Doctors Lounge

What the heck is ‘PVRP’?? And why the heck should I care???

sanvas — Tue, 12 Dec 2006 19:49:00 GMT

PVRP is the newly minted acronym for Physician Voluntary Reporting Program. At some point in the future, we are going to be looking at PCRP (Physician Compulsory Reporting Program). That is the ground reality, we better get used to it. This is the program that has been recently approved by the congress and senate and should be law any minute. This little item was buried in the massive bill they just passed prior to the republicans handing over control of the house and senate to the democrats. It looks like no one seems to be paying attention to this from the dearth of interest to another post on this subject, so I figured I would stir the pot a little. Admittedly, I am not an expert on this yet, but we are working through the details on this currently.

The details:

The main idea here is that there will be 16 items that CMS will track from data submitted by the participating doctors. The specific areas of interest are listed below.

Acute MI -Aspirin Therapy

Acute MI - Beta Blocker

HgA1C - Diabetes Type 1 or 2

LDL - Diabetes Type 1 or 2

High BP - Diabetes Type 1 or 2

ACE Inhibitor/ARB for LVSD

Beta Blocker for Prior MI

Assessment of Elderly Pts for Fall

Dialysis Dose in End Stage Renal Disease Pt.

Hematocrit Level in End Stage Renal Disease Pt.

Receipt of autogenous AV Fistula in end stage renal disease pt requiring hemodialysis

Antidepressant medication during acute phase for pt diagnosed with new episode of major depression

Antibiotic prophylaxis in surgical patients.

Use of Internal Mammary artery in Coronary Artery Bypass graft surgery

Pre-operative beta-blocker for patient with isolated coronary artery bypass graft

Thromboembolism prophylaxis in surgical patient

This data will be extracted from claims data and the performance will be monitored. In return for the participation, the physician will be paid a 1.5% bonus on Medicare.

Now, it is not simple for people to follow the ‘guidelines’. Essentially the logic goes that if you are reporting a particular Diagnosis (ICD9 code), then you would have certain associated CPT or HCPCS codes to meet treatment guidelines, or other CPT or HCPCS codes (with modifiers) explaining that the patient does not qualify for the treatment and why they don’t. There is no realistic way for doctors to remember or use many of these combinations without the help of ‘technology’.

CMS’s position on this is that since this reporting is based on claims data alone, you could get by without an EMR. But once docs start getting report cards based on this, why would you want to score low? And what really is interesting to me, is why docs (at least the ones with EMR’s already) are not falling all over themselves to sign up?

Currently we have been analyzing the requirements and have started work on a rules engine to guide doctors as I am sure other EMR vendors are. I would suspect that if nothing else, this would help pay for more than the cost of the EMR in a reasonably busy practice. I would suspect that this would be a very well received (and financially useful) feature. But I have been known to be wrong before.

Under utilizing your EMR?

sanvas — Tue, 10 Oct 2006 11:53:00 GMT

Sure things are going smoothly. You did your EMR implementation, went through the learning curve and now everyone in your office has settled into a routine. Most things work well, and some things on the EMR you wish you knew how to do, but who’s got the time to learn it? After all, why not leave well enough alone?

A surprisingly high percentage of EMR users are found to be under utilizing their EMR. By itself, it does not sound bad. But when you take into consideration the cost in terms of time loss, efficiency loss etc, it adds up to a nice chunk. Software packages evolve over time. Generally, new and improved features are introduced to make your life easier. It is to your benefit to take advantage of these. If you don’t, you are only short changing yourself.

So this is where retraining comes in. Call up your vendor and ask them to do another ‘demo’. Usually the sales folks will make sure that the best features are highlighted in their demo, so this will give you a great overview of the current functionality of the software. Once you do this, then you can talk about retraining. Most companies should do this for free or a minimal charge, but even if there is a charge involved, it is probably well worth it. In fact, including some training time each year may be a feature you could ask for in the software contract.

So stop for a minute and take a look at your EMR again. The short time you spend retraining could end up saving you a significant amount of time.

Naveen V.

DoctorsPartner EMR and PM

www.emr-electronicmedicalrecords.com

How NOT to get financially suckered

sanvas — Sat, 09 Sep 2006 11:53:00 GMT

It is true. You are a doctor. You have spent far more time learning far more important (and life saving) things than how to work on your office revenues. But even the greatest minds in the world need to be bankrolled, and even the most brilliant physician will be out of business in short order, if they don’t pay attention to their office finances.

Having worked with doctors for a while now, it never ceases to amaze me how many of them believe in the purity of human nature. Too many times, this very admirable trait gets taken advantage of much to their own detriment. In a small way, following some of the steps outlined below, will help at least hold the fort down in your office, which is the single largest source of your income.

Where does your revenue come from?

The first step in financially tracking your office and your career is to identify where you make your money. Obviously you make your money seeing patients.

But where do you see your patients? You could see 100% of your patients in your office, or you might have a good percentage of your patients in the Hospital or Nursing Home or Assisted Living Facility etc. It is always good to know where your money comes from, and what percentage of your billing for each source is getting paid.

Why is this important? You only have so many hours in a day. If you find that you are getting only a small percentage of your income from a Nursing Home that is a 45-minute drive away, you will definitely be better off trying to improve your presence somewhere else with better returns than wasting your time on this source. There is also the question of revenue analysis, such as are the CPT (E&M) codes I am charging getting paid? Am I overusing or under using a code? Etc. that is critical for you to address. More on this in a separate article, but this is something to keep in mind.

Who is responsible for the revenue cycle?

Simple answer – You (the doctor) are. It does not matter if you have a biller par excellence or an office manager extraordinaire. You are responsible for the revenue cycle.

What do I mean by the revenue cycle? The processes of generating a bill, submission to the clearinghouse/insurance carrier, follow up on open bills (collection calls), receiving and posting payments and the patient billing cycle is the overall revenue cycle.

Does this mean you should do all the work yourself? Not at all. The idea here is that on any given day, you better have a darn good idea of your outstanding receivables (in the 30, 60, 90+ buckets) and your average cash flow (how much you collect versus how much you spend per month). Your employees will do the work, but you will have to carefully review the data and supervise the work.

How do you do that? Not that difficult really. Any good billing software package (PM) should have reports at least on the following:

Aging (Receivables – how much money is owed to you and how much is current – less than 30 days old, and how much is overdue – more than 30 days old)

Collections (how much money did you collect in a given timeframe)

Write offs (how much was written off)

The aging report allows you to figure out if you are doing a good job as far as how much work is being billed out. If you are not generating enough revenue to keep your practice going, your aging will look ‘slim’. There are further trends you should also keep an eye on in aging. If you notice that your more than 60 and more than 90 days buckets are growing, it is a clear indication that there is a collection problem. You will need to then do further analysis by looking at the aging for each insurance company to see if one of them is not paying well or perhaps your collections person is not making the calls. If you happen to notice that your current billing is a little lower than normal, that could be indicative that bills are not getting sent out on time.

The Collections report shows you how much you are collecting. If you notice that collections are below average, that is something you should investigate immediately. If you notice that there is a change in the form of collections (a sudden spike in Credit Card collections with a drop in cash collections), that is also something that should draw your attention. A subset of the collection report is the Day Sheet that concentrates on collections per day. This is critical to look at every day. In fact, we advise all clients to print out and retain copies of the day sheet. If there is any suspected fraudulent activity, looking at these day sheets will very quickly highlight it for you.

Write offs. Let’s face it - there will be a ton of write offs for different reasons. Typically doctors may charge a standard amount for a service knowing full well that each insurance carrier will pay a different lesser amount than charged. So there will be write offs. However, it is critical to track unusual activity here to make sure that there is no untoward event such as ‘lazy’ write offs (I am just going to write this off instead of making a couple of calls to collect on this) or true fraud.

When the heck do I do all this? I barely have time to practice!

Think of it this way – if you are able to run an efficient and careful operation, you can make as much money as you are making, with a lot less work! If you are able to collect anything over 77% of your expected collections (insurance and patients), you are above industry average. If you can get it to anything in the 80s, you will see a significant boost in your income. You should make it a point to go through this review of reports and processes at least once every 2 weeks.

Will this cure all the financial ills in your office? Probably not, but at the very least, these steps will help you spot any problems at least in the long run. The first step you should take is to call up your software vendor to discuss the financial management reports I have listed above and ask them for suggestions on the specific reports to look at. This may be the best time you ever spend for your practice! There are more ways to lose money than to make money in this business, so be aware to your own benefit.

Naveen V.

http://www.emr-electronicmedicalrecords.com/

DoctorsPartner EMR and PM

Handling incoming Faxes in your EMR

sanvas — Sun, 06 Aug 2006 21:16:00 GMT

More often than not, greater than 50% of the paper floating around in your medical office came in via the fax machine. That innocuous machine sitting is the corner is a notorious killer of trees! You have lab results, consult notes, referral letters, refill request and a plethora of other medical documents pouring into your office over thin copper wires!

Let’s take an incoming lab for example, in a typical paper office with no EMR. The fax machine spits out the coversheet and lab result. Your nurse (or designated person), collates the faxes, hunts down and pulls the patient chart, attaches the fax to the front of the chart, drops it off on your desk (possibly with a post it note on top of the fax with any notes). You read the fax and assuming everything is normal, sign off on the result, put another post it note (or another type of note) on the chart and hand it back to your nurse/MA/assistant to call the patient and let them know all is well. Beautifully choreographed like ballet, except not quite as graceful! Now if the lab results are not normal, you just added another layer of complexity to this dance.

Now let’s take the example of an office with an EMR. I will make the assumption here that most EMR’s today have a document management module built in, as that is usually the case. Most EMR’s today also have some capability for fax management, whether it is built in or using a third party tool. Either way, the faxes are now coming in as digital images to your fax server, no longer denuding the rainforests in Brazil. You do not have to automatically print out every fax. You could now load the incoming fax directly to the patient’s electronic chart (no more hunting for the chart). Via a built in notification function, the doctor is notified of the lab received and can now view and sign off on it electronically. If the patient needs to be called, the doctor fires off an internal message or internal email notification to the nurse to do the same.

There are many advantages to this change in your workflow:

Save trees (I am a certified tree hugger, so this comes first J)
Save money on paper
Speed – from fax receipt to notification, the work process is measured in seconds, not minutes. The subsequent follow up actions are also greatly streamlined.
Improved patient safety – no more misplaced faxes.
Improved tracking functions – audit trails as to who did what, when etc.

Surprisingly, many offices, even those with EMRs already, are not taking advantage of this ability. It is in your best interest (especially in the best interests of your pocket book) to make sure that you do consider this method as a ‘must do’ step. If you already don’t have an EMR, then this is a perfect example of the workflow benefit you could be getting once you do make that jump!

Naveen V.

http://www.emr-electronicmedicalrecords.com/

DoctorsPartner EMR and PM

Starting a New Practice – The EMR Perspective

sanvas — Sun, 30 Jul 2006 04:57:00 GMT

Starting a new practice is not an insignificant task. Is that the best time to really look at an EMR? Many of the new docs have voted yes by going the EMR route. The logic here is why not start now and avoid a whole conversion effort later? However, this move needs to be planned carefully as this does add another layer to consider in your newly minted practice. The following are checkpoints taken from our standard implementation plan for you to add to your new practice checklist.

Gather your physician/provider setup information. This typically includes:

License Number(s)
DEA Number
SSN and or/ Employer Id Number (Your federal tax ID)
Office location(s) and addresses
Hospitals, Nursing Homes, ALFs that you may see patients in
Your commonly used ICD codes, CPT codes, HCPCS codes and Medications

Gather your practice setup information. This typically includes

Practice Address
CLIA number
Practice hours

Gather your insurance related information. This typically includes:

Your insurance carriers – names and addresses.
Your practice group number (if applicable) for each carrier
Your PIN number for each carrier
Default charges for each CPT or HCPCS code
Allowed amounts for each CPT or HCPCS code (if you have an integrated package)
If you are planning on filing electronic claims, please be aware that it will take about 4-8 weeks to get approval for electronic claims submissions for Medicare, Medicaid and Blue Cross. Plan for this delay and sign up early.

Training

· Please make sure that you schedule UNINTERRUPTED time for training. This is the single biggest favor you could do for yourself to prevent a lot of headaches later.

· Please make sure that your staff are sufficiently trained in the appropriate areas and please participate in the training to ensure that they understand the software

Other items

Your referral network – who refers to you and who do you refer to?
List of users – who is going to be using the system
List of access rights for users – who is going to be able to do what?
Plan a lighter schedule for the first couple of weeks to ensure a smooth transition.

While this is not an exhaustive list for all EMRs, getting all of this ready prior to starting any EMR software implementation will make things smoother right from the start. In any EMR or Billing software, the more time you spend in carefully planning and setting up the system, the less time you will have to spend on a day to day basis fixing things!

Naveen V.

http://www.emr-electronicmedicalrecords.com/

DoctorsPartner EMR and PM

Ralph Millsaps, MD (cardio1) is one Doctor who did start a new practice from scratch with an EMR solution. You can read his EMR Interview here where he describes how he got started and what challenges he faced.

More on backups - watch for the weak link!

sanvas — Sun, 23 Jul 2006 02:53:00 GMT

As discussed in the primer for database backups, multiple methods exist for backing up your server and database to an off site location to comply with HIPAA requirements. However, in most backup plans there are certain weak links that could wreck the whole process.

In the old days, you had to stop the database to take a backup of the data file. That is typically not necessary these days. There are two ways to backup databases in general.

One is using the database programs own backup utility to create a backup file on a fixed schedule, say at 3:00 AM every day. Then this backup file so created, is then copied or ‘backed up’ to portable media or an offsite location or both. So essentially, you are creating a backup of the backup. This is a tried and true method. As you are using the database program’s own backup utility, it does a very good job of backing up the actual database file, even if it is open and in use (in most cases). However, there is one not so obvious weakness in the process. In many cases, the database’s backup utility relies on an agent to launch the backup process. Sometimes, this agent may fail for whatever reason and may need a server restart. Unless the notification of failure options were set correctly, you would be carrying on none the wiser that no backups were now occurring.

The other method is to use a third party ‘Open File Agent’ to directly create a media or off site backup from the open database file. So you are creating a straight backup, not a backup of a backup. This is relatively new, and more importantly, you are relying on a third party vendor’s tool, not the database vendor’s own tool. The reliability of these methods have improved significantly, but still, failure is not unheard of.

So what is the answer? Realistically, you should make it a point to verify that the backups are working on a periodic basis. It could be as simple as looking at the backup file to see the date on the file as to when it was created or updated. If the date of the last update is earlier than yesterday’s date, it is worth checking to make sure your backup routines are running. Some of the newer backup programs also offer email notifications of success or failure or both. These are also good options if you do have a program that has this.

Naveen V.

www.emr-electronicmedicalrecords.com

DoctorsPartner EMR

A (Necessary) Primer on Server and Database Backups

sanvas — Fri, 21 Jul 2006 03:28:00 GMT

Please note that HIPAA regulations require a backup and recovery plan that includes a daily offsite backup of your data. This requires that at the very least, you should backup your database containing your patient records and store it offsite on a daily basis. In addition, it is usually a good idea to do monthly full backups of your server and store it at an offsite location in case of a disaster. These steps will help to get you up and running quickly in case of a disaster.

In order to comply with HIPAA requirements, my specific recommendations are listed below.

Weekly/Monthly Full Server Backups:

At a minimum, I recommend a full server backup on a monthly basis. Weekly backups are even better, if possible. In the event of a complete server crash, this, in combination with the latest database backup should have you up and running in a very short time.

Daily Database Backups:

There are several options you can follow to meet this requirement. Each of these is listed below with a recommended cycle time.

Daily Tape/CD/DVD Backups

If your server has a built in tape drive, you may want to take this route. In this case, you will have to purchase a minimum of seven tapes, each with the capacity to hold a full daily backup of the database. Each of these tapes will be labeled with a day of the week like ‘Monday’, ‘Tuesday’ etc. Each tape will be inserted into the tape drive on the day labeled. You can set the built in database backup utility of SQL Server to backup to this media every day at a specified time. This media will then need to be swapped out every day and taken off site. This will ensure that you have at least 7 days of backups available of the database.

Pros of this approach:

Once the routine is established, you just have to follow it to ensure that you have the backups done.

Cons of this approach:

This is the slowest method for backups and takes the longest time
Tape media (at least in my experience) is not as reliable as using External Hard Drives or CD or DVD media
This involves the most manual involvement and needs you to swap out and take the media off site every day
As the backup size grows, you could run into space issues on the media, forcing you to switch to higher capacity media such as external hard drives etc.
Tape drives are expensive and add to the initial investment

Daily External Hard Drive/Thumb Drive backups

If your server has available USB slots, you may be able to attach external compact USB hard drives or high capacity thumb drives to use as the backup media. This is easier to use and you can create folders in the drive that each day of the week backs up to. You can do the backups using the built in SQL Server backup utility.

Pros of this approach:

· Easier to setup and use and easier to carry in your pocket

· Once the routine is established, you just need to follow the schedule

· More reliable than tape backups and as reliable as CD or DVD media

Cons of this approach:

You still need to remember to swap out the drives daily
Though the media is more reliable, it is still susceptible to failure
Though your backup may physically be off site, you are opening yourself up to the possibility of misplacing or losing the backup media (a problem with HIPAA Regulations)

Automated Online Backups

This is the third option. Here you install a client software on your machine that automatically launches a backup to a remote server through the web. The backup software should be carefully picked to make sure that it meets the encryption requirements for HIPAA.

Pros of this approach:

The easiest to setup and use – no media to carry, no need to remember to swap anything.
The backup is physically located on a server hundreds of miles away, insulating your data from a regional disaster.
The most reliable of the 3 options as far as media stability goes.
The newest option here is the ‘Open File’ backup that can backup your database file in open mode to an offsite location. This means you don’t have to take a copy of your local backup file offsite, but actually send a backup of the open file offsite, maybe more than once a day. This is currently the last word in backups.

Cons of this approach:

The initial backups will take hours to run. With the right software, the subsequent backups should run in a few minutes a day using 'Bit Patching' or similar technology.
In the event of a disaster, you will need to contact the server and go through a download process that will again take a few hours.

What do I recommend?

It is my experience that you can never have too much redundancy in data backups. I recommend using at least 2 of the above 3 methods, with automated online backups being one of them. This will serve as your ‘safety net’ in case your primary local backup method fails. The loss of even a small amount of data can be a significant blow to a doctors’ office, resulting in weeks of catch up work. It is far better to insure against that by putting in redundancy in your backup plan, than to fret about it after the fact.

Naveen V.

www.emr-electronicmedicalrecords.com

DoctorsPartner EMR and PM

Browsing the Web and Reading E-mail Safely as an Administrator

John Doe — Thu, 20 Jul 2006 10:13:00 GMT

Originally posted by DSeiNeuro

Original Post: here
Source: Microsoft MSDN Site

Michael Howard
Microsoft Security Engineering

November 15, 2004

Summary: Michael Howard discusses how you can run as an administrator and access Internet data safely by dropping unnecessary administrative privileges when using any tool to access the Internet. (10 printed pages)

Download the DropMyRights.msi file.

I've said this many times, but I'll say it again, "Running with an administrative account is dangerous to the health of your computer and your data." So, whenever someone says they must operate their computers as administrators, I always try to persuade them it's not the correct thing to do from a security perspective. That said, every once in a while I meet someone who has a valid reason. For example, I use one of the computers in my office to install the latest daily build of Windows, and I need to be an administrator to install the OS. However, and this is a big point, I do not read e-mail, browse the Web, or access the Internet in any form when running as an administrator on that machine. And I do not do so because the Web is the source of most of the nasty attacks today.

What if someone does want to browse the Web? Or read e-mail? Or do Instant Messaging and so on, and for some reason must run in an administrative context? If you look at the major threats to computers, they are from user interaction with the Web through tools like browsers and e-mail clients. Sure, there are non-user interaction attacks, such as Blaster (http://www.cert.org/advisories/CA-2003-20.html) and Lion (http://www.sans.org/y2k/lion.htm), but that's in part why we turned on the firewall in Windows XP SP2!

Note For Best practices on running as a non-admin, I urge you to look over Aaron Margosis' blog to glean tips on running as a non-admin in Windows.

An Example of Why Running as an Admin Is Bad

Some nasty malware works only because the user browsing the Web is an administrator. A good example is a recent variation of the Bagle/Beagle worm named W32.Beagle.AV@mm. I would recommend you read up on what the worm does once it is invited onto a computer system. Symantec has a good write-up at http://securityresponse.symantec.com/avcenter/venc/data/w32.beagle.av@mm.html. I say invited because the malware is not taking advantage of a coding or design defect. It is using simple human error to execute.

Amongst the many things this malware does, all of which require admin rights, are:

Creating files in the system32 directory.
Terminating various processes.
Disabling the Windows Firewall.
Downloading and writing files to the system32 directory.
Deletes registry values in HKLM.

All these fail if the user running the e-mail client is not an administrator.

So wouldn't it be useful (read: safer) if you could browse the Web, read e-mail, and so on as a non-admin, even though you need to perform your normal daily tasks as an admin? Luckily, Windows XP and Windows Server 2003 and later support this capability using restricted tokens.

Further Detail

Windows XP and Windows Server 2003 and later support functionality called Software Restriction Policy, also known as SAFER, which allows a user or software developer to run code at a lower privilege without having the user enter credential information when the application starts. For example, an administrator could run an application as a normal user by stripping out certain SIDs and privileges from the application's token as the application is launched. Some applications, most notably Internet-facing applications, such as a Web browser, instant messaging, or e-mail client, should never be run under an administrative context.

The DropMyRights Application

DropMyRights is a very simple application to help users who must run as an administrator run applications in a much-safer context—that of a non-administrator. It does this by taking the current user's token, removing various privileges and SIDs from the token, and then using that token to start another process, such as Internet Explorer or Outlook. This tool works just as well with Mozilla's Firefox, Eudora, or Lotus Notes e-mail.