October 15, 2007

A Winning Combination
By Mary Anne Gates
For The Record
Vol. 19 No. 21 P. 14

Physician practices that have closely integrated practice management and EHR systems often reap the benefits of an appetizing bottom line.

In some medical practices, physician practice management (PM) software and electronic health records (EHRs) have been combined to form a fully integrated system, providing better quality and more efficient patient care. Additionally, the dual system has enabled medical staff to document procedures, capture charges, and better track reimbursement issues. Due to easier access to patient records and a more efficient way of capturing patient charges, reimbursements have increased.

At Seattle’s Fremont Family Practice, a small group primary care practice, procedures are documented and stored as part of the patient’s medical record. From this documentation, coding information is fed to a billing system to ensure that charges for all procedures are filed. Additionally, the system is capable of tracking reimbursements.

In fact, the system is so well integrated, it’s hard to see where the EHR stops and the PM system starts, says Eric Rose, MD, FAAFP, a family physician at Fremont.

Advantages of EHRs
According to Rose, also EHR product manager at McKesson Provider Technologies who designs and develops EHR systems, the benefits of EHRs fall under three main categories.

1. Availability of medical records
“Just the fact that paper records are often not available or lost is a problem. With electronic health records, that part goes away,” Rose says.

George Rodriguez, MD, chief medical director at Graybill Medical Group, a California-based multispecialty clinic, agrees. “What helped us the most was getting a patient record right when we needed it,” he says. “Whether it is after-hours or at a hospital, we can get a chart anytime we want it. It’s right at our fingertips.”

According to a Graybill Medical Group report, the group schedules an estimated 120,000 patient visits annually, generating revenue of more than $19 million.

2. Quality of documentation
“A good EHR application allows you to document much more quickly in much greater detail,” says Rose.

Besides documenting the patient’s medical chart faster and in greater detail, Graybill Medical Group’s system requires that billing codes such as ICD-9, CPT, and HCPCS be entered before a patient record can be closed. This eliminates the need for the billing staff to locate necessary information before submitting charges. Additionally, the enhanced functions of the system make sure Graybill Medical Group physicians code to the highest level of specificity, thereby generating maximum revenue.

3. Ability to leverage data
“EHRs do a lot to improve the quality of patient care and improve reimbursement,” says Rose.

Better quality patient care is achieved through drug interaction automatic notification, patient-focused reminders about preventative measures, and the elimination of errors of omission and commission, he says.

Additionally, the ability to generate reports on a patient’s existing illness allows medical personnel to see how he or she is doing “qualitywise” over time, says Rose.

Documentation and Billing Streamlined
The division between closely integrated PM and EHR systems can be so invisible as to appear seamless. For example, a single-entry system that documents the patient’s electronic chart also codes procedures to the billing part of the process. Such a system helps eliminate errors and inconsistencies in the documenting, coding, and billing processes.

By capturing charges in real-time, the patient and any applicable insurance are billed more quickly. “Delinquent accounts are down significantly because we are billing more quickly,” Rodriguez says.

The Graybill Medical Group system is set up to bill a patient for all charges immediately after the visit. For example, a cash patient will have charges complete at checkout instead of being billed for services weeks later, says Rodriguez. Graybill Medical Group estimates it has reduced missing or incomplete patient bills by 80%.

To further improve the charge capture, the system can generate monthly reports on physicians who may be undercharging or overcharging for services. For example, undercharging may occur when a new physician is undercoding for a patient visit. Overcharging can happen when a physician isn’t aware of the correct charge. It’s a matter of educating physicians to understand the appropriate charges for their services, says Rodriguez.

Besides documentation and capturing charges, PM and EHR technology can track the progress of claims through the system, says Ellis Keitt, administrator of Radiology Associates (RA) in Corpus Christi, Tex. Changing from a paper-based system to filing claims electronically has sped up RA’s claims process from three or four days to hours. “We know to the minute the status of every claim,” says Keitt.

In the Waiting Room
Graybill Medical Group reports that the wait time for patients to get an appointment has decreased dramatically. Prior to implementing the Advanced Access Program—which uses data found in both the PM and EMR systems—patients waited an average of 18.25 days for a nonurgent office appointment with their preferred provider and nearly one month for preventative care appointments. Currently, patients can see their primary care physician within three days.

Check-in time for patients visiting Fremont Family Practice has become more transparent to staff and less labor-intensive. Patient check-in information can be seen on a scheduling screen so no one has to walk to the back office to let staff know that a patient has arrived. Additionally, when a patient is escorted to an exam room, the necessary medical personnel can view room location and how long the patient has been waiting.

“There is more time spent taking care of patients and less time with the logistical details of patient care,” says Rose.

Selecting a System
Before moving from a paper-based system to an electronic computer-based system, Rodriguez and a few key Graybill Medical Group staff members analyzed the practice and compiled a list of needs that could not be fulfilled in a paper environment. They discovered only a handful of vendors met their needs.

Meanwhile, Rodriguez and his staff made site visits to several medical group practices with systems already operational. Eventually, the group discovered only two products were both cost-effective and able to meet all their needs.

Implementing a System
One key to making any new system work well is making sure everyone is aware of the impending changes and prepared to accept them. “The key is to keep everyone involved up front before you get into it, or it really slows down how the process works,” says Rodriguez.

Graybill Medical Group’s physicians are also the practice owners and were looking for a way to make the group work better. “We spent more than a year talking about all the components of the electronic medical record we wanted,” Rodriguez says. “Part of that discussion centered on fine-tuning the software to meet all our needs and how to make changes and enhancements to the system.”

Currently, physicians meet weekly for approximately one hour to make any necessary changes or enhancements to the system, which was implemented in 2004, says Rodriguez.

System Capabilities
Fremont Family Practice is taking advantage of the software’s ability to configure to specific needs. “EHR software allows you to make changes to your schedule template very, very easily so you can make adjustments even at the last minute. You don’t have to delegate those decisions to someone else who doesn’t have as much understanding about the patients’ needs,” says Rose.

Features of various document management systems include automated scanning of paper documents and attachment to a patient’s EHR. Also, a faxed copy of a patient’s health record can be entered into the user document health management system and become part of the patient’s EHR.

Additionally, patients can log-in and explain the reason for their visit. This feature gives patients an opportunity to think through whatever problems they are having and what may be making their illness better or worse before they see the doctor. “It enables patients to set priorities,” says Rose.

Chronic or long-term conditions such as diabetes can be handled more effectively. Data on daily blood sugar levels stored in a glucose monitor can be uploaded and added to the patient’s EHR, enabling the doctor and the patient to get a clearer picture of how to control the disease over time.

Patient educational resources are also enhanced. Brochures about patient issues, medications, or general information such as proper child development can now be sent and viewed electronically. Some systems are also set up so patients can view their own chart, see when their next appointment is, update their demographics or insurance information, and even check in online. “It saves a huge amount of time and better serves the patient,” says Rose.

Besides the patient benefits of electronic scheduling, the doctors can also gain more control of their day by reserving certain time slots for the same type of appointment, setting limits on other types of appointments, and allocating time for more urgent appointments.

Overall, the integrated system has compressed the time frame between scheduling an exam and when the practice gets paid, says Keitt.

“Scheduling, billing, and remittance have compressed the entire system from beginning to end. That’s a huge benefit,” he says.

Cost and Return on Investment
The cost of an integrated PM and EHR system includes the hardware, software, and a monthly maintenance fee.

“It’s in the seven-figure range and well over $1 million,” says Keitt. “To justify that, you have to analyze the cost vs. the benefit.”

At RA, where 17 board-certified radiologists provide a full range of outpatient imaging services, the price was right. “The cost on the technology side with the computers and the infrastructure increased phenomenally, [but] the benefits of increasing efficiency in the imaging center more than offsets the increased cost in the technology or IT department,” according to Keitt.

Elsewhere, Graybill Medical Group’s integrated system is expected to generate a net gain of $900,000 by the fifth year.

Rose notes there is considerable evidence to show that the money saved by an outpatient practice substantially exceeds the amount spent on an EHR and PM system. He says the break-even point is typically reached in approximately two to three years.

Staffing
Changing to a system featuring PM and EHR capabilities modifies staffing requirements and adds another benefit to a private practice group.

For example, the change to a PM system nearly doubled the number of examinations RA performs per day. Keitt estimates the group currently handles 530 examinations per day between six facilities.

Revolutionizing the system and dramatically increasing the number of examinations made it obvious that staffing changes were needed in the IT department. “The technological infrastructure has to be very sophisticated to handle this volume of transactions. The IT department has gone from one person to six people,” says Keitt.

However, other staff changes were not needed. “We became more efficient as we added all these electronic processes. We can now do more examinations with the same number of people,” he says.

Graybill Medical Group reduced the number of medical records staff needed for filing and now uses staff for scanning documents into the system. Other staff, such as a transcriptionist, are no longer needed in-house, says Rodriguez. “We have eliminated all outsourced transcription services at a significant cost reduction. In-house transcription is significantly reduced as well, allowing us to reduce the number of in-house transcriptionists,” he says.

Rose experienced similar staffing changes after implementing a PM and EHR system. “We were able to reduce staff or redirect them to other areas,” he says.

The Learning Curve
Implementing a new system usually involves a learning curve. At Graybill Medical Group, where the transition from paper to paperless was spread over a few months, system training varied. “Most physicians were up and going within a few weeks, while training by some others took six months. And a few took more than a year to master the PM and EHR system,” Rodriguez says.

Training to use all functions can take a little more time, says Rodriguez. “It took me three or four months before I felt very comfortable using all aspects of the EHR,” he says.

Anxiety-charged reluctance about changing to an electronic system from a paper-based system may cause some physicians to carry around a paper chart even when the electronic version is available, says Rodriguez. “Once you overcome that, it’s very easy. We don’t have a single physician that would go back to paper,” he says.

Despite the learning curve and any anxiety felt during the change, being able to get to a patient’s chart quickly is paramount. “The ability to have it right there on the spot when you need it—that’s enough to keep going,” says Rodriguez.

— Mary Anne Gates is a medical writer based in the Chicago area.