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Is one of the reasons that your practice is avoiding moving to an E.H.R. is due to most E.H.R. Systems feel like “working in a spreadsheet”? Is it due to the inflexibility of the software to adjust to your practices system of treating patients? Up to date E.H.R. systems do not need to be inflexible. There are many E.H.R. options for a practice. Some items to consider when selecting an E.H.R. system include is the system:

• Easy to learn and utilize
• Designed on modern platforms that minimize operating costs (i.e. Cloud Computing)
• Flexible to work around the clinical workflow of the practice.
• Maintain direct connections to Surescripts for Electronic Prescriptions and formulary advice.
• Efficiently designed to Allow providers to see 20-30 patients per day and complete their charts within 30 minutes of seeing their last patient.
• Easy to use for providers with all levels of interest in computers as well experience (e.g. ‘good’ for new associates as well as Senior Partners)
• Contain links between the E.H.R. and the billing and practice management systems to optimize revenue for the practice

Recommend complete an on-line or in-person demonstration of the various E.H.R. systems. Evaluate the systems based on ease of use in your field of Medicine, flexibility, interoperability, functionality and price. Should also identify if the company is devoted to continuous improvement. Ask your company contact to describe the improvements in the system over the last 12 and 24 months. This person should also be able to describe how they improved the usability, quality, function and interoperatibility over the last two years. Compare the rate of improvements between companies you are evaluating. A company with minimal improvements might have most of their capital focused on Marketing and Sales versus continuous development.

Some further questions to ask:

• Does the company sell data, allow advertisers to influence providers that utilize their E.H.R. system?
• Request the E.H.R. Company to provide a list of their partners? Are these partners ‘high quality’ partners?
• Does the company maintain all the data within the United States?
• Is there a cost for updates to the Software? Is the Software ‘static’ (rarely changes) or ‘dynamic’ (continuous improvement)?
• Is the practice able to pay for customization of the system/software? What is the cost of this customization?

These questions are different for each practice and each specialty. A “Good” clinical workflow will optimize the work of providers; staff members and patient flow in the practice.

The revenue cycle is comprised of the front office staff (check-in, registration), the providers (charge capture of diagnosis/CPT Codes) and the back end billing team (processing codes for payment). The Medical Group Management Association (MGMA) has some great resources and courses to train yourself and your staff on various areas of the revenue cycle as well as benchmark tools to identify how your practice performs.

For primary care medicine, various resources recommended by MGMA benchmark back office billing to cost 7-9% of collected revenue. If your practice manages all aspects of billing, the estimate this cost the practice needs to include the cost of the biller(s), the software for billing, the clearinghouse, training for the biller, postage, phone lines, management time. Some challenges for a smaller practice include:
• Hiring a qualified candidate and managing their on going performance
• Developing a contingency plan for when the biller quits or is on extended leave.
• Limited budget for the biller to train via approved courses
• Developing and maintaining an audit function for the biller’s work
• Monitoring the day to day work of the biller
• Retaining the biller in the practice due to limited opportunities for advancement.
• Providing an acceptable level of benefits (healthcare, vacation, etc.)
If the practice outsources the back-end billing function, the cost is listed in the contract as a % of revenue. Some questions to ask include: does the billing company specialize in Pediatrics? Request them to share their performance versus MGMA benchmarks. What is the collection rate to the contract amount? What is the average Accounts Receivable days for the company (ask for the minimum and Maximum)? Will they provide an dedicated toll free line for patients to call related to questions on their patient statement? Are there individuals available Monday – Friday to answer questions and help the front desk as needed?

When evaluating a Pediatric E.H.R. system, evaluating the connections and technology is challenging even for a technology savvy individual. One indicator of a system, the skills of individuals at an E.H.R. company or the dedication to solving a technology issue is the connections to other companies. Electronic prescriptions (ERx) are sent through a network/hub developed by the three large Pharmacy Benefits Managers (PBMs) known as Surescripts/Rx Hub. Surescripts allows E-prescription companies to link up directly to their network as well as E.H.R. system vendors. There are two primary levels of certification for Surescripts. The first provides the capability to send prescriptions, refill prescriptions and receive refill requests from the Pharmacy. The second level of certification provides all the formulary files for almost every plan in the country as well as the medication history of a patient. Some E.H.R. vendors choose to connect through an e-prescribing company (e.g. Dr. First) for one or both of these major components.

The second level of certification requires large files to be moved and managed. A small vendor might not have the technology capability and/or the financial resources to complete both level of certifications. A good question to ask a contact at the E.H.R. Company that you are evaluating is if they have direct connections for Surescripts? If not, ask why and explore other facets of the system – has the vendor been denied to link to a Health Information Exchange for lack of technology capabilities? If so, ask why?

If there appears to be a gap in the technology, consider exploring the credentials of the technology team – are they led by a CIO with experience in technology as well as a degree in Computer Science or Engineering?

Each encounter at a Physician’s office generates numerous Diagnosis and CPT codes. A practice needs to appropriate manage their billing and collections for the practice to be effective and efficient. If a physician has 20-30 patient visits a day, the physician might generate 100-200 CPT codes (or more) each day. Each of these CPT codes needs the appropriate DX codes to optimize payment with each insurance company. Even with the ‘right’ diagnosis codes, Insurance companies change their ‘scrubbers’ and ‘rules’ to accepting claims. For instance, one of the regional carriers changed their scrubbers in Mid March 2010 to deny multiple adm codes 90466 unless the code utilized “Units” on the first 90466. The biller needs to follow-up on the claim, resubmit, if denied, investigate the reason further. In the 90466 example, we learned that neither the local insurance representative or our clearing house group were aware of the change (the carriers do not inform billing teams of the changes in their practices and how to be appropriately paid).

How does your billing team monitor this issue? Do they take the time and extra effort to resubmit the claims? Are there other billers that do not have day to day responsibility for the account that perform an audit 1x per month? What are some benchmarks to monitor how well the practice is doing with the billing and collections?

On the last question, there are standards/guidelines established by the Medical Group Management Association (MGMA). The benchmarks in MGMA are fairly non-biased and provide data for a practice administrator or physician partner to monitor the billing performance. Three benchmarks include % of collections to contract amount, # of Accounts Receivable (AR) days, distribution of sick-code office visits, and % of total revenue spent on billing and collections. The ideal is to move the practice to be collecting above the MGMA benchmark goal, maintain the number of AR days to less than 35, a ‘reasonable’ distribution of visit types, as well as a cost of billing that is within the national rate for the specialty. If your practice is meeting/exceeding all these benchmarks – great job…congratulate your billing team and look for further areas to optimize the revenue cycle. If your practice is below is more than one of these areas, drill down and identify what is the ‘root’ problem and work each week to improve.

Health and Human Services named three certification bodies within the same thirty day period: The Drummond Group, CCHIT and InfoGard. These organizations all test on the same requirements to verify that an Electronic Health Record (E.H.R.) system or an E.H.R. module meets the guidelines established by the Office of the National Coordinator (ONC). E.H.R. certifications started in September 2010 and will continue into 2011. A certification is good for 2011/2012.

For E.H.R. systems that focused in a single specialty (e.g. Pediatrics), these systems still need to meet the standards for all the criteria. Further information can be found in the final rule created by ONC. A vendor needs to work with an ONC approved certification body to confirm the terms and conditions of certification including the time-line that is agreeable to both parties. There are hundreds of Vendors starting the certification process now that the criteria is confirmed as well as the first three certification bodies have been named. Interesting that some of the large E.H.R. companies paid about 2x the cost of certification a year ago to one of the current certification bodies (CCHIT) anticipating that they would have certification first and this would be a competitive advantage. From the providers perspective, there is no difference to them if the E.H.R. is certified in October 2010 or March 2011.