Category: The technical world

Privacy: Where are you now?

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One of our customers recently shared a NY Times column about photos you post on the web revealing where they were taken. Geotags provided by some digital cameras and many smartphones with built-in GPS features indicate where the photo was taken. If you post a photo of your child’s at-home birthday party taken with geotags turned ‘on’ in the camera/phone you used, everyone who looks at the photo can also know just where you live.

The technology, while very useful in operating your GPS or helping you keep track of where your teenager is at this moment, is also a potential privacy threat because it embeds the longitude and latitude of where the photo was taken. 

While many people are not very concerned about this matter, others fear that this is just one more step in the gradual erosion of our ability to protect our privacy. This is largely because most people do not even know about geotags and have no idea that they can be turned on and off. The above-mentioned article by Kate Murphy points you in the direction of controlling who has access to where your photos were taken.

The Web site ICanStalkU.com provides step-by-step instructions for disabling the photo geotagging function on iPhone, BlackBerry, Android and Palm devices.

Those of us who work in the behavioral healthcare world have long been concerned with issues of privacy for our patients and consumers of our services. We work hard to assure that only appropriate individuals have access to their treatment records, demographic and other protected health information (PHI). In fact, the law requires us to assure that only those who have a right to access this information have the ability to do so.

What are the implications for geotags on the issue of PHI? Right now, you need to post a photo on the internet or utilize an application that specifically makes use of the geotagging capability of your device to reveal your location. What happens when that capability is not revealed to you…or when it is revealed in a use statement that is so dense with legalese that you do not even read it? Here is a scenario from a not very distant future.

As a case manager for a community behavioral health organization, I want to be sure that I can always reach persons who use our services in case of an emergency. As a result, I keep a listing of the phone numbers of all my clients in my smartphone. Any time a new client comes in or a current client changes their contact information, I synchronize my phone list with my computer list. It has become so easy to do over my wireless network at home and the office that I am always up-to-date. Besides, having the list with me when I make a home visit means I can confirm my appointments before I head to see the consumer. I only include first name and phone number so confidentiality is protected, and my phone is password-protected.

I know I am not supposed to, but I also use my phone for some of my personal activities. I like to surf the web when I am waiting to see a client or while sitting in the train station. I have not disabled the features of newgoogle that customize the advertisements I get to match the web surfing I do…in fact I kind of enjoy it. I don’t use Twitter very often, but I like to check in every once in a while. And the new video feature is a great way to see where my friends are when they tweet. Last week I tweeted from the train and from the park across the street from my client’s apartment. Sometimes, I insist my kids do video calls with me so I can see where they are. I never thought I would enjoy this new technology so much!

What’s wrong with this picture? Is the client’s PHI actually protected? Do you see any concerns in this scenario? How far are we from someone who telephones us being able to know immediately exactly where we are? Is the casual attitude of many people toward privacy and technology something to be concerned about? Is our ignorance about the technology we use acceptable?

What do you think…am I just a bit paranoid? Is the customer who sent me this article concerned about something that is of no consequence? Where do you stand on the issues around privacy and technology? Please share your comments below.

New Phone Systems: Frustrations of an impatient newbie

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The last two weeks have been extremely challenging for me. As many of you know, I am not a techie; I am an end user. Without excellent in-house and outside product and computer support, I would not be a happy computer user most of the time.

We have been using a hosted PBX-style telephone system (Onebox) for the last couple of years. This service gives us the general functionality of a PBX system without the cost. We have extension numbers for each phone. We have automated attendants with different messages at different times of the day and night, as well as for Technical Support vs. Sales and Customer Service. We have multiple voicemail boxes at which customers can leave messages. We told the company what we wanted. They set it up for us. We use it.

Our one frustration has been the length of time needed to transfer a call from one person to another within our organization. It takes so long customers sometimes hang up. And sometimes transferring just does not work at all.

In 2009 and 2010 we have been cost saving fanatics. Since long distance telephone calls and numerous telephone lines are among our biggest expenses, we began to research options other than land lines and long distance contracts. About a year ago, we started using Voice over Internet Protocol (VOIP) telephone service through T-Mobile for our outgoing technical support calls. It has mostly done the job at a fraction of the cost of long distance service, so this month Seth started to research moving our entire telephone system to a hosted VOIP solution. After a couple of days of intense research, he decided that we should try Vocalocity, a company that focuses on small businesses.

Then Manon, our lead technical support staff person, left for vacation and my headache began. You see, Seth assists with doing tech support when one of our primary staffers is out. That meant the VOIP project was handed over to me…and oh what a mistake that was….because, remember, I am technologically impaired. Much of my other work has been on hold while I tried to make this work.

Seth had begun to set up our Auto Attendants, but they were not working properly. He emailed our phone system flow chart to a support representative at Vocalocity so they would know what we wanted to accomplish. Then, I needed to work with the support representative to make it happen. Over the course of three days, an excellent representative named Nathaniel worked with me to make changes in the setup of our account. It was much more complicated than either Seth or I realized. There were some things that had to be initiated on their end to accomplish our goals; they were not end user configurable. Finally, on Monday we tested all the work Nathaniel had done and the system appears to do what we want it to in the way we want. It even lets us transfer calls from one extension to another without a long wait time.

Today I called our telephone service provider and had our main line forwarded to the number assigned to us by Vocalocity. Tomorrow I expect to start receiving calls on the new system. We will let you know the outcome.

The moral of this story is this: using new technology may be just the way to save your organization lots of money; however, have your most tech-savvy person work to accomplish the goal. Giving the task to a less-than-patient person who just wants the darned thing to work is not the most effective way to adopt the new technology….no matter how cool the technology is.

What technology implementation stories do you have to share? Has your experience taught you some things about how to most effectively adopt new technology in your organization?

Just enter your comment in the box at the bottom of the page. If you don’t see a box, double click on the title of the article then scroll back down to the box to enter your comment. Please share your experience. I must get better at this!

How to Choose an EMR…and other pressing questions

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For those of you who attend to news about Health Information Technology (HIT) last week was a busy one.

  • The 10th annual meeting of the Health Information Management Systems Society (HIMSS) in Atlanta took top billing. One of my favorite bloggers [EMR (EHR) and HIPAA] attended and posted frequently during the conference. John has been writing about EMRs since December 2005 and his knowledge is considerable. In fact, he just published his own e-book on how to choose an EMR. He is sincerely interested in the best ways for a facility or practice to choose the best EMR for their organization. John’s Sunday post referenced an article by Didier Thizy from macadamian titled “Electronic Medical Records – 3 Key Differentiators“.The three most interesting and possibly most important differentiators Mr. Thizy heard being promoted by EMR vendors at HIMSS about their systems were:

The EMR has excellent UI (user interface) and usability.
The EMR is designed for a specific speciality.
The EMR’s technology makes the user’s life easier.

Obviously, when it comes to electronic medical records, one size does not fit all. Making sure that you take usability, specialty specificity, and life simplification into consideration is likely to make your selection a better fit for your organization.

  1. The Veterans Administration and the Department of Defense have been working diligently through a contractor to connect their respective EMRs so they can communicate with one another. After incorrect communication of patient information (providing information about the wrong patient in response to a user query), the VA decided to shut down access to the DoD system. Hopefully, this is a very temporary glitch and does not mean a complete return to the drawing board.
  2. The Medical Group Management Association (MGMA) expressed concern about results of a survey they completed recently. They found that practice executives are not as optimistic about productivity gains as software and information management executives. Over two-thirds of those surveyed believe that physician productivity will decrease because of the proposed meaningful use criteria. The other third of practice executives felt productivity would increase. This split resulted in MGMA’s chief Dr. William F. Jessee’s statement: “For the incentive program to succeed, the meaningful use criteria must be practical and achievable. If the final rule mirrors those outlined in the current proposal, there is significant risk that the program will fail to meet the intent of the legislation, and that a historic opportunity to transform the nation’s health care system will be missed.”The survey results indicated which criteria will be most difficult to meet:
  • The proposed requirement that 80 percent of all patient requests for an electronic copy of their health information be fulfilled within 48 hours (45.9 percent) and
  • The proposed requirement that 10 percent of all patients be given electronic access to their health information within 96 hours of the information being available (53.5 percent).

    • Those of you who like to closely follow news in the health care IT space might consider following these two excellent sources yourselves:

    EMR (EHR) and HIPAA and FierceHealthIT

    Remote Conversations: How do you do it?

    Posted on | by SOS Blog | 7 Comments on Remote Conversations: How do you do it?

    I’ve mentioned here pretty often than I am not a technology sophisticate. I use technology every day in my work life, but I am a slow-adopter. For some of you, this article may be so old-hat that you will ask “Kathy, where have you been?” But I know there are others out there like me, so here goes anyway.

    My mother-in-law had back surgery in Miami early this month. Since my 89-year-old mother lives with us, it has been impossible for me to go down to see her since the surgery. This past weekend, we arranged to skype a conversation so she could talk to me and my mom and we could “see” how she is doing. That word I just used…”skype” did not exist as a verb until August 2003 when a group of Estonia-based developers released the first version of what became Skype.

    So what in the world is a skype? It is a company that created a technology that allows one computer to make voice and video calls to another computer free of charge. It also allows one to make phone calls from your computer to land lines and cell phones for a very low charge. Of course, it is the free-of-charge calls to other computers, especially video calls, that makes it so exciting. The process of doing this has become “to skype” or “we skyped.”

    The technology allows high quality computer connections without going through a telephone service. As long as you have a high-speed internet connection, there are no voice/video delays. As long as your web cams are decent quality, picture and voice quality are excellent…and Skype has built-in tools to help you improve quality if you are having any difficulty.

    But here’s the rub…Skype has become so popular that our Sunday morning attempt to connect was unsuccessful. The servers were all busy! So what’s a computer video newbie to do? Well, use Google Chat instead, of course.

    SOS has recently switched all of our email to a Google corporate account. This gives us access to a number of other tools…Google Chat is one that we have used in-house for instant messaging. While I only learned about this through our Google account (I told you I am technology-impaired), this tool is also available to anyone who wants to use it…just check out the link above. I had not input the settings correctly before this weekend, so we combined old-fashioned cell phone technology with Google Chat computer video. There was a lack of synchronization between our cell phone service and the video, but now that I have my webcam microphone set up as the sound source it will be synced on future calls.

    Yahoo! Messenger has provided similar service and functionality for years, and for Microsoft fans, Windows Live Messenger also allows these same capabilities. Ichat is a similar service used by Apple aficionados.

    I must tell you that I do not have much interest in using this technology for work, but for personal contacts with family members who live far away, these are wonderful tools. My assessment of this may change over time. For many of you, the time may be now. Video conferencing is a wonderful way for scholars and far-flung colleagues to work together. It is also a fantastic way to provide behavioral health services to remote and home bound clients.

    Several months ago, a Florida psychology listserv to which I belong was the setting for considerable discussion about remote provision of services. While some of the practitioners were hesitant to consider providing psychotherapy via computer video, some have already begun doing so. Community behavioral health organizations are actively considering such services for rural clients and others who require case management but are not readily available for visits. Over time, providing low-income, seriously mentally ill individuals with an inexpensive computer, internet service and webcam could save thousands of dollars in case manager travel and time costs, not to speak of hospitalization costs when deterioration not noticed on a telephone call but readily apparent on a video conference, is beginning.

    The biggest push for these services may come from Medicare, Medicaid and other payers. A December 2008 article from the American Telemedicine Association details Medicare’s authorization for payment for remote services. These are provider and location-of-recipient dependent, so check out the details before you decide to start billing Medicare for such services. Since psychotherapy is a covered service for the purposes of telehealth, I expect more practitioners will begin to provide these services. I hope more abundant research on comparative efficacy will follow.

    Has your organization begun providing any services remotely using video conferencing? What methods do you use? What benefits and limitations do you experience? If you are not already providing services in this fashion, what might it take to move you to do so?

    Please share your comments by clicking on the title of this article and entering your comments in the box at the bottom of the page. Thanks for participating in the discussion!

    Workflow and EMR: How do you do it?

    Posted on | by SOS Blog | 5 Comments on Workflow and EMR: How do you do it?

    During the past two weeks, I have spent several hours creating process diagrams or flow charts for a customer. After using our billing software and a custom attendance/reporting module we created for them in 2003 but maintaining paper clinical records, they are now implementing a custom Forms module and preparing to implement our behavioral health electronic medical record (EMR) product.

    Clearly, understanding their current work flow is essential to assure that the steps we follow to implement the electronic record will cause minimal disruption of their productivity and maintain their confidence in their billing and cash flow. The goal of the CEO and CFO is to seamlessly provide and document services so payment audits do not result in lowered funding; the goal of the clinical staff is to help addicted people recover from their addictions and become productive citizens; and the goal of the billing staff is to assure that services are accurately reported and billed so the agency is paid for services provided.

    The end point we plan to reach is that billing will not occur until documentation of the treatment is in place, but getting to this point will be a gradual process. Helping clinical and business office staff understand the job responsibilities, work flow and the anxieties of their colleagues will allow them to work more effectively as part of a team. The team, of course, shares the goals of providing the best clinical services as efficiently as possible and assuring that payment is obtained for those services so they all can continue doing their respective jobs.

    While this flow charting was a time-consuming process, it was most instructive. One thing we have learned in almost 25 years in business is that our customers rarely use our products in the way we designed them. . . .and each organization does things differently. This customer was no exception. For us to make assumptions about how the counselors and business specialists in this or any of our customer organizations do their work would be foolish, at best.

    A couple of months ago, our business development manager indicated that she gets frequent questions from prospective users wondering how they will integrate an EMR into their current work flow. Should they enter the progress note into the program while the consumer is in their office? If they wait until the client leaves, won’t it take too much time? Trish suggested that we write a blog article on how clinicians utilize our EMR in the course of their work. We decided to ask a couple of our customers to describe their work process so we could get a more accurate idea of how they work.

    The answers to our inquiry were very interesting, and different from one another. As could be expected, the work flow of a psychiatrist/psychopharmacologist and that of a psychologist/psychotherapist were quite different. We are grateful to Scott P. Hoopes, M.D. of Meridian, ID and Scott Gale, Ed.D. of Franklin, TN for their input.

    We were interested to find that neither Dr. Hoopes nor Dr. Gale enter a progress note while the patient is in the room; that happens after the patient has left. We also learned that neither provider relies upon a staff assistant to enter clinical information; they are both comfortable with a keyboard and prefer typing their own note to the more involved process of dictating, reviewing and correcting transcription, copying the note to the patient file and signing it. Dr. Hoopes does manage prescriptions while the patient is present, including reviewing, creating and sending the prescription to the pharmacy.

    We learned that Dr. Gale, in spite of his use of our electronic clinical record since 1992, still scribbles notes and thoughts on paper while the patient is in his office. He scans these notes into electronic storage and shreds the paper. (As a solo provider without support staff, he does everything in his practice.) While he could attach these scanned documents to the patient’s file in the EMR, it is my impression that he considers this brief process note to be his work product. . .the psychotherapy note that HIPAA allows a psychotherapist to keep and store separately and not to release to an insurer. His note in the EMR is the formal record of the service provided. While some recommend against maintaining a separate set of psychotherapy notes, we have found that many of our customers do so. For some, this is the main reason not to move to an EMR. . .they are not sure how they would continue to maintain these psychotherapy notes while also using an electronic record.

    Dr. Hoopes’ work flow was developed after time working in a community mental health setting where he was expected to see five patients in an hour. In 1995, not very long after starting his private practice and struggling for a while with paper records, he started using our software for billing, electronic claims filing and clinical records. Eventually, he also added scheduling.

    His current work flow allows him to see his schedule at all times. Prior to the arrival of his patient, he brings their record onto the screen and makes a quick review. He duplicates the last progress note into one with today’s date for editing after the patient leaves. In the fifteen minutes he spends with each patient for a medication check, he is able to be engaged with them to determine their progress or lack thereof. Based on the information obtained, he decides to continue or alter their current medication, making any needed adjustments and sending the prescriptions to the pharmacy. He walks the patient out to the receptionist, who electronically schedules their next appointment. He returns to his desk, edits the progress note with today’s status, signs the note, and calls up the record of the next scheduled patient, repeating the process between 20 and 32 times a day.

    My guess is that other users of our EMR product and of other products in the marketplace follow both very similar and very different work processes in their organizations. After all, while most of our customers provide behavioral health services, each is different, with varying clinical and business cultures. In every case, to most effectively implement a behavioral health EMR, it is essential to have a clear picture of your pre-EMR work flow and your goal for use of an EMR. Both of these will make it easier to choose and to implement the EMR of your choice.

    Please share your experiences with the work flow in your business. Is work flow analysis something you have ever done? If so, what was your motivation? We would also love for you to share your work process experiences with implementing an EMR, if you have done so. What changes were necessary in your work flow to fully utilize the EMR? How successful have you been in that process?

    If you would like to enter a comment, just click on the title of this article and enter your comment in the box at the bottom of the page. Please let us know your thoughts.