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June/July 2002

By Ben Weinstock, PT, CISSP

One of the most difficult decisions a private practitioner makes is choosing the right software. Often this decision is made when the practitioner is frustrated by the difficulties of trying to manage the ever-growing mountain of paperwork and is feeling intimidated by the thousands of products on the market.

SOFTWARE SEMANTICS

Software refers to programs or instructions written in code that tell a computer what to do. Without these instructions, computers (the hardware) are useless.

There are two main categories of software: operating system software and application software. Operating system software controls the "behind the scenes" functions of the computer. These functions include the booting up process, and the allocation of computer memory. Applications are the programs that we see running on our computers. They can be general purpose applications, such as word processing programs, or specialized applications, such as gait analysis programs, medical billing programs, and clinical documentation programs.

Applications relating to medical records are referred to by many acronyms: EMR (electronic medical record), EPR (electronic patient record), POC (point of care system), to name a few. However, the most generic term is CPR: computerized patient record.

Further complicating the decision-making process is the choice of having a program run on the desktop or on the Web. A desktop program is installed directly on your computer by means of a floppy disk, a compact disk, or a download from the company Web site. Running the program does not require simultaneous Web access. By contrast, a Web-based program is accessed through a Web browser. The company that provides its software over the Web is known as an application service provider or ASP. The difference between a desktop-based program and an ASP program is an example of the dichotomy of convenience versus security. A desktop-based program may involve a bit more work initially for installation as opposed to an ASP, which can be accessed simply by logging onto a site on the Web. However, the data transmitted to an ASP may be at higher risk due to Internet-based attacks by hackers.

Just as we perform a patient evaluation before we formulate a treatment, we must first evaluate our software needs before making a purchase. I have developed a basic scheme for evaluating software for private practitioners. This software needs evaluation has five aspects: functionality, costs, ease of use, technical support, and security.

EVALUATING YOUR NEEDS

Functionality. You must first ask yourself what you want computerized. This could be your most common business activities, such as scheduling, billing, clinical note writing, or producing graphics of exercise programs. There may also be needs specific to your type of practice, such as gait analysis, balance assessments, and cognitive assessments. It is critical to get input from your coworkers, as they will also be using the software. In particular, pay close attention to the needs of billing personnel, as they may be using the software more than anyone else in the practice.

The Institute of Medicine, a division of the National Academy of Sciences, Washington, DC, has developed guidelines for assessing the various features of CPR. For example, common data lists, such as current procedural terminology (CPT) codes, should be stored, billing codes should be assigned easily and/or automatically, and claims should be able to be transmitted electronically. In order to comply with Health Insurance Portability and Accountability Act of 1996 (HIPAA) Transaction and Code Sets regulations, it is advisable to have your claims transmitted through a clearinghouse. Clearinghouses are intermediaries between practitioners and insurance companies; they translate transmitted data into standard, HIPAA-compliant formats.

As you consider what aspects of your business you would like to have computerized, write out a list of priorities: what features you definitely need, followed by what you would like but may be willing to forgo. By sticking to your list of priorities, you can avoid the common mistake of purchasing software that is not quite what you need. It is not unusual for private practitioners to purchase complicated software with many bells and whistles; unfortunately, those extra features are rarely used. Other common mistakes are the purchase of solely a billing program, when in fact a more comprehensive package that also includes the capacity for clinical documentation is needed, and vice versa. Such mistakes can not only be costly, but can also lead to frustration on the part of the practitioner, which can lead to the abandonment of the software.

Costs. Software costs range from free to tens of thousands of dollars. Free or low cost does not necessarily mean the software is inferior, and expensive software does not mean that it is superior. Keep in mind that the total costs associated with the purchase of new software can be much more than just the basic price of the product. You must also factor in any additional expenditures that may be required, such as new hardware or extra software, licensing agreements, customer service contracts, and upgrade and training costs. The cost of downtime during repairs or upgrades should also be considered.

Ease of use. Software usage should be intuitive, without complex features that are difficult to master. This can vary from person to person, as each of us learns new skills differently. Software that is difficult to learn will result in additional time (and expense) needed for training and may also pose a risk: more errors may occur if the users of the program have trouble utilizing the basic features.

I strongly recommended that you consider the options available for the input of data: typing, touchscreen, bar code scanning, voice recognition, or voice dictation. Other considerations include the overall ergonomic appeal of the software. Is it easy to read? Does it have a color scheme that is pleasing to the eye, or does it cause eyestrain or headaches?

Technical support. Sooner or later, problems may arise. You need those problems to be fixed as soon as possible. How quickly does the software vendor respond? Is the vendor's support staff knowledgeable of how your facility operates? Once again, you need to think about the costs of downtime.

Security. You cannot ignore HIPAA security requirements. Possibly the most important software security feature is the tracking of who accesses the software, and where data are transmitted. This is known as an audit trail, which is used to investigate an intrusion into your system. Audit trails provide data concerning user names, passwords, which files have been accessed, when the files were accessed-in short, all the information you need to hold someone accountable for his or her actions.

YOUR SHOPPING LIST

After you have completed your evaluation, you will be able to articulate what you are looking for. For example, you may be looking primarily for software that handles scheduling and electronic billing, but you do not require a clinical documentation module as you prefer to write notes the old-fashioned way. However, you may consider upgrading in the future to another version of the software that includes clinical documentation features. Of lesser priority may be a module that produces illustrations of home exercises.

Let's say you are willing to spend $5,000 for the software and a customer service contact. As you have experience with Windows operating systems, you would like a program that has a display similar to Windows. You will input data by typing. In order to comply with HIPAA, you will transmit your claims through a clearinghouse, and you want the software to have the capability of producing an audit trail.

Once you have your shopping list, you can begin the process of gathering information. This information can be obtained from colleagues, from professional journals, and on the Web. I recommend that you do not base your decision solely on endorsements or testimonials. You will get to a point where you can narrow your purchase down to just a few products. The best way to see if you like the software is to request a demonstration version from the software vendor. If it takes a few months to go through the various demos from different vendors, you will benefit in the long run as you will have adequately explored the various options and you will know which works best for you.

Ben Weinstock, PT, CISSP, is a New York state-licensed physical therapist and a certified information systems security professional. He lectures and consults on a wide range of topics including medical informatics, HIPAA, and computer security. He can be reached via email at Ben Weinstock@worldnet

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June/July 2002