PAPERLESS OFFICE CONVERSION

 

Review of **** Practice Associates

 

 Prepared by: Jordan Rice

 

 

Synopsis of the Practice

 

**** Practice Associates has been in business for 7 years and has 12 M.D.’s, 5 P.A.’s / N.P.’s and 45 other staff members, of which 8 are part-time.  They started with three partners, all from the immediate area, although two went to medical school in other states.  The physicians now buy into the practice after an 18-month “engagement” with the practice.  All the physicians are Board Certified in **** medicine.  Although the center has six offices, only four are open five days a week.  Two satellite offices in rural areas of **** are only open two and three days respectively.  They are considering expansion into other areas, but one of the biggest inhibitors to growth has been their computer system.

 

The main concerns facing the practice from the initial interview process are:

 

  1. Although the doctors feel they have maximum income, there are questions on how to code correctly.  A recent audit showed that there may be issues with having coding personnel reviewing charts and “upcoding”, “unbundling” or adding certain modifiers to increase revenues from OMMS.
  2. The practice has been researching EMR’s for the past two years, but each doctor practices medicine slightly differently, all of them use transcription and they are concerned about terrorist activities, which they might survive, but there is now a concern with paper charts being contaminated by nuclear waste, biological agents or even chemical agents.
  3. There is universal agreement that productivity will be a key to the practices continued success in the coming decade.
  4. The practice has also been in negotiations at several points in the past two years with billing services, but they do not see how this will increase revenues enough to cover the 7% fee (one service actually quoted 9%) of collected revenues, to justify the service.  This led to looking at integrated packages which might alleviate the need for many internal billing and coding people and avoid having to outsource the service.
  5. The staff more than the doctors have greater concerns about using paperless systems.  The oldest physician in the group is 53 and is very computer literate.  All of them rated themselves “above average” in most areas of I-Med’s internal survey in terms of computer knowledge.  Only two believed they were “average? In computer knowledge.  On the other hand, 27% of the staff considered themselves “novices” and almost 50% believe that a switch to a paperless system would lower productivity markedly.
  6. Many of the staff dislike the current billing package, Lytec, which was not the first choice of the Practice Manager, who used Medic (now “Misys”) and Medical Manager prior to taking over the practice two years ago.  She was brought in to help the office make the conversion to paperless, as part of the solution to HIPAA that the practice is now putting into effect.  She has not made wholesale changes to the staff, but is willing to (and is backed by the physician owners), if she needs to, in an attempt to find more “computer literate” staff.
  7. The main hospital the group admits to has an older SMS system, but it is neither HIPAA nor HL-7 compliant and is not expected to be in the foreseeable future.  Three other hospitals have systems from HBOC, Meditech and IDX, all of which have little ability to transfer patient files electronically.
  8. The current ECS vendor, NDCHealth is free to the practice, as it is part of the annual support contract.  They would like to continue with this arrangement.
  9. Many of the doctors have seen some PDA solutions from sales people in the **** area and at the American College of **** show in **** this March and they would like to know if this can be part of any EMR solution.
  10. All of the doctors responded in the survey, that they thought is was “very important” to have an interactive web site that allowed patients to do things like schedule appointments, get refills, download aftercare instructions and get information pertinent to their condition.  One of the comments repeated several times, was that more patients were now seeing alternative medical providers than M.D.’s and that they would like people to see their web site as a legitimate resource for medical information on **** medicine.
  11. They are concerned that they may get the wrong product, as they have noticed that many times the best salespeople may represent a mediocre product, but that many of the best products were not shown by what one physician termed as “competent” salespeople.  They also did not think that they knew how to properly research a company.
  12. Several were concerned about Logician’s sale to GE, since they had looked at it seriously.  They have looked at Greenway, which is very “slick” in the words of several people in the practice, but they have only 14 installations and this is a major concern to the practice.
  13. The doctors feel that support issues are “very important”, which is the biggest complaint they have with the dealer who sold them their current billing system.
  14. Concerns about the total price of the system were ranked “very important” by all of the physicians.  The staff on the other hand, noted “ease of use” as their #1 concern.  The administrative staff was most concerned with document handling and best practices issues.
  15. The practice like Windows and would like to continue using a system that is Windows based.  Interestingly, this was not a requirement for the web server, which they would like to host in-house, if it is not cost prohibitive.
  16. A recent corruption of the Lytec database has now convinced the administrative staff the off-site real-time back up of data is a requisite.
  17. The office would like dual servers and the Practice Administrator, who attended the last MGMA meeting, believes that dual servers will be required in the final HIPAA regulations for any EMR or document management system.
  18.  The practice currently has a mix of computers, with an HP server, several older Compaq’s and newer Dell’s in the outlying offices.
  19. The system uses a dial-up network for billing, but has looked at T-1 and DSL for connecting the remote offices to the headquarters in ****.  When I-Med mentioned some alternatives such as satellite, due to high costs of T-1 service at two sites and the lack of any DSL service at the same two sites, they would look at any alternative proffered.
  20. One of the reasons that they retained I-Med, was the belief that they did not even know the questions to ask in the RFP, during demos and when doing price comparisons.  
  21. Virtually everyone surveyed in the practice were concerned about lack of training and hidden costs, after the system was installed.  Apparently, it now costs the practice $300 each time it wants a custom report.
  22. Finally, the practice uses Peachtree Accounting and would like some integration, if possible with the billing part of any package it selects and they would pay fees to a vendor for customization to have this capability.

 

Scope of I-Med’s Work

 

I-Med provided the following to the practice under its standard “Paperless Conversion” contract, but the for the project (which has been budgeted at $320,000 based on previous quotes) at $12,500, instead of the standard $7,500 fee, due to the amount of on-site time which will be required at the other 5 offices:

 

ASSESSMENT

 

Initial On-Site Evaluation

 

Evaluation of available accounting systems

 

Evaluation of computer systems

 

Evaluation of vendor based systems

 

Evaluation of staff

 

Evaluation of ECS / outside vendors

 

DEVELOP RFP

Billing

Scheduling

EMR

Document Management

Hardware

ECS

Preparation of RFP

 

SYSTEM REVIEW

Schedule Vendor Meetings

Demos

Follow-up

Preparation of Comparison

 

ASSESSMENT

Develop Report

Rank products - Subjective

Rank products - Objective

Price software

Price hardware

Develop TCO

 

OVERSIGHT

Installation

Implementation

Integration

Training

 

FINAL ASSESSMENT

 

SIGN-OFF OF PROJECT

 

OVERHEAD (preparation of bill, time tracking, etc.)

 

 

I-Med’s Research & Review Process

 

I-Med spent four days on-site at the practice’s headquarters and one day at each remote site.  Each of the six facilities were visited by I-Med staff, who gave confidential and anonymous questionnaire’s to all staff and physicians, each of the 12 physicians were interviewed as part of the assessment process, as were all the senior and middle management staff.  All the computer systems were inventoried and tested by I-Med personnel.

 

The practice provided the following to I-Med

 

 

 

 

·         Any other quotes related to the computer system

 

·         Quotes from tele-connect vendors for T-1, DSL and other high speed data connections

 

·         Information from outside billing services

 

·         Copies of the existing computer software manuals

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I-Med Materials Work and Final Recommendations

 

I-Med first developed a report with results from the staff survey.  It showed issues that the practice will face when converting to a paperless system.  I-Med made specific recommendations, some of which are included below.  Clearly, there was no issue by the physician owners that the need to use an EMR and that the frustrations, costs and staff concerns, far outweighed the continuation of a paper-based office.  By dealing with the obstacles perceived by the staff in an orderly fashion, using proven management techniques, much of the anxiety of the staff will be overcome.

 

A timeline was developed for the practice showing a realistic schedule and giving target points, so that everyone involved with the process would have clear objectives and understand the entire process.

 

Visio diagrams were also developed for the practice, to show various configurations, so that everyone using the computers knows the various methodologies for input, viewing of data and limitations of different technologies.

 

The layouts of the individual offices were overlaid with various computer configurations to show where equipment could be placed to find the optimal positioning in terms of staff use, ease of installation, maintenance concerns and to meet proposed HIPAA regulations.

 

A comprehensive 8 page Request For Proposal (RFP) was developed for the software.  It was divided into the following sections: Overview, accounting, scheduling, billing, electronic claims filing, Internet access, collections, claims remittance, electronic medical record (extensive), document management, integration issues, training, implementation, support, maintenance, upgrades and many other issues.

 

RFP’s were forward to 12 companies, 5 of which were unknown to the practice, but each having over 500 installations and a solid financial record.

 

From 10 replies, 4 companies were chosen for on-site demonstrations.  One was unable to do a live demo, but used PCAnywhere to do a demo from their home office in ****.

 

I-Med collated the opinions of the physicians and staff on each product both objectively and subjectively and presented these are part of the decision-making package.  Key staff comments were made.

 

In two cases, the companies did not sell hardware as part of their installation.  The hardware RFP was developed based on the needs of practice and the capabilities of the systems.  Five hardware vendors in **** were contacted and **** was contacted, as they do direct sales of their hardware.

 

A compilation of the software and hardware quotes was developed for the practice.  I-Med was able to show the “costs” for the hardware and extrapolated the “cost” for the software, to ascertain how much money could be saved through negotiation.  It was decided to try to cut $21,500 from the hardware bid, part by changing some of the recommended equipment and in part by getting the primary hardware vendor to lower the bid.

 

The software vendor selected, lowered the price by 8%, even though they had previously told the practice that they did not negotiate their prices.  I-Med’s experience with the company allowed them to make a specific bid on behalf of the practice and it was accepted.

 

I-Med personnel reviewed all hardware specs, equipment as it was installed and looked at all configurations after installation was completed to assure the practice had gotten what it paid for.

 

All training materials, schedules and curricula were reviewed by I-Med personnel prior to training to ensure that they staff would receive quality training.  Even the trainers were interviewed by phone prior to coming on-site to assure that they had the experience, ability and knowledge to provide proper education to the entire staff.

 

Once the software was installed, I-Med personnel reviewed the installation to make sure that all hardware, software, networking and operating systems were working properly.  In fact, there were several problems and I-Med acted as arbitrator with the various firms to fix several problems, which could have caused significant downtime or even data loss at some later date.

 

I-Med personnel tested back-up systems thoroughly.  It was decided to use a different method for off-site storage once the system was in place, which will save the practice over $1,000 in the first year.

 

All the Internet connections were tested, as well as the inter-office connectivity.

 

Many recommendations were made to the interactive web site by I-Med, which made the site easier to navigate, gave more medical content at no additional charge to the practice and allowed greater flexibility to patients.

 

One of the high-speed scanners was changed to another company’s product, as there were compatibility issues with the EMR software, which had not been previously detected.

 

A different uninterrupted power supply (UPS) was changed for the servers, when it was apparent that the system would not do an orderly shutdown of the **** servers, which had been selected and installed.

 

Visio diagrams were updated

 

I-Med was selected for an on-going I.T. Support contract, based upon the work completed.