EHR – Hope and Reality


Seth Godin wrote very well about Hope and Reality in our lives. “Sometimes, we don’t sell what we’ve got, we sell what could be.”

He gives the example of Bruce Springsteen’s autobiography. just the proposal can sell for $10 million, not the finished book. Why? It is what can be.

That’s how the Stock Market works.

That is how EHR companies sell. Hope. That is what Doctors buy – Hope.

Hope is not necessarily a bad thing if it is combined with due diligence and trust. The problem is not many providers and medical practices have experience in conducting proper due diligence on EHR systems. I have written about this in the past. Prepare instead of hoping.

The only way to get the maximum out of EHR demonstrations is preparation. I have seen too many demonstrations where they are all over the place. You must know what you want. Write it down. Here is a simple guideline.

1. Write your current workflow. Office workflow, from patient calling for appt, check-in to check-out. List your staff, and write down who does what and in what order.

2. Identify ‘gaps’ or ‘areas of improvement’ in your workflow map.

3. Potential pitfalls and fears in implementing technology.

Now, Prepare a Demonstration Script.

1. Take your most common encounter/patient visit. Look at a few finished visit notes.

2. De-identify the set of note(s) so that patient information is removed.

3. Send it to the demo person(s) – at the time of the demo, or just before so that they have enough time to review it, but not enough to ‘fudge’ their system. Also, send them or tell them your workflow.

4. Ask them to stick to the script. Only after that is done, they can show off their system with other ‘features’. But tell them what you care about and what you don’t.

5. Finally, ask them – ‘What would you do to improve my workflow and make my practice more efficient’? This is one of the most important questions, don’t skip it. It will tell you a lot about how this vendor approaches things.

Proper preparation converts hoping to reality

FREE Data Conversion from EHR System

“Free data conversion from your current EHR and Practice Management system!”

— ANY EHR Vendor

As a Provider or Practice manager, what do you think when you read this sentence?

  1. ‘This vendor will extract the data from my existing system AND import it into the new system – for free.’
  2. ‘This vendor will just import the data into the new system – for free. This means it is still my responsibility to get data from the old system.’

Let me know – 1 or 2?

Is Practice Fusion the Next Victim? Why Should You Care?

“Not good enough to pay for,” a physician client told me in a recent conversation regarding Practice Fusion. The old cliché, “You get what you pay for,” is true after all!

I have been talking with a lot of practices and physicians who use Practice Fusion as their electronic medical records system. After the recent announcement Practice Fusion is being acquired by Allscripts, clients received notifications Practice Fusion will no longer be free.

From the practice and physicians’ perspective, the main and perhaps only attraction of Practice Fusion was that it was a free system. For most practices, it served its purpose, allowing them to be compliant with meaningful use and even receive incentive money.

The question is, if this system worked for doctors in the past, why are they looking to switch? After all, they are used to the system, and change is never easy. I’m not saying everybody will switch, but I suspect a majority of practices have started looking for cheaper or more stable alternatives.

The Acquiring Company Is Allscripts;
What Does That Mean for the Future of Practice Fusion?

Look at the history of Allscripts with respect to acquisitions. Their journey started with a merger with Misys in 2008. Since then, they have had a number of acquisitions including Myway, Eclipsys, Medinotes, DB motion, Jardogs, etc.

In most cases, these products have eventually withered away. Allscripts tried to move their customers onto their main platform of choice. Practices suffered.

Allscripts’ most recent acquisition before Practice Fusion was McKesson. With all these islands of technology and Allscripts trying to achieve economies of scale, it is nearly impossible to maintain and keep them all alive and thriving at the same time.

At one point, Practice Fusion was the darling of the industry. So many investors got in, that it was worth $1.5 billion. In the end, Allscripts got the company for a measly $100 million. That should tell any provider remotely considering sticking with Practice Fusion that it is time to abandon the sinking system.

I can see the writing on the wall—or my blog just a few short years from today—Allscripts is sunsetting Practice Fusion and doctors won’t be riding into the sunset with it.

Fighting Physician Burnout – Don’t Blame EHR or Healthcare IT

The Healthcare IT News article “Fighting Physician Burnout: How Tech Can Undo the Damage Done by EHRs” is enticing; it promises that healthcare information technology and EHRs can solve the burnout problem.

I have a different take on it. The physician burnout problem is not caused by technology per se; it’s about workflow and how technology is used.

As I read the article, standard concerns about healthcare information technology stood out:

  • Software should not go down.
  • Service should not be interrupted.
  • EHR should be integrated with critical systems.
  • Better document management is important.
  • Information should be readily available and easily searchable.
  • The information must be reportable.
  • Communication within the practice is important.

There are many very good systems I’m aware of that do all of the above quite well. Many tech-savvy physicians have been using these systems, and despite all of this, these tech-savvy physicians complain of burnout — they complain of turning into data entry operators!

What is the real issue?

Efficiency must be measured in terms of the big picture rather than as just software and clicks. Physicians are a practice’s most important — and expensive — resource. Their every moment is valuable and must be spent taking care of patients. All other tasks can, and should, be delegated to staff who can utilize healthcare information technology to accomplish everything a physician needs for critical clinical decision-making.

What this means is using technology to have information at the physician’s fingertips and making the information available when and where he or she needs it; however, the physician doesn’t have to be the primary technology user to enter or pull data.

It’s all about the workflow

I’ve helped many physicians jump the hurdle of the EHR technology barrier. It is possible for the provider to deliver good care without becoming a data entry operator, but still take advantage of everything healthcare information technology has to offer. The provider can do all this with minimal keyboard and screen contact.

Workflow example

Provider walks into the exam room. Past notes, triage notes, vitals, results of orders, and radiology, are all available and displayed on the computer screen for the provider to review immediately. How that happens varies from practice to practice. The important thing is that the provider doesn’t have to spend time clicking or typing.

Provider spends time talking to the patient. It is important to note that the provider’s only task is to talk to the patient while maintaining eye contact.

As the provider talks to the patient, the nurse or medical assistant interacts with the EHR to enter the discussion’s pertinent details.

The provider has minimal interaction with the computer. Their interaction should be limited to selecting diagnostic and CPT codes and e-prescriptions, if necessary.

The provider goes to his or her office and dictates a personalized narrative into the EHR system. This should not take more than 60 seconds. Often, it takes fewer than 30 seconds.

The provider can quickly view the note and sign it.

The provider moves on to the next patient.

Some of you may argue that the provider cannot afford to have additional staff in the exam room. What I fail to understand is when it becomes acceptable to have a provider with a very high hourly rate perform data entry instead of a medical assistant. The above workflow may allow a provider to see one more patient per day, or to go home early, thus achieving a work-life balance.

Efficient medical practices use a combination of great technology and improved workflow. The above scenario allows all the advantages that EHR technology has to offer without converting a provider into a data entry operator.

How Much for EMR? Nickel and Dime?

I had written about how much you should pay for an EHR system.

I would like to talk about the concept of EHR pricing: Chinese menu versus nickel and diming. Some vendors are notorious for nickel and dining every little thing about their system. The reason I’m bringing this topic up is because sometimes we get confused between the 2 types of pricing.

We’ve all gone to Chinese restaurants and we know what a Chinese menu looks like: it’s long, it’s huge, but the idea behind this is that you pick what you want to eat. Similarly, you pick what you want in terms of EHR features and functionality versus just very high-level bundled packages like a prefix dinner.

This is perfectly normal because when you do your practice analysis in terms of what your needs are, you know what specific things you need in your system.

What bothers me most is when people start nickel and diming. For example, when you go to a Chinese restaurant you don’t want them to charge you extra for soy sauce, and you don’t want them to charge you for a cup or a fork – that is nickel and diming.

EHR system vendors say they are including text messaging and faxing, It is a cloud system so storage is included. They say that we will allow 100 faxes, 1 GB of data storage, and so on. That to me is nickel and dining. It’s very similar to your mobile/cell phone plans where they give you a certain number of minutes per month; they give you a certain amount of data per month.

They don’t have any more genuine unlimited plans where I don’t care how much you talk, I don’t care how much data you use. A flat fee that is predictable, is absolutely essential for business.

What I’ve seen typically is. There are at a high level probably 3 types of main bundles:

  • Clinical/EMR module
  • Billing module and
  • Combined software

Within these, there may be many features that are probably included and you need to evaluate them carefully. There may be certain optional items, and these could be anything ranging from EPCS which is controlled substances electronic prescribing to text messaging.

Some people have good productivity tools such as digital pens, medical card scanners, and so on, and that, I can understand as optional.

Therefore when you’re comparing different systems and vendors what I want you to do is to start making a list of the things that are included and what different vendors want to charge.

Watch the video above to see how to compare EHR software vendors’ pricing.

How Much Should You Pay for EHR?

They range from $0 (Practice Fusion) to $800 per provider per month. Most EHR systems charge a monthly subscription fee these days.

So, how much should you pay?

If you think all EHR systems are the same, buy the cheapest Certified EHR system. Right?

When you say ‘they are all the same’, what you really mean is that all certified EHR systems have the same ‘features’. i.e., they do charting, they store patient data, labs, ePrescription, ICD-10, CPT, and E&M coding, etc.

For Example, both iPhone and Android devices have all the ‘features’, yet you choose one versus the other. Why?

OK, so they are all NOT the same. 

Second Question: How much can you afford to pay?

Before we try to answer that, ask yourself this.

“What would be at stake if this is NOT the right system for your practice, makes everyone non-productive, staff wastes lot of time?”

EHR should not be taken lightly. The negative impact is very critical. By implication, looking at EHR as a cost and expense is not correct. EHR must be a proper financial and investment decision. You wouldn’t hire a nurse that wants the lowest salary, would you?

Let’s break it down.

  1. All EMRs are NOT the same.
  2. Don’t go by Price. Don’t start a conversation with ‘how much’? You are not buying potatoes.
  3. Prepare very hard and meticulously – as if you are starting a business.

Prepare very hard – as if you are starting a business

This is one element of your practice that, as I mentioned earlier, can have a tremendous impact on our business bottom line if you choose the wrong system and the wrong vendor. Here are some things I recommend you must do before you see any demonstration.

  • Have a written document outlining the complete practice workflow.
  • Have your staff write specific parts of the practice workflow that are inefficient and can be improved.
  • Identify 5 cases that represent 80 – 90% of your patients (unless you’re a super-specialist where each patient is truly unique). Use these cases to benchmark systems. Share these cases with the vendor (de-identified) and ask them to walk you through these cases.
  • Ask the vendor to show how they can bring improvement to your practice rather than focusing on particular features. There may be many ways to accomplish the goal.

And finally, determine a budget that you can afford and something that can bring positive ‘return-on-investment’ (watch the video below)

EMR Systems are NOT expensive.

Talk to your Accountant/CPA. Look at your Profit and loss statement and determine the distribution of costs. You may quickly find that you sometimes spend more than the monthly fee of an EMR on things that do not have such an impact on the success (or failure) of your practice.

And finally, don’t be afraid of spending slightly more than you can afford to get the maximum value and support from your vendor. It will pay off!

A Pre-Judgement Problem – Why Most Practices Select Wrong EMR/EHR

For most companies, businesses, medical practices included, success depends a lot on the team that you have recruited. It goes without saying that picking a winning team is crucial. The problem is we are very bad at it.

SAT is a bad indicator of college performance and even life performance. Yet colleges have to use it anyway. Somehow we keep on pushing our kids along the same path.

Professional sports spend billions of dollars every year to recruit what they think are the best players. Yet scouts continue to pick the wrong players. Having watched Moneyball we know that we tend to ignore useful data and rely too much on our instincts.

Selecting and choosing EMR systems is no different.

When we invite vendors for a demonstration do we even think about what was a criteria for their preselection? We may have gone by recommendation of a third party or a trusted friend. We allow somebody else to prejudge us. What we should really be doing, is to understand our internal needs first by talking to the entire team. Focus on prioritizing what is important and what is not.

It takes guts to stop prejudging because it feels like we’re giving up control. But, as far as EMR is concerned, we never had control did we?

Inspired by Seth Godin.

Small Independent Medical Practice Financial Analysis and Reporting

Medical Practice Financial Analysis and Reporting

How do you keep track of the financial health of your practice?

Providers in small private practices rely on a variety of information that makes them comfortable. Some providers will ask for all kinds of data ranging from total billing and charges per month, amount of money received every month or even weekly, total aging, collections by procedures and CPT codes, patient balances, etc.

On the other hand, there are providers that rely on their office managers and builders tremendously, and as long as money is coming into the bank they don’t question too much.

In the majority of the cases, providers missed the mark entirely.

This is an age where we have data and information overload. Everything is digital, everything gets stored as discrete data and therefore everything can be reported on. Does that mean everything is useful? What information should we look at and what should we ignore?

Bits of data in isolation are irrelevant. Total charges per month and a graph of it over the year are irrelevant if not compared to the productivity and the total number of hours that a doctor puts in per day.

Absolute numbers don’t matter as much as looking at a trend over time. Keeping the total number of patients seen over time constant and the total number of hours that you put in on a daily basis constant, if the trend indicates a downward slope on collections, that is what we should be worried about.

Similarly, ratios and percentages are more important than absolute numbers. Total revenue per patient, revenue per procedure, productivity per employee, and similar ratios are perhaps more important than absolute numbers.

I understand that providers do not have the time to look into this in detail themselves. Most office managers are not equipped to think like business accountants. That is why you should look into experts and consultants who can help you analyze this data. If you are outsourcing your billing, many of them can provide this insight.

ICD-10 Whitepaper and Information Overload

I just googled the term ‘ICD10 Whitepaper’. Google said, “About 134,000 results” found. Plus, there were so many paid adverts and placements. If you search for ‘ICD10 information’ you can multiply the search results by 4!

Why? There is a lot of fear and even misinformation surrounding ICD-10.

There are three kinds of sources publishing information related to ICD-10.

ICD-10 Whitepaper - Avetalive

I just googled the term ‘ICD10 Whitepaper’. Google said, “About 134,000 results” were found. Plus, there were so many paid adverts and placements. If you search for ‘ICD10 information’ you can multiply the search results by 4!

Why? There is a lot of fear and even misinformation surrounding ICD-10.

There are three kinds of sources publishing information related to ICD-10.

  1. CMS and government websites (eg,
  2. Academies. Physician and provider academies have generally done a good job of publishing information and distributing it via websites as well as member newsletters and emails.
  3. Vendors. EMR, EHR, Practice Management, and medical billing vendors have also created and published lots of content. This is the biggest category of content publishers. Some of it is for their customers. Most of it is to entice more people to their website, their products, and services in the hope that providers sign up with them.

You will find written content in the form of “Whitepapers” that is supposed to be vendor-neutral information that anyone can use to educate themselves. They can take the shape of thought leadership articles or even blogs.

The other form is that of Webinars. Some vendors and consultants have offered Seminars in the form of ‘webinars’ (Live or Recorded) that focus on and address the main concerns that most providers have.

Finally, you can sign up for and attend live physical events related to ICD-10. Some Academies organize these during their regional or national meetings. I have also seen experts and consultants offer these seminars. Some offer free seminars, and some charge.

For Fee, seminars are usually more focused on your specialty and are much more detailed, and can also have hands-on step-by-step workshops helping providers and practices get ready for ICD-10.

What should you do?

1. Read some Articles or Whitepapers. Just don’t overload yourself. Focus on those that are published by:

  • CMS and Government. These articles generally try to address regulatory implications, which is important.
  • Your Vendor. They are and should be your first point of contact for anything to do with ICD-10. You are going to use their software to submit your claims and be compliant so that you can get paid. You should get not only general information but also specifics about using the software to create appropriate claims.
  • Your specialty Academy. Academy should be your source of information about mapping out ICD-9 to ICD-10, and what codes and modifiers you should use to maximize your reimbursement.

We are not too far from the deadline. It is time to take action. Your information-gathering and education phase should be over by now.

You are still not ready?

Nothing to panic though. My simple advice is to first talk to your vendor as soon as possible. Find out if:

  • Is your software ready and enabled?
  • Do they have anyone who can help you prepare and update your Superbill? They may charge you consultation fees and that is normal because as a vendor of software, help with your Superbill is generally not covered as a standard fee. Whoever you hire/engage, be prepared to spend time with them if you don’t have someone on your staff who is a billing/coding expert.

Second – if your vendor does not have a billing/coding expert for your specialty on staff, that’s okay. You can then look for help from one of many experts in your specialty. Talk to your Academy – they should be able to help locate consultants.

Finally, make sure your Superbill is ready one month before the deadline.

What is Wrong with This Title – “AAFP and HealthFusion Partner to Deliver EHR Benefits…”

When you read this headline, what goes on in your mind? If you are a Family Physician and member of AAFP, wouldn’t you think – ‘my academy had whetted, evaluated, or done something where they tested hundreds of EMRs out there and picked the best one for me’?

Media twists it even more – read this.

Nothing can be further than the truth.

I am sure AAFP does not have the time to do any of that. Also, AAFP in general does not endorse any product. Furthermore, this headline gives the impression that AAFP picked Healthfusion exclusively and recommends it. If I want, I can read even more into it thinking there is perhaps an incentive for being an AAFP member, or that it is being subsidized.

This is misleading Advertising.

AAFP should be more strict about how their partners put out press releases.