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Table of contents.

Section I. A typical patient encounter

a. Scheduling the Appointment

i. Prior Authorizations

ii. Patient Reminders

b. Start the Patient Encounter

i. Sign-in with Clerk

ii. Patient Tracking in Clinic

c. Exam Room with Patient

i. Nursing Intake

ii. Starting Physician Exam and Evaluation

iii. Automatic Chart Review

iv. S - Subjective Information

v. O - Objective Information

vi. A - Assessment

vii. P - Plan

viii. Prescription Writing

ix. Patient Instructions

x. Additional Features for the Physician

xi. Physician Sign-Out

xii. Assisted E&M Coding

d. The Exiting Process

Section II. System Features and Benefits

a. Database Components

i. Family Database

ii. Individual Database

iii. Medical and Billing Database

iv. Expert Systems Database

b. The billing System

c. Security

d. Management Tools

e. Maintenance, Upgrades, Support

f. Operating Systems

g. Implementation of Operating System and Hardware

h. The APPGEN® Run Time Engine

i. Turnkey Solution


A typical patient encounter using SmartDoctor...

The following narrative illustrates how the SmartDoctor automated medical office system works as a patient goes through a typical office encounter.

Scheduling the Appointment
The appointment system is the initial point of interaction with the SmartDoctor® system. New patients are integrated into an existing family or become the first member of a new family. If the patient is part of an existing family in the database, the address, phone number, and other information such as the guarantor or head of household is verified at each encounter. The system also alerts the scheduler to any unusual family problems or billing problems if such attention is needed—for example, to be sensitive in the death of a family member or to a patient who tends to get hostile quickly.

The appointments are made on the basis of acuity, patient preference, and the patient’s own sense of urgency. The system appoints with the appropriate physician for an appropriate amount of time based on the type of problem presented and the type of exam needed. Each doctor in the system can define the length of time for each type of exam and by sex of patient. Further, the types of exam are determined by each doctor. This eliminates the problem of having appointments made for a doctor who does not do a specific procedure, such as colposcopy, and makes sure the appropriate amounts of times are assigned for the appropriate type of visits (different times assigned for male and female complete physical).

Scheduling is facilitated for the appointment clerk, in that the symptoms are maintained in a Symptom/Reason file which allows the clerk to enter just part of a term, such as HA for headache or "dia" for diarrhea, diabetes, etc. All appropriate terms in the cross reference system will be brought up. This improves accuracy of entering data for the clerks, flagging of potential visits needing prior authorization, and also allows for better sorts and searches in the future. Then the type of appointment can be selected as the default of Routine (R), or Non-medical (N) as in a school physical, or as Mandatory (M) in the case of a follow-up for an abnormal blood test. The appointment status is indicated as Pending (P) at this point. The clerk then selects from a list of appointment types for the specific doctor as described above.

The clerk can then either look at the schedule for that doctor, or all doctors in the clinic. The schedule shows the date, the number of slots available, the number of slots that are booked, and the percent booked. In this way, the clerk can help balance the clinic schedule, both for that doctor and for the clinic as a whole. The clerk then selects the date and time, and the schedule is blocked accordingly for the amount of time allotted for that specific visit type. The clerk can now go on and schedule this patient for other appointments if necessary. (top)

Prior Authorizations
To prevent subsequent problems, when the clerk makes the appointment the system will check to see if this patient is covered by a carrier that requires prior authorizations. If one of the patient’s insurance carriers does require prior authorizations and the Symptom/Reason for the visit indicates a potential for prior authorizations, then SmartDoctor® will bring this to the clerk’s attention. The clerk can then ask the appropriate questions and make decisions as to whether this needs a prior authorization. The clerk can quickly check (hitting one key) for which types of exam the patient has been given prior authorization. The clerk can then answer the next prompt as to whether this appointment should be placed in the Prior Authorization Required file. All appointments placed in the Prior Authorization Required file can then be worked by the office staff on a daily basis. This file contains all the information needed to secure and document the prior authorization for later use in billing. If this is not done, then the system will prompt for procedure-specific prior authorization on exit, as described in Exiting, below. (top)

The system will generate a phone list or post cards to remind patients of their appointments. (top)

The patient encounter
The physician can start a patient visit, record a Non-Visit encounter (e.g., a patient call or chart note), do the nursing intake if the nurse is busy, or access the phone book or personal medical library. However, the normal flow is as follows: (top)

Sign in
When the patient arrives, reverification of the patient’s name, address, responsible party, presenting complaint, and other relevant information, is made. If the reason for visit has changed this is easily noted, while still showing the initial reason for visit. The patient is also asked if this visit is urgent. If it is urgent, then appropriate flags are given both to the physician and the nurse to alert them of the patient’s concern, and the clerk is asked to notify the nurse of the patient’s concern. If there are any family flags present, then the clerk, nurse, and physician are prompted to look at the patient’s family record to see what the problem may be. Since these may be problems of a sensitive nature, they are kept secured and protected by a password so that a screen will not just pop open: You must know how to access this information in the Family File. For added security, all screens go blank after a set period of time.

A check to see if prior authorization is required is made again as in scheduling above. If needed, the clerk can then take action to get prior authorization before the patient leaves. If for some reason this doesn’t happen, the checkout procedure will catch this on exit. (top)

Patient tracking
To facilitate tracking of patients in the clinic, there is an on-line listing of patients who are scheduled to be seen, appointment slots still open and available, and indications are made of when a patient has arrived, when the patient is seeing the nurse, when the patient is seeing the doctor, when the doctor has completed seeing the patient, and that the patient has been billed for the day, and all the paperwork has been completed. SmartDoctor® allows for dynamic changes in the physician’s schedule, and keeps everyone informed of the patient’s progress through the clinic. This procedure assures that the provider does not leave the office without seeing all patients who have arrived, and that all billing and exiting procedures have taken place before the patient leaves. If the patient leaves without doing the necessary interaction, it will be apparent to the physician, nurses, and the front office that further attention or communication is required. (top)

The examining room
Nursing Intake
When the patient enters the examining room, the nurse ascertains the patient’s name and logs on the room’s terminal. The nurse’s orientation screen displays the patient’s name, age, date of birth, description of the problem initially appointed for, and the reason the patient is being seen now, and indicates whether the patient felt this visit was urgent. Also, any flags that were set for the Family File to make the nurse or physician aware of specific problems would be indicated at this time.

For example, the patient is Mrs. Smith, 85 years old, female, date of birth is then also listed. At this point, the nurse is prompted for appropriate vital signs (e.g., height, weight, temperature, BP, respirations, and if this was a child, head circumference and length). The SmartDoctor® system automatically flags for abnormal values (based on sex and age) in the form of first and second level abnormals, and indicates when the patient is first in the abnormal range, then if this has become a major or serious deviation that needs attention. This allows the nurse to immediately identify errors in data input and also bring any serious problems to the nurse’s attention (e.g., a heart rate of 130 in a 2 week old is normal, that heart rate in this patient is a double flag **). The nurse can then enter any subjective free text. The nurse can stop here but, depending on practice style, she can take the patients subjective history including: full description of problem(s), a review of systems (ROS), and update of the patient’s complete social history. This information is then automatically presented to the physician on the start of the visit.

Before exiting this screen the nurse is shown the patient allergy list and must ask the patient if it is up to date. If she enters "N", then the system takes her to the allergy update screen for updating.

The nurse then logs off by indicating a secondary password which is equivalent to the nurse’s signature. (top)

When the physician enters the room and logs into the system and selects Provider Visit, the physician’s schedule for the day is presented. The physician can immediately see his list of scheduled patients, and if any changes were made in the schedule. The physician then selects the appropriate patient.

The physician is able to identify the patient by name, sex, and age, and is asked to verify that this is the correct patient. The physician is then immediately presented with the patient’s vital signs indicating any abnormalities and nursing notes. (top)

Automatic chart review
The SmartDoctor® system provides an automatic information-rich chart review for medications, active medical problems, and past medical history. Once the physician has reviewed these screens, he can move to any area of the patient chart.

Next, we will proceed in a logical fashion to the physician’s part of the office visit. However, the physician can branch to any point of the chart at any time, or go back to any point of the chart at any time prior to completing the chart. The central "F Keys" on the keyboard, the F5, F6, F7 and F8 are used for the SOAP note. If the physician hits the F5 key, it takes him to the Subjective screen.(top)

S- Subjective
The first part of the Subjective screen asks some basic questions such as, will this be dictated or not, is this a new problem or not, and appropriate prompts are given depending on the answers. The timing of the illnesses is also prompted. Next the physician can enter as many individual problems as he wishes. The physician always has the opportunity to enter free text; however, it is best to limit free text because it makes future computer searches on this information more difficult.

The physician may wish to branch from this to the Social History screen, which is only available on-line for the provider. This includes demographic information that was gathered during appointment scheduling, and basic patient history such as the patient’s marital status, living arrangements, and so forth. Other highly confidential information such as educational level, diet, religion, race, occupational history, habits, sexual history, and HIV status is also on this screen. This screen is not available to any clerical staff.

All physician input to the system is assisted with either pop-up selection screens to select appropriate terms, or default values. This saves the physician a great deal of time in documentation.

The physician may choose a ROS from the Subjective screen. He has the opportunity to either select a ROS template, where all values are set to normal, or to go through each ROS category individually. Values are usually normal with few exceptions. To save time, the physician can simply set all values to Normal and edit the individual items, or just blank out those that were not checked. If the physician finds an abnormal, he may select from pop-ups which give him a range of choices. Choices can be added or customized for the particular nomenclature that is required at that site. This saves time, prevents spelling errors, and allows for future searches. Once the physician has finished with the Subjective, he would normally go to the Objective screen. (top)

In the Objective screen the physician can select from normal templates by entering "yes" at each question. The normal templates can be changed for each clinic or doctor. Most of the time a physician will do a certain type of exam, the same way, checking the same organ systems. These too can be custom-tailored by the clinic or VAR. This saves a tremendous amount of time since the physician can pick a typical exam and all the areas that he would usually examine would appear as normal. Then he only has to select the specific item to correct (i.e., make abnormal) such as on an exam for a cold, everything may be normal except for a reddened pharynx. In this case he would go to the area for pharynx and indicate abnormal. Then a secondary screen opens to describe the abnormals. Context-sensitive pop-up screens then allow the physician to select the appropriate terms of the area being examined. For example, only pharynx terms will pop up for the pharynx; neck terms for the neck, and so on. These terms can be dynamically added and tailored for each clinic. Before leaving this screen the physician has the opportunity to put in free-text objective notes. (top)

In the Assessment screen the physician can see and choose from previous diagnoses for the patient. The benefit is that coding remains consistent, without cluttering up the chart with multiple descriptions with only slight variations. Also, this saves time in selecting these terms. However, the physician has a very powerful cross-reference tool in which he or she can put in just the terminology they are familiar with, to bring up the most likely diagnosis. For instance, DM for diabetes mellitus, or HTN for hypertension, or HTNB for hypertension benign. In the first case, the five most common types for diabetes mellitus are listed. In the second case, 25 elements will be shown, but by designating "B" for hypertension benign, the physician will get a direct hit. The system can be taught to recognize the terms the physician would like to use to call up a specific diagnosis. (top)

The Plan screen is where the physician can order lab and other tests, order injections, document procedures, write prescriptions, make referrals, schedule procedures, make specific types of follow-up appointments, and designate other diagnostic-related plans. When ordering lab tests, other tests, and procedures, the clinic has the prerogative of changing the order of which tests are listed as well as the names of the tests to conform to local usage. The timing and the indication for the test would also be listed on these screens from pop-up windows, so there is a minimum of key strokes by the physician. All tests ordered are indicated on the patient’s chart as it is printed. Optionally, this can be printed on a specific form, if so desired.

Procedures can be done in a very cost-effective way. Most medical procedures by a given physician are fairly similar with only a few variables. The procedure screens are designed so that the physician can document the indication for the procedure, select the procedure, and then document the procedure, using a combination of variables likely to change in a procedure note and a pre-typed note that can be edited. All variable information has pop-up choices that can be modified by the clinic. After the variables have been entered, the physician calls up the specific standardized note that he would like to use, and adds it to the patient’s chart for that procedure. The physician has the ability to modify these notes at that time. All the standard good documentation practice indicated variables such as closure type, number of sutures, drains, premeds, final condition, anesthetic used are listed. As many separate procedures notes as necessary can be documented for that visit. Because the system is fully integrated, all these procedures are brought to the final billing screen as the physician goes to the exit screen. Optional procedure notes and formats can be developed for specific specialties. (top)

IMS has developed a proprietary data base of drugs designed to interact with the logic of the SmartDoctor® software. This proprietary data base is developed by experienced physicians, the majority of whom have been practicing 10 years or more. The information is unique in that it is clinically relevant—not just a listing of all possible indications and contraindications that the drug manufacturers use to cover every possible contingency. Our physicians, in addition to using the standard medical references, use their own judgment and experience to categorize drug contraindications as either Relative or Absolute. For example, estrogen may be contraindicated in a patient with severe liver disease, but not in a patient with Hepatitis C and basically normal liver function tests. Therefore this contraindication would be Relative (relative to the degree of liver disease). In another example, if a patient has been on Propulsid chronically for gastroesophageal reflux, and then you try to prescribe Biaxin, this will result in an Absolute contraindication and the prescription will be blocked. The physician can still write this prescription or any other non-listed drug with limited assistance, but will be warned that no database checking will be done. The system also categorizes allergies as Major and Minor. Major allergies to a compound type will block the prescription. Minor allergies to a compound are allowed with a warning.

The data is cross-referenced and checked by experienced physicians to give you the latest information. This minimizes the number of false alerts that would cause you to start ignoring the system, as happens with many other drug interaction assistance programs. Although it would be less costly to use the nationally accepted drug databases, those systems work best in pharmacies—not in clinical practice. Also, our physicians have selected the most likely choices for prescribing a drug, so that in many cases all you need to do is hit the <Enter> key to get the standard prescription. Further, drugs are used in different dosages and frequency depending on the disease. For example, the dosing of azithromycin for otitis media and pneumonia vs the dosing for pharyngitis and strep throat is different. Our physicians input these drugs and identify them for you as appropriate. Other drug databases often have no clear definition of the compound class of a drug, nor do they provide dosage based on weight and age as in SmartDoctor®.

The SmartDoctor® system for prescription writing is extremely powerful. It checks for allergy contraindications, drug-to-drug contraindications, drug to disease contraindications, drug-to-age contraindications, drug-to-pregnancy, drug-to-breast feeding, and calculates dosages for pediatrics based on weight rather than age, though age restriction limits are applied. When the physician selects a drug, he inputs only a part of the drug name (similar to diagnosis selection) and a list of drugs comes up. The physician can simply hit the return key and the drug can be prescribed by taking the first choice in each data field as the system automatically goes through the data fields. The most logical, common prescription format for these drugs appears as the first response in each data field pop-up, so the physician can fill many prescriptions simply by repeatedly hitting the <Enter> key. For example, the typical dosage for Premarin would be 0.625 mg. as the first dosage, even though there are both smaller and larger sized pills. This is the most common dosage written in practice, but may be customized for your particular prescribing needs.

If you are trying to decide which drug to use to treat a given disease, SmartDoctor® has the ability to show a built-in history of the drugs used previously for a given disease class, both by percentage and total prescriptions written for this disease class. This is useful when you are already using certain drugs, for hypertension as an example, and you want to see what other drugs you have used, or to get ideas from other clinicians on what drugs they have used. This information is based on actual drug prescription history that has been stripped of patient data.

All prescription drug checking is done as a background process. That is, it is transparent to the physician unless there is a significant problem. For instance, in a female patient who is in a reproductive age range, if the drug selected is a Class A or Class B drug for pregnancy, the physician will not be queried as to whether or not this patient is pregnant. However, if this is a Class C, D, or X drug, then this question will be presented. The same is true for breast-feeding. Drug-to-drug interactions, drug-to-allergy contraindications, drug-to-disease contraindications, and drug-age contraindications pop-up a warning immediately as the drug is picked, and the type of contraindication or interaction is presented to the physician.

If for some reason the physician does not see the amount, dosage and frequency that he wants, he can indicate the "as below" choice which is always the last option on the Dosage, frequency, and duration pop-up windows. In this case the system allows him to fill in two lines of up to 40 characters each for the "Sig." part of the prescription.

SmartDoctor® automatically checks for controlled substance class and puts the appropriate restrictions on duration and number of refills. It also blocks nurse refills for these drugs. Drugs can be indicated as chronic, acute, or sample. Chronic medications are automatically defaulted to values of 6 refills, for up to one year. However, these can be overwritten by the physician. When appropriate, as in the case of controlled substances, the quantity being dispensed will be typed out in both a numerical and text format, and the number of refills and duration will be restricted by class. The medical indication for the drug, which is required in some states, will pop up showing what assessments you have entered for this patient on this visit, from which you can select. Then, standard default instructions that our physicians felt were appropriate for these drugs are indicated. These can be deleted or modified, or changed at that point in time.

Additionally, SmartDoctor® helps the physician decide whether to use a brand or generic drug by showing the cost per day for brand and generic, when available.

The system automatically checks to see if the drug selected is restricted or covered by the patient’s formulary. If the patient’s insurance carrier has a formulary, and the drug is not covered, the physician will be alerted that the patient may have to pay for this. Alternative drugs that may be useful will be listed if available.

Once the prescription is completed, SmartDoctor® will go through the patient’s medication list and check for another drug with the same generic name. If it is an identical match of the prescription, it would just be incremented by one (1) as a refill. However, if it is not, the system will prompt the physician to discontinue the previous drug if appropriate. For example, the physician may have had the patient on Synthroid, 0.1 mg. Now the physician decides to increase the dosage based on the patient’s thyroid test results. The physician prescribes Synthroid 0.112 mg., and the system will bring up the Synthroid of 0.1 and ask if the physician would like to discontinue the item. All the physician has to do is hit the return key to have this accomplished, or exit if they do not want to have this done. In this way, the medication list is current at all times, and there will not be a problem when a patient calls in for a refill.

However, at any time, the physician has the prerogative to do a free-text prescription with limited assistance. In this case, the physician may prescribe a drug that is not in our system or in a totally different format, and is given limited assistance with the pop-up terms such as the route, form, etc. Of course no database checking can be done, so the physician is more or less on his own with this prescription. But it is legible.

As stated above, the SmartDoctor® prescription writer system has the ability to indicate whether a medication is an acute or chronic medication, or a sample. The acute medications are kept on the medication list for one year and the current chronic medications are kept on this list until changed or deleted. When the physician indicates that this is a sample, SmartDoctor® will prompt the physician with the appropriate questions regarding the sample, such as manufacturer, lot number, expiration month and year. Assistance is provided in finding the manufacturer with the cross-reference system, and almost all manufactured drugs that are produced and sold in the U.S. are listed in a manufacturer cross-reference index. Therefore, you can simply enter SK & F or SKF to find Smith, Kline, and French, or input Kline and any companies with that name will come up. Again the key here is to reduce typing for the physician and gain accuracy of data.

Therapeutic injections and medications given in the office can be requested by the physician during the visit, and the nurse can update this as the injection is given, from a different location if necessary. The same database checking is employed here as in prescription writing. When the order was given, when the nurse gave the medication, and any reaction are noted by the system including lot numbers, manufacturer, etc. (top)

Preprinted instructions can be given to the patient by using the cross-reference feature to search the Patient Information file. We recommend using the AAFP instruction set of 160 basic patient information booklets. These are well done and approved by experienced clinicians. Additionally, many other forms of documents can be entered so that the physician can fully document what is being given to the patient. If referrals are needed, SmartDoctor® prompts the physician, using the cross reference system, and will bring up the physician by name, specialty, etc. The physician then just indicates, from a pop-up window, when he wants the patient seen and for what problem. (top)

Other information from the physician screen
From the physician’s screen, he can do chart reviews and look at prior charts of this patient (including non-visit encounters); review or add to the active medical problems, active medications, or past medical history; or review the current visit. The physician can page through to see what has been documented, at this point in time, in the chart. This will be done automatically on exiting, as well. For facilities that have the optional diagnostic imaging and laboratory software with the ability to transmit data in a digital format, these can also be reviewed on-line.

The physician can see the patient’s insurance screen during a visit to determine whether prior authorization may be needed to send the patient for an expensive test at another facility. The physician can do this easily by pressing one key. The physician can also see the patient’s appointment time, when the patient signed in, when the nurse started seeing the patient, and when the provider started seeing the patient to give you an idea of the total wait time the patient has had in the clinic. (top)

Additional features
The physician has a "Quick Menu" which branches to other parts of the system, including "Phone Book" to look up phone numbers of the hospital, ambulance, and others, "Calculator" to make use of a powerful on-line calculator, "Medical Library" to look up a general information library input by the clinic, "My Notes" where every individual in the office has their own private scratch pad, "Mail" to check system and interoffice mail, "Change password" so the physician can change his password as necessary, "See Clinic Appts (& Over Book)" to see appointment slots, "Review Summary Schedule" to see a summary of appointments for entire clinic, "Suggestions or Requests" to send messages to the systems administrator, which is a public area, and to branch to other program areas or programs such as WordPerfect. Additional systems features include a calendar that can display the current month, or months or years in the future and past. (top)

Physician Sign-out
When the physician is ready to sign out, he presses one key and the sign-out process begins. An automatic review of the patient’s note for the day takes place, showing all areas of the chart that were reviewed and documented during the visit. The physician can scroll up or down through this visit encounter note. After the chart review, any clinic defined health screening or reminder messages for the patient are shown to the doctor for consideration, such as, a messages indicating that the patient is over 65 years old without a flu shot for over a year, or without a Pnemovac vaccine in the past 10 years. If there are errors or recommendations, he can just go back to the main screen and make any necessary changes.

The physician is now presented with the sign-out screen. Any procedures done will be documented and flagged for any problems with the correct coding initiative checks. Medicare now has over 300,000 checks for codes considered to be a component of another code or mutually exclusive of another code and therefore not reimbursable (i.e. rejected). These are called the Health Care Financing Administration’s (HCFA) Correct Coding Initiative (CCI) checks. The SmartDoctor® database is updated quarterly or as soon as new codes are released by the HCFA for audit checks to its insurance processors. An example of how the system checks work would be having done an I & D of an abscess on the right hand, and then an I & D of a subungual hematoma on the left hand. This would be stopped and rejected by the HCFA CCI checks. SmartDoctor® alerts you that these codes will be rejected unless the proper modifiers are added. Then the system facilitates adding the modifiers, such as, right and left hand, as per Medicare documentation guidelines. (top)

E & M Coding
The E & M coding section for office visits is next. The system will show you what you have documented so far as defined by the latest 1997-1998 HCFA rules. The system counts the elements of the history of present illness, review of systems, and past family and social history; it counts the exam bullets and the number of body areas that were examined, to give you the history code and the exam code. Based on the number of problems and subjective complaints, the code level for diagnosis is developed. SmartDoctor® then presents the physician with choices for indicating the category of data reviewed and the diagnostic risk (with explanations). The system then goes through the HCFA Guidelines, and offers a recommended charge. The physician can accept or override the charge, increasing or decreasing it as appropriate. If the physician is satisfied that the note is complete, then he enters a secondary password which acts as an electronic signature. Up to this point the physician can go back and modify his note or exam, and then return to the sign-out screen with updated information. However, once the signature password is input and accepted, the note is signature, time, and date stamped, and no further changes can be made. Addenda can be made in the form of Non-Visit encounter notes if needed. (top)

The Exit process
The patient now goes to the exit desk, where billing and exit are done. The billing clerk sees that the provider is finished with the patient, and selects the appropriate patient. Once again, verification is made that this is the correct family, and any warnings (i.e., family notes regarding sensitive issues) are displayed. If an insurance carrier has been entered into the system, then all the insurance's are shown and the default insurance is the carrier noted on entry. If not, the insurance can be selected now. As the billing clerk continues, she is asked if the referring and billing provider were the same and, if not, who the referring provider is, then a cross-reference list of the referring providers for this clinic is presented. Other pertinent insurance questions e.g., Workers Compensation, illness, auto accident, date of similar illness, date of first date not able to work, date able to return to work, and hospitalization dates are also asked. If none of these apply, the operator can simply press the Exit key to bypass all these.

Next the procedure charges that the physician indicated will appear on the screen. At this time, the clerk can add any modifiers and is warned again, using the CCI checks, if there are any coding problems or necessary modifiers. If there is a problem and nothing is changed, this charge will be rejected by the automatic Medicare audit.

Additional procedures and charges can be added, such as devices or equipment that were given to the patient, or additional lab tests that had not been indicated by the physician. The amount due will be shown, depending on the type of insurance. If Medicare is the insurer, the Medicare discount will be shown, and the amount due. The clerk will be asked for the Medicare deductible paid so far this year. The system will then calculate the remaining deductible, the patient’s portion of the deductible, and the co-payment. It then presents the clerk with the total payment needed for the visit. At this point, the patient has the option of paying now or later.

Once payment or billing is complete, the clerk can print the patient’s updated Problem list and Past Medical History sheet, the Visit Note, and the insurance bill. If this bill is to be sent electronically, as indicated by the insurance carrier file, then the bill will be placed in a file for transmission during the night. Any CPT codes requiring prior authorizations not yet obtained will be flagged at this time and put in a suspense file for the office manager to fulfill prior to sending the bill; the charges however will be posted to the Family file. Any orders, follow-up visits, future appointments can then be made from the reference information in the printed out chart, or can be viewed any time during the checkout process. (top)

System features and benefits -
Database components
The Family database
SmartDoctor® treats the patient as a member of a family that is composed of individuals, starting with the responsible party. Each individual family member is then assigned to the Patient database. Each individual responsible party is generally considered head of a new family group or household whose members may have different last names. This organizational logic is helpful for Family Practice and other primary care specialties where there may be many members of one family, all not necessarily having the same last names, that should be billed together and should be able to be looked up together. This also allows for family units being transferred easily to other physicians in the group, or in the case of residency programs, where residents are graduating and their patient families need to be transferred, in totem, to another resident without fragmentation of the family unit. This further expedites the billing by billing the responsible party. (top)

The Individual database
Every patient has an individual database comprising of all diagnoses, prescriptions, surgeries, allergies, immunizations, etc. Anything that is unique to that patient will be in the patient data file. This database interacts with the other components of the SmartDoctor® system at the time of the encounter, to provide the health care provider with the most current medical information necessary for correct diagnosis and proper treatment. The benefits of on-line checking for allergies and other contraindications are both cost effective and beneficial to the patient’s health and well being. All the data about the patient, the drugs interactions, and billing questions are all contained in the same database, so there is no need to look in multiple places or reenter data in other programs to do this type of checking. This is all done automatically by this fully integrated system. (top)

Medical/Billing information database
These databases comprises information regularly needed for prescriptions, abnormal alert values, immunizations and health care needs, especially for the primary care specialist. The medical information is updated quarterly, and ad hoc as necessary for significant emergent changes.

The system has a proprietary form of over 11,700 International Classification of Disease (ICD) codes to the highest level of specificity (i.e. no unbillable codes), by age, sex, and with custom cross reference terms. It also has a proprietary form of over 7,900 Current Procedural Terminology (CPT) codes of the licensed from the American Medical Association (AMA), further categorized by age and sex, and with custom cross reference terms. In addition the AMA’s CPT codes are enhanced to make them clinically relevant. For example, in documenting the past procedure for a hysterectomy, the CPT code is 58150. For billing purposes, this means "Total abdominal hysterectomy, including (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s)." From a billing standpoint, there is no difference since the payment is the same regardless of what is done. In SmartDoctor®, a letter after the CPT code indicates that: 58150(blank) is "TOTAL ABD HYSTERECTOMY W/O BILAT SAL OOP", 58150(A) is "TOTAL ABD HYSTERECTOMY W BAL SAL OOP", 58150(B) is "TOTAL ABD HYSTERECTOMY W RT. SAL OOP", 58150(C) is "TOTAL ABD HYSTERECTOMY W LT. SAL OOP." Since the basic CPT code has not been disturbed, the system will only use the first five digits of the code so billing will be correct; however, the text stored by the system will be displayed for the provider to read. The age range limit on this particular CPT code is from 13 years and older, and the sex check is for female. Each clinic can modify these restriction locally for unusual cases on an ad hoc basis.

This data base also contains the CCI codes from the National Technical Information Service (NTIS) of the U.S. government, with more than 340,000 codes of component and mutually exclusive codes determined by the HCFA. (top)

Expert system capabilities
SmartDoctor® provides expert medical support in the background while the physician performs his or her evaluation and treatment. The system automatically checks for immunization levels, flags abnormalities in height, weight and head circumference in pediatrics, does prescription and drug formulary checks, suggests alternatives and drugs for many diseases, and much more. (top)

The Billing System
The billing system is unique in that data and documentation requirements are both captured and checked as a function of this fully automated medical office system. All diagnoses and procedures that the physician enters from the selection menus are automatically checked for age and sex compatibility, and diagnosis codes are at the highest level of specificity as required by Medicare and other insurers. Workers Compensation cases automatically trigger a query with appropriate questions regarding the date illness started, time to return to work, and the level of work that the individual can do. Bills can be generated based on the insurance provided for that specific visit, so that isolation of bills for a specific insurance company or a Workers Compensation carrier can be pulled out from the family database on a monthly or ad hoc basis without need for a separate filling system just for Workers Compensation cases. The monthly bills indicate all the information needed to rebill any of the charges, line item by line item, and in addition indicate the responsible party. The aged totals are shown for both the combined bills, those owed by the insurance company, and those owed by the responsible party.

The daily chores for the office manager are to check prior authorizations that are needed before the appointment, after an appointment was completed, and to check any electronic bills that require a correction. The program facilitates entering the appropriate data, giving access phone numbers to the insurers, and information about the visits so that approvals can be obtained. In the event of an electronic billing error, the errors that failed our pre-sending audit are displayed for correction. Once this information is obtained, SmartDoctor® will facilitate rebilling. Electronic billing is done automatically for the main insurers such as Medicare, Blue Cross, Blue Shield. (top)

Full security of the billing system is insured by restricting access to a specific class of employees with individual passwords for entering charges and posting receipts. All actions by all users are audited and permanently attached to each transaction. This auditing goes on as a background process, so you can quickly tell who scheduled the patient, who signed the patient in, who posted the bill, etc. This billing system is for accounts receivable only.

Depending on the need of the site, the SmartDoctor® system, in conjunction with the SCO UNIX® Operating System (and other specific UNIX operating systems), can be made as secure as necessary, up to the Department of Defense’s Trusted Computer System Evaluation Criteria (also known as TCSEC or the Orange Book). This system can be installed with the TCSEC or highest level, Improved level, Traditional level, or low level. We normally install the system in the traditional level, and then add specifically tailored security features to meet the needs of a particular site. (top)

Management function
Medical office managers and physicians may analyze any aspect of their operations or care at any time, and in any way that they choose. The user is never dependent on Intelligent Medical Systems, Inc. (IMS) to produce specific reports, bills, or analysis.

SmartDoctor® provides data that can be downloaded by authorized users, a complete roster of built-in standard reports, and the powerful APPGEN® Easy Query (EQ) language for customized reporting. PCs and other computer systems, including mainframes, can analyze the data in any manner required. EQ is a query language that also serves to prevent damage and loss of data while searching and reporting, because it is a read-only program. This powerful information delivery system enables physicians and managers to negotiate better managed care contracts, as well as better office management and patient care.

A fully integrated accounts payable, payroll, inventory control, general ledger, and other optional programs can be added at any time as part of the APPGEN® suite of small business programs. (top)

Maintenance for the SmartDoctor® system software can be provided remotely or on site if required. Routine system maintenance and support is required to use the system. Since updates from HCFA, IMS propriety drug data, and system upgrades are done quarterly, and ICD codes and CPT codes are updated annually, it is imperative that this data be maintained and kept current for the system to remain functional. Routine system enhancements, upgrades, and debugging of the SmartDoctor® system are provided by IMS as part of its ongoing total maintenance contract agreement through its VARs. More significant program modifications can also be provided on a fee-for-service basis. With the ongoing maintenance contract provided by IMS you will never have to worry about your programs becoming obsolete or having to make decisions on whether or not to buy the latest upgrade. Hardware and equipment problems are normally handled by the VAR, as are basic system questions. For more specific questions regarding the medical aspects of the program, IMS provides physician-to-physician clarification of issues and problem resolution, as part of the maintenance agreement. (top)

The operating system
The SmartDoctor® automated medical office system deploys on Linux, SCO, AIX, or other UNIX operating systems that provide powerful, proven, state-of-the-art technology for automated data handling. The system can also run on a Windows NT server; however, this is not recommended. UNIX is a true multi-user, multi-tasking technology that permits linear expansion at any individual site without any exposure to the massive costs and inconveniences usually associated with data reentry, reprogramming, and retraining. SmartDoctor® can be easily integrated with independent PCs, microcomputers and mainframes as may be required, and parallel microprocessors may be added to increase your computing power.

The operating system, in conjunction with our recommended base system of a PC server with serial port network for character-based terminals and attached printers, offers the most cost-effective medical office solution available today. With appropriately higher pricing, the SmartDoctor® system can also be deployed with a TCP/IP network or combined with a serial port network to give the greatest flexibility that includes PC workstations, touch screen capability, and radio LAN communications for portable and tablet computing. SmartDoctor® can also be deployed on Windows NT and Windows-based clients, but is not recommended because of higher overall cost, less stability of the operating system and network, and overall reduction in efficiency. The character-based systems are much more efficient for basic data entry and are preferred by data entry professionals. (top)

Implementation of the operating system and hardware
The operating system is mounted on a PC server with one of more microprocessors. It is recommended that there be a clone microprocessor used in the office that can be swapped if needed, which could be set up to be used as a regular terminal in small clinics. Similarly, in very large practices, a totally redundant system should be considered.

The server must have a tape drive for unattended nightly backups, an uninterruptible power supply (UPS) as well as surge protection and power distribution systems. All terminals and PCs connected to the system must have a small UPS to avoid having data loss and record locking. The server PC must be connected to a clean electric supply line (i.e., a dedicated line from the main circuit breaker box to the server PC). Also, in high lightening areas, additional surge protection is required on this line. This line cannot have other devices (e.g., copiers, laser printers) attached to it, as they can interfere with the back-up power supplies and cause frequency distortions on the line. All network wiring must be shielded Category 5 cable. If this is not done, electrical medical equipment such a electrocautery and hyfercators and other equipment will cause errors in data transmission. Further, all such wiring should avoid all transformers such as in fluorescent light fixtures, electrical motors, X-Ray equipment, etc.

Tape back-ups, which must be done nightly, are automated for the end user. All that is required is that the end user change the tapes daily, and review the logs that are presented in the mail to the multiple users and the clinic manager to be sure that data was backed up and successfully verified. A full tape backup and emergency boot diskettes must be taken off-site at least weekly to ensure that the data is available should there be a disaster such as fire or flood.

Phone access to the system will be by unlisted number. An unlisted number is required for the system so that IMS and the VAR can dial in to update the system remotely as needed—at least on a quarterly basis. A second unlisted line is suggested for the prescription-faxing feature of the system, which can significantly tie up lines during the daytime, thus preventing access to the system by IMS or the VAR. (top)

The APPGEN® database engine
The state-of-the-art fourth generation APPGEN® variable length relational database and built-in query system has been serviced by a worldwide network of value-added resellers since 1979. It is associated with a complete general business and accounting package that can be used in conjunction with SmartDoctor® and provides all of the financial and management applications needed for any size operation. APPGEN applications include general ledger, accounts payable, payroll, inventory control, job cost tracking, and many others.(top)

Click here to go to the APPGEN site

Turnkey solution
We believe that it is best for a physician’s office to contract with a single VAR who can provide both hardware and software, so that there is only one number to call, and there can be no finger-pointing when help is needed. There are more than 300 APPGEN VARs in the United States alone. (top)

The SmartDoctor® Electronic Medical Records and Billing System is the Smart move for the medical office of today.

SmartDoctor® is the registered trademark of Intelligent Medical Systems, Inc. of Alpine, TX.
APPGEN® is the registered trademark of Appgen Business Software, Inc., of Bohemia, NY.
CPT® is the trademark of the American Medical Association.
SCO® and SCO UNIX® is the trademark of The Santa Cruz Operations, Inc.
AIX® is the trademark of IBM, Inc.
UNIX® is the trademark of UNIX Systems Laboratories, Inc.
WindowsNT® is the trademark of Microsoft, Inc.

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