From Fairytale to Reality: Finding an EHR That Fits Just Right
FEATURE
By Kama W. Morrow, CPC, RCC, CCS-P
The childhood fairy tale Goldilocks and The Three Bears comes to mind when anyone discusses the perfect fit. One may be too large, another too small, but the simplicity of the story offered “one” as being “just right!” How might that story line unfold if our main characters were from a small-to-medium size multi-disciplinary medical practice searching for the perfect electronic health record (EHR)? EPIC® may be too large, paper charts may be insufficient in today’s world, but “just right”, what might that look like?
Chiropractors today have carefully constructed the “just right” clinical team focused on providing collaborative care to their patients. This integrated practice compliments primary medicine with the specialty approach of chiropractic and possibly physical therapy (PT) service lines. Some even added massage therapy or other holistic service lines to meet the needs of their growing patient population.
The same commitment to a software search can result in an EHR system that is “just right” providing the integration needed to meet the needs of each specialty and their unique workflow requirements.
The search starts with evaluating the appointment scheduling module. An integrated system will recognize the need for chiropractic and PT services to be scheduled, modified, rescheduled and deleted as a reoccurring block of appointments, as these services are commonly scheduled as a series of appointments. Look for that one-step process to confirm a patient’s visits for the next weeks, month, or if required even multiple months out. The other providers in the practice may still need more flexibility to accommodate the walk-in patients, the virtual patients, or the ability to recall a patient for an annual wellness visit. Will the system accommodate both needs? And when those appointments are scheduled, can you view a single day across multiple providers on the same screen?
The “just right” EHR will anticipate a provider’s request to move an entire week of appointments to another provider or location or date. The Coronavirus (COVID-19) pandemic has recently demonstrated the priority to have a flexible, but automated, appointment system.
COVID-19 has clearly called-out the need for specific features within an EHR for an integrated practice. Virtual visits are but one such function and the reasons for including tele health capabilities on the EHR search list are extensive. The delivery of healthcare is changing, and adapting can benefit both the patient and the practice. The “just right” fit delivers the functionality without adding a completely separate process. Tele health simply works in conjunction with the patient portal and continues to help bring the practice to the patient.
COVID-19 has also reinforced the need for a truly cloud-based software. Gone are the days of having the ball and chain relationship with a server that comes with expensive overhead costs. The “just right” EHR delivers unlimited accessibility to your practice and a flexible platform that can adapt to your device of choice so that documentation can be completed simultaneously with clinical care.
The patient experience is key to evaluating the fit of an EHR for the integrated practice. Collaborative care inherently means the patient is managed by multiple providers, but it shouldn’t mean the patient is providing the same information multiple times. The “just right” integrated EHR will share data across the practice and reduce the administrative burden to both the provider and the patient. Whose family history or medication list really changes from the family practice visit Monday and the referred chiropractic consultation on Friday? The review of systems (ROS) is clinically reviewed by each practitioner with the focus of that visit but it can be reviewed on Friday without the patient completely starting over with the clipboard and piece of paper. Similarly, a daily treatment note should build on the data collected during the initial evaluation and not require the provider to redocument static data elements (i.e. treatment plan, diagnosis) within a case management workflow.
The positive patient experience includes an integrated check-in process. Many practices have not yet scanned that ream of paper into the chart when the patient is roomed, and time is wasted asking patients the same questions they just answered on paper. Some of that is the way the data is verbally “reviewed” with the patient, but during that first impression the patient needs to feel the practice staff is aware of them, their needs, and their medical history. A patient kiosk removes this pain point, saves the staff time from scanning in records, and reduces the documentation time of the providers when the HPI, ROS, past family social history and medication list are automatically available in the EHR when they walk in the room. The display on an iPad/tablet can also be adapted to the visual needs of a patient vs. the static font on a printed page. The search for a “just right” EHR will include a search for the integrated kiosk with the ability to import key forms and eliminate the front desk clipboard.
The "just right" integrated EHR will share data across the practice and reduce the administrative burden to both the provider and the patient.
Additionally, the kiosk check-in process has demonstrated an increase in payment collections. Staff at the front desk are frequently multitasking and do not consistently ask a patient for their co-payment or balance due on their account. Many are quick to accept the first excuse from the patient and move onto the next task. An electronic device is more persistent. The request remains on the screen until it is resolved. This sets the expectation within the practice for payment at the time of service that those notices on the wall and back of the exam room door have yet to accomplish.
It is a common complaint within clinical care circles that it takes longer to document the care of a patient than it did to evaluate the patient. The search for the “just right” EHR will remember this pain point and the solution will reduce, if not completely remove it. Look for templates that are specialty specific and offer the ability to display the available templates based on the individual specialty of the provider. There is no reason for the chiropractor to scroll through a library of templates designed for family practice. Within a designed template, look for the ability to retain the provider’s style both in content and process. Can you incorporate free text, dropdown, point click, by exception dictation, and even Dragon or other voice recognition workflows within the same note? Are you able to add/ remove sections or even change the options within a designed picklist on the fly?
Prescribing medication, especially pain medications, is a closely monitored task within any medical practice today. The physicians and therapists need to know even what the patient is reluctant to share. Many physicians view the pharmacy record as inherent in the consent to treat release, others have explicitly added the pharmacy as one the patient agrees to release information to as part of their care. This is helpful only if the EHR is integrated with a source to provide additional information to the practice at the time of the visit, specifically at the time that script is being electronically ordered. Look for the EHR that will offer a real-time search of the prescriptions written/filled for the patient. This information may just be used to confirm the dose the patient can’t remember or confirm the name that neither the nurse nor the patient can pronounce. But it may be used to identify the patient filling the same or similar medications from multiple practices in the same area or avoid an otherwise unknown contraindication. Either use reduces the risk to the practice and improves the overall patient care. Treating for a positive outcome relies on accurate data. All available data should be the goal of the “just right” EHR. From a pharmacy, to a lab result of your own partner, to imaging done across town, practices today need an EHR to help them manage their patient with access to complete data.
The "just right" EHR will also help the business management side of the practice.
The “just right” EHR will also help the business management side of the practice. If the services rendered are not reimbursed accurately and in a timely manner, the practice will not survive to treat the patients. It is a wicked reality. Filing an insurance claim or even being able to obtain the eligibility and authorization for the patient’s insurance is essential to the financial health of a practice. Not all specialties are treated equal within the insurance world. Chiropractors may require authorizations for a specific date range, or specific number of visits, or even lately, a specific procedure code for a specific number of dates. This payor authorizes by visit, that one by service line, and then there is always that one no one has figured out yet. Primary care providers struggle with visits on the same day as even minor procedures, and the rules for modifiers can be challenging to apply in the real world. Both may face the medical necessity obstacles when ordering imaging studies. Each may face their own denials or lists of non-covered services that frustrate both the practice and the patient.
The “just right” EHR will guide the staff through the maze of reimbursement. From the first step of checking eligibility by type of service, (i.e. PT v. chiro v. medical) to tracking the number of units provided, to the total monies spent against the Medicare CAP for therapy, the system should provide the necessary alerts to help the staff make the best financial decisions. Surprise statements aren’t welcomed by any patient and can quickly sour their perception of the practice - despite clinical care that exceeded their expectations.
Medical necessity is the number one denial after demographic related denials. It is an obstacle in every medical practice, regardless of the specialty, to remember which of the 65,000 available ICD-10-CM codes communicatethe complexity of this patient. Any EHR will provide the pathway to find the 7th character when it is required, some may alert the provider that “back pain” is not sufficient for the 15th visit, but the “just right” will offer space on the electronic superbill to remind the provider to include the common risk factors (i.e. long term use of.., chronic pain due to, history of radiation, non-compliance due to..). Those codes may well be the reason for the 15th visit or repeated treatments or falling short of an expected outcome. Communicating the true clinical picture in diagnosis codes can reduce or prevent the denial, reducing rework and delayed reimbursement.
Look for that EHR with the ability to add edits necessary for the payors involved, with the ability to alert when an order or an authorization has not yet been received for treatment, or even with the ability to automatically check units when specific circumstances exist such as the 8-minute rule for CMS. Can it add modifiers that are ALWAYS included such as those used in physical therapy? Simple steps within the setup of the EHR can save rework downstream in the billing department.
Once upon a time the primary goal of an EHR was to improve the quality of data, and timeliness of the data available to treat the patient. Reduce the redundancy of both data and ancillary testing. Goldilocks was able to find the “just right” in each of the presented scenarios in her story. It isn’t just a childhood story to expect the same outcome within your practice.
Kama Morrow, CPC, RCC, CCS-P, is an implementation manager for Practice EHR. She has spent nearly three decades in the industry leading electronic health record (EHR) implementations and providing consulting and training for a variety of healthcare organizations. Morrow is a frequent contributor to highly regarded industry publications and national conferences, providing insights on practice management, coding, billing and other industry-related topics. For more information on Practice EHR Software, you can email [email protected] or call (469) 305-7171.
