How a practice becomes a hostage to its EMR

When an ENT doctor wants to buy an EMR, electronic medical record, they usually check with their colleagues in the world of Otolaryngology. This practice makes sense, to an extent. But how many purchases or decisions that you make stick with you for most of your life? And how many of those did you make without testing and trying for yourself?

Put it another way, would you buy a $50,000 car without driving it first? Would you buy it just on a recommendation? Would you buy it based solely on what it looks like in the show room or because you saw someone drive it down the street?

Most software companies offer a free version or a trial version to see if it meets your needs. EMR companies generally do not. They have valid reasons for these restrictions, but surely they can figure out a way to make things happen.

My gut tells me that EMR companies are generally afraid. Its fairly well known that many practices who launch an EMR project will abort or end up using limited aspects of the EMR. Sometimes a great implementation falls short because the users figure out that the program doesn’t quite satisfy their needs. I would like to see an EMR company be bold. Is there an EMR company that is confident enough in their product that they would let a practice try it for free for a span of several weeks?

There are some who say that playing it safe would be to buy an EMR from the biggest company. Big does not make it better. A few urology groups I know have gone several BIG EMR vendors. Each of these vendors talked about how many urologists are using their products. So these urology groups signed up and spent a fortune. After implementation, they wanted to add some features that were common to the practice of urology. The EMR vendors patted them on the back and said here they are for an extra $30,000 (and for a larger urology group $100,000).
Once you have put in a lot of time and money, the BIG vendors can sometimes hold you hostage.
Ok. Anyone can hold you hostage. A small fry EMR company can custom make an ooberEMR that works so well…except that it doesn’t interface with anything. Or the 1 programmer that built the whole thing gets burned out and switches career paths.

Its not only the EMR companies that hold you hostage. Once you have an EMR, your employees suddenly become more valuable. If one of them quits, it takes time and money to get the next employee trained. Doctors who have become very dependent on their few employees have acquiesced to cost of living adjustments. Now several years into an EMR practice, the employees are making 30% more than what they made before. All the return on investment goes POOF!

AAO-HNS and AOA, time to nationalize an ENT assistant curriculum

Coordination within AAO-HNS and AOA in standardizing a workforce

The Association of Otolaryngology Administrators is an organization, which I have only recently become aware of and will be joining. I have been a member of the American Academy of Otolaryngology- Head and Neck Surgery since starting residency. I have attended almost every annual meeting since then and have walked thru the OTO-Expo every year. But it was only in the past year that I paid attention to the AOA booth.

My interest took off after my struggles in developing Physicians Angels. At last year’s AAO-HNS meeting, Karen Zupko had a course that touched on managing employees and theft. She spoke in earnest about how ENTs and physicians in general need to take more care in hiring and training. She shared cases on employees with criminal records that somehow get hired over and over again in physician offices. I found the talk fascinating considering how the vast majority of the people we hire get a very superficial review.

Physicians often believe that they are the central figures in their practice. The hierarchy is doctor, practice administrator, audiologist, nurse and then all others. So in terms of focus on hiring and training, doctors reduce their efforts in determining the quality of their applicants as they go down the chain. After all, as the organization gets bigger it gets harder and harder to pay attention to the “little people”. That is until one of the “little people” creates a big problem.
The AOA is relatively new compared to the AAO-HNS. The AAO-HNS is relatively new compared to the AMA. Medical school education did not develop nationalized standards till 1919. ENT residency training did not become standardized until the late 1970’s and is continually being updated. The trend has been to specialize the workforce from a general practitioner to a specialist to a specialist’s office administrator and now to nurse practitioners or physician’s assistants. But that still excludes the vast number of employees in a practice. The typical specialist will have 4 support staff often excluding the administrator/manager. The only resource that is available for the general office staff is Primary Care Otolaryngology produced by the Education Faculty of the AAO-HNSF.

When developing the Angels concept of creating a workforce for the ENT and other medical specialty markets, what struck me was that most communities did not have a training program for specialists. Check out the community colleges and trade schools around the country and they mostly produce assistants for primary care. The burden and expense falls on the specialists to take these low skilled employees and raise them to the level of functionality. The time frame from personal experience ranges from 6 months to 2 years to get a generic medical assistant to a high level of performance. The hidden cost is not obvious to most doctors. The other thing that is often forgotten is the turn over in medical assistants. The average assistant stays for 3 years at a practice. In many cases they end up taking time off to raise children or pursue additional degrees or worse…take that precious training and hop to the next employer who pays a dime more per hour.

So why don’t schools teach a specialized curriculum? Consider than in many markets there are just a handful of ENT practices within reasonable driving distance. Even large markets like New York or Chicago ultimately have very few new job postings within a specialty every year. A school and student would think twice about a curriculum that graduates people into an environment where the job market is ultimately very teeny weenie. Yet on a national level, there are jobs to be had but most of these potentially skilled workers are not going to move/travel more than 45 minutes daily for a job that pays less than $15/hr. This leaves ENTs and other specialists with 3 options: 1) accept the status quo 2) enter into a wage war 3) embrace a virtual staff model.

The virtualization of staff creates new flexibilities for both workers and the office. Physicians Angels has proven over the last two years at multiple practices around the country that employees from anywhere can work anywhere with minimal impact on daily routines at an office. This of course means that the office has to have an electronic medical record and adequate broadband.

We have undertaken an ambitious effort to translate Otolaryngology into teaching modules for the average high school graduate. This teaches them enough to understand a conversation and the activity of a busy ENT office. We have formulated a curriculum with Terra Community College. This curriculum will be placed online and students from anywhere can take the course. This will provide ENT practices around the country with a curriculum for new hires.
Physicians Angels plugs the graduates of these courses into offices around the country. Angels can take graduates working in a data center in Montana and have them work in Miami. Telecommuting, telemedicine, and telepresence has been present in every industry. The cost of doing this is now cheaper than driving to work every day. Yet we are stuck in the past when it comes to our daily routines. Once you take a manila paper patient chart and digitize it, the extra space in the office where the files used to be disappears. But guess what? Do you still need all your physical staff sitting at desks taking up real estate that is usually more expensive? They had to be there when the chart was physically a few feet away. Now the chart is anywhere they are with a computer.

Wages for a skilled virtual ENT assistant cost a minimum of $12/hr. The same person in Manhattan, San Francisco, and similar cities earns wages reported up to $17/hr. Doctors and administrators often forget that the cost of their employees include the physical space they take up ($ per sq ft), parking, utilities, taxes, and miscellaneous expenses. Then take into consideration of having to train, inservice, and retain these workers, wouldn’t it be easier to have this done in collaboration with other ENT’s around the country? I will be pushing this at the AOA and AAO-HNS in San Diego.

I invite your comments and questions.

Look for IT training when hiring medical assistants

By Patty Enrado, Contributing Editor
09/24/08


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WASHINGTON - A shortage of healthcare professionals across the board is spiking employer interest in hiring medical assistants. Demand for medical assistants with specific training in computer applications such as practice management software, scheduling, billing and electronic health records is making the category one of the fastest-growing professions through the 2006-2016 decade, according to the U.S. Department of Labor .

Approximately 62 percent of medical assistants work in physician offices, 12 percent are employed by public and private hospitals, including inpatient and outpatient facilities, and 11 percent work in offices of other health practitioners, according to the U.S. Department of Labor . Most of the remainder works in other healthcare settings, including outpatient care centers and nursing and residential care facilities.
According to Judy Jondahl , director of accreditation for the American Association of Medical Assistants (AAMA ), associate degree programs are putting a bigger focus on information technology skills and requiring IT competency as part of the their curriculum. AAMA recently approved of new standards and requirements for its medical assistant curriculum.

“Multi-skilled medical assistants can be very advantageous to a practice," Jondahl said, noting that many physician practices are scrambling to hire anyone with applicable information technology skills right now. She said medical assistants already are being required to develop expertise in data management of electronic health records and electronic medical records, including hardware and software skills to maintain EHRs, EMRs and anything Internet-related to the medical office.

In the front office, medical assistants need to administer and management patient admission through computerized office billing systems. While in the back office, IT skills play a big role in data gathering of lab samples and basic vital signs.

IT competencies have become more common among large practices, she said.

Here are three things to look for when contemplating upcoming staffing moves:

· Work with local medical assistant programs to identify strong candidates with IT skills

· While certification isn't necessary, choosing certificated medical assistants ensures competency on basic IT systems

· While experienced CMAs can earn, on, average, $38,000 -- about $10,000 more than an entry level CMA -- it may be worth the effort to land a candidate with the skills and knowledge to get to work on Day One. That employee can be come a key trainer and leader when it comes to IT adoption.

Implementation Mistakes

Advice for the AAO-HNS OTO-EXPO, Implementing EMR into an ENT office

I am very smart. I know it all. I am young, brilliant, and able to multitask. My only shortcoming is that I can’t walk on water. Training…I can pick it up on the fly.

A couple of weeks ago I attended the AllMeds User Conference. This happens every two years and gives the offices a chance to share their wide range of emotions, thoughts, and experiences. If you are an AllMeds User, you should go at least once. William Rust, the CEO, and Sherry Hunt, the COO, along with all the people at AllMeds make sure that the event is fun and educational.

Sitting in on the specialty discussion session for ENT, I was reminded of our deployment and the next several years of hell. The opening comment on this blog summarizes the thought processes of an amalgamation of individuals. If you think the opening comments were about you, Carly Simon, may have pegged you right. Some other thought processes that I sensed at the conference:

Why should I know how to do it? I’ve been here forever. My people should know it and take care of it for me. I’ll just modify what I have always done a little.

Hire more people? Not on my watch. Heck we just spent $50,000 on computers and software not including the $20,000 on the IT guy’s labor. The doctors are going to learn how to use this “thing” or we will throw it out.

In 2004 we launched our EMR. At that time we just became a 4 man ENT group. The week that we had the training, one partner was overseas, I was on call, and two partners sat through the complete training. Our staff was new to computers. We had only 1 dust covered OLD pc running Windows 95. The rest of the computers were the green screen dummy terminals from the mid 1980’s provided by the billing company. I remember one of our employees not knowing how to use a mouse.

AllMeds sent their top trainer, Lucy Stephenson (now a VP), and she laid down the laws. I subsequently broke them all (and suffered). She went over what it takes to make an implementation successful and how to reap the full benefits of an EMR. It takes some time to learn, a commitment to change daily processes, and the right people. She introduced the concept of an HIA or health information assistant. In the EMR world there is a great debate over HIAs. I know several EMR vendors who hate to mention the role of HIAs. I know of practices that REFUSE to hire HIAs and are somehow willing to live a miserable existence. If you have an EMR vendor tell you their product is SO WONDERFUL that it does not need an HIA, RUN AWAY. Nothing turns off patients more than a doctor working on a computer screen like someone working behind a fast food restaurant counter. So your ear is draining, would you like fries with that?

I digress. Lucy’s comments about HIAs did not sit well with me or anyone else for that matter. My partners and I did without HIAs for 3 painful, excruciating, gut wrenching, and family wrecking years. Each person found a solution for themselves…often antithetical to EMRs.

ENT Physicians Inc. is a medium sized practice by national standards. But when we started we were small. Regardless of how big or small, we suffered with labor. Finding, hiring, retaining, and managing employees gets harder every year. Even in a bad economy, finding the right workers is not easy. Between 2004 and 2009, we had less than full staffing 70% of the time. Pre EMR days we could hire temps to fill in. Now with EMRs it takes 3 months to get a new employee to speed.

My patient care coordinator, Amy is a young fertile lady. She and I started 3 new practice locations in a span of 3 years all the while, she kept having babies and had to take time off. I ended up working longer hours and saw my personal time spent clicking on keys. Unlike some, I can’t see patients and do paper/computer work simultaneously. I find it rude to patients to be scribbling or working on a computer when they are sharing their problems. I finally figured out how to use express documents and leverage the full power of the EMR. But after all that, I was still spending more time with the computer than with my wife and kids. I went to the AllMeds conference in 2007 to pick up tricks and tips. Karen Zupko talked about the difficulties of the labor market and something stuck in the back of my head. I had a sense that my labor pains were shared in many ways.

I remember the day that Amy got sick at work. This was just before the AllMeds conference. I jokingly said are you pregnant again. A few weeks after the conference, she came to my office terrified that she may have to stop working because..she was pregnant AGAIN! Having invested so many years into her and also because my life was still a hell, I sat down and worked through what my problems were. Our office had never developed a pool of HIAs, health information assistants. For reasons beyond my understanding my partners have no interest in HIAs and would rather live with lower productivity and income. So building a HIA pool would be cost prohibitive if I was the only one using the service. Amy wanted to work but we were unsure of her availability. My former patient care coordinator, Dawn, had been transitioned to managing the Allergy patients. We were going to have her fill in on days that Amy was out. But that fell through when Dawn’s husband got a job in Tennessee. Both Amy and Dawn needed at least part-time work, but could not physically be in the office.

For the next several months I was racing the clock, Amy’s biological clock. Since most HIA’s are women, we needed a solution that created flexibility and mobility. My evenings and weekends were devoted to solving Amy’s, Dawn’s, and my problems. I realized that I had to get real time encrypted work/data to Amy and Dawn regardless of where they were. The closest thing was telemedicine. But in this case, the patient and doctor were not separated. I hired a team of engineers and business processing specialists to help me design a patent pending system to get Amy and Dawn into my examination rooms. By the time Amy delivered her child, we had built our system. Amy and Dawn were among the first of my HIA’s who I call Angels.

Over 3 years after Lucy spoke about implementation and HIAs, I finally got it right. It cost a fortune in time and treasure. But in the process we created the first virtual HIAs, aka Angels. Our challenges have resulted in an opportunity for medical offices throughout the USA to share a common labor pool broken down by specialty and EMRs. ENT offices, and now other specialty offices around the country are joining in to help build nationally standardized virtual labor pools that we call Physicians Angels.

More on this on the next blog.

ENT EMR CCHIT, The skinny on Otolaryngology Software

EMR, electronic medical records, have been a constant at the American Academy of Otolaryngology Annual Meetings since I was a resident. The AAO-HNS has an OTO-Expo (its trade show) at the annual meetings. The OTO-EXPO has seen the number of EMR vendors start with just 1 vendor and climb up to, I believe, a peak of 13. AllMeds EMR has held the consistency spot being there every year for the last decade. NextGen, AllScripts, Greenway, MiSys, and a few others have joined the scene.

AllMeds, Greenway, and Misys have progressed from being small startups to now being sponsors of major events. The AOA, Association of Otolaryngology Administrators, now lists AllMeds as a platinum sponsor, Greenway as a gold sponsor, and Misys as a silver sponsor. The AOA and the AAO-HNSF do not endorse one EMR over the other.

The AAO-HNS has multiple lectures and seminars on practice management systems and electronic medical records. Dr. Tom Upchurch, an otolaryngologist and co-founder of AllMeds, has been a perennial speaker at these events. To his credit, he has maintained his objectivity during these presentations. The first time I heard him talk about EMRs, I realized the pain that we would all be going through. Tom is a visionary and is a mentor to me. He has an interest in what we are trying to build out.

I expect the crowd at AAO-HNS conference in San Diego scheduled for Oct 4 through Oct 7 to be bigger than ever despite the economy. With the stimulus package encouraging IT expenditures, ENTs who have been sitting on the fence will come out in force. Having recently listened to Karen Zupko at a conference extolling the potential government money to be had, and watching the fall in PC prices, the return on investment is so much faster than when we bought ours.

Karen Zupko and her firm Karen Zupko & Associates, KZA for short, have presented at the last several AllMeds user conferences. At each conference she has shown the improving rates of return with EMRs. When she first started advising ENT surgeons, the software choices for Otolaryngologists were minimal. Now there is a plethora and the gaps between them are closing. But every single one of them still has the same problem….the people at small offices like yours and mine who have to run them.

So which EMR did we choose and how did we pick it? We started our review of EMRs in 2002. Having looked over AllMeds, Greenway, Misys, and a dozen others, we picked AllMeds. At that time, AllMeds had the greatest number of ENT users. If I am biased towards AllMeds, it would be out of familiarity. I would love to be able to have all the EMRs available to me on a regular basis to test them out and try them. I called all the software providers to see if they would be willing to provide a fully functioning product for me to keep on our test servers. Only AllMeds, GE, and AllScripts called back. AllMeds was kind enough to give me a second software package to put on teaching/training servers. GE will participate in the Fall. All you other EMR Companies….still waiting for the software to test.

What makes comparisons between EMRs frustrating is that testing is not done in the same fashion that cars are tested. It is easier to spend $50,000 on a luxury vehicle than on an EMR. Test-driving it at a convention floor or even in your own office for 15 minutes does not really tell you how it would work in your daily grind. AllMeds has made it easy for me to let you do a test drive. Contact me and we can make this happen.

Say CCHIT three times fast. As acronyms go, this does not bode well when trying to make a sale. In the early days, EMR users did see sh*t. The software was not robust or interoperable and the hardware was expensive. CCHIT stands for: Certification Commission for Healthcare Information Technology. CCHIT has been a blessing and curse to the EMR world. It has forced EMR vendors to improve aspects of their software, but also raised some onerous demands. CCHIT inhibits and promotes natural selection of EMR companies. If you are an EMR designer with a very novel approach, you may find yourself running up against a wall of standardization. But overall, the goal of CCHIT is to provide buyers/users some degree of security and interoperability. The CCHIT website goes into detail and has volunteering opportunities.

Email me about your EMR purchasing decisions and if you have changed your EMR. AllMeds claims to have a 94% retention rate. We are in our fifth year of using their software. AllMeds nor their competitors have given us reason to change. So I need to hear from those of you with different systems. While this blog is directed toward the ENT community at large, I welcome feedback from doctors of all stripes. Please include any industry affiliations. Lets get the skinny on EMR for otolaryngologists.