Author: Chandresh Shah

I was asked to evaluate a ‘request for proposal’. One of the questions was – ‘Is The Integration To Other Internal Systems Seamless Or Integrated Bolt-Ons From Acquisitions?’

Most EMR systems claim they are fully integrated. On the surface, what this means is – you can do everything from within the same platform. You don’t need to buy different modules to do different things.

EMR, Scheduling, Practice Management, billing, and patient portal are all offered by the same vendor.

As the title suggests, these modules may have been purchased from a third-party vendor, or developed as separate products and then ‘bolted’ to provide a semblance of seamlessness.

What is wrong with that?

Nothing superficially, but anything that has ‘seams’ can break.

From the software perspective, not being on the same ‘database’ and platform means that data integrity can be compromised. Something can go wrong somewhere.

When upgrades and updates are made to the software, connectivity between these bolted products can break. This can happen more with stringent regulatory compliance and the need for interoperability between different vendors.

I read a fantastic piece written by Dr. Daniel Essin, MA, MD, FAAP, FCCP for Physician’s Practice.

With EHR, Two Heads Are Not Better than One

He discusses the push and pull between the need to analyze discrete data versus providers’ need to ‘articulate’ the patient’s condition without getting to the SMD (Slow Me Down) factor.

Most practices adopt EHR motivated by Meaningful Use Incentives. The goal is interoperability and data analytics. However, at the point of care providers struggle with improving productivity and they look at alternatives such as dictation, which in turn is against the objective of capturing discrete data.

Dr. Essin said it well:

For many years I struggled with a simple problem – Getting things done.

Symptoms of this problem:

• Going home late
• Not finishing tasks on time
• Unread emails
• Stacks of paper on my desk
• Incomplete or improper responses to clients
• … and the list goes on.

A little over a year ago, it became unbearable. I had tried everything, read many ‘self-help’ books, tried to improve my time management, and attended seminars. Nothing seemed to work. I just did not have the ‘details’ gene.

It dawned on me that I was so much better at other things than writing emails, sending replies, answering and making follow-up phone calls, and doing paperwork. I would get into the nitty-gritty of installing software, doing excel spreadsheets, and lose focus of the ‘big-picture’. I was penny-wise and pound-foolish.

What did I do about it?

I hired a personal assistant. Something I would never have dreamed of doing earlier. How can I afford to hire someone? I did some analysis and math. Quickly I realized I could not afford not to hire help. I was scared.

It has been a year and a half since I made that decision. I must say, I have never been happier. My quality of life has become so much better, I am focusing on things I love doing and my revenue has actually gone up. My Productive senses are on full alert all the time, and I don’t get tired.

Wow, such a simple thing changed my life.

I am seeing a similar pattern with a lot of Doctors I speak with. In order to save money, they compromise on some critical elements of running a successful business. Running a Medical Practice is a serious business. I just don’t understand why they cut corners.

Doctors want to install modern EHR software systems but don’t want to pay for training. They are smart – granted, but then that is not where their efficiency should be used. EHR software systems are a paradigm shift not just for themselves, but for the entire practice. If not done well, it can make or break a practice. Revenues can suffer, and employee morale can suffer.

I just want to let them know – don’t be penny-wise and pound-foolish like I was.

An important element of a medical practice workflow is Order Tracking.

When Providers order labs, radiology, etc, a practice must follow up at least twice to ensure that results are received or there is some follow-up action taken.

In a technology solution that drives a practice, I frequently see questions related to the ability to ‘task’ someone with a responsibility to take some action.

This is where the process versus technology debate comes in.

When you ‘task’ or message someone to do something, that is like walking over to your staff and saying, ‘Can you take care of this’?

Let me illustrate this. There may be an eFax queue where lab results come in, or they come in electronically via lab connection. Someone needs to look at these results. Someone needs to determine if the doctor should be looking at these or if they are normal. Next comes the determination to call or inform the patient and whether or not the patient must be called in for a visit. Finally, any comments must be entered to close out the test.

All Doctors, Office Managers, Practice Manager looking for EMR systems should read this blog – Courtesy The Healthcare Blog.

It will open your eyes; at least make you think – and take all the online reviews with a pinch of salt. How influenced and flavored are these reviews?

Having worked with many vendors, I will say that most sites do not allow vendors to post reviews directly. However, they may certainly be influenced. Read past the ‘blandly positive’ reviews as the writer of the blog says, and focus on those that appear original. If possible, find and try to talk to the provider or practice that wrote this review.

Generally speaking, we buy cars with emotion, not logic. If logic alone prevailed we would buy the cheapest and safest transportation to get us from point A to point B.

We evaluate –

• Convenience
• Looks
• Safety
• Value
• Something that matches our Status (and more)
• Comfort of passengers

There are two important similarities I want to highlight.

1. When you get an EMR, don’t just look at your comfort and convenience. Don’t evaluate just from a clinical charting perspective. Involve ‘passengers’ – your staff. In fact, they will be driving more than you.
2. The old adage – you get what you pay for holds even for EMR systems just as cars. Look at your value, convenience, and overall workflow benefits. Buying the cheapest is not always a good idea.

And as with anything else, look at recommendations from peers and third parties.

A lot has been written about the benefits of an integrated system versus ‘best of breed’ as some vendors like to call it. Best of Breed is really a loose term for ‘we don’t have other components, so we’ve partnered with another company’.

Interfaced System

An Integrated System does not mean an ‘interfaced’ system. Applications may be owned and perhaps developed by the same company. But if they were developed as standalone applications, they may be connected by interfaces or bridges. Applications may not share a single database or development platform.

To an end-user, the workflow and process may appear seamless because the vendors pass data from one application to another behind the scenes automatically and the user does not have to do anything.

Integrated System

Systems and applications designed to and developed from the ground up on a single database are considered truly integrated systems.

Which is Better?

From an end-user perspective, it should not matter; at least theoretically. Vendors on both sides of the fence have written about the benefits of each.

Consultants have always favored the Integrated system approach. However, they have not successfully been able to convince me from an end-user perspective. From a software and database integrity point of view, I agree it makes absolute sense.

Benefits of Integrated System

I was sitting with a Doctor’s friend at his office. His biller walked in and said, ‘Doc, you just saw patient Jones and I think you under-coded. I saw the note, I believe this would be a 214-level coding.’

The doctor just opened that patient’s visit note in his EMR and updated the chart.

The biller saw that the claim was updated with the new code.

I suddenly realized something and asked the biller, how did you know or see the visit note? Do you have access to the EMR system?

My friend said we have an ‘integrated’ system, so she can view my notes on the same screen where she creates and views the claim. She does not have to go to another ‘app’ or module or software. It is all in the same system and database.

Now it suddenly came together – A single database Integrated system. This is also the reason why when the Doctor updated his note with the new code, the claim was immediately updated.

It took a real-world example to be finally convinced of what consultants have been saying all along.

A lot of companies are waiving upfront fees because there is so much pricing pressure. I know owners of several EMR companies, and most of them have their support and training staff offshore. That is not necessarily bad, but then you don’t get the quality of training you deserve.

Plus, many studies have shown that successful implementation has to do with the level of training and support.

Rather than zero upfront costs, what you should be asking for is –

• One day of Onsite Training during ‘Go-Live’.
• Unlimited Remote Training
• Dedicated Phone support number for you.

Rather than compromise on a bit of upfront cost, it is imperative that you focus on making your practice more efficient and profitable.

This is not a Trivial System you are going for – EHR and Health IT have business implications. If not done right, it can slow you down, create chaos and you end up suffering.

If cash flow is really a concern, work out creative ways to spread it out. I’m sure your vendor will work with you.

If you think you can train yourself and your staff (assuming you have a lot of time on your hands), and set up the system yourself, why not go with the Free software Practice Fusion? Of course, if you add up your time and cost of time, you will conclude very soon that the free system was actually more expensive.

I was going through some notes from 2008. Eric Schmidt of Google announced Google Health at HIMSS 2008. Google pulled the plug in 2011. What happened?

At that time, Google Health and Microsoft’s HealthVault were the two PHRs that decided to fight it out. Google quit, and HealthVault still chugs along.

Among several reasons why Google Health did not work out:

• It did not involve Physicians (and EMR systems).
• Google found it tough to partner with Insurance companies – Insurance companies tend to be a walled garden.
• Poor Marketing and Poor support for users. Even an EMR pioneer like me struggled to use it.
• Perceived waste of time by users. Young people did not care to enter data themselves, and those that PHR mattered most just couldn’t do it. It was too cumbersome.
• Google could not find a way to popularize it or figure out a way to bring in partners to monetize somewhere.

I think HealthVault will probably go down the same route as Google Health.

The main reason is that EHR systems now have sophisticated Patient Portals built in. Secondly, with MU2 and beyond, interoperability will eventually become a reality, making true secure data exchange possible, irrespective of the PHR platform.

Transition to ICD-10 is not about being Compliant. It is an ongoing Transformation.
Everyone is affected – Payers, Providers, and Vendors. But physicians would be on the losing end because they are the ones submitting claims. If not submitted accurately, physicians don’t get paid, plain and simple.

Getting Ready for ICD-10 means two things:

• Planning
• Training

Your vendors can only help by providing the right tools to help plan and eventually submit claims but ultimately you are responsible. If claims are not done right, you don’t get paid which means you lose 100%.

A lot has been written about ICD-10, its complications, etc. so I will not harp on it here.

Some simple steps you should take are:

• Start off with your existing superbill.
• Map out the relevant ICD-9 to ICD-10 codes. Your technology partner – EHR/Billing platform should help with that.
• At the very minimum, your biller should be formally trained. I recommend the entire staff, including physicians attend training.
• For a small practice, your Biller or Office Manager should spearhead the transition effort and guide the rest of the staff, coordinate with vendors and clearinghouse.
• Explore possible boosts in overall revenue. Overall, ICD-10 has the potential to boost revenue.
• Testing – work with your technology partner and clearinghouse to send test claims.
• Most importantly, budget for the transition cost including the cost of training so that you don’t get caught with unplanned expenses.