And then there’s a printer/fax/ scanner in the office that’s not yet fully operational; implementing a scanning process for incoming documents has also been occupying Gondo’s thoughts.

“I would like to find a system in which we could go totally paperless and start archiving everything,” he says, mentioning that other practices in the area are also confounded by how to “really eliminate a need for paper charts.” It’s not at all clear, however, that going completely paperless is feasible for Gondo — or even advisable.

Most physicians we know who are happy with their EMRs don’t scan every piece of paper that comes through the door or sits in old chart folders. Bertman, for one, scans only the key items he wants to be able to flip through. Digitizing only consult notes is a much more sane approach than trying to capture every EKG and phone message within one’s EMR.

Even though he’s unable to make the most of the technology he already has, Gondo talks about improving electronic communications with his patients. He’s applied for a Qualis Health grant to make more tech upgrades, and he mentions the possibility of allowing his patients to schedule their own appointments online. As if all that weren’t enough, Gondo holds up a digital camera he’s been trying to use to enter patient photos into his EMR. He hasn’t been able to establish a process for doing that, either.

Quite understandably, Gondo says he can’t keep up with current technology, and he feels as if he’s drowning in it. This physician clearly thinks he should adopt every new gadget on the tech market, even if he has no idea how it might actually benefit his practice. As with the charts, Gondo’s attention appears completely fractured. No wonder he can’t find the time to finish a note.

In spite of all the gizmos lying around Gondo’s office, some tech-enabled fundamentals are sorely lacking. The practice is a month behind on its billing and an alarming three months behind on posting. Part of the problem is that Gondo trusts no one other than Angela to handle the practice’s financial data. With daily office management falling to her as well, she simply has too much on her plate to keep up.

Add to that the fact that Gondo uses a 10-year-old version of Medisoft to generate his billing. That leaves Angela lacking some very basic capabilities that would make her life much easier. For example, with the tools she has, she is unable to bill Medicaid or secondary claims electronically, and electronic remittance and denial tracking is next to impossible with her outdated system.

Ken Kark, vice president of sales for Per-Se Technologies, which owns Medisoft, assures us that the newest version of the product allows e-billing to virtually every payer, and it includes features like integrated eligibility verification. He also promises that the data Gondo’s practice has captured in the old Medisoft version he still uses will translate to a new one. Even if a hardware upgrade is required — the office’s computers are three to four years old — the relatively small investment in upgrading his billing software would be more than worthwhile in terms of the potentially dramatic increase in speeding the practice’s billing and collections. Gondo should jump on this relatively easy method to eliminate at least some of the paper he has floating around.

Additional basic tech issues need to be addressed before Gondo can launch more complex technology. The practice is still working on its ability to allow for debit card payments from patients. The Gondos know they need this capability, but as with other processes, it hasn’t yet materialized. Simple upgrades like this one can directly increase the practice’s cashflow, and thus should be given priority status.

In a perfect world, Gondo himself wouldn’t be personally responsible for implementing these types of upgrades. As the physician and owner, he certainly needs to know what’s going on, but because the details of smaller projects are draining his attention, he should delegate them to a staff member. However, the practice retains only two staff members in addition to Angela — a medical assistant and a receptionist, both of whom are new to the office. (More later on Gondo’s staffing difficulties.)

All Things to All People

Gondo is very much a family doctor, happy to be practicing within a close-knit community. But there’s an inherent tension between that small-town-doctor style he prefers and the demanding reality of 21st-century medical practice. Pearcey cites as a major work flow obstacle the fact that Gondo tries to address patients’ every concern each time they come into the office, often dealing with “a grocery list of problems,” regardless of the ostensible reason for the visit.

As we discuss this issue, Angela points out the chart of a patient whose recent unscheduled procedures won’t be reimbursed because the practice characteristically failed to obtain the necessary authorizations beforehand. She reminds Pearcey to try to help the doctor remember not to perform unscheduled procedures.

An elderly man then enters the office, complaining of a head injury. His visit takes nearly an hour, not because of Gondo’s concerns about the patient’s injury, but because the man wants to discuss his medication list, his gout, and so on. The patient’s lengthy medication list includes a couple of drugs prescribed by another physician that Gondo can’t readily identify. He leaves the exam room to embark on a search for information on the drug among his many stacks of papers and books piled on each available surface. (Why he did this is a mystery, as every exam room computer has Internet access.)

Later, with another patient, Gondo leaves an exam room to search for a medication sample. Rummaging through drawers is not a good use of his time. Instead, he should communicate to Pearcey what he needs, letting her pick up tasks that fall within her scope of work to allow him to focus on tasks that fall within his. It’s great that Gondo has set up one of his exam rooms to more easily allow for procedures, but that doesn’t mean he should be performing them as soon as patients bring up any minor issue. Why? For one, Medicare pays for only one procedure per day per diagnosis. Wanting to help every patient on the spot is laudable, but not always realistic. And overloading each appointment isn’t helping that charting backlog, either.