EMRs For Dermatology Care

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EMRS For Dermatology Care
Ease In With Careful Planning and Selection

How many ways can you describe a blister? You've no doubt seen them all. Today when Fred Blum, a dermatologist in Durham, N.C., treats a patient with a blister, or a rash for that matter, he no longer has to run through his mental thesaurus and pen his personal observation in a paper chart.
Instead, Blum and his partner at Triangle Dermatology Associates, PA, simply click off the most apt adjectives provided by their MediNotes Corporation electronic medical record (EMR) and move without delay to the other significant aspects of the patient's visit--such as coming up with a diagnosis and treatment plan. "I spend much less time doing the more mundane stuff and more time charting with the more important things," says Blum, who has had the EMR for two years.

Kentucky dermatologist Artis Truett is also reaping the benefits of his EMR, made by NextGen Healthcare Information Systems, Inc., which he has had for five years. "We are doing a much better job of answering [patient] questions and responding to their needs," says Truett. "I think the level of patient care has increased dramatically," as has the "customer service" aspect of his practice, Owensboro Dermatology Associates, PSC. Truett wishes more dermatologists would come into the EMR fold. "I really want other dermatologists to adopt EMRs. I would like to have a dialogue with other practices that have done EMRs. I think we are really at the beginning of the whole process, and there is a lot that can be shared, and a lot to learn. I am always willing to change, and my partner is, too. We are not stuck in the past.

First, Understand Your Needs
Truett and Blum are true believers in EMRs. But they weren't always that way. Like other dermatologists, they feared spending too much on the wrong product, ending up with a system that didn't interface with their other software, and getting stuck on hold while frantically calling their vendor's help line. They also worried about having an EMR that didn't reflect their needs as dermatologists. Then there are the patient-related fears, often centered on slowed documentation and increased wait times. None of their fears came true, thanks to a careful process of vendor selection, phased-in implementation, and their active involvement in troubleshooting the system once it was installed. These are key to a successful implementation and to combat the fear associated with EMRs, says Robert M. Tennant, senior policy advisor for health informatics for the Medical Group Management Association (MGMA).

Before dermatologists make any decisions, they should begin the process with a thorough understanding of their own needs, Tennant says. He advises having a checklist of things your system should be able to do. "The question to ask yourself, as a dermatologist or a dermatology practice administrator, is, 'How do I want my EMR to impact and improve my practice?" says Tennant. "Is it simply better recordkeeping,...e-prescribing, treatment protocols. ...When the physicians want to move away from a paper health record, it certainly broadens the opportunity for system changes. However, the more functionality you want, the more demands you have, the fewer product choices you are going to have. It's unlikely that any system is going to meet all your needs."

Don't go blindly into an EMR purchase and installation thinking it won't cause changes. Once you understand how the EMR functions, "Ask yourself, 'How will this impact our workflow, and the way that we practice medicine?'" Tennant suggests. Consider also whether the timing is right, and weigh your decision against other technology and patient needs of the practice. Tennant notes that dermatology practices tend to be smaller, so they may need to decide whether to build on existing practice management system (PMS) software or convert everything at once. "To ensure a seamless transition, it might make more sense to convert to a fully compatible PMS and EMR at the same time," Tennant says. "In many cases," he warns, information technology (IT) "systems have failed because of poor integration between administrative and clinical systems."

Custom Tailored?
Like other specialists, dermatologists must address the issue of whether to purchase an EMR designed for their field, or choose a basic one and tailor it themselves, relying at least partly on the embedded features provided by the vendor. It isn't necessary to get an EMR made just for dermatologists, Tennant says, "as long as you can customize it to meet your needs." Blum says he never considered a dermatology-specific EMR. "[Dermatologists] do have needs, but they are similar to other specialists," he says.
Among the issues to be factored in is the "viablility of the company," Truett says. "I wanted to go with a company that was financially secure. If [a firm] came out with a just-dermatology product, but they were a small company, you'd have to be careful."But both physicians knew certain EMR features would be important to them as dermatologists. "I wanted a program that had a lot of graphics capabilities," Blum says. His EMR enables him to pinpoint the location on the patient's body of any problems. "You can put a mark right where the lesion is," he says.

Recoginze, too, that these features may not be standard. Adds Tennant, "In many cases, physicians will have digital cameras, and you want to be able to store high-resolution images. If a practice goes in that direction...don't skimp on disk space." Storage capability is crucial for optimized use of digital imaging: "Whatever size hard drive you think you need, "says Tennant, "double it." There's no quicker way to annoy dermatologists and other users of the system--and impede patient care--than by subjecting them to a slow system. And a hard drive that is running out of space slows data retrieval considerably.

An EMR that is not designed specifically for dermatology will need some tinkering, which makes having a responsive vendor all the more important. For example, MediNotes included graphics for all parts of the face, but not the top of the head. "Bald guys have all kinds of trouble on the top of the head, "Blum says. He was able to work with MediNotes to add this feature. Such a relationship is important. Good EMRs are always evolving, and those vendors that value the input of practicing physicians--and act on their suggestions--are able to best accommodate the real-world practice environment.

Learn From Others
There's no substitute for seeing the EMR in action. Ask potential vendors for references, and make site visits yourself if possible. The fact that NextGen didn't have a lot of dermatology clients wasn't an issue for Truett. "I visited one of the practices in Texas. I went out with several members of their staff," he says. Not only was the visit valuable, but he still stays in touch with the practice, getting advice and support when needed.
To make the most appropriate comparisons, Tennant advises visting practices that share your specialty, size, and general patient demographics. This will also give you an idea of other features you might want, such as remote access. Both Blum and Truett are able to access their EMRs from their home computers, which is invaluable when the physician is on call and is summoned to care for a another dermatologist's patient. "Some patients know that dermatologists will give codeine if you call on the weekend," Blum says. Without access to a patient's chart, it might be unclear when such a request is a ruse. "That hasn't happened since we got the EMR," Blum says. "But there have been dozens of times when I wasn't sure what was going on, and I could go to the note and [help the patient] from home, and I can do a quick note on what I did."
One way to minimize problems integrating an EMR into the practice, Tennant says, is to "create a super user--a nurse or an administrative staff member who can be an expert on the system, who can be around so you can say, 'come on down to my office,' when you have a problem. You can't assume the vendor will hold your hand." Truett's last piece of advice: "Be prepared to take on a challenge." EMR implementation, he says, "is not for the faint of heart. [But] the end result has definitely been worth it."

By Theresa Defino
The Patient-Centered Dermatology Practice

Skin Cancer Is “Real” Cancer

Related Document: Skin Cancer.pdf (Reprinted with permission
from the Messenger-Inquirer)

A patient relates how she felt after being diagnosed with skin cancer, and Dr. Crowe details the importance of early diagnosis and treatment.

Cheri Moss had a normal childhood. She played outside and went to the pool like any other kid. She got sunburned pretty badly several times, but didn't think much about it. After all, most people get sunburned at some point.

Fast forward to adulthood. About five years ago, Moss, now 43, noticed a small bump on her leg she thought was a pimple. It wouldn't heal, so she finally went to Dr. Michael Crowe at Owensboro Dermatology and found out she had skin cancer.

"I was devastated," she said. She was grateful, however, that she could be successfully treated. Dr. Crowe has treated her several times over the last few years as new skin cancers appeared on her legs, chest and face. She's fine now, but will most likely face the disease several times again.

Ninety-nine percent of skin cancer is caused by the sun, or ultraviolet (UV) light, Dr. Crowe said. Basal and Squamous cell carcinomas are the most common forms of skin cancer. According to the American Cancer society, more than a million cases occur in America every year. Basal and squamous cells are located in the epidermis, or outer layer of the skin, and they cover internal and external surfaces of the body.

The third and most deadly form of skin cancer is melanoma. It begins in melanocytes--cells that produce the melanin that colors our skin. The American Cancer Society estimates that around 54,000 melanomas occur every year. Melanomas cause about 7,600 of the 9,800 skin cancer deaths each year.

Dr. Crowe said skin cancer is common among 50-and 60-year olds, and people in that age group should keep a close watch on their skin. Dr. Alan Mullins of Ohio Valley Surgical Specialists agreed. "All cancer is a disease of aging," he said. "The prevalence of all types of skin cancer goes up as you age. The good news about skin cancer is that it's easy to find out. Don't ignore the obvious."

That means keeping an eye on any moles you have and watching for any new spots. "Our primary message is that the sooner we can catch it, the smaller the area is and the easier treatment will be," said Dr. Artis Truett, a partner with Dr. Crowe at Owensboro Dermatology.

"There's a lot of evidence that one of the most important criteria for a mole being suspicious is a history of recent change," he continued. If a mole darkens, bleeds, or is irritated and doesn't seem to heal, those are "signs of turning into cancer," Dr. Crowe said.

May is National Skin Cancer Awarness Month, so it's a good time to be sure you're in the clear. Moles should be checked for the ABCD's of skin cancer:

Asymmetry: If one half of a mole doesn't match the other, it may be cancerous.
Border irregularity: If the edges of a mole are ragged, notched or blurred, it may be cancerous.
Color: If the color varies from one area to another, with shades of tan, brown, red, white or blue, a mole may be cancerous.
Diameter: If a mole is larger than six millimeters (about the diameter of a pencil eraser), check with your doctor. Growth of a mole is also cause for concern.

In addition, Dr. Crowe said if you notice white bumps that scab or bleed and aren't healing after three or four months, you should have them checked. Ask your physician when you have your annual checkup if you have any questions about suspicious spots, especially if you've had skin cancer in the past. If you have one skin cancer, you're automatically at higher risk for having another," Dr. Mullins said.

The good news is that skin cancer is quite treatable, especially when caught early. "Almost all patients that have skin cancer that come in are cured," said Dr. Crowe. So what treatment options are available? That depends on what type of skin cancer a patient is facing.

Precancerous spots on the skin can be frozen off or lasered off. Small cancerous moles can be numbed and then burned or scraped off if they're on the back, arms or chest where the skin is thicker. For cancers on the face and neck where the skin is thinner and the cancer can reach farther into the skin, Mohs surgery is in order, Dr. Crowe said.

Mohs micrographic surgery is a specialized technique recognized by doctors as the most effective treatment available for the removal of basal and squamous cell cancers. Doctors carefully remove and examine a layer of the cancer at a time until they reach a layer where no more cancer is found. Dr. Crowe said the technique enables them to examine 100 percent of the skin edges to make sure the cancer is gone. It's much more accurate, leaves a smaller incision and has a higher cure rate than simply excising the cancerous spot.

Mohs surgery works on basal and squamous cell cancers because the cancer cells are all attached as one piece. Therefore, "If you're checking a very narrow edge, if there's nothing on the edge, you know you have it," Dr. Crowe said. Melanomas, however, are made up of cells that are not all attached, so a wide excision must be made in the hope that all the cancer in the area will be removed.

Dr. Mullins treats more serious forms of skin cancer as well. He said squamous and melanoma cancers can spread to lymph nodes in the body. Those types of cancer have the same potential as lung cancer or esophageal cancer, he said. Dr. Mullins thinks people tend to treat skin cancer as not really a cancer, but, "The take home message is particularly squamous cell and melanoma are real cancer. They can spread and they can kill you. They have to be thought of in a different way."

Another tool the doctors at Owensboro Dermatology employ is the FotoFinder dermoscope. Dr. Truett said when a person has a great deal of moles, it's often hard to track changes in them. The Fotofinder dermoscope uses a digital camera attached to a computer to take a high-powered photograph of the affected skin area. Moles are then scanned by the software developed by a university in Germany and the program indicates whether or not the spot is cancerous.

The patient can come back in a few months for another photograph, and the program will compare the two scans and tell if any of the moles have changed.

"It's a really nice tool," Dr. Truett said. "For certain high risk people it's a wonderful device." It's not an absolute test, but it's a fairly good indicator of cancer. The machine often helps decide whether or not to biopsy a certain mole.

The best way to deal with skin cancer is to avoid it in the first place. Dr. Crowe said 80 percent of the sun exposure a person gets in their lifetime comes before age 18. That sun can have lasting effects later in life. Many patients come in 20, 30, even 50 years after extensive sun exposure with skin cancers that are now surfacing due to that sun.

Both Dr. Crowe and Dr. Mullins said you don't have to hole up in your home to keep away from the sun. "You have to live your life," Dr. Crowe said. But they both recommend using caution outdoors. Wear sunscreen and a hat, expose as little skin as possible and avoid the hot sun in the middle of the day. Dr. Crowe recommends a sunscreen that sprays on like water and dries up in a few seconds, preventing the drippy mess that can get in your eyes and leave you greasy.

Taking care of kids is especially important. Make sure you put sunscreen on them when they're outdoors. With the spray version, Dr. Crowe said, "It takes 15 seconds to put it on a kid before he starts baseball practice."

Avoid tanning beds as well. "You want to limit any way you can the exposure of the skin to ultraviolet radiation which is damaging to the skin and eventually leads to cancer developement," Dr. Mullins said.

Moss' final thought: "My generation--we love the sun. If I hadn't come here I'm sure I would still be tanning. [Now] I don't get out in the sun--ever."

By Ben Hoak
Messenger-Inquirer Special Publication

Free Skin Cancer Screenings/World Record Set

Related Document: Free Skin Cancer Screenings.pdf (Reprinted with permission
from the Messenger-Inquirer)

Free cancer screenings offered Saturday, May 6, 2006.
Appointments required; limited slots remain

The annual skin cancer screening push for Owensboro Dermatology Associates will have a twist this year--joining an effort to create a world record for most screenings in one day.

The office will be part of an effort Saturday by the American Academy of Dermatology, of which the local practice is a member.

"We've got over 200 people signed up already," said Sandy Merkel-Finley, marketing/public relations director for the practice. More than 62 percent of the 308 available slots were filled, she said. People "need to make an appointment or they're not going to be seen," Merkel-Finley said.
Two dermatologist, two physician assistants and a certified advanced registered nurse practitioner will do the screenings. The day is meant to be an outreach effort for people who have never had a screening, Merkel-Finley said. They also will be taught how to do self-exams of the whole body, including the scalp, back, shoulders, soles of the feet, between the toes and on the palms.

Learning about moles and changes in them "is one of the biggest helps in getting (skin cancer) treated," said Dr. Michael Crowe with Owensboro Dermatology. Other educational efforts will include advising about sunscreen, protective clothing and avoiding peak sun hours.
"This is just a check. It doesn't include treatment," Merkel-Finley said.
"It's really meant to evaluate people who might not otherwise have it available to them," Crowe said.
More than 200 sites are aiming to screen 5,606 people, which corresponds to Saturday's date, said a spokewoman at the academy's Schaumburg, Ill., headquarters. There is no record for single-day skin cancer screenings, but the Guinness Book of World Records has said it will create a category, she said.

It will likely be June before paperwork is in from all sites and the final tally is known, the spokeswoman said.
"We're trying to increase everyone's awareness of skin cancer," said Dr. Sandra Read, a Washington, D.C., dermatologist and member of the academy's Skin Cancer Task force.

The academy, which has screened more than 1.6 million people since 1985, has planned the record-setting event for about a year, Read said. The event will start the academy's 22nd annual National Melanoma and Skin Cancer Screening program. Skin cancer affects about 1 in 5 Americans, and more than one million new cases are diagnosed each year, according to the academy.

By David Blackburn
Messenger-Inquirer

Physicians’ Volunteerism and Giving Recognized in Dermatology World Magazine

Related Document: Derm World - May (17).pdf

Proceeds of afternoon’s work donated to local and national relief efforts.

Getting to know people in the community is one of Michael J. Crowe, MD's favorite reasons for being a dermatologist. His visits with patients in his Owensboro, Ky., clinic allow him to "gain insight into more important things in life." One of those important things is helping those in need - something he experienced firsthand last year when he and his business partner, Artis P. Truett III. M.D., and their staff dedicated one Friday afternoon to see patients on a volunteer basis to raise funds for those affected by recent natural disasters.

When they initially conceived the idea, Dr. Crowe and his staff intended to donate all the money earned to those affected by Hurricane Katrina. Then on Nov. 6, just before the event, a tornado hit neighboring Newburgh, Ind., killing more than 20 people. As a result, the staff opted to aid those affected by both disasters and donated the funds they raised to two different organizations.

Staff was happy to contribute time for such a good cause, said Dr. Crowe. "It's a good way to get involved and contribute without hitting the pocket book" of employees, he said. Doctors and staff worked for free and patients were billed normal copays and insurance. "We were able to schedule regular patients and skin cancer patients as well as some surgeries (to raise the money)," said Dr. Crowe. The practice saw more than 100 patients that afternoon, bringing in $8,591. Half of those funds went for hurricane relief and half for those devastated by the tornado.

"They lost their homes, jobs and way of life," he said. "We wanted to try to do something for those who lost everything." The contributions made by the staff also boosted employee morale, he noted.

On charity day, when one patient - a fellow physician - found out that the practice was donating their fees to benefit those affected by the hurricanes and the tornado, recalled Dr. Crowe, he opted to pay his entire bill out of his own pocket, even though insurance would have covered the expenses.

This hurricane/tornado relief effort was the second such volunteer day Dr. Crowe and Dr. Truett's practice has organized to benefit a particular cause. In addition to these efforts, Dr. Crowe also enjoys contributing to the community through his involvement in his children's activities. A father of three, he volunteers as a Cub Scout Den leader and a baseball coach.

Dr. Crowe, who has been in practice for 13 years, said he enjoys the appeal of being able to treat a wide variety of patients - from babies to teenagers to the elderly - for a range of diseases. "You don't do the same thing all day long and every day," he said. He also enjoys being able to hear his patients' stories. "I get to meet and talk to a lot of older individuals who have led interesting lives."

Inspired by the stories of those who enjoy helping the community, Dr. Crowe said he hopes other practices will consider organizing charity days to help those in need as well. "The spirit of medicine is what it is all about," he said.

Dermatology World May 2006