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 EHR 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.
  • 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 spending 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.

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

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.

Provider can quickly view the note and sign it.

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 does it become 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, 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 certain number of minutes per month; they give you 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 a digital pen, medical card scanners and so on and that, I can understand as optional.

So 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 do 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 your self 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 likely. 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 EMR 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 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 for 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

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 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 as 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 such 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.

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.

  1. CMS and government websites (eg,
  2. Academies. Physician and provider academies have generally done a good job of publishing information and distributing them 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 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, some charge. 

For Fee seminars are usually more focused to 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, 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 advise is to first talk to your vendor as soon as possible. Find out if:

  • Is your software ready and enabled?
  • Do they have anyone that 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 standard fee. Whoever you hire/engage, be prepared to spend time with them if you don’t have someone on your staff that is a billing/coding expert.

Second – if your vendor does not have a billing/coding expert for your specialty on staff, that’s ok. You can then look for help with 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 EMR out there and picked the best one for me’.

Media twists it even more – read this.

Nothing can be further than truth. 

I am sure AAFP does not have the time 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. 

How do you know it’s time for a new EMR?

I read this blog from Seth Godin (New Times call for New Decisions) and it struck a chord.

Remember when you bought your first EMR? Perhaps you’re still on it, or you may have changed. Each has it’s reasons. Here is what Seth wrote:

New times call for new decisions
Those critical choices you made then, they were based on what you knew about the world as it was.

But now, you know more and the world is different.

So why spend so much time defending those choices?

We don’t re-decide very often, which means that most of our time is spent doing, not choosing. And if the world isn’t changing (if you’re not changing) that doing makes a lot of sense.

The pain comes from falling in love with your status quo and living in fear of making another choice, a choice that might not work.

You might have been right then, but now isn’t then, it’s now.

If the world isn’t different, no need to make a new decision.

The question is, “is the world different now?”

— Seth Godin

Nothing has changed more than Healthcare and in particular, Healthcare IT, EMR, EHR. We persist because Change is Fear!

In the world of EMR/EHR, implications are more than just fear. They have to do with real costs of change – cost of moving data from one system to another. 

Cost of Change

  • Cost of Training everyone
  • Cost of productivity – (it takes an average of 3 months before a practice become productive on one EMR/EHR system)
  • Cost of Transition – moving data from one system to another

Cost of No Change (Status Quo)

How do you determine if you need to change your EMR/EHR? Here are things that determine if you need to change your system:

  • Seeing less patients per day than you did before EMR/EHR
  • Drop in Revenue (not because of overall healthcare changes)
  • Unhappy staff. Listen to everyone, even if you are happy with the system
  • Inefficient workflow

How do you determine the cost of Status Quo

This may require some detailed financial analysis. Compare the cost of change and cost of no-change. If this cost is just incremental, do not change. Think of the analysis you do when you think of re-financing a house. Money saved per month versus cost of re-financing. 

But most important, do not remain stagnant.

Wrong Reason not to choose Cloud EHR

A Doctor mentioned today he does not want to use cloud EMR. 

Reason? A colleague ‘lost data on the cloud’. 

I’m not really sure what that means, but I have a sneaky suspicion that the vendor of that particular cloud EMR system did not provide data when the doctor wanted it, or that the EMR vendor was holding data hostage for a large fee. 

In fact, client/server systems are more prone to losing data in the traditional sense. The solution to that problem of not getting the data from a cloud EMR vendor, is not to use client server systems, but to do a better job of negotiating upfront and incorporating associated data extraction fees into the contract. 

I have seen too many cloud EMR vendors holding doctors data hostage and demanding a large sum of money if the doctor wants to switch their EMR system.

What should you do?

Don’t jump from frying pan to fire. If you think cloud systems are a problem with your data, client server systems are even worse – unless you spend a lot of resources managing the infrastructure internally.

Apple and Healthcare IT – Fuzzy Scary Lines

Apple Could Lead In Healthcare. Here’s Why It Won’t.

— Dan Munro, Forbes

In his Forbes article, Dan is very clear – Apple will NOT lead in Healthcare. 

The choice of words is important. He uses ‘healthcare’, not ‘health’ as in hundreds of health, fitness  and wellness apps such as fitbit. Real healthcare is in the realm of health monitoring such as blood glucose.

Once we understand this distinction, the implication becomes apparent. Healthcare is highly regulated. Just ask traditional healthcare players how difficult is the environment when it comes to providing products and/or services.

I think Apple is getting heady by trying to control and ‘own’ an entire ecosystem rather than being a part of it and facilitating the system.