HIStalk Practice Interviews Dan Nelson, Practice Administrator, Desert Ridge Family Physicians

Dan Nelson is practice administrator with Desert Ridge Family Physicians of Phoenix, AZ. He recently testified before the HIT Standards Committee’s Implementation Workgroup.

Give me some background on the practice.

The practice was started about 6½ years ago. When we opened, we started with NextGen in-house. We host all our own servers. That’s all internal. We retained control of all of that.

Because we started six years ago with NextGen, we really had a substantial head start on all of our infrastructure, and I guess in getting ready for Meaningful Use. I really had no idea that this was coming. Once it was all laid out, we found that we were really well situated for it.

You’re a six-physician family practice, correct?

That’s correct.

You’re using NextGen for the practice management application as well as the EHR?

That’s right. We also have NextGen’s Internet portal as well for patient communication.

Tell me about the experience of testifying for the HIT Standards Committee. How were you selected and what were some of the overriding messages you heard from other presenters?

I have no idea still how we were selected. We’ve been certainly involved with NextGen and a team of user groups. Because we’re a rich user, we talk with them to some extent. We’re very involved with our local Regional Extension Center, and because of how well-situated we are, we’ve done the best that we can to help them. We also had previous relationships with members within the REC, so that helped. Recently, just a couple of months back, when the ONC had come in town, they had brought back some members of the ONC to come and visit us. 

Which one of those was directly responsible or just added to us getting selected, I have no idea. When we got the call that we were invited to participate, it was really a shock to us. It was really interesting to participate in the panel.

I think the biggest thing that I took away was just how much they’ve actually accomplished in a very short amount of time. In my eyes, the program has been extremely successful — in less than in two short years, to bring electronic health records to the forefront like this program has. I think it’s a huge success.

When you watch the news, you see all the political divisions and people fighting, but I was really impressed with the committee. It was a big group of people all working for a common goal. Certainly there’s some different viewpoints and whatnot, but I was really impressed with the work ethic that everybody on the committee had.

In terms of the feedback that presenters gave the committee, were there any big issues or problems that were consistently mentioned or was it a variety of issues?

There was a whole host of issues. There were some commonality in viewpoints. Certainly I think there were a lot of little details that can use some fine-tuning, maybe some better communication coming from the ONC on interpretation of rules. But I certainly understand that each one of those interpretations was a single case, and so it’s going to be very difficult to make all those determinations. I certainly understand ONC having difficulty answering all of these questions.

On Day Two, there was even a little bit of pushback on electronic health records to begin with. That was fascinating to witness.

I read over the written testimony that you submitted. One of your comments was that the technical bar to meet Stage 1 of Meaningful Use is quite low for most of the vendors, but you think many of the vendors may have difficulty meeting Stage 2 and 3 requirements. If that’s the case, do you predict a shakeout of EHR vendors or do you see a lowering of that bar?

It’s difficult to say. I can only see a very low level from my position of a small practice administrator.

There’s something like 250 EHRs that have been certified by one body or another. That number astounds me. In looking through that list of the 250, I certainly see some EHRs that I don’t think should be on there. I don’t think they would be even be considered an EHR by some people.

I would caution any practice out there that’s in EHRs to not go with the cheapest one or the very basic one just as an attempt to get some Meaningful Use dollars. In my mind, that’s not what this program is for.

I’ve heard some practices made statements that the incentive won’t even cover the entire cost of the EHR. In my mind, I would be shocked if it did. I don’t think that it’s a program to make money off the government. I mean, for the program to improve your medical practices and help lessen the blow for that transition, but certainly it’s not a way to make extra money. I would caution any medical practice out there when making the choice, make the right choice for the long term and choose a quality EHR.

My biggest fear is that if these — I’ll call them under-qualified EHRs — are successful, and there’s a large market that they hold, then it will be very difficult to have serious Stage 2 or 3 criteria. I think that’s where we’re really going to start seeing the savings and the efficiencies and the quality improvements from sharing information on most medical practices. That’s what I’m really looking forward to in all of this. If at the end of the three stages all we have are a bunch of islands of electronic practices, I don’t think we’ve gotten our money’s worth. But if at the end we have an interconnected medical community, then I think that this will be a worthwhile program.

Tell me some of the challenges that you’ve experienced communicating with other providers. For example, establishing interfaces with the hospital and using external portals with insurance carriers and others.

I’m really not a fan of portals. We connect to probably 20 different portals on a daily basis for one reason or another. Most of those are health insurance companies. There are also labs, radiology, hospitals. For every single one of them, each user is supposed to have their own login name and password, but of course you don’t want to duplicate any of your login names or passwords across multiple portals. Just the management of those passwords is a nightmare. Besides that, it’s not part of their flow. When they’re seeing a patient and then they have to go and log on to some portal, it takes them out of what they’re doing.

Our goal is to have everything embedded within our EMR system. To do that means we need to be interfaced in one way or another. Up to this point, that’s been a rather difficult thing to do, but I think that has more to do with the state of information exchange than it does interfacing difficulties. The problem right now is in order to interface, it’s a single practice interfacing to a single carrier, and that carrier has to interface with every single practice. When you want to interface with a second carrier, that’s a whole other project, and they have to build a thousand interfaces.

So once we get to the point that exchanges are realistic, we should be able to connect to the exchange, and then by extension, we connect it to many different sources of information. But that’s what we’re looking forward to. In Arizona, our exchange is not ready for that yet.

How are you doing data exchange with your hospital?

With our hospital, we connect to them through a portal. I guess it just has all the same problems that portals do. We’re not proactively notified that we need to be logging into the portal. When we get to the portal, we don’t really have an expectation of what we’re going to find. We log in and then we find out what’s there. They are working always to get us interfaced into more of an exchange, but there’s just a lot of work to be done.

You had mentioned in your testimony the need for discrete data and that your hospital vendor was surprised that a huge data dump of information was not a sufficient solution. Is that still an issue for the practice?

Oh, absolutely. When talking about discrete data, my first worry is there’s going to be a bunch of EHRs that really aren’t capable of handling discrete data. They will just have big, huge text blobs of a bunch of information the physician then has to weed through. Or, it could be exchanging of large PDFs of information instead of, say, lab information, instead of having that lab as discrete data that could be properly imported.

My hope is that the EHRs are capable of using discrete data and then the exchanges can be capable of exchanging it that way. That remains to be seen. Certainly the technical complexity of discrete data is going to be far higher than just exchanging blobs and PDFs, but then the benefit of the discrete data will be the usability. If that information could be imported by our EHR and put into proper categories and spaces, then it’s very useful for our physicians. Otherwise, we get a whole bunch of documents that we have to read and it’s not usable in a full sense.

Is your hospital working to make the process better or are their hands tied due to the vendor?

I’d say it remains to be seen. I don’t know enough to know which way it will end up being. Actually, I think that’s a desire to make sure that their exchange is useful, but it’s difficult as well. I have hopes that they’ll do it the right way. But we really are a ways away from these types of things. I think they’re still all in the planning stages and they’re not rolling out an exchange yet.

Shifting gears a bit, why do you think it’s so much harder for smaller practices to adopt EHR?

We have — and I say “we” because I have many of the same problems, even though we’re a couple of steps ahead– but we still have all these same problems. We have too few people, we have a small practice environment, and you need to run a lean organization. We have too little time.  Especially in primary care, there never seems to be enough time, and certainly too little money.

I think the Meaningful Use program helps with that end. I think the Regional Extension Centers help with too few resources and too little time. They really can be a great asset in assisting practices and feeding them the right way and making sure we don’t need to learn everything ourselves. We have very useful guides. 

Another thing for our small practice is that there’s probably too little expertise. We’re getting into some very complex areas of IT and vendor selection and things of that sort, and that’s not always an expertise that a small practice has in-house. All those things add up. It’s difficult for the small practice environment to tackle a project this large.

Are you seeing in your area a lot of consolidation with practices?

Yes, we are. There’s absolutely a lot of acquisition going on in our area.

I trust that’s something that your practice is trying to avoid at this point?

I don’t think that I’d word it that way. It’s something that we’re not interested in. I don’t believe it’s the right move for healthcare. I don’t think that it will improve quality. I think that it increases complacency and I think that it’ll lessen innovation with all that acquisition.

You noted in the testimony that NextGen is a top-tier EHR. How do you respond to practices that say they simply can’t afford an EHR like NextGen, so they select one of the lower-end options?

I certainly don’t think that one size fits all. I wouldn’t try to necessarily talk a practice into going with NextGen or to spend a lot of money to get the very best. They have to do what’s right for them, what’s right for their technical abilities, what’s right for their flow.

I would show a practice what we’ve been able to accomplish with NextGen and try to make the case that by spending some extra money, you can get these efficiencies and these capabilities in return. That may or may not be worth it to them.

When we started off, we were a brand new practice with no patients and made the decision to with NextGen. We’ve never regretted it. We’ve been able to do some pretty amazing things with NextGen. That’s not to say that every practice could do what we’ve done or that any practice would want to do what we’ve done. They have to make a decision for what’s right for them.

I would just make sure that they are paying attention to the direction where healthcare is going. Practices being interconnected to each other and to exchanges. Make sure they have a system that won’t hinder their abilities to do so.

Any other thoughts on your testimony or EHR that you’d like to add?

Maybe only that I feel very fortunate that I’ve been able to participate with the committee hearings and that I’m really optimistic about the future seeing the great work that’s been done, how much they’ve accomplished, and how successful they’ve been at bringing a focus to electronic health records for the medical industry. I think it’s a huge jump start to where we want to take healthcare.

An HIT Moment With … Jim Riley

An HIT Moment with ... is a quick interview with someone we find interesting. Jim Riley is president of Capario.

There are dozens of RCM vendors offering different services and serving different constituents. How would you categorize the major market segments and where does Capario fit in?

I would say the vendors in our market fall into one of three general groups.

The “back-end guys” are the legacy players whose primary value play is on the payer side. They have strong back-end payer connectivity, but their submitter offerings are lackluster. That’s because the bulk of their business and revenue is derived from the payers, which causes them to have a payer-centric view of the industry.

The “front-end guys” are the newer generation of clearinghouse/RCM vendors who came in with a submitter-focused strategy and new RCM solutions over the last 10 years or so. They built good front-end solutions, but rely on connectivity from other vendors. Transactions from this group are typically bouncing around to multiple different points to reach their final destination.

And then there are the “captive-audience players” who are primarily run by the demands of a parent organization. There are a number of vendors in the RCM space who are owned by a payer, a group of payers, a practice management or billing system, etc. Each of them has good offerings but their situation results in an owner-centric disposition of the industry. This group tends to be the least flexible of the three.

Capario really is a best of both worlds, blending of the first and second groups. We’ve been around for more than 20 years and have amassed thousands of direct connections with payers. This helps us to know how payers think and allows us to customize payer edits that we can push directly to the provider. That said, providers will always be our primary customers. It’s where we provide value in the revenue cycle. We’ve built our company’s focus around the needs of the provider community and have built one of the industry’s leading RCM portal applications.

CMS will begin accepting 5010 claims as of January 1, 2011 and the new format will be required by January 1, 2012. Is Capario, and more importantly providers, going to be ready for these deadlines?

Capario will be ready and we are actively testing with a handful of our customers and partners today. We think the vast majority of payers and large providers will be ready by 1/1/2012 as well. Some smaller submitters will struggle to meet the deadline but we have solutions to help them bridge the gap.

The bigger concern, frankly, is timing. Very few entities are ready today and we anticipate an incredible crush on resources and testing during the latter half of this year. It will be challenging, but these types of industry mandates are where Capario earns its stripes. Our plan calls for the ability to readily translate into and out of 5010 format as needed by our submitters and our payers. The industry needs entities like Capario to create flexibility around the implementation deadlines for all parties in order to ensure a smooth transition.

How will the transition to ICD-10 affect Capario and other claims clearinghouses over the next few years?

From a systems perspective, once we complete our 5010 system updates this year, we will be able to accommodate the ICD-10 codes. The bigger challenge will be with clients whose Practice Management Billing System cannot generate an ANSI 5010 file. 

Capario and many of our competitors are currently evaluating different solutions we can offer our clients that choose not to upgrade their system to the 5010-compliant version. Those options include both revisions to legacy file formats to accommodate ICD-10 codes and online portal solutions to allow customers to select the appropriate ICD-10 code for their claims. This is still a very fluid situation and we are actively pursuing all options to ease this transition for our customers.

If you could give a practice five criteria on which to choose an RCM vendor, what would they be?

Look for vendors that offer the most direct routes to the broadest list of payers. This is really important for two reason. You don’t want to make unnecessary stops. Just like with flights, every layover is an opportunity for a delay or problem. And,  you want a vendor who’s working directly with payers, that understands each payer’s edits and can push that information to the forefront. A vendor that can validate your files at submission will stop problems at the onset of the process, letting you fix errors and get claims back on their way quickly. No more costly and unnecessary delays.

Find a vendor that has visibility into the entire claims process, not just their portion of it. You need real-time tracking information for every step your claim takes on its way to adjudication and payment. Good, actionable information helps you fix problems fast. Beyond that, the vendor needs to offer business intelligence reporting tools that let you see the macro-level trends happening within your claims. When you have this kind of insight, you can make small billing changes that have dramatic effects on AR days and cash flow.

Find an option with a good and flexible patient eligibility verification system. You want a system that will let you do bulk file (think patient schedule-based) checks as well as ad-hoc individual and group checks. You want all of these options because bulk-file checks are the most effective, but you need the ability to run ad hoc inquiries as well.

Look for a vendor with staying power. Capario has been operating in this space for more than 20 years. There are a number of other long-term players in the industry, but there are also an equal number who have only been around for a few years. Experience really matters in this business.

Lastly, and on a very practical level, use the “contact us” test. Look for a vendor that makes it easy to talk to them. We get new customers everyday who are fed up with one of our competitors. Some won’t disclose support phone numbers. Some only offer e-mail support. Find a vendor who actively promotes how to get a hold of them and lets you talk to a live person. You’ll immediately increase your chances of having a good experience.

News 1/20/11

The 230-provider Summit Medical Group (NJ) picks athenahealth to provide RCM services. Summit will interface athenaCollector with its existing Allscripts EHR application. The Street apparently liked seeing athenahealth win business at the enterprise level: shares hit an all-time high Wednesday, reaching $49.30 and closing at $48.06.

Is this for real or perhaps a publicity stunt? Weno Healthcare issues a press release saying its ONC-ATCB application was denied without an appeal option. Apparently CEO Tina Goodman is unhappy with the situation and believes her company has the credentials to qualify as an ONC-ATB. Goodman says she has asked HHS Secretary Kathleen Sebelius to investigate “misconduct in the ONC’s ATCB application review process” because she believes ONC followed an unethical review process. She also suggests that Dr. David Blumenthal was involved in misconduct and believes her company’s application “threatened some who had political influence.” I can’t say whether or not Weno is qualified to serve as an ONC-ATCB, but it a quick tour of the Weno website indicates a business that’s not in the same league as Drummond/InfoGard/CCHIT and the rest. Weno’s primary service is a “free healthcare e community which connects healthcare organizations.” Just over a year ago, Weno announced it was offering a fully hosted, free EMR, but that product is no longer mentioned on Weno’s website. Something else interesting I found on Weno: the above press release from December 20th announces Weno’s approval as an ONC-ATCB; SpringCharts is lined up to be their first EHR tested.

Lenox Hill Radiology (NY) contracts with Healthcare Administrative partners to provide medical billing services.

EDI provider SSI Group partners with BNY Mellon to offer SSI provider clients a link to BNY’s electronic payment services.

The local paper claims that Norman, OK physician Cynthia Taylor is the nation’s first doctor to receive EHR stimulus funds. Whether or not Taylor was the very first, I’m sure she is pleased with her $21,250 check. Her office went live on eClinicalWorks in February of 2008.

Also from a local paper: Columbiana Clinic (AL) is moving its physicians to EMR. I’m guessing that’s pretty big news in a town that has a population of about 4,000. The four doctors are migrating one at a time and only two have made the switch so far. The first doctor reports her patient volume dropped from about 22-24 patients a day to as low as 10-12 per day, though it’s picking back up. The practice also plans to add a patient portal by January 2012.

PHRs have the potential to help patients manage their health, but technology needs to be designed with the patient in mind.That’s the opinion of two Virginia Commonwealth University family physicians whose editorial appears in JAMA. The physicians describe a new PHR model that goes beyond simply showing patients how to access health information. Key elements would include the collection and storage of information from patients and doctors, the translation of clinical information into lay language, informing patients how to improve their health based on personal information, and making actionable items for patients. In other words, leverage technology to make the PHR more relevant to individual patients. Great suggestions, but it still does not address the issue of who will actually enters the clinical data into the PHR.

The CEO for GW Medical Faculty Associates (MD) believes his practice’s advanced EHR (Allscripts) will help attract new physicians. The group is obviously pretty proud of its EHR usage which, according to the video on its Web site, is pretty extensive. The 550-physician GW Medical is negotiating to buy 15 different groups ranging in size from three doctors to over 100.

AHRQ will survey about 400 Medicaid providers over the next two years to identify barriers to the meaningful use of EHRs. AHRQ will tailor its technical assistance and support programs based on the feedback.

A pair of bariatric surgeons help create a free iPhone app that gives patients an idea of how they’d look with a few less pounds. Using the Thin Me app, patients can upload a photo and use the apps’ tool to reshape their figure. Patients can then forward the surgeons their before and after pics and ask for a price quote. The app was actually developed by Pixineers, a company specializing in medical apps to help doctors “increase patient interest and loyalty.”

E-mail Inga.

Intelligent Healthcare Information Integration 1/19/11

Home Runs & Hat Tricks vs. Game Winners & Buzzer Beaters

Jordan fades back, it’s up…it’s GOOD!!!

Who doesn’t love a good, last-second, game-winning, buzzer-beating score – in sports, literally, or at work, in a more figurative sense? We all want to be the one who nails an amazing game changer or at least be a part of the team that does.

On the EMR/EHR hunt these days, I’ve seen some pretty impressive home runs and even a few hat tricks. But, there’s a big difference between home runs and hat tricks compared with game winners and buzzer beaters.

In fact, many of the EMRs and EHRs I’ve looked at lately have hit a homer or two, maybe even completed a solid hat trick. But hat tricks and home runs are a far cry from game-winning grand slams. Many — maybe even most — vendors have found some really cool ways of getting certain tasks or job functions digitally handled. But, that is where the problem begins.

I’d wager that pretty much every EHR out there started off with at least one or two unique ideas, genuinely cool features or functions that hadn’t been created elsewhere. But since there is a lack of standardization, each of these cool tools must then have a full EHR built out around it. Unfortunately, the cleverness doesn’t seem to pervade the rest of the build out – almost never.

Thus, as the EHR hunt continues to show, really great ideas are often trapped within an overall dull total package. Slick data capture gets caught up with a horrendous user interface. Cool communication functionality gets mired in a mountain of clicks and drop-downs. Stylish user experiences get hamstrung by a lack of good templates or content. Fancy evidence-based tools lose value from dull-witted programming that causes unacceptably slow workflow.

Imagine if none of our electronic gadgets had a standardized plug or wall outlet design. All the best electronics in the world mean nothing if you can’t get power connected to enable their meaningful use.

Here’s a great example of a very cool tool I just learned about that would benefit from more intersystem connectability: Doctrelo eRx Plus. OK, this link doesn’t really give you deep insight into the product; it’s actually still in alpha. But, trust me: Doctrelo’s eRx Plus e-prescribing system, based on clinical problems and designed around how providers actually think, is the slickest e-prescribing tool I’ve ever seen.

Just like having a standard shape for electrical outlets and plugs, having such standardized EMR component “work-togetherness” would sure go a long way in bringing about real, cream-of-the-crop, game-winning EHRs. Goodness knows I’ve seen some really phenomenal parts and pieces recently. I continue to think, “What a great system I could create if I could take one from vendor A, two from vendor B, etc.!”

But then, as anyone who’s tried to charge their phone in Kathmandu or Kuala Lumpur will attest, we can’t even get electrical outlets or voltages standardized. I’m probably hoping for too much from my next EHR. Maybe just a good hat trick will have to hold me for now.

From the trenches…

“You have to expect things of yourself before you can do them.” – Michael Jordan

 

Dr. Gregg Alexander, a grunt in the trenches pediatrician, directs the “Pediatric Office of the Future” exhibit for the American Academy of Pediatrics and is a member of the Professional Advisory Council for ModernMedicine.com. More of his blather…er, writings…can be found at his blog, practice web site or directly from doc@madisonpediatric.com.

News 1/18/11

From Ann Thrax: “Re: Testimony for HIT Standards Committee. Have you listened to the testimony? You don’t want to miss hearing what Dr. Scott Monteith has to say.” The written transcript is not yet posted on the ONC site, but you can cue the recording around 2 hours and 49 minutes to listen to Dr. Monteith’s five-minute testimony. Here’s a snippet:

“ONC’s strategy has put the cart before the horse. HIT is not ready for widespread implementation. The problem isn’t Luddite doctors not adopting. The problem is that HIT isn’t ready, especially if we want safe and efficacious bells and whistles like CDS, interoperability, etc.”

From Doubter: “Re: Practice Fusion. Awesome interview, but it just doesn’t smell right. How do you have 500% growth and no idea when you will be cash flow positive, or better yet, turn a net profit?” In fairness, CEO Ryan Howard probably knows these details, but as a privately held company, he chose not to share.

Speaking of Practice Fusion, they were among the top six EHR vendors in a recent report by Black Box Rankings. The survey considered the satisfaction of primary care physicians with their EHR vendor. The other leaders included eClinicalWorks, DrFirst/Rcopia, Amazing Charts, Greenway, and ChartLogic. The Practice Fusion rep told me they earned more #1 rankings on individual criteria than all the other EHR vendors combined.

Hayes Management Consulting announces the formation of a new revenue cycle practice under the leadership of Sharon Christoforakis. She previously served as SVP of revenue operations at ABQ Health Partners and as a manager / consultant at Pricewaterhouse Coopers.

With the start of a new year, most deductibles are reset and patients pay more out-of-pocket costs. It’s also the time of year that the risk for embezzlement in practices is highest. Patients, unlike insurance companies, often pay in cash, and 45% of thefts occur before or after cash transactions are recorded on the books. The trend for higher deductibles and co-pays means the potential for embezzlement is rising. Consultants recommend that practices develop a system of checks and balances and provide plenty of physician oversight, including the monitoring of refunds and checking for “phantom” vendors. MGMA says that 83% of practice managers report that at some point in their career they worked in a medical offices where employee theft occurred. Less than 30% of practice embezzlers are prosecuted, though about 82% are fired from their jobs.

Please join me in welcoming MD-IT as HIStalk Practice’s newest Platinum sponsor. The Boulder, CO-based MD-IT offers medical transcription services and software that are used by over 7,000 physicians in 950 practices across the country. Their offering includes traditional dictation and transcription services, speech recognition tools, document management, EMR, health information exchange, and practice consulting, including assistance qualifying for Meaningful Use incentives. Their Web-based platform provides 24/7 access with 99.9% uptime and a nationwide network of regional offices providing local service options. MD-IT is also sponsoring HIStalk, so we are doubly appreciative of their support.

The 52-physician Infinity Primary Care (MI) joins the 1,300 member Henry Ford Physician Network. No doubt Henry Ford’s future plans include the formation of an ACO.

Patients looking for a primary care provider want to be able to access more detailed information online, according to a new Harris Interactive poll. Results also indicate that in the absence of quality data, patients will select their provider based on location and recommendations from family and friends. Also noteworthy: 42% of Americans are worried that healthcare reform will require them to change their doctors. These findings are based on a telephone survey of 2,020 adults, which has me thinking: am I the only person who avoids answering the phone if I suspect someone is calling about a survey or who refuses to participate if I answer the phone in error? I doubt it. So who, exactly, are these people that participate in phone surveys?

Think you are an EHR incentive program guru? Try taking this EMR Straight Talk quiz from the folks at SRSsoft. It includes all the details you should know if you are seeking Meaningful Use money. I actually found it a little tricky, yet my (perfect) score is listed above. Guess that means I get to keep my job for now.

As patients look for ways to trim their healthcare costs, more will likely turn to direct-to-consumer lab tests. In 2009, patients spent about $20 million on tests like lipid panels, hormone levels, vitamin D, and liver function. Look for the segment to grow 15 to 20% annually. The AAFP, of course, advises that patients seek counsel from their physician, since “there are a host of factors that go into whether a test is needed, warranted, or a waste of money.”

E-mail Inga.