Comparison to T-System

The number of templates is a primary difference. T-system has over 50 templates. Each one is different by design. According to T-system, their templates are designed to make a comprehensive record of a visit using templated forms. By necessity this means that an incredible level of complexity must be incorporated into each form. It also assumes that the patients complaints will fit neatly into the complaint as envisioned by the designer. This is akin to patients always presenting with textbook presentation of problems - fine for 80% of cases. But what about the other 20%. And what about the patient who presents abdominal pain that turns to chest pain. Or the "simple" URI that is really a cough with a malignant effusion or cardiomyopathy. The system also "predicts" the E&M level expected to be billed. Documentation of greater complexity than anticipated is not supported directly.

Also the T-System has so many templates, you need special rack to hold them, an inservice to assure that RN's pick the right one for you at triage, a second set (another rack?) in the back for when the one they picked simply won't do and a commitment to pull a clean sheet and start over when it was not right. All of these things are major issues in productivity and billing efficiency. Our chart reviews regularly reveal lost revenue related to insufficient data recording on patients documented on templates that the designer assumed would be of a lower complexity than the actual visit. Our templates allow level 5 documentation of HPI, ROS, past social and family history on every patient - or not, your choice.

And don't forget updating and revisions. Many practices simply don't bother because the task seems insurmountable.

Attention to individualization. The "do everything on the template" approach of the T-System means that the templates are crowded,  and leave little space for free form entry. In reality, documentation of medical decision making is about showing what you think. This is not necessarily well suited to templating. T-system attempts to template everything which makes information hard to find and doctors wondering where to write those things that aren't there (or they can't find). Our approach is to template the things that are either required or are common.

Allowance of variation in findings. T-system's circle and slash was a great idea. But it limited the physician to only POS or NEG responses. A typical review of systems might list some back pain (was that mild, moderate, severe, acute or chronic), headaches (same questions), nocturia (you get the idea). allows coding of severity (0=none, 1=minimal, 2=mild, 3=moderate, 4=severe, 5=extreme, C=chronic). Can you look at at chart and understand why the physician did or did not spend time digging into such complaints or understand why the visit progressed as it did.

Discharge risk management. philosophy follows through both the physician documentation and patient discharge instruction sheets. The discharge plan needs to be specific, contain instructions and agreements with the patient or family, and admitting or follow up providers must be noted and must be time specific.

Working in the teaching hospital. T-system has no real solution for the teaching environment. Our templates each have a "resident version". Since we have a small number of templates, this is not a major undertaking. Consider what would have been involved to redo each of the more than fifty T-System templates - how big of a rack would you need then? The resident version has a clear separate section for the teaching physician to document the required portion of the encounter on the same sheet. There will be no questions about adequate supervision.

Mid-level provider support. This is built right into our template if you use this option. Our system was designed in an emergency deptarment using PA's so we had it right from the beginning. We can easily take it out if you don't want it. It encourages both the physician and the PA to document the physician level of involvement so there is not question of who did what. Hospitals resort to all methods of documentation to take care of this. If you are sharing templates, you may not know who did what, only who signed the form. T-system does not provide this support.

Risk management. While not directly required, good department management means encouraging doctors to put risk management thinking into every chart. ER doctors are smart, and once keyed to this, they do a very good job with little extra effort.

In evaluation of template solutions, consider your specific objectives. We use our moto, "TAKING CARE OF BUSINESS AS WELL AS TAKING CARE OF THE PATIENT", to help define our objectives and our templates stick to that philosophy. The templates make easy work of full compliance, maximum billing, and directed risk management. That is the purpose and that is what they do.

When the federal government (and commercial carriers when they could pull it off) decided that coding of charts would be guided by specific counted "elements" for each section of the chart, many groups were hit hard as they tried to re-educate their physicians. Providing good care to complex patients was no longer the basis for coding. Now high level billing is assigned only when these elements are recorded. Groups rushed to assure they complied with this requirement and templates were a good way. Our templates do EXACTLY that. They make quick and easy business of compliance with without boxes and checkoffs for a lot of unneeded data. Record that as you need to. Only very common data is templated. The list of included items was developed over years of use in a real emergency department setting. As working physicians noted things they repeatedly had to handwrite, they were asked to note these items on a list that was then incorporated into our templates.

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