HIStalk Practice Interviews Karen Zupko

Karen Zupko is president of Karen Zupko & Associates, Inc., a medical practice consulting and training firm in Chicago, IL.

I understand you’re starting a new radio show on ReachMD on XM Satellite Radio. What will be the show’s focus?

That show launched on July 17th and people can access those spots. The series is called Practice Success. They are three-minute spots highly focused on a positive step that a practice can take. In some cases, an improved use of technology to lower accounts receivables, to reduce denials. In some cases, positive steps to be taken at the front desk to improve collections. The most recent spot that launched this week is on predicting whether you’re at risk for an E&M audit.

Those are all the past spots. Obviously, it’s on XM160, but it also is at www.ReachMD.com. The interesting thing, I think, is that there’s radio, there’s the Web, and all of this is, of course, accessible on people’s iPhones, which is pretty cool.

Another person on my team is Cheryl Toth. Cheryl has a very cool Webinar coming up about using technology in the practice level to improve communication with patients. She is really our queen of technology. She’s the KZA Queen of Tech

So it’s not a show per se, but actually spots that come up on different times of the day?

The spots come up four times an hour, and then it may expand into a larger show. These are short bullets — take this action step.

Have you gotten any feedback from listeners?

Yes, because some of them come back to our KZA Learning Center. So people are following up on those links.

How do you think healthcare will look in the next five years?

This may surprise people. I don’t think that even if legislation passes, it’s going to look dramatically different. Why do I think that? Because I think all of these health systems, the healthcare delivery, as you travel around the nation — which I have done extensively since the late 70s — everybody’s not at the same starting line.

You have one experience when you go to the Mayo Clinic. There is electronic medical record, and when you leave, you leave with a jump drive with all of your test results, versus many other academic medical centers that have yet to adopt the technology, or, have done it on the inpatient side, but not for ambulatory patients.

I think when you look at the technology adoption on the ambulatory side, whether that’s a hospital-owned practice, a multi-specialty group, or a private practice group down to the solo practitioners, for example, doing simple things like checking eligibility, easy things that should have been common sense like checking the patient’s ID versus their insurance card to be sure that the person and the card match, it’s a slog. That’s how I would describe it: it’s a big slog.

There is progress. The stimulus money is going to cause some people to get on with it faster than they would have if left to their own devices. I think the growing number of young physicians entering practice who are trained in technology are going to have a big impact as they become the majority.

But am I looking for the world to suddenly change? I’ve been working in healthcare since 1973. I’ve been through more physician manpower studies than you can shake a stick at [laughs]. Just like every five years, I expect somebody to pronounce with great definitiveness, “We have too many doctors.” “No, we don’t have enough.” “Too many.” “Not enough.” It’s like the tide goes in, the tide comes out. So it’s kind of where I sit.

Will there be major changes to the way doctors get paid or the type of insurance patients use?

I think that there are people, as we speak, looking at different payment options that are going to definitively reward people who have thought about cost, who have thought about collaboration, who have thought about the benefits of a central record, so when you look at those proposals that say, “We’re going to pay everybody for doing this hip, or doing this knee, or doing this heart, and this is the amount of money, and you all are going to figure out how you’re going to divide that up.” I think it’s pretty clear in all of this discussion that paying doctors based on volume of services provided hasn’t proved to be particularly successful.

So that system may go away?

I think it’s going to be reshaped. Again, it’s so vast. You have to be very careful about the law of unintended consequences, you know, like you push here, and it causes four bubbles over there that you didn’t really think about.

I don’t know where you were then, but when Oregon began discussing the fact that under Medicaid, not everybody was going to have everything. There wasn’t the money. So we’re not paying for the removal of benign lesions — benign lesions are benign. So that was probably 15, 20 years ago. It caused a lot of stir.

I think that the disingenuous elements that have been inserted into the current considerations. Those people should be ashamed of themselves. Death panels — I mean, please.

What type of IT tools do you think are a must for every doctor’s office?

Well, first of all, I think they need a computer.

To do what?

You absolutely have to have a computer to do more than e-mail. We should be doing all the scheduling, we should be using these cool, nifty tools such as the functionality offered by companies like Medfusion. Patients should be registering online. That data should then be dumped to the practice management systems. I’m working with practices to do that.

Companies like A-Claim that allow a practice to check the eligibility, that allow you to determine if the deductibles been met, what the co-pay really is, and is that service covered. Companies like RealMed and A-Claim both that allow for adjudication of claims while the patient is standing there.

We still go to practices that are not filing electronically because of the cost, unbelievably, and therefore, they are not getting electronic remittance, and not getting electronic payments, which therefore require that you have more people in the business office doing busy work. You would want to be using automated systems that take a promise to pay and turn it into the reality of payment.

I just had a conversation with a doctor today about meeting with his billing office staff. They have a half million dollars in receivables. It’s just totally, completely inefficient and incompetent. And then, if I get the business side done, then I would have the money certainly and price would not be the biggest objection to doing the electronic health record.

We go to practices that have a robust computer system, and somebody’s just decided to go dumb and not figure out how to do PQRI, or get the credits from e-prescribing. We think 4% of your Medicare money on the table — I mean it’s just hugely expensive.

That’s not an IT issue, that’s a personnel issue.

They can’t figure out how that is going to work. It is an IT issue. You know what, there are very few things, I think, as we go on, that are just an IT issue. I think in many cases — let’s do this as a summary statement — the technology is ahead of the skill set of the people who have to use it. We’ve got very sophisticated tools, and very unsophisticated users.

Are you saying the tools need to be easier to use or we need to get the personnel up to speed?

I think it has to be a combination of both. I think the description of how to do PQRI was rather poorly articulated by the government to start out with. And then some people tried, and were unsuccessful, and then they just say, “What the hell with it, then?” Does that make sense to you?

Yes. So, is the EMR an essential tool?

If you were a young doctor starting out in practice, then I would say absolutely, positively yes. If you were a six-doctor group with receivable problems, were an update or two behind on the practice management system, and have a lot of business process issues, I’m probably not going to tell you to race to implement the EMR at this moment. I think there are just so many things that you can try to do while the practice is seeing a full load or a full load plus of patients.

That may mean they’re going to leave some of that ARRA money on the table.

Right. I think practices have to up-hire. They’ve got to look at the level of people that they’re hiring. They have to buy more advice out in terms of tech. Do you understand that in many of these practices, the back-up is being done on a tape that sits on a shelf three feet away from the computer? I could not make this stuff up.

So the sophistication is not there?

Well, even if somebody can say, “I understand this is a problem,” — and I’ve got such a person right now; she is very articulate about what the problems are. She is not a technology wizard. She said, “I’ve got this problem, and it’s on this server, and that server has this issue; I need this fixed. I’m not even sure who can help me.” Then she calls two tech companies; one comes up with a support figure so unbelievable, something like $8,000 a month. The other one comes back three times and can never quite take notes about getting the story down, and they’re tech support. So it’s rather frustrating, to tell you the truth.

What’s the answer for the average doctor’s office that wants to move forward in technology? Outsource it?

Outsourcing what piece of it? You do have to outsource the hardware support and the backup. I would say one clear and positive thing that anybody reading this should do, and that is, please, double check, filled with skepticism, that your backup is as good as it should be and needs to be. If a comet fell out of the sky and hit your office while you were not there — you were at home sleeping — do you have the backup to be able to say or put out on the Internet, “Hey, we’re three blocks over in rented space, you can come and see us here,” and you can have everybody’s medical records and all the financial information.

I guess that’s the test. A comet hit your office. Boom! And if it’s not that good, and somebody’s not willing to put that guarantee in writing — “Yeah, it’ll take a couple of hours, we’d have to get the computers hooked up” — but the backup system is somewhere else, the backup tape is not three feet away [laughs] from the hard drive. Do you see what I mean?

Or somebody says, “Oh, it takes so long; we only back up once a week.” Can they afford to lose a week’s billing and scheduling? Medical records? No.

There’s been a whole series of emails back and forth between us and one of our consultants who’s now actually running a practice. All the doctors are using these iPhones to connect and the level of security that needs to be on the iPhones so if somebody picks it up, they can’t get into your EMR system.

And is it secure?

It depends. On her practice, absolutely, yes. There’s a lock and there’s an ID, but I’m going to guarantee you that for plenty of doctors, that’s not the case.

And you think there are still a lot of practices out there only doing backups once a week, for example?

Yes. Yes. I promise. I’m not naming names, but I’m not making that up, honey. [laughs]

Alarming.

Alarming, yes. And it’s not that these are dopey doctors. These are doctors medically who you would want taking care of you. We still have a long way to go.

Intelligent Healthcare Information Integration 9/4/09

From the Mouths of Babes

Ok, I know this is not directly an HIS tale, but with all the hubbub about healthcare reform here in the US and with healthcare information technology being touted as one of the linchpins to its reformation, I figure this is at least tangentially relevant … plus, maybe a bit of a hoot to boot.

In my office today with a mom and her three rather rambunctious young’uns, I heard perhaps the most brilliant idea for lowering healthcare costs and increasing patient care outcomes that I could imagine. Of course this little jewel didn’t spring from my lips nor those of the other adult in the room. It sprang from the untarnished brilliance of a six-year-old.

As the terrible trio was bouncing around, off, and into every nook and cranny they could find, the middle child, our precocious little thought leader, suddenly and without apparent provocation stated, “You know, if we kids would behave, you could probably charge my mom less money.” Exactly what inspired this nugget of insight to pop from his mouth, I can only conjecture. Regardless, it hit me like a bolt of enlightenment straight out of the Buddha himself.

Absolutely, there are parents I would gladly provide with the daily Blue Light Special if only they would encourage their precious darlings to not crayon my walls, tear my vinyl, rip my books and magazines to smithereens, ram chairs into walls, pull paper towels endlessly from the dispenser, etc., etc., etc. I would undoubtedly save significant wear and tear costs, which I would gladly pass along to healthcare crisis community tills.

Furthering this notion, what if we could charge everyone, adults, kids, and everyone else, a reduced fee for good behavior? You know, things like showing up for scheduled appointments, taking medications as prescribed, making healthier lifestyle choices, and just generally being punctilious. Wouldn’t that help lead to some of the “clinical outcomes management” goals for improving healthcare quality we all seek? Wouldn’t that help lower healthcare costs by bringing about improved health at lower cost? (Prevention versus pound of cure and all that.)

I guarantee you that if I could lower my charges for patients who are “being good”, I would gladly forego the $44,000 in reimbursement bucks; happily buy my next round of server, pen tablets, or EHR tools from my own coffers; and let the ARRA funds go toward building the bridges for data sharing and aggregation we all really need to accomplish something with all this information. Talk about your meaningful use!

"Out of clutter, find simplicity. From discord, find harmony. In the middle of difficulty, lies opportunity." – Albert Einstein

Dr. Gregg Alexander is a grunt-in-the-trenches pediatrician and geek. His personal manifesto home page…er..blog…yeh, that’s it, his blog – and he – can be reached through http://madisonpediatric.com or doc@madisonpediatric.com.

News 9/3/09

From: Curious George “Re: OSHA. I hear that hospitals are definitely on their toes in case an OSHA inspector drops in for a chat. Do you have any information on how many physician clinics are being targeted by OSHA? Have you heard of anyone who has and what their top five non-compliant issues were? I’d like to hear from practice managers what they are doing with regards to OSHA and how many have actually ever been audited, and what your take on this is. How serious is the threat of inspections are in our business because the articles I read were way beyond that book of MSDS pages most of us have stuck somewhere, but rarely update – not to mention all the other issues we could be hit with during a visit.” I’m glad to some asking around. In the meantime, I’d also like to hear from any practice managers (or doctors or consultants) who have opinions on this.

Patient-centered medical home models provide patients better primary care, without adding additional costs. Medical home patients had 29% fewer ER visits and 11% fewer hospitalizations than patients utilizing services in a traditional primary care environment. Group Health Cooperative conducted the one-year study and found that providers relied heavily on e-mail and made the most of technology, including EMRs. Providers also reported burn-out rates 20% lower than the control group.

Time magazine also took a look at the growth of retail clinics and says these practices “are rapidly becoming to the health-care industry what Fotomat was to the camera world.” The Fotomat analogy is particularly interesting given that Fotomat closed its online presence just this week. Of course, the cute little drive-up kiosks closed several years ago as Fotomat’s one-day photo developing service became obsolete with the advent of one-hour photo processing, then digital photography. Which all leads me to wonder if the growth of telemedicine will one day make retail clinics obsolete.

ZirMed introduces a new package that includes eligibility verification, claims management, and electronic remittance, targeting smaller practices with its new ZirMed One product, which essentially bundles three stand-alone products into one.

athenahealth’s Maine Operation Center is named one of the 2009 Best Places to Work in Maine.

Delaware’s Board of Medical Practice sets the maximum rates for copying patient medical records at $2 per page for the first 10 pages. The maximum per page fee declines based on volume and 50 cents is maximum per-page fee after the first 60. Though the costs are currently for both paper and electronic records, the board is considering lowering the fees for electronic records.

Pfizer agrees to pay the government a whopping $2.3 billion to settle a healthcare fraud case. Pfizer was accused of fraudulently marketing the anti-inflammatory drug Bextra and illegally promoting other drugs. It’s the Justice Department’s largest healthcare fraud settlement ever.

Atlanta Women’s Specialists puts out a press release about the benefits of its EMR system, which includes increased staff efficiency and safer care. The practice posts and flags abnormal test results within 24 hour, sends prenatal records directly to the hospital, and exchanges information with other medical practices via the Medicity Novo Grid. The practice will soon deploy smart phones as well.

We are looking for some guest columnists to share their knowledge on HIT in the ambulatory world. In particular, we’d love a clinician who is willing to share his/her EMR journey. If that’s not your thing, but you have other relevant insights to share, let send over an e-mail.

AHRQ plans to collect data from phyicians and pharmacies to identify what accelerates and what hinders the adoption of e-prescribing. The two year study will include interviews physicians, administrators, and pharmacists across 110 different organizations in order to determine what real or perceived barriers can be obstacles for physician practice and pharmacies.

Bridge Community Health Clinic (WI) partners with Healthport to implement practice management, EMR, and RCM solutions.  Bridge is an FQHC serving 21,000 patients a year across three locations.

E-mail Inga.

News 9/01/09

From Dr. T: “Re: Practice Fusion. I was under the impression that Practice Fusion did not have patient-to-MD e-mail.” Back in February, Vatsal Thakkar, MD participated in an HIT Moment and said, “Practice Fusion says it is in their future plan to incorporate e-communications to/from patients that are HIPAA-compliant and/or encrypted. What I am currently using is an add-on from my MS Exchange hosting service called SecureMail. It simplifies the process for users of Outlook such that encrypting a message is a simple click which prompts you to enter the challenge question that the patient can answer to open the email and write back. It also informs you if the message was NOT opened by the end of 30 days (at which point it expires). The vendor is at www.intermedia.net.”

Speaking of Practice Fusion, it is offering free integration with Quest Diagnostics for lab results.

Greenway Medical announces its 11th consecutive fiscal year of positive growth, ending its 2009 fiscal year with a 38% increase in sales over 2008 and 88% over 2007. Ever since I can remember, Greenway competitors have loved to discuss how the privately help Greenway wouldn’t be able to make it long term, that they would run out of money and never turn a profit. While higher sales do not necessarily equate to increased profits (or any profits for that matter), but, you have to hand it to Greenway for its tenacity and continued growth. There are a lot of sunset companies out there that would have loved eleven years of positive growth.

We are indeed fortunate to have Medicity as a new Platinum Sponsor of HIStalk Practice. The company was the first sponsor of HIStalk many years ago and continues as a Founding Sponsor there, which we certainly appreciate. It in inspiring to see how the company has grown, both organically and via strategic acquisitions that include a gem of EHR interoperability technology, the former Novo Innovations (now the Medicity Novo Grid). Other offerings include the ProAccess Clinical Application Suite and MediTrust Clinical Interoperability Platform. Ten years after its founding by Chairman and CEO Kipp Lassetter MD, the company leads the market and will undoubtedly continue its leadership role in RHIO, HIE, and national health network projects (it’s offering a September 4 Webinar entitled Maximizing New ARRA-Funded Federal Grants for Health Information Exchanges).Thanks to Medicity for its continuing support of HIStalk and HIStalk Practice.

Greenway also introduces its new partnership with RelayHealth, giving PrimeSuite clients access to lab results, radiology reports, and transcribed documents from their community health system through Relayhealth’s Virtual Information Exchange.

Supermarket chain Harris Teeter (found mostly in the eastern US) implements a PHR to improve prescription accuracy in its pharmacies. An agreement with Connectyx Technologies Holdings Group gives customers the opportunity to obtain a MedFlash drive for their PHR information, including medication specifics.

Claims clearinghouse provider Navicure adds three South Carolina practices to its client roster.

Physicians who perceive quality problems in their practices are more likely to experience dissatisfaction, isolation, and stress. Doctors in practices that have implemented quality initiatives and evaluated their effectiveness where less likely to feel that way.

eClinicalWork partners with Correctional Medical Services  (CMS) to provider EMR solutions to correctional facilities affiliated with CMS. ECW already provides EHR to Rikers Island in New York.

Speaking of ECW, co-founder Raj Dharampuriya  is interviewed by India Knowledge @ Wharton. He mentions that the company has opened a Mumbai support center to handle US customers that run 24 hours a day, such as a prison. The company will hire 500 people in the next two years, most of them in implementation and support, and will open an office next month in San Francisco. He credits the Indian culture of the founders in helping them focus on their goal of building a business and changing the delivery of healthcare. He still practices medicine part time and says he’s in the top 10% of performers according to BCBS.

If you are feeling the need to get up to speed on the upcoming ICD-10 coding system, you can review the new fact sheet being offered by CMS. I was sure it was going to be something I could use to cure my insomnia, by it’s actually nicely laid out, provides an easy-to-read overview, and includes plenty of graphics.

The MGMA sends the CMS a 12-page letter, providing comments on the proposed 2010 Physician Fee Schedule. Topping the list: MGMA urges urges CMS to accelerate the use of reporting from  EHRs for 2010 PQRI participation. MGMA also believes that groups of any size should be able to report on proposed measures, using a properly structured group practice reporting mechanism.

Three-provider Walker Family Medicine (AZ) selects OminMD for its EMR and practice management solutions.

CMS reports that almost all of the 610 small practice and solo physicians participating in a pay-for-performance demonstration project earned bonuses. The practices are being paid a total of $7.5 million for meeting quality standards through the use of HIT. The average payment was $14,000, with some practices earning as much as $62,500. To qualify, practices had to show their use of HIT improved the quality of care for patients with chronic conditions.

A local paper reports that Outer Cape Health Services (MA) has had a “mass resignation at the senior level staff level” as a result of management reorganizations and cost-cutting measures. The article is published in The Wicked Local, which I envision as of of those freebie newspapers you pick up in the local coffee shop, the kind that includes a listing of what bands are playing at which pubs, and a wide assortment of personals that cover every conceivable dating choice. Anyway, the rather lengthy article places most of the blame for staff resignations and turnover on the  health clinic’s new CEO, who took over the financially struggling practice in January. A disgruntled staffer says the new CEO put morale “in the toilet.” Another says she “humiliates people who don’t agree with her.” Essentially, they all but call her “wicked.” It may not be a Pulitzer Prize-winning piece of journalism, but it’s certainly more juicy than anything in the NY Times.

E-mail Inga.

Intelligent Healthcare Information Integration 8/29/09

Of Spices, Garnish, and Flavor Integration

Cooking, while not my passion, is always something I love. HIT, my passion, is not something I always love. Despite the discrepancies in appreciation, the former can lend insight into the latter. To illustrate, let’s take a little jaunt around the chowder pot…

Not that I am one, but a good chef will tell you the right ingredients make or break the creation of any dish. So, first, we want to insure the freshness and quality of the components which are going into our dish. If we try to build our foundation upon stale or outdated stuff at the start, we’ll only end up overseasoning in an attempt to turn a poor base into something it just never can become: fresh.

Speaking of seasonings, spices cannot be overemphasized. Appropriate use of spices in an intelligent and relational blend is the pièce de résistance, the icing upon the cake. The cake must be scrumptious, but the icing provides the “wow!” So, too, the soup must be solidly constructed from the best stock and the most delightful amalgamation of the finest available elements; however, it is the right use of the spices which elevate mere cold soup to an elegant vichyssoise.

Underspice, and the outcome is bland, lacking in pizzazz. Overspice, and the palate is overwhelmed and confused. But, with attention to the interactions of the flavors – spices with spices as well as spices with main ingredients – the individual elements integrate to transform the dish into a starburst of flavor sensations only achieved by their proper integration.

The heat necessary, at the right moments and at the right temperatures, can bring about the conjoining of flavors we seek, but not if we are inattentive to its application. As with custard, we might even need a bain-marie (a protective pan of water) to help guard our creation from the onslaught of direct flame. But, don’t be mistaken: the flavor sensations we seek will never arise if not allowed the time to assimilate under just the right conditions or if not tempered with just the right fire.

Preparation to the moment of presentation is only partiellement fini. Without question, the garnish and overall appearance of a dish, just like the wrapping of a gift, can turn a meal into a masterpiece. A present may be appreciated, but beautiful wrapping heightens the anticipation of the gift within. So, too, what the eyes see even before what the nose smells or the tongue tastes can greatly enhance (or diminish) the appreciation of even the finest culinary concoction.

Now, for the clarification:

• HIT/EHRs need up-to-date (fresh) ingredients.
• Building upon outdated (stale) platforms and software (ingredients) will yield an EHR (broth) no amount of techno bells and whistles (spices) or gorgeous GUI (presentation) or marvelous marketing and support (garnish) can overcome.
• The oven of time and incubator of “in vivo” use of these tools has cooked a few to finesse, many others to overdone and perhaps best fed to the dog.

A master chef knows a quality meal is only good for a brief period. Most grocery items have an expiration date. Even Budweiser has a “Born On Date” indicating that it has only 110 days before freshness has passed. Maybe EHRs, many of which are well past their prime and only capable of continued use by those tolerant of the dull and tasteless, should adopt a similar ethos to enable continued “freshness” of our HIT banquet.

I don’t even butter my bread. I consider that cooking.  – Katherine Cebrian

Dr. Gregg Alexander is a grunt-in-the-trenches pediatrician and geek. His personal manifesto home page…er..blog…yeh, that’s it, his blog – and he – can be reached through http://madisonpediatric.com or doc@madisonpediatric.com.