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From the October 2001 Issue HIPAA and MCOs: Administrative Simplification or IT Modernization? |
Integration Crossroads In their quest for efficiency, physician practices must cope with the inclusion of EMRs, the business impact of HIPAA and an ever-changing vendor landscape. By Richard R. Rogoski is a free-lance writer and a contributing editor to HMT. Contact him at rogoski@aol.com.
Most PMs are standalone solutions that can readily handle the administrative and financial demands of a growing practice. But with the growing acceptance of electronic medical records (EMRs), physicians and administrators are often forced to purchase separate PM and EMR systems—and they seldom work well together. Efforts are underway to design PMs that include an EMR component, but developers are split over whether this is the best solution. Some believe that managing a practice includes everything from billing to clinical documentation—and that a single software package should support every aspect of the practice. Others say a better solution is for the physician to buy the PM and EMR systems best suited to his particular practice, then integrate the two. Populating the Landscape
e-MDs’ topsSuite solution is an integrated system that automates the three primary areas of medical practice—charting, practice management and scheduling—into a networked trio of modules so information can be seamlessly passed from one software module to another. The efficiency of integration is underscored by John C. Durham, M.D., chief medical officer at Greenway Medical Technologies in Carrollton, GA. “Data collected in one module doesn’t have to be re-entered into another module,” he says. “Most systems that are not integrated don’t have this capacity.”
Others, though, take an entirely different approach. Neil Simon, chief technology officer and vice president of operations at Millbrook Corp. in Carrollton, TX, is bucking the trend toward a one-suite-fits-all solution. He believes physicians should buy a best-of-breed EMR system and a best-of-breed PM system, and then integrate them if necessary. By using both client-server and Web-based technologies, the Millbrook Practice Manager™ system runs on Windows NT with an SQL server, Simon says. Since it uses a pure Microsoft architecture, “it’s also Microsoft BackOffice–certified,” he adds. But Millbrook also offers the “Millbrook Integration Kit.” This Microsoft Windows NT system service creates seamless integration between a variety of systems, applications and facilities.
Through an alliance with Philadelphia-based MicroMed, DrFirst. com offers clients “NextGen,” a Windows-based suite of proprietary software systems that include EMRs, appointment scheduling, billing, claims processing and managed care plan implementation. It also offers its own secure Internet messaging, Web- and PalmOS-based e-prescribing and charge capture applications. The EMR Factor For Kaufman, at least, the Internet has become one of the best tools for integrating existing PMs with newer EMR systems, and he says this integration is crucial. “Practices already have PM applications and often are not willing to go through the additional pain of switching. If it weren’t too complicated, they would like a seamless interface between the new EMR and their current PM.”
While the use of electronic medical records is growing, most estimates show that less than 6 percent of physicians use them. The push to include an EMR component in a complete PM system is based on the belief that EMRs can dramatically improve a practice’s efficiency and reduce errors. “In terms of financial benefits, the EMR allows more complete documentation and should make it easier to allow the physician to enhance the quality of the visit by reducing the burden of documenting the additional information,” says Kaufman. “That can translate into higher coding levels and, by producing complete and legible documentation, better reimbursement for those higher codes.” It can also eliminate missed charges. With integration, procedures that should be billed are automatically sent from the clinical documentation system to the billing system. “High-end EMRs provide a framework for triggering health maintenance questions, visits and tests so records are complete and legible,” Kaufman adds. Winn summarizes by saying that in the future, the most successful practices will be those that employ both PM and EMR solutions and have a paperless office. “Those not using an EMR will not be able to compete,” he says. Vendor Benders One of the biggest roadblocks to integrating PM and EMR systems is lack of cooperation between vendors. “It is difficult to get a competitor to partner with a competitor,” says Winn. That would be like Ford and General Motors agreeing to make interchangeable parts, he explains. In the long run, though, these vendors will suffer. “If applications do not work together seamlessly, they will not be used because double entry is inefficient. Worse, data may be lost between the programs, threatening the safety of patients. In the future, middleware applications may grab and transfer data from even recalcitrant vendors’ programs. But for now, I’d avoid applications from uncooperative vendors,” says Kaufman. Another problem, he adds, is that those making EMR systems generally don’t develop PM programs, and “links between applications from different vendors can be expensive and unreliable. EMR systems from legacy PM suppliers are often less robust than those written by EMR companies, but practices purchase them to avoid interface problems.” However, Millbrook’s Simon says his company’s “software cooperative program” brings together 25 to 30 partners to ensure the integration between different vendors’ products. He says consolidation within the industry is taking its toll among vendors and predicts that as companies continue to consolidate, there will be fewer choices and more competition. Standards and Devices Perhaps as important as vendor cooperation is the development of a program that can accommodate complex clinical differences. Creating a PM system that works across different medical specialties is relatively easy since most administrative functions are the same in any practice. But patient records and clinical data can vary greatly from specialty to specialty, making it difficult to develop a one-size-fits-all EMR component. Charting done by a cardiologist, for example, is different from that done by a primary care physician. Developing and adhering to standards that facilitate the integration of PM and EMR systems is another issue, Simon points out. “I think Windows will be the mainstay of the industry, especially on the medical records side.” Simon and Kaufman agree that the most successful integration of disparate systems uses HL7 (Health Level 7), an industry standard that can even be used with legacy systems. But Winn notes, “We’re building our software to XML (extensible markup language), which is an open standard.” Since XML technology allows medical records to be centralized or sent across the Internet, it also allows disparate systems to communicate with one another. No one denies that the Internet and Web-enabled applications will become a great leveler in the field of systems integration. But there is a question about how large a role wireless handheld devices will play in the PM/EMR arena. “EMR does not mean just notes entered by a doctor on his PDA (personal digital assistant),” says Winn. “The PDA is a real simple device. But the PDA itself has a screen too small for an EMR. We’re looking to use wireless tablets to access records.” Kaufman adds, “The smaller, handheld devices are very portable, but lack keyboards, have slow processors incapable of good speech recognition, and have small screens that show limited data at one time,” he says. “Touch-screen tablets are maturing rapidly, and some now have XGA resolution screens, wireless keyboards, and/or handwriting recognition. Wireless networking, at least LAN, is here, and IEEE 802.11, or ‘11base-T’ is fast and cheap—and getting faster, too.” No matter which way you slice it, today’s physician is still waiting for technology to catch up with his day-to-day needs. “The Holy Grail is an infinitely-connected device that is infinitely available. But the answer for now may be a combination of a wireless touch-screen tablet in the office and a Palm or PocketPC device with limited data to carry with you,” says Kaufman. The Courage to Change Physicians also are waiting for technology to provide point-of-care solutions. “Doctors have seen the power of computers and want to bring it to the point of care. They are anxiously waiting for solutions that, so far, haven’t been seen. In my opinion, if they’ve looked at EMRs, they’ve probably made the right decision not to purchase those to date. Most systems don’t provide the functionality that is needed,” says Greenway’s Durham. But Millbrook’s Simon sees lack of support for an integrated PM/EMR system as key to physicians’ reluctance to change—and incorporating an EMR is a major change. “Healthcare is a locally-delivered mechanism. Only when physicians are forced to change, do they.” Many physicians view EMRs and PMs as completely separate entities that don’t need to be integrated. To them, medical records are viewed as an integral part of the practice while practice management solutions are still viewed as back-office functions. Kaufman envisions a time when physician-run practices will embrace the newer technologies. “Versatile, user-friendly systems will flourish if they are affordable. Staff turnover, at least in metropolitan areas, is higher than it used to be, and it will become painful for practices to maintain their legacy systems. Systems that are successful will be easy to learn and use, flexible in terms of hardware and connectivity, and easily connected to other systems. The better ones will be able to link to PalmOS or PocketPC devices, the Internet via browsers, and to hospital information systems.” Here Comes HIPAA With HIPAA looming on the horizon, many practices have already begun to scrutinize their PM systems and how they handle medical records, and Winn says the role of EMRs can only increase. “EMR is the only method that will be HIPAA compliant. It will be virtually impossible to be HIPAA compliant with paper systems.” But Simon challenges the extent to which HIPAA will affect medical records. “HIPAA says the billing has to be sent electronically. It doesn’t say how records can be moved within a practice or stored.” Simon says his company’s Practice Manager product uses 128-bit encryption and includes an auditing component to track viewing of medical records. Durham says Greenway is ready. “We consider ourselves fortunate because we’ve been developing our product with HIPAA on the horizon,” he says. “This has allowed us to build directly into the primary structure of the product features that support HIPAA compliance. Being a Web-based platform, we’ve dealt with security issues in detail.” Although it will take two to three years before all HIPAA-mandated regulations go into effect, some physicians believe the impact will be felt sooner. “I can’t walk through a hospital doctors’ lounge without being stopped with a question about medical informatics,” Kaufman says. While many physicians are concerned about the cost of compliance, equally many seem to believe there is still plenty of time to upgrade. Durham says many physicians he talks with are taking a wait-and-see attitude. He adds that many doctors are looking at the privacy and security aspects and asking themselves, “Are there any paybacks to me, or is it just another level of costs?” But he also warns, “HIPAA regulations must be taken seriously. There is unlikely to be any substantive change in the regulations, and practices must be ready to implement them on schedule.” Simon again poses a challenge, indicating that certain HIPAA requirements may change before they become law, which in turn has physicians asking, “Why should I spend a fortune now, when regulations can change?” His challenge showcases a critical issue for hundreds of practices that must balance their desire for the functionality and efficiency promised by technology against a changing regulatory landscape that can drive costs beyond a reasonable limit. Patients’ Rights Another aspect of HIPAA that concerns physicians is granting patients the right to access their medical records and to question the information those records contain. Because most patients already use the Internet for research, they may expect to access their medical records the same way. In ramping up, Durham says Greenway has created a new module called “PrimePatient” which not only allows patients to review their records online, but also to fill out the pre-examination information they normally complete sitting in the doctor’s waiting room. While some physicians say allowing patients to question entries in their medical records is tantamount to second-guessing the doctor’s knowledge and judgment, both Simon and Durham say it provides a layer of checks and balances. “If a patient finds a mistake, he can amend it but not change it,” explains Simon. “It’s like your credit report. You have the right to question the information that’s in it.” Durham also believes patients should have the right to see what’s in their medical records. “One area patients like to check is what might be sent to an insurance company, for example, to make sure the record is accurate.” Without doubt, the next two years promise to be an active period for physician practices and practice managers as they strive to gain important business efficiencies and simultaneously negotiate a fluctuating horizon of vendors, clinical functionality, standards and regulations. All eyes will be on how well technology serves them in the process. © 2001 Nelson Publishing, Inc |
Anyone who has shopped for a practice management (PM) system knows how hard it is to bridge the gap between clerical back office functions and the clinical aspects of patient
care.
David Winn, M.D., believes a successful PM solution should combine the administrative and clinical functions of a practice into a single, integrated system. As founder, CEO and chief software architect of Cedar Park, TX-based e-MDs, Winn has developed an integrated suite of clinical and financial information management solutions for physician practices and groups.
Durham says that since the software required for scheduling and billing modules is easier to write than the clinical components, most developers have concentrated on the administrative aspects of PM automation. Like Winn, he believes solutions should be fully integrated. As a result, Greenway is planning a full launch in early December of its Web-based PrimeSuite of products that combines charting, scheduling, registration and billing components into one
PM/EMR solution.
Another company charting its own course between integrated systems is Rockville, MD-based DrFirst.com. According to Peter Kaufman, M.D., the company’s chief medical officer, DrFirst.com is an application service provider (ASP) that provides physicians with communication, practice management, EMR and business productivity solutions.
But Simon says if a practice purchases an EMR that doesn’t integrate with the PM system, staff usually have to double enter everything. Rather than do that or upgrade their whole system to accommodate an EMR, the practice may limit or forgo its use of the
EMR.