The Technology Review Site for Primary Care Providers
Advances in technology have improved healthcare providers' ability to rapidly diagnose patients at the point of care, screen for common conditions, and provide a variety of effective treatment options. Providers need to be aware of what innovations are available - or will become available in the near future. It is the purpose of Medgizmos to educate and inform healthcare providers regarding the latest and greatest technologies.
Clarius mobile Ultrasound system facilitates POC diagnoses!
I’ve long been a fan of the pulse oximeters produced by Masimo (Irvine, California). Please see my article from Contemporary Pediatrics October 2014, Pulse oximetry: The fifth vital sign, for a discussion of the history of pulse oximetry, review of the technology, and tips for using pulse oximeters.
An oximetry sensor consists of red and infrared light emitting diodes and a photodetector placed on opposite sides of a measurement site, usually the finger in adults and children but the palm or foot in neonates and toddlers. The ratio of red to infrared light that passes through the tissue depends on the percentage of oxygenated versus deoxygenated hemoglobin in the arterial circulation of the tissue. In turn, the percentage of oxygen saturation displayed by a pulse oximeter is determined by an algorithm in the microprocessor of the device based on saturation measurements obtained by sampling a large population of patients breathing mixtures of decreased oxygen concentrations. These algorithms are unique for each manufacturer. Pulse oximeters take hundreds of readings over a 3- to 6-second time period and update their measurements every 0.5 to 1 second. In the best of circumstances, pulse oximeter readings come within 2% to 3% of those produced by co-oximetry, the measurement of arterial blood directly by a blood gas analyzer.
When using oxygen saturation clinically, it is important to recall the oxygen dissociation curve we learned in medical school . The upper “bend” in the oxygen dissociation curve occurs at a pO2 of 60 mm Hg of oxygen, which corresponds to an oxygen saturation of 90%. Therefore, one needs to be aware that saturation levels of 90% and below are associated with hypoxemia.
Masimo uses a proprietary technology called “signal extraction technology” (SET), which provides rapid signal acquisition and signal stability even when used in the “wiggly’ patients pediatricians deal with every day. I have been using the Masimo Rad-G pulse oximeter for some time. It features a touch screen interface, is very durable, and provides readings of pulse oximetry, wave form, perfusion index, as well as a respiration rate from a photoplethysmogram. Best of all there is a new pediatric sensor that is now available for children 10 kg and above which makes it easy to obtain reading in young patients.
Primary care physicians have been using Welch Allyn diagnostic sets for decades.
In 2008, Welch Allyn introduced the MacroView otoscope with improved magnification and increased field of view compared to traditional otoscopes. At the time it was a major improvement upon previous versions. It provided a nearly complete view of the tympanic membrane, included a rotating wheel to adjust focus, used a longer lasting halogen bulb, and it optics produced a cool light without reflections. Three years later the company introduced the PanOptic ophthalmoscope with a much wider (5x) view of the retina compared to traditional ophthalmoscopes.
In 2015 Hillrom acquired Welch Allyn, and this year they are upgrading their diagnostic tools.
The new MacroView Plus Otoscope uses LED lighting and improved optics to provide up to 3x the view of traditional otoscopes, a focus free design, and the capability of attaching to a smartphone with a SmartBracket accessory so that tympanic membrane images can be captured and magnified via their iExaminer application. In addition, the MacroView plus can be used with Hillroms new Lithium Ion Plus battery handle that is charged via an usb-c port. They have also released the new LumiView clear, single use speculum, providing up to 8x brighter views compared to those provided by a black speculum. Lastly, their new PanOptic Plus ophthalmoscope uses longer lasting LED lamps to provide up to a 20x larger viewing area when compared to the view through a standard scope. It also integrates their Quick Eye alignment technology to help direct patient gaze during the examination. Online the handle sells for $286, ophthalmoscope for $841, and Otoscope for $455, and a bag of the Lumiview specula sells for $342. A new diagnostic set (new Lithium Ion Plus battery handle, MacroView Plus otoscope and the PanOptic Plus Ophthalmoscope is selling online for $775 without the SmartBracket and $830 with the SmartBracket.
A significant update to provide clinicians with a better view of eyes and ears……
There are now 63 state, regional, and city-based vaccine registries, called Immunization Information Systems (IISs), each operating independently under its respective local and state policies. It is the responsibility of the administering site to enter the required data and it can be a burden to staff when they need to enter the data in multiple locations such as the registry, the EHR, and the patient vaccination card.
One method of speeding data entry is the integration of bar code scanning into EHRs. After receiving a shipment of vaccine, the shipment form is scanned into a vaccine inventory which is integrated into the EHR. At a patient visit the provide orders are placed and the vaccines retrieved and scanned once more. Warnings appear if the vaccine is being given too soon, not age appropriate, or issued by the wrong funding source (eg Vaccines for Children program), or the vaccine has expired. The staff manually enters the vaccine administration information into the EHR, and the information is electronically sent to the appropriate IIS. Over the next few years, it is anticipated that a growing number of EHRs will have this capability.
I can tell you that in many pediatric offices, it is very time consuming and unwieldly for staff to enter vaccine information in multiple systems. One startup company, called Canid has a novel approach to facilitating IIS entries for pediatricians. The founder and CEO of Canid, Pedro Sanchez de Lozada, recently sat down with me to discuss IISs, and how the current IIS entry system can be improved.
Canid is establishing relationships with pediatric practices in the New York City area, where the company is located, and eventually hopes to expand services nationwide.
As discussed in the video interview, Canid helps practices acquire vaccines and has developed a software system that either integrates with popular EHRs or facilitates data entry into EHRs by providing a data file that is uploading into an EHRs on a daily basis. The Canid system keeps track of a practice’s vaccine inventory, replenishes supplies when appropriate, and most importantly monitors patient appointments so that a child receives all necessary vaccines. They do this by distributing barcode scanners (see above) that integrates with their proprietary software platform. When vaccines are ordered and taken out of a refrigerator or freezer, they are scanned, and fields are populated into a practices EHR (assuming the EHR supports Canid integration). Little or no manual entry is needed.
We discuss quite a bit in the video, and the conversation is quite enlightening. At the moment, Canid is assisting healthcare professionals in NYC make appointments for administration of Covid vaccines.
The Center for Medicare and Medicaid Services (CMS), with guidance from the American Medical Association (AMA) implemented a new evaluation and management (E/M) coding system for outpatient visits effective January 1, 2021. This was the first change in 25 years and was developed to ease the documentation burden on medical providers.
The updated CMS guidelines are based only on 1) a clearer method of assigning MDM or 2) a new methodology for assigning a time component to the visit on the date of service.
The new guidelines:
Eliminates the history and physical as elements for code selection
Gives providers the option of choosing whether documentation is based on MDM or time associated with the visit on the date of service
Modifies the criteria for MDM by removing ambiguous terms, clearly defines important terms and concepts and re-defines the Data MDM measures
As in the past, CMS recognizes 4 levels of MDM (straightforward, low complexity, moderate complexity, and high complexity). MDM quantifies the complexity of establishing a diagnosis and/or selecting management options by measuring:
• The number and complexity of problems addressed at the encounter
• Amount and or complexity of data to be reviewed and analyzed
• The risk of complications, and/or morbidity, of patient management
Coding by time
Indicating the time associated with an encounter is an alternative method of determining the level of the visit. For many, utilizing time to determine a level of service is much less confusing and more straightforward compared to assigning a level of service using MDM. In contrast to pre-2021 method of assigning time associated with the face-to-face time spent counseling the patient or coordinating care, now time consists of the following elements:
Time spent preparing to see the patient, reviewing tests and external notes
Time spent obtaining a history from the parent
Time spent performing an examination
Time spent ordering medication or tests
Time spent referring to, and if necessary, communicating with other health care providers regarding management
Time spent documenting in the health record
Time spent communicating results (on the day of service) with the patient/family or caregiver
Time spent in care coordination
This webinar discusses the new coding system in detail.
In the opinion of Dr. Schuman, the data element component of MDM remains too complicated and rarely elevates an office visits category appropriately. A more practical method is to code by time.
My son, Robert Schuman and I have developed MDMtool.org to assist providers in coding according to the new guidelines. One selects elements of MDM or time associated with a visit (coming soon) and copy and pastes the text into the bottom of your note. My other suggestion to avoid audits is to list as many appropriate visit diagnoses as one can.
Nuance Communications, the company that pioneered voice detection software for medical practices, partnered with Microsoft in 2019 to develop an “ambient clinical intelligence” system, called the “Dragon Ambient Experience” or DAX for short. DAX uses an application running on a smartphone, either alone or in combination will a wall mounted “machine vision” camera and 16 microphone array to record a patient’s visit with a physician. The information is transferred to Nuance’s cloud based Artificial Intelligence system which analyses the captured recording and creates an office note. The note is reviewed by Nuance technicians, and then transmitted into the physician’s electronic medical record for review and signature. Now available for use in clinics by specialists and primary care providers, in the near future DAX will be available for use in hospitals and will facilitate note creation by nurses and other support staff- as well as providers. As the system enables providers to see more patients per day, DAX virtually pays for itself.
My interview with Jared Pelo MD, Nuance’s Chief Information Officer, Ambient Clinical Intelligence, is wide ranging and discusses the evolution of DAX, as well as how it is used in a clinic environment. I think you will find the discussion interesting and even provocative – as it provides a look into healthcare’s promising “virtual” future.
The old-fashioned way to communicate with patients is via letter or phone call. Too often patients who wish to schedule an appointment or ask a physician a question, have long waits on hold. Patients get frustrated and often consider seeking care outside of their medical home. Additionally, physicians who return calls to patients, encounter full mailboxes and waste precious time leaving messages for patients. What follows too often is an endless game of “phone-tag.”
The best method of communicating with patients, given today’s technology, is via a HIPAA compliant messaging system such as Gnymble, detailed in this video interview and demonstration of the system. Gynmble was developed by Bryan Fine, a pediatrician and entrepreneur. The interview with Dr. Fine and Kaylee Niederhelman, Gnymble’s Director of Business Partnership discusses the nuances of Gnymble. One can message a patient or broadcast a message to many patients. One can copy and paste messages into the office notes. You can even customize your responses with the names of the parents, and patients, and include images or files to enhance communications.
The system is very affordable and should be considered by any primary care or specialty practice who wishes to improve communication with patients.