Clinical Documentation System: Fill & Download for Free

Practice Management (PM) systems help run the business functions of outpatient healthcare organizations. For a typical small or mid-sized doctor’s office, this includes features like patient appointment scheduling, filing the insurance claims, handling accounting, etc. It is categorically not used as the EHR system or by the clinician. Instead, the main user is the office manager or front-desk staff.A PM system relies on integration with an existing EHR for clinical documentation. All outpatient software vendors end up offering both EHR and PM systems because they need to be together for either of them to function properly.- - End of Short Answer - -Here is a framework for thinking about EHR fundamentals and how PM fits in:EHRs help with billing - that’s “Revenue Cycle Management” (RCM).EHRs let clinicians and staff record data about care - that’s “Documentation.”EHRs enable physicians to prescribe - that’s “Computerized Provider Order Entry” (CPOE).EHRs can digitize day-to-day operational logistics, specially for clinics and outpatient facilities - that’s “Practice Management” (PM).EHRs can let patients view their own data - that comes under the “Personal Health Record” (PHR).6. EHRs can serve as the information system for various departments of a hospital. Each specialized adaptation becomes a particular “Departmental System.”Note: This answer is adapted from my book “Before Disrupting Healthcare: What Innovators Need To Know.” Available for free in iBook store. $0.99 on Kindle, $9.99 in Print and $14.00 on Audible. The book goes into more details about EHRs, PM and related topics.

I have taken the liberty of expanding this post to represent “How do we exchange data” rather than only focusing on “libraries and interfaces.”Update Jan. 11 2018: Broader interoperability is being mandated by Congress through the 21st Century Cures Act and rule making : Trusted Exchange Framework” will be finalized by the end of 2018.From the http://HealthIT.gov website:“The Draft US Core Data for Interoperability (USCDI) and its proposed expansion process aim to achieve the goals set forth in the Cures Act by specifying a common set of data classes that are required for interoperable exchange and identifying a predictable, transparent, and collaborative process for achieving those goals. This document provides ONC/HHS first draft of the data classes that would be in the USCDI and lays out the process and structure by which the USCDI will be updated and expanded. The USCDI and its expansion process are intended to be collaborative vehicles around which ONC and the industry can coalesce to identify the critical data needed to enable interoperability and achieve the goals outlined in the Cures Act.” SPECS are FHIR & CCDAThe roadmap of further candidate data classes through 2021 is here with a listing of emerging data classes beyond that: https://www.healthit.gov/sites/default/files/draft-uscdi.pdfThe most common interface types for medical records we see are HL7, FHIR (the HL7 successor), Interconnect , Cloverleaf, Rhapsody, and Ensemble depending upon the specific EMR vendor being integrated with. The best thing that can happen for interoperability is strict enforcement of standards since implementations are highly variable. You can google any of these interface tool names and find the information on both documentation and implementation. If you have at least a year before commercialization, I would get familiar with FHIR, it seems to be gaining some traction in what is currently a small number of health systems, though will be in the future, a larger pool of customers interested in increasing digitization and driving/accepting consensus around standards. In this article, Dr. Joshua Mandel at Harvard discusses the scope and goals of FHIR: (article also covers Clinical Decision Support Hooks). What Is CDS Hooks? An Interview with Josh Mandel About FHIR and Clinical Decision SupportYou will also need to know HL7V2 and V3 as explained further below. In addition, even the most “closed” EHR systems are developing FHIR API's for new apps and connectivity that are required to maintain their EHR certification for physicians to qualify for the Advancing Care Information measure portion of the soon to be released MACRA rule which dictates how physicians will be paid. If you need to understand how certification affects how providers are paid, review this article: http://www.beckershospitalreview.com/healthcare-information-technology/does-ehr-certification-by-the-government-mean-anything.htmlYou can also read more about MACRA here: https://www.linkedin.com/pulse/macra-mips-what-you-need-know-plain-english-medicare-part-douville?trk=prof-postHere is info from the FHIR website: Overview - FHIR v1.0.2General documentation that describes how resources are defined, and gives background material including definitions of data types, codes, and the XML and JSON formatsImplementation - how to use resources using REST, Messaging, as clinical documents, or in a service based architectureUpdate July 15, 2016FHIR interfaces will take hours or days instead the weeks that it took to build HL7 interfaces.According to Jitin Asnaani at CommonWell,"FHIR [Fast Healthcare Interoperability Resources] is two things:1) There is the FHIR standard which enables you to package discrete bundles of data,2) Then there is a thing called the FHIR transport standard which enables one application to be able to connect in a physical way with the data repository underneath it, like the EHR.Providers will soon be able to enable the data that flows on our network to be discrete packets of data, not whole clinical documents."Dr. Russell Leftwich, who is an HL7 International board member, also says "that for the foreseeable future, healthcare providers will need to translate between different standards—HL7 v2, HL7 v3 and Consolidated-Clinical Document Architecture (C-CDA) and FHIR—as there will be a need to transform back to earlier standards so that legacy systems can consume data. Further, he states that "organizations need to be strategic about the architecture they build out and the capabilities that are in the information architecture to adopt new standards like FHIR, but also to allow access to data that exists in these legacy systems that use older standards.There’s the existing standards, HL7 v2 and C-CDA, and they are not going away, not in the next 10 or 20 years. They will still be in use, and the HL7 version 2 standard is the most widely used standard, and it’s being used in countless systems out there and people aren’t going to simply replace those systems. They are going to continue to use those systems because that standard does what it does very well, as far as exchanging lab orders and lab results, between the EHR and the lab system.And there’s work to be done with FHIR, as different parts of FHIR are not yet built out, particularly those parts that deal with very complex clinical data elements. The part of FHIR that deals with the more basic things like what’s the information around a patient or information around a particular condition, the way we specify a condition or a lab test, those things are fairly far along in FHIR. But more complicated concepts that relate to specialties and genetics and things like that are yet to be fully built out in FHIR. What needs to happen is that the entire FHIR community and the clinicians in particular need to get together, one data element at a time, and agree on a model, or how to represent that piece of data. You have to have that to really have interoperability across organizations."A Clinical Informaticist Shares Why FHIR Won’t Extinguish HL7, At Least Not in the Near-Term

-strong and loyal medical professionals that have the best practices of quality care, and strong clinical documentation.-Simple Operating systems that is easily implemented from your employees to clients.-Making complex operations simple.-Making strategies for internal communication and external communication.-Strong business development team, and a hands on operator.