1. I just read an article on your Web site that explained tips for purchasing a chiro billing program. Do you have any recommendations on which companies have a good billing program, or can you refer me to someone who might know? I'm really having a hard time picking out a program. -- Christina Palermo.

    • import_expert_question such as yours often result in a variety of opinions. Each opinion will likely be based on the limited experience of the individual who provides it. The result is often sensory overload. Here are some things to consider as you evaluate companies & products:

      You may think you know what features you want, but has it occurred to you that that’s simply based on your prior experience? Some products may have unique features that can boost your efficiency and help you trim overhead. However, they won’t be on your radar because you didn’t know they exist or don’t realize their potential. Take advantage of live demos (in-office or via the internet) whenever possible. Look at features carefully and ask what they can do for your practice. Obviously, you’ll have to separate wishful thinking on the part of sales personnel from features that may provide huge benefits.

      Most programs implement common features in very different ways. Flow and implementation are important. You shouldn’t need to jump through hoops to accomplish basic tasks that are utilized daily, such as entering charges or creating bills. Different parts of the program should work together seamlessly. For example, scheduling software should be aware that a service was added so it can act accordingly (e.g.: note that a visit has been completed).

      Ideally, any company whose product interests you will have a long track record with many chiropractic offices. But don’t forget that every successful company started with one or two clients. Perhaps a small startup that you dismiss now will be the name on everyone’s lips 10 years from now. After all, when I first developed ECLIPSE for my wife’s practice (I was a grad student and contract programmer at the time), who knew that 20 years later, thousands of chiropractic offices would rely on it daily?

      Most companies can provide you with glowing testimonials. In the real world, problems occur regularly. Ask a company for the names of clients who had problems of one sort or another and learn how they were resolved. In fact, learn how the company supports the software. Is there a dedicated HELP Department? What are their hours of operation? Do they have an answering machine? Or a sophisticated system that automatically sends calls to the next available technician? What’s their typical call volume? Can the existing staff easily support that call volume? What kind of training is available to HELP Desk personnel, sales representatives, and clients? How do these differences reflect in the price? Is support centralized? Or provided locally? Is your entire call history available to allow any technician to instantly review current or prior issues?

      If the software has a track record, does the company lead or follow trends? How long has it taken in the past for the software to become compatible with requirements such as new forms and government mandates (e.g.: HIPAA)? What types of features have been added to the product over the past 2 (or 5, 10 or 20) years to justify your faith in future upgrades?

      Can the software handle your volume? Not just how many patients you treat weekly, but the growing database that results from years of records? Even small offices accumulate large data volumes as time goes by. Volume can have a dramatic effect on performance. These days, any product should be capable of providing instant access to hundreds of thousands or millions of records, including a patent’s entire appointment and billing history.

      Cost should always be a consideration. However, evaluate both short term (purchase, training) and long term (maintenance, updates) costs. For instance, many providers switch among multiple products during their careers –- a costly endeavor. (Better than 90% of our new clients each month have replaced existing software. We of course pride ourselves on a better than 99.5% retention rate over the past 20 years.)

      Finally, don’t ask companies about competitive products and expect them to provide knowledgeable and/or truthful answers.

      That’s a brief estimate of generic things to consider. Search the Web and look at ads in your professional magazines to find different companies that provide the capabilities you want. By the way, there are no right or wrong answers to the above import_expert_question. But they should help you to form an opinion.

  2. Why not have one package to run your office, bill payment, checks, payroll, and SOAP notes all in one? Word processing also. This would be one learning curve. Then, you would not have to buy quick books, SOAP, and Microsoft Outlook for your calendar. What are your thoughts? -- Joseph Diana, Hazelton, PA.

    • There are applications that purport to do everything you need right now. Such purchases reflect a personal choice. However, there are considerations that should be taken into account by examining those choices closely. The phrase "Jack of all trades, Master of none" may be applicable here.

      I've been using Quicken (not Quick Books) since about 1990 and consider it indispensable. I don't feel that reproducing those features in ECLIPSE is the most productive use of our time when a program like Quicken is available so inexpensively.

      The billing, appointment, and EHR features in ECLIPSE are tightly integrated. For example, at a bare minimum, ECLIPSE will inform front desk personnel that Jane Doe is late for her appointment; mark the appointment as completed automatically when services are added; and print the SOAP notes along with a CMS 1500 form if a bill is created. Thus, these features -- though independent of one another -- benefit from tight integration "under one roof."

      Of course, the features of a business program such as Quick Books certainly have potential for integration as well. You may want to use collections information from your billing program in your general ledger (e.g. Quick Books) -- but that's generally of less value to your accountant than your actual deposits (and little different from supplying statistics reports).

      But "integration" can take different forms. In fact, that's one of the reasons ECLIPSE has a fully open, well-documented, ODBC-compliant database. Offices across the country have had custom reports and interfaces created by independent programmers to handle special circumstances.

      Last but not least, Microsoft encourages Windows application developers to maintain a common user interface. These days, products such as word processors use the same or similar command structures. Thus, if you know how to use Microsoft Word, you can begin using the built-in ECLIPSE word processor immediately to change fonts, colors, and handle spell checking. Therefore, the "learning curve" you refer to may not be as much of an issue as you think.

      In general, independent products may be (it's not guaranteed) more specialized and offer a wider range of features. You may write your first novel with Word, but who would expect (or want) to do that with their chiropractic office management software? And imagine what that might do to the average user's learning curve!

      To sum up, there are advantages (potentially tight feature interaction) & disadvantages (some features are much less robust than others) to fully integrated products. And historically, most products add more features as time goes on. You need to examine each product on its merits. For instance, you might like product A's billing section & product B's SOAP notes.

  3. Looking into the future, will it become increasingly common to see Internet-based office management billing software? What concerns would you voice regarding things to look out for or warnings with this developing scenario? -- Craig Nelson, Omaha, Neb.

    • I can only assume that you’re referring to a situation where your patient data is off-site (hosted) and your access is via thin client PCs from your office? In the mid to late 90’s – when it was predicted that all of us would be renting software this way rather than purchasing licensed copies to put on our own computers – a variety of startups relied on this business model (hosting everyone else’s software). Later, during the “DotCom” bust, these companies virtually disappeared along with the business model. Of course, like everything else, this approach has pluses & minuses. It simply provides another choice to consumers. Will it become more likely for you to see it? Sure. As technology improves, such approaches become more viable. However, let’s look at the advantages & disadvantages of this approach.

      First, let’s discuss what’s great about hosting. Ideally, you don’t have to worry about backups or upgrading the server where your data resides. If the company that created your software is hosting your data, they will automatically handle updates and should respond instantly to data corruption. Also, you ultimately may be able to spend less on computers. Certainly, startup costs may be much lower. Sounds pretty good thus far? Well, the world rarely seems to work as envisioned by Voltaire’s Candide. So let’s visit some of the more likely issues that you’re bound to experience sooner or later.

      Performance. Even a fiber optic connection to the Internet won’t buy you performance as good as you can get with a $100 gigabit router on your own (local) small network. Also, if the company hosting your data is either growing too fast, or not fast enough, you may suffer the consequences of too many users (from other offices just like yours) accessing data on the same servers, or equipment that simply can’t keep up with volume. Since the host server isn’t dedicated to you alone, any performance benefits over a local network are generally lost. Cost. When you’re paying “by the month” forever, you will eventually pay a huge premium compared with having all the hardware at your location. Monthly costs include your connection (usually via the Internet), hosting costs (your data is on someone else’s computers), and potentially enforced software contracts. From a business perspective, this is the best possible scenario for the vendor you chose. They get perpetual income as long as you’re in business!

      Connectivity. In your office, when the power goes out, it’s likely you can’t use your computers. When your data is hosted by a third party, you must also worry about their power and the integrity of your connection. Depending on where your office is located, this can be a serious problem. Control. Suppose you want a contract programmer to create a custom interface or report of some sort? She may not be able to get access to your data! And a HIPAA contract with the vendor is essential in the event your data is compromised. Suppose the vendor raises the monthly fee? Think how this may affect you over the life of your practice. Suppose you discover some cool new feature in another product and want to purchase it. Is the data yours? Will the vendor make your data available along with the necessary documentation to convert it? Suppose you want to continue the hosting but discontinue your ongoing support contract? What if the business is sold? Or goes bankrupt?

      My wife started her practice in 1982 – renting office space. As soon as her cash flow allowed it, she purchased a nearby building. Over the life of her practice, this has saved a minimum of tens (if not hundreds) of thousands of dollars. Rent only goes up. It may be a write-off, but it still comes out of your cash flow. If you’re concerned about how rapidly technology makes your equipment obsolete – consider leasing. But some hosting situations leave you permanently indebted to a new landlord – the software landlord. If you’re comfortable with that, go for it.

  4. How do you see the movement toward requiring health care professionals to utilize electronic medical records affecting chiropractic practices, and in particular, single practitioners? Is an electronic medical records system an affordable option for solo practice chiropractors? -- Gerald Anzalone, Peekskill, NY

    • First, if EMR requirements are standardized by government agencies, the standards will be the same for single practitioners as they are for those in group practices. As to affordable, all I can do is point out that the extensive documentation capabilities in ECLIPSE are included at no additional charge across all versions of the program.

      Now, will future EMR requirements force you to go electronic when dealing with third-party payers? If you look at billing as an example, the answer is, “unlikely.” In fact, the ANSI 837 electronic billing standard doesn’t include specs for electronic documentation. On the other hand, there are groups working on such specs. Bottom line: in the near term, I don’t see an EMR documentation standard that could be forced on you the way CPT & ICD codes have been. As for the long term… ask me again in five to ten years…

  5. Which EMR would be good for physical therapists without considering the attached billing program? We like something that is simple, prints brief reports that can be edited after formatting, and allows fax/email of reports rather than printing. -- Mary Engles, San Diego, Calif

    • As always, it’s beyond the intended scope of this Q/A series for me to recommend specific products. I suggest you carefully review available products, don’t fall for slick websites and advertising, and find similar offices that have been using the product for at least 6 months to a year under similar conditions. If you have an opportunity, see it in action, do so. A physician I know received a rave review from a doctor in his specialty and went to the office to observe the EMR system. The doctor there was taking an additional 20 minutes to enter each encounter into his EMR. My friend left. He still hasn’t purchased an EMR.

  6. I am comfortable with my current billing system but want to decrease the time writing daily progress notes. Where are—as it relates to utilizing voice recognition—devices that can send the information to a computer and thereby print the progess report into the patient's chart? -- Jack Close, Las Vegas, Nev.

    • Dragon Naturally Speaking (http://www.nuance.com/naturallyspeaking/) can be installed on almost any system to dictate notes in place of typing them into an editor.

  7. I need a recommendation for backup software that will back up my entire system and is easy to use.

    • Walter-I’m not familiar with each & every product on the market. We use EMC Retrospect for network backups. A variety of online sources are also available – though you’d need to ensure they can guarantee that HIPAA won’t be violated. The most important aspect of the backup process is a regular backup regimen and verification that the backups are viable. You should maintain separate daily backup copies & rotate them weekly. At least one of the backups should be kept at a second location. In the event of a hard disk failure, multiple copies are available. Thus, if the most recently used backup proves defective (remember Murphy’s Law), you can resort to a copy from earlier in the week. Since backup media such as tapes are subject to wear and tear, they should be replaced at least once each year. In addition to the weekly backups, one or two separate backups should be rotated at the beginning of each month. The monthly backups should be maintained separately. They provide an added safety net in the event that a potentially disastrous problem does not show up immediately.

  8. I work for a hospital system with four off site PT facilities. We are confused about the exact definition of "Meaningful use"? We are trying to implement an out patient PT EMR/scheduling package that will integrate with our hospital wide system via an HL7 interface. Our problem is that our rehab volume is quite high and most hospital based systems are not as out patient focused as other programs that were developed for multiple site out patient focused rehab. Out OT department is really hung up on the meaningful use definition but I have been unable to verify if the term applies to PT?? Any information would be geatly appreciated.

    thank you

    • Mark-First, I’m going to refer you to two URL’s. Then, I’ll briefly discuss your question. An overview from the New England Journal of Medicine exists at http://content.nejm.org/cgi/content/full/NEJMp1006114 . More to the point, the 864 page “Final Rule” document with regard to “meaningful use” can be reviewed at http://www.ofr.gov/OFRUpload/OFRData/2010-17207_PI.pdf . In your case, since you’re hospital based (outpatient facility not withstanding), I expect that once the hospital receives certification, it will automatically cover your facility (and all providers within the facility) – especially given the HL7 interface to the main hospital system. You can actually search the document for keywords such as “outpatient” to review the comments and clarifications. Also, if you review the “Comment” section on page 289, you’ll note specific clinical decision support comments with respect to PT’s. Finally, keep in mind that, as of this date, organizations to perform certification of Eligible Providers and hospitals haven’t been approved. These organizations must interpret the Final Rule and create certification standards. As an example, consider Medicare. Medicare should be uniform in all 50 states. Yet, the reality is that various regional Medicare carriers interpret the rules differently. Thus, my interpretation of the Final Rule may be different than that of an accrediting body that implements standards in the next few months. Regardless, I expect your offsite facilities to be covered within the hospital’s certification unless they’re separate business organizations that can’t demonstrate a relationship with the hospital.

  9. Thank you for the information, I will review it. My main issue is with the current system that has been implemented; it is not out-patient focused and offers us no real help with EMR/scheduling. I am looking into different vendors, some with an HL7 interface and some without. The meaningful use term is being proposed by the IT department as a deal breaker and that any other EMR system that wont communicate via an HL7 or be in the current system is outside the definition? Is there a resource that would help me understand what I have to do to meet that standard if I need to bring on an additional package that is out patient focused?

    • Mark-Odds are better that software with an HL7 interface will be more likely to meet the later Stage II & III standards. However, HL7 is a broad standard. The fact that a particular vendor implements an HL7 interface does not guarantee that the specific information you want to move back & forth (e.g. appointment information) can be handled “out of the box.” And the fact that a second vendor previously ignored the HL7 standard doesn’t mean it’s beyond their capabilities to add this functionality. There are also other factors to consider. You need to weigh the expense of the system you intend to implement against the payback you expect to get based on your Medicare/Medicaid patient load. Any purchase you make will have ongoing, annual expenses associated with it. Other questions then arise, such as “Are we paying a premium to achieve meaningful use?”

  10. I work for a not-for-profit company that owns EMR software with a rehab module that we do not use as it is terrible "as is". I located a facility that uses the same software, however they have massive amounts of customization. They are a large chain and have significant IT Dept. availability - I do not. I am wondering if it is standard with every MFR update to need to customize the software all over again. The MFR has terrible customer service and have not been helpful in determining this for me.

    • Caveat emptor, or “let the buyer beware” has been the rule of thumb for as long as people have been doing business with one another. It’s unfortunate that you’ve had such a bad experience. However, you can use that experience to become a better informed consumer should you choose to make another purchase. In my opinion, the software should be terrific “out of the box.” The ability to provide customization should be an added bonus – so the software doesn’t end up cluttered with “features” relevant to each of thousands of offices. In general, software vendors should handle the macrocosm while allowing independent programmers to handle the microcosm. Examples might include a specific type of report or billing statement. It’s unfortunate you can’t customize the EMR templates (I’m making an assumption that such templates exist) on your own. Regardless, there is no standard practice on the part of vendors with regard to healthcare software. Better software comes along and other vendors either keep up or eventually become extinct.


  11. What are the features I should look for when shopping for an electronic documentation system for PT?

    • Flexibility, customization options, and the potential to get data into the system fast enough to avoid issues handling your current patient flow. Talk to other providers who are using it. Ask how long it takes to complete documentation and whether they were forced to sacrifice anything to go from paper to electronic documentation. Ideally, you should also have the choice of using a variety of data entry methods: standard mouse and keyboard, tablet, touch screen. (Each has advantages & disadvantages. You must determine what works best for you.)