HIStalk Practice Advisory Panel 9/4/12

The HIStalk Practice Advisory Panel is a group of physicians, ambulatory care professionals, and a few vendor executives who have volunteered to provide their thoughts on topical issues relevant to physician practices.  I’ll seek their input every month or so on an important news development and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a practice, you are welcome to join the panel. Many thanks to the HIStalk Practice Advisory Panel members for willingness to participate.

For this report, I asked panel members about patient volumes and the impact of EMRs and other technologies and the anticipated impact of the Affordable Care Act. Their responses have been edited for brevity and to ensure their anonymity. Your comments are welcome.

How did your patient volume change after your EMR implementation?

• We implemented an EMR in April 2009. The volume of patients I could see decreased dramatically. I work in an occupational medicine setting, so we see only on-the-job injuries. At that time, the recession was really hitting hard and the volume of patients that were coming into clinic dropped dramatically. The lower volume of patients allowed us more time to learn the EMR and set up our templates. I used the system for two years. It never became an efficient tool. When patient volumes started picking back up, I could no longer handle the volume with the slow EMR speed. At that point, I gave our administrators choices: add another provider with its attendant costs, go back to paper, or I quit. We went back to paper. There are still providers in some of our slower clinics that use the system. Our clinic efficiency analyses have shown that it takes one hour longer for those clinics to see a patient than it takes me with paper.
• My patient volume remained unchanged after EHR implementation. Although we did trim schedules for a few weeks during the initial implementation (cut by about 25%) we’ve been at goal since then. We saw some dips last year but they seem to parallel the overall market rather than having anything to do with upgrades or other technology maneuvers.
• It did not change at all.
• Patient volumes at our clinics and hospitals are not influenced by the usage of EMR, though we scaled back the number of available appointments during the initial weeks of EMR implementation. We used the general guidelines of scaling back to 50% of capacity during the first week, 75% the next six weeks, and 100%+ by Week 8. Most providers were able to achieve 100%+ before the eighth week after EMR go-live. Some were able to achieve 100%+ by week two and a few still struggle months after go-live. Those providers are given additional training and other resources to assist them with their usage and adoption of EMR.
• We cut schedules to 50% the first week of go live. Most docs were at 75% by end of week and close to 100% by end of the month. However, many felt like they were “working harder” to get there. On the other hand, that was partially because the system made it easier for them to document more extensively, and thus allowed them to code more appropriately (meaning higher). The end result was increased revenue. And now, almost a decade after the initial go live, we are seeing more patients than we did back then. However, it’s hard to tease out whether that is simply the nature of maturing physicians and high growth in primary care demand or how much the EMR allows us to do.
• Our patient volume went down for a little while. It’s been a few years since we turned the “fully live” switch on, so I don’t remember the exact numbers. I do know we did a gradual transition, so the impact was less evident at any particular time. I also know, our numbers are equivalent to any time BC (Before Computers) and I am almost always fully done with all charts (i.e., “paperwork”) and home by 5:00 PM these days. Ya’ gotta like that!
• Our patient volume dropped slightly for a month or so but then returned to its pre-EMR level. We attributed that to good pre-implementation training of all staff and providers and to concentrating on our processes of care (including process-mapping for all critical processes involved in patient care.)

Do you use (or know of) any technologies that might help you see more patients?

• One of my favorite technologies is the digital pen from vendors such as Shareable Ink. Although my EHR vendor supports one of these solutions, I haven’t really had time to sit down and design forms to feed the EHR templates. From peers who have done it, however, it sounds like it’s a great way to speed up the intake process for patients (not only the patients in the waiting room, but also for clinical assistants documenting histories and vital signs).
• Scribes.
• Depends on the physician. Voice recognition is very helpful to some who have used dictation services for years and/or are not proficient on the keyboard.
• To increase volume, there are a variety of tools which identify patients with gaps in their care (e.g. overdue for a visit for diabetes, hypertension, etc.) and then do outbound calls to those patients to get them in for appointments. We plan to do some of that with internal technologies to start (e.g. run reports, and feed them to our outbound call software). Of course, in the ACO world, we will not want to “see” those patients, as much as “manage them appropriately” (e.g. phone-based care).
• To decrease non-direct patient care related work, there is a class of companies that creates tools which automate or delegate aspects of the physician’s workflow so they have more time for direct patient care. A great example is RefillWizard from healthfinch, which uses a rules-based workflow engine to intercept renewal requests, run them through a rules engine, and then empowering the physician’s staff to contact the pharmacy and the patient. The result is that a physician would see 50-70% less refill messages in their inbox, saving 15-30 minutes a day, and thus have more time for patient care. Full disclosure on healthfinch: I am co-founder and chairman. A second class of tools for decreasing non-visit related work are those that help speed up the documentation process by creating easier to use templates (e.g. Salar) or voice recognition (e.g. M*Modal, Nuance).
• Personally, I don’t want to see more patients. I’m too busy most days as it is now.

Do you expect your patient volume to change as more people get insurance under the Affordable Care Act?

• Being an occupational med clinic, I would not expect any changes in our clinics. I think it will increase volume in primary care practices slightly. There are three kinds of patients in primary care: a) those that do everything right to stay healthy. They don’t use the system much. These people are generally employed and have insurance. They won’t change utilization. b) There is a large group of patients that have a medical condition and appropriately utilize the system to maintain their health. As more people have access to the system, these people will increase clinic volume. c) There is a sizable group that does everything wrong (eat and drink excessively, smoke, no exercise) who have chronic conditions who show up when something really bad happens and say, “Fix me doc”. These people will keep doing this and won’t increase volume.
• No. We already went through that transition in the state of Massachusetts.
• I really don’t see the volume at my practice changing. As primary care physicians, we’re as busy as we’d like to be while still having enough time for our families. I imagine there will be more patients calling, but we have no plans to add capacity. Several of our physicians are already at the edge of burnout, and for my clinic, we’re maxed on space. No one wants to work evening and weekend hours, either.
• Potentially. More so in the ED of our hospitals. I think clinics could potentially see an increase in requests for appointments if there is a massive nationwide marketing campaign to the public about the availability of benefits via the ACA. However, capacity is fixed at many clinics. Just because there are more requests for clinic appointments doesn’t mean that a provider can see more patients in a day if they are already at capacity.
• As a primary care group, we are already close to booked most days, so we don’t expect a huge increase in office-based volume as we simply don’t have the capacity. Therefore, we are looking at the ability to start doing more visits virtually (phone or web), especially if we have lower level providers taking care of this. This will initially focus on the “low level” visits like URIs and UTIs – we believe there is almost no reason for an external type of clinic or an external virtual care provider to do these for our patients.
• Our patient load bucket is pretty much at the brim. I don’t think the ACA will have any real impact on us since we are already partially closed to new patients.
• No. We currently see anyone who needs care, have a family assistance plan, and practice in a reasonably rural area of VT/NH adjacent to a major medical center. We don’t expect the Affordable Care Act to have much of an impact on this area.

DOCtalk by Dr. Gregg 9/1/12

I Gotcho Future Right Here …

You just knew it was going to happen. The infamous “tricorder” from Star Trek (you know, the little handheld device that could scan every little thing, both around you and within you ) was going to come into being one day. I mean, really, who doubts any longer the futuristic insights of Gene Roddenberry? For predictive power, the man rivals Nostradamus, Jeanne Dixon, and Arthur C. Clarke … well, almost.

If you haven’t seen it yet, I’m betting the ranch that you will soon. A start-up called Scanadu has a countdown clock on their web site ticking away the seconds until launch time, now just over two weeks. Their team has a lot of heavy intellectual hitters including biomedical engineers, artificial intelligence specialists, medical experts, and, of course, the prerequisite software and hardware developers.

They’ve got funding.

They’ve got a profound slogan: “We are the last generation to know so little about our health.”

They’ve got some cool quotes:

• “Sci-fi stories are business plans in disguise.” – Walter De Brouwer, CEO & co-founder
• “Today, the health tools in your home probably consist of a thermometer and a box of band-aids. We can do a lot better.” – Misha Chellum, COO & co-founder
• “We’re building a way for people to check their bodies as often as they check their email.” – Scanadu video promo
• “Sending your smartphone to med school” – Scanadu web site

They’ve got a cool little video describing the first phases:

They’ve also got my friend, Dr. Alan Greene, founder of “the pioneer physician Web site,” DrGreene.com. Alan is the founding president of the board of the Society for Participatory Medicine that, along with “e-Patient Dave” deBronkart and a host of others, is driving patient empowerment from a grass roots level. (It’s gaining more and more traction every day.)

Scanadu looks as if it can empower consumers of healthcare better than anything I’ve ever seen with such “auto-diagnosis” tools as:

• Scanning skin lesions and rashes to provide etiologic and care management insights
• Built-in thermometry
• Urinalysis (No, I don’t think you’ll be peeing on your smartphone)
• Symptom checker
• Diagnostic guidance
• Medical alerts specific to you and your geographical area
• Connectivity to medical providers and facilities

Imagine the other “auto-diagnostic” tools that could/will be added!

This is a game-changer. This could have a huge positive impact upon healthcare delivery, HIT, and maybe even the national budget deficit.

Maybe it isn’t yet a true tricorder, but as they say in their video, “It’s all possible … and it’s only the beginning.”

From the trenches…

“Hmm. Maybe I’ll start calling my tricorder "Sally." – Chief O’Brien (Star Trek: Next Generation)

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is Chief Medical Officer for Health Nuts Media, directs the Pediatric Office of Today! exhibit for the American Academy of Pediatrics, and sits on the board of directors of the Ohio Health Information Partnership (OHIP).

News 8/30/12

NextGen announces plans to integrate Nipro Diagnostics’ TRUEresult blood glucose monitoring system into NextGen ambulatory EHR, allowing users to view and graph the captured data.

The governor of New York signs a law requiring physicians or their designated employees to check a real-time registry maintained by the state health department before prescribing certain drugs, including oxycodone. The law also requires pharmacists to report each time they dispense the drugs.

Avon Urgent Care (IN) selects iSALUS Healthcare’s OfficeEMR. ISALUS also announces that Quest Diagnostics has certified OfficeEMR as a Gold Health IT Quality solution based on its interoperability with Quest’s lab orders and results.

Consumer Reports publishes ratings on 552 Minnesota physician group practices, based on findings from the Robert Wood Johnson Foundation and Minnesota Community Measurement. Data was based on “quantifiable measures” collected by the practices and focused on diabetes and cardiovascular disease care. Practices were scored based on the percentage of patients achieving all the targets for managing their blood pressure, cholesterol, diabetes, and blood sugar. Sounds like any practice that wants to be included in similar rankings needs an EMR to adequately capture and report the required data. A couple of months ago Consumer Reports published similar ratings for Massachusetts physicians, so maybe Consumer Reports will soon be the go-to source  to identify the best dishwashers, cars, AND physicians.

Hillcrest HealthCare System (OK) contracts with Phytel to provide its Outreach population health management solution to 100 primary care physicians, along with Phytel Insight for analytics.

The 300 provider Cornerstone Health Care (NC) selects MedAptus’s Pro Charge Capture solution for coding and billing.

MGMA reports that median compensation for practice administrators of groups with seven to 25 FTE physicians rose almost 5% in 2010 to $120,486. In groups over 26 physicians, however, compensation fell almost 3% from the previous year. In practices with less than six physicians, administrators earned an average of $88,118. Administrators affiliated with the MGMA-ACMPE certification and fellowship programs earned as much as $30,000 per year more than their non-certified peers, a point that MGMA will undoubtedly leverage to promote certification programs.

HIStalk Practice sponsor Kareo updates its Website and branding to reflect its commitment to small practices and billing services. The Kareo folks tell me the company has doubled in size each of the past three years and now serves 15,000 providers.

E-mail Inga.

News 8/28/12

From Sleepless “Re: Practice Wise. Julie McGovern’s ‘One Project at a Time’ article was great! If only the business world really would acknowledge how much disruption it creates and the resulting levels of frustration.” Sleepless is referring to Julie’s recent post, which addresses the hard work of EHR implementations and how clinics would be prudent to avoid tackling multiple large initiatives simultaneously. She offers some great tips, beginning with:

If other initiatives must be tackled, try to stage the projects to preserve the sanity of everyone involved.

The one-year delay for the ICD-10 code set is confirmed by HHS Secretary Kathleen Sebelius and the new compliance date is October 1, 2014. Following the announcement, MGMA expressed concerns that HHS didn’t undertake due diligence to ensure ICD-10 won’t disrupt cash flows and recommended additional ICD-10 pilot testing before a full roll-out. Meanwhile, the AMA issued a statement recommending “CMS delay the move to ICD-10 by a minimum of two years.”

RCM provider ZirMed hires Kenneth Willman (Humana) as VP of payer solutions and strategy.

I read this profile on startup HealthTap and am not convinced of the model’s viability. HealthTap allows patients to pay $10 to have a secure, private conversation with a physician in a format similar to email. Patients can share documents and images and the doctor then analyzes the case. The patients can choose a physician to engage with “out of a million” in HealthTap’s database (or 14,000 licensed US doctors.) I understand how this could be attractive to a patient, though I have to wonder what kind of doctor would be willing to participate. The company says their site allows physicians to use their knowledge to “build an image” and as a business development tool. I thought we were facing a doctor shortage, not a patient shortage, so how many physicians – particularly quality primary care doctors – really need to recruit more patients? What am I missing?

Emdeon expands its Clinical Exchange solution to include e-prescription routing, lab orders and results exchange, care alerts, medication history, and clinical messaging.

More evidence of telemedicine’s growing popularity: in a survey of 440 mid to large size firms, 9% indicated they had plans to offer telemedicine consultations in 2013; another 27% are considering them for 2014 or 2015.

simplifyMD adds billing software provider Healthpac as a reseller for simplyMD’s EHR.

Seventy-five percent of 21,000 physicians participating in a Medscape survey say they use an EHR system, while an additional 20% plan to adopt one in two years. That sounds high to me, but adoption is no doubt trending up. The top-ranked EHRs among smaller practices were Amazing Charts, VA-CPRS, and Practice Fusion, while groups with 25 physicians or more favored VA-CPRS, Epic, e-MDs, and Medent. The most widely used EHRs were Epic, Allscripts, and Cerner.

Last week on HIStalk we mentioned some key items from the Stage 2 MU final rule, which was published last week. A few items impacting EPs include:

• Stage 2 will begin in 2014, a full year later than the date published in the original ARRA legislation. Providers have two years after achieving Stage 1 to achieve Stage 2.
• Providers don’t have to achieve Stage 1 MU until 2017, though Medicare penalties will begin in 2015.
• EPs have a new core measurement requiring at least 5% of patients seen by the EP to use secure messaging to communicate health information.
• Hospital-based physicians who can demonstrate they funded the purchase, implementation, and maintenance of an EHR without reimbursement from the hospital and use the EHR in place of the hospital’s EHR can apply to receive a MU payment.
• Certain physicians that don’t have a lot of face-to-face time with patients can apply for an exemption to the MU program to avoid Medicare penalties. Exceptions are also possible for physicians that live in geographic areas without sufficient Internet access and those subject to unforeseen circumstances, such as natural disasters.

E-mail Inga.

Practice Wise 8/26/12

One Project at a Time!

We as a human race are experts at creating our own chaos. Just check out the news on any given day for proof. Less publicly advertised is the chaos unfolding in clinics and hospitals all over the country as they make the move to EHR.

What I find most intriguing is the clinics who also decide it’s prudent to simultaneously tackle other large projects and initiatives. EHR implementation is hard work, just in case you’ve not been down this road yet. It is incredibly disruptive to all organizations. Processes may not radically change, but determining how those processes will be performed takes much thought and effort every time you perform them.

If other initiatives must be tackled, try to stage the projects to preserve the sanity of everyone involved.

Some things to consider when doing an EHR implementation:

1. If you plan on doing a clinic remodel (which might be necessary to accommodate computers and new workflows), do that prior to implementation, not the week of go-live. It’s stressful to move computers around after a day of using a new system. Even having the computers in a different place the next day can cause disorientation and confusion for all users.
2. If you plan to replace your phone system, consider that these, too, are computers. You’ll be learning to use another new tool with complex processes, which can take away the ease of answering a call and putting it on hold. This is another frustration point and can be exasperating. Don’t over exasperate yourself!
3. New computer hardware, and operating systems are likely a must-do item for your implementation. Do not order your new systems to arrive right before you go live on EHR. Your staff are not likely to be network engineers, and the differences between Windows XP and Windows 7 — soon to be the completely different Windows 8 — or Office 2003 and Office 2010 are so vast, it’s another point of disorientation for the staff. There is a learning curve involved in these upgrades, and clinics rarely consider additional training for operating system and Office product upgrades. We all just assume we can figure it out on the fly. This is a bad decision. The loss of productivity when employees are trying to figure out logins (user name requiring a domain\user configuration in W7) has kept staff from being able to log in to their computers. If you are doing a major system upgrade of computers, consider this another implementation and treat it as such. Get training!
4. Other initiatives such as Patient Centered Medical Home may be part of the reason you are moving to an EHR. However, trying to meet all the goals and measures of PCMH at implementation is not realistic. Don’t set yourself up to meet some reporting deadline within the first month (s) of your EHR installation.

EHR implementation can be compared to being pregnant. There is a beginning, middle, and end. In the beginning, you are tired and often feel like you have morning sickness. The first trimester is the hardest. In the second trimester, you start to get your legs under you, your energy starts to return, and you feel less beaten down by the EHR. By the third trimester, you start to see the light at the end of the tunnel, it’s starting to be second nature, the product is making more sense (hopefully), you’ve got good workflows and everyone is starting to forget how hard the first trimester was.

If you are going to tackle multiple projects and initiatives, consider doing them before you get pregnant if they are pertinent to a healthy pregnancy (buying computers for the EHR), or else wait until your third trimester or later when you can handle the extra burden gracefully.

Don’t create more chaos than you’ll already have with your EHR implementation!

Julie McGovern is CEO of Practice Wise, LLC.