As providers adopt electronic health records systems, they gradually become more adept with the technology as they flip the switch on advanced features and become conversant with the capabilities and quirks of the software.Each advance, however small, leads to more efficiencies. Before getting an EHR at Hillside Medical Office in Wichita, Kan., phone messages for nurses were written on paper. Now they're put directly in the EHR while the operator is talking to the patient. There are no more lost messages from a patient who never got a response.
"We know who took the message, when they took it, what the message was and who they sent it to," says Dave Gordon, practice administrator. "The person who answers the phone calls up the patient name and puts in the message, tasks it to a nurse and the message is instantly in the patient's chart and pops up on the nurse's screen. That creates efficiency throughout the whole building. It's not a lost transaction."
But it gets even better when an EHR is interfaced to a practice management system, Gordon says. A Hillside coder working in the practice management system-which is on the same platform from Pulse Systems Inc. as the electronic record-can click on a patient chart in the EHR and look at the actual physician notes to determine if the encounter was appropriately coded.
Billing staff in the PM system's accounts receivables module can click over to any needed clinical information in the EHR. Front desk staff or clinicians answering patient phone calls can click over to the patient chart during the call and answer questions rather than hunt down the paper chart.
Transcription costs have gone down, as have costs for managing paper charts, "not to mention the frustration when that chart could not be found or was being used by another person," Gordon says.
"Granted, we have more expenses associated with computers, but I haven't determined the exact dollar offset. But that's unimportant-there's no way we would go back to the paper format," he adds.
Running the numbers
Physician I.T. consultant Steven Lazarus, however, has run the number for clients, and the math adds up.
One, a money-losing, 15-physician cardiology group practice that adopted an integrated EHR/PM system, created efficiencies that paid for the new system in just one year, says the founder of Denver-based Boundary Information Group.
"Practices that figure this out will make a lot of money and have happy patients who won't want to go anywhere else," says Lazarus, ticking off the clinical and financial windfalls for combining EHR and practice management efficiencies: better data capture that reduces lost charges; improved coding; automated patient reminders; and proper follow-up treatment of chronic patients, among other benefits, can help a practice's revenue grow.
But it doesn't necessarily happen overnight. Eighteen months after going live on an EHR from gloStream Inc., Troy, Mich., Julie Hopkins, practice manager at BayView OB/GYN in Petoskey, Mich., noted such efficiencies, but only now is indentifying the financial impact.
The practice has a large Medicaid population and has had its reimbursements cut in that business segment, but while overall revenue is down, net income is up. "While I can't pinpoint all the efficiencies, we're running more efficiently with fewer errors, and the result is better performance all around," Hopkins says.
Seeking domino effect
Practices that become adept at using EHRs, however, sometimes face problems with "throughput" to their practice management systems. To get the full benefits of an EHR/PM integration requires clinicians and administrative staff to upgrade their practice management skills.
Steven Seligman, M.D., co-founder of Omega OB-GYN in Arlington, Texas, notes that clinicians rarely go near a practice management system. But as a clinician and administrator, he's finding previously untapped but useful PM functions now that his EHR is up and running.
For example, he can be in the EHR while talking to a patient on the phone, and toggle to the practice management system to check the patient's next appointment and remind them about it during the call.
He also runs PM reports showing monthly collections and staff productivity, and can access a physician's schedule for the next day and if necessary add a patient to the schedule.
Gail Burdine, administrator at Omega OB-GYN, is using the EHR/PM integration to cut several steps out of the billing process. Omega uses a combined, single database system from Greenway Medical Technologies, which takes an electronic superbill created in the EHR to generate a claim in the PM after billing staff review.
Six months after getting the combined system in 2004, billings and collections were up 16 percent, she adds. Seven years later, the practice is run by four billing FTEs and one collections staffer. Prior to the EHR, Omega had up to five FTEs managing records, work now done by a single employee. And two physicians have been added without an increase in billing staff.
"Reimbursements for what we do are trickling downward. If that's how it's going to be, then we need better ways to get the claims downstream. These are all little things, but they add up to better efficiency."
Next steps
At BayView OB/GYN, the implementation of an electronic record has given staff the confidence to dig deeper into the practice management system.
After the practice's first EHR went live, the provider replaced its practice management system because the vendor was not cooperative in integrating it with the electronic records system.
During the intervening 10 months before a new PM was in place, staff got comfortable with the EHR.
When the new practice management system was in place, the staff got "braver" with the software, Hopkins says: front desk employees, for example, started looking deeper into billing and insurance information and resolving issues, instead of shoveling all patient billing questions to the billing staff.
"They were less reluctant, they were ready to go in it," Hopkins adds.
The new practice management system also started drawing interest from an unexpected source-clinicians. Some nurses and physicians are occasionally accessing the PM system from the EHR during the course of the day.
Nurses, for example, will check demographics and pharmacy orders rather than ask registration to do it. "All physicians send electronic prescriptions; they need to in order to meet meaningful use requirements, but they actually love it," Hopkins says. "Some of them even send their own referral letters and corresponding paperwork."
But even years into a market push for integrated EHR/PM systems and a focus on cross-pollinating the systems to gain efficiencies, there's still plenty of room for technological and process improvements.
Wunna Mine, CIO at three-site Camarena Health in Madera, Calif., says there are practice management functions that are medically useful to clinicians, but haven't garnered much attention because caregivers don't make a habit of using the practice management system.
Unused functionality
Camarena Health uses an EHR from MED3000 interfaced with a practice management system from HealthPort. With the PM, a clinician can run a report on the last time diabetic patients were seen, but the system doesn't prompt a user to generate such a report, so the functionality goes largely unused.
In addition, even after four years since the EHR came in, providers still check off charges on a paper superbill.
The process could be automated, but physicians still are not entirely confident the EHR can and will generate the appropriate codes, Mine says.
While Mine hasn't seen a spike in the use of the practice management system, Camarena Health is piling up efficiencies. The EHR makes it easy to know if patients are up-to-date with treatments by running reports when a patient comes in, and prompting the treating physician to check on gaps of care.
Data validation also is much better since the EHR arrived, he notes.
For instance, when the practice first started running outcomes reports on patients with diabetes or asthma, it found it wasn't capturing data on race and other demographic information in the practice management system, which it has since added.
So once again, it comes full circle. While implementing an EHR doesn't always lead to more efficient use of a practice management system, it does create an opportunity for improvement.
Before adopting an integrated EHR/PM from Allscripts, billing staff at Physicians Medical Center in Las Vegas had to do some running around when insurers wanted physician notes to support submitted claims.
Now, "instead of going down stairs, finding the notes and copying them, they just print the notes from the EHR and send them to the insurance company," says Sharron Grodzinsky, CEO.
That's just one example of efficiencies seen in the billing department, she notes.
In the three years since the software went in, the department has lost two staff members to attrition and didn't replace them. Coding has improved with use of the EHR's code-checking capabilities, Grodzinsky says.
Revenue opportunities
Physicians now routinely code one level higher, which translates into nearly 10 percent more revenue for the practice, according to her estimates.
Other EHR functions are translating to more revenue. Patients who like automated checks for drug formulary compliance or gaps in care, or getting their patient care summaries, are referring others to the practice, she adds.
Archer Physical Therapy and Pilates Institute Inc. in Aventura, Fla., opened in October 2008 with an EHR from WebPT in Phoenix.
It wasn't until March 2011 that the three-therapist firm got a practice management system from Kareo Inc., Irvine, Calif. Kerry Siman-Tov, a therapist and the owner, isn't sure if she's using the PM to its full capability, but says it serves all the practice's administrative needs.
But she knew she couldn't get by any longer using QuickBooks for accounting, a claims submission application for Medicare, a clearinghouse for major commercial insurers, and paper claims for some other payers.
"I do all the finances so if I get bogged down in that I can't treat patients." What she's learned, however, is that documentation comes from the EHR, and documentation is the bedrock of billing. "Without the EHR I'm lost, I can't manage the practice efficiently without it." Before the EHR, for example, the practice had to hire staff to manage patient notes, which is now done by the caregivers themselves.
"What I've learned about using an EHR is that it saves a tremendous amount of the therapists' time in documentation, provides for accurate HIPAA and Medicare compliant documentation, and instantly populates the claim into the Kareo system upon completion in WebPT," Siman-Tov adds.
"This eliminates the need for redundant data entry and eliminates the need for additional personnel to transcribe dictated notes, proofread them and file into paper charts, which then need to be stored."
The EHR saves time and resources and improves the efficiency of health record management in our facility. It also allows us to fax our documentation to the referring physicians with an internal fax feature."
But even providers who have made a concerted effort to maximize EHR and PM efficiency still grapple with a learning curve.
Having implemented its PM and messaging system in May 2010 and its EHR in November 2010, Dave Gordon, the practice administrator at Hillside Medical Office, believes some of the practice's seven physicians are less efficient than they were when they were dictating notes.
On the other hand, while the docs aren't going home any earlier, they no longer need to cart charts home to complete since they're able to access the system from anywhere they have the Internet, Gordon says.
Comprehensive use of EHRs may or may not bring better use of the practice management system, but integration between the two applications magnifies the efficiencies made possible by EHRs.
BayView OB/GYN, which implemented its EHR in March 2010 but went nearly a year without integration between the EHR and PM systems because of a tiff with its old PM vendor, was forced to do dual data entry during that time, recalls Julie Hopkins, the practice manager.
So it was a relief when the gloStream PM went live in January. Now, aside from billing charges, clinicians and support staff can access any other part of the PM from the EHR, such as schedules, insurance information, account balances and coding.
They no longer have to use two systems to check on past or current appointments, or no-shows, and registration staff save time by shooting out test orders from the EHR.
Nurses can even schedule appointments from the EHR if working late and support staff has gone home, and front-line staff can access prescriptions and orders when patients call.
"There's a lot of administrative questions they can answer themselves," Hopkins says.
When the EHR went live, she feared one of the biggest hurdles to acceptance would be elimination of the paper superbill.
The whole flow of the practice ran off the patient checking in and printing off a superbill that followed them through the office.
But the EHR was going to generate and house the superbill, and "my staff could not fathom life without those paper bills," Hop kins recalls.
"Then, one day they had them and the next day they didn't. I honestly thought that would have been the biggest transition, but it went off without a hitch."
And the electronic superbill delivers efficiencies the practice never even considered.
It tracks the patient-when the patient has checked in, received certain treatments and incurred certain charges-but also enables staff to look at the bill and know where the patient is, such as the waiting room, getting an ultrasound or in exam room 11.
"We're not going around hunting for patients," Hopkins says.
How Far Does Meaningful Use Go?
Attempting to snag incentives for meaningful use of electronic health records opens physicians' eyes to capabilities within EHRs they never knew existed. But meaningful use can open the eyes of staff members and administrators as well. Having had 11 of its 14 physicians successfully attest for meaningful use of electronic health records in May and June, Sharron Grodzinsky, CEO at Physicians Medical Center in Las Vegas, credits the initiative with helping her learn how to generate reports for measuring quality indicators.
Meeting the patient education meaningful use measure also reminded her of a library of body images in the EHR that can be drawn on, enabling clinicians to better explain certain conditions or procedures, such as blockage in the heart.
Kansas City Dermatology in Overland Park, Kan., expected its physicians to attest to meaningful use in September 2011, and just following the path to meaningful use made everyone a better EHR user, says Shirley Sherwood, office manager.
Because of meaningful use criteria to have a problem list for patients and conduct drug-allergy checks, the practice revamped how it tracks allergies. For instance, if a patient is allergic to latex, an alert will pop up on the screen when the patient's chart is accessed. "So it's there from the get-go," Sherwood says. "You can't go past the alert until you click on it."
The newest twist on using the software is embedding patient educational materials into the records system to click and print on demand during a visit, says Karen Eggers, practice administrator.
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