Technology Can Enhance Facility Efficiency, but Not All Solutions are Created Equal

Nathaniel Moore, MD, knows that technology can lead to greater efficiency, but he is well aware of the potential pitfalls. He is president and chief executive officer of Rocky Mountain Urgent Care, PC, in the Denver area and takes the adoption of new programs and software seriously. Moore, like most urgent care center (UCC) operators, wants to be able to see more patients and knows that efficiency is key to that goal.

His seven centers have embraced technology in several ways, but adoption of an EMR system has not been one of them. Moore's open to it in the future, but any vendor he will work with must answer a litany of questions. In the meantime, he’s happy enough with paper records and has ample storage room for paper charts.

“We use a template-based chart note so that our providers can literally finish a paper note by the time it would take to log on to the computer and enter all the data,” Moore says. “As an urgent care center we also do not frequently access charts after the patient visit. Ninety percent of our charts are less than 10 pages.”

President Bush in 2004 called for a majority of Americans to have electronic personal health records within 10 years,¹ but so far that goal is far from met, and adoption of information technology in the healthcare industry lags far behind other sectors of the economy.

But does that matter much in the urgent care industry? Electronic medical records (EMRs) and other forms of IT might be best for some practices, but at Rocky Mountain Urgent Care, for instance, paperwork can be reduced well in other ways.

“If we can streamline our note completion and spend less time writing prescriptions and processing referrals, we can see more patients,” Moore says. In order to do that, technology is sometimes the answer, and sometimes isn’t.

Efficiency is an attitude, and some doctors are better with it than others, says Ross Ose, president of Business to Business Consulting, LLC, which provides healthcare practice management services. “Simple discipline based on an attitude towards the work is what makes or breaks the physician’s impact,” Ose says. “Simple stuff (makes a big difference) like correctly filling out the superbill, charting correctly and legibly, and signing the chart and support documents today, not tomorrow or the next day.”

Ose believes that doctors should bill for services immediately after care is given or as close to then as possible, and says that the likelihood that fees will fall through the cracks increases dramatically for every hour that the billing goes unprocessed. Human error — such as incomplete charts — can lead to a lack of reimbursement.

The top efficiency issue, however, is patient flow in the clinic, says David Stern, MD, CPC, chief executive officer of Practice Velocity. Stern has one center in Oklahoma and nine centers in Illinois and uses Practice Velocity in all of them.

Practice Velocity provides medical software solutions —including modified electronic EMR systems, computerized medical coding software, medical transcription, and Internet EMR access to physician practices.

“Virtually every center that has a significant patient volume will tell you that the No. 1 reason they generate complaints and have patients walk out … is related to the fact that patients waited too long in the clinic,” Stern says.

Some reasons for waits that are too long include inefficient doctor documentation systems, and trying to do everything in the clinic rather than locating jobs off site or outside of patient flow.

“You don’t need to complete billing of the patient visit (and) you don’t need to give insured patients itemized invoices at the time of discharge,” Stern says. “You can let someone else do that and the patients do not need to be held up for that.”

Billing and collections are definitely enemies of efficiency, says Shawn Lohnes, vice president of sales and marketing at DocuTAP. He recommends that urgent care leaders find technology-based solutions for billing and coding.

“(The solution) should ensure that all activities are easily and accurately captured,” Lohnes says. “This captured information should pass seamlessly to the practice management solution for processing and billing. Some coding expertise will be required with any solution; carefully examine the skills and expertise within your clinic. If you don’t have the skill set, then hire a thirdparty billing company.

“If you hire a third-party, make them work your finances within your system; do not simply send them electronic or paper files to be processed,”

Lohnes adds. “Sending this information away means that the clinic operator is also giving up control over their finances. If the billing company uses the clinic’s software, then the clinic will know at all times where they stand financially — no surprises, no excuses. Look for a solution that can assist with the entire billing process — including automatically generating and sending patient statements.”

Technology-driven systems can definitely be helpful, Moore says, but the simple solution of using templates is also a big time-saver.

“Providers need only to circle positive answers on the template and cross out negative answers,” Moore says. “This saves tremendous time that one would otherwise spend dictating or handwriting a note. Along the same lines, pre-printed prescriptions and discharge instructions save quite a bit of time for the provider.”

A common system that improves clinical efficiencies, as well as patient and customer satisfaction, is to effectively segregate patients by service requirements and triage, Ose believes. Easy services such as urine drug screenings can be handled through a “fast track” process, unlike serious injuries.

Another answer some clinics don’t think of is to ‘take the clinic’ to the client, Ose adds. For instance, if an employer wants your clinic staff to perform 100 random drug tests, send one or two staff members to the employer’s office to do this.

“100 drug screens in the clinic are going to wreck the day,” Ose says. “100 drug screens at the client’s site is money in the bank.”

Efficiency wise, it is also smart to think about long-term growth when it comes to equipment. Ose advises clients to acquire at least a four-line phone system, get more than one handset per staff member, buy a bigger and faster copier than what seems necessary, and make sure there are extra computers.

Ose adds, “’Do it now, and do it right the first time,’ are good attitudes that create efficiency. Also the doctor is usually going to set the standard for office efficiency. The staff will follow his direction.”

According to Lohnes, a well-designed floor plan can greatly enhance workflow. He also recommends technological efficiency options, but only those that allow urgent care staffs to see as many patients as possible at the lowest reasonable cost.

Efficiency and greater revenue can be gained through: real-time creation of the patient’s “superbill,” lab order management, inter-company messaging, occupational medicine account management, operational and ad-hoc reporting, electronic claim submission, integrated accounts receivable and collections management, Lohnes says.

Many in the healthcare industry believe that a specific discussion of healthcare IT is challenging due to the rapid change of technology, wide variation in applications and a lack of precise definitions. There is a huge variation of definitions in the industry and that causes confusion for purchasers. EMRs, for example, are often referred to as electronic health records (EHRs) and the definitions fluctuate.

EMRs are generally more accepted in new urgent care clinics than in existing centers, Lohnes says. As an EMR and practice management solution provider, Lohnes and his team do believe that every clinic should have an EMR and practice management solution. “However, we realize that our solution may not be the best fit for every urgent care center,” Lohnes says. “Every clinic should carefully consider their clinic processes, staff experience and skills, and desired functionality prior to beginning their search for an EMR.”

Lohnes says the registration process is shortened considerably when patients can register online.

“The patient can complete registration forms in their own home prior to coming to the clinic and the clinic can follow-up with the patient to coordinate an arrival time, which enables the clinic to more effectively manage patient wait times and clinic flow,” Lohnes says. “A ‘true’ EMR will, by the very nature of the technology, save the clinic time and money by making any patient’s ‘chart’ available to anyone in the clinic at any time.”

Not everyone, however, is a fan of EMRs or all technology-based options. Ose, for example, has looked at more than 40 EMR systems over the last few years and has researched many billing systems and is not impressed. “In my opinion EMR is a luxury at best and an expensive mistake at worst,” Ose says. “Software costs, software upgrades, hardware costs, hardware maintenance, staff (and) staff training all add up. Staff turnaround kills technology efficiencies.”

Moore recognizes that technology can lead to big advantages in claims submission, sending notes to (primary care physicians), and in sending prescriptions electronically to pharmacies, but he remains skeptical. “These advantages simply do not outweigh the cost of putting in an EMR,” Moore says. “And, I cannot recall one single group that has indicated that they are satisfied with their EMR.”

Will the electronic medical record (EMR) “audit” a chart note for coding purposes so that coding is more accurate? What are the ongoing maintenance costs of an EMR system? What are the storage costs of paper records? These are all questions that Moore and his staff members asked themselves when determining whether they should get an EMR system. Ultimately, they decided not to.

Moore feels that the healthcare industry should continue to move toward EMR systems, but he believes it will take time for them to be truly beneficial. “It is somewhat like our current energy dilemma,” Moore says. “The price of oil is still so relatively cheap that alternative fuel source technology, on a large scale, is just not practical and is very expensive. In my opinion, the same is true for EMRs.”

There are several aspects of urgent care that differentiate it from other medical practices, and therefore, the software needs are unique. Urgent care centers revolve around walk-in, unscheduled visits, generally perform higher-acuity care, sometimes serve the occupational medicine needs of corporate America, stay open for expanded hours, and are often staffed with part-time physicians.² 

Stern believes that smaller urgent care centers need software solutions and efficiency even more than big facilities, since small centers often operate on razor-thin margins. “They may think they can’t pay for it but it’s the sort of thing where you can’t afford not to do it,” Stern says.

However, there are several bad products that should be ignored, he adds. Over the years Stern has looked at about 40 systems and says that all 40 demonstrations started with an appointment book. He couldn’t find anything that was adequate for his clinics, so he started Practice Velocity. “When the vendor starts showing you the software, is the first thing they show you an appointment book?” Stern asks. “They have no clue what urgent care is if they show you an appointment book. And that will be 95 percent of vendors.”

Stern finds it ironic that many of the vendors walked right past his sign that said “walk-in clinic; no appointment needed,” and yet still didn’t understand the urgent care business model.

Most systems were made for some other type of practice and then retrofitted into urgent care, and many slow down patient flow significantly, Stern says. This is because most systems are generated to document ongoing long-term patient records rather than an event record.

Stern advises that potential product purchasers should ask if patients can sign in online. “Is support available whenever I’m open, including on Christmas day?” Stern recommends asking. “And when I say support I mean, ‘Will a human being answer the phone?’ And if it’s around a holiday, call and see.”

The biggest hurdle for any center is culture change, Lohnes says, since many people are inherently fearful of altering habits.

“Moving from a paper-based system to anything else will create a certain amount — potentially considerable — of discomfort for all staff,” Lohnes says. “Clinic administration must decide early on how they will address those who are resistant to change.

A single physician does have the ability to significantly disrupt the implementation of an EMR and minimize the benefits obtained from it.”

Lohnes recommends that all efficiency technology purchasers ask the following questions before they make any big decisions.

• How comfortable is your staff with the system?
• What processes will need to change when you implement this system?
• Do you trust the vendor?
• Who will update the technology?
• How many vendors do you have to work with to complete the implementation (information technology, hardware, software, etc.)?
• How many paper processes will remain after the implementation?
• What are your financing options?
• Will this system prepare you for the future (pay-for-performance initiatives, etc.)?
• Who has access to the patient data?

Stern says that any system must be relatively easy to use, especially since urgent care centers tend to use lots of part-time physicians. A doctor should be able to learn a system in an hour or less, Stern contends.

“Most system (reps) will tell you you’ll get up to speed after using it full time for about three months,” Stern says. “That won’t work. A lot of your part timers will never get up to speed. You need something that’s very intuitive, very easy to learn and something that people can pick up and use right off the bat.”

Facility owners need to pay special attention to how much infrastructure a supposed solution will require. This is most important at smaller urgent care centers where capital and resources are not as available. Some systems can operate off the Internet, which Stern says is easier than depending on a server.

The best advice may be to ask your peers and see what has or hasn’t worked at centers similar to yours, and weigh that carefully with what vendors claim. After all, you’re the one who’s either stuck with a system or blessed by it.

References 

1. Burt CW and Hing E. Use of computerized clinical support systems in medical settings: United States, 2001-03. Advance data from vitaland health statistics; No. 353. National Center for Health Statistics. 2005.

2. www.practicevelocity.com 

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