Practical Steps toward a Paperless Office

(1)

American College of Physicians Annual Session

Philadelphia, Pennsylvania

April 6-8, 2006

Faculty

Practical Steps toward a Paperless

Office

Jeffrey P. Friedman, MD, FACP

Disclosure

Stock Options/Holdings:NexSched

Robert J. Lamberts, MD, Member

Disclosure

No significant relationship to disclose.

Educational Disclaimer: The primary purpose of the Annual Session is educational. Information presented, as well as publications, technologies, products, and/or services discussed are intended to inform participants about the knowledge, techniques, and experiences of the faculty who are willing

to share such information with colleagues. A diversity of professional opinion exists, and the views of Annual Session faculty are their own and not those of the American College of Physicians. The ACP disclaims any and all liability for damages and claims which may result from the use of information, publications, technologies, products, and/or services presented at the Annual Session or distributed in association with the meeting.

March 24, 2006

Posted Date:

(2)

Practical Steps Toward a Paperless Office

and Realized Efficiencies

ACP Annual Session April 7, 2006

Jeffrey P. Friedman MD, FACP Founding Partner-Murray Hill Medical Group, PC Clinical Associate Professor of Medicine, NYU School of

Medicine Managing Partner-NexSched

[email protected]

Assumptions

• We all want to practice high quality

medicine

• Our patient populations are similar

• Our reimbursement is not very different

• Manhattan expenses are not inconsequential

• We expect to practice at least another 10

years

• We want to be happy

Agenda

• MHMG - A Brief History

• Paperless - Meaning, Guide on “How to do it” • Avoiding Pitfalls

• Realizing Gains

Murray Hill Medical Group

A History

• 1992

– 4 Partners, 2 Associates

• 8 employees, POL • 1 exam room per doctor • No ancillary help

• Office staff all “generalists” re billing, appointments • Local small electronic billing package

History

• 1995

– Added 5 partners (including subspecialists). 5 associates

• Added EGD, Colonoscopy, Echo, EST, Holters as “profit centers”

– Built out more space

– Upgraded PMS and added Electronic Scheduling

– Staff became “specialized”

History

• 1997-1998

– Added partners and associates – Added more space

– Started with EHR ( Logician)

• 1999-2000

– Added associates – Added more space

• 2001

– Added Internet scheduling – Letter/ Lab/Mail Merge

(3)

History

• 2003

– Added Anesthesia Services – Added associates

• 2004

– Added On-line Refills and Referrals

• 2005 – Hospitalist – Rehabilitation Medicine – Podiatry – Added associates • 2006 – New PMS – Bill Paying On-Line – Email Patients

Murray Hill Patient Statistics

• 95% have Internet access

• 25% have Medicare

• 15% are PATOS

• 60% are “fee for service” managed care

• No patients are “capitated” managed care

MHMG Stats 2005

• Income is Productivity Based

• Partner Expenses for 2005 =$60,000

• Income for Internists and Subspecialists is

2-3x the national average

• Expenses for malpractice, 401K and Profit

Sharing is paid by the practice

• Practice Overhead for 2005 is 39%

• Employee/Doctor Ratio = 2.3

Agenda

• Realizing Gains

What does Paperless Mean?

• Electronic Medical/Health Record (EMR/EHR) • Electronic Billing/Reporting

Practice Management System (PMS) • Electronic Scheduling

• Scanning Inside Documents ( consents, HIPAA info, living wills and health care proxies, home b/p and glucose results, etc. ) and Outside Documents ( consults, xray reports, etc) into Charts

Paperless Continued

• Integrated Electronic Ordering

• Fully integrated with lab ( POL and Outside Labs ) • Message Documentation

– Phone notes – Refill requests

• Seamless communication between staff , providers • Faxes into/out of EHR

• Kiosk Registration – Auto insert into PMS-clean data – Prepay co-pays

(4)

Converting to the EHR

The “How To”

• Pick The Right System

– ACP Practice Management Center – Visit Install Sites

– EHR Adoption Roadmap at www.acponline.org/pmc/ehr.htm • Training

– Make someone “ THE BOSS”

– Develop workflows before going Live-talk to install sites – Formal – outside of patient care time

– “Practice” Software – Spend Time!

• At MHMG, we gave doctors months with formal training classes starting in April-July

Converting to the EHR

• Preload

– Pick Most Active Patients

• “Frequent Flyers” with multiple problems and medications

• Those patients scheduled for 1st_{2 “live “ weeks}

– Preload the most common diagnosis, medications and orders

• College students, PT help, etc • Cannot pre-convert the entire chart

“Going Live”

– Delegate “who does what”

– Make a decision and stick with it-no exceptions unless wrong!

– Stager doctors

– Cut office time in half for 1-2 weeks for “live” docs – Get coverage for doctor’s “over-flow” patients! – Pre-load those that were not done for tomorrow before

going home

– Do it during “slow season” • End of June thru early September • Cut down vacation time

Agenda

• Realizing Gains

The Pitfalls

• Doing it “Both Ways”

– Eliminate dual processes as much as possible

• Not Enough Training

– Do “dry runs”

• Too Many Patients • Poor Delegation • Inadequate Workflows • Poor Communication

(5)

Agenda

• Realizing Gains

Benefits of Paperless

• More Income and Less Time

– Efficiency in documentation re- E/M coding • Increase level of codes appropriately • Decrease liability of insurance audits – Quick refills

– Quick DRUG interaction info – Automated preventative reminders – Automated recalls

(6)

Benefits of Paperless

• Less Expenses

– Staff • File personal • Phone personal • Lab personal • Billing personal

Overhead

Medical Economics Nov. 7, 2003

Overhead

Getting Worse

MedicalEconomics Jan. 21,2005

Expense as a Percentage of Gross

Income

Medical Economics Nov. 7, 2003

0% 5% 10% 15% 20% 25% 30% Payroll Office Space

Malpractice Supplies Lab

Staff Reductions and Reassignment

• Less Filing

• Less Registration

– Kiosks – On-line updates

• Less Phone Staff

– On-line appointments, refills, referrals

Patient Internet Data

• Centers for Medicare and Medicaid Services 1999

– 21% of Medicare patients go on-line for medical information

• Harris Interactive Poll April 2003

– 80% of all patients use the Internet to view and search medical information.

– When on-line, they go to an average of 5 web-sites for information

• Kaiser Family Foundation Study 2005

(7)

Phone Message

Paper Chart EHR Secretary Writes

Message on Pad Staff Locates Chart

Attaches Note Doctor Responds

And Documents

Secretary Types Message in Chart

Chart is Filed Away

Doctor Responds And Documents

Scheduling

Patient Scheduling Telephone On-Line Patient Calls, Secretary

Discusses Limited Options All Phone Lines Ringing Staff Stressed Patient Feels Rushed

No one is Happy

Patient Goes On-Line 24/7 To Make, Cancel, And View Appts Email Reminders

Confirmations

Refills

Refills Paper Office On-Line Secretary Writes

Message for Rx

Staff Obtains Chart Attaches Message

Doctors Retrieves Info, Writes Rx Checks Interactions?

Chart is Filed Away Documentation? Patient Clicks Mx, #Pills

and Refills

Doctor Reviews Checks Interactions Routes Appropriately

Benefits of Paperless

• Ease of Following Practice Guidelines

– Measure QA

– Improved Disease Management – Better Pay?

• Obtain Medical Records Remotely

– Improved Care On-Call

• Less Liability

Conclusion

• There Is A Way To Make A Living – Modernize

• Invest time and money now for your future

• Approach changes in practice as you would a “sick patient”

– Deductive reasoning to understand the differential diagnosis – Make a reasonable game plan and stick with it – Change one variable at a time • There Is Light At The End of The Tunnel

– Increase office efficiency – Increase revenue – Decrease overhead – Increase patient satisfaction