It Takes Two to Tango

Bill Briggs, Senior Editor
Health Data Management Magazine, January 2005

For Primary Care Associates, the sum of its practice management and electronic medical records systems is greater than its parts. But the parts aren't bad either.

The 25-physician group implemented a practice management system in June 2002 and will roll out an electronic medical records system this month. The practice management software was a giant leap beyond the previous DOS-based system and improved claims management, revenue tracking and patient scheduling, says Bo Greaves, M.D., a family practitioner and president at the Sonoma County, Calif.-based practice.

It will be the electronic records system, though, that widens access to patient data, enhances practice patterns and ends the group's dependence on paper.

"So much of what we do in the paper world is repetitive," Greaves explains. "We ask for the patient's name and date of birth over and over." Soon, all such data will flow from Primary Care Associates' practice management application into its electronic records system.

Helping the provider

"And it will migrate back to the physician's note," he adds. "That will help the provider determine the appropriate level of coding. Data then returns to the practice management system and drops into the claim."

Primary Care Associates is among a small but growing faction of group practices that believe these two applications together can improve patient care and operating efficiency. They also believe these information technology tools will become status quo in the new world of performance-based patient care contracts and reimbursement.

What these groups seek is access to information, which will improve operating efficiency, charge capture and patient care, says Rosemarie Nelson, senior consultant at Medical Group Management Association, an Englewood, Colo.-based trade association for group practice administrators.

"A paper chart just can't be made more accessible," Nelson says. Physicians complete nearly a third of all patient encounters without a patient's chart in-hand, she notes. "The chaos of the paper chart is a huge driver. It's the one thing people want to fix."

Data culled from a March 2004 MGMA member bi-monthly survey indicated that 27% of 355 responding group practices had electronic health records systems in place.

Improving care quality and documenting results are key factors for providers who implement both practice management and electronic records systems. Plus, electronic data can be searched easily, a critical factor in last year's recall of the Vioxx pain medication, Nelson says.

Mind over paper

Group practices also run more efficiently with the twin applications in place, experts say, enabling many to eliminate or reassign labor. "Reassigning office staff means people get to take on roles with higher responsibility," Nelson explains. "There is no longer so much mindless paper-pushing. With more access to information, people are working at a higher level, providing more value and better service."

Nelson notes that group practices have shown increasing interest in electronic records systems in the past 18 months. "I've worked with a lot more groups who went from the system-search phase to selection, and then signed vendor contracts. In the past, they might have searched then said `let's wait a bit.' "

Some groups are turning I.T. up a notch because they foresee greater reliance on outcomes-based reimbursement and potential economic incentives from Medicare to communicate electronically. "A lot of groups are responding to the need to get better at demonstrating the quality of their services," says Margret Amatayakul, president of Margret\A Consulting, a Schaumburg, Ill.-based health care I.T. consulting firm. "They need data to support quality of service for pay-for-performance initiatives."

Physicians also are addressing quality issues of a different sort with these combined applications. "Doctors today say if they can't make as much money as they did in the past, they will address the quality of life factor," she explains. "That includes seeing the data they need at home or wherever they might be, and not staying late to complete charts or review prescription refill requests."

Group practice physicians also are beginning to feel pressure from tech-savvy patients who expect doctors to be automated, Amatayakul notes. "Otherwise patients will think, `If my doctors aren't using an electronic health record, what else aren't they keeping up with?' "

The path group practices take to add one or both systems varies, with some groups implementing or upgrading practice management systems and then adding electronic records technology. They are mindful of the weighty costs associated with integrating systems from different vendors, many say, and so tend to give careful consideration to existing vendors that offer both applications.

Costs to install both types of full-function systems can range from $20,000 to $50,000 per physician, Amatayakul notes, with those integrating systems from different vendors at the top of the scale. Less expensive systems are available, but she cautions against spending less than $10,000 per physician because of limited functionality.

In some cases, the add-on is the electronic medical records application, often from a group's existing vendor. In other cases it's a second-generation practice management system. But group practice decision makers will bite the integration bullet and deploy disparate systems for the right reasons, including satisfaction with an existing vendor's product and performance of the individual applications.

Some group practices take pains to stick with one vendor, helping to develop one or the other of the two applications. But Amatayakul advises against excluding other vendors from consideration.

"If the group has an incumbent vendor for one and is happy with that vendor and feels it has kept products up to date, that vendor should be in the mix for evaluation," she says. "Looking at others keeps the incumbent vendor on its toes. If a system is working well, that's a plus. But it's not absolutely essential they be from the same vendor."

Group practices that choose separate vendors for practice management and electronic records systems can expect maintenance costs beyond the upfront outlay for an interface. Software upgrades will incur labor expense, as will adding other functions later, such as e-prescribing software. "Physicians need to understand there will be greater costs over time," she adds.

Shouldering the cost

Primary Care Associates is shouldering the cost of integrating an electronic records system from NextGen Healthcare Information Systems, Horsham, Pa., with its practice management system from athenahealth Inc., Waltham, Mass.

NextGen offers both applications, but Primary Care Associates was pleased with results from the athenahealth system, says Greaves, the physician. "Our performance has improved a lot over the last two-and-a-half years and the vendor has been very responsive."

Another reason to stick with the practice management application was the group's experience of migrating from the DOS-based system to athenahealth. "We remember how painful that was and how it slowed us down," Greaves explains. "We were not eager to repeat that process while also migrating from paper to electronic records."

Primary Care Associates' decision to go with NextGen for the electronic records system also hinged on work done by the Leawood, Kan.-based American Academy of Family Physicians.

The AAFP developed partnerships with hardware and software vendors that yield price discounts. More important, however, is that the participating vendors have agreed to data management and exchange standards established by Health Level Seven Inc., Ann Arbor, Mich.

Greaves declined to disclose how much the practice has invested in the technologies, but the standards factor gives him some peace of mind regarding vendor staying power, he says. "Even if they go bankrupt, we'll be able to move to another system."

Other group practices don't mind putting both practice management and electronic medical records systems eggs in one basket. Middlesex Cardiology Associates in Middletown, Conn., for example, implemented an electronic records system first and plans to replace its practice management system, says John Colebaugh, administrative director.

Records in action

The group practice's eight physicians at three offices are using a records application from Amicore Inc., Andover, Mass. Middlesex Cardiology Associate has a Unix-based practice management system in place, but it does little more than generate bills and post payments, Colebaugh says.

The group practice is partnering with Amicore to develop a new practice management system and rollout is expected by the third quarter.

The practice is taking the electronic records system implementation slowly, working on the clinical aspects first. That keeps revenue flowing while working with Amicore to develop the interfaces with the new practice management system, says Bud McDowell, M.D., a senior physician at the practice.

The group practice expects the two applications to help it cope with the changing patient care delivery scene.

Both necessary

"It's necessary to have both applications in today's world," McDowell says. "It's hard to imagine any but the smallest group practices not having a practice management system. There are any number of tried and true systems available."

One reason the group is working with Amicore is to avoid the costs of maintaining an interface between different information systems, he adds.

System integration is a key factor for many group practices in the decision to stick with one vendor for both applications. At Berkeley Family Practice, a three-physician group based in Monck's Corner, S.C., buying practice management and electronic records systems from one vendor-AcerMed Inc., Irvine, Calif.-paid off in several ways.

"When systems are integrated like this it really follows physicians' workflow," says Chip Bounds, M.D. "It makes work easy. The electronic records software is written so that, to a doctor, the workflow is intuitive."

That makes physicians at the practice more productive because they don't forget charges and can easily see their notes, Bounds says. "It prompts for charges and suggests a level of coding. Then you know what you did and you're not guessing; you cut down errors and also decrease time spent training staff to use multiple systems."

Berkeley Family Practice has booked tangible savings as a result of the combined systems, reducing staff from 25 to 16 full-time employees, Bounds says. The integrated systems enable clinicians, while with patients, to enter billing and coding information on Tablet PCs from Toshiba, thanks to a wireless network installed by San Jose, Calif.-based Breeze Software Services Inc., an AcerMed I.T. services affiliate.

"It improved our cash flow by making us better coders," he says, and a claims checking function has nearly eliminated the practice's rejection rate.

Primary Care Associates anticipates similar revenue enhancement. "There is a fair amount of ancillary services we provide whose charges don't get captured 100% of the time," Greaves says.

These services include electrocardiograms and immunizations. With the combined systems, such services will be easier to chart; if charted, the practice will get paid, he adds.

Capturing previously unbilled charges is one of the reasons groups cite for pursuing the combined information systems. The cost of I.T., particularly for electronic records systems, has long been held up as a deterrent to investment.

But for many practices pursuing the two technologies, changing behavior has been the top obstacle to implementation. That's been the rule for Heart Place, a cardiology practice with 68 physicians, physician assistants and nurse practitioners at 20 locations, says John Bret, M.D., cardiologist and president of the Dallas-based specialty practice.

"Undoubtedly, the biggest challenges are changes in culture," Bret contends. "The electronic medical record will have us change the way we do things."

Still, the practice expects to spend somewhere between $500,000 and $1 million on the two systems, Bret says, depending on implementation labor costs.

Heart Place implemented a practice management system from NextGen in January 2003 and was about to select an electronic records system in late 2004. NextGen's offering was the front-runner, says Brett Bennett, director of the group's central business office, but one other vendor was in the hunt.

Clinicians' technology sophistication ranges from savvy computer users to those who don't own one, so making the adjustment to an electronic records system will determine Heart Place's success, officials say.

The practice's I.T. director agrees with Bret's assessment. "The big challenge will be getting total buy-in from doctors and other users we support," says David Keathley. His research on other practices' success-and failure-in implementing the technology turned on process reengineering.

The trick is to streamline workflow patterns enough to create efficiencies, Keathley says, but still "keep the system open enough to handle what individual physicians need."

Another hurdle

One additional hurdle to clear was the hardware used to enable information systems access in patient exam rooms. "Some doctors want to use Tablet PCs to review the chart, which makes sense because some exam rooms are small," he says.

Other physicians would prefer to use hard-wired workstations. "We may need some combination of hardware," Keathley notes. "There is no way to satisfy all users with one computer."

Sidebar

Why they buy

Physician group practices are looking for ways to cut overhead and improve cash flow when they pursue practice management and electronic medical records systems. They also see the writing on the wall regarding incentives for electronically exchanging claims data with payer organizations and the need to access their own data for performance-based pay initiatives.

When Primary Care Associates, Sonoma County, Calif., decided to add an electronic records system to its existing practice management application, management expected to see expenses for paper-printing and copying-to drop, says David Stone, administrator at the 25-physician family care and pediatrics practice.

Disappearing act

"The whole paper chart would disappear along with what goes into managing it in terms of real estate," he explains. Plus, Medicare is expected to juice payments to providers that can exchange claims data electronically.

Greater operating efficiency means Primary Care Associates expects to see more patients once the new information systems are mastered, Stone adds.

For Dallas-based Heart Place, a new practice management system enabled management to examine claims and billing data, resulting in a drop of outstanding revenue from 58 days to 38. Plans to add an electronic records application are driven by the desire to end inefficient and error-prone paper-based documentation, says John Bret, M.D., a cardiologist at the 68-phyisician practice.

Economics played a big role in the decision to add onto the practice management system capabilities. "We are very lean as far as our business model goes, but we calculated that 11 people would touch a patient's paperwork, Bret says. "That's a huge amount of people that we wanted to reduce."

Documented industrywide savings from these kinds of systems include reduced transcription, space and labor costs, Bret adds, "which will probably more than offset the cost of the systems."

On another note, some group practices hope to use practice management and electronic medical records systems to meet certification requirements, as well as mine their own data. For instance, Berkeley Family Practice, a three-physician group based in Monck's Corner, S.C., must meet complex new certification requirements from the American Board of Family Practice, says Chip Bounds, M.D.

One requirement is a quality improvement project that requires pulling 100 patient charts, such as those for diabetes care. "Just pulling them would be easy, but if they want cholesterol levels it will be a lot easier if it can be done electronically," Bounds says.

Berkeley Family Practice started with an electronic records system then added practice management. These tools will help meet certification requirements and other quality goals.

"One of our payers said if we get National Committee for Quality Assurance certification for hypertension and stroke care, they will pay 20% of the certification cost," Bounds says. "If the trend is to pay for quality, the only way to prove it is with computers."