National Experts Reflect on Information Management Systems in Occupational Health Q and A

Q: Getting occupational health-specific software to work in concert with larger institutional software such as Epic, Meditech or Cerner can be a daunting task for occupational health programs. What can program personnel do to facilitate a smooth integration?

Ms. Brandes: We are using our [program] as our platform and Epic as the repository. We upload into Epic rather than integrate Epic into our OM software.

Dr. Burger: We have interfaces and we have worked with vendors to create interfaces of data coming in and data going out. We had a clearly defined project plan and even started using Six Sigma to get higher management support before we began the project, then looked into the capabilities of all the different systems.

Dr. Crawford: We required Citrix in order to be able to communicate, as well as Adobe. I found that both of them potentially slow things down in terms of data transmission.

Q: What has been the most significant challenge that you faced in doing this?

Ms. Brandes: It has taken a lot of discussion with IT because we thought we would use Epic and then download some of the information into our OM software; once we were hands-on on it was going to be a better fix if we used OM software and then upload into Epic.

Q: What have you learned that you can share with others who are just in the foothills of the process? What do they need to do?

Ms. Brandes: Gather as much data as you can from users of both your OM software and your system platform and find other institutions that have made similar interfaces work. Then be prepared to talk to your senior leadership with that information at hand.

Ms. Gardner: The majority of the time IT does not want you to compromise their system by having any kind of upload. They would be happy to download things. The majority of the time you would register the patient in your mainframe and download that information into your OM software; that way you only register once.

Dr. Burger: Make sure you identify an EHR system that can work well in both worlds because there are different reporting criteria when you send information back to an employer or an insurance company. You need a system that redacts protected health information when you want to do occupational health in an urgent care environment.

Dr. Crawford: The biggest challenge is getting the other team, in our case Epic, to play nice with your software vendor and convince them to embrace the process. We want to share information back with that person’s provider in a meaningful way. We do not want to pull the information out.

Q: Information is essential but costs are a significant issue too. What can programs do to manage costs while ensuring timely access to crucial information?

Ms. Brandes: The manual process, from report generation to information gathering, is much more time-consuming and costly than the automated process. Look at return on investment. How much time are you spending doing something now versus what you might be spending in the future?

Dr. Crawford: Are you charged an annual fee and is it based on the number of users? We try to minimize the number of users because that is where the costs start adding up. We end up sharing access.

Q: What advice do you have for managing an IT budget once they have their software in hand? 

Ms. Gardner: Bells and whistles are wonderful but you want a core product. You do not want to spend money on things that aren’t going to be used as part of product management. Interfaces are awesome and you need them for lab and radiology, but you may not need interfaces for every department in a hospital, so you want to be clear on what data needs to come in and what data needs to go out. You need to know how are you going to do your billing and who is going to monitor it because those interfaces cost money. Educate people in the clinic. How many sessions are you going to need, because those cost money as well?

Dr. Crawford: If users are not trained properly it means many of the benefits of the program are not being used. We have gone to a super user at each site––someone who knows the program extremely well. If someone gets stuck, that super user can be helpful.

Q: If you had to pick one thing from your experience, the one 500-pound gorilla in the room that is eating up costs unnecessarily, what would it be?

Dr. Burger: I like a system that is structured and regimented so it works the same way for everybody and doesn’t have a lot of flexibility for people to customize things. My experience has been that we make mistakes when we do that. If you find a system that is robust, meets your documentation needs and gives you the right E&M coding and procedure code, you can train people easily. It is important to not only train them but also know what type of web-based training applications your partner uses. Our system has video-based training as well as hand-on within the video so providers can actually practice and learn how to document a suture repair or a chest x-ray. That makes their process of integrating and starting to see patients easier.

Q: User training is critical. From either a user or vendor point of view, what constitutes outstanding user training?

Ms. Carlson: You have to have your own staff trainer as well as the vendor trainer working on the day-to-day interfaces. Working closely with the vendor is part of that. They did not provide our clerical staff with the kind of in-depth training I wanted them to have. They got some basics and then they were on their own.

Ms. Carlson: For training to be worthwhile, you need to be able to measure it objectively. Ask yourself, is every employee that went through training competent? This is one area where I do not see a lot of testing on the company (vendor) side; making sure that users understand it totally.

Dr. Crawford: You need one person to be in touch with the folks at the system you are using so you have facilitated communications.

Q: It is inevitable that there will be turnover. What have you learned about the difference between initial training when you first get a certain kind of software and staff turnover training? What has been your experience with new staff coming in one at a time?

Ms. Carlson: It costs money to have someone fly to California and train a new nurse who is going to turn over next year. So we spend phone time with people because it is not enough to simply have electronic training. We sit on the phone with them and share desktops so that we can see what they are doing and help them problem-solve.

Q: What is your opinion on using Epic itself with modifications for occupational medicine versus specific OM software?

Ms. Gardner: Occupational medicine software was initially developed because [programs] could not find a vendor nationally that could meet the needs of an occupational health clinic. They provide a good mainframe, but they do not have an occupational medicine software product. It would be better use of time, energy, and money to go with what is already proven, rather than develop something on your own or customize something that was never meant to be used in occupational medicine.

Q: What are the most onerous hidden costs associated with an operating information system?

Ms. Gardner: Have a clause in your contract that addresses ongoing monitoring and support above and beyond so that you have one person to call when you have a problem and they are familiar with who you are, what you do, where you are, and what your needs might be.

Q: A common if not chronic concern of software users involves customer service. What are the earmarks of exemplary software support? Are there tipoffs to future lapses, or poor service going in?

Mr. Schudy: Medical practices are looking for a culture and philosophy that a company has as it relates to customer service. Customer service starts on the front end when you start working with the sales [department]. Do they understand your pain points and business issues? Also, are software vendors offering ongoing educational webinars? What is the vendor’s client retention rate?

Q: What is an example of over-the-top great software support and what is an example of support that has fallen short?

Dr. Crawford: Let me use the example of the ICD-10s, what an upheaval for a practice to have to change the way we code and bill things. A company that is able to implement and make the transition from an ICD-9 to an ICD-10 is a company that’s making your life easier.

Dr. Fanucchi: It is not only the response time, it is the resolution time. Look past the cost of support. Is it going to cost you an hourly rate every time you want a minor modification to meet your workflow or implement a new form your state has demanded?

Q: What would you say is the biggest lesson you have learned?

Dr. Fanucchi: Connectivity. From the software provider’s end––making sure we have enough staff to keep our phone line up 24/7.

Mr. Schudy: How well does a vendor respond in a crisis?

Q: From a clinical perspective how can occupational health software be used to enhance the practice of occupational medicine?

Dr. Stern: In workers’ compensation it can be tremendously helpful to quickly see the entire history of what has gone on with the patient over the course of treatment. In the past, when sorting through paper charts, it was difficult to see what was going on with the patient. There is tremendous benefit from being able to put notes in a system that potentially might not be seen, might not be part of the medical record but send a message to the next provider seeing the patient. If you are not following up with the patient the next provider can. You can get a message saying “Consider MRI if not better next visit,” which you might not want to put in the actual record. You have ready access to labs and you can quickly look and see if there are any MRIs or CT scans that have been done for the patient. It gives you the ability to see the whole picture of a workers’ comp case clearly.

Mr. Neville: Documentation is key and it might only be in the first couple of innings of a ball game in which we were able to use electronic medical records to enhance practice. When you get to the latter stages, where the power and opportunity is. If anybody has gone through the process of going from paper to electronic records you can see the difference. The number one thing from a clinical perspective is that electronic medical records provide as a tool to ensure that the data elements are much more controlled.

Dr. Peterson: Occupational health software is not going to be useful if it is simply a filing cabinet. First would be automated data entry from peripheral devices like vision testing, audiometry or blood pressure. Second, flagging abnormal results and other clinical findings that need attention such as an abnormal liver function test or a positive stool for blood…like a red flag that makes sure that the data is acted on.

Ms. Slocum: The consistency of documentation from providers and ease of patient consistency from visit to visit is key in the electronic medical record world. When a patient in the occupational medicine world comes in, they are not coming to see a regular urgent care provider, and when they are in and know that their records are there from their last visit it is easy for that provider to pull the second visit or the third visit. It is that easy from a provider or patient standpoint to not have to repeat themselves and have that documentation right there and be consistent each time.

Q: Integration of an occupational medicine EMR is quickly becoming the norm in occupational health software. What should users look for in this regard?

Dr. Fanucchi: Occupational medicine clinics that have parent organizations––hospitals for example––face the HIPAA issue and there are many parent organizations that want information stored on their data system as opposed to a confidential occupational medicine record that cannot be accessed by anyone without a HIPAA waiver. We have encountered a number of facilities that have difficulty implementing an EMR because their parent corporation wants all the information transferred over or some of it transferred over to their own in-house database. The fact that a parent corporation owns the occupational medicine clinic is not justification for violating HIPAA and those HIPAA compliance officers have been helpful to a number of facilities in saying administration and IT folks in the parent company may not use any of that occupational medicine information.

Mr. Schudy: It has to be easy because physicians are busy and they want to make sure they can see as many patients as they need to see and not be tied down to keying in documents.

Q: What are the must-have features that enhance the frontline user’s experience, making their job faster, easier, and more satisfying?

Dr. Fanucchi: The development of an ICD-10 module that allows permission in seven clicks to pull up the correct ICD-10 diagnosis and code is something that is going to help physicians and coders. As far as enhanced features, the ability to notify employees and supervisors of upcoming appointments and recall reminders so the clinic staff does not have to call everybody or email everybody individually to remind them of an appointment. The ability to attach scanned documents, electronic documents into a person’s electronic record . . .

Mr. Schudy: Integration. Have all systems talking to each other so you are not manually keying information in from one system or doing things manually.

Dr. Crawford: I do not find the electronic medical record faster, but I do find it is useful in how you manipulate the data you do put in. Producing reports, being able to determine what this particular patient’s respiratory, PFTs were last year and the two years prior.

Q: Are there systems that can incorporate all the must-haves and all that you have mentioned? Can I find a system that will follow the business workflow?

Dr. Crawford: You can but not without shopping. You figure out how their system works, how your system works and you need to have a bilateral discussion with them in terms of what you need and what they are capable of producing.

Mr. Schudy: Understand the business needs. Then you want the vendor to do a demonstration that shows how those needs would be handled in a solution that follows the workflow.

Dr. Fanucchi: Do your due diligence. It is easy to get on the phone or go on a webinar with several vendors and evaluate.

Q: Many long-time occupational health software users are dissatisfied with their product and would like to convert to another system, yet they are concerned about the time involved and associated complications and often remain mired in software purgatory. What should such users know about conversions and to what degree might their concern be justified?

Mr. Schudy: Find out how clean and relevant the data is. Whether it be scheduling data, patient data, clinical data, or billing data, if the data is clean and valid then I would convert that over. If the data has a lot of invalid information, you’re going to have converted a lot of misinformation into a new system,

Dr. Fanucchi: The biggest issues are lead time, (are we going to be able to do this in a period of days so we don’t shut down?), cost of conversion, cost of modifications, cost of training on the new software and of scrubbing data that is garbage that might be in a Legacy system.

Q: Many formerly pure-play occupational health centers are now offering urgent care services and vice versa. Accordingly, software that addresses both is becoming the norm. What factors need to be considered when selecting such software?

Dr. Fanucchi: The biggest issue is billing because in occupational medicine you are billing either the employer, a drug testing company, or workers’ comp. In non-occupational, you’ve got three or four different insurance carriers and billing can be a nightmare. When you implement a software program in a multispecialty clinic, you want to make sure you are going to be able to accomplish the varieties of billing.

Mr. Schudy: Is it meaningful-use certified? If you are getting into the urgent care space, you want to make sure your vendors are certified.

Dr. Crawford: You do have to have that meaningful use or you would not eventually be certified to do a lot of the CMS-type of work. There is a different set of rules that govern information exchange in occupational medicine versus [Medicare and private] health benefits. You have to pay attention to that consideration in the software program. Will it allow you to separate the two?

Q: What options might be available to the small practice that desires to go beyond the paper system but is short on funds?

Dr. Peterson: The modern option is SaaS or Software as a Service. Software as a Service means that the vendor simply needs to turn on your practice, they do not need to add a server or even a virtual server and they do not have to add in their server farm. They simply turn you on, and give you a username/password. Software as a Service can be cost-effective because the pricing tends to be as you use it. If you only see ten patients a day, you only pay for ten patients or ten visits a day.

Q: Not being affiliated with a particular vendor, do you find that carve-out uses are reasonable and that somebody with short funds can still manage things by not trying to be all things to all people with their software?

Dr. Peterson: Yes. Comprehensive integrated occupational health information systems are complicated, expensive, and challenging to use. In the last few years, we have had a number of simple, clinically oriented systems emerge and they are more user friendly.

Dr. Stern: Users have to understand the technologies that are available. If you do not have a large center and you are short on funds you want to go with an online service.

Q: What is the most significant stealth issue in judging the potential cost-effectiveness of multiple options that you might have in terms of software?

Ms. Slocum: Ease of usability for all your users and support for the service you are purchasing. It is going to take your users more time to learn a new software that is going to cause patient and staff dissatisfaction?

Dr. Stern: User friendliness is tops. User-friendliness by Black Book Rankings ranks occupational medicine. You can see how users feel about a software product at

Dr. Peterson: I would use a real estate analogy. It is not the price of the house. It is the cost after the renovation and after the move.

Q: What will the next generation of software look like? Will it address other avenues of workplace health and safety and, if so, which? What user enhancements might be available?

Ms. Slocum: Allowing the patient to register for appointments from home and schedule that time slot in an occupational medicine world. If they need to have an employer register them and let the clinic know that they are already on their way so that they are seen as soon as they walk into that clinic, that is key.

Dr. Stern: How about loading all of your DOT results automatically once you finish the physical and go straight to the record? That is a hassle for a lot of folks right now and that is going to disappear next year for some systems. The employer needs to see where everything is going. In a Jetson-type future, we are going to be interoperable with the client’s H.R. systems; if there was a standard where we could interact with their HR and safety systems, that would be a holy grail for the employers.

Q: What is the most important across-the-board advice that you can give on this matter?

Dr. Peterson: Do not listen to the salespeople and look at what was being demonstrated, talk with customers, talk with users, visit them, see how they are using it, and make sure that their use is going to meet your needs.

Ms. Slocum: Understand what your software is able to do for you and make sure it lines up with your goals.

Dr. Stern: Make sure your software actually has the specific design components for occupational medicine and make sure the functionality you need is there.

Mr. Neville: Expect to spend more money because of training and other considerations. You are going to keep learning as you go through the process, so a mentor would be essential.

Dr. Burger: When it comes to the electronic health record, make sure the system will work for all the service lines you are going to deliver.

Ms. Gardner: Do a grid analysis of each vendor and set by criteria. Make sure you talk with your IS department initially before you decide on a specific software so they (IT) can be a partner in your decision.

Dr. Fanucchi: Do not be afraid to push your software vendor if you need enhancements or modifications.

Mr. Schudy: Go slow to go fast. Meaning, do your due diligence, understand what your needs are, then validate that against what the offering is and determine if you have a good partnership with the company.

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