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Dr. Lynn Ho – Ultra-Solo Doc: Meaningful EHR User With Amazing Charts

1.  Please tell us about your background and training and when you became a sole practitioner?

I graduated from NYU School of Medicine and finished a family practice residency at the University of Rochester in 1989. Before opening my micropractice, I had worked in a variety of different settings, including an HMO, community health centers, a university health center and a typical private office practice. I opened my no-staff micropractice in 2004 after reading Gordon Moore’s groundbreaking articles on solo-practice and seeing a local colleague succeed with a similar type of practice in Rhode Island.

2.  I understand your practice is defined as a “micro practice”. Can you explain what you mean by that and how it differs from a traditional practice?

In my particular case, ‘micropractice’ refers to a small, low overhead, no staff, high tech – high touch practice.
– a small practice (850 patients vs. the usual patient size panel of 1500-3000 patients)
– that because of low overhead (25-30% of gross collections vs. usual 60%, attributable to not paying staff salaries and leveraging computers to run an efficient and effective practice)
– is able to spend adequate amounts of time with the patient during each patient encounter (30-60 minutes vs. the national primary care average of about 7.5 minutes)
– which leads one to be able to better provide the cardinal primary care functions of supplying “access, continuity over time, coordination and comprehensiveness” in a patient centric manner.

3.  What led you to make the change from traditional to micro practice?

The current financing model of delivering primary care – cranking on volume of visits to meet overhead and salary – is bankrupt and broken. I wanted to move to a model that would be better for patients and lead to more professional satisfaction for myself. I wanted more control over the way I practiced medicine.

4.  When did you start using Amazing Charts (AC) and why did you choose them over other EHR vendors?

One of the key underpinnings of running a micropractice is achieving and maintaining low overhead, (around 30% of gross earnings). I did know that I did NOT want to work just to have to pay for my EHR.

When I first started my practice my AC license cost me just $500. Back in 2004, AC did not have a lot of bells and whistles but as a startup I was nowhere near using the program to its fullest capacity. Starting out is tough! I had the naive idea that with a laptop, an all-in-one, an internet connection and an EHR as the centerpiece of my technology stable, I was set for life. I was blissfully unaware of what my burgeoning technology configuration (see list below) was going to evolve to include, and how many other pieces of technology were going to have to ‘play nice’ with my EHR. Luckily for me, and because AC is very responsive to requests from users, all of the software pieces that I use integrate well with my EMR, both via formal interfaces and in my informal workflow.

To reiterate, low cost, ease of set up, maintenance and use, and ability to easily integrate with other workflow processes are the EMR qualities that I’ve found to be essential in my micropractice, and I find that AC meets and often delightfully exceeds these criteria.

Instant Medical History – automated patient entered histories
Updox – document management and patient portal
Paperport – document management
Appointment Quest – online patient entered appointments
EZ Claim – practice management
Zyantus (clearing house) – electronic billing
Shortkeys – macro for documentation
HowsYourHeath – web based patient entered practice quality tool
Brinkster – website hosting

5.  Did you have any prior experience using EMRs?

No – actually I had never really used a computer (except for email, and that was a Mac!) before opening my practice in 2004.

6.  I understand you are in the process of attesting to Meaningful Use. Was it necessary to upgrade your current EHR in order to meet requirements for MU?

I had to upgrade to the latest version – version 6 to use the wizards that would count up my data.

7.  How long have you been working towards MU?

I’ve been counting data for about 2 months, and am on track to “pass” by month 3.

8.  How much additional time is it taking to meet the criteria for attestation?

It takes about 2-5 more minutes per encounter to include the documentation for Meaningful Use.

9.  Can you give us an overview of what the process has been like thus far?

Generally speaking, I find it exceptionally vexing to have to spend extra time documenting what I already do for bean counters. I could be using this extra time to actually improve patient care instead of just filling in boxes. Luckily, on a visit by visit level, the MU wizard in my EMR makes it mindless, simple and not too painful to collect the required data and document the required work processes.

10.  What changes have you had to make in your practice as a result of meaningful use?

I have not materially had to change office processes, though I have had to change documentation procedures so that items are compiled correctly for MU.

For example: I used to send patient summaries via email to most patients.
5 clicks: copy content – return to demographics screen – open email to patient – paste – send, about 30 seconds.
Now, in order to document that I am sending these summaries for MU, I have to click on the MU box, print that to a secure email, click( 2x )and type (2x ) within the secure email program to attach label and send, wait for the CCD to print and then click to return to the note. 8 steps and some are slightly more than just a click. It all takes about 90 seconds.

Another example – Smoking documentation requires a formal reassessment of the data as MU needs it, but it’s usually not the way I’ve previously free texted it.

It’s just a little more cumbersome, might take about 2-5 minutes more per patient encounter.

11.  Word is that you’re a “paperless office.” How do you handle things like the patient intake paperwork to avoid having lots of paper lying around?

Patients send me their clinical histories before every visit electronically using Instant Medical History from my website or from an office kiosk, so I don’t use paper for those forms at all.

I do have new patients sign a laminated “HIPAA-consent to bill-consent to email form” – one signature gets it all. Then I scan in the page along with a copy of the insurance card to a file. I rinse off the marker from the laminated sheet under the tap and am ready for the next new patient.

I use EDI interfaces for most labs and some x Rays and consults, and most consultants fax me their information electronically.

Other non interfacing labs and radiology reports come in via paperless fax to a folder on my computer.

If there is a particular consultant or facility that mails me information more than twice, I will call them and ask them, going forward, to fax their information to me.

There are a number of tricks to minimizing use of paper in the office. Having paper embedded into your office routine requires extra labor (opening mail, scanning, shredding, filing, retrieving files) and the expense of storage space and materials.

12.  Who has been helping you through the meaningful use process (consultant, your EHR vendor, your REC, etc.)?

Mostly the EHR folks- attended a webinar and then had some back and forth with the developers, as I was an early beta tester for the MU process.

The REC folks came by, but since the processes were in place they just encouraged me to actually decide to apply for MU by dangling the financial rewards in front of me.

13.  What would you offer as guidance to your fellow doctors regarding EHR’s and obtaining MU status?

If the processes that MU is supposed to document are already in place – if you are already leveraging your EMR to help you in your practice in a meaningful way, then depending on your Medicare/Medicaid revenues/patient mix, it may be worth it to apply. The question there is, are the monies received – or the penalty that you would incur, worth the time it will take you to: 1) learn about the MU program, 2) learn how to use the MU features of the EMR, and, 3) actually do the documentation?

Payout is also dependent on your payer mix and volume of the practice. For example, because my straight Medicare income was about $10K last year, I stand to get, over 4 years, about $22K so, coupling the payment with the curiosity factor of seeing what our cutting edge HIT people are up to, I decided it was almost ‘worth it’ for me.

If the processes are not in place – items such as, ‘you don’t use the EMR to collect demographic data’ to ‘your EMR does not support E-prescribing’, then there’s the additional work of adopting these processes into your workflow. Again you’d have to weigh the payment against the work of adopting new workflows AND becoming schooled and practiced in MU deployment. This work is not an insignificant burden and many small primary care practices that run with very tight margins and lack breathing room will not be able to succeed.

Of course, if you work for Kaiser or another large group, I would imagine that they would deploy both IT and clinical staff to do this work for you.

August 2, 2011 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Jan Patterson, Office Manager of West Broadway Clinic – Force Behind its MU Implementation and Attestation Process

West Broadway Clinic has three physicians and two PA’s – all three physicians successfully attested to Meaningful use on April 20, 2011. The practice encompasses multiple specialties including family medicine, internal medicine, endocrinology, diabetes, women’s healthcare and offers onsite x-ray, dexa scan and vasectomies. The following interview is with Jan Patterson, the Practice Manager who drove the MU process and attestation.

1.    How did you learn about and select Cerner as your EHR?

At West Broadway Clinic in Council Bluffs, Iowa, we learned about Cerner Corporation through a local hospital. After extensive research into Cerner and several other vendors, we made the decision that the integration of Cerner’s Practice Management System and Ambulatory EHR would be the most beneficial to our organization.

2.    What’s your take on EHR certification and did that influence your EHR selection process?

The EHR certification is a vital piece for being able to meet the CME incentive requirements, and we feel that we are practicing better medicine and using our EHR solution more efficiently after receiving certification. We selected our EHR well in advance of the reporting process, so it was not a major influence in the selection process. Still, we have been very pleased with how efficient our EHR solution has been with assisting us in reaching certification.

3.    How long has your office been using an EHR?  Is this your first EHR?

West Broadway Clinic started using an EHR in May of 2008 when our office opened. Prior to the clinic opening the providers were not using an EHR – but the providers made it an initiative to start the clinic on an electronic solution. We knew we would be up and running with an electronic solution on day one. This included an EHR and practice management solution.

4.    Would you walk us through the process you followed to meet the meaningful use requirements and how did Cerner assist you in the process?

In order for West Broadway Clinic to be able to meet the Meaningful Use requirements an extensive amount of time was spent by the practice administrator attending webinars provided by Cerner Corporation regarding Meaningful Use, as well as researching the CME website and examining materials available through Medical Group Management Association, MGMA. In addition, Cerner arranged a Meaningful Use summit at our office for our office along with several of the Cerner user groups in our area – this consisted of several Cerner associates highlighting important parts of Meaningful Use, answering questions and making suggestions to assist with the process to successfully attesting. Upon compiling the requirements, time was spent one-on-one with both the providers and the clinical staff to ensure that everyone fully understood the requirements and how to use the EHR to meet the requirements.

5.    How many of the meaningful use requirements were you able to meet with little or no effort because you were already doing them? Did the Cerner EHR affect this?

West Broadway Clinic was able to meet 9 of the meaningful use requirements with little or no effort since as were already conducting several of these requirements through the use of our EHR. The use of the Cerner EHR and the elements that were already built into the EHR were the major factor we were able to meet these requirements so easily. Additionally, as we ran into any issues – we were able to contact Cerner’s Meaningful Use team (a group of designated associates) to assist, which eased the process.

6.    Which meaningful use requirements did your clinic find most challenging to meet and why?

Probably the most challenging Meaningful Use requirement for our clinic was encouraging all of the providers to use the electronic prescription function. However, once they understood the necessity of using electronic prescriptions and became comfortable with the function they have continued to increase the number of electronic prescriptions they are sending to the pharmacies.

7.    How long did the actual process take for you to fully comply with the meaningful use requirements?

West Broadway Clinic worked in earnest to be fully complying with the Meaningful Use requirements as quickly as possible after the beginning of 2011. These efforts allowed us the opportunity to be able to attest on April 20, 2011 – two days after attestation opened.

8.    Is meaningful use of a certified EHR helping your patients receive better care? Why or why not?

West Broadway Clinic has seen many positive changes in patient care with the use of a certified EHR. With the use of Cerner’s Ambulatory EHR our staff has the ability to have the most current visit information and patient history at our fingertips. Patients receive more continuity of care due to the fact that regardless of what provider they are seeing within our office the provider can quickly and easily track what services and/or medications a different provider has provided the patient. We deliver a better quality of care and we’ve enhanced safety measures through our use of the EHR. Components such as eprescribe, medicine/drug interactions, allergy checks, complete documentation, immunization schedules, growth charts, etc., have made us more efficient throughout the office from billing to practice management to prescribing medications and providing more thorough care in the patient’s room.

9.    What was the driving motivation for your clinic to show meaningful use?  And why be one of the first to show meaningful use?

West Broadway Clinic is committed to providing excellent patient care and providing patient’s with the opportunity to benefit from the latest in technology. With meaningful use of an EHR our patients are afforded these opportunities. By being one of the first groups of providers to meet the Meaningful Use requirements and report on them successfully, we are further able to show our commitment to our patients and their healthcare.

10. As a practice manager, what techniques did you use to get your physicians on board with meaningful use and EHR?

As a practice we had been discussing Meaningful Use for over a year and as the time grew near to implement the process the physicians were fully aware of the expectations and requirements and the benefits that would be provided to our patients. A lot of communication went into ensuring that all of the physicians were on board.

11.  Would you recommend that every health clinic show meaningful use and adopt an EHR? Why or why not?

After being on an EHR for more than three years I cannot imagine trying to function efficiently with a paper system. While the training period was stressful at times and it took the physicians a while to adjust, the benefits far outweigh any of the pain points. In addition, the opportunity to be able to transmit and receive patient information from other facilities in the future will only continue to enhance our patient care and the delivery of quality patient care is why we are practicing medicine in the first place.

12.  For all healthcare professionals reading this interview, what advice would you give them in starting the meaningful use process?

For anyone starting the Meaningful Use process, my advice is to first gather all of your information and facts. It is vital to be clear on the direction you need to take in order to ensure that all of the requirements are being met. In addition to thoroughly explaining all of the requirements to your physicians/staff and gaining their buy-in communicate with your staff and ensure that they fully understand the benefits and the necessity of meeting the Meaningful Use requirements, which is primarily to use your electronic records in a successful, meaningful way that will enhance the delivery and quality of care that your office provides. Remember the main reason why you are attesting, the money is a great incentive – but the biggest factor in successfully attesting is the benefit to your patients. Anyone can purchase an EHR and use it unsuccessfully or at its minimal functionality – to use it to it’s very best ability and to meet the requirements set forth by the Meaningful Use standards is to practice better medicine for your patients and to encourage others in your field to make quality care the highest priority.

13.  What remains your greatest EHR challenge post EHR implementation and meaningful use?

The greatest challenge for EHR and Meaningful Use continues to be the necessity to ensure that all the physicians and staff are continuing to maintain their high level of entering the correct and necessary data in patient’s charts to enable us to increase our reporting requirement levels far after successfully attesting. I have continued to monitor my staff’s levels after attestation and I’ve found that their numbers continue to increase – which is a positive realization for our staff and for our patients. It will also be imperative that we continue to monitor any new information coming out of CME and Cerner regarding meaningful use requirements especially as we gear up for Phase 2.

14.  What’s been the biggest benefit to your clinic of having an EHR?

West Broadway Clinic has benefited from having an EHR in multiple ways from never having to track down a paper chart to the continuity of care it provides for our patients. Having an EHR that integrates with our Practice Management System has reduced the amount of time it takes for charges to be entered and then forwarded to insurance companies. The adoption of an EHR has enabled West Broadway Clinic to become more efficient and be able to focus more upon the patient as a person. The increased benefits of safety cannot be undersold. With the assistance of the EHR, we are practicing better, safer medicine than we could on paper records.

June 29, 2011 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.