The Automated Glaucoma Office
What will a typical practice look like 10 years from now?
In today's rapidly evolving world of medical advances, it is useful to pause and reflect on the technology we would find in the ideal automated glaucoma practice. Such a system could not only improve an office's day-to-day efficiency, but also elevate the quality of care clinicians deliver to their patients. This article describes a hypothetical, ideal, fully automated glaucoma practice of the future and discusses how close we are to making this vision a reality.
PREPARING FOR THE OFFICE VISIT
The benefits of automation will be immediately apparent to a patient when he is referred to a glaucoma specialist by a general ophthalmologist or internist. He can go online to check if he needs a referral, and if so, whether the referral has been sent to the glaucoma doctor's office. A patient might also be able to register with the practice, provide his insurance information, and schedule an appointment over the Internet. Instead of filling out forms when he arrives for the appointment, he can submit his demographic information and personal medical history through the practice's Web site.
Once the glaucoma office receives all of the patient's information, the staff can begin preparing for his visit. The patient will receive an automated phone call to remind him about the appointment 1 day before his scheduled visit. At the same time, the scheduling module in the office's practice management system will transmit a list of expected patients to a service that verifies insurance information, calculates copayments and deductibles that have not been met, and checks for the necessity and the presence of a referral and/or preauthorization.
All of this information is integrated into the patient's electronic medical record (EMR) when he checks in with the receptionist on the day of his visit. The patient's self-administered history, demographic information, and referral forms will appear in his newly created electronic chart.
EXPEDITING THE EXAMINATION
Before the patient sees the glaucoma specialist, he is interviewed and examined by a technician who records the patient's chief complaint, the history of the present illness, and his own observations into the electronic health record. Next, the physician sees the patient, reviews his self-administered history form, completes his history, and begins the examination. Instead of using a scribe, the physician dictates his findings as he evaluates the patient, and the discrete clinical information is automatically entered into the proper software fields in the electronic record.
The results of any tests ordered by the physician, including images of the patient's optic nerve and visual fields, are also automatically sent to the electronic chart. They can immediately be accessed for review.
DOCUMENTING THE EXAMINATION
After the physician completes the examination and reviews the results of any diagnostic tests, he verifies that the CPT and ICD-9 codes listed in the EMR accurately reflect the services he has provided and that the codes are entered into the patient's account in the practice management system. The system automatically collects the charges for all the patients seen that day and, at the close of business, transmits data to the various insurance companies through a claims clearinghouse. Within 24 hours, the insurance companies process clean (ie, completely correct) claims, adjudicate payment for the submitted services, and disburse fees directly to the practice's bank account. At the same time, an electronic file is sent to the practice, and after the practice's staff reviews the payments, they are automatically posted to the proper line item in the patient's account.
In some cases, the futuristic system described herein may be a single integrated software package, whereas in others, it may be several systems interfaced to work together. In either instance, the office's administrative and clinical functions can be handled by one unified operating system.
BACK TO THE PRESENT
At present, we find that many of the automated features described in the previous scenario are already naturally integrated into systems currently found in glaucoma practices. For example, existing practice management software handles patient, physician, and resource scheduling; charge entry; payment posting; and management reporting. Virtually all practice management systems interface with one or more clearinghouses that allow physicians to submit claims electronically. A smaller segment of the programs that support this interface also accommodate electronic payment posting. This system sends an explanation of benefits to the physician's office, where they are reviewed and posted to each line item in the patient's billing account. This automatic posting function can significantly reduce the number of staff needed to run a practice's billing department.
Most glaucoma practices have the capacity to store digital images obtained by ocular coherence tomography (Stratus OCT; Carl Zeiss Meditec, Inc., Dublin, CA), the Heidelberg Retinal Tomograph (HRT; Heidelberg Engineering GmbH, Dossenheim, Germany), and the GDx (Carl Zeiss Meditec, Inc.). Not all have the ability, however, to access these images from every computer in the office.
Given the potential benefits of integrating diagnostic and data retrieval systems, one might ask why all glaucoma specialists are not aggressively automating their offices.
CHALLENGES TO AUTOMATION
Clinicians who want to automate their offices in the current technological environment face several challenges. First, they must determine which functions they should computerize and to what degree they should integrate various systems. Next, they must overcome the problems posed by the cost, and for want of a better term, the maturity of currently available technology.
For example, your practice management software may not support an interface with an EMR or electronic payment (remission) posting system. Would it be more worthwhile for you to abandon an otherwise adequate practice management system and incur the cost and disruption caused by the acquisition of a new one to gain a higher level of functionality?
The best way to answer this question is to calculate the return on investment (ROI). Using this method, you can determine the time it will take to recover the cost of an acquisition. Once you have determined that your administrative workflow will benefit from a new software system (practice management or EMR), or that a new diagnostic instrument will improve your clinical environment, you total the costs involved (both initial and ongoing) and the savings. If the acquisition saves the expense of hiring a new staff member or increases your practice's income, how many months will it take you to recover the cost of the purchase?
To calculate the ROI for a new diagnostic instrument, add its purchase price, the cost of maintenance, how much space it occupies, and how much time it takes the staff to operate it. Next, estimate the number of tests for which the instrument will be used per month based on your current patient population, and multiply that result by the amount of reimbursement you receive for each test. This exercise helps you calculate your profit per test and determine how many tests, and therefore how many months, it will take to recover the cost of the equipment.
When calculating the ROI, you must avoid a critical pitfall by carefully estimating costs and savings. First, you must include all expenses. If you are contemplating buying a new EMR system, you may need to consider how it will affect your ongoing productivity. For example, if your average income per patient is $125, but your EMR affects your productivity so that you see three fewer patients per day, you will earn $375 less per day than previously. You will also continue to lose money if you and your staff have to make up the deficit by working longer hours and seeing more patients.
Similarly, if you are in solo practice, and the task of preparing, pulling, finding, and replacing charts takes 50% of a staff member's time, you will save money by buying a new EMR system only if it allows you to reduce your expenses by 50% of one person's salary.
You may find that the ongoing savings involved in acquiring a new EMR or diagnostic instrument are less than its cost. In that case, there is a negative ROI relating to an ongoing increase in cost. Consequently, it will be important to accurately measure the total cost and the total savings and/or income as part of the decision-making process. There may be circumstances in which you will elect to implement a new service or piece of equipment because it improves the quality of the care you are able to deliver, even if there is an ongoing net financial loss.
CONSIDER COMPATIBILITY AND RELIABILITY
The second impediment to fully automating the glaucoma office is the "immature" nature of some technology. Although OCT has been around for less time than EMRs, the financial characteristics of this diagnostic test are well known. Physicians are familiar with the cost of the equipment, the staff time required for the scan, the space required, and the criteria and reimbursement level for the test, all of which are stable across practices. Therefore, ROI calculations for OCT are very reliable.
The technology of EMRs, however, is still in flux, and it is characterized by a plethora of incompatible software packages, designs, degrees of human interface, ease of customization, and elegance of usability. Whereas physicians do not have to change their workflow to integrate OCT or practice management software into their practice, they may have to completely re-engineer their routine to incorporate an EMR into their patient encounters.
I use the term immaturity to describe currently available EMR systems, because physicians and their staff do not yet have a solid reference against which to evaluate the technology. In addition, the degree to which an EMR's implementation affects practices varies widely, even with the same software package. For example, a survey by the American Academy of Family Physicians showed that the investment per physician ranged from $10,000 to $250,000.1
I do not describe these issues to suggest that glaucoma specialists should not consider implementing an EMR, but that they should be careful to choose a system that fits their practice. The failure rate of EMRs is declining because practices are more thoroughly determining whether they can benefit from EMR. If they decide they will, they are more carefully investigating available packages before deciding which one to purchase.
Choosing the right EMR is especially important, not only because it has the greatest effect on how physicians conduct patient encounters but also because the system can be a hub for all of the other elements needed to automate a glaucoma practice.
IS EMR NECESSARY FOR AUTOMATION?
A common misperception among physicians is that they cannot automate other aspects of their practice without successfully implementing an EMR. They can, in fact, integrate their practice's administrative and clinical functions through other programs such as chart imaging packages. With these software suites, physicians can continue to use paper templates while evaluating patients and scan the paper into an electronic chart. This system allows them to access the patient's chart from various locations without interacting with discrete clinical data.
Chart imaging packages serve as a hub for images generated by diagnostic equipment and allow physicians to view scanned images of virtually every paper document generated in the office. Thus, imaging packages improve administrative efficiency by expediting access to patients' charts (automated chart pulling and immediate location), while allowing physicians to continue using a paper template for patient encounters. Because this type of automation does not require physicians to change their workflow, it is more likely to be implemented without failure than other systems.
Even if physicians are not ready to adopt an EMR or chart imaging software, they should consider purchasing another, lower-cost system that provides a central portal for accessing diagnostic data, such as the EyeRoute system (Anka System, Inc., McLean, VA). They can also investigate methods for automating time-consuming administrative functions such as insurance verification, preauthorization, and electronic remissions posting. If these approaches make financial sense for their practices, these measures should be implemented. Many systems that oversee these functions often interface with the practice management systems and are available through cooperation between the practice management software vendor and the claims clearinghouse.
Glaucoma practices can benefit from many currently available automation systems and programs that can streamline their clinical and administrative workflow. Before purchasing a tool, however, physicians should examine each one with a critical eye to determine whether it is right for their individual practice.
Ron Rosenberg, PA, MPH, is President of the Practice Management Resource Group in Tinley Park, IL. He acknowledged no financial interest in the products or companies mentioned herein. Mr. Rosenberg may be reached at (708) 623-8201; firstname.lastname@example.org.
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