• October 2008 FEATURE ARTICLES •
Physicians Practice Management
Tools of the Trade
Three approaches to PM systems and their interoperability within the care continuum reveal bottom line possibilities for all practices.
By E. Victor Brown, Senior Editor
When it comes to building a successful
practice in a healthcare world of increasing costs and shrinking
margins, technology is just a set of tools waiting for a plan.
The workflows of a practice can be greatly impacted by tools
such as practice management (PM) systems and their
interoperability with electronic medical records/electronic
health records (EMR/EHR) and other clinical and administrative
technologies. However, this requires a thorough understanding of
how your clinical and administrative staffs function at all
points throughout the continuum of care. This is the blueprint
for every practice that allows that impact to be maximized to
the good of all involved.
There have been many articles about how a
practice implements a computerized clinical or administrative
tool. Ultimately, it is why they implement these tools and the
results over time that proves more important to providing
actionable information to their peers on the same journey.
Regardless of size (in most cases) or specialty, the decisions
about what to automate, and how people and platforms can
communicate bidirectionally can often best be assessed through
views of multiple differing approaches rather than a single
perspective and circumstance.
From Legacy to Interoperability
While the concept of ideal interoperability
as it pertains to computerized clinical and administrative
platforms is often seen as bidirectional communication between
systems, efficient workflows can emerge from different and
separate choices in technology implementation.
Upstate Neurology Consultants, LLP (Upstate)
is a six-physician private practice started in 1992 serving the
citizens of upstate New York from a primary Albany office and a
satellite office in suburban Albany. The practice has admitting
privileges at a number of area hospitals
including St. Peter’s Hospital and Albany Memorial
Hospital, both in Albany.
Looking back on the move from their legacy PM
system in 2004 to their current system, practice administrator
William Henderson described the former system as "landlocked" by
its ability to do only one thing well, coupled with an inability
to communicate effectively with other systems. "The legacy PM
system would never have been able to provide Internet access and
interoperability, and we wanted to capture, access and analyze
more detailed data as well as streamline workflow processes in
terms of day-to-day operations," says Henderson.
The practice also had an eye to the future
for adding an EMR/EHR system. According to Henderson, the
practice saw the two potential choices as a selection of either
a best-of-breed PM solution with PM and EHR systems from
separate vendors; or, an integrated solution from a single
vendor. We saw the most value in an integrated system and
ultimately chose the Intergy system from Sage Software," says
Henderson.
As many practices move toward adding
EMRs/EHRs to their clinical/administrative workflow tools, many
of those same practices are simultaneously dealing with legacy
systems at the end of their life cycle. That was just one of the
important challenges facing Ophthalmology, P.A., located in
Edina, Minn.
In 2003, the practice adopted NextGen’s
Enterprise Practice Management system from MMIC Technology
Solutions, a local reseller, to primarily improve administrative
processes. According to practice administrator Karen Bartelt,
there were few options geared to ophthalmology at the time that
they chose the solution. "Some of the vendor offerings were
failing and no longer carried by the original vendor," says
Bartelt. "We had a very short window of opportunity to find one
to replace the previous system as it reached the end of its
product life cycle."
Integration and Interfacing
A very important consideration for
interoperability in an EHR vendor is to ensure that the vendor
has experience creating interfaces with the systems that require
interoperability in your particular situation.
Although interfaces are often seen as working
in one direction only, bidirectional communication — whether it
be attained via bidirectional interfaces or achieved through
workflow adjustments, or both — are necessary for achieving full
interoperability. One thing is clear: There is no one standard
or current approach that solves the interoperability challenge.
Jon M. Erickson, M.D., is an orthopedic
surgeon of a single practice that specializes in shoulder
procedures, which make up 90 percent of the practice’s patient
population. Although the Superior, Colo.-based practice is quite
busy with a maximized patient load, Erickson runs the practice
with just a P.A., an X-ray/back office staffer and a
receptionist.
Although he chose MicroMD PM from Henry
Schein Medical Systems Inc. to replace his legacy system just a
few years ago, his experience with PM systems goes back to the
early days of the technology. "I’ve been on some form of EMR and
PM since beginning to practice in California in 1982, and I was
one of the first people in the state at that point to go with
the computerized medical management system, which was decidedly
different than it is now," says Erickson.
After much research and consultation with the
vendor, Erickson chose MediNotes EMR, which he felt would
interface seamlessly with the PM system. Although two-way
interfaces that enable data and information to flow both ways
between systems might be touted by some practices as an ideal
solution, Erickson finds it to be unnecessary, depending on the
PM system’s functionality. "We have a one-way interface acting
as an electronic bridge that sends demographic and scheduling
info directly to the EMR as it gets entered into my PM, when the
patient first arrives or calls for an appointment," says
Erickson.
Workflows
Efficient workflows are well thought-out
plans that evolve over time in a practice, regardless — and some
times in spite of — the level of technology of the moment. For
Henderson and Upstate, efficient workflows start with people and
communication that allow the introduction of technological
systems to be applied to areas where the gains can be maximized.
"Before installing the new system, our
physicians agreed that they would use the system and document
their patient visits in the same way so that we had a consistent
amount of data for clinical information while streamlining our
business aspects," says Henderson.
"I can’t tell you the number of peers that I
talk to who have an EHR and there is total inconsistency with
how the providers use it, which, frankly, is a mistake that
ultimately hurts practices long-term because they can’t provide
necessary actionable information."
Ophthalmology PA is an example of that, as
their charting is still partially paper-based. "Even without the
EMR, currently, we have a kind of chart within the PM software
that provides the necessary level of basic information on the
patient, says Bartelt. "The staffer has the paper record, as
well as the patient data and any notes that they need to discuss
with the patient, contained within the PM, so everything is at
their fingertips when dealing with the patient."
Interoperability is about more than just
internal clinical/administrative systems and people sharing
information, it is also about applying those same principles to
the continuum of care beyond the practice doors. According to
Erickson, electronic billing has proven beneficial for
interaction with nearly 70 percent of the insurance companies
his orthopedic practice interacts with, but not all. "Some
insurance companies are stymied by that, so we’re still
generating some paper statements, but the whole process of
producing statements for insurance companies and patients is
easier to handle now," says Erickson.
The ability to generate meaningful reports
has also been a boon. "With insurance reimbursement rules in a
state of flux and individual insurance companies changing their
reimbursement procedures mid-stream, once an anomaly is
suspected, we can generate the types of reports that pinpoint
the problems, allowing staff to be proactive without any
difficulty," says Erickson.
Reports that permit checks and balances on
the work being done and its effect on the bottom line are
beneficial, regardless of specialty or practice size.
Ophthalmology PA takes advantage of an unbilled visit report,
which allows them to track patients from the moment the
appointment is made, revealing those patients that, for various
reasons, have not been billed. "That is easily $4,000 a week
that we recapture on that type of report, which allows us to
track A/R, collection efforts that we need to worry about,
changes in reimbursement from specific carriers that we need to
address, as well as track receivables and make adjustments as
needed," says Bartelt.
"Consequently, the PM system has facilitated
a 20 percent reduction in receivables and allowed us to pursue
and resolve aging accounts quickly — all without a staff
increase."
Cracking the Code
The physicians of Upstate Neurology have
always been the practice’s primary coders. They utilize
encounter forms, or superbills, in which the physicians actually
do their coding. With the previous PM system, once coding was
complete, the superbills would be collected and verified the
next day by the billing department. Then, they were entered into
the system.
Actual billing was done once a week on
average, by data-entry personnel working within the billing
department. The bulk of the information was entered manually,
and approximately 30 percent of the claims were submitted
electronically. "By contrast, I just did an analysis this
morning and in the last six months, 98 percent of our claims
have gone out electronically. This is a dramatic difference that
accounts for our ability to move some of the billing functions
to the front end of the practice, thereby maximizing staff
effectiveness," says Henderson.
According to Henderson, historically,
healthcare insurers that invested heavily in IT for data
analysis purposes knew more about physicians than they knew
about themselves. However, the growing sophistication and
adoption of PM software has given physicians the same or greater
level of information access.
For example, insurers profile physicians
through claims data, enabling them to develop individual
methodologies to determine case severity across patient
populations. "My in-house billing data now provides a much more
accurate representation of what we do with our patients than
just the clinical data, or the billing data utilized by
insurers," says Henderson.
The Bottom Line
The blueprint for a successful practice has
always rested on cutting costs while simultaneously maximizing
productivity, positive clinical outcomes and patient/staff
happiness. In today’s environment, true bottom line results such
as these can only be attained through careful attention to
workflows and measuring outcomes over time. "If I can’t measure
it, then I have a problem with it," says Henderson. "We spend a
lot of time benchmarking what we do against Medical Group
Management Association criteria, better performing practices and
completion of surveys from the American Academy of Neurology. We
benchmark against them so we utilize current-state technology
platforms to be truly critical of what we are doing."
That self-criticism and measurement has shown
that under Upstate Neurology’s old PM system, A/R days were 36.5
days. The practice saw an immediate 15 percent improvement in
A/R upon implementation of the new system, allowing them to more
quickly absorb the significant investment and begin making a
profit. Today, A/R days are down to a low 20.6 days. Even with
significantly more providers today than in 2003, the practice’s
overall A/R has dropped 60 percent. Ultimately, the practice was
able to recoup the PM system investment within two years and the
EHR, which was purchased in July, 2005, paid for itself in 12
months. "The A/R reductions contributed significantly to the PM
system ROI," says Henderson. "The EHR system allowed us to
reduce our transcription costs by 50 percent the first year,
which covered almost the entire cost of implementation."
Additional profits have been garnered from
the integrated system due to the ability to become involved in
the Centers for Medicare and Medicaid Services’ Physician’s
Quality Reporting Initiative (PQRI) projects, as well as
becoming a Bridges to Excellence provider. That has allowed the
practice to receive money from employers due to greater
documentation ability derived from the integrated system. "In
addition to being able to reduce staff size, we also regained a
total of 1,000 square feet in our practice offices due to chart
elimination. This allowed us to re-purpose 600 square feet of
that recaptured space for new exam rooms," says Henderson.
For Erickson’s single physician practice,
gains were also represented in maximization of patient loads
while simultaneously increasing patient and employee
satisfaction. "I’m a fairly busy orthopedic surgeon and I’ve got
one part-time X-ray tech, a full-time P.A., and a combination
billing person/receptionist that are all well paid, and we’re
still able to schedule Mondays off," says Erickson. "For me and
other small practices, this type of proper implementation of
technology is the only way to not lose money and make even a
marginal profit."
As Ophthalmology PA enters its fifth year
using a PM system, Bartelt has seen the system pay for itself in
two years while improving staff productivity by 20 percent and
reducing receivables to just 17 days.
Future Opportunities and Challenges
The word interoperability means different
things to different people. For Henderson, it means the ability
to get data in a digital format, import it into the EHR and
share that data with a patient’s other providers as well as the
hospital that requires that for provision of healthcare to an
individual. But the future of interoperability is equally about
mutually agreed standardization as well as innovation. "The
reality I have encountered in using my current product is that
even though the technology can put you ahead of the curve in
many respects, you find that the standards are not completely
agreed upon," says Henderson. "For instance, Health Level 7
(HL7) has an interface for data but there are at least 30 HL7
specifications that vary widely in what they will and will not
do, so I think that we really haven’t gotten to the point where
we can do clear data exchange between medical care providers and
entities in a useful way."
The past, present and future of health IT will always be one
of gains and stubborn challenges, but even under today’s
difficult climate, physician practices can still be profitable.
To accomplish this, they must become lean in all of the areas
that do not adversely affect patient outcomes. "You’ve got to
get it down to the basics without frills but not to a point
where patient care suffers," says Erickson. "I take pride in the
fact that the majority of physicians that I deal with are very
moral. It is nice to make money at this, but the days when you
became a doctor to make money are long gone, if they ever
existed. Today, the bottom line is helping people, but you still
would like to get paid for it as well. That is where EMR and PM
systems fit in. It allows you to strip your ship down to what
you absolutely must have."