Category: Technology

One of the biggest questions chiropractors are facing in X-ray today is what is the best way to “go digital”.

The answer is, it depends on a lot of variables. However, proper up-front understanding of the technologies and alternatives can make for a better decision and can create a positive long term effect on your practice.

With respect to the different technologies, there are basically two approaches for going digital—CR (Computed Radiography) and DR (Direct Digital Radiography). Both technologies produce digital images, but in different manners, with their own set of pro’s and con’s.

CR (Computed Radiography)

A CR system includes CR cassettes and a CR scanner. The CR cassettes contain a special screen that captures the X-ray image. The cassettes are inserted into a bucky or grid cabinet, just like film cassettes, and all of the imaging is performed in the traditional manner. After the X-ray is taken, the cassette is removed from the bucky or grid cabinet and inserted into the scanner. The scanner can sit in the X-ray room, so no dark room is needed. The scanner will scan the image screen and display a digital image on the monitor. This process usually takes less than sixty seconds.

One of the biggest benefits of CR is that, in most instances, you can use your existing X-ray system, as long as it is reasonably current technology. It should be at least a 300mA/125kV system, preferably high frequency. Very old systems with limited power will have the same challenges making high quality CR images as they do making high quality film issues.

 

Things to look for in a CR System: Image Quality: There is a variance in image quality of the different CR systems on the market. Much of that is due to image processing. This is a computer program within the CR system that takes the raw digital image data and converts it to an image which is displayed on the monitor. The top performing systems provide images that show excellent skeletal detail and soft tissue detail in a single image. The operator always has the capability to “window and level” the image further to enhance the visualization of specific pathology. System Speed: This refers to the dose sensitivity of the system. Most chiropractors are using 400 speed film/screen systems with their current film imaging. CR systems also have a relative speed, although the measurement varies slightly from film. This relative speed may range from 200 to 400, based on the specific brand of CR. The higher the speed, the lower the dose and the shorter the exposure times. This is especially important on large patients where motion and overall system penetrating power can be a challenge. Ease of use: All CR systems have a computer with monitor, keyboard, and mouse which are used for reviewing the images and managing the commucation/storage of the images. The software should be intutive and easy to use. Advanced systems will typically include a medical grade touch screen monitor.

DR (Direct Digital Radiography)

DR uses a digital capture device that takes the place of the bucky or grid cabinet in a wall stand or an X-ray table. With DR, the image is captured directly with the digital image receptor, so there are no cassettes to handle or feed into a scanner.

One of the benefits of DR is that the image displays on a monitor within a few seconds after the image is taken, and there is no handling of cassettes. However, DR is substantially more expensive than CR. Also, upgrading to DR usually entails buying an entire new X-ray system as opposed to upgrading an existing one.

 

Things to look for in a DR system: Image Quality and System Speed: There is also a variance in image quality of the different DR systems on the market. Much of that is due to the imaging system, itself. Most DR systems for chiropractic imaging use a CCD based digital camera system. The X-ray photons strike a scintillator plate and are then focused through a lens and on to a CCD chip. The material the scintillator plate is composed of plays a large role in the image quality and dose sensitivity. The two most common materials for the scintillator are Gadolinium Oxysulfide (Gad-OX) and Cesium Iodide. These materials affect both the image quality and system speed. Cesium has substantially higher dose sensitivity and, therefore, requires less dose and the images typically have lower noise. However, a system with a Cesium Iodide scintillator is usually more expensive. Gad-OX has a lower dose sensitivity and, therefore, requires higher dose, but is typically less expensive. Image processing also plays the same role as mentioned with CR systems above. Ease of use: All DR systems also have a computer with monitor, keyboard, and mouse which are used to review the images and manage the communication/storage of the images. As with CR, the software should be intuitive and easy to use.

Which is best for you? It depends on a number of factors, including your current X-ray system, exam volume, type of practice, and budget. The most important thing is to do your homework up front and make sure the system will provide the following: • Excellent image quality at reasonable dose levels • Ease of use • Will perform well with your current X-ray system • Fits within your budget • Is supported by a dependable and knowledgeable local dealer who has exten sive experience with installing and servicing digital X-ray systems. This is crucial when making the decision as to from whom you will purchase the equipment.

 

Additional important issue when you go digital   

The equipment discussion above dealt with the technologies used for acquiring the X-ray image digitally. Also important is the viewing, storage, and transferring of the images. The key is to establish a plan up front of where and how you want to be able to review, recall and store the images. A PACS system is the proper way to complete the system and accomplish these functions (Picture Archive and Communication System)

Viewing images: Most doctors will want to send the images from the digital imaging system, either CR or DR, to a computer in their own office where they can review the images, mark angles, and add annotation. In addition, some may want to be able to display the images in an exam room for patient consultation. This will require computers with the appropriate viewing software and licenses. Web-based access to the images is also available for reviewing images remotely.

Image Storage: This is an important area to focus so images are always safe and secure. There are a number of alternatives based on your volume and budget. In addition, you may want the ability to burn images on a CD for patients to take with them. This can be a good way to market the modern digital imaging technology that you are providing through your practice.

Terry Yochum, DC, DACBR, Fellow, ACCR is director of the Rocky Mountain Chiropractic Radiology Center in Arvada, Colorado. He can be reached with questions pertaining to this article at 1-800-742-4476 or at [email protected].

 

Iowa Chiropractor Dr. Lauri Wondra has been using a tablet PC-based automated practice management system for only a few months, but she is already on the way to her goal of doubling her patient volume to fifty visits per day. She hand-scribes some of her SOAP notes, but her use of electronic text linked to on-screen helpers plays an increasing role, one that continues to grow as she customizes the text with her own specificity elements and writing style. Dr. Lauri and her husband, Tim, also a chiropractor, have a young, progressive practice and, early on, the two decided that, to fulfill their growth and service goals, electronic office systems would have to play a part. Dr. Tim plans to open a second practice in a nearby community.

The most obvious benefit of electronic notes is the ability to employ standardized text in performing examinations and recording SOAP notes during patient visits. Doing so avoids the labor and distraction of hand-scribing, enabling doctors to preserve the intimacy of the patient visit and assure the quality of examinations, while accelerating visit procedure.

Helper-supported electronic notes software on a pen-based tablet also confers the ability to amplify text ad hoc with hand-scribed electronic notes to whatever extent the doctor chooses. However they are generated, storing the notes in a flexible, concept-based electronic database that builds the file automatically, visit-to-visit, precludes any need for the traditional paper jacket—along with the filing and maintenance that it implies.

The availability of the intelligent database, in turn, establishes the ability to automate production of interim and final reports and to eliminate the archaic, time-consuming processes of analysis, dictation, and transcription. An intelligent, template-based report writer can identify and selectively import specific fields that he/she needs to generate comprehensive, fully compliant clinical reports, literally, in seconds.

Expenditures of time and money for transcription services evaporate. Insurance claims and their supporting documentation can be dispatched quickly, even bypassing the hard-copy stage if the doctor and payer are set up to do so. The impact on cash flow cannot be overstated.

One cannot ignore the argument against electronic notes: that, although they support the precision and consistency that are critical to documentation of diagnoses and treatment, the uniformity that can result could reflect an indifferent attitude, even suggest to payer personnel reading the reports that indicated treatment might not actually have been performed. Regulatory discipline and/or professional censure are appropriate for the few unethical practitioners who might be guilty of this.

Fortunately, there are features within electronic clinical notes and reporting solutions that allow doctors to maintain unquestioned integrity as well as the uniqueness of their SOAP notes and reports as they gain the dramatic savings in time and effort afforded by standing text. These features are document cloning and documentation mutation.

Cloning allows doctors to import all or part of the data in any previously completed SOAP or exam note to create a new document, avoiding the need to begin with a blank page and reentry of personal, diagnostic, symptom and treatment information for each patient visit. Doctors can replicate any previous document, with the newly created document independent of the original and open to such modifications as are appropriate.

When treatments and conditions do not change from visit-to-visit, a mutation capability allows doctors to modify the cloned document using their own stored terminology to indicate that the patient visit has, in fact, occurred and that a treatment/exam has been performed. Time required to reconstruct the document is saved and the likelihood of a claim or billing challenge is avoided.

Simple observation is enough to convince almost anyone that paper processes in the chiropractic office—in any office—represent an enormous drag on productivity. And beyond the cost factors, the ever-present potential for challenges by medical examiners, regulators and litigators informs us that you can’t risk files getting damaged or lost. Increasingly, legal rulings demand that electronic files be available in litigation proceedings if requested.

In the contemporary clinic, electronic notes form the basis for reliable and systematic records. Using them leads to greater productivity and profitability, a more streamlined practice, and more effective communications with patients, payers, and other professionals.

Gregory T. Church is vice president and general manager of the Healthcare Business Division of ACOM Solutions, Inc. He can be reached at 866-286-5315, Ext. 401, or email [email protected].

 

The primary achievement Electronic Medical Records (EMR) lay claim to is to save time. Everyone knows, time is money; so which of these products is best for you and your patients? The EMR technology is quite advanced already but, because it is so recent and the development costs are so high, many of the technical assets and shortcuts are not grouped into a single product. Each is disseminated according to whatever the doctor’s specialty may be, advancements only being made when necessitated by the field. The real vision for the future of this market will take the best of each field to make one universal system.

Let me take you through a virtual office tour, where I will demonstrate an imaginary software named Dreamware-2007. This imaginary software will take current existing components of software sold on the market and group all of the best features together into one single package. One of our best resources for this endeavor is the EMR consultant website (www.emrconsultant.com) which harbors, by far, the most extensive collection of EMR software throughout the world (over 300).

First, from the Patient’s Perspective:

So you decide you’re ready to see your doctor. Do you grab your phone to get the voice-mail of your chiropractor. No, not this time; you go to your computer, then to your doctor’s online appointment book.¹ That’s right, there you reserve a slot in the time grid proposed to you online. You are required an upfront deposit which is not refundable, and charged if you do not honor your appointment. Your credit card number is entered and will be processed in the doctor’s office. Additionally, you are given your own password for future appointments. As the patient, your time is also valuable so, to expedite your visit to the clinic, you are asked, online, to answer a health questionnaire.² You can also go online to sign an authorization to release documentation from other doctor’s offices. As the patient, all you will have to do is to enter those doctor’s phone numbers, fax and emails, and the computer in the doctor’s office will auto-generate the form that will be directed to those doctor’s offices that will be releasing the documents.

Even though you have yet to see the doctor; the clinic is receiving all of its documentation ahead of time, and the time grid for the day is filling up with no personal interaction yet;³ the computer has generated and sent faxes (or emails or phone calls) to other clinics to ask for the relevant documentation about you the patient.⁴

To remind you of your appointment, the day prior, a computer generated voice mail is left reminding you of the time of your appointment. After the prompt, you listen to the short message and push “#” to confirm, or another key if you need to reschedule. Simple as that. The system automatically provides an easy to read report for the doctor at the start of the next day.⁵

Finally, you’ve arrived at the clinic. In the doctor’s waiting room, a kiosk touch screen system asks you to enter your password if you have been given one from the online appointment. You enter it, and you are greeted by your own name and asked to smile for a picture from the camera mounted on top of the kiosk.

You are also asked by the system if you would like a biometric finger scan or a facial scan to be saved in the system to avoid your having to memorize any password for next time.

You are then asked to swipe your insurance card on the card reader. The computer informs you of the price of the basic visit, which is owed prior to seeing the doctor. Your insurance card also has medical information about you, which the system asks you to release, and prompts you to enter a password in order to be HIPPA compliant.

Now, at this point, if you have not filled out your health questionnaire online, you are prompted to a series of questions on screen.⁷ You do not need to type, but just to touch one of the check boxes on the screen; this online questionnaire is asked of you in the language of your choice (English, Spanish, French), but the doctor will see the answers in plain English. You even have an audio file to each question in different languages, allowing the non-reading patient to still communicate. Those questions are interactive, meaning specific answer prompt to specific new questions. The questions are also illustrated with picture video clip animations to make them easy to grasp and understood by the patient, while keeping the questionnaire relatively entertaining.

Once everything has been answered, you are asked if you would like to have an electronic file of this questionnaire sent to your email address in an encrypted format, should you need to consult someone else; there is also a service you can purchase for a server in the US to collect all your medical data from every doctor that you ever consulted.

On the doctor’s personal screen, a warning informs the doctor that a patient has checked in and is currently filling out the questionnaire. The waiting room touch screen health questionnaire subsequently generates a form on the doctor’s computer screen. Additionally, the lab report, MRI pictures, and hospital records are directly wired and transferred to the doctor’s system and seen on his/her screen.⁸ The records are not shown on the screen as a faxed or scanned document, but much better. Each bit of data has been entered from the start in a particular field according to a nationally used format (HL7 or Health Level 7). Those fields can be retrieved and compared from different years, and analyzed in a way that the association search between diseases and abnormal values are automatically made. The doctor will also create for all his/her patients specific questions which seem important in his type of practice which have programmed specific warnings to be triggered following specific answers or abnormal biological values.

Finally, the personal encounter occurs, in which the doctor meets the patient after checking the result of the electronic questionnaire and the matching queries from each of the different electronic patient files. The system has already given him the type of exam he should perform and what different ailments he may be facing through the use of statistical projection.

The doctor is prompted through the exam via touch screen. Each test to be performed is shown on a screen as an animation or video that he taps to select. The result of the exam can be generated in several formats: form, text, text and pictures.

The doctor is prompted to several diagnostic possibilities and, for each diagnostic, a menu lists the findings that prompted such a potential diagnosis. The final decision is up to the doctor.

Then comes treatment; the treatment must be recorded with enough precision for exact duplication by any of his colleagues. If the doctor is an MD, then this is done in a very straightforward fashion, e.g., “5 milligrams of drug twice a day.” Anyone would be able to duplicate this treatment.

If the doctor does hands on treatment, such as a chiropractor, physiatrist, PT, OT, then some amount of system customization needs to be done, because no two “hands on treatments” are the same. Every chiropractor customizes his adjustment to a certain extent.

To make things easy, the software has provided the doctors with pictures from a hundred animated adjustments, mobilizations and modalities; for each one of those, therapeutic protocol is described with a biomechanical precision following a standardized description, enabling another physician to duplicate it. The most comprehensive database to date may be found at http://docurehab.com/TechniquesEX/index.html. The doctor merely needs to pick what he uses daily; further, he has the option to customize the technique he uses and keep it in his “often used” technique folder. Once in the folder, those techniques are retrieved by tapping on the screen and they become part of a menu that the doctor uses daily.⁹ With this software, the doctor has access to hundreds of techniques taught by schools, universities or fellow chiropractors, therapists, and MD’s.

Insurance companies have a tool to establish statistical data on the effectiveness of a given technique for specific ailments. As the technique is selected, the insurance code is automatically assigned to the billing section of the program. Insurance is billed online daily. Payments are electronic and correlated to the EOB (explanation of benefits) automatically.¹⁰

The patient’s medical record is wired and stored off site, backed up routinely so, even if a hurricane destroys the office computer, data can be retrieved instantly from another location.¹¹

All the elements of the system just described already exist in the industry; they are not yet found in a single source of software because there are too many health specialists with different needs to customize all of them at once. Many of those nifty applications require that all the ones that you communicate with be on an EMR system with a standard communication format such as HL7, which is not yet the case.

But our current systems already provide the most services by automating the patient’s health history, the note taking and the billing function; those functions, alone, have cut down at least two-thirds of the office clerical duties.

The industry is now gearing up toward the medical exactness of differential diagnoses from data retrieval. I predict the economic impact will be huge on the health market. On the level of the practitioner, initially, the benefit will be more available time. Second, reproducible therapeutic approaches will be more exchangeable, and assessable using statistics. The tedious function of billing will be expedited. Finally, epidemiologic studies will be streamlined with outcome assessment automatically quantified for each patient and each condition. The initial investment of a good EMR system is recouped fairly quickly through better billing, better collections, better time management, as well as better clinical presentation—which all equate to better medicine overall.

Etienne Dubarry has been teaching for twenty five years nationally and internationally, has published book s and articles on chiropractic, techniques, and rehabilitation exercises, their electronic documentation duplication and classification. He is the CEO of DocuRehab, documentation and rehabilitation software which has posted on line for every one to use the largest collection of animated treatments and rehab exercises (2000+) .http://docurehab.com/ExerciseExport/index.html. He can be contacted at: [email protected].

 

Dr. Patrick Gentempo, President and CEO of the Chiropractic Leadership Alliance (CLA) and the Creating Wellness Alliance (CWA), is one of the featured presenters at the Chiropractic’ 07 Convention sponsored by The American Chiropractor in The Republic of Panama, Feb. 22-24. His themes of “cutting edge chiropractic success” and “technology-based chiropractic practice” are resonating with many thousands of chiropractors worldwide.

Dr. Gentempo and Dr. Christopher Kent shared a vision, over two decades ago, of a technological revolution within chiropractic. That vision continues to become reality as the Insight surface EMG they first introduced to chiropractic in 1988 has evolved becoming a fully integrated multi-technology platform that will actually calculate a score indicating neurological function of those patients that are scanned. This technology is currently in use on six continents, in many thousands of chiropractic clinics.

In an interview with The American Chiropractor (TAC), Dr. Gentempo shares his views on technology, offering you a preview of what to expect in Panama in February.

TAC: By your interpretation, what is technology-based chiropractic?
Gentempo: Technology-based chiropractic is a model of thinking and practice where the traditional philosophical uniqueness of chiropractic meets 21st century technology and objectivity. When I graduated from chiropractic school in 1983 and started practice, I heard many leaders and mentors claim, “You have to believe in chiropractic or have faith in chiropractic in order to succeed in chiropractic.”

To me, chiropractic is NOT a religion. It shouldn’t rely on faith or belief. However, to practice with the premise that lifestyle stress causes neural disturbance in the form of vertebral subluxation and to recommend care for individuals without spinal pain, resulted in a significant challenge…especially in light of the fact that the majority of clinical evaluations performed by most Doctors of Chiropractic entailed traditional ortho/neuro tests that were designed to evoke pain. How was the DC supposed to transcend the limitations of the back-pain practice? Did their patients have to believe in the benefits of chiropractic also?

Surveys have shown that over 90 percent of our profession recommends wellness/asymptomatic care for their patients and over 88 percent use and recommend that we keep the term vertebral subluxation complex. This challenge caused us not only to create technology, but also training programs to compliment the technology to ensure success.

By now, I am sure most of your readers have at least heard of our four-day practice transformation training, called Total Solution. We have had over 5,000 graduates and it continues to grow each year. The number one reason DC’s come to Total Solution is because they have a back and neck pain practice, but want a lifetime, family wellness care practice. Our Insight technology with our Total Solution training combine to get the DC across that chasm. So, technology-based chiropractic is where the foundations of the practice literally rest: on the use of technology. The DC’s not only use technology as a basis for their care and recommendations—as compared to subjective and unproven assessments, such as orthopedic tests—but also use technology for their marketing, patient education, staff training, record keeping, and even in their adjusting. Welcome to the very exciting 2nd century of chiropractic!

TAC: How do you view CLA’s standards as a company?
Gentempo: Our standards are extremely high. I don’t settle for second best; never did and never will. I am obsessed with utilizing the absolute best technology available in every product we produce. I am also passionate about integration, meaning not only having multiple technologies, but having them integrate properly. Think in terms of a word processor, spreadsheet, database, e-mail and calendar management and presentation software…and then think, Microsoft Office. Integration translates into the whole being greater than the sum of its parts. Some vendors try to offer multiple technologies from multiple manufacturers. It has a cobbled effect that dilutes impact and usefulness. The Insight’s individual technologies shine as they stand alone but, through their integration, they create transcendence. I refer to it as technological poetry. An example of this is the overwhelming market response we are getting to our patent pending NeuroSpinal Functional Index, or NSFi for short. The findings of the Insight’s five technologies boil down to a simple, elegant, easy-to-understand number. With all this testing, the doctor now has one number to communicate and the patient has only one number to understand. It is simple, yet extremely powerful.

We hold several patents on the Insight and have several more pending. In the technology business, this is critical. It means other companies can be in our product category, but they can’t develop or sell what we do, because we have intellectual property protection.

Also, through technological superiority, we bring increased credibility to our clients. The Insight is the only technology in its category to receive certification from the Space Foundation, which was co-founded by NASA! An earlier version of the Insight was used on two shuttle missions and we are currently corresponding with NASA on proposals for new projects on which to collaborate. Our clients are trained to leverage this distinction with a press release and other marketing strategies to the benefit of their practice. When a DC can claim that he or she uses Space Certified technology in their practice, such a statement enhances the perceived value of their services and they, themselves, are held in high esteem by the general consumers.

Another clear standard that CLA has established is that we don’t sell a “machine,” we sell a result. Technology, by itself, does nothing. It is the person who uses that technology that gets the result. We are exacting experts on practice success. We have painstakingly analyzed where chiropractors have struggled, and often failed, and have developed systems of thinking and practice that resolve those issues. The technology is a critical piece to that puzzle. But, if someone is struggling in practice or seeking to move their practice in a new direction, simply adding technology without a strategy and the resulting tactics may compromise their desired result. In this scenario, they’ve now spent substantial money, yet failed to move forward. Our standards won’t allow for this to happen. That is why we have integrated programs like Total Solution with the Insight technology.

So, our standards are simply this: Get our technology, use it, come through our training. If, at that point, it is not right for you, give it back to us and we give you back all your money or cancel your lease. Our standard is that we only want people to win BIG with us, not spend money and get hurt. Our testimonials are strong evidence that our standards separate CLA from competitors, while having lasting benefits for our clientele.

TAC: What technologies have you put on the Insight platform and why?
Gentempo: CLA’s Insight platform utilizes up to five technologies. Surface EMG, infrared thermal scanning, pressure algometry, inclinometry (range of motion), and our most recent and immensely exciting addition, heart-rate variability. We chose these technologies based upon what is most critical for the DC to measure, along with what has the best literature support.

It all started with surface EMG or sEMG, for short. This technology measures patterns of motor nerve activity by looking at muscle energy patterns. There is published research that shows that chiropractic adjustments improve these patterns in a significant and positive way, as compared to controls. Since chiropractors are primarily concerned with the function and performance of the nervous system, it is important to note that the nervous system has three sub-systems: sensory, motor, and autonomic. We think it is critical to objectively and non-invasively assess all three—and we do. SEMG handles the motor portion.

What really excites me is that we have invested considerably in the Insight’s sEMG performance and features. Just recently, we released our newest version that performs full digital signal processing. The new Insight sEMG not only gives you signal amplitude, but also gives you a spectral analysis of each individual static site scanned. I realize I may be speaking Greek here for a lot of your readers, but I am excited because our technology developed for chiropractic is groundbreaking—the best EMG you’ll find worldwide. Not only is it number one in static performance, but the Insight’s dynamic sEMG performance also tops the industry. Bringing greater prestige to our profession is a major part of our company’s agenda.

The Insight’s infrared thermal scanner performs paraspinal thermal autonomic mapping. The autonomic system is the part of the nervous system that regulates one’s organs and glands. Rounding out the three dimensions of the nervous system is our Insight Sensory Sensitivity Mapper, generically referred to as an algometer. With this technology, we can measure and map sensitivity or pain, rather than subjectively recording it. The Insight maps spinal motion with our two-point inclinometer. It is critical, when measuring ROM, that it be done at two points, so that movement artifact can be removed and the clinician can measure pure spinal motion. The Insight ROM tester accomplishes this in groundbreaking fashion.

Last, but certainly not least is our Insight Pulse Wave Profiler, which measures heart rate variability (HRV). HRV is the most exciting new technology in the field of cardiology and, in my opinion, chiropractic. Recently, there has been research published by Zhang and his cohorts that concluded that chiropractic adjustments have beneficial effects on HRV measurements. This is a serious breakthrough! We are talking about the heart. The cholesterol craze has everyone concerned with the health of his or her heart. Imagine measuring the heart, adjusting the spine and then showing beneficial changes in heart function to your patients. The power of this is self-evident. This is why technology-based chiropractic is revolutionary.

To summarize all the Insight’s functions succinctly: We take the patient on a technological journey from pain (algometer), to movement (inclinometer/ROM), to non-symptomatic nervous system function (sEMG and thermal scanning) to whole body health and wellness (heart rate variability). Can you imagine the difference between lifting legs and pushing heads and this? When I graduated from school in 1983, this was inconceivable. Today, with the Insight, it is a reality. Technology is the best thing that ever happened to chiropractic practice.

TAC: What regulatory and research precedents are there for the technologies used by the Insight?
Gentempo: As for regulatory precedents, Dr. Chistorpher Kent and I have been, by far, the most active advocates of sEMG and the other Insight technologies in the profession. We—Dr. Kent more than myself—have helped write the regulations for sEMG in multiple States. We have been involved in writing diagnostic assessment and imaging chapters for a variety of guidelines documents. And, Dr. Kent has written chapters in leading textbooks on sEMG and thermal scanning.

A perfect example of how our years of work in this realm have benefited users of this technology, even if they aren’t our clients, comes from an article you recently ran in your magazine. The interviewee was describing what he referred to as a “landmark case” for sEMG in Florida. In essence, he had a client who purchased his equipment who was denied payment by insurance coverage. As a result, he went to Florida to testify on behalf of his client to help him get paid. The judge ruled in favor of the chiropractor. The funny thing is, if one were to read the Final Order of the Administrative Court Judge, the judge references the sEMG chapter in the Chiropractic Practice Guidelines and Parameters for the State of Florida. Well, Dr. Kent was the principal author of those guidelines. Due to his earlier work, this case was won.

In short, in defense and promotion of this technology, we have been to court, held high-level meetings with third party payers, testified in front of State licensing boards…you name it.

An extremely important regulatory issue is the Food and Drug Administration in the US, Health Canada (the FDA equivalent in Canada) and CE in Europe. You don’t want to even consider technology that has any issues complying with these federal agencies. This is a very tricky, resource-intensive road that some manufacturers don’t properly follow.

For example, if you can’t get a current FDA 510 (K) registration for the product, that lists the product’s name, all the technologies on its platform, and has displayed the intended uses of the technology, which must match up to the way you intend to use the technology, don’t buy it.  Some manufacturers may try to skirt the issue by simply registering with the FDA as a manufacturer, but that does not suffice and is not the same as having the actual device you are purchasing properly registered.

All this legalese could comprise a book.  But, suffice it to say, we are painstaking in our compliance issues with the Insight.  Our exclusive manufacturer has ISO 9001 and ISO 13485 registration that was not even needed to comply—but it puts us at a higher standard.

As far as research goes, the Insight sEMG technology is unique in that its reliability, applications, protocols, indications and normative data have all been published in peer-reviewed journals and are taught at leading chiropractic colleges.  Dr. Kent and I have ten peer-reviewed publications to our credit alone.  Also, I would like to point out that independent researchers have performed and published very impressive research and reliability studies with the Insight.  In one case, we only found out about it after it was done.  Having published reliability studies is a critical credibility factor with clinical technology.  I am proud to say the Insight has many of these.

TAC:  Why are there some detractors out there as to use of technology in the Insight product category?
Gentempo:  Thank you for this question.  What would chiropractic be without detractors?!

Seriously, there are multiple reasons, none of them good.  One is simply ignorance. They don’t know, understand, or have never used the technology.  These people just parrot what others who are ignorant have said.  In addition, there are some informed detractors who, to a reasonable extent, understand the technology.  The problem is they have different views of what the clinical goals for a chiropractic patient should be versus the majority of the profession. If you subscribe to the attitude that chiropractors should limit their practices to a handful of uncomplicated musculoskeletal conditions then, perhaps, for those purposes the technology is inconsequential.  However, if one is looking to measurably improve structure and function, one must measure it.  Hence, the Insight technology becomes a necessity.  Nobody debates that the Insight accurately and reliably measures what it claims to measure.  The only question is, are these measurements of importance to the practitioner, given the clinical goals he or she has for the patient.

TAC:  Lastly, what things should a DC consider when contemplating the purchase of technology?
Gentempo:  I suggest the following:

•    First and foremost, have a clear vision of what impact you want this technology to have on your practice and life.  Believe it or not, we have a lot of DC’s who have purchased the Insight, but didn’t get the vision of the technology till after they came to Total Solution.
•    Have reliability studies and protocols, specifically for the instrument you are purchasing, been published in the peer-reviewed literature?  Is there any university-based research?
•    Does the instrument have the proper federal agency registration (FDA, Health Canada, etc.), as I discussed earlier?
•    What is the company’s and its principals’ reputation in the field? Have they received significant acknowledgements or awards from the field?
•    What type of training and ongoing support can the company offer?  Do they have the resources and expertise to help you overcome your practice challenges or reach your practice goals?

TAC:  Any final thoughts?
Gentempo:  In order for technology to succeed in chiropractic practice, it must serve a specific and meaningful purpose.  When it does, the impact is immensely powerful.  Our profession needs significantly increased credibility and certainty.  The Insight technology does exactly that and I won’t rest till every DC recognizes the power and importance of technology to the future of this profession.  When it comes to technology, I have three words: Resistance is futile!

You may contact Dr. Patrick Gentempo at 1 International Blvd., #750, Mahwah, NJ 07495.  Phone 201-252-3220, Executive Assistant Mike Thompson, Ext. 114; www.subluxation.com; www.creatingwellness.com.

 

 

Dr. Michelle Zarzana came to chiropractic later in life than many of her peers, having previously established herself as a marine biologist and researcher and as a teacher. An injury had placed her in extended chiropractic treatment and it was so effective that she enrolled in the Southern California University of Health Sciences, finishing the five-year program in three and one-half years and earning her D.C. degree in 2002.

Dr. Zarzana regards herself as a “progressive” chiropractor, with a mission of getting patients well and maintaining that wellness with a regimen of limited visits for check-ups and reinforcement of her recommended exercise programs.

“Patients get better faster and stay better,” she says. “Once they are released from treatment, I like to see them about once a month for as long as necessary, but not longer.”

In her Long Beach, California practice, Dr. Zarzana normally sees about 30 patients per day in a six-day week – a workload that affords her the kind of time she likes to spend with each patient. Her clientele is weighted towards sports medicine, young athletes and their families, along with the traditional mix of personal injury and workers compensation cases and wellness patients. She employs two massage therapists and an acupuncturist/herbalist.

Like most of her peers, Dr. Zarzana often found herself bogged down in paperwork—handwriting SOAP notes and composing and issuing reports to attorneys, insurance companies, regulators and referring doctors. She tried dictation and outsourced transcription but found the process unsatisfactory, ultimately choosing to be her own transcriptionist rather than suffer the frequent delivery and quality problems. The  paperwork added the equivalent of a full day to her schedule each week.

Dr. Zarzana found her solution at ACOM Solutions, Inc., also headquartered in Long Beach, which was beginning to market diagnostic and document management software for chiropractic offices.

The solution, RAPID EMR, resides on a tablet computer that doctors can  carry in patient visits to streamline diagnoses and SOAP notes recording and later, to automate production and printing of patient reports. The software can also be installed on desktop and/or laptop machines. The RAPID EMR Total Solution includes the wireless-ready tablet computer, the RAPID EMR software suite, a multifunction printer/fax/copier, and a wireless interface card.

Building patient files in RAPID is highly automated. The software features intelligent interactive graphics and checklists for diagnoses, patient progress updates, and it also allows insertion of hand-written input. Doctors can simply tap on an on-screen  diagram point or check-box and associated text within the RAPID system is sent directly to the patient file. Handwritten notes are entered using an “Inking” feature, and external documents such as photographs and accident diagrams can be scanned into the file and automatically indexed.

The array of interactive screens include, among others, Patient Information, Chief Complaints, Range of Motion, Neurology Exam, Orthopedic Exam, Impairment Rating, Narrative Report, Outcome Assessment Reports and pictorial “Helper” screens for the entire body, the muscles, the spine, acupuncture, auriculotherapy and a genealogical tree.

Doctors can select any of four outcomes assessment reports at any point for printing and distribution, and a Microsoft Word-based report generator that operates independently of RAPID enables creation of custom text or reports that reflect an individual doctor’s style and personality.

Dr. Zarzana was not disappointed, for almost immediately she found that she was able to recover the many evenings and Saturdays that she had been devoting to paperwork. She further streamlined the practice with the purchase of ACOM’s Patient Self-Registration module. Now, when a patent arrives for the first appointment, he/she is handed a tablet computer with the file opened, and brief instructions on inputting the information Dr. Zarzana needs to proceed with the diagnosis: nature of the complaint, type of complaint, degree and location of pain, and so on.

“This information starts the file for the initial visit, and on subsequent visits, the patient revisits the file and the various screens and updates his or her condition,” she says. “The responses again go into the file automatically and continue to build it.”

The consistency, clarity and organized presentation of RAPID reports improve patient understanding and, she believes, help to support the prompt payment of claims.

“If the insurance companies can’t see the value of the treatment, they are reluctant to pay for it,” she says. “When you can document what you’ve done, you have a far better chance for uncontested payment. The RAPID reports we supply to referring MDs have actually impacted our credibility. Several doctors have called after receiving their RAPID reports to say that the level of professionalism is not what they are used to seeing from chiropractors. That certainly helps to support a professional image!”

For more information on the RAPID EMR call 866-286-5315 or visit ­http://www.acomemr.com/ac.

As a personal injury trial attorney, I am frequently asked by other lawyers how I win my cases. They also ask me why they are unable to obtain larger settlements for their clients, like I do? What do I do differently?

The answer is quite simple. You have to show the injury before they (the insurance adjusters or the jury) will show you the money. All too often we, myself included, try to persuade a jury, a defense lawyer or an insurance claims adjuster that our client’s injuries really exist, by relying on the medical records, X-rays, MRI’s and our treating physicians—without success. But now, I have seen for myself how to really “prove” the injury with objective tangible evidence that anyone can understand.

By using the reports generated by the DXAnalyzer© (computer aided X-ray digitizing software) with Flexion and Extension Motion X-ray in combination, I can easily persuade the most skeptical audience about the seriousness of my client’s injuries by presenting clear Evidence Based Objective Documentation.

With the use of Motion X-rays, the doctor can pinpoint the joint with the most damage and, with the DXAnalyzer© software, the doctor can now measure exactly how bad the injury is. Before this technology was available, the whole injury issue was a swearing contest of vague opinions. But now, with the DXAnalyzer© software, the doctor has exacting measurements which the defense doctor cannot refute. Or if he/she tries to argue against the injury, the defense expert loses credibility. The opinions are now gone and replaced with measurable observable injuries.

Here are a few reasons why the DXAnalyzer© reports are an absolute must for every trial lawyer:

• Seeing is believing:  It is hard for non-physicians to understand what my treating chiropractor is talking about and how serious the injury is, if they can’t see the damage.  The report from the DXAnalyzer© software makes identifying and understanding the injury very obvious and simple.

• Credibility builder:  Now we are not just using words to prove our case, we are showing objective measured documentation that removes doubt and skepticism.

• Juries love to look at things, especially scientific things.  Shows like CSI have made everyone a forensics expert.  Give them something to look at and analyze.

• Defense teams love to use the word “subjective.” Defense Attorneys can no longer use the word “subjective” to describe the evidence based objective documentation that has now been placed into evidence.

My testifying chiropractors feel a lot more comfortable on the witness stand explaining to the jury what the DXAnalyzer’s© biomechanical report demonstrates.  It builds the doctors’ credibility, and they find it much easier to testify when they have this powerful objective document to prove their clinical findings and treatment plans.  When they take the stand, it is now show and tell, rather than just tell.

The DXAnalyzer© images make the defense look like they are holding an empty bag.  The jurors think, “Okay, the injured person has shown us proof of the injury; what is the defense going to show us?”  The defense can’t “show” anything.

I used to try my cases by having the doctor stand in front of the jury with a view box, and try his best to show where the injury was on the static X-rays. This is a recipe for disaster. No juror knows what he/she is supposed to see, or what you are talking about and, generally, the plain film static X-rays alone don’t show very much at all to the untrained eye. But with the motion X-ray, objectified with exact computer mensuration, voilá!  We have clarity, understanding, recognition, and a fair jury verdict.

As a trial lawyer, it is my duty to use every reasonable way to prove my client’s case.  I cannot imagine ever trying a case again without using the DXAnalyzer© reports to prove to the court where and how badly my client was injured.  It just does not make sense to try to explain something, when you can show them instead.  It really goes to the old adage, “A picture is worth a thousand words.”

Matthew Powell is a trial lawyer in Tampa, FL, who started his career representing over 20 insurance companies.  After learning the defense side, he quickly found he could not represent insurance companies, and started out on his own to represent injured victims.  He is a frequent speaker and instructor teaching lawyers and chiropractors how to sharpen their skills in trying low-speed rear-end car collision cases.  He has had the honor of obtaining a $1,000,000 verdict for a case the defense described as a minor fender bender.  He can be reached at [email protected].

For more information on the DXAnalyzer call: 888-668-8728 or go here: http://www.theamericanchiropractor.com/dxanalyzer.

Chiropractic offices have traditionally kept pace with other medical practices in their use of technology. From patient records to billing, many chiropractors are better managing patient care, thanks to evolving technology.  More and more technological advancements are making their way into chiropractic practices. Today’s technology is not only streamlining chiropractic office administration, it’s arming these practices with better diagnostic tools. 

Weigh Costs vs. Savings

Switching from traditional X-ray films to a digital or computed radiography (CR) scanning system whose advantages are vast may seem enticing, but the bottom line questions are still, “Is such a system affordable for my practice?  Will the benefits outweigh the costs; and how long before I can recoup my investment in a digital system?”

Prices are coming way down and that has helped make the up-front investment more affordable for more and more chiropractors.  The new systems are suitably sized and priced for the private office.  That fact, combined with the long-term savings to be realized from the elimination of disposables such as film and chemicals, as well as freedom from frequent maintenance and waste disposal, makes the transition to digital an attractive proposition worth serious consideration.

In addition to doing away with X-ray film, costly chemicals, hazardous chemical disposal and film processor maintenance and repairs, digital imaging eliminates the need for sizeable film storage facilities and a dedicated darkroom.  The space savings alone provides a valuable advantage, allowing you to reclaim precious room that can be utilized for patient care.  The annual savings for a practice that takes as few as eight films a day can be as high as or even higher than $9,000 after switching to digital.

So, where does that leave you on the cost side of the equation?  Until very recently, digital and computed radiography imaging systems were priced well out of the reach of the average chiropractic office.  Today, however, there are a number of companies offering these systems that provide all of these advantages at a much more reasonable price.

Realistically, you are looking at an investment of between $32,000 and $40,000 for a computed radiography scanning system.  So, if you are taking eight or more films a day and saving approximately $9,000 every year (see chart), that means that, over the course of four to five years, you will have paid for the system with the savings.  From that point forward, you can start banking the savings. Obviously, a practice that is doing a larger number of daily X-rays would reach a breakeven point more quickly and recoup the cost of the system faster.

How Does CR Work?

The CR processor uses a special re-useable imaging plate containing photosensitive storage phosphors that retain the image until it is sent to the computer. These plates can be reused thousands of times before being replaced. X-rays are taken in the usual manner. The plate is then removed from its cassette, inserted into a scanner where the image is scanned, and automatically transferred to your computer in less than a minute. You’ll know right away if you need to take another view, so there’s less waiting for you and the patient.

Great Patient Education Tool

The beauty of digital is in the fact that you can enhance the image to bring out diagnostic detail.  You can magnify, heighten contrast, and even colorize the affected area.  It’s a great way for chiropractors to educate their patients about treatments and better demonstrate a misalignment or disk problem. For example, you can do a side-by-side comparison with a prior X-ray to show positive therapeutic changes. Your patients will actually be able to see, as well as feel, the physical improvement after treatment.

Dramatic Decrease in Need for Retakes

You have greater latitude in getting good readable images.  Digital is much more forgiving of exposure errors because it has a wider dynamic range than film.  If an image is under or over exposed, the computer can adjust for the error and provide a very useable image.  With film, an error in exposure often means that the X-ray must be repeated, which means that the patient must be irradiated a second time.  This is not only inconvenient, but results in unnecessary added radiation exposure. With digital, there are significantly fewer retakes. 

Is CR Right for Your Practice?

Computerized radiography offers the advantage of quick image access and does away with the need for stockpiling, searching and copying films.  All images are saved for easy retrieval on the computer system and stored on secured backups.

You can transmit digital images electronically in an instant to a colleague across town for consultation or diagnostic confirmation.  The image can be e-mailed while the patient is still in your office. If a patient wishes to have a copy of his or her X-rays, the images can simply be burned onto CD’s in a matter of minutes for just pennies. Simply hand the CD to your patient to take with him.

In addition, CR is a superior method of radiography because it’s faster; you can shave 10 to 15 minutes off a patient’s office visit.  Plus, digital images can be enhanced for greater clarity so that more diagnostic information can be derived from them.  Also, instead of manually drawing measurements directly on the film using a ruler and protractor, the computer can be programmed to automatically provide accurate measurements for you.

The use of computed radiography eliminates concerns about environmentally hazardous chemical waste disposal.  Across the country, government regulations continue to make disposal increasingly more costly and difficult.

Select the Right System and Service

If you do decide that your office could benefit from the advantages of computed radiography, make sure that you research not only the systems, but also their customer support.  As a new user of unfamiliar technology, the technical assistance, training and service a dealer and manufacturer can provide is critical.  While it’s easy to use, you and your staff will still need to learn how to adjust to and use the new equipment, and you’ll want to be able to quickly troubleshoot problems and get answers right away.  Make sure the manufacturer provides excellent customer service.
 
Conclusion

Many of today’s newer offices are fully computerized and are starting out paperless and filmless.  But practices with existing film radiography in place have to weigh the benefits of digital against its costs.  If you are doing a considerable amount of scans each day, then the advantages of switching are obvious; but for those practices that take less than five scans per day, the decision may be less focused on savings and more on getting faster, better results and maintaining a cleaner environment.  CR provides the practitioner with a paperless office where images are conveniently stored with each patient’s file on the computer hard drive and in backup systems.

Since 1985, Fred Fischer has been the senior executive at ALLPRO Imaging, a manufacturer of X-ray equipment for the medical profession. The company was founded in 1962.

Fred Fischer has been the senior executive at AllPro Imaging, Inc., a manufacturer of X-ray equipment for the medical profession, since it was established in 1985. A native of Hollywood, CA, Fred is a graduate of Manhattan College with a degree in electrical engineering. After his discharge from the service, Fred worked as an electrical engineer at RCA Corp., and was later a salesman for the Electrodyne Division of Becton Dickenson Corp.

For more information about ALLPRO and the ScanX 14, call Linda Schutt at 516-214-5611 or e-mail [email protected]. Also, visit ALLPRO’s website at www.allproimaging.com.