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.