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Considerations for EHR Section for The Sub-Specialist: Insights from A Case Study

A B S T R A C T

Context:Sub-specialists such as cardiologists have unique considerations when selecting and using electronic health records (EHRs).
Aim:We sought to identify key factors and considerations during system selection and implementation for the subspecialist.
Case Study:Insights from system selection and implementation for a start-up plastic surgery private practice were used to inform a broader set of principles for subspecialists in private practice selecting and using EHRs.
What can be learned:The nature of the provider-patient relationship is episodic and such as maintaining inventory, managing images, annotating images, documenting and billing in-office procedures, and integration of cash-based and insurance payment.
Conclusion:Procedure-based physicians in private practice and as part of larger institutions can use insights from this case study to inform their own efforts in system selection and optimization for ongoing use.

Keywords

Health information systems,electronic health records,organization and administration,medical record,practice management,ambulatory care

Introduction

Electronic Health Record (EHR) uptake and use has increased across settings and specialties. As EHRs have developed and matured, their uses have also changed. EHRs are used in different ways in medical practice including documentation, decision support, communication and integration with practice management and administrative functions [1]. The ways in which EHRs serve as a communication device between providers and staff, a repository of clinical information and an administrative tool differ across provider types. Primary care provider practices are characterized by long-standing relationships where providers see patients for years. In contrast, surgical specialties are characterized by shorter, more intensive bursts of care in which patients see providers on a frequent basis for a short period of time. Differences in the nature of the patient care relationship translate into EHR requirements and uses.

Many EHRs were developed and optimized in response to Meaningful Use EHR Incentive Program [2, 3]. One of the objectives of this program was to increase EHR uptake and information exchange across providers, particularly primary care providers. Uptake has largely increased in physician offices due in part to these efforts [4]. In response to demand, many EHR vendors developed their systems with qualification for incentive payments in mind, which are geared towards the primary care provider. Thus, many commercially available EHRs are aimed at the adult primary care provider and less so for the specialty provider, in particular the surgical subspecialist.

Those in specialty practice, particularly procedure-based subspecialties, have specific needs which may not be met by EHRs designed to meet the needs of the primary care provider [3, 5-9]. In addition, they provide care for a particular problem and may not be involved in the bulk of a patient's care, particularly for those with chronic conditions. Thus, it is important to identify end user needs and priorities for the procedure-based specialist [10]. This study reports on system selection efforts for a start-up solo plastic surgery private practice in Charlotte, NC. Insights from this experience can inform future efforts for technology development, selection and use for specialty EHRs.

Case Study

This case study is based on systems selection from a solo start-up plastic surgery practice. The plastic surgeon had previously held a faculty position and trained in several academic institutions and thus was familiar with several of the most common commercially-available systems. Insights from system selection were documented and analyzed upon selection. Documentation was reviewed and themes extracted from the first author, with input from the second. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

What can be learned from this case?

There were several priorities found to be of particular interest for procedure-based subspecialty practice. First was identification of practice characteristics relevant for system selection. This was followed by identification of EHR requirements, selection considerations and implementation considerations.

I Practice characteristics

An important step is to identify the context in which practice occurs. The context influences uses of EHRs and resulting data. Factors to consider regarding end-users include number of providers in the practice, ancillary providers, how related services will be documented, hospital affiliations, billing and practice management staffing and other memberships. Factors to consider related to service provision include the range of services, payment models (insurance versus self-pay) and whether or not the practice will bill insurance directly. Identifying practice characteristics is relevant to identifying a core set of user needs and services.

II Identification of Key EHR Requirements

Practice characteristics inform key EHR requirements. However, there are some features of surgical subspecialty practice which have common requirements. Many specialists see patients in the outpatient setting yet conduct procedures in the inpatient or hybrid setting. This type of patient care across setting means that the EHR needs to accommodate coordination of multiple resources (e.g., physician time and operating room time) and integration of clinical notes and physician orders across settings. Whether or not insurance is billed directly, the EHR must be able to accommodate billing and a variety of payment arrangements, including ongoing payment for services. In addition, practice management functionality such as inventory management and tracking sales of ancillary services is of particular import for the plastic surgeon. Given the importance of pictures in surgical specialties with an aesthetic component, photo capability including annotating photographs is a critical piece of functionality.

III Selection Considerations

When selecting the EHR it is important to identify the set of EHR requirements that are the most important to the end users. In addition, systems must be able to accommodate the practice type. A system for a hospital system may be different from that for a solo practitioner. During vendor demonstrations, viewing how the key pieces of functionality work and any necessary workarounds is a critical consideration.

During vendor demonstrations, multiple members of the team should attend and pay particular attention to different pieces of functionality and workflow. Because team members have different perspectives and roles, their ideas about workflow are crucial. After the demonstrations, team members may have different perspectives about system usability, functionality and customizability. Pricing and clarifying start-up and ongoing requirements for the system is another key consideration for selection. Pricing includes the system itself, any necessary infrastructure and ongoing support. In addition, there may be other costs such as training, and additional tracking and monitoring to clarify.

IV Implementation Considerations

Implementation considerations include identifying clear roles and responsibilities and allocating resources for implementation and use. Roles and responsibilities include a main point of contact for the vendor and a trainer for within the practice. Resources for implementation and use include training, data management and any documentation not addressed by the system.

Discussion

Subspecialists selecting and implementing systems have considerations that differ from that of other specialties. While each surgeon is different, the process of prioritizing functionality can help inform system selection. Those in single specialty, academic and multi-specialty practices can use the insights of this paper to inform their own efforts for system selection and use. Future directions include developing a more thorough understanding of subspecialty EHR requirements from plastic surgeons and ancillary staff members across settings. Then prioritization and consistent checklists and questions to guide system selection and use could be developed. This would be of use across settings to inform selection, updates, and customization.

Conflicts of Interest

The authors have no conflicts of interest to report.

Article Info

Article Type
Research Article
Publication history
Received: Tue 18, Jun 2019
Accepted: Wed 03, Jul 2019
Published: Fri 19, Jul 2019
Copyright
© 2023 Saira N. Haque. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Hosting by Science Repository.
DOI: 10.31487/j.JICOA.2019.03.02

Author Info

Corresponding Author
Saira N. Haque
Senior Health Informaticist, RTI International

Figures & Tables


References

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