EHR Selection

Reliability and Redundancy of Electronic Health Record (EHR, EMR) IT Systems

December 16, 2011 in EHR Selection by support Team  |  Comments Off on Reliability and Redundancy of Electronic Health Record (EHR, EMR) IT Systems

I am sure that most practices do not spend time thinking about redundant systems to manage and maintain their EMR, EHR, and Practice Management System. We had a major slow down earlier this week when we needed to move all practices to the back-up systems. This made me think of what does a physician office do if their server is down? Do they lose production for a ½ day, a day, two days, or a week? Does an office have a back-up plan if the systems are down? What is the disaster recovery plan? Good cloud-based companies have thought through these issues to maintain your data. When there is a system outage, how a team reacts, learns and improves their systems is important for minimizing the down time for practices.

One of our practices placed the outage disaster recover into perspective for me. Prior to switching to PhysicianXpress, this large practice had a server in their office for the practice management system. A practice in the same building complex moved to a server-based EMR System a few years ago. This year, there was a major lightning storm that ‘fried’ the router of the practice we served and ‘fried’ the server of the practice that was on a server-based practice. Our client needed to install a new router and they were back up and running with no loss of data. The other practice was not so lucky. A server in the office can deliver faster speeds; the down side is that the practice needs a qualified team of IT personnel either on staff or on call to insure back-ups are occurring multiple times per day. Even in this case, not many practices have redundant systems (2+ servers hosted in different locations to minimize chance of loss in a disaster like a building fire).
No system is available 100% of the time. An up time average of 99.95% means that there are >4 hours a year that the system is down. We evaluate system components and design to identify areas to increase system up time as well as verification of data back-up systems. We are in the pursuit of the perfect system design and operation – this requires continuous improvement reviews and changes. When evaluating a system, there are some good questions to ask including: how many locations and how often is the data backed up for my practice? Who is responsible for the back-up? What has your company done in the last 12-24 months to improve the back-up and recovery? If using a cloud based system, can I maintain a daily copy of our records and schedule on a local computer for read-only access?

There are a number of reports related to the reliability of the data in Electronic Health Record Systems. In fact, there are even international publications looking at the actual reliability of the data in the system (see http://www.scielo.cl/pdf/jtaer/v4n2/art06.pdf
By Alhaqbani, Josang, and Fidge). This component shows that there are data errors by other systems or users of the system. In the United States, some insurance companies calculate the HEDIS scores of practices (e.g. evaluating the vaccines given to a select number of patients versus an established recommended vaccine schedule). Their systems miss data routinely (e.g. they capture the vaccines given in the office but not the vaccines given in the Hospital or other locations). This is another area of Medical Reliability compared to the reliability of the hardware or software.

Could your ‘free’ Electronic Medical Records (EMR/EHR) cost you thousands of dollars a year? (A review of some free systems includes PracticeFusion, Mitochon, etc.)

November 29, 2011 in EHR Selection by support Team  |  Comments Off on Could your ‘free’ Electronic Medical Records (EMR/EHR) cost you thousands of dollars a year? (A review of some free systems includes PracticeFusion, Mitochon, etc.)

How does a company that provides a free electronic health record system make money? Do they need to make money? Why should I care if they do not charge my pediatric practice to use their system? Advertising to you while you use a system is one way for a free EMR vendor to generate a small amount of revenue; another method is to sell your treatment patterns and patient data to health plans and other organizations. By agreeing to a well written user agreement, a free EMR company will request you to authorize them to do both. The free system containing a user agreement to provide a company the right to sell your data to payers and other organizations could potentially cost you personally thousands of dollars in reduced income per year. This cost could be substantial even with the promise of using a free system.

The “free” EHR Company might be sharing each of your charts, patients, and billing practices with some of the insurance plans. Imagine your Health Insurance plan being able to audit all your charts and know where
they can pull back payments for what they believe is not enough documentation (they have the file, how easy is it to look before sending the request back for a retraction of money). Of course, the health plans will not audit your charts and show all the visits for which the practice “under coded” visits. This under coding is the loss of revenue to the practice. Additionally, with a list of all your patients listed in the “free” EHR system for which the insurance company has access rights to the data, an insurer will be able to calculate what percent of your revenue if from their insurance company versus other plans. This provides a Health Insurance plan data so they have the opportunity to determine/forecast how to minimize your fee schedule. I could see insurance carriers using sliding scales to determine the amount of pay increase or even decrease payments for a practice. Image an employee from a health plan whom receives a bonus for decreasing payments to providers know that 40% of your practice is with their insurance plan, why not decrease your practice’s payment by 10%?

There are other risks with a “free” EHR company selling your data. One risk is that a health plan or other organization will know the breakdown of the number of patients for each disease. For example, maybe you are very aggressive at identifying and treating ADHD to a point that you do not miss a signal diagnosis as well as treat patients with the most innovative methods. This ability has made you the “go to” pediatrician in the practice and/or community. However, since your “free” EMR allows your data to be sold, a health plan or other group might label you as an “over user” of ADHD medications. Do they send you letters directly to address their concerns or do they develop a list to ‘report overuse’ which in fact is not really overuse based on your patient profiles. The problem is, this list might not be accessible to you or known to you and who knows what they will do with the list (do they lower reimbursements or audit higher for Pediatricians on this list?).

The “free” EMR Company might advertise that they store your data in a secure manner. They should advertise how they make money as well as that users of their system provide them the authority to sell your data to organizations that have their own agenda (e.g. insurance companies). I believe many physicians whom ‘gave away’ their rights to their data are not aware of the potential risks to their income and the way they practice medicine. The user agreement is found when you sign up and there is a prompt that states you agree to their user agreements (you can click to review). If you are not sure, before using a system, ask for a signed letter stating that the company will not sell your data.

How do you know if a ‘free’ EHR company has the right to sell your data? REVIEW the USER AGREEMENT. If the user agreement is more than 7 pages, usually this is a reason to be very concerned (some agreements that allow the ‘free’ EHR company to sell as much of your data as possible have greater than 15 pages). Our user agreements are usually 4-5 pages, we only provide access to the data to the users of the practice as well as our staff (we maintain the servers and data files), we maintain the data with triple backup and use firewall systems designed for commercial grade systems. We do not sell your data and do not have any right to sell your data. Our interests are to serve our pediatric practices.

http://www.healthleadersmedia.com/page-1/TEC-249477/Free-EMRs-Too-Good-to-be-True

Items to Consider when Selecting a Pediatric Electronic Health Record System

November 16, 2011 in EHR Selection by support Team  |  Comments Off on Items to Consider when Selecting a Pediatric Electronic Health Record System

How do I select a Pediatric Health Record and Practice Management System? There are many questions to ask when looking for a Pediatric E.H.R. and Practice Management System. Some items to consider include:
1. Identify a company that focuses solely (preferred) in Pediatrics or primarily in Pediatrics. Don’t be ‘fooled’ by the companies that try to provide the impression that they are focused in Pediatrics via their Pediatric-Specific advertising when they are actually an Internal Medicine/Family Practice System (look on their web sites and see what other specialties they implement their system). Just like kids are not ‘small adults’, a Pediatric E.H.R. is not just some Pediatric Templates. A properly designed Pediatric Specific E.H.R. system should be simple and intuitive to use so that you are able to see 30+ patients a day and have your charts completed within 30 minutes of seeing your last patient. The system also should have Pediatric Specific billing rules and be updated at least monthly.
2. Obtain a demonstration from the Vendor. Is the system ‘simple’ or ‘complex’? Don’t let a seasoned sales representative whom knows how to navigate your obstacle cloud your judgment on what is simple. From your years of experience, you know what is a simple/easy to use and a better design for you as a Pediatrician. Keep in mind that it is very difficult to design a system that is simple while still being complete. Some of the ‘dated’ systems are complex since that was the old model in technology as well as the old thinking around design. In the defense of vendors that are trying to maintain the ‘old’ technology, it is very expensive to redesign a system so many companies just keep adding on to their base system developed over a decade ago. In the programming world, a decade is forever (think what has changed – smart phones (e.g. IPhone), Facebook, Twitter, I Pad, etc.). One of our advisors (an executive in the Technology field), is shocked at how ‘dated’ some of the technology companies are in the Healthcare space. Interesting that some of the vendors with ‘dated’ technology is proud to answer ‘how many installs’. This is a ‘weak’ argument. Consider that there are probably more ‘tube’ TVs (old technology) than Plasma/LCD (new technology) – would you purchase a ‘tube’ TV today based on number of installs of the dated technology? Electronic stores do not sell ‘dated technology’ in TVs but E.H.R. companies continue to sell systems that were built in the pre-plasma TV/IPAD days. Their fear is that customers will see the new technology – which is better, easier to use and lower cost to the practice than the ‘dated’ technology.
3. Does the vendor provide options to customize the system? What are the costs? Some companies will not provide small customizations at a nominal to no cost (especially if they did not develop their own software but paid an outside company to develop their software). Your Pediatric Practice, in most cases, is not a ‘cookie cutter’ of the beta site for which the vendor developed their product. What can be changed and customized? Find out the cost and time frame to make changes? Ask if the company employees full-time developers or if they outsourced their development (this will provide an idea of their level of technical expertise)?
4. Does the vendor have ‘fair’ and ‘reasonable’ pricing and contracts? I am shocked at the variation of contracts by Vendors. Some vendors will have an initial cost and maintenance cost for a client server system which requires the customer (practice) to incur all the costs of a server, backups, IT team to maintain the server while providing a high maintenance fee to the practice. Many vendors make it ‘difficult’ to provide access to your data (including vendors of client-server systems). They might ‘fool’ a practice owner that they are ‘safer’ with a client-server system, but the actual occurrences in the field show that this is not true. For example, some companies do not have an export feature of their client server system so that if you want your own data out of the servers that you have paid to maintain with your own IT people, you need to pay thousands of dollars to the vendor to extract the data. The contract should state the data is yours and that you can obtain your data with a nominal fee (spelled out in the contract) or no cost. The form should be a continuity of Care Record (CCR) or similar format. If a client wants to leave our service, they will receive their data in CCR form (in our current agreements).
5. Customer Service – can you actually speak with a technically knowable person during business hours? Some companies provide either ‘leave a voice mail’ or a customer service line managed by individuals whom have strong phone skills but minimal technology skills. Call the customer service line during the day and see how long it takes for the vendor to return your call.
6. Updates – What updates are included in the price? How often are the updates? Some client-server systems only update 1-2xs per year! Many cloud systems, update continuously with this cost included to the customer. This is how this should work.
7. After your demonstration online, take a test drive for yourself of the system. Is the system easy to use? Can you call and obtain feedback and answers to your questions from team members of the vendor prior to buying? Try to schedule and see a few patients. Ask how the practice management system is integrated with the E.H.R.. What Pediatric-Specific Billing rules are in the system? Does the system have a “Pediatric Specific Scrubber” for claims? How often is this scrubber and coding system updated? 1-2xs per year is definitely not acceptable to optimize the revenue cycle.
8. Ask yourself when evaluating the options for a Pediatric E.H.R. and Practice Management System: What is the worst that can happen and best that can happen if you choose this vendor? Consider cost, how current is the technology, ability to transition to other systems, focus in Pediatrics and how much ‘hazel’ will the system be for me (e.g. there is a cost in time and effort to buy servers, maintain servers, back-up data). For example, if the vendor provides a five year agreement without a clause specifying the data format if you leave, you might be in for a costly ride. Ideally, the E.H.R. Vendor should have a one year contract with a 90 day out clause at any time after that. The vendor should also provide the data back to you in a CCR format so that all the digital data can be converted into another E.H.R.. With this contracting, there is only the risk of not liking the system since you as a practice owner can always move the data to another system without having to move through the paper to data conversion again. This is how we word our contracts – minimizes the risk to the customer (practice) and assures that the contract favors us performing continuously.
9. Do I have options for the vendor to provide billing so that I can manage my practice with less staff and does the vendor have repeatable results? Many Pediatric offices would make additional revenue with less hassle by leveraging an expert in the Revenue Cycle Management. There are many obstacles in the revenue cycle to manage that require consistent processes and management systems in place. There is a major difference from developing, selling and training on software versus managing the revenue cycle. Some vendors are trying to ‘cash-in’ without their processes and systems designed from ‘day one’ to manage the revenue cycle for their clients. Contact analysts, venture capitalists and investors, they will all point to cloud-based systems where these leaders believe today’s technology and tomorrow’s is as well. Also, you will see that the outsourcing vendors in other industries usually leverage cloud based technologies. This is very important when selecting a company to manage your billing. Some questions to ask: What is the vendor’s collection rate? What type of report do they provide the practice monthly? What is their range in A/R days for their clients? How do they train their billers to obtain new information? How do they assure that your account has follow-up and resubmission of claims? Can you view your claims real time as they manage the revenue cycle?

Hidden Costs and Reliability Issues of Client-Server EHR systems

March 14, 2011 in EHR Selection by support Team  |  Comments Off on Hidden Costs and Reliability Issues of Client-Server EHR systems

While traveling to a potential customer, I met an individual that has 10 years experience as an IT consultant.  He worked at Accenture, then the Government and for the past three years works at an IT outsource company managing a department.  This IT professional reminded me, through his position and experiences, the issues that customers face when an application has multiple copies and versions.  He described the higher operating cost for the client-server systems and the difficulty at times identifying the issue due to variation of version, install, and local equipment (their team needs to travel occasionally on site to correct issues).

He expressed to me the advanages of cloud-based systems:  more consistent access for the IT support team to correct issues, continuous updates and lower operating costs.   He was familiar with the change from ICD-9 to ICD-10 and the impact on vendors of EHR/EMR and billing systems.   We discussed with client server systems, updates would need to be completed and verified with each location.   This is extra work for the vendor of client-server EMR systems as well as their clients.  Will client-server vendors use the ICD-10 changes as an opportunity to pass a cost on to their clients?  Well designed cloud-based EHR systems provides pediatric practices routine updates at a lower operating cost compared to client-server EMR systems.

The advantages of Auto Formulary Advice in Pediatric Electronic Health Record Systems

March 1, 2011 in EHR Selection by support Team  |  Comments Off on The advantages of Auto Formulary Advice in Pediatric Electronic Health Record Systems

Let’s face it; parents are much busier today than a generation ago.  Kids have more activities at a younger age.   There are more medications today than a generation ago with varying degrees of managed care coverage.   If there are three asthma medications in the same therapeutic category, prescribing the ‘on-formulary’ medication saves time for parents.    

A Pediatric office accepts health insurance from multiple plans each with differences in formulary coverages.   A ‘typical’ drug formulary is three tiers.   Tier 1 is the generics tier, tier 2 is the preferred branded tier, and tier 3 is the non-preferred branded tier.  Each plan has a range in cost to the patient.  For example, tier 1 usually ranges $5-$10, tier 2 is $15-$35, tier 3 is $35 and up.  Since the formulary status of medications at plans changes routinely, staying up to date would be a full time job for a busy Pediatric practice.   This is where a well-built system that uses auto-formulary advice can save a practice time, lower costs to patients, and increase the adherence to a managed care plans formulary.

E-prescribing vendors and Electronic Health Record vendors have different options when they design and develop their systems.   Surescripts/Rx Hub maintain the data on products on formulary for each plan.  Many vendors link directly to the source (All Scripts, Nextgen, Physicianxpress) while others choose an indirect route via linking to another vendor (Dr. First).  Either source is dependent on the Internet to check formulary and send the prescription (another reason to choose cloud-based system).   When there is a problem with formulary advice:  a vendor with a direct connection to sure scripts needs to only diagnose their own system and communicate with sure scripts while a vendor that connects to another vendor whom connects with Surescripts has three systems that there could be a problem.

Reliability Engineering confirms that more systems in a series lead to more chances of failure/error.   Six sigma concepts also support less steps in the process.  When selecting an EHR, ask if the vendor if their system has directs links and achieved certification directly from sure scripts for formulary advice and sending scripts/refill requests.

Over the next two years there will be some significant branded drugs that lose patent protection.  This change in the market place will motivate managed care plans to further change and control formularies.   Pediatric practices that routinely use the formulary advice feature of an ‘optimal’ system should reduce their administrative burden while reducing costs for patients and payers.