A practice's EHR growing pains

It was Friday-a morning that was the culmination of months of planning for the office-based physician and his staff of five employees.

For George G. Ellis Jr., MD, who owns a busy solo internal medicine practice in Boardman, Ohio, this day was going to be challenging. He knew it, and so did his staff. Hundreds of hours had been invested in tutorials, and thousands of dollars in computer hardware, set up, logistics, health information technology (HIT) support, system preparation, connectivity, and readying for months of detailed patient data entry.

For Ellis, it was his “go-live” day. It’s a day that is about as welcomed in a physician’s practice as black Friday to a stockbroker.

There’s going to be a downturn in productivity, Ellis says, and you can only hope there isn’t a complete crash.

For any physician, office manager, and staffer experiencing the first day’s use of a new electronic health record (EHR) system with active patients, it’s an event as memorable as some of history’s greatest tragedies.

Why? Consider exactly what is happening during an EHR implementation. The practice and its team members not only are adopting an entirely new electronic means of data capture, they are reinventing and reimagining just about every process in the practice, from patient data entry, insurance eligibility, billing, coding, communication with patients and staff, all the way to follow-up appointment reminders.

And although Ellis clearly understood the pain associated with any EHR implementation, regardless of system, he also could see the long-term vision as it related to engaging patients in new ways, recording medical and billing data, and ultimately improving patient care with so much access to relevant data about the practice’s patient panel, their health statuses, immunization rates, practice finances, denial rates, etc.

On this Friday, Ellis, who leads and participates in the 2-year Medical Economics EHR Best Practices Study, implemented athenahealth’s cloud-based service that has a comprehensive and integrated EHR with practice management, patient communications, and care coordination capabilities.

Although Ellis says it is a robust platform that takes time to learn and effectively use, it has incorporated some very useful tools related to its core functions. In this report, Medical Economics takes a closer look at Ellis’ practice and his strategy for implementing the system, as well as his quest for achieving meaningful use, and we share some of his “best practices” after 9 months since first implementing athenahealth’s system.

Back to the beginning

Ellis is no stranger to EHR systems. This is his fourth system, dating back to 1992. When he decided to switch from a server-based system to the athenahealth’s cloud-based system in December 2011, he knew that he would leave a tremendous amount of historical patient data behind. The practice made the decision that they would not operate in parallel systems, which is a move most HIT experts laud.

“We did not transfer data from the old system,” he says. “It just wasn’t worth the effort to do it.”

For most solo, office-based practices, the undertaking and expense to port over past medical records is nearly a deal-breaker when implementing these systems, Ellis adds.

When you work in a very busy practice with an open patient panel, the proposition is almost too much for a small staff. Ellis’ practice has 4,800 to 4,900 patients in its panel. Located just outside of Youngstown, Ohio, in a largely blue-collar community with a higher-than-average Medicare base, the practice employs an office manager, two receptionists, a medical assistant, and a billing person.

The practice, Ellis says, typically sees 10 new patients a week and shuffles between a total panel of 120 to 160 patients a week. The pace of the practice is fast, and he relies heavily on his staff, notably his medical assistant (a trained paramedic), who helps set up patients before encounters.

Although the average office visit lasts about 15 minutes, new patients typically take longer-closer to 30 minutes. Acute problems can be addressed in about 10 minutes, he adds.

All of these elements also are important considerations in assessing the functionality and fit of an EHR system, Ellis adds. The practice’s structure, Ellis explains, is important because the EHR system needs to help the practice maintain its pace and viability. Understanding an EHR’s capabilities upfront, and evaluating the system based on the needs of the practice, is extremely important for every physician. He took the time, and he believes the homework paid off.

In fact, the integration of clinical, management, analytics, billing, patient communication, and care coordination capabilities made athenahealth’s system attractive to his practice, and it helped streamline many of these core operational functions into one system.

Making preparations

As part of his evaluation, Ellis wanted a vendor with a solid reputation and a system with low upfront costs, a growing base of users, and depth in clinical and practice management functionality. And he wanted a system that not only closely matched the workflow of his practice, but also could be customized to help him see the volume of patients typical for his practice. He also knew that he wanted the ability to streamline and improve communication with his patients electronically.

As part of the Medical Economics 2-year EHR Best Practices Study, which paired 29 physicians with nine EHR vendors, Ellis was offered athenahealth’s service for 2 years as part of the joint agreement to participate in the study.

Once the end-user license agreement was signed, it triggered another very important, and often underused, aspect of implementation: training.

In fact, before the go live date, he and his staff performed online training tutorials during non-office hours. He paid them for the next 12 weeks of training. In fact, in the end, online tutorials helped, but working in the system before going live would have been a far stronger approach.

The practice had developed two “super users,” and that was extremely helpful before the go-live date.

A day at the office

When a patient steps into the office, he or she is asked to complete demographic questionnaire that covers past medical problems, family history, social history, and everything relative to that visit. The office staff collects the patient’s insurance information, collects a co-pay, and takes a photograph for the record. This begins the process of data entry into the system. And it remains one of the most time-consuming and important aspects to implementing an EHR, Ellis says. In essence, the practice is laying the foundation of data that will accompany all subsequent encounters. It’s the piece of an implementation that takes the most time, but one that pays dividends long-term.

During the go-live day, Ellis says, the productivity in his office slowed to a crawl as his patients supplied data and his staff entered them into the EHR and began to see patients and document the encounters. They were learning new aspects of the system not previously encountered, but they were trying to communicate with patients and practice an entirely new workflow as far as check-in, processing, performing the patient encounter, and check-out.

“We started putting every patient in the system as if it was the first time he or she was being seen,” Ellis says. “It was very disruptive. I felt like the engine fell out. During that first day, we saw 10 patients in 10 hours.” A typical day sees closer to 40 patients, and on some days, even more.

Not only was the first day taxing on the staff members, but they also had to explain to patients why they needed to re-enter demographic data in the system. “It was just a really slow process in the beginning,” Ellis recalls.

Although improvement was noted during that first week, it took the practice’s team close to 3 to 4 weeks to show noticeable speed at processing. During that first month of implementation, Ellis’ practice was seeing less than half of his normal volume. Although physicians should anticipate a 30% drop in productivity, they also need to plan for it financially and its impact to the operation, Ellis says. And importantly, physicians should set a timeframe for the practice to bounce back to normal productivity levels. Note: Ellis didn’t draw a paycheck for 3 months.

No pain, no gain

As the team improved its competency in using the system, and when Ellis began seeing a return to normalcy, the practice began implementing some of the advanced features of the system.

Data mining, denial reports, revenue metrics, patient portal establishment, email communication with patients, advanced callback features, appointment reminders, claims scrubbing, coding issues-all were features that began to offer insight into his practice and his patient panel.

Ultimately, Ellis attested for meaningful use in about 100 days after implementation. The process was made simpler by one of athenahealth system’s features, he says.

Long-term, the practice has returned to normal volume, as shown in “Ellis appointment count” below. It’s also important to note that his practice went live on May 18, 2012.

In terms of tracking accounts receivables, the practice had its worst showing during the first month and has since recovered.

The system’s focus on revenue cycle management, Ellis says, has improved its cash flow, submission of claims, reduction in denials, and collecting from private and public payers.

More on patient communication

And, importantly, access to a secured online portal to communicate with patients via email and enabling patient access to health information including education materials is helping the practice engage patients in new ways and build efficiency. In fact, Ellis was surprised at the interest of his patients as it relates to accessing and engaging the practice in their care online. He communicates via email with patients every day and is actively using advanced features associated with the online portal that allow:

• message exchange,

• review and payment of billing statements,

• appointment requests,

• researching of health topics,

• review of personal health information,

• completion and updating of medical forms, and

• updating of a patient’s profile and contact information.

When it comes to metrics, Ellis says the practice is moving forward and showing improvements in many of the core measures outlined the government’s EHR incentive program for meaningful use 1 and 2.

He also looks forward to the day when physicians will have the ability to communicate with each other and share medical information in secured ways, all in an effort to create new efficiencies in the delivery of care.

“That’s what this is all about-improving the health of patients and creating an efficient system that allows our practice to offer advanced care and further develop our services to remain economically viable,” Ellis says.

5 tips for an EHR implementation

• Pick the right electronic health record (EHR) system for your office. Identify the needs of your practice, and then make certain the system can adapt to meet those needs.

• Be thorough in your due diligence when it comes to hardware and software selection.

• Train. Train some more.

• Educate your staff and patients about the need for the implementation. And be open with your staff and patients about the short-term realities and long-term improvements associated with it.

• Experiment with the functionality of your EHR to make certain you are getting the most benefit from its use. Appoint and train “super users” in the practice to help answer questions during the implementation.

Anatomy of the practice

Practice square feet: 3,000

Number of exam rooms: 4

Number of physicians: 1

Number of full-time equivalents: 5

Electronic health record (EHR) system provider: athenahealth

Billing/coding provider: athenahealth

Number of computer workstations:

• Front office: 2

• Back office: 5

• Exam rooms: 5

• Waiting room: 0

Connectivity: wireless, wired, WEP IIa

Hardware: HP Elite Desktops, custom-built PCs, 1 tablet, 2 wireless laptops for emergent use in case of workstation failure

Laboratory interfaces: Access to labs real-time

Telephone system: Voice-over internet protocol to integrate with the EHR system

Medical Economics’ study enters second year; participants identify best practices

More than a year ago, Medical Economics connected 29 primary care physicians (PCPs) with nine electronic health record (EHR) system vendors to document best practices related to  implementation.

The Medical Economics EHR Best Practices Study allows physicians time to gain experience and knowledge by working with an EHR system over 2 years. As the study moves into its second year, all of the participating physicians have implemented systems, and many already have attested to meaningful use.

The ultimate goal of the study is to gather real-world data and identify strategies to help solo and small office-based doctors in their quest to implement and use EHR systems. To accomplish this goal, the study has been segmented into four stages of an EHR implementation: pre-implementation, implementation, post-implementation, and EHR functionality. Study participants are asked to report on everything from vendor selection, data migration, connectivity, and assessing a practice’s integration capabilities to developing a workflow and preparing for the unanticipated costs. Participants are reporting key benchmarks to help other physicians gain a realistic understanding of the process and identify creative ways to ease implementation in their practices.

Participating vendors include ABEL Medical Software, Amazing Charts, Aprima, athenahealth, CureMD, McKesson Physician Practice Group, MedNet Medical Solutions, Practice Fusion, and Vitera.

Examine your revenue cycle to keep pace with changing economic trends

New ways of paying for healthcare call for adjustments to billing, collections processes

By George G. Ellis Jr., MD

Revenue cycle management (RCM) tools can drive healthcare reimbursement to higher levels. And tools to actively and accurately monitor your revenue cycle are becoming rapidly available in the form of robust electronic health record (EHR) systems that are consolidating functions to streamline the way revenue is we collect and process revenue.

Consider that RCM refers to an entire billing process. The cycle begins when a patient books an appointment, and it ends when remittance is received from the payer and the patient. It also includes multiple steps along the way, including eligibility checks (verifying insurance); capturing, entering, editing, or scrubbing a claim, collecting accurate information needed to create a medical billing claim to a third-party payer, Medicare, Medicaid, and so on.

And the revenue cycle is taking on greater significance because of a variety of financial trends affecting primary care physicians. A white paper published by Triple Tree Consulting says that the inefficiencies of redundant data collection, manual process, and repetitive rework of claims submissions are “all contributing to a diminishing bottom line.” Sound familiar? And as the trend pushes payers (and many other businesses influencing our revenue cycle) to reduce healthcare costs, we physicians will need to become much more efficient in the way we manage and operate our practices.

Some of those efficiencies range from how we handle eligibility checks to the processes we have in place to scrub claims or investigate the reason for a denial. And there are just as many reasons to conduct a thorough examination of your revenue cycle.

Why? Not only are insurance deductibles increasing, so is the use of flexible spending accounts. More and more of our patients will be tied to costs associated with their healthcare. This trend has been called “consumer-driven health,” and Triple Tree Consulting suggests that it will be the greatest driver to healthcare since the rise of managed care. It will have a direct effect on how we organize and collect for our services for patients and payers.

We also are seeing consolidation of services that traditionally have helped us manage this revenue cycle-from billers and coders, to billing processing companies, to payer adjudication, to a wholesale integration of all of these functions within some of these EHR systems. The trend will help us manage our practices more effectively and efficiently, and it ultimately will simplify a very complex billing process and make entering and tracking reimbursements, claim denials, collections, and financial analytics that much easier.

When we examined my practice’s internal systems and ways to improve our revenue cycle, our cash flow improved.

My suggestions? Start by examining the capabilities of your EHR system. For the past year, I have been working with athenahealth’s practice management system and noted a decrease in claims denials secondary to coding errors, lack of modifiers, or incorrect insurance. In fact, in being part of the 2-year Medical Economics EHR Best Practices Study, which is working with multiple EHR vendors, I have been exposed to many systems in the market that can help you advance in a variety of ways to improve and streamline your practice’s revenue cycle.

Next, look at your revenue cycle processes as they relate to the pre-encounter, patient-doctor encounter, and back-office operation. We sought to improve our efficiency in the pre-encounter phase. In fact, we wanted to streamline the processes of our front-office staff as patients enter the practice.

Typically, at this point, the patient’s demographics are obtained, and his or her insurance information is acquired and verified before the encounter. The patient’s eligibility is verified prior to the office visit at 2 weeks, again at 24 hours, and on the day of service. Not only does insurance verification at the time of the visit help us manage and collect copays before the encounter, it also can substantially reduce denials on the back end.

Because of changing reimbursement models, more and more patients will have out-of-pocket deductibles. Therefore, collecting co-pays and deductibles at the time of the encounter is going to take on even greater significance to a practice’s financial health.

Once these steps have been completed, the patient is ready to see the physician, where a note is completed. The amount of information obtained during the exam, the complexity of the exam, the amount of documentation, and the complexity of decision making will all determine the evaluation and management (E/M) level of care and International Classification of Diseases, Ninth Revision, (ICD9) codes used during the encounter. The ICD codes and E/M level of care will provide the necessary information for charge entry, another critically important step.

As physicians, we not only drive patient care, we also generate most of the revenue for the practice. We clearly are the most valuable asset of the practice. Realizing this role, I have taken on the responsibility of charge capture and submitting claims for submission to payers as well. Why? RCM has enabled me to enter charges at the end of the day, and my doing so results in fewer lost charges (or omission of charges). Reviewing ancillary services performed during visits enables me to capture charges omitted by nursing or medical assistants.

With declining reimbursements, it is critical to capture all charges and submit them in a timely fashion with proper coding.  If you have a bad claim, tools such as Code Checker guide you to use correct modifiers or choose a more specific diagnosis.

Ultimately, better managing your revenue cycle will improve your financial performance. And as the healthcare market shifts to reducing costs overall, we need to look at every management strategy available to help us remain economically viable so we can continue to offer high quality care to the asset we care about most: our patients.