Pamela Moore, PhD

Your practice's biggest expense-and best asset-is your staff. Here's how to ensure you've got the right staff in the right roles working as efficiently as possible.

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Your practice’s biggest expense-and best asset-is your staff. Here’s how to ensure you’ve got the right staff in the right roles working as efficiently as possible.

Are Your Staff in the Right Roles?


A family physician with a gray beard and stooped shoulders shyly approached me at a meeting last week. Out of the corner of his mouth, he asked about EMRs. He knew the new economic stimulus package includes incentives to physicians; should he act now? 

But he wasn’t really interested in my answer. He’d already decided not to buy an EMR and his real purpose was to explain why: Since EMRs improve documentation, and since better documentation tends to increase physician reimbursement, the federal government will actually end up paying more for healthcare as more physicians adopt EMRs, not save money through improved efficiencies. Therefore it will eventually have to cut reimbursement further, so he won’t get an EMR himself. 

In other words, “There’s no real financial incentive to improving my practice’s efficiency because Uncle Sam will just penalize me later. So why bother?” But his unassailably circular logic misses the point: An EMR purchase is a business decision like any other. It’s an expensive decision, true, and it requires change. And change is scary. I get it. But it’s still just a business decision, meaning it’s best to leave the emotions and politics out of it. 

My grumpy new friend isn’t the only one struggling with this. Pragmatic physicians, trained to see a problem and drill to a solution, wax philosophic when it comes to business, and especially technology. Do EMRs improve clinical outcomes or just maintain the status quo? Can an economic stimulus payment really spur adoption? 

These are all fine questions, but I say let the researchers and the policy wonks worry about them. The essential issue for you is whether your practice would run more efficiently over the long term with electronic records or without them. Frankly, I think this question all but answers itself. Of 

you’d be better off, assuming you do all the other things more or less correctly like picking the right vendor for your practice and having a well-executed transition plan. After that it’s a matter of measuring benefits against costs: Would you be better off 

 to justify the expense? Again, I think that for most practices the answer was yes even before the stimulus. Now? It’s a no-brainer, especially when you consider the reimbursement 

 the government is already planning for intractable EMR holdouts.

The stimulus package promises payments in the $40,000 range to physicians who can demonstrate use of certified EMRs, starting in 2011. (Learn more about the stimulus payments by typing “stimulus” into the search engine at PhysiciansPractice.com.) Even more importantly, it posits that physicians who aren’t using an EMR will shortly thereafter see a reduction in payments from Medicare. 

There’s no sense debating the merits of such a plan. It’s done. See if you can take advantage of it by having an EMR in place by 2011. One hint: You better start shopping now. Making a decision and implementing the technology takes some time.

Similarly, if you’ve been procrastinating on getting a revenue cycle management product or upgrading your practice management system, there may be no time like the present. Some 2 million people are expected to lose their jobs this year. That includes a lot of your patients, who will be losing health benefits. You should be requiring preverification for every patient, and technology is the only way to make that happen effectively.

Time is running short for many small practices. The cost of business is up. Reimbursement isn’t going to change short-term. Walgreens, CVS, and other retail clinics stand ready to take your patients if you can’t adapt. The world is changing - quickly. It’s time to stop pretending that you don’t have to.

The plummeting economy should have added a sense of urgency but instead seems only to have added panic. Many practices just seem paralyzed by their own inertia. Now is the time for flexibility, speed, and practical decision making.

So, to action. Consider this guide a different sort of stimulus: one for sensible solutions. Some are big, some are small, but all are just business. Focus now on trimming waste and boosting revenue. Save the moralizing for better times. 

This article originally appeared in the 2009/2010 Physicians Practice Technology Guide.

Articles

An EMR purchase is a business decision like any other. It’s an expensive decision, true, and it requires change. But it’s still just a business decision. What questions should you really be asking yourself?

Tough Times Call for Technology


“If you implement [technology] correctly, it will make you money,” promises James Leavitt, a gastroenterologist in Miami. 

That’s a big “if.” But not too big for Leavitt’s practice. The staff there used its EMR to makeover its work flow, getting every physician on board. The result: more than a million dollars in return for the EMR investment. 

Many kudos to Leavitt. Unfortunately, many physicians are worried they won’t get similar results, says the latest 

 annual technology survey, with 55 percent of respondents stating cost as the most pressing technology problem. Apparently, it’s not so much what technology actually does that matters - it’s the price of technology. 

This is the fifth year we’ve run the tech survey. Some things are the same: Half a decade later, the debate over whether EMRs pay off remains lively. Now, though, it’s pretty clear that it’s not the software itself that makes the difference between an EMR investment that works and one that fails. What matters is how well a practice implements its new system. The process - using EMR adoption as an opportunity to retool work flow and to break some long-held inefficient habits - is what counts. 

Here’s the rundown on what physicians like you are thinking about technology. Are you ahead of the curve or behind it? 

Cost is the top concern among our respondents, outranking EMRs, billing, and communicating with patients. 

In fact, the price of technologies, especially EMRs, evoked a strong reaction in our respondents. Can you feel the rage in these responses? 

“Stop ripping off physicians just because we have an MD/DO behind our names.” 

“The price of medical software is ridiculous. I think the medical industry and MDs are targets, and the general consensus is that we are poor at business but have extra money.” 

“I simply don’t see the value in office software that costs $15,000 to $20,000. Considering the actual function of the software, these prices are simply ridiculous.” 

Apparently, technology vendors are joining managed-care companies on physicians’ mental list of people out to get them. It’s an emotional issue. 

To be more analytical, perhaps, the majority of those who bought an EMR - which is certainly the technology 

 - report that the investment was in fact worthwhile. Sixty-nine percent found the EMR increased work flow efficiency, while 70 percent expected to see a return on investment - both promising stats. 

And despite the seething comments above regarding cost, reported EMR price tags are all over the map. About a third of respondents paid between $500 and $3,000 per physician. A third paid between $3,001 and $6,000, and 33 percent paid more than $6,000 per doc for their EMR. And get this: 8 percent paid less than $500. 

So you can see why it’s a bit hard to pin down what the costs, generally speaking, really are. 
Anecdotally, many sense prices are dropping. “Some companies thought doctors would pour money into it; prices have dropped,” says internist Ronald Hirsch of Signature Medical Associates, Elgin, Ill. Perry Krichmar, a non-invasive cardiologist from Pembroke Pines, Fla., agrees. “There is such a broad range of prices out there, but I think prices are coming down as competition gets more fierce,” he says. 


Even if an EMR is super cheap, of course, you won’t see any return on your investment if you don’t implement it well - that is, if you don’t change operationally or if you don’t really use the system. 

And that seems to happen a lot. A troubling 18 percent of practices we surveyed have an EMR they haven’t implemented. 

“I’ve known people who have paid close to seven figures who have not fully implemented the EMR,” Krichmar says. “If you are not willing to make the changes, then you are wasting your money. The pricing is not scary; it’s more scary to make the change.” 


One key to success is to take control of the process yourself, instead of relying exclusively on the vendor. Only you know how you need to re-work your processes. “Usually how companies ‘implement’ you is they load the software and train you [on] how they demo the product. What you really need to look for is an implementation plan that is based around processes. That’s what a successful EMR implementation is about: improving processes and gaining efficiencies,” says Leavitt. 

That’s a challenge. And it may be why EMR implementation remains relatively low. Thirty-five percent of our respondents have a fully implemented EMR. But while another 21 percent say they expect to get one within the next 12 months, an equal number say they’ll never get one. 

Our data on adoption exposed three big surprises: 

First, EMR adoption was about the same, regardless of group size. Historically, penetration has been highest among large groups; this data suggests some evening out. 

Second, recent relaxations in the Stark regulations that allow hospitals to help private practices out with technology investments have had little effect thus far: only 5 percent of our respondents have an EMR from their hospitals. 

Third, for the first time in our five years of investigating healthcare technology, reported EMR use actually declined. In 2007, 39 percent of practices reported having an implemented EMR. This year, only 35 percent did. Our best explanation: Physicians are abandoning systems they implemented. Why on earth would they do that? Because they never really made proper use of the system or the system itself failed to deliver on hoped-for cost savings. 

Part of the confusion is that we’re now in the “upgrade” stage of EMR adoption. Follow-up interviews revealed that physicians who bought low-cost and low-complexity EMRs are now moving on up to more costly and more complex systems. It’s round two. 

Case in point: Susan Andrews originally used the very first version of e-MDs simply to generate charts for her family practice. When the Murfreesboro, Tenn., clinic went independent, leaving the nest of a hospital-owned set-up, it decided to move on to “something a little more robust with billing, and a scheduler plus the EMR,” Andrews said. Now she uses Practice Partner to handle everything from charting to e-prescribing. And she got patients on the band wagon, too. Medfusion, a web portal that runs through Practice Partner, lets Andrews do online house calls and patients can type their own medical histories into their chart from home or in the office. 

Krichmar had a similar experience, realizing more advantages from a system that goes beyond charting. His practice, South Florida Cardiology Associates, acquired its first EMR in 1997. “The first one was a way to cut down on transcription costs, but I never fully used it, even though it was in place eight or nine years. I was only using 25 percent of the system. I was just using it for better documentation. … If we were audited, it was there. But the only money it was saving was transcription fees; it wasn’t really making us efficient.” Now with gMed, Krichmar is much more confident that he’ll see more savings because this new system requires the practice to change how it works. 


Another handy piece of healthcare technology is voice recognition software. That’s software that transforms your voice into typed documentation. Only 18 percent of the physicians responding to our survey currently use voice recognition, but those who do use it, like it. 

Given the success rate, it’s surprising that voice recognition usage isn’t growing faster. In 2006, about one in five practices used voice recognition. Last year, 19 percent of our respondents were using it. Forty-three percent said it only took them a day to get their software “trained” to recognize their voice and 58 percent have entirely stopped using a transcription service. 

For all the chatter about EMRs and other documentation-related technologies, it’s practice management where the biggest growth seems ready to hit. While 37 percent of respondents installed new management software within the past two to four years, more than a third are still using systems that are five to ten years old - a veritable geologic age for technology. Another 13 percent don’t use any management software at all. 


And here’s the kicker: A full 60 percent of respondents don’t really like their practice management system. Most complain that their software doesn’t make it easy to generate reports that can help practices identify where things are going wrong. Others want a more intuitive interface or less expensive upgrades. 

Given the complexity of coding, it’s interesting that only about half of all practices use technology to help select codes. Of those that do, 29 percent had revenue growth beyond 10 percent as a result. Another 20 percent also realized more cash, though less than 10 percent more. 

Physician-patient e-mailing remains fairly limited as well: Thirty-four percent of practices do it, and the overwhelming majority don’t charge for it. 

And while 64 percent of practices do have a Web site, only 21 percent of them use their sites to interact with patients in any way, such as scheduling an appointment or requesting a prescription refill. 


Reluctance in adopting technology might be expected, given physicians’ general skepticism about such things. Most have a sense that the promise is a lot bolder than reality. Here are some typical, ahem, suggestions that readers provided to vendors: 

Do not oversell your product. Be open and honest with the advantages and limitations of the specific product you are offering. 

Quit lying to us about how great your products are. 

Marketing pitches do not correlate to actual technology performance. 

Respondents also cried out for products that really, truly provide for continuity of care from hospital to practice to the ED - products that are intuitive and user-friendly yet easy to customize. 

Most products don’t seem to meet these needs, at least in our reader’s eyes. But it’s worth noting that it’s not impossible. 

David Willis, a family physician, told us how he and others are making the future real down in Ocala, Fla. Willis is with Ocala West Family Medicine as well as medical director for Healthy Ocala, a health information trust. He describes Healthy Ocala as a “grass roots effort to establish a health records exchange.” 

Basically, the idea is to provide one portal that lets physicians in the community tap into a patient record no matter where they are in the system. “As patients transition from inpatient to outpatient or home health or [skilled nursing facility], everything will be aggregated. If the patient has given permission, the physician can go in and see everything that has happened with that patient. We’ve seen estimates that more than 60 percent of a physician’s time is spent collecting data. This should save us a tremendous amount of time.” 

Private practices can join in using any EMR. “Seeing what people go through, we know there is not a one-size-fits-all solution. We’re trying to create a model that will allow adoption at whatever rate,” says Willis. 

And who pays for all of this? Well, the hospital is providing some technology, but patients and major employers will be paying too, making the model self-sustaining. 

An unusual model, but it points to what may be a better future for technology - one that physicians find more user-friendly and affordable. 

This article originally appeared in the September 2008 issue of Physicians Practice.

What are physicians like you doing when it comes to purchasing new office technologies? Our Fifth Annual Technology Survey cuts through the hype and gives it to you straight.

Navigating the Tech Maze


President Obama has promised as much as $44,000 to physicians using EHRs as part of the stimulus package he signed this year. Payments start in 2011. But there’s a catch. 

You have to be using a qualified electronic heath record and be using it in a meaningful way. Details on what “meaningful” and “qualified” mean should be out soon. The irony is that the stimulus bill may have had, for a time, the paradoxical effect of stifling technology purchases while uncertain physicians waited for clarity on some of the details. Everyone’s afraid they’ll buy an EHR, only to find out later that they bought the “wrong one” or that, for some other reason, they won’t get the money. 

Meanwhile, EHR companies are trying to convince physicians to buy now. They’re offering guarantees, rebates, and plain old promises that their system 

Practice Fusion, for example, guarantees that it will be a certified or qualified EHR, its users eligible for stimulus dollars. GE offers a warranty that its Centricity product will be certified, and also offers zero-interest financing to qualified buyers. NextGen guarantees that if it doesn’t meet the requirements for stimulus dollars, users will get their money back. Such deals have become 

 in the stimulus-fueled EHR world. These programs contractually oblige the vendors to meet the requirements. And it should lend some security to your purchasing choice. Get these promises in writing and check the fine print, of course, but remember that the vendors have every incentive to ensure that their products meet the federal guidelines. 

But keep in mind that the actual EHR you buy is just the first step to opening Uncle Sam’s wallet. Vendors can say only that their software will meet the guidelines; whether it is used “meaningfully” really depends on you. 

do something doesn’t mean that you’ll actually use it to do that. Buying a software product will not, by itself, improve your practice operations any more than buying a thesaurus will improve your vocabulary. You have to commit to revising work flows and actually using the software. Some products will seem more intuitive to use than others, given your sense of how things should work. That will be at least as important to your purchasing decision as whether the vendor guarantees to be qualified. 

Also, to get the full $44,000 pay out, practices need to qualify annually for chunks of money; the cash begins flowing in 2011 and continues through 2015, and vendors will have to stay qualified for each of those years. Qualifying the first year will be relatively easy. Expect the requirements to get tougher and tougher every year and to focus even more on improving and reporting on clinical quality and interoperability - the ability of a provider to communicate easily with hospitals, other physicians, labs, and even patients. Ask vendors about their current strengths and future plans in these areas. Will you need additional products to really keep track of the needs of your patients? Does interoperability mean some patched together interface where multiple vendors have to agree to play together (fat chance)? Or something more seamless? 

Sure, the clock is ticking. You should be shopping now and be implementing a system by mid-2010 to start getting your money in 2011, when the biggest incentive dollars roll down. But, as with any purchasing decision, you need to make the right choice, not just a fast one. (For help in selecting a system, search “EMR” at physicianspractice.com for multiple articles and other tools). Go wisely. 

On a more personal note, this will be my final column for 

. I’m not entirely leaving this beloved magazine; it’s my baby. I’m just also going to be helping out with some other magazines in our parent company and won’t have time to write. I’ve made many friends through this forum over the years, and I appreciate every e-mail you’ve sent and every nod or hoot of derision you’ve made as you’ve read my column. I hope we’ll stay friends. I know that this magazine, you, and I will remain true to the vision that physicians can have better practices, the way they want. I continue to applaud your every step along the way. 

is vice president, content and strategy, for CMPMedica,

parent corporation. Have parting thoughts? E-mail her at 

This article originally appeared in the November 2009 issue of Physicians Practice.

President Obama has promised as much as $44,000 to physicians using EHRs as part of the stimulus package he signed this year. Payments start in 2011. But there’s a catch.

Guarantee Me

 I am considering taking a new job where I’d be paid based on productivity. They’ll measure my productivity based on relative value units (RVUs). Before I accept the position, I’d like to roughly figure out what I’d be making if I keep working about as hard as I am now. But I don’t have any real idea what an RVU is or how to figure out what I’m producing.

Isn’t there anywhere that I can find out the number of RVUs per billing code or procedure?

 Let’s start with an RVU primer. RVUs are the key part of the Resource Based Relative Value Scale (RBRVS). Basically, under RBRVS, every procedure or service gets assigned a relative value unit. In other words, it gets a value that situates it relative to other procedures or services.

It’s easier with an example: A mid-level 99213 office visit had a relative value unit of 1.68 in 2008. The even less complicated process of removing ear wax had an RVU of 1.26. Total hip replacement? 37.66.

You see these are values that express what it takes to do each service, relative to other services. Removing ear wax involves less than replacing a hip. Medicare uses that as a basis for deciding what to pay for each service or procedure. Most commercial payers follow the same model.

Every CPT code - every imaginable kind of service or procedure listed in the Common Procedural Terminology manual put out by the American Medical Association - has an associated relative value unit. Medicare changes the RVUs every year and publishes the total list online.

To find out what RVUs are associated with the codes you use, you need to go to the annual Physician Fee Schedule.

The easiest way to get the file is to visit 

 and click on the tools section. A link there sends you straight to the 

You’ll find the work RVUs - the piece that most practices use to measure productivity - in column F.

Now, the unstated but often-related question is why in the world practices measure productivity using a method that requires this much explanation. Suffice to say, assessing productivity can be a huge issue in group practices. Every physician is pretty much convinced that he works harder than anybody else. And, sure, you can compare the number of office visits each one does, or the number of procedures, or even collected revenue per physician.

But here’s the problem: If Dr. Slow sees fewer patients per day or per year, he’ll be quite sure it’s because he takes on the really hard patients, the ones that take a lot of diagnostic skill or hand holding, while Dr. Greedy over there just does quick procedures and gets his easy patients in and out. Or, if Dr. Rich collects more, that’s because he refuses to see Medicaid patients, the big meany. You can see how these conversations are not so good for group longevity.

RVUs offer a decent alternative. The work RVU is meant to capture the amount of work done. For example, if a physician sees a patient that is more critical or needs more help, she’d pick a code that reflects that greater intensity of service and, with it, the related, higher work RVU.

Plus, work RVUs let you compare even if the physicians are in different specialties.

Do the math and see if the job is what you want.

is Vice President, Content and Strategy for

This article originally appeared in the October 2009 issue of

The best measure of physician productivity is the “relative value unit,” or RVU. But many new physicians don’t know where to start, or even what an RVU is. Here’s help.

Making Sense of Productivity


More physicians are having to say “no” to patients these days, thanks to economic and other factors. So much so that I’m beginning to fear physician-patient conflict breaking out across the country, practice by practice. 

You have to do the right thing by your patients - and your practice - and sometimes that means saying no. How can you do it in a way that doesn’t annoy them? By starting from a position of caring and mutual cooperation, rather than from a stance of annoyance and frustration. 

It may be better medicine not to give an antibiotic for a viral illness, for example, but try explaining that to a patient who insists he 

 an antibiotic, clinical evidence be damned. Pay-for-performance programs may encourage good control of diabetes, and may be in the patient’s best interest and good for “the system,” but for physicians it means confronting patients who aren’t controlling their diet or monitoring their glucose. 

The recession is also forcing practices’ hands. No, they can’t waive copays anymore. No, they can’t write off a balance. No, it’s not okay if a patient keeps missing scheduled appointments. And, no, really, they don’t want to barter for services. Practices are (justifiably) tightening financial policies just as patients most need some slack. 

And then there are the government crackdowns. Consider the internist who e-mailed me recently, worried about Medicare’s RAC audits. He wants to stop billing Medicare patients’ “annual exams” as problem-focused visits. He’s been coding that way for years, so that Medicare will cover the visit and the patients will be happy. But he knows it’s not right. He wants to code a physical - and have his patients pay out of pocket. 

Of course, that will annoy patients who think they have a “right” to an annual exam. 

Whether you are saying no for financial reasons or because it’s in the best interests of the patient, I think it’s where you are coming from that matters most. 

Saying “no” to a patient is akin to saying “no” to other sorts of people in your life you’d rather please - a romantic partner, child, or colleague. I really believe that most people respond to intention as much as specifics. What worries me, then, isn’t the internist explaining (or having his office manager explain) that Medicare doesn’t cover preventive exams. That’s easily done with some printouts from the Medicare Web site and a quiet statement of fact. Patients who want the exam can pay out of pocket. That’s just doing upright business. 

Similarly, if a physician takes a thoughtful, caring approach to helping a patient, say, manage his diet, that is just practicing good medicine. 

The trouble starts when, as is often the case, the physician begins from a defensive (or aggressive) position: assuming the patient will never pay, for example, or just wants to be “fixed” by the doctor without ever taking responsibility for his own health. 

My sense is that antagonism is infecting the physician-patient relationship more these days. Physicians seem more inclined to assign bad-faith intentions to patient requests, so they assume that taking the high road won’t work. And surely there are some patients like this. But so what? You can still do the right thing and be willing to let the chips fall where they may. 

So, if the internist loses some patients who really, really want him to defraud Medicare for their benefit, so what? There are many Medicare patients now who can’t find internists. And lots of them will be happy, truly, to pay out of pocket for an annual exam or just decide they don’t really need one after all. 

It’s your business, your risk. Set your policies. Explain and make them clear. And build a practice with patients who want to work the way you do. 

That is so much better than building a business around patients you don’t trust and expect to fight with. Physician-patient battles aren’t required. 

Are you saying “no” more? Join the conversation in our 

This article originally appeared in the October 2009 issue of Physicians Practice.

The customer is always right, until he is wrong. In an age of consumerism, how do you say no without losing patients?