From the Consultant’s Corner 9/7/12

Collaboration: The Key to Future Success for Independent Practices

For the last few years, there’s been a lot of talk about healthcare’s transition to collaborative care. But all that stuff about a “paradigm shift” goes in one ear and out the other if there’s no financial incentive to get on board.

If you’re part of an independent physician practice, that day has arrived. There are plenty of sound financial reasons for jumping on the collaborative care bandwagon—and a distinct financial downside for not doing so.

In short, small independent practices can’t do it alone any more. While Marcus Welby could afford to be a maverick, I believe all practices now need to work closely with other physicians and hospitals to be able to document the quality care that leads to higher reimbursements.

For independent physicians, this requires a completely new mindset: moving from individual episodes of care to a focus on improved outcomes for entire populations. It also requires electronic medical record data to document quality improvements as well as greater teamwork with other area physicians and hospitals.

You have to demonstrate that you’re helping improve care for, say, all of your diabetic patients and helping to lower the number of avoidable hospital readmissions. Your practice’s financial health will be directly tied to how well you meet these metrics.

Now’s the time for small independent practices to begin leveraging data to prove that they can hit the quality and financial benchmarks that will land them a share of the reimbursement pie. Here are four strategies that can help independent practices access the systems that can help them enjoy the financial benefits of quality-based care:

• Take the EMR plunge. Access to an EMR is critical to future viability as a practice. There are affordable EMRs many practices can implement right now.
• Get help from a Health Information Exchange (HIE). This strategy works well in some localities like Rochester, New York, where the HIE is already selling information technology services to independent practice associations (IPAs) in the region.
• Start or join an IPA in your area. This is arguably the best choice because you get more negotiating leverage when you join forces with other independent practices. You can band together to get the best pricing on EMRs, risk contracting, and incentives from commercial payers. Better yet, focus on clinical integration – providing the right care for your patients at the right time.
• Work closely with your hospital’s medical staff.  Many forward-looking medical staffs are actively reaching out to independent practices, offering to share strategies and the hospital’s formidable IT resources.

In recent years, we’ve seen countless articles about how cooperation and care coordination are the pathways to a brighter healthcare future. But now those aren’t clichés—they’re the key to your practice’s financial performance.

In the state of Massachusetts, for example, there’s already been a sea change due to Blue Cross/Blue Shield’s Alternative Quality Contract (AQC) program, which provides incentives for large physician groups to meet quality care metrics. Physicians who meet those metrics get a sizeable bonus—up to 20 percent of total reimbursement.

Working closely with other physicians and your hospital isn’t optional any more. It’s the only way to gather the quality data that leads to higher reimbursements.

Jeff Wasserman is vice president of strategic and executive leadership services for Culbert Healthcare Solutions.

News 9/6/12

Greenway Medical Technologies certifies Patient Prompt’s patient communication solution for use with PrimeSUITE. Greenway’s PrimeLEADER 2012 user conference, by the way, begins Thursday at the Gaylord Palms Resort in Orlando.

Today’s young doctors embrace technology and teamwork, according to this AP article. Unlike older generation physicians, Gen X physicians want a life outside of work, rely heavily on EMRs and smartphone apps, and like sharing the load with other doctors. Thirty-two year-old medical resident Emal Nasiri is not unlike many of his peers:

He likes the idea of working in a large health plan group where doctors, specialists and other medical staff work as teams, with easy access to patients’ electronic medical records. That kind of setup is more likely to be “wired’’ than smaller practices, and Nasiri can’t imagine working without his iPad.

Most physicians and staff are concerned with the transition to ICD-10 and its potential impact on operations and finances, according to a Nuesoft Technologies report. Of the 480 physicians, administrators, and billing staff participating in Nuesoft’s survey, 96% say they are concerned and 60% indicated they are significantly or highly concerned. Also from Nuesoft: a video highlighting the challenges facing medical practices today.

In a letter to CMS regarding the proposed 2013 fee schedule, MGMA urges CMS to combine its e-prescribing incentive program and the EHR incentive program. MGMA says that the duplicate requirements “unfairly penalize providers,” even with proposed hardship exemptions and recommends that all providers meeting MU requirements automatically receive PQRS bonus credit for e-prescribing.

Over the weekend we published a new post from our HIStalk Practice Advisory Panel.  We asked providers about patient volumes and the impact of EMRs and other technologies and the anticipated impact of the Affordable Care Act. Interestingly – and perhaps surprisingly to some policy makers – the potential for additional income may not be adequate motivation for primary care physicians to work harder and see more patients. It could be a Gen X/life balance thing as the above AP article suggests, or it could be that physicians are already working at capacity. As one of our physician members noted, “There may be some who have a little room for growth, but most every PCP I know is pretty much stretched as thin as they’re capable of being stretched.” Your comments are welcome and appreciated.

Surescripts acquires Kryptiq, a company in which Surescripts had invested $8 million in 2010 for a 21% share. Surescripts uses Kryptiq’s secure messaging technology for its network. Other healthcare IT vendors are also among its customers (GE Healthcare and Vitera), and its other offerings include clinical messaging, a patient portal, and electronic prescribing. Kryptiq announced earlier this year that its revenue grew 60% and its user count exceeded 40,000.

E-mail Inga.

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.