- Are there questions appropriate to the disease, and how detailed are they?
- Is there a logical flow and are the elements counted by the Centers for Medicare and Medicaid Services for the encounter obvious?
- How do they record pertinent negatives as well as positives? How do they treat bilaterality?
- How do they handle free text?
- Is spell checking with a medical dictionary incorporated?
Don’t dwell on past medical and surgical histories at first because these will be pretty standard. Look for how vendors present questions required for meaningful use documentation. Look for good detail in the head and neck exam. They should volunteer time-saving “macros” which allow you to easily create your own normal findings and then chart by exception. Be wary of company defaults because you will no doubt enter unintentional data that, at the very least, could get you into trouble and at worst, could harm your patient. Remember: Everything you check means you did it or asked the question!
Explore This IssueOctober 2011
Review the plan. Ask yourself: Have the designers of the pathway taken the time to outline possible medical and surgical options? This is not to push you into a “doc in the box” modality but to assist you in choosing viable options.
Check coding. You should also look at the assessment portion of the EMR. It should be presented to you as a differential diagnosis with embedded ICD9 codes. This is important because the list will remind you of less common diagnoses. Don’t forget to ask about their strategies to incorporate ICD10 on October 1, 2013.
Get samples. Ask for a printout of the chart note and referring letter. Free text that describes your assessment and plan succinctly is very valuable when it is incorporated into the referring letter. Your referring doctor does not want to see your entire chart note, just a one-page letter that explains that you saw the patient, what you thought was going on and what you are going to do about it. This short text is invaluable at your follow-up appointment. Reading this assessment and plan will instantly tell you what you thought was going on and what you did.
If you like the initial pitch, dig deeper. Ask for a sight visit or a webinar for a more in-depth look at the product. For example, ask for references to sites of similar size that use the product. Be respectful of these practices because your visit can be disruptive and costly. Make sure you take billers, nurses, and administrators with you. Also make sure you get unchaperoned time with the users; you’ll be amazed at what comes out. Particularly important is an assessment of the company’s training and support. You will be dealing with a whole different animal after the sale! ENT Today