Imagine an EMR without Billing

hmmmmmmmmm…… Its a thought provoking question; in our case, we can redploy the resources to focus on EHR as opposed to the logistics of billing. Billing is part of the territory; comes with it. At the end of the day, we consider Ambulatory Care Physicians and Clinics as small businesses that do not have to be burdened with multiple vendors; rather have one throat to choke…………… Ideal to have an excellent EHR system with required billing functionalities that can be improved over time.

@pheski –

Nice analogy.

I guess the salient difference — where the analogy breaks down — if that you don’t file a claim for reimbursement for your airline ticket. Yeah, I know; that’s somewhat implicit in your observation.

One of my own REC medical directors expressed some irascible dubiety regarding the HITECH initiative, in that “these systems are all really about the billing.”

@Umar-

“With inter-operability criteria maturing as well as health information exchange getting standardized, more modular EHRs may be the route to go”
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One thing we learned during a HITRC conference put on by ONC in Salt Lake City last week is that, if you go modular and wish to retain your current Practice Mgmt system to be interfaced with your EMR, the front/back-office PM system itself must ALSO be ARRA Certified. They were unequivocal on this point.

Bobby … “They were unequivocal on this point.”

Wow.

@ peski – love your analogy.

Taking the billing requirements out would allow developer resources to focus on EMR usability, workflow and patient care. All the complexities of billing would be eliminated but a practice would still need to handle billing in some other way which can lead to another entirely new set of problems to deal with.

In another time in another industry there was similar dialog relating to need for integration of several different modes of operations, customer service, and billing functions.

Of course one vendor wanted to supply it all and other vendors just parts touting ‘best in the World accolades.

What we ended up with was a common data core warehouse and then ‘snap on’ applications for the various functional centers. Functional data developed fed the core and had to meet core data standards. Functions did not feed functions.

Suggest those who want to build self standing EMRs might want to spend some time with the top PM providers and figure out how to effectively share data and then comarket yourselves.

If you don’t and practices are going to have to deal with the data gap … your EMR may be the best in the World … but few will want to buy it.

Who would buy a computer workstation that is not networked?

Practices are businesses first.

@Dr Robert Schertzer – What makes this EHR product so amazing that it’s worth the hassle of integrating disparate systems? It could be worth it.

The problem with demo’s as they can razzle dazzle but without time in, it’s hard to know what questions to ask. Functionality issues crop up after implementation after you’ve taken care of 80% of the stuff and your ready to move on to the next level.

You want to make sure you have flexibility with your software so that when you get to this point, you are able to address them. So powerful software with a vendor who understands your environment are certainly important. A great vendor also knows enough about your environment to know what questions to ask you to make sure they really are a good fit. Sometimes this means the vendor should walk away from an engagement. Alfred– infomd.net

The broader problem is that the billing aspects have many more insidiously negative effects than simply sending a charge transaction across an interface.

They actually degrade the quality of the documentation by requiring certain elements to support specific levels of billing. The whole issue of needing to have a certain number of elements done and documented to bill a particular E&M code is one example. A particular visit may have extremely complex history/assessment/decision-making but to get “credit” one also has to document a certain number of irrelevant review of systems items.

It is no surprise that the places that have used EHRs most effectively such as Kaiser and the VA are incentivized to give care that will produce better outcomes. They are less beholden to bureaucratic insurer-driven documentation demands that do not aid in patient care or communication.

Eliminating all of these items (and similar demands for information to fulfill PQRI and other measures that are irrelevant to a particular patient or that fragment thought processes) would improve workflow and efficiency in any system, paper or electronic. It would certainly make it easier to develop an EMR that would support patient care needs.

But just having distinct EMR and billing software isn’t going to do the trick in our current dysfunctional health care system. It is only if an EMR can be designed (and insurer/payor/regulatory demands can be synchronized) so that the health care system looks like a single payer system to the EHR user and clinicians can go about the business of treating patients.

I think the most fundamental question that a physician should ask is “who do I want to answer to?” Most have chosen one of two options – payors or health systems (i.e., being an employee). Both are perfectly reasonable options but they have direct implications on the viability of the question you pose. The third option is the patient — i.e., the “Marcus Welby” model of a direct relationship between a patient and MD unfettered by insurance bureaucracy.

If the answer is the payor, this requires playing by their rules. Even if you are answering to the health system, you are indirectly answering to the payor. Having reviewed or implemented 100+ different healthIT systems, they have one thing in common — their main purpose is to get bills out as big and fast as possible. That is a rational response to the legacy reimbursement model we have today. Fundamentally, the “patient” in those systems is really not much more than a vessel for billing codes. [Google “Patients are more than vessels for billing codes” for more.]

The most professionally satisfied MDs I know have decided to answer, first and foremost, to patients and have jettisoned insurance billing altogether. At most, they’ll produce a super bill that a patient can use to file for reimbursement. The most common model there is Direct Primary Care (think of it as concierge medicine for the masses — i.e., typically 1/3 of their patients are uninsured) — see delicious.com/chasedave/DPCArticles for more. It’s two parts Marcus Welby, one part Steve Jobs. In some sense, it’s a bit of a mini-ACO/IDN in terms of payment.

Outcomes studies of these models have been very impressive (e.g., 40-80% reduction in surgeries, hospital admissions, etc.). Guess what, when you have a model such as that, the centrality of billing in legacy healthIT gets in the way. Thus, those orgs have often either built their own (Iora Health, WhiteGlove Health, Qliance, etc.) or more recently have used off-the-shelf EHRs that aren’t about billing. [Disclosure: my company, Avado, has that as one module of a broader Patient Relationship Management system.]

This is all a very long way of saying. Start with the goals of the practice and it will be self-evident whether an EMR without billing makes sense. If you follow the link above, you can see that Direct Primary Care is “hidden” in the PPACA which is why they are quietly exploding in popularity right now.

How will this play out? Naturally, in U.S. healthcare that is a difficult thing to predict but I will outline one way that it could play out.

One of the things that is starting to play out is insurance companies are realizing that direct primary care (DPC) can actually be something that helps them, rather than threatens them. Why? In the insurance exchanges, one of the ways to compete will be on price. When one combines a DPC model with a high deductible wrap-around (that is clause in the PPACA for DPC), it is typically 20+% less than a conventional health insurance program. In the last couple months, I’ve seen an uptick of interest around that combo coming from insurance companies.

Other factors that could drive it include the following:
* A vocal opponent of Obamacare (Rep Bill Cassidy, MD – GOP Louisiana) has proposed HR3315 to expand DPC to Medicare showing that DPC is one bipartisan facet of PPACA.
* A California GOP legislators is proposing DPC legislation similar to what is in places like Washington state to expand DPC.
* States such as West Virginia are looking at DPC for their Medicaid population which would be fulfilling the vision of this article – http://www.forbes.com/sites/davechase/2012/03/11/the-marcus-welbysteve-jobs-solution-to-the-medicaid-driven-state-county-budget-crisis/.
* Employers & unions are increasingly realizing that the best bang for the buck there is for their healthcare dollar is increasing primary care access. This is driving the explosion of onsite clinics and to a lesser degree DPC (best for smaller employers…thus why it isn’t happening as quickly).
* For orgs wanting to play in the ACO world, DPC is sort of a mini ACO so it’s a great place to get one’s feet wet so some providers are also driving this.