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.”

October 2008