Author: Chandresh Shah

Chandresh Shah specializes in Healthcare IT and Medical Billing. He knows the market inside out; what works, what doesn’t. He advises and works with small business owners.

How Much Training is Enough?

Last week’s article – “All EMR Software is the Same” got a very good response. I got interesting feedback, one of which is about training. They asked me about the different approaches various vendors take on the subject of training.
I’m assuming we are talking about Web-based EMR software that is based on a monthly subscription fee. I have seen two models – one where a vendor does not charge any ‘upfront’ fee, and another where a vendor charges an upfront fee for training but their monthly fee is lower. Which one is better?

Before we look into “which one is better”, I’d like to talk about the fundamental differences in approaching Training that have a profound effect on how training is imparted.

No Upfront Fee model

If there is no upfront fee involved, a business tends to look at Training as a ‘cost center’ – an expense that a company has to deal with. We know that financial accountants and business owners try to minimize expenses. By direct implication, they cut corners. The quality of training tends to suffer. There is a general lack of ‘incentive’ for the management as well as employees since there is no ‘accountability’.

As they say, there is no free lunch. In spite of the ‘no upfront’ fee label, guess what, you’re paying for it- financially by raising the monthly fee or in terms of quality.

What I fail to understand is why providers fall for this.

In fact, I venture to say that Training and implementation are more important than the software system itself. A bold statement, yes, but I want to stress the importance of not compromising Training because Quality and Quantity are both important.

Upfront Training Fee model

I urge you to look into this model because of two very simple reasons.

  1. The company is accountable and responsible for doing adequate training within a timeframe. Since this is a source of ‘revenue’, they are liable to hold their employees accountable for the quality of training satisfaction.
  2. Second, it holds you and your staff accountable – you have a set number of hours to get trained in. You and your staff better pay attention and learn as much as you can.

Another Model

Seek out unlimited training options if available. I guarantee that not many companies will offer it. In fact, try to do this – put a ‘penalty clause’ if training is not scheduled within a stipulated timeframe.

The next best thing is, to have the option to buy training ‘on demand’.

How much Training?

Here’s a guideline that I have created and found useful after many years of experience. This is based on practice sizes of 1-5 providers. There is variability in individual experience with technology, tech savviness, etc.

Before Starting with the system, but after the system has been set up and customized 8-16 hours
1 Month after going live 4-8 hours
Month 2-6 4 hours per month
Months 6-12 2 hours per month

What this means is that in the first year, you need between 44-56 hours of training, however,

Training works best if…

The Vendor and your Practice work in the spirit of ‘Partnership’ rather than an adversarial ‘client/customer/supplier’ relationship.

What does this mean? How do you determine whether or not a relationship is a true ‘Partnership’?

A good partnership begins with the first call to your web-based software system supplier (prospective partner). Here are some examples of indicators:

  • When you call and leave a message, how are you treated? How soon is your call returned?
  • Does the company attempt to answer your questions, ask you about your concerns, or just try to sell you their system?
  • Do you answer their questions in a professional manner? Do you return the salesperson’s calls? If not, why not?
  • Do you show up on time for online demos and meetings? If not, why not? Don’t some practices charge patients for ‘no-shows’? So, let’s treat each other equally.
  • When trainers are there in your office or online, do you spare time for them and really give them full attention?
  • Does the Company support staff give you their best attention and care as you would to your patient?

Now you know what I am talking about.

So, don’t skimp corners when it comes to training and, please, strive to establish a true partnership. If there are genuine financial reasons why you can’t afford a system that you truly like, tell them. They may work out something for you. But at the very least, have the courtesy of telling them why you can’t partner with them. No one is going to hound you for your decisions. There may be a few ‘used car salespeople’ out there, but by large, they want to help you.

All EMR Softwares Are The Same

“I’ve looked at so many systems, they’re all the same – just tell me how much is yours…”

I hear this every day. So many of my colleagues at various EMR vendor companies echo this.
So, are they really the same? Yes and No. Let me break it down.
Yes, they are the same, if… All you need is a ‘vehicle’ to go from here to there, then all cars are the same, without taking into consideration quality, manufacturer, long-term value, resell value, comfort, and so on. When it comes to EMR, they are all the same if –
  • the only reason you are getting an EMR is to get the incentive money from CMS
  • you believe your practice is so efficient, that there is no scope or room for improvement
  • you think of EMR as just an ‘island of automation’ without consideration of other moving parts of your practice
  • you think of your Practice as a center for patient care, which is great; however, you don’t run it as a true ‘business’ trying to bring efficiency, increase productivity, and therefore profitability.
  • you fail to recognize the benefit of ROI. Unfortunately, most practices run on a weekly/monthly cash basis rather than as an ‘enterprise’ that looks at return on investment
  • you fail to ask a critical question to your prospective vendor – ‘tell me the background of this company/product’.
I will elaborate on the last bullet point – “Tell me the background of this company/product” a little bit later.

No, not all EMR software companies are the same.

  • Who is the founder of the company?
  • Does that person have an IT background?
  • If the founder is a physician what is the role of the physician – just an investor, or, an active designer of the system?
  • Does the company have a physician as a partner or owns 90% or the majority of the company?
  • Where is the support based?
  • Who are the people that provide the support? Is it clinical people or information technology people? What are the credentials of the support people?
Now let me talk about why it is important to find out about the background of the company/product.

If you look at the history of EMR software, it is clear that originally medical record software was created just to record clinical charts. Billing software was the first piece of technology for healthcare. They did not talk to each other in the beginning. Then everyone realized that clinical charting software and billing software need to talk to each other to become efficient. However, they were on different database platforms. They were then ultimately ‘interfaced’ – NOT – ‘integrated on one platform’. May not matter to you, but there is a huge difference.

If a vendor started off as an EMR company and then added or merged a billing component to it, that shows that the emphasis is more on clinical documentation, and vice versa. It would be ideal to find a vendor who had the vision to create a system with a common database trying to optimize the business of a medical practice to begin with.

What would you call such a system? Practice Management System? I would call it a Practice Business System. It sounds like a new term, but if you keep it in your mind it will allow you to focus on what you need and how to approach vendors when considering a ‘system’ for your Business; not just clinical charting.

Web EMR Selection is Hard?

I fully understand and know how hard it can be, given that Web-based EMR is not just another way of ‘clinical note taking’ as some people call it, but it is a paradigm shift for practices. I call it a paradigm shift because it changes almost everything that you do in your practice. It affects not only you but the entire staff.
There are several things that I urge Physicians to do.
  • Don’t make a decision in isolation, involve your staff, get their full buy-in and commitment, and not just because the ‘boss’ wants it.
  • Look at the impact on the entire practice – the workflow, productivity (loss or gain), and also the impact over time. How does the ‘curve’ look? How long will you ‘hurt’ before it starts yielding the benefits?
  • Don’t just look at the ‘features’ – I know. Most good systems have all the features. It is about the implementation, the support, the productivity.
Before I show the system, I try to understand your practice, and your workflow and then try to ‘map’ it to see how it may work in your practice. If it is not a good fit, I will tell you upfront. It would not make sense to ‘fit a square peg in a round hole’.

Simplicity of EHR

Must the EHR operating instructions be so complicated?

http://www.ehrwatch.com/blog/must-operating-instructions-be-so-complicated

Segmenting and dissecting implementation and product operating instructions in isolation is not appropriate. It all starts with product design, which you alluded to in the beginning. The easier and simpler the product, the more difficult it is to design and build on the backend. Ask any engineer and software designer. Ask Apple. But, once you design a truly simple product, simplicity in operating instruction and therefore implementation is an extension of that philosophy.

Stage 2 Meaningful Use – Most Asked Question

The most confusing element of the Stage 2 Meaningful Use Final Rule has to do with a ‘mandatory’ requirement for patients to access their records online.
In stage 1, the objective was the following:

Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, and medication allergies), upon request.

The key here is ‘upon request’. In my experience, I have not a single instance where patients have requested an electronic copy of their health information.

Stage 2 objective now states the following:

Provide patients the ability to view online, download, and transmit their health information within four business days of the information being
available to the EP.

If you notice here, the words ‘upon request’ have been eliminated. Let’s examine and dissect what the Stage 2 Measure states. The measure is split into two parts:

  1. More than 50% of all unique patients seen by the EP during the EHR reporting period are provided timely (available to the patient within 4 business days after the information is available to the EP) online access to their health information.
  2. More than 5% of all unique patients seen by the EP during the EHR reporting period (or their authorized 4 representatives) view, download, or transmit to a third party their health information.

This Measure will be left to individual interpretation by both the certifying authority as well as the EHR Vendor. Every vendor has a unique way of presenting information and the implementation will vary. It will be easiest for vendors that have an integrated Patient Portal system. This way, the entire measure can be ‘automated’ without requiring the provider to do anything at all.

The second part of this measure will be tricky. How do you require and ensure that at least 5% of patients view, download, or transmit to a third-party their health information? What if your patient population does not have online access? Who can be defined as a ‘third party’?

The first bit of clarification may come from the certifying authorities. In any case, seek clarification from your vendor.

Solo Physician Practice is Dead? Web EMR Inquiries are Up! Go Figure

I just read this headline today “Recruiting Firm Says Solo Physician Practice is Dead”. I’m not sure if I agree. Read this article here.
The reason why I don’t agree is very simple.

  1. Inquiries from Solo Physician Practices looking for Web-based EMR systems are up. If what this report says is true, why would solo practices want to invest in new technologies?
  2. Inquiries from Physicians starting New Practices and looking for Web-based EMR are also up.

I was actually surprised when I analyzed some data of incoming inquiries for web-based EMR systems and tried to figure out how many of them were from solo practices and how many were actually starting new solo practices. It has actually been up in the last two years.

While I think there may be a trend, American Entrepreneurship is not dead, in spite of what is going on in the healthcare world.

EHR Meaningful Use Audits

CMS has hired a CPA Company, Figliozzi & Company out of Garden City, NY, to perform audits of providers that have attested to having achieved EHR meaningful use under ARRA.
Those providers ‘chosen’ for audit will receive a letter from the contractor. The letter will have the CMS logo on the letterhead.

CMS has posted audit guidelines on its website.

Who can be audited? I don’t think there is a way to determine who may be audited. There is no legacy data or history to come up with a pattern. If you receive an audit letter, there are just a few things you may need to provide.

  1. You would be asked to provide proof that you have purchased and are still in possession of (or access to, in the case of a web-based EHR) an ONC-certified EHR system.
  2. Second, prove that the data you reported for core and menu set measures were generated from this system. So, in other words, you really used the certified EHR system to generate data for reports, and therefore you used the system in a ‘meaningful way’. This should be easy to do if your system generates the report for you. You should also be able to generate the same report again if required by plugging in the attestation time period you originally selected.
  3. There were some items that were a yes/no attestation, based on what the EHR system is capable of, for example, ‘implement drug-drug and drug-allergy interaction checks, or ‘Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities’, i.e. Security risk analysis. I am not sure if you will be required to submit proof of this, because this capability is something that is intrinsic to the Certified EHR system you selected. So, even if asked, you would have to get the auditors in touch with the vendor.
  4. Finally, will they do site visits? I honestly doubt it. I think since Attestation was an honor system, they are probably just looking for major defaulters, or identify general failures with some key requirements.

I would like to hear from anyone who has received such a letter.

Upside Down Evaluation of EMR

Three questions a physician asked me yesterday.

  1. How can I save money?
  2. What can I do to NOT slow down?
  3. Yellow Pages is now Dead. What should I do So that patients find me?

All of this was in the context of EMR. What caught my attention immediately was that he was not focusing on ‘features’ and ‘tech’ talk but on real issues related to running the business of medical practice. If you look at these questions again, it tells you one major thing. Focus!
FOCUS!

  1. Address the main Business issues and concerns first. Not just your business afflictions or ‘pain points’ but also your ‘Aspirations’. This includes all the questions the doctor asked me that may be applicable to your situation, and more.
  2. Only after You’ve written your questions and business concerns, then you start drilling down to level-2 questions such as -what technology?
  3. Level-2 questions would include – Web-based EMR? Cloud EMR? Client Server? Windows or Apple? Mobile?
  4. Finally, the features, user interface, accessibility, and so on.

As you start making a list of each of these four levels, make sure it Connects with the level above.
Unfortunately, most providers (and even vendors) start in the reverse order and try to ‘retrofit’. This is a recipe for disaster and failure. This is why by various estimates 70-80% of EMR implementations fail.
In another blog, hopefully, soon, I will try to list out sample questions for each of these 4 Focus levels.

WHY Ask WHY

Why are you a Physician?
Most of the doctors don’t think of this question anymore unless you just graduated. You don’t think about why you chose the medical profession. It has probably been your life for a long time, but if you had to think about it, I would venture to guess that it had to do with joining (as a human being) a unique profession which is given by our society great responsibilities and challenges at the same time. You have been entrusted lives of others in your own hands.

You are different from an airline pilot that is also responsible for the lives of many but that also includes their own. When you save a life it is not because doing so saves your own life.

There is more to being a doctor than society’s approval. There is a genuine good feeling from doing good. There is a sense of fulfillment.

Then of course, there is the comfort in doing all this that you are being financially well compensated and assuming you have the time to enjoy the fruits of your labor, you can ‘own’ the best things that the material world has to offer.

If your motive was altruistic, that’s fantastic, but then WHY are you in your OWN Practice? WHY not just work for a hospital or large group?

Your human need to be helpful to society is fulfilled, and you start looking at the financial side of things. You start looking at who you are as a person. You enjoy the freedom; both personal and financial, of being in charge of your own destiny. You like being your own boss. Being in your own Practice, and being in your own Business affords you all of that, and hopefully more.

Time flies, and you quickly find out grass is not as green as it looked. Being in business has its own set of challenges. Ranging from managing human resources, paying bills, and balancing books to decreasing reimbursements from payors. Compound that with the fact that you seem to have ‘lost’ your life. Look at the first WHY – Why you chose the medical profession. You are probably still dedicated to your patients, but then you have sacrificed something along the way. You no longer have a ‘life’ or freedom to pursue your other dreams, your hobbies, and spend quality time with your family.

You embark on a Mission to Save Yourself.

WHY?

You’ve worked hard to become a Doctor. You’ve worked hard to establish yourself in the community and sharpen your skills. Your patients like you, and your peers respect you. Employees adore you (hopefully!). Your family respects you, but you need their love, not respect. You need time for yourself, and your family and do things that you promised yourself you’d do someday.

In the meantime, the world of Healthcare is turning upside down. CMS is pressuring you to go ‘digital’.

WHY?

The general consensus is that it will, over time, improve patient care, reduce costs, and make healthcare more affordable for the overall population. But what about you – the Provider? They didn’t ask you, did they? Anyway, you decide to jump onto the bandwagon.

WHY?

Because if you don’t, you’ll be outdated, your reimbursements will be cut and you will miss out on the attractive ‘EHR Incentives’ that CMS is giving out – a nifty $44,000 worth (for Medicare). Then you convince yourself, we’re being forced to do it, so hey, why not take advantage of it?

Wait a minute – the WHY became WHY NOT.

Along the way, you lost something. You lost the purpose. You lost the vision. Go back and read the first two WHYs. Do you see what I am saying? Honestly, it is okay to go Digital. But for God’s sake, don’t do it for the wrong reason. Don’t do it as WHY NOT. Do it for the real reason.

“Do it because you want to reclaim your life.”

HOW?

EHR or EMR or whatever the hotshot consultants decide to call it needs to be recognized for what it is; just a tool. Before you buy or acquire anything, don’t forget to ask WHY. Then connect that WHY to the first WHY and the second WHY.

WHY should I buy an EMR? Will it improve my quality of life? Will it give me myself back? Will it put quality into my life again? If not, don’t get it. Because by getting it, you’re just going to make things worse. It will be one more ‘master’ to which you have to answer and bow down every day.

Seek out tools, technologies, and widgets, that give you the Real answer to your WHY. Is there such a thing or are we dreaming of Utopia?

I believe there is. It is perhaps disguised under a cloak of some lame name. Perhaps there is an ‘Apple’ out there. Even Apple has to call their cool stuff – guess what – computers, and smartphones. But, it is not ‘just’ a computer, is it? So, there are such hidden gems out there that will give you your life back. They may be hiding behind the ‘EMR’ curtain. Seek them out.

HOW?

When you ask for a ‘demonstration’, seek to answer the WHYs. Your WHYs. Don’t fall for the trap of Can it do this, can it do that?

Let’s seek out these hidden WHY-Busters together.

Fear and Risk of EMR Implementation

This is another story of a conversation I had yesterday with a two-provider clinic that is considering a web-based EMR (Cloud EMR or SaaS EMR, whatever you want to call it).
The Providers are all excited, and gung-ho about getting started. They’ve done their homework. Started off with an on-site demonstration, and talked to some of the vendor’s clients in detail, probing them with everything from ‘Are you happy’ down to the nitty gritty. They even visited the Vendor company to get a feel for who’s behind the company and talked to the CEO as well as their support and training personnel. Finally sat down to negotiate the price.

Oh, by the way, they did the right thing. Initially, they did not ask, ‘How much’? They wanted to know if the solution was within their range and affordable, rather than asking for a full quote upfront. That’s the way it should be. You are not buying candy or commodities. This is a complex solution that will change the way a Medical Practice does business forever. How can you just buy on price? If so, why not just have ‘shopping carts’ for EMR – one of this and one of that? Pardon my anger and frustration, but some providers just don’t get it.

Anyway, I digress…

In a casual conversation with their staff, initially, no one spoke in front of one of the owner providers. Someone casually mentioned – ‘Dr. is excited, I’m not sure about us’. That broke the ice.

We had a very candid conversation to bring out what the fear really was about. Everyone had their concerns, and as I listened, it became clear that this was not unusual at all. I think this kind of fear exists everywhere, it is just that most people don’t express it. Here’s what I heard in a nutshell –

  •  Biller – I’m just afraid about the entire migration. Will something get dropped in the process? I will have to work with two systems in parallel for a long time, I don’t know how long… when do I know when to transition entirely?
  • Office Administrator – What do I do with paper charts? Doc is not very tech-savvy, I am afraid this will just create chaos. Something will be on paper, some on the computer, and will we scramble to find what is where?
  • Front desk and other staff – Just the usual fear of the unknown.

It was interesting that at the end of the meeting, everyone was looking forward to going electronic.

Why?

It is always the fear of the unknown. Bringing out the issues and fears in the open, addressing them head-on, is half the battle won.

The key is for all Practices, their EHR / EMR champions to hold such meetings and bring out issues in the open. Hold these meetings with vendors, and consultants so that it does not appear one-sided.

It is extremely crucial to have a complete buy-in from all involved, otherwise, you will not have a great implementation.

In summary, EMR Implementation success is about communication more than anything else.