on one day - it goes in our stack of charts for that day, we sign it off. Then, in another 1- 2 days, etc. another lab comes in - and the cycle gets repeated. So the chart recirculates in our stacks for a few days. So, I am also REALLY hoping to reduce wasted time and increase the efficiency of this whole process - and am hoping that we can develop a system within the EMR that will make this easier. Granted, it probably won't be any faster. The "cycling" will still occur unless we change how we do the labs (not likely, because tests that are run less often get run in batches) - but at the very least, we won't have the paper issue, and the time it takes for the staff to find and pull the chart and attach the lab will be erased.

Having labs scanned in is certainly doable, but with the volume we have, it sure would be nicer to have an LIS that would interface with all of our devices and send the results of all of our in-house tests into a patient's chart. My Lord, that would be faster and simpler! And - no paper, no scanning.

I think I have a vision of a setup that would work for us - if we use UpDox (or a similar program) to have our faxes and send them directly into the EMR, and a LIS to link our in-house labs to the EMR, then it is "simply" a matter of learning the logistics of how to send things back and forth to the M.A.s, and each other, etc. It seems to me that while that is certainly not the least expensive setup, it may be the most seamless we can get...

We have a very high-volume practice, and speed is essential to our flow. If we're gonna have an EMR, it needs to be as easy as possible to use. That's one reason we have developed templates for our ROS and PE areas of the chart. Yeah, I probably am overthinking it, but it is going to be hard enough to make the switch without having an EMR drag us down to a near halt. The more I can make a roadmap of how things will fit together, how we will do what when, then the transition should be somewhat easier (I hope!) None of us wants to be there till midnight each night finishing off lab results, messages, etc.

We have looked at demos from Greenway, Practice Fusion, Unicharts, Meditouch, AdvancedMD, Dr. Chrono...everything has it plusses and minuses, some more than others. The cost issue is a factor, and the integration with Dragon is super-important, since we will be dictating. Some EMRs say that they "work with Dragon", but in practice, it's just not as smooth as they sat it is!

AC works extremely well with Dragon, is affordable, has been around long enough that we don't have to worry if it's going to disappear in another year, and - one of the most important things - has the terrific support from other users, like yourself. Now, if ONLY I can find a way to make our template work within the body of an AC note, we may have a winner...!

Melanie

Where in California are you located Melanie?

Well I can assure you that you won't be there until midnight. AC overall is the fastest EMR made.your workflow will be much faster than what you describe.you can always change if you don't like it. Epscribe alone will save a lot of time not to mention doing notes in 30 sarcomas or less. Get updox and start. That will define your flow. And get the docs involved.

Marty,

I live in San Francisco, and commute to our office in San Jose. Too bad you aren't closer, we'd love to come over and see AC in action! How many providers are in your office, and how many pts. do you see in a day? It still might be worth a day hop on Southwest to come take a look!

Melanie

Bert,

Sounds like a great idea.
I'm bummed, though - I still had time left on my 3 month trial, and after messing around installing LogMein on my iPad and my PC yesterday, now for some reason, AC won't work! I get an error message telling me it was in the process of shutting down (it wasn't) and to try to run it as administrator (I did try, no luck). In desperation, I uninstalled it and tried to re-install it, and now it's stuck at a "registry" thing. Arghh. Do you have any suggestions?

Melanie

Melanie,

We currently have 3 providers in our office, there are usually two of us seeing patients on any given day. We see about 20-25 patients each per day. We use Updox right now and we are soon going to be using an interface for our lab (few test patients done through the new interface, more clicks but results will be searchable & can be graphed to see trends etc).

Once we got Updox, I requested faxes only from our labs, radiology etc. I didn't want anything mailed to our office. These are then filed through AC.

As for your in-house labs, we are in the same dilema. We are also doing in-house drug screens, lead testing, hemoglobin etc. There are basically a few ways to deal with these:

1) continue to use paper & scan them in
2) Use Excel to put the results in, then send a message to the appropriate provider. You can make your own custom speadsheet. Save it to the desktop then drop & drag it into your imported items section for that patient. From there anyone with excel (or Openoffice) can double click on it from within the imported items section and can read results, make comments, etc.

I do use the tracked data for HgbA1C's at the present moment, but once we use our interface then I won't have to do this anymore.

We aren't completely set up with AC how I want, but we are slowly getting there.

Marty,

We have 4 providers (three docs and a P.A.). On M -F we have one doc on from 8 till 6, and a second provider (doc or PA) from 11 - 6. On Sat and Sun we have one provider (doc or PA) from 9 -3. On weekdays, we usually see 65-75 patients - sometimes more, sometimes less. Like I said, it is a high volume practice. We have HMO, PPO, TriCare, and Medicare pts. Pretty much the only insurances we don't take are United PPO and MediCal.

To scan all the lab results is obviously doable, but an interface would be SO much better. Are you looking into having a third-party vendor do yours? I was checking out Apex Healthware online. Not cheap - I am guessing it might run us about 10K to have them do all of our interfaces...

Have you completely transitioned to AC, or are you doing a mix of paper and AC? I'd love to hear more about how it's working out for you - do your providers type or dictate with Dragon?

Melanie

We right now have a mix of paper & AC but I hope before the end of the year to be paperless. I think doing an interface for in-house labs would be too expensive.

Have you considered doing your in-house stuff in Excel as I described above?

Me again... I've been trying to digest all of this as we continue to wend our way towards an EMR. I think I am beginning to envision how our workflow would operate - and I do understand that there are multiple ways to do this. But what I want to know, is, is what I have outlined below a doable process? And if not, what step is not, and is there a workaround?

To make it easy and avoid redundancy, please look at the summary of what I need to do, in the last paragraph; and then if you need further clarification as to what I am asking, refer to my outline.

I have outlined everything in stepwise fashion not only for myself, but also because I want to be crystal clear on what I can and cannot do. From my reading so far, this is what I understand to be possible:


1) I CAN have a system that will import BOTH faxed/scanned items AND scan BARCODED items into a searchable PDF format (i.e., in OCR format). We do many in-house labs, and the machines are just old enough that an interface is not supported - so we will have to print them out, barcode them, and then scan them to import them in PDF-OCR format into the chart.

Is Abode Pro X a good choice for this? Does UpDox import barcoded files? Can every file uploaded in UpDox be in PDF-OCR format, or will they only be in non-searchable PDF?

2) The file can be directly uploaded into a pt's chart in AC.
Is UpDox the only program that will do this? Remember, it must be in PDF-OCR format.

If the PDF-OCR file is able to be uploaded directly to a pt's chart, is a message then sent to my mail inbox telling me that there is a new file in "John Doe's" chart for me to review? If not, how am I to know that any file has been newly uploaded into a given pt's chart?


3) I can then use Adobe Pro X to annotate that document (in PDF-OCR format), in such a way that my comments are overwritten on the report and become a permanent part of the report - (no temporary sticky notes.)

Q: Is Adobe X Pro the most efficient program to do this with? Can Paperport do it, and if so, what is the advantage with Adobe (remember, files will be generated from barcoded items as well, and I want to be able to search the file, so it has to stay OCR). Does Paperport convert both barcoded and faxed/scanned items into PDF-OCR?


At this point, my workflow will go in one of four directions -
a) I will want to forward the document to my colleague, who has been seeing the pt., as an "FYI."
b) I will just "sign off" on a document that needs no further action (like a consult report).
c) I will want the M.A. to call the pt. with advice ("stop all alcohol and repeat LFTs in 4-6 weeks).
d) I will want the M.A. to call the pt. with a question, and get back to me with an answer (did the pt. run out of their thyroid meds before the last lab was done?)

This is where I get really confused.... In the case of the latter two, HOW do I review the pt's chart along with the report? Has the report now been directly uploaded into the pt's. chart, or is it a separate item, requiring me to look up the chart in another "window" so I can see what was going on at the last visit? If the report is actually IN the chart, what is getting emailed back and forth to the M.A.? The actual chart and report???

I would then plan to do this for each scenario:
a) Simply send the document to my partner via email.
b) Sign off on the report, and send it to the M.A. to file in the pt's chart. (Or is it already attached to the pt's chart?)
c) I will sign off on the report, BUT ask the M.A. to contact the pt. with my advice.
d) I will NOT sign off on the report, and ask the M.A. to contact the pt. and ask my question, etc.


4) At this point, let's say the M.A. receives my email, and has to contact the pt. - either to simply advise them, or to ask them a question. In either case, she will then annotate the report further, with her own notes that she has contacted the pt. on such-and-such a day/time. Again, this will be a permanent part of this particular report.

5) Now, the M.A. now has to let me know one of two things - either she has contacted the pt. and advised them of my recommendation, OR, she has an answer to the question I had her ask the pt.

6) So - she emails me back...

In the case of advice, she emails me that she has contacted the pt. and has filed the chart (remember, I already signed off on it).
OR, she emails me with the pt's. answer to my question. If I am satisfied at that point, I can sign off on it send her a message to file the chart (do I really have to go through that, or can I sign-off and file it myself with one click?)
OR, if I have a further question, I again annotate the lab (because I want all this to be a permanent part of the record AND to have the info stay with the report I am referring to) and send it back to her again.


LOTS and lots of questions, I know!!! But I seriously have to get a handle on how each step of the workflow would go, in practice.

If there is a more efficient manner to do the same thing, I'm all ears.

BUT, the things I MUST be able to do are:

1) Have faxed/scanned paper AND BARCODED documents imported into a pt's chart in a searchable PDF (OCR) format.
2) Understand exactly how I can review the document vis-a-vis the patient's chart - once it is uploaded into AC, is it actually IN the pt's chart? Do I get a message that a given pt. has a new lab report for me to review, and is the chart "right there" for me to refer to, or do I have to go and pull it up?
3) Have these documents be easily annotated in such a way that the annotations are a permanent part of that particular record ("overwriting" the record with comments is best)
4) Have an easy way to pass these documents back and forth, again being able to annotate each step of the way, if necessary.
5) Know how and where to look in AC for these documents -is there a particular folder in a pts. chart where I will find them? Can I make my own folder (one for consults, one for labs, etc.)?
6) Be able to easily generate a report/list of all of my pt's who (for instance) have an A1C above 7%.


Whew! That's pretty much all of it.
Melanie

FAIL: Imported Items are not (presently) searchable in Amazing Charts, with the exception of labs imported with a lab interface.

I get around this by labeling each document as I am importing it (ie, "renal, Smith" document goes into the CONSULTS file in that patient's Imported Items, "CBC, CMP, lipid" document goes into the LAB file, etc.) The items are time stamped by default with the date imported, but the date can be edited.


PASS: It is saved in the electronic patient chart, accessible by opening the chart on any computer.


PASS: A notice appears in your messages. Clicking on the message opens the lab or document to be reviewed and signed off. It is already imported at this point, but marked in red in the Imported Items of that patient, indicating it has not been reviewed.


Qualified FAIL: You cannot open the patients chart while you are signing off labs or imported documents in Amazing Charts, until you exit out of the sign off window (you can send reminders to staff, emails, etc, however).

The way I get around this is to use Updox to receive (most) imported patient data, review it in Updox (able to open & review the patient's chart in AC while sorting through docs in Updox), and them import & sign off the docs into AC from Updox (bypassing the AC sign off window).


PASS: There is a comment box available for each imported lab or doc available when signing off in AC, which becomes part of the document. The annotation is more flexible with Updox -- either the comment box or marking up comments directly on the document.


PASS: Messages can be generated and responded to, and saved to the chart, recording each step.


PASS: All imported labs & documents end up in Imported Items. AC has a stock set of folders, but custom folders can be created.


PASS: but only if the labs are imported via a AC-to-Lab interface. Labs imported manually into AC cannot be searched.

What if...the documents were imported to the patient's chart in PDF-OCR format (searchable PDF)? Wouldn't that be searchable?

Wow, wonderful help!!! Thanks you, John!!

Melanie

Yes, fax board puts a PDF in a folder. Press one button and they're all OCR'd in that folder. You can set this up to be done automatically. For the scanner, you can just scan directly into an OCR'd document. What do you mean by barcoded documents?


When you import a document from a folder in the patient's chart. It's copied to imported items. You can access it using the imported items tab in AC. You put whatever reports you want into AC and send a reminder to whoever needs to read it. Neither UpDox nor a faxboard knows which fax belong to which person. So either way you're going to have to put it in the patient's chart.


Nothing beats Acrobat in marking up PDFs. Add images, signatures, stickies, text, comments, etc. Anything you can do with a PDF can be done with Acrobat.


AC's internal messaging is the best way to keep track of these changes. Import, then send a Reminder to the designated user. They can mark up and send the reminder back.


Yes, you can separate items intofolders in the Imported Items to organize. E.g. Non-Medical Info and have all the docs under that and Outbound letters with all the info under that.


Only if imported via Lab interface. OCR'd documents can't do that. You can define any Tracked Fields and Values in AC. Say I wanted to keep Track of people I like. The Item name could be "LIKE?" and the value could be "Yes/No/Maybe". I could generate a report using the reports button to find all of the people I that have yes in the LIKE? field. Then, send them a Christmas card.

More on this later. My favorite food place is about to close.

Melanie,

At the risk of making an enemy, I am completely confused by your agenda and the way you are going about it. I read your last post, and the initial questions prior to your summary are so detailed and convoluted, they almost make no sense. I got a headache just reading them. On most of the workflow questions, I couldn't tell the difference. I do admire the time and effort it must have taken you to write it.

I couldn't begin to help you with your workflow, because I do about 10% of what you are asking? Rather than asking for the entire workflow, why not use AC and then ask as you go.

I know I have answered your questions in the past, and John and Sandeep have been nice enough to try to answer your questions.

Again, the summary is doable as far as help is concerned, but the rest of the post is beyond comprehension.

Here is what I don't understand. Your first question was in a thread called:

Thinking about getting AC - have questions on 2/18/2010. It is now 27 months later, and you are still trying to develop the perfect workflow. It would seem that if you haven't come up with one by now, you just aren't. And, I hardly think it is fair to those who do not know you have asked almost 100 questions over two years -- all of them in threads pertaining to the workflow of AC -- to spend valuable time answering questions. Questions that seem they are never ending and do not seem to bring you any closer to your goal.

As I have been one of those users and now have been able to step back and see where this going or, more accurately, is not, I have to wonder what EMR you are using. Again, while I am prepared to receive a post back asking me to kindly refrain from commenting, I do think I can give you the best advice on workflow, the use of AC, and AC in general that you have ever read. I am sure it has been offered to you before.

You can't learn AC's workflow by asking multiple, multiple questions on the board. You can't learn about AC in general as an EMR by asking questions. Think about it, Amazing Charts has moved through two versions since you started your research, both of which are completely unique.

So, download the trial version (if you haven't already) and start using it. I think you will find that you will answer most of these questions yourself. Every practice is different, and no one on here can design your work flow. All we can do is 1) tell you that AC is the best EMR out there, and 2) be around to help you once you are up and running.

Two years and 100 questions is remarkable research, but it is not going to get you any closer to using an EMR.

You can use Acrobat Standard to OCR all the PDFs in folder too. Acrobat Pro has some other things you can do with it's action sequence. If you like to automate the process.

I agree with Bert. It seems like a better idea to partition your questions and give AC a trial run. Post 44936 is hard to follow.

Melanie,

I think Bert has a good point. Before we decided on AC, we did the trial version. Of course before we started we had a bunch of questions but the best thing we could have done was do the trial version. From there, we were able to see what worked and what didn't. I used the board to see how others did things in AC. The best part is there is usually more than one way to do things.

You can't plan for every scenario, trial and error is the best way.

Wow!!!!!
I am a bit embarassed. I started this thread and didn't get a lot of response right away so I thought it was abandoned. Guess I was wrong. Took me nearly a 1/2 hour to read it all.

Melanie,
Just wanted to give you my two cents of advice on what I have learned in implementing AC in our office. We too have 4 providers, 1-MD, 2-ARNP's and 1 PA-C. We are open M-F and about 3 Saturdays a month for 1/2 day with 1 provider in office. 3 of our providers work 4 days a week and 1 works 1 day a week. We see on average 15 to 20 patients per provider. So some days 30-40 and busy days 50-60ish. After much investigation we chose AC and after much more investigation decided to start implementing with our most "Tech Savy" provider on staff (who also was the only one who voluntered). We didn't really worry too much about workflow processes in the beginning because we just wanted to learn the program and understand how things would work and kind of went with the motto of "change things as we go". We have since implemented our MD who started in January and our PA-C in April. We have 1 more provider to go and we will be all electronic. Now I don't know about your providers but all of ours were at different stages of computer skills so some were easier then others. We are now at a stage where we are starting to figure out our workflow and what works best for us. AC can do most of what you are wanting to do with a few exceptions but there are ways around anything I have found. We do have our labs interfaced which has been a big plus. We still get paper from some labs and our next workflow process project is implementing a fax server or Updox type of software to further make us more efficient. I think you will be happy with AC and can adapt it to work for your office but my advice is to use it, learn it and then see what other tricks people on the AC board can help you with. That is how I have been doing it and it has worked very well for me.

Oh, and I have one provider who uses Dragon 11.0 and it works very well with AC. He had never used it before so it was a bit of a challange at first learning AC and Dragon at the same time. I would advise to start using Dragon first before AC.

Good Luck!

Thanks, everyone for trying to help. I understand. But just so you know, I (we) do not have any EMR as of yet.

If the choice were solely up to me, it would be a done deal now with AC.

Melanie

Robynne, thanks for your input.

Demo it. Then ask one question at a time. I/We can't even begin to answer your questions when you are asking for the entire workflow from start to finish along with every possible scenario that can happen.

OK. I sent you a PM, Bert.

Robynne,

Thanks so much for that information. It is very good advice. I think that you are absolutely correct; one cannot predict every scenario that may arise, and to a certain extent, we will just have to learn/work out the bugs as we go along.

You also illustrate an interesting method - have one provider at a time get comfortable with it. My two partners are close to my age, and we all grew up with computers that used keypunch cards! None of us is good at typing, and one is NOT tech-savvy in the least!

Melanie

Thanks. You can just send them; I'll always get them.