Taking the Pulse of Practice Managers

Oct. 1, 2006

Seven practice managers discuss what works best with their current practice management systems. They also join an “open mike” on how they view federal initiatives and imperatives affecting their futures.

The old adage dictates: The more things change, the more things stay the same. That may no longer apply to physician practices. Here’s what is true in the “staying the same” column.

Seven practice managers discuss what works best with their current practice management systems. They also join an “open mike” on how they view federal initiatives and imperatives affecting their futures.

The old adage dictates: The more things change, the more things stay the same. That may no longer apply to physician practices. Here’s what is true in the “staying the same” column.

Practice administrators still rely on physician practice management (PM) systems to provide the backbone of administrative and financial efficiency for the practice. They still focus on information technology solutions that are customizable for their individual practices, ignoring the one-size-fits-most concept. They opt instead for administrative and financial systems that fit particular administrative and financial needs, and for clinical technology that best serve the practice’s physicians, and they understand the value of integrated systems that can swap data. They still take seriously their charge of making and keeping the practice profitable.

But a lot more than that has changed, including the array of information technology available and the vast healthcare landscape in which they operate:

1. Physician practices are more about data than ever before—demographic data, eligibility and verification data, claims data and clinical data. The evolution of medical practice and the increased complexity of health plan coverage have put more of every type of data on the practice management table than in the past.

2. Many practice managers also have assumed—or been handed—expanded responsibilities beyond office administration to include serving as the champions and purchasers of information technology. Increasingly, they have become responsible for making sure that data moves to an array of professionals who need it, within and outside the practice.

3. The days of the fax are coming to a close, but not soon enough. Most practice managers want to be able to fully and electronically exchange patient care data with other local and regional providers. Some practices have bitten the bullet, made the investment and are fully engaged in regional data exchange with other provider organizations; others take a more gradual and guarded approach, usually for budgetary reasons, and occasionally for reasons of physician preference.

4. Finally, while most practice managers are enthusiastic about the future of data-sharing with other providers—i.e., they share the federal government’s vision of a national health information network (NHIN) and universal adoptions of EMRs—some healthy skepticism remains about how the healthcare sector as a whole can get there. Budget is an issue for nearly everyone. Individual practice needs and the preferences of physicians are an issue for many. The desire for financial incentives usually works its way into the conversation. And many still wonder if Washington is involved in an expansive endeavor that might result in another unfunded mandate.

A few have advanced their technologies to the point where they are ready for whatever the government mandates. One practice, in particular, can look east to toward Washington, D.C. and say, “We’re ready. Bring it on.”

Awash in Data

Today’s physician practices are awash in data. They still have all the patient demographics, insurance and eligibility information, plus clinical documentation they always had, but they also have an incoming flood of clinical data including referral reports, lab and imaging results, and patient data from provider organizations outside their own system, to say nothing of an immense volume of health plan data. The degree to which those in charge think data can be integrated or should be integrated varies from practice to practice.

Integration of multiple types of data is crucial for Anthony Sala, Jr., chief administrative officer at Urology Associates of South Texas P.A. (UAST) in McAllen, Texas. A client of Microsys Computing, UAST is a seven-physician urology practice with five offices and two radiology/oncology centers. The practice sees between 3,100 and 4,200 patients in any given month.

After dumping its antiquated UNIX-based PM system, UAST installed Windows-based MicroMD in November 2005 and plans to purchase an EMR sometime this fall. “We can’t wait two or three years,” to deploy an EMR, he says. “With our five offices, an EMR would facilitate communication among those locations.” While he admits that physicians tend to “do things in a traditional way,” he says an EMR will definitely improve their documentation, and he also looks forward to greater claims and coding efficiency that can result from improved data integration.

Not everyone is convinced that data overlapping or integration should be a function of practice management, sometimes not even those with advanced PM and EMR systems. “I view PM systems and EMRs separately, and I think that they should be separate,” says John Dew, chief financial officer at Will County Medical Associates in Joliet, Ill. A multispecialty practice with 30 physicians and four locations, Will County Medical Associates has been using a PM system from Experior Healthcare Systems for about 15 years and the Allscripts TouchWorks EMR for about four years. The practice went chartless in December 2005.

Dew stresses that his physicians “never touch the practice management system.” Rather, office staff will use it to register and schedule patients, and to manage data to send out bills. “That’s what its purpose is,” he says, adding that almost everyone in the organization who needs to can access the EMR, but only about 20 percent of employees have access to the PM system.

That doesn’t mean the two systems aren’t linked; they are. “The integration between Experior and Allscripts is excellent,” says Dew. “We decided in advance which entered data we wanted to use to prepopulate the EMR, so we have eliminated a lot of data re-entry by building an interface. Data entered in the PM system flows right through to the clinical system.” This also facilitates the exchange of data between the clinical staff and the practice’s own lab and diagnostic imaging center. Should a patient go elsewhere for a test, those results usually are sent to the practice on paper, then scanned into the system. “The difficulty,” says Dew “is that it is scanned data, not data we can manipulate and extract back.”

For Dew, extracting data is a key function of the PM system. Will County Medical Associates doesn’t use a contract management module or system; staff enters all financial data into the system by insurer or payer, so the practice can extract it back out in a meaningful way. If a report is not extracting out, Experior will usually modify the system for Dew. “We regularly use the practice management system to evaluate if there are areas where we don’t get paid as much for certain services, so we can consider whether or not to shift those services somewhere else.”

All physicians at Will County Medical Associates use Motion Computing tablets in the exam rooms, so the doctors can view their entire schedule, knowing which patients have arrived and who is waiting. They also can add their progress notes and enter what services they provided along with charges. Finally, the addition of e-prescribing “has just about eliminated all call-backs from pharmacies,” says Dew.

Functionality Generates Efficiency

Managing data isn’t always the greatest challenge. For some end-users, maximizing the PM system to simply provide optimal office efficiency on a day-to-day basis—to use internal resources to the best advantage—is where it’s at. Scheduling, for example, is a hassle, but one that is critical to generating revenue.

With three physicians and two nurse practitioners, Family Practice Associates in Atlanta doesn’t yet have an EMR, but has been using a PM system from Nuesoft Technologies for about four years, says Patricia Golden, the office manager. Since each doctor sees between 25 and 30 patients a day, this system has definitely improved patient scheduling. “The NueMD system lets us view the schedules of all five clinicians at once, so we can schedule a patient to see a specific physician and a specific nurse at the same appointment, if necessary,” she says. “We can scan the entire day on one screen and move easily from patient records to scheduling to billing.” She says that because all coding and billing is electronic and the practice submits claims through a clearinghouse, “very few claims require us to use paper, and that’s a plus.”

Donna Sandello, the practice manager at Framingham Pediatrics in Framingham, Mass., also has seen major improvements in scheduling since rolling out both a PM system and integrated EMR from eClinicalWorks. “At a glance, I can see what’s happening in the office at any given time: how many patients are here, how many have come and gone, how many are yet to come in and for what,” she says. With six physicians, three full-time nurses and three to four part-timers, three medical assistants and about eight people in the front office, Framingham Pediatrics sees between 120 and 125 patients a day.

Keeping track of them could be challenging, but because the system color-codes the patients, nurses and physicians can easily track patients’ movement. That means physicians know exactly how much extra time they can spend with an individual patient, a big plus in a time when time for office consultations might be limited. “A lot of times, mothers will have questions for the doctor during the exam,” Sandello says. “With this system, the doctor can look at his tablet and know that if his next patient hasn’t arrived yet, he has extra time available for the mom.”

Having a Web-based system and doctors who are all computer savvy has helped the practice achieve its coverage goals without having to look to external source, says Sandello. Since the doctors cover for one another on weekends, having access to all patient information through the EMR is crucial. “Everything is funneled through the system,” she says. “Each patient has a folder and any incoming information gets assigned to an individual patient’s folder, or goes first to his doctor for review and then into the patient folder.” She says all physicians carry tablets into exam rooms and utilize e-prescribing; with automation, their clinical notes are formatted and legible, and referral notes are uniform and faxed directly from the system.

Systems That Think Like Payers

Gathering and disseminating information is part of every practice’s operation; the larger the practice, the more data to gather and disseminate. When Susan Nix went looking for a PM system, she wanted one that would function as if it were tailor-made for her practice.

As director of reimbursement and managed care with Sonterra Medical Management Group Inc., the administrative arm of San Antonio Orthopaedic Group LLP and the Orthopaedic Surgery Center of San Antonio, Nix says she evaluated products from six or seven vendors before choosing a PM solution from athenahealth Inc. in 2001. This vendor was chosen not only because it is an ASP (application service provider), but also because it caters to individual practices by “looking at what the practice needs and what will work for that practice,” she says. Two months ago, athenahealth announced a Web-based EMR service, something that athenahealth clients, including Nix, have waited for.

Nix says the 59-year-old practice has evolved into a “one-stop shop” with five locations including a six-bed surgery center, 24 orthopedists, a podiatrist and 15 occupational and physical therapists. The practice has about 12,000 patient encounters a month. She particularly likes the athenahealth rules engine in her PM system, which makes verification easier. “It’s a proactive look at claims,” she explains. “They have broken down every encounter into a formula, so from the time you enter a patient into the system, it starts scrubbing them and looks at what could be wrong.” Since all denial codes have been entered into the system, and because it has built-in triggers for every insurance company that has also been loaded, “it looks for what the payer says it wants,” she says. “It acts just like the insurance company when it gets the claim.”

Getting the Desired Results

Sala at Urology Associates of South Texas is another practice manager who expects his PM system to generate financial results, and he says the functionality of MicroMD has achieved that objective. As the practice grew, the original PM system didn’t, partly because it wasn’t Windows-based. Payments were received, but were not tied to individual encounters, making claims and accounting a formidable hurdle.

“Now we have achieved improvements in all aspects of managing data entry, coding and claims processing, posting payments and follow-ups on denials,” he says. “In early 2006, we submitted more than 1,000 claims totaling about $1.3 million in charges with no rejections from our fiscal intermediary clearinghouse. That level of performance has become routine.”

Efficient claims handling was what Jerry Wells wanted when he passed over three vendors before choosing both a PM and an electronic billing system from Companion Technologies. That’s because Wells has some challenges that other practices don’t.

Wells is the chief financial officer for Columbia, S.C.-based UCI Medical Affiliates Inc., the parent company of Doctors Care, a group of urgent care and primary care clinics that serve Columbia, Charleston, Greenville, Spartanburg, Myrtle Beach, Beaufort, Sumter, Aiken and Lugoff, S.C., as well as Knoxville, Tenn. “We had 600,000 patient visits last year, so we need to divide up claims in manageable batches,” he says.

Of 54 operating locations, 32 are Doctors Care facilities, but all billing is done from a central location, and there are seven separate databases. Although the company transmits its claims to a third-party administrator, the ability to manage claims from each location required an efficient and robust system. “Because we’re so high volume with many one-time patients, we need to key in the data correctly,” he explains. Wells says he is just about ready to implement an EMR, but also admits that since many urgent care patients are seen at the clinic only once, an EMR may not be as fast, in the long run, as dealing with paper charts.

A League of His Own

Then there is Tom Carli, clinic administrator at Spokane Internal Medicine in Spokane, Wash. Carli epitomizes the new generation of practice administrators. When it comes to routine practice management challenges like scheduling, extracting financial data and integrating incoming lab results into an EMR, Carli and Spokane Internal Medicine have been there, done that, bought the tee shirt.

A primary care practice with nine physicians and two nurse practitioners, Spokane Internal Medicine serves about 300 patients a day, 65 percent of whom are 65 or older. Since opening its doors in 1992, this practice has used an integrated PM system and EHR from Practice Partner, formerly Physician Micro Systems Inc. Taking the system enterprisewide in 1995, Spokane Internal Medicine went chartless in 1997.

It was about that time that Carli joined a local RHIO (regional health information organization) committee to build a data exchange among local providers. “What the nation is trying to do, we have done in our community already. We couldn’t wait for the rest of the world to do what we wanted to do, so we came up with methodologies with which we share information and communicate it to each other.” Carli says there are 33 hospitals in his region, all integrated with the system at Spokane Internal Medicine. “We receive between 450 and 500 healthcare documents every day in this office,” adding that maybe just 5 percent arrive on paper.

If a patient from the practice is seen at a local emergency department (ED) in any of those 33 hospitals, that ED electronically generates a report back to the practice. Citing ease of movement of data as the top functionality within his PM system, he says, “If we didn’t have that, the physicians wouldn’t have the information they need at the time of encounter with the patients.”

In the beginning, the clinic chose the Practice Partner product for one primary reason. “We looked at the application in two ways: How easy is it to get information into, and how easy is it to get information out of?” The strategy worked well; he says the product “integrates very nicely with every application” encountered in his region.

The Future: Changes Afoot for the Next Decade

Wells and his practice executive colleagues see numerous changes in the years ahead—some major, and others minor but with lasting impact—and they expect their vendor-partners to keep pace with product improvements that address these changes. In most cases, however, these changes aren’t necessarily the same issues upon which the federal government is focused. Rather, they are a combination of what today’s practice managers have begun to encounter in servicing their patient populations and the technology they want to help them do that better tomorrow.

“With the invention of healthcare savings plans, we’ll see a lot more people paying at point of service,” says Wells. He says he is uncertain exactly how it will affect office operations, but he wants to be ready. Golden, too, forecasts changes coming in payments and reimbursements. “We have a lot of Medicare patients,” she says. “More than 60 percent of one physician’s patients are Medicare patients. Enhanced verification capability will probably be needed, with so many different options for Medicare.

“We’re also starting to see more health reimbursement accounts and health savings accounts,” she notes, adding that it behooves patients to educate themselves about such options. “Patients are used to coming into a physician’s office, paying a $15 copay and not worrying about it. But health plan changes are hard to understand, and too many of them will put the burden on physician practices to explain to patients. The practice’s systems need to handle as much on an automated level as possible.”

Another influential trend, according to Wells, is consumer love of the Internet. “The patient population expects to do more online,” he notes. “A major complaint for patients is wait time. If they can go online and register, that would save time.” What patients need, he says, is connectivity with the practice management system, and PM systems that accommodate self-registration and self-scheduling efforts, plus the electronic handling of patient queries.

Carli agrees. “The focus must switch to include more than support for the staff and physicians that give us better delivery of product and must include patient involvement. We could benefit from adopting the kinds of customer-care services airlines use in online ticket-purchasing or check-in. We need to position ourselves for more customer-friendly services that can come from the next five years of technology.”

Links and More Links

Physician practices that view customer service as a critical underpinning of their business all support increased “links”—online connectivity for self-service among patients, online communication between patients and physicians, electronic entry of physicians’ orders for meds, labs and images, and data sharing among multiple provider organizations that serve the same patient so no treating clinician is short of data. Wouldn’t it be lovely?

The federal government agrees in theory, but is addressing some of these needs in a big way through construction of a national infrastructure for data exchange. Agencies like the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services are moving single-mindedly in the e-direction for all meaningful and monetary transactions. In fact, at a press conference last summer, when HHS Secretary Mike Leavitt joined Mark Leavitt, chair of the Certification Commission on Health Information Technology (CCHIT) in announcing the first 18 vendors to have their EMR products CCHIT-certified, he said that in the future, entities that wish to do business with the federal government will do it electronically.

When the feds refer to links, they mean the NHIN and a shared information superhighway previously unimagined by healthcare users—so seamless and so transparent that any clinician treating any patient can access the data he needs with a mouse click or two.

Practices Have Goals of Their Own

A stumbling block for some practices would be the cost of technology required to participate in a viable network, even if they didn’t have to help pay for construction. For many practices, even if funds were available, the first priority would be to purchase technologies that satisfy the immediate needs of the practice—not a regional or federal network. “We’re trying to implement and adopt IT as we can afford various functionalities and applications, often one module or feature at a time,” says Dew. Even if he had unlimited funds, Dew says he would still implement IT technologies incrementally because that particular style works best at Will County Medical Associates. “Administrators like me work for doctors, so part of our job is keeping the physicians happy.”

Cost is a concern for Atlanta’s Family Practice Associates too, where, again, the internal needs of the practice are clear and the top priority. “We’re in favor of data exchange; we’re not nervous about it,” says Golden, speaking of the federal initiative. “But there are many simple components we don’t have yet. We definitely want to be able to interface incoming lab data with our patient data and not to have to re-enter data. But an EMR is an expensive investment for a small practice. Until our administrator finds one that he thinks will really meet the needs of a small family practice, we will wait. We need the time savings from computer systems, and we need to be able to communicate with other systems, but first we need an EMR system that works for all the doctors in this practice.”

Nix of San Antonio Orthopaedic Group and the Orthopaedic Surgery Center of San Antonio says that she has seen “no incentive in dollars for the practice,” to head in one NHIN direction or another, so the decision to contract with athenahealth for its EMR service was driven by “our own desires and our own needs, and by looking at what we want to achieve.” Nix says “the intent is good,” but she wonders whether the government can succeed in implementing such a large-scale project within the narrow timeframe it has set.

The slowness with which certain practices have adopted newer technologies also has Golden wondering about the future. “This kind of a vision requires that every referral practice uses technology. Right now, we refer patients to practices that won’t accept a patient unless we fax a paper form. That kind of situation needs to be remedied first,” she says.

The Crystal Ball

Practice managers are well aware of federal initiatives like standards consolidation, the NHIN and universal adoption of EMRs. Real-life physician practices must scope out, test and buy products that meet their needs today and tomorrow. For most practices, planning for business in the uncharted waters of 2024—a realistic timeframe for the NHIN, systems interoperability and universal adoption of EMRs, according to pundits—isn’t part of their “here and now.”

At the end of summer, 22 EMR/EHR products had been certified by CCHIT. Hopefully, more will be certified, but how many more and what of the products that aren’t certified? Will they disappear? Certification of EMR/EHR products is closely related to development and consolidation of standards. In fact, all of the products certified met more than 250 standards for clinical functionality, security and interoperability. Carli knows firsthand how critical standards are. “When setting up our community infrastructure, we spent the largest part of our time developing standards that we could all play by.”

In just his RHIO alone, the 33 hospitals may represent 1.5 million patients in their database, and Inland Imaging, he says, may have close to 1 million names in their database. A local laboratory provider that operates in multiple states might add another 2 million patient names to the total. “And our little office here has about 17,000 or 18,000.” The point, says Carli, is that RHIOs and their systems must be able to identify every patient and dozens of documents and images belonging to each patient—and none of it can be implemented without strong national standards.

Will these physician practices and their counterparts across the country be ready to plant their feet on the information superhighway of the future? Some have a way to go including utilization of an electronic medical record. Others, like Dew at Will County Medical Associates, are confident that they will be ready if and when a nationwide network is launched. “We have the right mindset for the future already—to share data about patients with local EDs and with physicians in other locations—because all this makes it better for the patient,” he says. “Now, we’re just watching to see what the government mandates.”

At Framingham Pediatrics, Sandello says the practice is undaunted. They have the technology important to doctors and office staff alike. “I think we’re ready at this practice. In fact, we’re waiting for the rest of the world to get connected.”

And then there is Tom Carli and Spokane Internal Medicine. “Bring it on.”

Richard R. Rogoski is a free-lance writer and contributing editor to HMT. Contact him at [email protected].

For more information about practice management products from:

athenahealth www.rsleads.com/610ht-208
Companion Technologies www.rsleads.com/610ht-209
eClinicalWorks www.rsleads.com/610ht-210
Experior Healthcare Systems www.rsleads.com/610ht-211
Microsys Computing www.rsleads.com/610ht-212
Nuesoft Technologies www.rsleads.com/610ht-213
Practice Partner www.rsleads.com/610ht-214

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