Even practices on their own ambulatory EHR face likely data integration challenges with a new owner. "A health system can't always just force practices or other acquired hospitals to adopt their system," says White, the consultant. "The I.T. integration issue could upend the effectiveness of the consolidation. If you can't share data, you are not helping the patient. Systems that don't communicate will become mass chaos."
Advantage got an object lesson in systems integration when it first attempted to deploy an ambulatory EHR five years ago, Blair recalls. Rather than adopting a best-of-breed ambulatory system, the group attempted to run on a module that was part of its hospital owner's inpatient EHR. The still-immature software module couldn't accept data from Advantage's long-standing patient registry, a customized application it used to track various lab values and keep track of patient progress. As a result, Advantage two years ago switched to a more compatible EHR, from NextGen. Documenting patient histories in the EHR can be cumbersome, Blair says, but says the software enables much safer medication management. "You can see what has been ordered and filled," he says.
Unlike Advantage, which mandates the use of the NextGen system, some hospital-based practices offer a choice of ambulatory systems. That can be a smart move, notes Jerilyn Cowper, solutions manager at CTG Health Solutions, a Dallas-based I.T. consultancy brought on for EHR implementations. For many practices, a knowledgeable corporate parent can be an I.T. godsend, Cowper says. "Small groups don't know where to begin with the EHR. They lack the funds and they don't have any expertise. How do they go about looking for an EHR?"
Yet, many hospitals lack the support staff to properly train physicians and deploy an ambulatory EHR-particularly when their own staff are already saddled with other projects and regulatory challenges. That can lead to a sour relationship, Cowper says.
"Hospitals can't maintain their own level of expertise, yet they are bringing on more groups. Staffs are really stretched. The risk is whether the hospital can support the new practice they way they're expecting. You need to install, update, get hardware going, and get on a network. You need a person in the trenches who can go to the group, train them, and bring them up efficiently. Some practices are rebelling-they want to go back to their old application."
Despite the many pitfalls, for MacKenzie, the emergency physician, a hospital-based group has a better chance of overcoming care fragmentation. The 30-year veteran recalls when physicians used to routinely show up when their patients were admitted to the hospital. "Today there's less communication. If you don't have the I.T. connection, a patient is admitted and stuff is being done on them that often doesn't need to happen." At Lehigh Valley Health Network, ED physicians document on an EHR, from T-System, that feeds its output into the hospital's inpatient EHR, from GE. Patients admitted via the ED enter the hospital with some semblance of a chart-the first step to care coordination, MacKenzie says.
Performance Pediatrics is fast becoming an anomaly-and its founders intend to keep it that way. It's a bare-bones practice, with, count 'em, one physician, one nurse practitioner, one practice manager and two part-time receptionists. "We are quite small; we have 700 patients," says Leann DiDomenico, the manager. "Most pediatricians have double that.
"But unlike mega-group practices owned by hospitals, Performance is a family affair-literally. DiDomenico is the spouse of Terrence McAllister, M.D., who launched the "micro-practice" six years ago. He had just finished his clinical stint with the U.S. Air Force, which paid for his medical training in exchange for serving in the military health system. The experience left McAllister with a desire for more autonomy. "He had 5,000 patients and was seeing 30-plus a day," DiDomenico recalls. "Less than five minutes a day with each patient. Not what we wanted in primary care.
"So the couple decided to open up their own practice in their hometown, Plymouth, Mass. "The start-up years were tough," DiDomenico acknowledges. "But now we have a solid bank of patients. We might expand to one more physician or nurse practitioner, but that would be as big as we'd want to get."
The practice's payer mix is roughly divided into thirds among Medicaid, Blue Cross, and a mix of other commercial payers. "We are fiercely independent, but not completely isolated," she says, explaining that the practice is part of a larger IPA affiliated with Boston Children's Hospital. The IPA negotiates payer contracts with the Blues plan and a couple of other commercial payers. Performance Pediatrics is incentivized financially to meet certain quality measures, such as regular wellness exams and flu shots. McAllister may see fewer patients than his peers in larger groups, but in turn, he has to do more work himself, such as taking his own vital signs and giving his own shots. DiDomenico handles all the billing. "My husband doesn't enjoy the business side of health care," she says. "His passion is primary care and keeping kids healthy. He loves it, but if he didn't have me in the back room pushing buttons, he would have to be employed by somebody."
Those buttons refer to a small array of I.T. systems the practice has deployed to manage the practice. These include a hybrid EHR/practice management system, from Office Practicum; an adjoining patient portal, used to communicate lab results and collect online payments; and an EDI feed to its clearinghouse, Instamed, which handles eligibility checks, claims submissions and electronic remittance advice and funds transfers from the practice's payers. About 60 percent of reimbursements come back electronically, which simplifies back-end justification of EOBs and payments.
To launch the practice, the couple borrowed about $200,000, of which about 40 percent went to technology. The practice already attested to Stage 1 of meaningful use and got a payment of $22,000, "a huge help" in paying down the debt, DiDomenico says. She says the I.T. is crucial to their operation. "We treat technology as if it were another staff member or two. It is that important to us."