Lowell J. Kleinman, M.D., has made a pretty good name for himself as a nationally known antismoking advocate and co-author of The Complete Idiot's Guide To Quitting Smoking. But Dr. Quit, as Kleinman has been called, is also a savvy technology consumer, having traded in his physician practice management (PPM) software last year for a new integrated package featuring an electronic medical record (EMR).
"The old software could interface with a couple of EMR vendors, but most of the EMRs I looked at came with their own practice management software," says the solo general practitioner and owner of Family Practice of San Ramon, Calif. "I had a very specific need for an EMR and a practice management system built on the same platform, as opposed to being tacked on to other ones. I wanted a fully integrated PPM-EMR with good note-taking capability."
Kleinman gained a great deal of buying knowledge through hearing lectures and participating in online forums sponsored by San Francisco-based Lumetra, California's quality improvement organization. Lumetra has a federal government contract to assist small and medium-size practices in selecting EMRs by offering advice on choosing vendors, implementing systems and improving care. Kleinman ended up buying a PPM-EMR software package from eClinicalWorks, Westborough, Mass.
A sweet suite
The addition of an EMR is the newest wrinkle in PPM software. Some EMR vendors have added PPM modules or purchased practice management companies. Some PPM vendors have done the same thing in reverse, buying EMRs or building their capabilities into current software suites, reports industry veteran Gary O'Gwen, president of software vendor MDanywhere Technologies Inc., Baltimore.
Only about 15 percent of the more than 70 percent of U.S. physicians in small or solo practices currently use EMRs, according to industry sources. Vendors of integrated solutions point to a variety of benefits, such as a common registration process covering all aspects of billing and care, improved workflow and simplified training.
For example, any changes in a patient's record will update that individual's entire record through the EMR and PPM modules. Data no longer has to be entered twice. Doctors and their staffs learn how to use just one common interface for recording and reporting financial and care data, notes O'Gwen.
Neil Simon is COO of Mountain View, Calif.-based iMedica, which sells an integrated PPM-EMR known as PhysicianSuite Patient Relationship Manager. Formerly, iMedica sold a stand-alone EMR, but this year it added practice management to the solution to attract physicians looking for software capable of more functions. Scheduling with practice management, common today, could not be done in the early 1990s, says Simon, but "You couldn't sell physician management today without scheduling. And in the future, you're not going to be able to sell practice management software without a clinical management system. The combination will be like customer relationship management software is in the business community," he predicts. "This kind of [PPM-EMR] software is paving the way."
Antonio P. Linares, vice president of medical affairs at Lumetra and a recipient of Healthcare Informatics' 2005 Healthcare IT Innovator Award, agrees. His organization received a grant from the Centers for Medicare & Medicaid Services a few years ago for a program called Doctors' Office Quality Information Technology (DOQ-IT). It's the program Kleinman participated in before making his decision. "One of the things DOQ-IT strongly supported was that EMRs must interface with a practice management system," says Linares. "I don't know of any practice in DOQ-IT that had a problem with interoperability with practice management systems, because they were only looking at options that provided interoperability with clinical appointments, scheduling, billing and the EMR clinical component."
Interoperability is still not a reality, says Justin Graham, associate medical director for quality and informatics at Lumetra. Organizations still struggle to get different vendors' systems to work together, he says, even though many vendors attempt to comply with HL7 standards, which are intended to allow healthcare software to share data with minimal programming.
Small physician offices remain wary of technology, says Vincent Hudson, a competitive intelligence expert in physician office and medical information. "They all have an inner voice that says, 'I've got to incorporate technology,' but they don't know what to acquire," he says. "And they don't trust anybody."
What vendors see in the combination package is a way to satisfy both administrators and doctors drowning in multiple systems and paperwork, says Hudson. For example, Linares found plenty of support from the vendor community. Of the more than 40 vendors that agreed to work with DOQ-IT participants, more than half offered a PPM-EMR solution. And not every vendor with a combination solution signed up to be part of DOQ-IT, he points out.
Tee Green III, president of Greenway Medical Technologies Inc., Carrollton, Ga., says small practices' apprehension over PPM-EMR suites is understandable, considering that many of the initial solutions "failed miserably." Three or four years ago, physicians who chose to add an EMR to their existing PPM found the proposition to be expensive because of the need for customized interfaces, Green says. And if the PPM software was upgraded, the interfaces might not work with the existing EMR, and vice versa.
Common queries dealing with clinical reporting and population management would have to be run on both systems, argues Green, since the software using HL7 standards often did not allow for cross-database inquiries. Programs by Greenway and other vendors who provide a fully integrated PPM-EMR built from the ground up rather than cobbled together represent what Green dubs the third generation of software for small physician offices.
The cost of these combination platforms remains an issue. Many vendors and their resellers offer the application service provider (ASP) option, allowing small physician offices to pay a monthly subscription fee to have a vendor host their software and data remotely. But Green points out a catch--bandwidth. Some offices will have to increase their online capacity, and much of the savings of going the ASP route may be eaten up by new charges from their broadband provider.
A view from the clinics
Glenn Van Stavern, administrator for two-physician Johnson County Dermatology, Olathe, Kan., has been using the PPM system from NextGen Healthcare Information Systems, Horsham, Pa., for two years and its EMR for more than a year. He likes having one electronic record for every patient, with billing and clinical data in an easily accessible form. The change to a paperless office freed up enough room for the clinic to expand and redesign its front office, he says.
The staff member who once handled much of the coding has moved to answering phones and other duties. Van Stavern figures the automated combination system saves the cost of one or two employees who would be filing, coding and doing other tasks associated with paper and administrative functions. "There's no question of a return on investment," he says. "The software will pay for itself."
PPM-EMR software also offers a more seamless billing solution, which saves time and money and satisfies payers, notes Kleinman. "The biller has the ability to easily see the note written by the doctor. This allows for accurate coding," he says. In addition, "the doctor can create the charges immediately upon conclusion of the visit, and it can be batched or sent electronically on the same day."
Combination software reduces users' concern over multiple vendors and multiple solutions. "I didn't want a hodgepodge of various companies taking care of our needs and wants," says Stephen Hryniewicki, M.D., of Long Beach Internal Medical Group, Long Beach, Calif. "I don't have the time and energy to put things together. I wanted something that could help schedule patients' appointments, check them out, bill them and close the deal."
Hryniewicki, a purchaser of Greenway Medical Technology's PPM-EMR solution, likes the ability to answer queries and see reports presented in one package. If he finds a phone message on his desk, he can electronically pull a chart and see a patient's entire medical record without leaving his desk. His staff can quickly find answers to insurers' questions and fax a response within minutes, he says, resulting in a less stressful office environment.
Solo practitioner Matthew White, M.D., in Lakewood, Wash., uses Total Practice Partner from Physician Micro Systems Inc., Seattle. An early proponent of EMRs, White decided a few years ago that an integrated system would make record keeping and billing more seamless. His office has a wireless network, allowing him to enter medical records into the system from the two different laptops he uses in the office.
On the medical record side, White likes the ability to check on his electronic notes every few days to ensure they are complete and have a digital signature. And on the billing side, he likes his administrator's ability to drill into data for the number of patients seen, average charges and accounts receivable. His staff has found the messaging features useful and "relatively easy to use," he says.
Not everyone is sold on using the same vendor for both solutions. Jeffrey Hyman, who operates a three-physician clinic in Brooklyn, N.Y., and serves as medical director of the Staten Island, N.Y.-based University Physicians Group, points out that most doctors rarely even see their PPM software because administrative staff handles billing. For doctors, the most important piece of software is the EMR, he says, and they should select one they like, regardless of whether it's bundled with PPM software.
Hyman's EMR is from iMedica and his PPM, which is attached to his billing system, is from Advantedge Health Systems, New York. He estimates that the price is around $3,000, or $1,500 per program, to create interfaces so the two programs can share and transfer data. Though iMedica has released a PPM-EMR package, don't look for Hyman to purchase it anytime soon. He emphasizes that the key component of such packages is the EMR, "and don't let any administrator tell you any differently. This is your pen-and-paper chart, and this is how you're going to practice medicine. This is how you're going to take notes."
Beyond the technology, the role of a combined platform should result in fewer physician errors and more accurate billing, says Megan Salmela, electronic records project manager for LSS Data Systems, Eden Prairie, Minn., partner vendor of Westwood, Mass.-based MEDITECH for physician systems. "What we're seeing is interoperability across the care continuum, which has significant benefits for physicians," she says.
A few challenges
Some vendors, including Greenway and MDanywhere, offer to help small office clients by arranging financing through existing financial institutions. Even so, Linares says, the No. 1 barrier to EMRs in California remains financial, followed by concerns over data entry and the cultural transformation required for full implementation.
Another issue is the fluid nature of EMRs. Some physicians are gun-shy about committing for fear the government or medical societies will decide on a set of standards or certification their vendor cannot meet, says Linares. Once sold on EMRs, however, they might see the advantage of adding a PPM module.
O'Gwen adds that many physicians are waiting to see how various pay-for-performance programs play out and whether an investment in a PPM-EMR system will pay for itself through higher reimbursements. Another concern of small offices, which struggle with high turnover rates among administrative staff, is repeated training on complex software systems.
Kleinman ended up paying $25,000 for his PPM-EMR package, and he believes now he would probably subscribe to an ASP to deliver the software rather than host it himself. Still, despite a large outlay of cash, the investment has paid off richly for Kleinman and others. The combination software has provided a way for administrators and physicians to share an interface and a database that offers all sorts of clinical and billing data. And that's a real advantage, Kleinman says, in a time of tumultuous change among small and solo offices.
Frank Jossi is a technology writer in St. Paul, Minn.