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 For
Thomas D. Kiel, MD
Series Preface

This series is directed to healthcare professionals who are leading the trans-
formation of health care by using information and knowledge. Launched in
1988 as Computers in Health Care, the series offers a broad range of titles:
some addressed to specific professions such as nursing, medicine, and health
administration; others to special areas of practice such as trauma and
radiology. Still other books in the series focus on interdisciplinary issues,
such as the computer-based patient record, electronic health records, and
networked healthcare systems.
Renamed Health Informatics in 1998 to reflect the rapid evolution in the
discipline now known as health informatics, the series will continue to add
titles that contribute to the evolution of the field. In the series, eminent
experts, serving as editors or authors, offer their accounts of innovations in
health informatics. Increasingly, these accounts go beyond hardware and
software to address the role of information on influencing the transforma-
tion of healthcare delivery systems around the world. The series also will
increasingly focus on “peopleware” and the organizational, behavioral, and
societal changes that accompany the diffusion of information technology in
health services environments.
These changes will shape health services in the new millennium. By
making full and creative use of the technology to tame data and to trans-
form information, health informatics will foster the development of the
knowledge age in health care. As coeditors, we pledge to support our pro-
fessional colleagues and the series readers as they share advances in the
emerging and exciting field of health informatics.

Kathryn J. Hannah
Marion J. Ball

vii
Preface

Doctors’ offices have evolved from family businesses of single physicians to

networks of tens and even hundreds of doctors with different specialties.The
payment systems have migrated from fee for service to capitation. Con-
sumers have become more involved in their own care, readily asking ques-
tions and desiring to be more informed. And, along with all these changes,
there is the ubiquity of technology. Technology allows physicians to be geo-
graphically distant, yet in touch with their colleagues and patients. It pro-
vides for efficient documentation and payment of services. It also allows the
patient to search for information on providers and conditions and to “speak”
electronically with others who have the same condition.
This book describes the effects of technology on office workflow, patient
registration, patient records, prescription writing, patient education, prac-
tice finances, credentialing, the management of managed care, messaging,
and remote medicine. The first section, “Utilizing Technology to Arrange a
Physician Visit,” provides information of the technology utilized before the
patient visit and includes examples of physicians who utilize e-mail and Web
sites to attract patients, electronic scheduling systems that decrease waiting
time, and registration systems that verify insurance information. The second
section, “Utilizing Technology to Enhance the Physician Visit,” demon-
strates how technology is utilized when the patient is in treatment and/or
follow-up care. Focusing on electronic medical records, electronic referral
systems, billing and collection systems, and follow-up patient education and
discharge information, the section portrays the “future physician office
visit.” The third section, “Utilizing Technology to Enhance Physician Prac-
tice Operations,” focuses on the physician practice manager’s daily opera-
tions and how technology can achieve efficiency.
Each chapter begins with ten opening questions and/or issues that are
meant to stir the reader’s imagination and interest in the subject. You may
also wish to use these lists as mechanisms to begin discussions with your
staff. Another use is to convert them into checklists for your practice. They
integrate theory into practice and will be an effective mechanism for imple-
menting the ideas in this book.

Joan M. Kiel

ix
Acknowledgments

The idea for this book emerged out of a need to teach students using oper-
ational examples—that is,“to tie theory into practice,” a concept that under-
lies my educational philosophy. Daniel Herman of the First Consulting
Group saw merit in this idea and directed me to the “dynamic duo of health-
care informatics,” Dr. Marion Ball and Judith Douglas. This book is a reality
because of those three people.
There are so many stories to share of the wonders of technology. This
volume captures some of them, and I thank the contributing authors
and their associates, Buddy Blackwood, Jayme Calabrese, Ron Cousino,
Catherine Diver, Matthew Ferrante, Vicki Fry, Molly Grasso, Mollie Houns,
Eileen Kanewske, Janice Kennedy, Debra Knox, Phillip Levine, MD,
Pam McFarland, J. Richard Presser, David Ray, Charles Reynolds, Sandy
Shroyer, Harold Swenson, MD, Stephanie Thum, and Susan Zillmer.

Joan M. Kiel

xi
Contents

Series Preface vii

Preface ix
Acknowledgments xi
Contributors xvii

PART I UTILIZING TECHNOLOGY TO ARRANGE A

PHYSICIAN VISIT

Chapter 1 Physician Practice Management:

Into the Technology Age 3
Joan M. Kiel

Chapter 2 Workflow in Physician Practices 22

Workflow in the Primary Care Physician’s Office:
A Study of Five Practices 23
Jeffrey D. Cooper, James D. Copenhaver, and
Carolyn J. Copenhaver
Workflow Concepts: The Challenges of Managing
Healthcare Business Processes 35
William F. Andrew
Workflow and Usability 38
Vinson J. Hudson

Chapter 3 Electronic Registration 45

Interviewing Patients with the Aid of a Computer 46
Allen R. Wenner and Duncan C.H. Belser, III
Internet-Based Registration 73
Jonathan Ephraim

xiii
xiv Contents

PART II UTILIZING TECHNOLOGY TO

ENHANCE A PHYSICIAN VISIT

Chapter 4 Electronic Medical Records 81

Clinical Documentation That Improves
Patient Care (or Tips for Avoiding Potholes in the
Road to the Electronic Medical Record) 82
Thomas E. Sullivan
Selecting and Installing an EMR:
HPHC’s Successful Implementation 94
Walt Zywiak
The Ambulatory EMR 104
Kathy Patrino, Thomas Landholt, and Linda Brackett
EMR Reduces Costs and Protects Revenues 110
Kathy Patrino, Thomas Landholt, and Linda Brackett

Chapter 5 Clinical Applications with Information Technology 113

Patient Acceptance of Computerized Progress
Note Documentation 114
Janet Huber
Key Characteristics of an Electronic
Prescription Writer 118
Robert Keet

Chapter 6 Patient Education 127

Clinical Software for Strengthening the
Physician–Patient Relationship 128
J. Peter Geerlofs
Computer-Based Patient Education:
The X-PlainTm Experience 141
Moe Ajam
Consultation and Education:
MedicineNow 145
Richard J. Osborne
The Health Network 151
J. Tod Fetherling
 Contents xv

PART III UTILIZING TECHNOLOGY TO ENHANCE

PHYSICIAN PRACTICE OPERATIONS

Chapter 7 Entrusting the Finances to the Computer 159

Billing for What Your Practice Deserves 160
David Jakielo
Duke University Medical Center 170
Rosemary Price
St. Bernard’s Financial System 172
Mary Beth Clay

Chapter 8 Credentialing Physicians 173

John M. Kiel and Barbara S. Waxenfelter

Chapter 9 Managing Managed Care 188

Using Web Technology to Manage Care, Enhance Patient
Experiences, and Improve Outcomes 189
John D. Halamka, Anne Marie Audet, Elizabeth Pappius,
and A. Kim Saal
Implementation of IDX LASTWORD at Mercy
Healthcare Sacramento 203
Michael O’Rourke

PART IV TECHNOLOGY ACROSS

THE CONTINUUM OF CARE

Chapter 10 Connecting the Continuum with Technology 209

Implementing an Automated Clinical
Messaging System 210
Robert Keet
EMRx Implementation at MedClinic of Sacramento 216
R. Paul Miller
PhyCor of Corsicana 219
Rebecca Gallagher and Joseph Cisna

Chapter 11 Reaching Beyond with Telemedicine 225

A Rapidly Evolving Definition of Telemedicine 226
Jonathon D. Linkous
xvi Contents

Introduction to Telemedicine 227

Odysseus Argy and Michael Caputo
Medical Applications and Benefits 234
Odysseus Argy and Michael Caputo

Chapter 12 Security of Medical Information 246

State of Security Features for Medical Information 247
Kathleen Frawley, Dale W. Miller, and Cynthia Miller
Establishing Information Security Policies 254
Kathleen Frawley and Dale W. Miller

Index 267
Contributors

Moe Ajam, PhD

Director, Division of Research and Development, The Patient Education
Institute, University of Iowa, Iowa City, IA 52242, USA
William F. Andrew, PE
President, JMJ Technologies Inc., Marietta, GA 30066, USA
Odysseus Argy, MD
American Telemedicine Association, Washington, DC 20005, USA
Anne Marie Audet, MD
Executive Director of Clinical Effectiveness, Department of Healthcare
Quality, Beth Israel Deaconess Medical Center, Boston, MA 02215,
USA
Duncan C.H. Belser III
Marketing and Product Development Director, Primetime Medical Soft-
ware, Columbia, SC 29169, USA
Linda Brackett
MedicaLogic, Hillsboro, OR 97124, USA
Michael Caputo, MS
American Telemedicine Association, Washington, DC 20005, USA
Joseph Cisna
Experior Corporation, Fort Wayne, IN 46804, USA
Mary Beth Clay
SMS Communications Consultant, SMS, Inc., Malvern, PA 19335, USA
Jeffrey D. Cooper, MD, FAAP
JMJ Technologies, Inc., Marietta, GA 30066, USA
Carolyn J. Copenhaver, MA
Vice President, JMJ Technologies, Inc., Marietta, GA 30066, USA

xvii
xviii Contributors

James D. Copenhaver, MA
President and CEO, JMJ Technologies, Inc., Marietta, GA 30066, USA
Jonathan Ephraim
Chief Executive Officer, Cognio.com, Los Angeles, CA 90035, USA
J. Tod Fetherling
President, The Health Network, Nashville, TN 37205, USA
Kathleen Frawley, JD, MS, RHIA
Cochair, Work Group on Confidentiality, Privacy, and Security, Computer-
based Patient Records Institute, Bethesda, MD 2-814, USA
Rebecca Gallagher
Corporate Communications Specialist, Experior Corporation, Fort Wayne,
IN 46804, USA
J. Peter Geerlofs, MD
President and CEO, Medifor, Inc., Port Townsend, WA 98368
John D. Halamka, MD, MS
Chief Medical Information Officer, CareGroup, Boston, MA 02215, USA
Janet Huber, MD
Internal Medicine Associates of Rockdale, Conyers, GA 30012, USA
Vinson J. Hudson, MS
President, Jewson Enterprises, Menlo Park, CA 94026, USA
David Jakielo
President, Seminars, Training, and Consulting, Pittsburgh, PA 15205,
USA
Robert Keet, MD, FACP
Axolotl Corp., Littleton, CO 80127, USA
Joan M. Kiel, PhD
Chairman, Department of Health Management Systems, John G. Rangos,
Sr., School of Health Sciences, Duquesne University, Pittsburgh, PA 15282-
2241, USA
Thomas Landholt, MD
Clinical Consultant, MedicaLogic, Hillsboro, OR 97124, USA
Phillip Levine, MD
ACMS, Pittsburgh, PA 15212-6098, USA
Jonathon D. Linkous, MPA
American Telemedicine Association, Washington, DC 20005, USA
Cynthia Miller
Project Team Leader, Work Group on Confidentiality, Privacy, and Security,
Computer-based Patient Records Institute, Bethesda, MD 20814, USA
 Contributors xix

Dale W. Miller
Cochair, Work Group on Confidentiality, Privacy, and Security, Computer-
based Patient Records Institute, Bethesda, MD 20814, USA
R. Paul Miller, MD
Medical Director, Clinical Information Systems, Mercy Healthcare
Sacramento, Rancho Cordova, CA 95670, USA
Michael O’Rourke, MBA, MIS
Information Officer, Sacramento Region, Mercy Healthcare Sacramento,
Rancho Cordova, CA 95670, USA
Richard J. Osborne, MD, FRCP
Consulting Physician, MedicineNow, Dorset, FT11 ONP, UK
Elizabeth Pappius
Director, Center for Quality and Value, CareGroup Healthcare System,
Boston, MA 02215, USA
Kathy Patrino
Practice Development Manager, MedicaLogic, Hillsboro, OR 97124, USA
Rosemary Price
Partner, Price Houns Associates, Minneapolis, MN 55416, USA
A. Kim Saal, MD
Chief Medical Officer, CareGroup Healthcare System, Boston, MA 02215,
USA
Thomas E. Sullivan, MD
Medical Director, Peabody Medical Associates, Peabody, MA 01960, USA
Harold Swenson, MD
ACMS, Pittsburgh, PA 15212-6098, USA
Barbara S. Waxenfelter, RN
Caredata.com, Ambridge, PA 15003, USA
Allen R. Wenner, MD
Vice President, Clinical Systems Design, Primetime Medical Software,
Columbia, SC 29169, USA
Walt Zywiak
Account Representative, Epic Systems, Inc., Madison, WI 53711, USA
Part I
Utilizing Technology to Arrange
a Physician Visit

Chapter 1
Physician Practice Management: Into the Technology Age 3
Joan M. Kiel

Chapter 2
Workflow in Physician Practices 22
Workflow in the Primary Care Physician’s Office:
A Study of Five Practices 23
Jeffrey D. Cooper, James D. Copenhaver, and
Carolyn J. Copenhaver
Workflow Concepts: The Challenges of Managing Healthcare
Business Processes 35
William F. Andrew
Workflow and Usability 38
Vinson J. Hudson

Chapter 3
Electronic Registration 45
Interviewing Patients with the Aid of a Computer 46
Allen R. Wenner and Duncan C.H. Belser III
Internet-Based Registration 73
Jonathan Ephraim
1
Physician Practice Management:
Into the Technology Age
Joan M. Kiel

Ten Questions to Guide a Practice

Management Candidate
1.What software programs have you worked with?
2.Did any of your previous practices utilize electronic billing?
3.What size budgets have you worked with?
4.How many staff members have you managed?
5.What is your knowledge of personnel laws?
6.How would you use data to market a practice?
7.What information systems are you familiar with, and what systems
have you specifically utilized?
8. Have any of the practices you worked for utilized electronic
registration?
9. How do you analyze managed care contracts?
10. What continuing education courses have you participated in?

Health care is a continuing, evolving industry. In the past, health care

focused on illness and disease; today its focus is health and wellness.
Managed care, through a continuum of care, is replacing segmented
providers, and these providers are being networked into large systems of
care. Patients, or consumers as they are now called, are much more informed
due to the media and the Internet. This has resulted in the healthcare indus-
try becoming much more service oriented. Responding to the patient is not
only good customer service, but it also creates an efficient and effective
healthcare delivery system.

3
4 Utilizing Technology to Arrange a Physician Visit

Like health care, information technology is a continuing, evolving indus-

try. Healthcare organizations are spending millions to upgrade their
systems. At Sutter Health in Northern California, the technology budget
doubled in the years 1997 to 1999 to $79 million and staffing tripled to more
than 500 positions.1 It is not uncommon for large healthcare systems to be
spending on technology ten times what they were only five years ago.2
Combine the changes in healthcare and information technology and you
have an evolutionary dynamic. Much has been written on the hospital
sector, but as healthcare changes from an inpatient industry to an out-
patient industry, so too must the emphasis of study.

Physician Practice Defined

The term physician practice can be defined clinically and organizationally.
Common clinical terms for physician practice are primary care, ambulatory
care, group practice, and outpatient care. The World Health Organization
(WHO) definition of physician practice is “an outpatient healthcare deliv-
ery system which encompasses all aspects of a person’s well being—physi-
cal, mental, and social.” Physician practices care for many aspects of a
person, providing the person (patient) with an apparent outpatient con-
tinuum of care. In managed care, the term “covered life” is used to indicate
that all health needs over the lifespan of a person are covered. Thus, one
can say that clinical practices provide “covered life” services.
In organizational terms, physician practices can be solo, partnership, or
group, with group being the most prevalent. All provide a network of care
to the patient, either within a multispecialty practice or through referral to
specialists. The American Medical Association (AMA) defines a group
physician practice as “three or more physicians working together and
sharing their earnings in some way, regardless of organizational form.”3 The
following two definitions do not suggest a size, but they do specify further
organizational issues. A group practice is “a number of physicians who
decide to practice medicine in a coordinated manner and typically in a
single location.”4 A group practice is “where single or multispecialty physi-
cians share space and staff, where they may pool the income earned from
all of the patients, pay the physicians as partners or on productivity, and
share around-the-clock coverage.”5 Organizational definitions focus on size,
location, finances, and business operations.
What is needed is a definition that combines both the clinical and the
organizational aspects. Physician practice is an outpatient health care
delivery network in which two or more physicians with a specified financial
arrangement work under one mission to deliver quality health care over
the patient’s lifetime.