pediatrics

This week on the front page of the Market Place Section of the Wall Street Journal, there was an article titled “Worries Emerge Over Outsourcing of Electronic Medical Records” (By Amol Sharma in New Delhi and Ben Worthen in San Francisco, November 2, 2010). The authors of the article discuss that companies based out of India have less success winning E.H.R. contracts for Hospitals due primary to concerns of patient privacy of Health Records outside the United States. Patient privacy is a major concern within the Healthcare community. There are a few companies based in the United States that will provide a basic E.H.R. system for free if the physicians agree to advertising within the E.H.R. System.

With the risks of Medical Malpractice in the United States, a practice should first check with an attorney that specializing in Healthcare law prior to adopting a system with adverting and/or a company that ‘mines the data’ for selling to another company. Does the company use data ‘crawlers’ to identify treatment patterns and then send a targeted message to impact the way a physician treats a patient? If so, does this advertising increase the utilization of services/products paid by the government? Recommend a Healthcare attorney provide an initial review of all aspects of the ‘free’ system as well as a yearly audit. The reason for the yearly audit is that the patient privacy and healthcare laws change routinely.

Would a Malpractice attorney be able to pay a ‘free EMR’ company for a list of physicians that treat outside of certain standards? If the ‘free EMR’ company does not do this directly, there might be independent companies claiming to be advertisers whom are really companies that obtain this information from a ‘free EMR’ company via advertisers then sell this to Malpractice Attorneys.

Some points to consider when to optimize the protection of the patient data in an EMR system include:

• Security of the system is critical, some software EMR systems are secure but the system is maintained on a ‘weak security’ network in a physician office. If using a client-server system, insure the network is consistently being maintained by qualified personnel.
• Does the EMR Company maintain written protocols and procedures on how they maintain their data?
• Ask the EMR Company where they maintain their data (e.g. is the primary or backup data maintained in the United States?)
• Does the company have an Error and Emissions (E&O) Policy?
• Is the data of the practice only seen by authorized users of the practice as well as authorized users of the E.M.R. company?
• Does the company allow for selling of data or advertising in their system?

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?