Key Insights On Integrating EHR Into Your Practice

Bruce Werber, DPM, FACFAS

The challenges of integrating a new practice management system and electronic health records (EHR) system into your practice can be tremendous, especially with a busy practice. However, these upgrades can increase efficiency and potentially reduce the need for additional staff members, thereby improving your bottom line.

   In addition, an integrated practice management system can reduce the potential for errors and the need to enter the same data multiple times. If one must enter the data multiple times, the rate of errors increases exponentially. The secret to rapid payment is submitting clean claims with excellent documentation. One can achieve this by reducing the number of times staff needs to enter patient demographic information and insurance information into the system.

   Additionally, having a software package that verifies the patient’s coverage, deductibles and co-pays improves your ability to collect the appropriate payment at the time of service. The system should scrub each claim to ensure that one places the appropriate CPT codes and ICD-9 codes as well as modifiers appropriately within the electronic claim.

   Once the claim is paid, it will be remitted electronically and posted electronically in your system. This also reduces staff time in processing payments and reduces errors.

   Additionally, data collection can be automated in the latest systems with scanners having the capability of scanning driver’s licenses and insurance cards, and inputting data directly into the demographics section of the software package. Again, this is another step in automation to reduce the risk of incorrect data collection.

Essential Pearls For Implementing The New System

Preparation is essential. First, the physicians cannot delegate this task to their staff or the office manager as physicians must fully participate in the evaluation of practice management systems and electronic health record systems/electronic medical record (EMR) systems.

   After choosing a system that fits the practice model and method, then the real preparation begins. The practice must collect and document all of the insurance/worker’s compensation companies that they do business with on a regular basis. The staff should include the provider numbers of these companies, electronic payor ID numbers, addresses and phone numbers.

   One must decide on an electronic claims clearinghouse (intermediary). Typically, the software package has already developed this intermediary relationship and the package will assist in the process of signing up with the payor intermediary. Be aware that it can take upward of six to eight weeks to have authorization from Medicare and the larger insurance companies to start utilizing electronic submission or even changing how you submit your claims electronically.

   The practice needs to identify all of the CPT codes that it uses as well as the charge schedules for each CPT code and supplies that the practice uses and/or sells. One must gather reimbursement fee schedules from the insurance carriers. This will be necessary in order for the system to identify when the practice receives a payment correctly or incorrectly, and report any incorrect payments to your staff.

   The practice must develop a list of referring physicians with names, phone numbers, fax numbers and addresses to input into the system. This will simplify the process of sending out consultation and thank you letters after treating a patient.

   It is time to evaluate your scheduling process. Developing templates for scheduling will improve your practice efficiency by maximizing your time. Consider how much time is necessary to see each type of patient and then establish an appropriate template for each day. Consider blocking certain types of patients to one specific time section. For example, see all post-op patients on Tuesday mornings and all orthotic follow-ups on Tuesday afternoons. This helps your staff be prepared and moves the patient flow along much more effectively.

   My recommendation is not to import data from one system to another. By treating each patient as a new patient, you have the opportunity to clean the data, update it and ensure that you have minimized errors. If you import the data, you carry over past errors and may not catch new insurance information, address and phone numbers. You also may subsequently miss collecting patients’ cell phone numbers and e-mail addresses.

Making The Transition To Electronic Charting

Now that you have prepared for the practice management portion of your new system, how do you prepare for moving to an electronic chart? First, collect and put in a Word document your most common exam findings.

   For example, in a vascular exam, you can have a preset paragraph that looks like this: “Vascular: +2/4 dorsalis pedis and posterior tibial pulses, positive digital hair, capillary fill time less than 2 seconds, feet are warm bilaterally and symmetrically, no edema, no erythema, no lymphangitis, no lymphadenopathy, no signs of acute infection.”

   All I dictated was “normal vascular” and the system noted the whole paragraph in a macro. I have developed macros for most of the areas required in a typical history and physical examination, or follow-up. I recommend obtaining a charting system that allows the use of Dragon NaturallySpeaking For Medical Professionals Version 10 (Nuance) in addition to templates. By using a combination of templates and voice commands, one can complete a note and have it coded very quickly. Additionally, this ensures that you have put all of the required insurance information into your note.

   The practice can change its workflow to capture all pertinent information. When this happens, the more information gathered, the more potential for having met criteria for a higher evaluation and management (E&M) code then the practice might otherwise qualify for. Additionally, it will help you qualify for a Physician Quality Reporting Initiative (PQRI) bonus from Medicare.

   My recommendation is to train your medical assistant to capture medications, allergies, history of present illness, past surgeries, list of medical problems, review of systems and social history. If your team members have time, they can gather this information the day or two before when they call to confirm a patient’s appointment. At each visit, your medical assistant can document that he or she has reviewed and updated the information.

   When preparing for implementation of an EHR/EMR system, everyone in the office should learn the ins and outs of each system, especially the doctors. The more the physicians are aware of how the system functions, the less pain there will be when one actually implements the system and sees patients.

   This also translates to the bottom line as the unseen cost of implementing systems may be a 20 to 25 percent decrease in productivity in the first three months of implementation. In contrast, if the physicians are present during planning and training phases of implementation, the productivity losses may be less than 10 percent.

   Patience is also necessary for all staff members in the first two to three months as they learn the system and discover shortcuts. I can assure you that once you and your staff understand the system, your productivity goes up and your cash flow improves since the claims are clean and well documented.

In Conclusion

I fully advocate integrating practice management and electronic health record systems. To do anything less will leave your practice behind and your profit margin ultimately will be affected.

   Consider having the ability to complete your note, patient instructions, imaging orders, lab orders and charges prior to the patient walking out of the treatment room. If you can do that, not only will you be happy not to have to think about that note later in the day, you will know that the charges will be submitted to the insurance carrier before you walk out of the office that evening.

   When evaluating systems, I would also recommend looking at the systems being promoted by your primary hospital or by the state medical association or even the state as many of these systems are designed to integrate sharing of patient information. The system Noteworthy Medical ( not only integrates practice management systems and the EHR/EMR but also allows integration between practices, hospitals and clinics that operate this program. If another practitioner on the system refers a patient to my practice, I can pull in the patient’s H&P from that primary care physician. All of the information is present and I do not have to re-enter it.

   On another note, make sure any system you are going to implement has the ability to be upgraded to the new ICD-10 coding system that will be instituted in 2013.

   Yes, it is intimidating to consider change but with the coming challenges and changes proposed in the healthcare reform law, we must redesign how we practice and run our businesses if we are going to prosper under the new system.

   Dr. Werber is in private practice in Mesa, Ariz. He is the Director of Clinical Education at the Midwestern University College of Health Sciences in Glendale, Ariz. Dr. Werber is also a Fellow and Past President of the American College of Foot and Ankle Surgeons.

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