Typical Doctor visit in USA :Workflows in Medical Practice

Workflows in Medical Practice

Understanding the workflows and processes within the medical practice will increase the likelihood of success of both your client and your business.

 With your baseline knowledge of the workflow, you will be more prepared to address current challenges and identify solutions. 

. For workflow scenarios that we do not cover, spend some time looking at the HIMSS site. Its documentation on ambulatory care practices is the best we have found. Depending on your focus, the customer and practice interactions may change. When studying the medical practice, pay attention to the touch points between the customer and business, between the business and its business associates, and between the provider and payer. When these interactions can be standardized or automated, that is where you’ll find the biggest bang for the buck.

Let’s take a look at a few of these processes.

Scheduling a New Patient

More than likely at some point you have sought the services of a doctor, and you are aware as to how they schedule appointments. For an average patient, scheduling an office visit takes about 12 minutes. In addition to coordinating schedules, information regarding new insurance is often obtained. For new patients, there are additional forms that might be mailed so that the patient doesn’t have to fill them out upon arrival. For specialists, they might provide instructions to the patient about restrictions on taking medications prior to their visit.

Once the patient is scheduled, their insurance must be validated. The office staff generally completes this task prior to the patient’s arrival. If there are issues with the patient’s health insurance, the staff will try to resolve any problems prior to their scheduled appointment. As you can see, the process is more involved than simply asking to see the doctor at 5 p.m. on Friday.

After waiting for some period of time, the patient arrives to see the doctor. For some specialties, it could take months to get an appointment. For others, such as your general practitioner, it should be just a day or two.

An Office Visit

Here are some interesting facts about an office visit. A 15-minute office visit actually takes 72 minutes to complete. This includes a period of sitting in the waiting area, being triaged by a nurse, being visited by the doctor, then receiving discharge information from the nurse, scheduling any appropriate follow-up appointments, and finally paying any additional fees.

Upon arrival, the patient will check in with the front-office staff. The staff is already armed with the copayment amount. Because many Americans change their jobs frequently, the front-office staff will confirm that the system has the latest insurance information. If any additional paperwork needs to be completed, the patient is asked to complete these forms in the waiting area.

At this point, the staff will scan in any relevant information from previous visits, assuming this is the first time the patient has seen the doctor since the EHR implementation. The insurance card is also scanned into the system on the patient’s first office visit.

Within this simple doctor’s office visit, there are a number of regulations that must be considered. First, because it is a medical office, both HIPAA and HITECH must be followed. In the state of California, for example, the SB1389 privacy law must also be adhered to. If a credit card transaction occurs, more than likely PCI-DSS must be followed. Lastly, the interaction has caused FTC red flag rules. Because there is a copay amount, the medical practice is loaning the patient money until the insurance claims are paid out. This should be a simple transaction between the patient and the medical office. You can see how quickly this simple visit becomes complicated.

Often the next interaction is when the nurse will come to the waiting area and call your name. In certain confidential settings (STD clinics and anonymous testing centers), providers are not allowed to address a patient by name. Once the nurse gets your attention, they will guide you into the exam rooms and record your weight. Weight and height help the doctor calculate your body mass index, which helps them predict future health risks.

After the weigh-in, the vital signs are taken and recorded. The nurse may use a tablet or other computing device to input the data into the EHR. Once the nurse has assessed the patient’s initial condition, they leave the exam room, and the patient waits for the doctor’s arrival. If there are additional items to address, the nurse will take care of them prior to leaving. If the right questions are not asked or documented, the doctor will have to reexamine the patient, which only wastes valuable time.

After a period of time, the doctor enters the exam room and greets the patient. After washing his or her hands, the doctor will proceed to ask the patient questions while reviewing and tapping away at the EHR. If the EHR template for the visit is properly configured, the doctor may spend more time examining the patient than fiddling with the EHR system. If the system is relatively responsive, the doctor may also make small talk while conducting the exam. If the system is nonresponsive or acting up, the doctor’s frustration with using the EHR system may be released toward either the patient or the office staff.

Once the data is collected within the EHR application, quality metrics can be calculated. For patients with chronic diseases, the medical practice can track which treatments are working and which are not. If necessary, the doctor will prescribe medications and enter this data into the system. Most modern EHR systems will then automatically send the prescription to the pharmacy of the patient’s choice. Sometimes, there is a batch job that runs several times a day to push the data to the pharmacy. After a few more minutes, the doctor wraps up the appointment and leaves the exam room.

Though it appears straightforward, the previous example was for a general practitioner. If additional tests were needed, then they would have been ordered at that time. If a breathing test or perhaps a skin test in an allergy office was ordered, then the doctor would temporarily leave the exam room and return later to analyze the data and final results. If the testing systems are electronic, it is possible to directly input the data into the EHR system.

After the doctor completes the examination, the nurse reviews the notes from the doctor. They may have discharge orders to communicate with the patient and may hand out informational pamphlets that the doctor wants the patient to read. To be a complete medical record, even a pamphlet on diabetes care must be entered into the system in order to correctly document the educational component of care.

Once the nurse completes these tasks, the patient checks out at the front desk. This could entail scheduling another visit, getting directions to a lab, or making any additional payments. Now the encounter for this patient visit is complete.

Though it has taken a few pages to outline the flow of a standard office visit, please be aware that this is just general guidance. It is to give you context for the remainder of the book. Not knowing the basic workflow can impact how you would create solutions. Without a thorough understanding of the particular practice or hospital system you are working with, implementing IT for IT’s sake will reduce your positive impact in the organization.

Monitoring and Diagnostic Equipment

When working around diagnostic imaging systems, it is important to understand the potential health issues. First and foremost, never enter an area without the proper training or attire. The information presented here cannot be construed as safety training. Please see your employer for their complete training. If you are not comfortable with the training you received, do not work around diagnostic equipment—particularly diagnostic imaging equipment. When serviced and used properly, safety is maintained, but the inverse is also true.

Radiation

A CT scan of the abdomen and pelvis exposes you to a radiation dose of 10mSv. This is one exposure is comparable to three years of just general radiation exposure. An X-ray of the chest is just 0.1mSv, which is comparable to ten days of exposure of natural radiation. To protect yourself from these imaging systems, it is always best to minimize the amount of time exposed to the system. Moreover, the effects of the X-ray or other radiation falls off rapidly as the distance between the diagnostic device and yourself increases. Additionally, wearing a leaded apron is a generally accepted practice for all X-ray general use. When using fluoroscopy, leaded glasses and thyroid shields are also suggested. CT scanning, fluoroscopy, interventional radiology, and nuclear medicine use the highest doses of radiation.

Currently, there are no studies that demonstrate that low-dosage radiation causes cancer. However, at moderate and higher levels of radiation, it has been shown that cancer has been induced. When radiation causes cancer, it falls into two general classes. Skin effects and hair loss is classified as deterministic radiation. A stochastic effect is cancer. For example, a patient getting high-dosage CT scans multiple times a year will generally experience deterministic radiation. However, higher dosages of radiation when used for imaging the brain or thorax might result in cancer. The jury is still out on whether low-level radiation exposure is harmful.

Magnetic Fields

Be very careful around MRI systems. Most MRI systems are never turned off because it takes roughly three hours to make them functional. Because of the strength of the magnetic field, never work or even walk around the device. The smallest amount of metal can go flying across the room. Employees who have a screw to strengthen a bone, a camera in their pocket, and even someone with a PC in their hand can see it fly across the room and attach itself to the magnet. The event would make the self-aligning iPad2 case look like child’s play.

For years, diagnostic equipment did not communicate with other systems. The information from the diagnostic image, an X-ray, for example, would be studied by the radiologist. The findings from the study would be manually entered into the patient record system. In the next section, we will cover how these diagnostic systems now communicate in real time with other patient care systems. Getting the right information to the right people at the right time is what data exchange is all about.

Data Exchange

To work effectively in healthcare IT, you need to understand how data is exchanged between providers, clearinghouses, and the future Nation Health Information Network. Table 1-3 describes the standard types of data interchange.

Table 1-3: Standard Data interchange Types

Data interchange Type	Description
Flat file	Typically comma- or pipe-delineated files that are shared via email or FTP.
HL7 or Health Level 7	A common method for exchanging data between clinical systems. A clinical application has information on admits, discharges, and transfers (ADTs). The admit is a fundamental event in an acute-care facility like a hospital.
X.12	Typically used to transfer financial information.
X12N	A subset of the X12 family that focuses directly on insurance transactions.
Diagnostic Imaging and Communications in Medicine (DICOM)	A standard for storing, printing, transmitting, and archiving imaging data. It’s often used in a radiology department to associate images with a particular patient. Without an ADT feed from the admitting system, the radiology tech must type in the patient demographics. Doing this can cause an increase in medical errors.
XML	An extensible markup language. This is a file format that encodes documents with tags. Very much like HTML, it allows for the developer to choose the encoding. Data can be exchanged using web service calls, Simple Object Access Protocol (SOAP), and other methods.

Spend some time reviewing the data exchange technologies that will have the greatest impact on the consulting and implementation practice your business will be building. For example, if you will not be working with a hospital or radiology practice, it may not be necessary to study the DICOM format in depth.

International Classification of Diseases Code Sets

The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease. The World Health Organization (WHO), operating under the United Nations umbrella, acts as a coordinating authority on international public health and publishes the ICD. By classifying diseases and other health problems, these codes provide a basis for compiling and tracking mortality and morbidity statistics by WHO member states.

The adoption of new code sets is required periodically. Earlier code sets might not reflect the currently diagnosable diseases or the treatments a provider might be able to give. Just as a dictionary periodically adds or removes words based on their frequency of use—words such as Internet, intranet, email, and others would not have been used at all when the dictionary was originally released—so the transaction and code sets are updated to reflect latest trends. For example, the last version of the ICD-9 diagnosis code set had just 13,000 codes. ICD-10 has roughly 68,000 diagnostic codes. For procedural codes, ICD-9 had 3,000, while the ICD-10-PCS has 87,000.

The administrative simplification portion of HIPAA requires that covered entities apply and use eight electronic transactions and defines the code sets to be used for those transactions. Table 1-4 lists the transactions and code set used for each transaction.

Table 1-4: Transactional Code Sets

Transaction	Code Set
Healthcare claims	X12N 837
Eligibility inquiry and response	X12N 270/271
Referral certification and authorization	X12N 278
Healthcare claim status and response	X12N 276/277
Enrollment and disenrollment in a health plan	X12N 834
Healthcare payment and remittance advice	X12N 835
Premium payments and payroll deduction	X12N 820
Coordination of benefits	X12N 837

Table 1-5 lists the diagnostic, service, and procedural code sets.

Table 1-5: Diagnostic, Service, and Procedural Code Sets

Code Set	Used For
International Classification of Diseases, 9th Edition, Clinical modification, Volumes 1 and 2	Diagnosis codes (to be replaced with ICD10-CM no later than October 1, 2013)
International Classification of Diseases, 9th Edition, Clinical modification, Volume 3	Procedure codes for inpatients (To be replaced with ICD10-PCS no later than October 1, 2013)
Code on Dental Procedures and Nomenclature	Dental procedure codes
Health Care Financing Administration Common Procedure Coding System	Physician and other health services, equipment, supplies, and other items used in providing services
Current Procedural Technology, 4th edition	Physician and other healthcare services

EDI reduces the costs of doing business. It reduces the cost of having staff open, sort, scan, and store the received mail. When processing the transaction manually, a greater error for over- or underpayments can occur. Patients can even die. EDI is not meant just for the business-side transactions. Lowering costs across the care continuum was the major reason for simplifying the HIPAA administration. The lack of a common and shared code was a major obstacle, which is why government interaction was needed.

An important identifier in all of these transaction sets is the national provider ID. In the past, health plans would assign a unique identification number for each health provider. In some cases, the payer even required a different identifier for each location. Providers spent an enormous amount of dollars and time resubmitting claims because these provider IDs were unique to each payer. The nation provider identifier (NPI) is a unique ID to the provider but is not generated by a health plan. This number, as created by the government, is for use by not only the provider but all health plans and clearinghouses. An NPI is a 10-digit number with a validating check digit at the end. No information about the provider is included in the NPI. Doing so would have created an administrative burden for both providers and payers if physicians became specialists or if they changed how they practice medicine either privately or in a hospital setting. To receive an NPI, the physician applies online at https://nppes.cms.hhs.gov.