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Billing and EHRs: the myth of integration

Until a few years ago, billing applications took advantage of doctors’ lack of familiarity with EHRs to sell “integrated solutions.” According to this marketing pitch, an EHR is better and more effective when it contains all of the functions needed in a clinic, including billing and other administrative task management. Although it sounds attractive at the outset, this logic is fundamentally flawed: an EHR is an incredibly complex product, and is therefore best designed and developed by and for physicians, not by billing experts.  Studies on usability and satisfaction tell us just that- and have done so for years!

The goal of billing software is to make you the most money at the lowest cost and with the least effort. Companies with good billing platforms are successful because they know how to best maneuver through the insurance system and other red tape. But what does that have to do with medicine? You’ve got it- nothing! Why would anyone assume that great billing companies would also make great EHRs? And why would anyone assume that great EHR companies also make great billing software?

Fortunately, after seeing continuous failure and customer frustration, many billing applications have stopped attempting to develop EMRs and have adopted new strategies. Billing platforms now form strategic alliances with what they perceive to be the best EMRs. The theory behind this approach is solid, and a win-win for all concerned: if your clinic is happy with your billing service, why change simply because you need an EMR? While “integrated solutions” seem to be convenient “one-stop-shops” for all of your clinical needs, they will cost you in the long-term. In contrast, good billing programs contain added value because they earn money by optimizing reimbursements.

Do not be deceived by the integration myth. In today’s technology market, any superior billing application should be easily interfaced with your EMR of choice, and most interfaces should be completed at no charge. The myth of integration has been a major factor in the rise of user dissatisfaction in the EHR market. It is time for doctors to rise above this marketing pitch: demand specialization and interoperability from all of your medical tools!


CMS warns that templates don’t make the cut: Template users face Medicare denials

EHR templates have long been under scrutiny, but only now are consequences being established for the use and mis-use of templates. In a recently published addition to its instructions for payment review contractors, Centers for Medicare and Medicaid Services (CMS) states that templates do not provide adequate documentation of clinical encounters. In fact, in cases where templates are used without other documentation, progress notes will not qualify for Medicare payments. As stated in CMS instructions:

“Review contractors shall remember that progress notes created with Limited Space Templates in the absence of other acceptable medical record entries do NOT constitute sufficient documentation of a face-to-face visit and medical examination.”

This change in CMS review guidelines follows a string of criticism in recent months regarding the limitations, and even unlawfulness, of EHR templates. While not all templates use or allow for the much-maligned copy-and-paste feature, all templates limit user input in some way, whether it be by pick-lists, checkboxes, or boilerplate fields. Further, some templates are built primarily to maximize revenues, not to document detailed information about the care provided. CMS has come down particularly hard on these templates, stating:

“Physician/LCMPs should be aware that templates designed to gather selected information focused primarily for reimbursement purposes are often insufficient to demonstrate that all coverage and coding requirements are met.”

The risks and limitations presented by templates will be under heavy attack for a long time to come, and prospective EHR buyers must make themselves aware of these risks. If you are shopping for an EHR, make sure to ask template-based EHR vendors lots of tough questions. While all templates are templates in the end (and template-free alternatives, while few, are available), certain templates do put physicians at greater risk than others. As the financial and legal challenges to templates continue to mount, it is critical to implement an EHR system that allows you to capture patient care in your own words, and at a level of detail that properly documents each case.

All practitioners will agree that patients are more than simply lists of symptoms; it seems that CMS is finally beginning to punish EHR users who attempt to reduce patients to lists and checkboxes.


Praxis EMR Training Seminar: Sept 13-16

From September 13-16, Praxis EMR clients, trainers, and staff gathered in Orlando, Florida for the 2012 Praxis Training Seminar.

After a welcome address from CEO Dr. Richard Low, participants divided into beginner and advanced groups.  Course material covered the new features included in Praxis v5 as well as a detailed walk-through on how to attest to Meaningful Use.  Dr Jeremy Bradley, Praxis EMR user and director of Kentucky’s first NCQA Patient-Centered Medical Home, also gave a presentation on improving medical quality and reimbursement through pay-for-performance initiatives & practice advisories. All participants worked directly with their clinic’s Praxis EMR systems via wireless internet, allowing them to implement their new skills in real-time.

We love spending time with our physician users, receiving their input, and seeing first-hand how they use Praxis EMR in daily practice.  Many thanks to all who participated this year: you help us make Praxis EMR better and better!


Technology is Far From Objective: Implications for the EMR/EHR Debate

Published on June 23, 2012, by in EMR/EHR.

It is widely thought that because computers are machines, they are objective tools.  Indeed, this is the perspective that leads many of our colleagues to unconditionally trust EHR software systems: unlike a human being, they think, the computer will make always make the right decision- we programmed it to do so.

This viewpoint misses the basic concept of what software, or any technology, really is: a framework built by human beings that includes certain capabilites and excludes others.  Computers are incredibly biased by the programmers who create them.  This affects not just the capacity of the computer itself, but our own conception of how to use them.  And the consequences don’t end there: the structure of a computer program also affects how we view possibilities in the world around us.  As psychologist Abraham Maslow observed, “If all you have is a hammer, everything looks like a nail.”

The subjectivity of software has huge implications for the EMR/EHR debate.  As we’ve discussed elsewhere, EMRs are designed explicitly for physicians.  EHRs are designed to serve all of the stakeholders in the healthcare realm: doctors, hospital administrators, insurance companies, patients, and other third parties.  As a consequence, the biases and capabilities of these programs are very different.  Several recent studies have highlighted the ways in which the limitations of template-based EHRs in turn limit the decision making capabilities of the physicians who use them.

All computer programs take sides, and a good program should take the side of its user. If your position is that of the controller of healthcare in a financial institution, your needs are markedly different than those of a physician in a small practice, or a hired physician in a larger healthcare institution, or even a patient.  As a doctor, should your program be built for doctors (EMR) or for “society,” whatever that means (EHR)? As a practitioner of medicine, you deserve to have your software tailored to make sure you benefit as much as possible.  And because the vast majority of doctors put patients first, patients will benefit as a result.

The good news is that computer programs, like human beings, are constantly interfacing.  You can easily link the specialized software you need with other specialized programs built for other constituencies (billing, laboratories, immunization registries, etc).   All software should interface with other interested parties’ software in real time, each benefiting its respective client base. You cannot be all things to all people, and neither can software. This is what the voices behind EHR fail to understand.