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!
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.
The Covid-19 pandemic has created an opportunity for the engineers at Remmie Health to develop and begin distribution of an inexpensive ($150) otoscope that can be used to capture images of the tympanic membranes and throat of an ill child or adult. The Remmie Otoscope is now available on Amazon and is designed to be non-threatening to children. It complements ear or forehead thermometers that are likely used routinely by parents to screen children for fever. The Remmie Otoscope transmits images to a mobile application which then can be sent to a child’s physician for review.
Several years ago, the CellScope Oto otoscope was developed to enable smartphones to be used as an otoscope. However, it was awkward to use even though the images it captured were of high quality. Because the camera’s associated with smartphones changed so rapidly, it was difficult for the company to produce the plastic adapters necessary to connect the device to smartphones, and sadly the company went out of business.
As more and more physicians have adopted Telehealth, I anticipate that the Remmie Otoscope will prove useful for the Otitis prone child, as physicians can now diagnose otitis media or pharyngitis remotely. It can also be used to detect impacted cerumen, otitis external, and visualize ear canal foreign bodies.
Remmie Health is now working on developing a Software development Kit (SDK) so Telehealth platforms can integrate the device into their software by developing an application programming Interface. In my view, a provider should recommend that families consider acquiring the device and using it in conjunction with your Telehealth visits, as it will reduce much of the guess work when evaluating an ill child.
As a pediatrician I routinely care for children with asthma. As we all know families of asthmatic are frequently non-compliant with our recommendations – and many children do not take their medications as prescribed. As a consequence, asthmatic patients may have exacerbations, or may in fact be unaware that they are not optimally managed. Furthermore, when such patients begin to wheeze, they may not seek care from their primary care physicians, preferring to be seen at more convenient urgent care clinics or, all to often at an emergency room.
VitalFlo is a company that will enable physicians to better care for their asthmatic patients as well as older patients with COPD and other respiratory conditions. It combines a high-tech spirometer that is provided to your patient that communicates with an app on a smartphone. As seen in the interview with Wendy Stevens BSRN, Director of Business Development for VitalFlo, the app is easy to use, includes a tutorial for using the spirometer, a very brief survey of symptoms, and directs the patient to produce 3 good blows into the device. Patient results are transmitted to a portal that can be viewed by patient or clinician and recommendations can be discussed with patients via office or Telehealth visits. Depending on disease severity the provider makes recommendations regarding the frequency of testing. Vitalflo is a prescription-based service that costs a practice $35 per patient per month (less if the patient purchases the spirometer). The provider can generate revenue by charging for testing/monitoring (billing codes and reimbursement are discussed in the video), and seeing patients for regular visits.
The system was developed at several academic institutions in North Carolina, and studies have demonstrated its ability to improve patient management.
I’m very impressed with the VitalFlo system, and will include it in my “Best Tech for Pediatrics 2021” article that will be published by Contemporary Pediatrics in September!
I’ve been using Dragon Medical for years and each iteration improves on the previous version. Nuance recently released Dragon Medical One and it is truly wonderful. No longer do you need to “train” the software. With your first use – the accuracy is terrific. This version is server based and users install an application on their smartphone to enable the phone to function as a wireless, network connected smart microphone.
The application enables users to assign commands to different “buttons” so you can choose to move from one field to another, activate voice macros that insert templates or move to different areas of the EHR.
One can dictate twice or three times the speed at which one types. This means than once you become facile with Dragon Medical One – you complete your notes much faster than you can by typing. This means that you can complete notes before the end of the workday. No longer will you need to take work home with you. The need for completing notes at home is a major cause of provider “burnout”.
It is worth your time to not only to become skilled in dictating notes, but to take the time and effort to develop macro voice commands that insert phrases, templates, or navigate within the EHR or within the operating system. You should read the manual (of course) which will quickly educate you how to delete or replace phrases, correct words or add words to your vocabulary. Outstanding!