Posts tagged ‘CPT’

RE: EHRs in Surgical Practices

Recently, on his blog “Life as a Healthcare CIO,” Dr. John Halamka gave advice on how to implement EHRs for surgical practices. Dr. Halamka points out many of the issues we’ve found when meeting with surgical practices and ambulatory surgery centers (ASCs). Surgical practices offer a unique set of problems as they have a very specific purpose, are less likely to have many returning patients, and capture a limited amount of information (the rest being captured by referring general practitioners/primary care physicians and their respective facilities). So where is the incentive for these practices to adopt an electronic solution? How can EHRs address these particular needs without being too disruptive to the surgeons’ workflows? Dr. Halamka has some ideas – based on his own experiences – but I think there’s more to add to this discussion.
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November 17, 2010 at 4:25 pm Leave a comment

A Useful Meaning for Meaningful Use?

Image via HealthITBlog

While the march towards universal EHR adoption continues, some resistance to implementation has emerged, including from inside the medical community. Some of the hesitation is based on safety issues and privacy concerns – people worry that the personal content of health documents could be viewed by anyone or that opportunistic hackers could easily gain access to our most intimate details. I’ve written about this argument before and concluded that, while I agree it’s important to proceed cautiously and intelligently, we must proceed nonetheless.

One of the biggest impediments to electronic health record adoption has been the lack of concrete definition of “meaningful use.” But let’s not get too far ahead of ourselves. In order to receive government funding/aid in the form of incentive payments from Medicare and Medicaid, facilities have to demonstrate that their electronic health record serves or provides “meaningful use” to the practice and physicians. The definition for meaningful use has been murky and vague; a subjective and fleeting characterization that made many physicians and health facilities reluctant to commit to any electronic solutions for fear of not being reimbursed or not qualifying as “meaningful use.” Luckily, this issue has been resolved – mostly – thanks to the definition put forth by the Office of Health and Human Services. So what is the definition and what does this mean for health information technology?
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August 5, 2010 at 4:02 pm Leave a comment

Health Information Managers – We Want to Hear From You!

While developing OpNote, mTuitive has sent out numerous surveys to various sectors of the healthcare industry. We’ve heard from surgeons, coders and hospital administrators to help us figure out the best ways to improve postoperative reporting. By gaining feedback from domain experts (and our targeted customers), we can identify issues that need to be addressed in the current system and more accurately create solutions for everyone that would be affected by adoption of mTuitive OpNote.

We are now reaching out to HIM professionals to gain their perspective and build the business case. If you are unfamiliar with the design of OpNote, please follow this link for an example of a completed report. OpNote’s goals are to make better use of transcription resources, streamline the reporting process and capture discrete data for use in disease registries, outcomes analysis and quality reporting initiatives.

Thank you for your time and your input!

Click here to take survey

June 2, 2010 at 5:13 pm Leave a comment

Coding in the Time of EHRs

While developing OpNote, we’ve encountered some push back and criticism from the various organizations. But the most pointed barbs of criticism have come from medical coders at the hospitals and ambulatory surgery centers (ASCs). Based on the way that we have constructed OpNote, physicians automatically capture the Current Procedural Terminology (CPT) codes and the International Classification of Diseases (ICD) codes. While the coding is evident – and users can search by codes, if so desired – surgeons are not forced to navigate through codes, but instead they find the proper procedure and diagnosis by using words and common phrases.

Some coders have balked at the idea of doctors coding their own procedure. There are nuances to the coding structures that could easily be missed by those who have not made it the primary focus of their jobs to know how codes are generated or what factors in the report lead to changes in the coding process. The number of physicians that confidently know medical coding is increasing, but there will always be various subtleties to coding that really only come from education and experience. However – that doesn’t mean there isn’t room for improvement.
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May 27, 2010 at 10:01 am Leave a comment

Use Your Words: The Importance of Structured Data


One of the uphill battles that mTuitive has faced over the years has been convincing people the value of structured data. Actually, to step back, the uphill battle has been defining structured data and then explaining its import to various medical facilities. Luckily, that battle is progressively easier as more studies are published on the strengths of synoptic reporting and as the term grows in popularity and familiarity. What was once a part of a sales pitch is quickly becoming unnecessary as people are getting much more comfortable with the idea of structured data and interested in how it can immediately help their organizations. A recent piece in California HealthCare Foundation’s Issue Brief does a great job of illuminating the various levels of data and why there’s not only a growing need but also a growing desire for employing these techniques in health facilities.
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May 14, 2010 at 3:09 pm 1 comment

Demo Video – How to Use Defaulted Reports in OpNote

Behold the latest video from mTuitive that demonstrates how users can utilize the default report option in OpNote to quickly generate postoperative reports for their most common procedures:

May 3, 2010 at 1:25 pm Leave a comment


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