Is your practice paperless yet? The answer is probably yes if you work in a large ENT practice, with Veterans Affairs, or at a major hospital. The idea of transitioning to electronic health records (EHRs), can be daunting for many audiologists in a solo or small group practice. Is an EHR system a must? What are the benefits, and how difficult is it to make the change?
First, let's dispel a few myths. The government does not mandate that all healthcare providers must adopt EHRs by 2014. Rather, Congress, as part of the 2009 federal stimulus package, enacted incentives for healthcare providers to put EHRs in place swiftly.
The EHR Incentive Program, administered by the Centers for Medicare & Medicaid Services, offers payments to healthcare providers caring for Medicare and Medicaid patients who have an approved — and this is a key point — EHR system in place by 2012. Smaller bonuses are available for those in place by 2014. The government has capped how much all this is worth, so the most anyone other than hospitals can earn back is $44,000 over five years for Medicare and just under $64,000 for Medicaid. (Centers for Medicare & Medicaid Services. EHR Incentive Programs; see FastLinks.)
THE MOTIVATION OF PENALTIES
Providers who do not get on board will be penalized, which may be why many believe implementation is mandatory. Providers who do not adopt EHRs by the end of 2015, if they do not get a “hardship exemption,” will see their Medicare pay cut by one percent, a reduction that increases to three percent for 2017 and each year after that. (Centers for Medicare & Medicaid Services. Medicare Electronic Health Record Incentive Program for Eligible Professionals; see FastLinks.)
How much does this actually mean to audiologists? It might be significant to those who do a lot of Medicare or Medicaid billing. Individual providers have to do the math to determine which is more beneficial — swallowing the Medicare penalties or jumping through the hoops to demonstrate “meaningful use” of EHRs, a requirement of the legislation. (See FastLinks.)
Say, for example, a provider bills Medicare a nice round Figure of $100,000 a year. Noncompliance or late compliance with the meaningful use requirements will ultimately cost $3,000 a year — three percent of $100,000. Only the provider can decide if it will cost more than that in fees and inconvenience to adopt a CMS-compliant EHR system. (See FastLinks.)
It is often said, as goes Medicare, so go third-party payers. It is possible that nongovernment insurance companies that cover hearing healthcare may also adopt similar EHR incentives. So far, though, they have not made that move.
Incentive payments and noncompliance penalties, however, are not the only reason to consider an EHR system for an audiology practice. The transition can be difficult, but benefits include practice efficiency, customer service, improved follow-up, and time and resource maximization.
“The transformation to go from paper to electronic is intrusive, but it's intrusive with a start and an end date,” said Paul Pessis, AuD, the owner and founder of North Shore Audio-Vestibular Lab in Highland Park, IL. “From someone who has been on an EMR system for a little over three years, it's paradise.”
Dr. Pessis drew a distinction between an “EMR” and an “EHR,” noting that a true electronic health record is interoperable and can manage office data and interface with external systems and other EHRs. “Our EMR is a wonderful system, but it's wonderful for us,” said Dr. Pessis. “There's no real interoperability, but that doesn't mean that it can't be changed.”
Dr. Pessis uses an electronic system developed for ENT practices. It is not as comprehensive as one certified for otolaryngology, but he said it gives him what he needs. “For example, it automatically interprets the EOB [explanation of benefits], pulls up the patient's account, and reconciles it,” he said. “For CPT and ICD-9 coding, I push a button and the bill is at the clearinghouse that day. It has hearing aid–specific functions that allow us to keep inventory of our aids and supplies and track referring physicians.”
Dr. Pessis said he is seeing a host of savings and care improvements as a result of adopting the EMR system. “The scheduler will not let you make an appointment if there is an opening for a provider but no room available, so we're getting fewer ‘double-parked’ patients,” he said. “Our expenses on collections, our correspondence with patients, and interpretation of EOBs are all going down. Manpower is being saved.”
WHICH SYSTEM TO USE?
What are the options when adopting an EMR or EHR system? First, it is important to realize that EHRs in private audiology practices are different animals from the ones that dominate in hospitals and medical practices.
Virginia Ramachandran, AuD, an audiologist with Henry Ford Health System, which has four audiology clinics spread throughout the Detroit metropolitan area, noted that her practice is within a mammoth, closed system. “The majority of the physicians are hired by the medical group. Everyone's in-house, and there are no outside practitioners at all,” she said. “We occasionally get outside records, but if you see your primary here, you usually also see your ENT here, your OB-GYN, and so on. We have a massive, custom-made system, but it's actually going to be changing in the near future because we're moving to [a new medical software company] to accommodate the transition to ICD-10 codes.”
Most individual and smaller group audiology practices cannot afford the cost of a “massive, custom-made” EHR system or industry behemoth brands, however. Estimated costs of installing a point-and-click EHR system in a private, professional healthcare office vary widely, but CMS's meaningful use rules estimate installation costs at about $54,000 and maintenance at $10,000 per user per year. Most audiology practices cannot afford that steep price, and most do not need the extensive medical functionality that is built into standard EHRs either.
“I contacted a true EMR system, and what they offered was more of an ENT system than an audiology system,” said Gyl Kasewurm, AuD, who practices in St. Joseph, MI. “They were going to adapt the program to come up with something for just audiologists, but it ended up not being worthwhile to them. And the system for ENT and audiology wasn't affordable for an audiology practice on its own; it was something like $75,000.”
That is typical, said Mike Huskey, the president of HearForm Office Management Software, one of a triad of EHR/EMR programs that dominate the audiology market. “We're just such a niche industry. No one can afford the huge startup costs and annual fees of the big EHRs. The funding is not there to create a true audiology EHR.”
Dr. Kasewurm uses an Internet-based office management system in her office. “You can manage your database, schedule appointments, and do all of your billing through it,” she said. “But it's not possible to totally get rid of your charts. Signatures still have to be done on paper, and then you sign things you need to keep.”
Sycle leads the audiology EHR market, reporting use in more than 5,800 practices. HearForm has about 1,700, and the trio is rounded out by TIMS Audiology Software, currently in about 2,000 offices. Other systems include Oticon, and Dr. Pessis raved about a new contender he saw at the most recent American Academy of Audiology meeting called Hear Fusion, which has yet to be released. “That thing walks, talks, and makes breakfast for an audiologist,” he said, adding that it can also be scaled up or down specifically for audiology.
Although audiologists may be considering different programs from a hospital or multispecialty physician practice, the process of choosing an EHR should not be all that different for an audiology practice, said attorney Jonathan Tomes, the president of EMR Legal and an expert on health information law who wrote Electronic Health Records: A Practical Compliance Guide. (Overland Park: Veterans Press, Inc, 2011.)
“Certainly some of the modules for practice in audiology will be different from, say, OB-GYN or psychiatry. A good EHR has links to clinical information, and you won't need a link to the American Psychiatric Association's Diagnostic and Statistical Manual, for example,” he said. “Audiologists probably won't have the same need for pharmacology and prescribing alerts,”
Everyone needs to go through the same process of choosing the right record, Mr. Tomes said. Eighty-five percent of all practices that implement an EHR system are dissatisfied with it, largely because the system leaders do not sit down with their support staff, clinicians, and business people to determine what they want the system to do.
That might not be such a stumbling block in a small, one-clinician audiology practice, but audiologists should not rely only on the office manager to buy the software. “The bigger the practice, the more people you need involved,” said Mr. Tomes. “The single biggest thing that messes up EHR adoption is insufficient clinical involvement from the get-go. Talk about what functions you need, what modules you need, and who you need the system to be able to communicate with.”
Research possible vendors and send a request for proposals explaining the practice's needs and giving details about the practice. Evaluate proposals from potential vendors, narrow the list, and ask for a demonstration and site visit from the ones that seem best. Mr. Tomes suggested selecting a finalist and a runner-up. “First, you may not come to terms with your first choice, and even if you do, having them know that they have a competitor may make the pricing better for you.”
Dr. Kasewurm said audiologists need to pay special attention to how glitches are managed. Her own software temporarily lost data during an update. “We were integrating their sync, and we had problems with the data syncing. [Data] just disappeared. We got it back, but it took days to be restored.”
She also told the story of an internist whose switch to a new EHR system with a different approach to billing affected cash flow for several months. “Audiologists aren't hospitals or multispecialty clinics. We can't afford to absorb that,” she said. “Any system we adopt has to be tried and true and proven, and have reliable service.”
Key Questions to Ask When Choosing an EHR System
* Is the system NOAH compatible?
* How does it handle audiograms?
* Does it have a Health Level 7 (HL7) interface? (This is the standard for exchanging health information between EHRs, and software with that capability would qualify more as an EHR than an EMR system.)
* How will the system facilitate HIPAA compliance?
* How does it handle electronic claims?
* What is its imaging functionality?
* Does the program offer SOAP-based (Simple Object Access Protocol) provider reporting?
* Is the software installed in the system or is it cloud-based?
* Does the system incorporate business development and clinical functionality? How does it support the retail side of the business? Can the practice track devices sold as they go through the system and trace them to their marketing source?
* What kind of support is provided? What is the ongoing cost of support? Does the EHR firm charge any other mandatory ongoing fees beyond the original purchase price?
* Does it have an enterprise version for practice with more than one location?
* Does the system have a native iPhone or iPad app, or is it compatible with such devices?
* Can users choose their own clearinghouse for electronic billing?
* Can users add custom fields? What kinds of queries and searches are possible
Find out more information about the EHR/EMR companies mentioned in this article at:
* AllMeds: http://www.allmeds.com.
* Epic: http://bit.ly/Epicsoftware.
* Siemens: http://bit.ly/SiemensEMR.
* McKesson: http://bit.ly/McKessonEMR.
* Allscripts: http://www.allscripts.com.
* HearForm: http://www.hearform.com.
* Sycle: http://web.sycle.net.
* Oticon: http://bit.ly/Oticonsoftware.
* Learn more about CMS' EHR incentive program at http://go.cms.gov/EHRprogram.
* Become familiar with CMS' hardship exemptions at http://go.cms.gov/CMSincentiveProg.
* Read about CMS' meaningful use requirements at http://go.cms.gov/CMSMeaningfulUse.
* Find out which EHRs are CMS compliant at http://bit.ly/CompliantEHRs.
* Visit HJ's Student Blog at http://bit.ly/HJStudentBlog.
* Check out HJ's R&D Blog at http://bit.ly/RDBlog.
* Click and Connect! Access the links in The Hearing Journal by reading this issue on our website or in our new iPad app, both available at thehearingjournal.com.
* Comments about this article? Write to HJ at HJ@wolterskluwer.com.
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