Understanding how EHR Works With Your Clinic
Interview with Steven Kraus, DC
Steven Kraus, DC, is chair of the Iowa Board of Chiropractic Examiners and a former president of the Iowa Chiropractic Society. He is the Iowa delegate for the American Chiropractic Association (ACA) and a member of ACA's Medicare committee. Dr. Kraus is also the president and CEO of Future Health, Inc., an electronic health records and chiropractic practice management company with 40 employees.
Dr. Kraus has practiced chiropractic for over 20 years and serves as clinic director of a multidisciplinary clinic in Carroll, Iowa, which includes two chiropractic physicians, a family practice physician, a certified physician assistant, a physical therapist, physical therapist assistants, an athletic trainer, and two massage therapists. His clinic has been visited by Iowa Governor Tom Vilsack (now Secretary of Agriculture) and Senator Tom Harkin, who mention it frequently when illustrating the benefits of collaborative disciplines working together through the use of Electronic Health Records technology.
Dr. Kraus speaks on a variety of different health-related topics. His most common include electronic health records, clinical documentation, Medicare regulations and guidelines, integrative practice, and the role of chiropractic in the health care system.
What are the benefits to a chiropractor adopting EHR software into their practice? How does this improve interactions with doctors and other parties outside the practice?
There are three main things that they gain: efficiency, quality of care, and financial incentives. Federal stimulus money will soon be offered to clinics who adopt eligible EHR software. This was designed to help in health care reform and allow clinics with EHR to avoid financial penalties in the future.
The number one benefit gained by the EHR adopters is efficiencies in the office. These can range from overhead cost savings to streamlined communications within the different departments of the office.
Consider the amount of time spent in your clinic in simply managing files. Every time a patient is involved in any aspect of your clinic, their file has to be located, pulled and placed back. In addition to this file movement, documents that need to be added to the record also have to be located, hole punched and placed into the appropriate place in the patient's record. All of this file manipulation takes time, time that might be more efficiently utilized elsewhere. In a time trial study, we discovered an annual saving of over $2,600 annually purely in staff time, with the adoption of electronic health records.
With this newly rediscovered time, doctors are more capable of providing better quality of care to their patients. The whole reason they want "qualified" or "certified" EHR would be to improve "interoperability" between departments. This is the reason they're driving health care professionals to adopt EHR. They aren't looking to necessarily improve your own office efficiency, though that certainly is a benefit, they are simply looking for improved quality. With EHR managing your patient's files, there are logs, repositories, alerts and reminders for case management, and so on. It is this information that can be shared electronically with other health care providers.
What would be an example of how EHR implementation would affect a chiropractic clinic?
The best thing about this technology is that it can help chiropractors manage their cases in a more timely fashion. It is fairly easy for chiropractors with a large number of patients to have trouble remembering exactly what their previous instructions were. Let say, for example, you've asked the patient to perform a variety of home exercise and add a few key nutritional changes to their diet.
When the patient returns a few weeks later, it is difficult to recall the exact type of exercises you asked them to complete and what dietary changes they made. Sure you could look them up in their record, but that would involve getting the file, locating the visit, rereading the chosen plan, all before the patient arrived for their appointment. This redundant activity takes up time, time which could have been better utilized by your practice.
With EHR implemented into you clinic, you can simply generator lists or logs for certain types of patients that indicate the exact plan you had set for them on their last visit. This report can alert you when a specific document, say an MRI report, comes in. Maybe the patient isn't coming back in until they find out if there is a disc herniation. This provides the reminder and helps us to manage our cases better.
EHR also helps to regulate the various different requirements of say the CCGPP [Council on Chiropractic Guidelines and Practice Parameters], or the NCQA [National Committee for Quality Assurance] or any other documentation needed by Medicare or another third-party payer. This way chiropractors don't have to spend years trying to remember which provider needs what documentation. The requirements are all clearly listed right their in front of them.
So basically the EHR works to organize all of this information and tells you how to proceed with the provider's documentation requirements?
Exactly. That is the beauty of true EHR documentation, like Future Health's EHR. This software knows what provider the patient is under and the types of documentation that provider requires. This software can then lead the practitioner through the necessary steps in order to meet those requirements. However not all EHR do this. In fact, a majority of them don't even qualify as a true EHR.
How is a chiropractor to know if they are adopting a "true EHR"?
Well, the CCHIT [Certification Commission on Health Information Technology], plays a large part. This is a nonprofit organization that has been selected as the certifying body by the federal government since 2006. Both Medicare and ONCHIT [Office of the National Coordinator for Health Information Technology] reference CCHIT as the valid certifying body.
So what provoked you into starting your own paperless clinic in Carroll, Iowa and sell your software to other chiropractors on the market?
It began with frustration. I was tired of not being able to utilize documentation systems to manage my practice. Before I created the Virtual Office Suite (VOS), I had to use four different digital documentation and billing systems. It was a mess. None of the software was able to communicate with each, the entire system lacked the "interoperability" I really wanted for my clinic.
So my solution was to start up my own company and finally design my own version of software that would meet the needs of my fellow chiropractors. Future Health now has 40 employees and over 1000 users in 48 states. We took all of the various components of a practice and integrated them so that alerts, reminders and tracking systems were in place and the doctor could finally manage his or her clinic. It has all the speed I could ever want for my clinic and creates compliant notes easily. I now had the perfect system for my chiropractic clinic.
Has your software been certified by CCHIT?
It isn't as of now, but we are working towards that goal. As of January 2009, there was no other chiropractic specific software that was CCHIT certified. I feel that obtaining certification is an important step for my clinic, because it is going to be a necessity for clinics to receive the economic stimulus funds. These regulations haven't exactly been set in stone, but it is virtually certain this CCHIT is the certification that will be used towards obtaining validation to receive payments from the stimulus funds.
From what I can understand the federal government, in preparation for the health care reform, will be offering a monetary incentive through the Medicare system for those doctors who purchase and implement EHR software into their clinic.
Right. From the information I've read in the bill, as well as discussions taken from the Department of Health and Human Services, the framework is all in place. There are still some minor details that still need to be ironed out, but the plan is for the money to be reimbursed through the Medicare check.
Is there specific requirement of the amount of Medicare billings necessary to qualify for the refund?
As of now, I'm not exactly sure yet. It is likely to be decided by the end of 2009. Originally the amount of $25,000 billed annually to Medicare in approved billings was suggested for the minimum amount required for reimbursement. However now it is being discussed as to whether those clinics that bill Medicare for less than $25,000 could be eligible for a portion of the reimbursement. On average though if you have around 16 Medicare patient visits a week you will most likely qualify.
How is the reimbursement calculated by the government when a clinic obtains a qualifying EHR?
Basically its 75% of the amount you bill to Medicare. The reimbursement money will then be split up over the next four years for a maximum reimbursement of $44,000 per individual physician. This amount was designed to help offset the costs not only of the purchase of the software but of the training, hardware and implementation your clinic went through in order to get it up and running.
The sooner you get the EHR system up and running in your clinic the sooner you will be able to start receiving your incentive payments. If you don't implement in 2010, you won't be eligible for the 2011 payments. Therefore the longer you choose to wait, the less money you will be eligible for in the future.
This is the type of structure the government is leaning towards.
So the earlier you adopt EHR the better, right?
Exactly, by the beginning of 2015, there will be no reimbursement at all. In the following years, Medicare payments will actually begin to decrease each year you fail to implement a qualified EHR system. Another requirement is that you not only have to adopted the EHR system but you must put it to "meaningful use".
"Meaningful use" means you have an EHR system with the following:
Based on these criteria, our software is Medicare qualified in the current PQRI program and we are now in the process of becoming CCHIT certified by the end of this year. My prediction is that there will be approximately four or five chiropractic software vendors that will become CCHIT certified between now and the first part of 2010.
What types of costs are we looking at for adopting EHR software?
Well for the initial software, clinics are looking at somewhere between $12,000 and $14,000 for a true EHR system. You have to understand that this is far more beneficial to your clinic than a simple digital note generator. A true EHR system has the ability to communicate with or retrieve data from any other computerized system outside your clinic and any of the digital systems inside your clinic.
The average chiropractic office has 2.5 office staff and one chiropractor. They are working out of two adjusting rooms, and we recommend putting a workstation in each room. Having a simple, reliable $450 workstation in each room will work, and then you're networked within your office so you control your own data. From a survey we did in May 2008, 76% of all chiropractors want to have the patient data in their own office and to have control of it, as opposed to using a 100 percent web-based application, with the data stored somewhere else. I do believe that we'll start to see that change over time, since the younger generation is more comfortable with the web hosting their data and trusting the outside world with their data. In either case, you would have off-site data backup.
Then the cost of training staff and updating any outdated software will probably run around $5,000 to $10,000 more. So all in all your clinic is probably looking at an investment of around $20K.
True EHR systems, like offered by Future Health, are already being implemented around the country. How are the issues with confidentiality being dealt with?
Ah, yes, this is indeed a noteworthy concern. But I want to point out one key point first. The idea that there will be one record following a person around from birth until death is not yet ready to be implemented in our current stage of health information technology. Therefore there simply won't be one all encompassing document of your entire life's health records. However what is far more likely is that a patient will have multiple EHR available under the patient's different doctors. It is the interoperability of these various EHR to communicate certain data between them that makes them unique. The transfer between two EHRs is determined by the patient authorization.
Ah that does make a difference.
Yes. So the patient is still in control of what gets shared. Inevitably this leads to the advent of the PHR, the personalized health record. The patient will instruct the doctors to transmit their data to their PHR, which they are in control of. And then when the patient goes to a fifth doctor, they can simply click the desired items, such as the obvious demographics, the history, and so on, and submit that to the fifth doctor. So now if the patient's got an orthopedic problem and needs hip surgery, they can transmit the data that they choose directly to that surgeon. That is how I see it happening.