Experts discuss the burgeoning implementation of paperless practices.

Advances in computer technology and software over the last decade have sped up the communication process. Physical therapy practice owners now have an array of options that make it possible to run their business as a “paperless” clinic. A paperless practice not only allows physical therapists (PTs) to access and share information more efficiently, but it can also help PTs focus on providing quality patient care. Taking a practice into the paperless era is easier than you might think.

Here to discuss the feasibility of becoming a paperless practice are: Gerry Stone, PT, MEd, GCS (retired), president, founder, and CEO at The Rehab Documentation Company Inc, Nashville, Tenn; Steve Gottfried, director of sales and marketing at Medical Information Management Systems LLC, Waukesha, Wis; Greg Winterkamp, president and CEO of Addison Health Systems Inc, Addison, Tex; Jim Plymale, CEO of Clinicient Inc, Portland, Ore; Stephen Welty, vice president of sales and marketing at Raintree Systems Inc, Temecula, Calif; Robert Brooker, CEO at PTOS Software Tarzana, Calif; and Steven L. Petrie, CEO of SpectraSoft Inc, Tempe, Ariz.

What are some initial steps PTs can take to implement paperless systems?

Stone: First, the director of the clinic needs to break down the process of establishing a paperless system with regard to hardware and software. They need to decide if they want to go completely paperless, partially paperless, or simply automate their documentation and paperwork flow. Becoming completely paperless will be the most expensive and will require some radical changes in the clinic’s work-flow processes and extra software. Nobody likes change, but the disruption of the change can be minimized by talking with other clinic owners or directors who have gone through the process at their clinic. Established software vendors should be able to provide a reference list of comparable clinics that are completely or partially paperless.

Gottfried: A good place to start is to define the work-flow processes in each department. What is the life cycle of a patient’s entire medical record now? What is the life cycle of a claim? By analyzing the current manual processes, a clinic can gain insightful information into creating paperless steps.

Winterkamp: It is important to first get organized. Do an audit of your infrastructure. Make a list of your staff, their organizational and technological skills, and their roles in getting computerized; the age and level of in-house technology, such as computers, printers, operating systems, network, and backup procedures; your clinical protocols and super bill information; and your practice goals, such as what process you need to get computerized first, and how far you want to computerize your clinic.

Plymale: First, it’s important to understand the reasons you are eliminating paper by asking yourself where paper is inhibiting the growth and profitability of the business. The true goal of a paperless office is to make information more easily accessible so that everyone can do their job as efficiently as possible. Some questions you can ask yourself are: Does the front-desk staff have everything they need to collect copayments and coinsurance? Is there a way to know which patients have been referred but haven’t been scheduled, or which patients have visits remaining but have become inactive? Going 100% paperless is possible, but the cost of removing paper for some simple, but seldom-performed tasks may not be worth the expense and hassle. The real focus should be automating business processes that can improve patient care and the bottom line.

Welty: The first step should be to gather and consolidate the paper forms that are being used by all of the therapists within the practice. It is a good idea for managers to complete an iterative review process with their therapists to examine which paper forms are most effective and develop a best-practice work flow for the documentation process. Completing this internal review process should provide managers with a list of ideal forms and work-flow documents that can be turned over to the new software vendor during the implementation phase.

Petrie: First, make the commitment to take this important step, realizing that electronic scheduling and documentation will be the norm in the future and will provide real benefits today. Second, make a prioritized list of benefits you expect to receive from an electronic scheduling and documentation system. Third, review the systems and companies that offer physical therapy-specific systems.

How should PTs assess individual business aspects of their practices to decide whether to switch to electronic medical records (EMR)?

Stone: Look at the projected bottom line by calculating the savings in time and money by going to an EMR system. There are hidden savings that are harder to calculate, such as the decrease in denials, which translate into less administration time when doing appeals. Other hidden savings are less turnover and burnout of the therapists because of hand-written paperwork, a decrease in the time in takes to be reimbursed (legible reports are processed faster), and a decrease in the possibility of preparing and going through an audit by CMS or the OIG.

Winterkamp: The most important aspect is complete financial, time, and resource commitment. You cannot “plug” in a software. It has to mimic your work flow, and it may take time for it to become your daily process. You cannot get discouraged, and you need to commit yourself to see it through.

Welty: Therapists should examine the time it is taking their staff to prepare the charts, complete the documentation, and file the documentation. In most cases, provider organizations will see that the paper process is taking each full-time therapist a minimum of 4 hours per week to complete. A modern EMR application should reduce the labor time by at least 50%.  

What are some of the fears of moving toward a paperless practice?

Stone: Fear of the unknown, the overwhelming sense that it is way too complicated, and that they will have to become information-technology (IT) experts to make it work. They also feel it might turn into a money pit with no end. They need to know that thousands of their professional peers have made it to the other side and are reaping the enormous benefits of this type of technology.

Winterkamp: PTs fear that the software will not perform the way they presently do business. It is important to get a very customizable system. However, you do not want to be forced to completely put in all your protocols. That would undermine the reason to go paperless. You need to be ready to change and adjust, because your present way of doing business will be changing drastically due to the increasing federal mandates to computerize all of health care over the next 10 years.

Plymale: The biggest fear that PTs have is that they will spend a lot of money and see no improvement in revenue. Many have concerns about hardware and IT support costs—they’re not sure they have what they need to be successful and whether purchases today will be made obsolete by new technologies in a few months. The investment costs (both in terms of software and hardware, and the implementation time spent by staff) can be significant. Here are some important things to keep in mind to ensure a better chance of success: take into account the needs of each department, and don’t take on too much change at once. Taking on too many changes at once has a big impact on staff productivity and morale. When you run into the inevitable problems, make sure to communicate with your staff and your vendor and stay focused on the goals.

Brooker: Moving to a paperless office can radically change how clinicians and office staff go about their workday. If you’re comfortable with what you’re doing and how you’re doing it, it’s easy to ask yourself, “Why change?” There is also the investment of money that some PTs wish to avoid, or at least defer until later.

Welty: The most common fear therapists have when moving forward with an EMR application is that it will dramatically increase the time it takes them to complete their documentation. If an application is formed around an efficient process, it should actually reduce the time it takes for them to complete their documentation. Software should, at a minimum, reduce the duplicate data-entry process by automatically populating the patient’s demographics, treatment plan, and previous daily notes during the course of treatment.

What are the advantages and disadvantages of running a paperless practice?

Stone: At this time, going completely paperless may not be all that advantageous because most doctors are not using electronic signatures, so they will still need paper to sign. The fiscal intermediaries are not set up to accept electronic claim attachments, but that day is drawing near. However, using computerized documentation, scheduling, and billing software to create paper or electronic files is still much more advantageous then hand-writing and transcription.  

Gottfried: An electronic chart allows the practice to route the information where needed. This key advantage translates into more efficient processes, which ultimately benefit the practice from a referral, patient, and financial perspective. The only aspect that may seem disadvantages to the practice is the effort, planning, and patience it takes to get there.  

Winterkamp: There are many advantages such as efficiency, speed of access, and professional-looking reporting, which increases patient referrals. The main disadvantage is overcoming a level of comfort with paper and the need for change. People are resistant to change. However, you will have to change and adjust when you become paperless.

Plymale: One significant advantage is the time saved finding and retrieving patient information. This is especially valuable for businesses that have multiple sites and that need to communicate information to a centralized billing staff. Giving billing staff electronic access to schedules, patient documentation, and up-to-date information from the clinics can save time for both the billing staff and the clinic staff. Other benefits include the elimination of storage space for paper files, the increase of PT productivity by reducing manual data entry, and clearer and more consistent documentation. The disadvantages can be significant if the PT underestimates the impact of implementing a paperless system: A common failure is not allowing adequate training time, which results in frustrated staffs and often abandoned efforts. Many clinics don’t go to the trouble and expense of having redundant hardware systems and the staff to support them. These systems are mission critical. You are only as strong as the weakest link in your technical chain. With improperly implemented technology, you can actually increase your risks. It is important to have a solid strategy for backup of data.

Welty: In addition to the time savings in terms of reducing chart-preparation time and duplicate data entry, another advantage of a paperless system is integrating the charge-entry process based on the services rendered and documented. Outcomes-reporting capabilities are also much easier to generate from a computer-based system.  

Is a paperless practice ideal for all types of PT practices? Please explain.

Stone: It will become ideal for all types of PT practices to be paperless, but PT outpatient clinics will become the first type of setting out of necessity, because of the reimbursement structure and compliance issues.

Winterkamp: Coming from more than 25 years of a computer-software background, I think that PTs who do not computerize their practice will increasingly be at a disadvantage when competing with other health care providers. Insurance companies, attorneys, and hospitals are computerized, and Medicare has and will continue to force the computerization of health care. Thus, all PTs will need to become paperless to compete and be profitable in the future.

Plymale: It’s not ideal for any practice where the therapists won’t use the system, nor is it ideal for anyone who is not ready to step up to some amount of change management. Every PT practice can benefit from technology, though many specific forms may be easy to fill out on paper, or a paper system may be more intuitive to the temporary staffer or occasional user. Overall, most practices benefit from enabling their information to be available to those who need it, and from reducing the redundant work associated with paper-based systems.

Petrie: A single practitioner with a slow practice and lots of unproductive time will not benefit as much from going paperless. If you expect the practice to grow, however, there are significant benefits in starting with the paperless office now because you can grow revenues faster than overhead with a good system.  

Is there one business aspect of running a practice that challenges PTs the most when switching to EMR?

Stone: The three biggest challenges are: setting up the right configuration of hardware, going through the change of many established work-flow processes, and learning the new software. However, this disruption can be minimized by learning from others and knowing it will be well worth the effort.

Gottfried: The number of errors generated from managing with a manual, paper-based filing system would surprise many practices. These errors can translate into denial of claims, noncompliant reporting, and other barriers to success.

Plymale: Automating bad business practices just makes bad business happen faster. When switching to an EMR, PTs often optimize around individual departments or functions rather than taking the opportunity to streamline the entire work flow. As a result, they end up with a system that doesn’t easily give them the business intelligence they need to make their practice run profitably. For example, a patient visit with an expired insurance authorization or prescription is an unpayable visit. The PT shouldn’t have to dig through a number of reports to find this information. In fact, the system should be able to notify you of this problem before you even begin the visit. In summary, look for a system that is “proactive” and can notify you of potential problems before they impact your patient care and your bottom line.

Welty: A common mistake therapy providers make when switching to electronic medical records is not allocating the right internal resources to the decision-making process. When implementing a new application, it is critical that the configuration decisions are made by at least one qualified clinician that has a global perspective on the best practice patient workflow. Delegating this task to an individual who lacks executive-level decision-making power may lead to implementation missteps.

Petrie: Electronic scheduling and documentation should enforce improved work flow in the practice. Changing methods and practices will take some getting used to, but is usually short—a week or two.

Can PTs switch one aspect of their practice to be paperless? If so, what is recommended?

Gottfried: Changing the entire office to become paperless may seem like an overwhelming task. In some cases, it may be wise to consider automating the clinic in phases. Generally the easiest and quickest change is in front-desk processing, from new-patient enrollment to electronic scheduling. Remember, the goal of the true paperless practice is to automate all areas of the clinic, so be sure to keep improving!

Winterkamp: You do not want to force-feed a system into your practice. You start computerizing smaller processes, and over time, have the goal of being paperless. This may take weeks to many months, depending on your size and infrastructure. Most clinics should tackle their subjective office assessment plan notes first and then move to more detailed exams.  

Brooker: Most practices start with paperless (or paper-minimized) billing and then move to scheduling and EMR. The most ambitious practices may decide to do paperless billing, scheduling, and EMR at the same time. The right choice really depends on how comfortable you are making drastic changes in the way you run your office, and your willingness to invest a lot of money up front. Some practices prefer to take things step by step, integrating new paperless modules after things are running smoothly with what they have previously installed.

Welty: A good first step in the process of converting from a paper-based to an electronic-based system is to implement the service/charge ticket in an electronic format. A flexible application will enable provider companies to convert their charge ticket into an electronic form that will mirror the paper version. The application can pull the patient demographics and services rendered into an electronic form that will provide the therapists and other staff with an instant work flow advantage over their paper-based process.  

Petrie: The greatest  benefits will come in adopting both scheduling and documentation systems. Implementing scheduling first, followed shortly by documentation, has been very successful in our experience.

What new software developments can PTs expect in the near future to assist in building a paperless practice? 

Stone: Most PTs have yet to take advantage of software that is on the market today and would rather hand-write and/or spend money on transcription. However, many aspects in the technological components that make up the “paperless practice” are rapidly improving and getting less expensive. Waiting too long to begin the process of moving to the paperless direction, however, will only prolong the agony.

Winterkamp: Better tools that offer integration with other software products. In other words, more “interoperability” so you can utilize a number of software tools that can “talk” to one another.

Plymale: We’re already seeing productivity and communication benefits as the traditional barriers between departments break down and staff can process patients in parallel. In the near future, patients will be able to log in to a secure Web site to fill in their paperwork, request scheduled times, view exercise instructions, get directions to the clinic, print statements, and make payments, and a whole host of other services that would be impossible with traditional software approaches. In the future, we’ll also see better communication between the physical therapy practice and the physicians and payors with information being exchanged electronically. We’re already sending the claims electronically and posting remittance advice electronically. Soon, we’ll see electronic referrals, eligibility verification, and electronic transfer of documentation, to name just a few areas

Welty: The development of document-scanning features will enable therapists to collect and store insurance cards, prescriptions, and other patient-specific documents within their records. Tablet PCs and other new hardware options are making data entry more convenient for the therapists. Wireless Internet advances are also increasing the ability of therapists to complete their documentation online, anywhere, at any time.  

Petrie: Developments will be evolutionary, not revolutionary. Systems will continue to become more comprehensive, reducing the workload for the therapist and increasing the productivity of the practice.