Technology: Time, at Last, for an Upgrade?

Douglas Blair, senior director of physician information systems at Mount Carmel Health System in central Ohio, describes its pre-upgrade practice management software as “essentially broken for us. My understanding is that it has code in it that’s over 30 years old.”

From a technology standpoint, 30 years is analogous to a geologic age. Even with regular upgrades, older systems - often running on a first-generation Unix platform - simply cannot keep pace with today’s data handling needs. Yet when Physicians Practice surveyed physicians on their technology usage last year, we discovered that practice management systems (PMS) seem to be on many offices’ IT back burners. Nearly three in 10 practices told us that their PMS is at least five years old, while 10 percent bought their systems more than a decade ago.

Is this because practices are so happy with their systems they just can’t bear to part with them? Hardly. Only one-third of the 365 responding practices report being satisfied with their PMS; six in 10 wish their system could do more than it does. (See the full results of our 2006 Technology Survey.)

So what gives? Why is this piece of medical technology lagging behind its glitzier cousin, the EMR? If you’ve waited too long to upgrade this important administrative tool, read on to discover the benefits and mechanics of doing so.

It is broke, but don’t fix it

Bristol Park Medical Group in Santa Ana, Calif., upgraded its PMS many times, but the practice ultimately found it needed something more functional and modern. It went with a system that uses the state-of-the-art in PMS technology platforms: a relational database management system, or RDBMS, and its communication partner, structured query language, or SQL.

But if your practice operates at a more modest level of technology-know-how, fear not. An RDBMS/SQL implementation can hide its geeky guts behind a socially adept Windows-based facade and still offer an intuitive and comprehensive solution to your practice’s administrative needs, such as flexible scheduling, smooth and effective billing and claims management, and customizable “practice adviser” system start-up screens that greet you every morning with a useful, near-real-time snapshot of your practice’s administrative health.

Do your cranial muscles ache from keeping an almost constant fisheye on your front-desk workers, because otherwise they would shirk posting copays during patient processing? With an upgraded system, there’s help for you with nanny-type “auto-flow” tools, a series of steps that users must follow - mandated by you.

Modern practice management software also has advantages in terms of easing user interface, starting with graphics. First designed when character-based, low-resolution monochrome monitors were the norm, legacy systems are easy to spot with their green or amber screens, chunky ASCII-standard text, and quarter-inch-high blinking cursors. Today, high-resolution LCD flat screens grace many administrators’ desks. Through these monitors, the software can draw upon millions of color choices to simplify practice management processes. For example, one color can be assigned to a specific physician or procedure. Then when your front-desk person schedules a patient appointment - often a hectic and distracted affair, especially over the phone with a worried parent - the colors communicate meaningful information back to her, as her brain can process a picture much more quickly than text. Hmm, what’s that pink doing there? We don’t do well-child visits on Friday afternoons.

Talkin’ ’bout my generation

Beyond the aesthetics, an upgraded user interface offers functionality far beyond even the most well-implemented old-school system, and it’s familiar to newly hired support staff, who tend to be 20-somethings - a generation unfamiliar with life before Bill Gates. This greatly facilitates training. “We can teach them the philosophy of their jobs as opposed to the navigation of the system,” says Darlene Jenkins, practice administrator for Obstetric & Gynecologic Affiliates of Katy, located 30 miles west of Houston. “They immediately know ‘drop-down.’ Now I can talk about the art of scheduling and not ‘backslash-R-C-L.’”

Jenkins is spelling out a typically cryptic Unix-style command used by her office’s previous practice management system, Medical Manager. Absorbing the “language” took awhile, but once users had mastered it, they became über-efficient with system navigation. Jenkins notes that this hard-won veteran expertise can actually work against an otherwise smooth practice management transition.

Blair agrees. He says that although replacing an old system makes for a vast improvement in functionality and data quality, it also means that “you lose a lot of experience with the senior billers. Tips and tricks get lost, which affects work flow. In the billing department, they lost several hundred years of accumulated training.”

Still, if you upgrade your practice’s PMS, you can count on an overall improvement in staff productivity and, by extension, increased patient satisfaction, thanks to more flexible scheduling and easy data access.

You can also expect faster, more accurate claims processing with a modern PMS - down from a typical 30 to 60 days for paper submissions to 10 to 14 days electronically. “Often we get paid within the same month,” says Jenkins. “Or at least we know how bad it is that much sooner.” Another major area of concern addressed by upgrading is that of standardized data regulations. HIPAA compels practices to achieve such compliance or else suffer the consequence of claims rejected because of missing or incorrect data. Practice management vendors are not required to make your legacy system HIPAA-compliant. Also, there are other encroaching data-standardization issues to bear in mind, including the mandatory, unique National Provider Identifier numbers, which must be in place by May 23, 2007, for all providers who use HIPAA-standard electronic transmissions.

PMS/EMR interfacing

Finally, with EMR adoption on the rise nationally, you’ll want a practice management system that interacts well with your EMR because the data between these two applications overlap. Ideally, you should stay with the same vendor for both applications, suggest veteran upgraders, “because otherwise you can really get burned,” says Jenkins.

Bristol Park’s Pat Dolphin completely agrees. “That was an absolute factor [for vendor selection] for us,” she says. Blair notes that initially, “We felt it was a little bit too much risk to put everything into one system. … Lo and behold, we ended up selecting a system that was integrated, and got the best of both worlds.”

Besides, says Jenkins, upgrading your PMS is simply easier to do than implementing an EMR. “The PM upgrade wasn’t painful; EHR was painful,” she says. Why? Because physicians are generally less involved in ongoing practice management tasks than they are with those carried out via an EMR; thus, their impact carries less weight.

And why waste time cobbling a connection between your spiffy new EMR and old-school practice management software anyway? Previously, these two systems worked off two databases; now, just one elegant, flexible database serves both entities if both systems come from the same vendor - although some EMR-less vendors will tell you how easy it is to share data across platforms. Be wary of this, especially since there are as yet no set national standards for EMR data records.

Planning pays off

As with any major change, careful planning, thoughtful analysis, and informed decision-making are crucial to success. To ensure this outcome, keep the following steps in mind:

Analyze your current system. Take a hard look at the way you currently conduct business within your practice. What is the work flow? How much time do you spend on routine practice management tasks? What protocols do you follow when performing these tasks?

Stay open to new ideas. A great deal has changed since the PMS niche grew from an ugly duckling into today’s lovely swan. So what do you currently skip but wish you could do? Are there specific data slices you’d like to be able to access in a handy report? Do you get frustrated with some of your workers because they jump over certain tasks you’ve deemed important? What about appointment scheduling? Are you currently limited to just 15- or 30-minute appointment slots? What if you could set aside 20 minutes for a patient you know is going to need that extra five? Make a wish list of all that you see lacking in your current system, and take note of vendors that could potentially meet your needs.

Decide what to ask. Every PMS vendor wants your business - badly. To select the right one, ask the right questions. Cover every aspect imaginable, down to the last keystroke needed to sign off every evening, and level the playing field by asking them all the same questions, including:

• How is scheduling handled? Can we double- or even triple-book appointments?

• What’s the maximum number of providers allowed?

• Does the software properly handle the procedural and diagnostic codes our practice needs?

• What about search capabilities, such as finding unpaid claims? Or data scrubbing? Can our billers choose how to submit claims?

• How are financial data tracked? What reports are available? Which will we find truly useful?

• Is the system fully HIPAA-compliant and secure over the Internet? Can we control user access?

Naturally, you’ll want to put the vendor itself through the question mill, too. Here’s one for your current vendor: Does it still exist? A lot has changed since the original practice management software entrepreneurs first hawked their solutions. “Back in the eighties, there were hundreds of vendors. Then the market matured, and many vendors fell out,” says Paul Stinson, senior vice president of Sage Software, the manufacturer of a practice management product called Intergy.

Treat the issue of vendor robustness very seriously. Scrutinize each one’s financial stability and growth; ability to offer an integrated EMR; level of compliance with HIPAA and other regulations; responsiveness when you have questions; quality of software servicing and support; user training programs; clarity of pricing; and competency of salespeople.

Beware of any vendor making inordinate promises to customize the software; in all likelihood, that software is simply not right for your practice. Also, feel free to pop in your jaundiced eye and cast it about whenever you see fit, especially if a vendor claims unique features. “If any salesman comes in and says their system does something the others don’t, they’re probably lying, because they all pretty much do the same thing,” says Blair.

Send out an RFI and an RFP. Dolphin advocates presenting your questions to vendors in an RFI, or request for information document. Here, you can present to vendors all your unknowns in an orderly fashion, as well as any scenarios unique to your practice. “Once we received [the RFIs] back, we rated [the vendors],” she says. “We selected five for RFPs [request for proposals] and started what we called the ‘dog and pony shows.’”

Advice to the upgrade-worn

If you’ve chosen wisely, your vendor will be an invaluable partner during your transition, as long as you both firmly commit to a high level of communication. “You need a project manager who can appropriately communicate with the practice and the vendor,” says Stinson. He recommends establishing an implementation team that develops a project timeline and facilitates weekly or even daily update calls between vendors and practices. Also, expect the upgrade process to take some time - a minimum of one week, and perhaps up to 10, depending upon your practice size and needs. But if you’ve done all your homework, it shouldn’t be a traumatic affair.

Still, heed these hints and advice tidbits from those who’ve been there:

• Train your staff twice. Blair noticed that his staff was floundering somewhat several months post-implementation, especially the veteran billers. This came from their deeply embedded knowledge of “the old way” of doing things. A session of advanced training, concentrating on tips and tricks to navigate the system more nimbly, helped get them back on track.

• Insist on user compliance. “Some people got overwhelmed at the ‘go-live,’” says Blair. So instead of following the procedures and protocols they had just learned in training, they “set that work aside - and that becomes a habit.” Keep encouraging consistent compliance; it will come.

• Reward positive behavior. Jenkins provided fun incentives to encourage positive attitudes toward training, including points-for-progress drawings. She even awarded coffee mugs depicting a woman in the midst of a hot flash that read, “I’m going through the change at OB/GYN Associates.” Jenkins says, “Even though they were supposed to do it, they were rewarded for it.”

• Barter your tech support. OB/GYN Associates is “on the team that [the vendor] can use us as a ‘site’ visit,” Jenkins says, meaning another practice may stop by for a demo. “So I insist we be as up-to-date as possible, and we get a discount on our support contract.”

• Consider scrapping your legacy data. Why would you do this? All that information, seemingly wasted. “Because it gives the practice a chance to clean up its data,” says Blair. “We had 88 ‘Aetnas,’ all with the wrong address.” Be honest with yourself: Are the data worth cleaning up, which, if outsourced, could cost $10,000 or more? Re-entering as patients come in takes some time, but the data will be much more reliable.

• Create or join a user group. There’s nothing like a good discussion over an issue of common interest. “Not everybody asks the same questions in their RFIs,” says Dolphin. “You become more informed: ‘How do you do this? How do you solve that?’ California is a different beast, although I’m sure every state has its beast.”

Any major shift in a practice’s paradigm dictates that everyone involved be on board to ensure success. Foot-draggers can really sap the positive energy flow from everyone else. But with patience, calm insistence, and positive feedback, you can win over the most stubborn holdouts. Jenkins had one such case - a seasoned employee who kvetched bitterly about the new software, insisting she could never master it. But then Jenkins came in late on a day a site visit had been scheduled by another interested practice. “By the time I got here, she had done the whole tour. She’s the point-and-click queen now,” Jenkins chuckles. “When the person who’s been here the longest and fought me the hardest does the tour, that really warms my heart.”

Shirley Grace, senior writer for Physicians Practice, holds an MA in nonfiction writing from The Johns Hopkins University. Her articles have appeared in numerous publications, including The Washington Post and Notre Dame Business magazine. She can be reached at sgrace@physicianspractice.com.
This article originally appeared in the February 2007 issue of Physicians Practice.