Touching on electronic medical records.

For Steven J. Kraus, DC, DIBCN, CCSP, FASA, it's all about understanding what a true electronic medical records (EMR) system is and having the foresight to acquire it sooner rather than later. There's no question, he says, that "within 10 years paper records will be dead," to be replaced entirely by digital technology. Ample proof of this, Kraus opines, can be found, among other things, in the agreement in principle between such disparate characters as Newt Gingrich and Hillary Clinton, both of whom stated in the 1990s that going to EMR would save the country $77 billion annually.

Our government already has a leg well up on the impending conversion, with the entire Veterans Affairs hospitals system having gone paperless, with very favorable results. In addition, the state of Minnesota, playing the vanguard role, has mandated that all health practitioners must be using EMR by January 1, 2015, or they will not be able to practice in the Land of 10,000 Lakes.

So how is it, then, that only 15% to 18% of the chiropractic community has to date embraced EMR? According to Kraus, many DCs are, in fact, using some form of digital technology in their offices. But all too often they are using not true EMR systems but rather digital note generators, devices that fall far below the capacities needed to perform the multiple functions required of a genuine EMR system.

Sometimes masquerading as real EMR technology, these relatively inexpensive note generators fail to fulfill the true purpose of EMR, which is to provide storage and transmission of patient data as rapidly and securely as possible in compliance with all prescribed rules and regulations. Interoperability is also a major concern, as an EMR system must be capable of interfacing with other sources and systems, including third-party payors, hospitals, clinics and offices; as well as digital x-ray systems, range-of-motion computerized systems, and so on.

From Frustration to Solution

It was Kraus' sense of frustration over the lack of health record solutions and efficiency, both in his own practice and in chiropractic in general, that led him, in 2004, to develop the technology that became the principal product of his company, Future Health Software, Carroll, Iowa. Prior to that, he had specialized in managing the practices of other chiropractors nationwide, which had provided him with a bird's-eye view of the documentation problems endemic in the industry.

He cites the OIG General Report of 2005 as a tipping point: "It was a scathing report on the quality of documentation in chiropractic. It showed that we failed to meet the health records standards required by Medicare." In an earthier vein, Kraus adds, "Everyone knows that we suck at our documentation."

The answer, he determined, was to provide a solution that would address all the necessary concerns, including function, speed, efficiency, security, interoperability, and cost. Thus was born the Virtual Office Suite, Future Health's flagship product, and, Kraus says, one of less than a half dozen true EMR systems currently available.

The Virtual Office Suite consists of five modules: billing, documentation, EMR system, scheduling, and patient education. Each module can be purchased separately. An additional module, which consists of hundreds of high-definition videos, is available for an additional cost.

And the payoff, financially speaking? "There are five things that happen with every patient encounter: scheduling, documentation, storage, billing, and patient education," Kraus explains. He says that the cost of a true EMR is 47 cents per encounter, versus an average collection per encounter of $47. This means that there is a mere 1% operating cost per patient for an EMR system.

Over a 5-year period, Kraus claims, this translates into a seven-to-one return on investment for the average single-doctor clinic, and a whopping 32-to-one return for a typical large, multidisciplinary facility. An individual chiropractor can save $2,000 to $3,000 per year on filing costs alone.

Is long-term cost savings the only advantage of EMR? Not by a long shot, Kraus says, given the many technological benefits that can dramatically improve patient care.

"Information in an electronic format can be turned into graphs, document progress, and compare visit to visit," Kraus explains. "It can help analyze and extrapolate data, and alert the doctor about insurance authorizations. In compliance with HIPAA regulations, it can provide encryption, keep track of where and why documents are sent, and prevent unauthorized viewing of patients' records by anyone, including office staff.

"What you will see happening in 10 years is that electronic notes will be attached to every billing, providing all the patient records needed by Medicare. There will no longer be any need for requests for records or reviews. There are many wonderful benefits to this technology."

Quick Notes' portable PDA allows doctors to carry its technology from room to room.

The Evolution of EMR

Greg Winterkamp, president and CEO of Addison Health Systems Inc, Addison, Tex, has closely watched the EMR trend develop since the 1980s, from the computerization of the HIPAA form, to forms that could be scanned, to the creation of electronic billing. Addison's WritePad Electronic Medical Reporting System is utilized by 17,000 daily users that include hospitals, pain specialists, and doctors of chiropractic. With its customizable screens, separate modules, and ability to stay ahead of compliance, WritePad can meet a doctor's varying needs, particularly when it comes to EMR.

The versatility of WritePad speaks for itself, as new screens can be created by Addison or the doctors themselves for literally anything needed. This gives the doctor flexibility without having to rewrite the whole program.

"The customization allows us to do things quicker as new regulations happen," Winterkamp says. "However, what needs to happen is more standardization. E&M—evaluation of management codes, the requirements of Medicare, which are standard for the way you document—are becoming more detailed. To be manual, it is very difficult to meet those requirements.

"If you are not computerized, you are at a very serious disadvantage. There are more insurance companies that are not taking handwritten notes anymore," Winterkamp states, citing the 2004 executive order given that health care records be computerized by 2013. Winterkamp also notes that even a cash-based practice is not immune from such legislation. "If the patient has insurance, they can still file it. It is still a claim, and the patient will come back and ask the doctor for notes."

Keeping an Effective Solution Simple

From day 1, Quick Notes Inc, Cooper City, Fla, has followed its goals of providing the most user-friendly, easy-to-implement software solution while also ensuring that the solution remains safe, secure, and easy to manage. Now celebrating its 20th year, and with more than 4,000 clients around the globe, Quick Notes offers chiropractors a truly portable, easy-to-use, handheld system that provides 100% customization based on the doctor's needs.

Quick Notes Vice President Ken Schenley notes that, as an EMR and documentation solution, Quick Notes gives chiropractors an easily accessible way to create and maintain proper documentation, along with protection against fraudulent claims and catastrophic losses. It even helps eco-conscious doctors and staff "go green" by reducing their dependence on paper records. Most importantly, Quick Notes offers a way for chiropractors to keep it simple and play it safe with their EMR.

Additionally, Quick Notes' portability allows doctors to carry its technology from room to room, with the ability to generate complete and compliant notes in the palm of their hand. "You have got to touch the notes like you touch your patients," Schenley says. With notes created in seconds, instead of at the end of a busy day, a doctor can obtain the documentation he needs without the hassle.

Ease of use in practice, and the ability to generate notes in a doctor's own words, are integral components of Quick Notes' technology. "We have to constantly be there for the client in many ways … from the verbiage we create in our PDA, to the storage of notes in the EMR, to the long-term portability of the patient records," Schenley says. "We have spent 20 years mastering the art of chiropractic documentation. And we keep it simple!"

Leading Chiropractic to EMR

"Chiropractors are cowboys," proclaims Michael Silbert, DC, who practices in Chicago, about the independent tendencies typical of the profession. " 'Chiropractic' in Latin means, 'I'm gonna do it my way,' " Silbert discourses, "so I had to design software that provided the resources they needed for the part of the country they practice in and for the scope of their practice, including the various modalities they prefer and are allowed to practice."

Silbert is himself a practicing chiropractor, having bought a practice in Chicago in 1994 that included a "checkbox" system of note dictation, which he eventually realized was too minimal. His seminal moment vis-à-vis electronic medical records came when a DC in an office across the hall remarked that he overheard Silbert's dictations and noted that they were always very similar in approach and content. This was so, Silbert explains, because he worked in the Chicago Board of Trade building, and most of his patients were commodity traders and law enforcement personnel, so the notes tended to follow a pattern reflecting the repetitiveness of his cases, and the checkbox system did not allow for substantive expansion.

Feeling "fed up" with his own dictations, Silbert jumped at the chance when his neighbor (and future partner), Russ Manktelow, DC, offered to design a software program that would augment and streamline the documentation process. "Russ is brilliant, a mad scientist type," he explains, "while I'm the anal one who can attend to the more practical matters."

Together, starting in 2002, they developed EZ Notes, which is now utilized by about 1,000 chiropractors nationwide. The system, which has 26 buttons on the main screen and covers an array of options, such as treatment plans and impairment ratings, that contribute to creating as "complete a record of the patient encounter as possible," also features password and privacy protection in compliance with HIPAA.

Capabilities include the storing and accessing of x-rays, an electronic book of protocols for dealing with various conditions such as carpal tunnel syndrome and headaches, nutritional sources, and 267 exercises that can be customized for sets and repetitions and printed out for the patient to take home. "When working on patient history or consultation, I actually give them a copy of the document and tell them, ‘This is the story that you gave me as I perceived it. If there are any inaccuracies, please let me know,' " Silbert says.

EZ Notes has 26 buttons on the main screen and covers an array of options, such as treatment plans and impairment ratings.

Silbert takes pride in the fact that "we update our software every other week, more than any other company." The updates are free for the first 6 months, after which a $300 annual tech support fee applies. The system is self-contained with no separate modules, at a total cost of $2,000. No special hardware is required at the beginning.

In fact, Silbert recommends that doctors don't buy new hardware so they can learn the system on the equipment with which they're already familiar. "Ultimately, what they want to have is a tablet PC with touch-screen capabilities," he says.

So is EZ Notes a "genuine" EMR? "Yes," Silbert says, "in regard to providing a full range of features for chiropractic practice." However, he qualifies, it can't really be called a "practice management program," because it lacks billing capacity. "But we designed it that way on purpose."

Embracing EMR Technology

Perhaps most crucial of all, Kraus believes, is the necessity of upgrading the system for the benefit of the chiropractic community itself. While acknowledging that chiropractic has made gains in terms of general acceptance, physician referrals, and third-party payments, he is certain that "the only way progress will continue is if documentation demonstrates the quality of our care," he says.

Kraus goes on to note, "We need to embrace technology to help us tell our story, show our results. Then we'll get more referrals from the medical community, have fewer denials from the insurance companies. The question is, how are we judged by others, by Medicare, by third-party payors, by lawyers and jurors in personal injury cases? By embracing a comprehensive and robust EMR system, we'll be accepted even more in the whole health care system."

Alan Ruskin is staff writer for Chiropractic Products. For more information, please contact .