There has been an obvious trend towards medical practices moving or purchasing cloud based EMRs. For many practices – especially those on the smaller side – there is almost always no cost reason to undertake the effort of provisioning a server, paying for its installation, paying the cost of patching and maintenance, and replacing it every three-five years. Here’s a guide on moving your EMR to the cloud.
Cloud based EMRs – why?
EMR vendors themselves have been pushing cloud-based solutions as it is more efficient for them to maintain their clients on their own infrastructure and, often, hosting is an additional revenue line for vendors. This trend is not exclusive to ambulatory practices; increasingly, vendors are offering cloud-based solutions to healthcare systems as well. For example, Cerner partnered with Amazon to assist in more effectively deploying and maintaining its HealtheIntent analytics platform.
Hospitals – especially smaller ones – are also increasingly examining cloud-based EMRs to compensate for smaller IT staffs and leaner IT capital budgets.
Medical practices looking to move to the cloud may concentrate on the benefits – fewer costs, access to a more robust infrastructure, and better security – without thinking through the items that may be potential pitfalls in the migration. The first item that a practice must consider is what type of cloud to move to.
For example, what sort of cloud does one want to move to?
A practice can often move to a completely hosted solution by their EMR vendor. In such an environment, the practice or their MSP (managed service provider) would no longer need manage any EMR infrastructure with the exception of possibly managing the client PCs that run the EMR.
Downsides of cloud based EMRs
While that may seem easier there are, however, downsides. Selecting this option provides the EMR vendor with complete control over one’s EMR infrastructure.
In this case, the practice is essentially at the mercy of the EMR vendor to get access to one’s data. This could be expensive and time-consuming especially if one is in the process of migrating to a different vendor.
The other alternative is to use a third-party to host ones EMR. Options would include companies such as AWS (Amazon Web Services) or Microsoft Azure.
There are also smaller third-party hosting companies that can be used. In comparison with the EMR vendor-controlled option, the practice or the MSP on their behalf has access to the underlying infrastructure. It is – in a sense – a rented server or servers (and sometimes a rented database).
In this case, the practice can access the EMR data and use the database server to manage a migration to another EMR. There are, however, some downsides. The costs are usually more than hosting with an EMR; however, there are some capabilities that may make it more worthwhile.
One could access data more readily by pulling it directly from the database. This could make connectivity to an analytics system or migrate more easily to a different EMR. A practice must, however, review security processes and capabilities to ensure that the third-party hosting company is adequately protected.
Regardless of the type of cloud hosting chosen, a practice must also consider a few items. First and foremost, one must consider bandwidth. If the practice has slower internet access but there are a fair number of providers and staff, one may consider – if it is available – getting fiber optic broadband.
Additionally, the practice must decide if it makes sense to get backup internet access. One could use – if there are few users – portable cellular WIFI hotspots or, if there are a fair number of users, it may make sense to obtain DSL or cable to act as a backup to the main internet access method.
With a cloud hosted EMR, it must be recalled, that if Internet connectivity is down, so is EMR access. One could also invest in downtime tools. One tool is Carefinity from eMedApps; it makes a copy of the EMR database frequently. There is then a local application that can be accessed to read clinical information in the event of a downtime. A practice must also ensure that BAAs are existing with the correct parties are covered.
Cloud hosting is likely going to continue to be a trend. Practices deciding to undertake the move to cloud will probably benefit in the long-run from doing so; however, there are some warnings that must be addressed to ensure that the migration is smooth and the work in the practice is not interrupted.
Tips for making the best of your EMR
It goes without saying that physician and practice manager burnout is increasing with no end in sight.
This justifiable exhaustion and pessimism about the future of their vocations can distract from capitalizing on opportunities to increase practice efficiency and increase revenue – not to mention increase job satisfaction for physicians, practice managers, and the rest of the staff.
Despite their glaring deficiencies around areas such as usability, EMRs are key to achieving this goal.
In this article, I will discuss some ways to use your EMR to boost productivity for staff and physicians.
Decrease Repetitive Actions
This probably seems like common sense; nevertheless, if you monitor or record your tasks – or your staff’s – for week, how likely are you to find a significant number of repetitive tasks being undertaken?
This could be with a provider’s charting behavior, communication to patients, or even internal workflow tasks.
Your EMR has features for providers to simplify charting along with features to ease the reporting burden placed on practices by health plans.
EMR Efficiency for Clinical Staff
Are the providers using their EMR’s templating features?
If not, a first step would be review a set of notes for common visits – e.g., Welcome to Medicare, Annual Wellness, Well-child, UTIs, etc. – to see what items can be templated.
For example, some structured tasks such as preventative screenings, documentary evidence of education provided for items such as weight counseling or tobacco cessation are good targets for templating.
Additionally, in some cases, most of the visit can be templated and then the provider or other clinical staff can simply change structured text result or date values.
Templates have also been successful with planned diabetic visits.
Dr. West, an Endocrinologist in private practice, has written a very good summary of how he has found tangible benefits from using templates for common visits.
If your EMR has dictation capabilities, this may be another area to examine for improving efficiency.
Some providers have found tremendous success – especially, if they have used dictation at previous practices or in a hospital setting – with using Dragon from Nuance or another dictation product that is available within the practice’s EMR.
If your practice’s budget supports it, hiring scribes can be a surefire way to increase efficiency and take away a huge burden from providers.
Think of having a scribe as the next step above dictation software.
With a scribe, the provider spends the entirety of the visit interacting with the patient, and instead of having a prescribed documentation period outside of patient care time, the scribe performs the charting in real-time while the provider is treating the patient.
A scribe that is paired with a specific provider quickly becomes adept with how that specific provider conducts patient visits; moreover, as proficiency with the EMR grows, the scribe can concentrate on translating a provider’s care into structured data that will make it is easier for billing and other back office staff to send quality data to payers.
Also, as a further benefit, since providers with scribes can see more patients, an article in Keiser Health News noted that the use of scribes can boost a primary care practice’s revenue by up to $105,000.00.
There are also many other EMR tips and tricks that can be implemented. Some of them include using order sets for common diagnoses to speed up the documentation of a treatment plan, taking advantage of any capabilities to store favorites such as favorite diagnoses, medications, lab, or radiology orders.
Back Office EMR Efficiency
Clinical users aren’t the only ones in a practice that can benefit from more efficient EMR use.
Administrative staff within practices are increasingly responsible with providing quality data to health plans, fulfilling reporting requirements for CMS incentives such as MACRA/MIPS or GPRO for ACOs and large practice groups, and ensuring that claims – oxygen for a medical practice – are filed and paid in a timely manner.
Every practice is probably accustomed to receiving gaps in care reports or record requests from health plans that they subsequently must work through to maximize their eligibility for performance-based incentives.
Along with both the desire to maximize the quality of care received by their enrolled members, health plans are rated by the NCQA on their aggregated HEDIS scores; the push for practices to close gaps in care is part of that effort to increase their NCQA ranking or their Star rating with Medicare.
In addition to their recent increased pivot to cost, CMS is also still focused on providers’ quality. On both the CMS and commercial health plan front, optimized EMR use by staff can lead to increased quality scores.
As mentioned in the previous section, providers have a few options to increase the effectiveness of their charting.
Regardless of the method chosen, more standardized and structured data makes it easier to report HEDIS data and get ahead of health plan generated gaps in care reports.
For example, designated personnel – e.g., an incentive coordinator if one exists – can use registry functionality that exists in almost every EMR – although it may be an add-on with an associated additional cost- to run reports to create a list of, for example, patients whose last blood pressure put them in a hypertensive category, patients with abnormal BMIs that lack the requisite weight management counseling, diabetics with uncontrolled A1Cs or no recent A1C screening, or Medicare patients that need a fall risk screening.
Ideally, staff would run regular reports and then reach out to patients with gaps that also don’t have appointments scheduled, and if the patient has an appointment scheduled, make a notation in their chart to resolve the care gaps at the next visit.
Along with registry functionality, there are other features that EMRs and EMR vendors have available that can assist practices.
Given that there is a continuing migration away from the traditional fee for service payment model to value or population-based payments, accurate risk stratification is increasingly important.
Ensuring that your practice is billing that maximum number of allowable claims – when applicable – and that the services rendered are billed properly is critical to accurately assessing risk for a practice’s patient population.
Outside of risk stratification, effective billing is also important for closing HEDIS care gaps for patients. CPT codes – even those billed without a cost – are the preferred means to close gaps in care by payers, and the more performed services that a practice codes, the fewer items they have to manually submit from EMR data to close HEDIS gaps.
Examples would be coding exclusionary diagnoses – e.g., complete hysterectomy without residual cervical tissue to exclude a patient from the cervical cancer screening measure – or coding the patient’s BMI to avoid having to manually enter height and weight values into a payer’s web portal.
Maximizing Your Portal
If you don’t have a patient portal, you are most likely missing out on some potential efficiencies.
Most EMR vendors have portals that can be implemented in a relatively straightforward manner at low or no additional cost.
With a concerted effort at driving patients towards your portal, you can move towards decreasing the volume of calls to your prescription renewal line, non-emergent questions can be pushed into portal messages and responded to in a more efficient manner (using batching techniques for instance), patients can view their own clinical summaries, and patients can often request appointments.
If these tasks are increasingly moved away from discrete events that interrupt the concentration of the staff – i.e., if they are no longer bombarded with phone calls when they are trying to complete other tasks – they will be able to take advantage of optimal work methods to complete tasks with fewer errors, at a higher level of quality, and in less time.
Additionally, patients – regardless of their age – are increasingly comfortable with mobile devices, so taking responsibility for some of their healthcare through a mobile patient application won’t be any different than a lot of what they do with the rest of their life.
Think of how much of our personal financial life is managed through a mobile application.
There is one final area where portals shine – visit prep.
Increasingly, patient portals let practices push down forms or assessments to patients.
Examples include screenings on alcohol usage, the PHQ-2/9, and screenings for future fall risk to name a few.
Often, these forms are then tied to structured data within the practice’s EMR so that when the results of the assessment are pushed into the EMR, the data is already structured.
This then loops back into efficient charting to both save clinician time but to also make it easier for other staff to glean quality data to report to health plans.
Using the tool to make life easier
It is undeniable that for many physicians, the transition to EMRs has resulted to more time spent charting and increased burnout.
It, however, doesn’t have to be that way.
Despite their known challenges and deficiencies, there are many tools that EMRs have that can – when used properly – increase the efficiency of the practice and generate additional revenue.
How to use your EMR for improving HEDIS Scores
It is not news to anyone in the healthcare industry that payment is continuing and that there is an increasing migration from fee-for-service to fee-for-value.
Fee-for-value usually encompasses some combination of cost and quality. In the commercial market especially, HEDIS metrics are often the primary focus of quality measurement. Such metrics are often preventative measures that involve targeted actions at specific populations.
It is often the case that most practices are not maximizing their revenue by optimizing their quality/incentive processes and making optimal use of their EMR and its reporting functions.
Prior to discussing some strategies to effectively use one’s EMR to close more HEDIS gaps, it is important to recognize that regardless of how well thought out and accurate one’s EMR processes are, if that data is not making it to the payer, than it is irrelevant from an incentive perspective.
The most straight-forward method of getting data to a payer is by attaching it to a claim. Wherever possible, a practice’s billers should put forth the effort to attach such informational data to claims so that it is processed by the payer.
Administrative or claims data is the easiest data to use for HEDIS as it does not have as much of an additional audit threshold as does supplemental and non-standard supplemental data (the other ways to enter data). If one’s payer – for some reason – does not allow such data, they may very well have a portal that can be used to enter such data. An audit may be required but is likely relatively straightforward.
While this may seem duplicative – charting in an EMR and then in a data entry tool – the financial benefits may outweigh the staffing costs. The final way is through a feed from one’s EMR to the payer; this is an efficient method, but it is not always available.
Practices that are part of an IPA or ACO are more likely to have this available as it is may be a part of any extensive risk-based payer contract.
Within the practice, however, the first step that must occur is to have an agreed upon method for charting data related to measures. If your EMR has a HEDIS module, their guidance is likely best to be used because they can calculate quality measure numerators and denominators and probably provide additional reporting tools.
If there isn’t a HEDIS module, one is fortunate because a lot of HEDIS measures are fairly straightforward. For example, A1C screenings for diabetics, BMI screenings, and blood pressure screenings are simple enough; however, there are more challenges for measures such as retinal eye exams for diabetics and depression screenings.
If you don’t have an EMR with a PHQ2/9 form and scoring tool, you can convert a paper version of the form – at least the final score – into some sort of electronic notation in the chart and with the retinal eye exam. You must convert the findings (date of the exam and positive/negative for retinopathy) from the referral note.
Often there are structured data fields that can be created or templates that can be used for such information. What is important to be mindful of is if your EMR has a generic reporting/registry tool, the recording of such measurement information should be done in a way that can be reported by with such tools (examples include eClinicalWorks’s registry and EBO reporting tools).
Once your practice has determined a documentation strategy, the processes must be put in place.
For example, during chart prep, staff ought to check to see what gaps the patient has. That can be done by either referencing an internal EMR registry or – if available – looking up the patient on a payer portal.
To make things more efficient, if the provider is needed, such requests should be documented in a standard area that is check during every visit.
Also, at regular intervals staff should pull lists of patients in need of gap closure (e.g., patients that need colorectal cancer screenings) and contact them via a messaging service built into the EMR, the patient portal, phone calls, or all three in order to be sure that needed services are performed.
Practices may decide to concentrate on one or two measure per month for example. What is important is to have a methodical, regular, and consistent process that ensures that patients are tracked for compliance with HEDIS measures and contacted appropriately.
Patients that persistently have large numbers of care gaps may be candidates for care management; sometimes care managers are more successful than other staff members at bringing a particular patient into optimal compliance.
It is important to remember that recording data in one’s EMR is not the goal; it is only a tool. The data must be tracked and sent somehow to the payer at regular intervals to optimize incentives and to allow a provider to demonstrate their effectiveness as a healthcare provider.
Practice managers should look first to send the data through claims, then through an EMR interface if possible, and – finally – by entering the data into a payer portal.