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Part II: Missing the Performance Improvement Boat

Here is the second installment of WRS Health’s 10-part series dedicated to Dr. Lawrence Gordon’s recent white paper, “10 Implementation Mistakes to Avoid: Why Practices Fail.” Each segment of the series examines one of the 10 most common implementation mistakes by medical practices when implementing electronic health record (EHR) systems.


Practices that miss taking advantage of the myriad of opportunities for performance improvement are doomed to failure. Plan and seize every opportunity for performance improvement. Dr. Chin’s experience reveals the enormous opportunities for performance improvement that allows easy embedding of content in a myriad number of ways throughout the Electronic Health Record.

“With an EHR, the opportunity exists to use an order requisition as a way to communicate not only from the clinician to the ancillary department but also as a way for the organization to communicate to the clinician at the time of ordering. By embedding guiding information in an order requisition, guidance can be provided to the clinician seamlessly during the ordering process,” said Dr. Chin.

Another simple but effective way to embed useful content is to automatically print patient information related to an order on the after-visit summary that is given to the patient at the end of the visit, according to Dr. Chin.

Medical practices that have experienced successful EHR implementations report that they painstakingly placed opportunities for performance improvement on the practice’s radar.

When William R. Blythe, M.D. of East Alabama Ear, Nose & Throat, P.C. took the leadership reins in the Cloud EHR search for his three physician practice he had several goals he wanted to meet for performance improvement over the practice’s original software system.

Reflecting on the inadequacies of the practice’s first EHR system, Dr. Blythe said, “Like most practices, we had a Unix-based system with a dedicated server and work stations. We basically used it for scheduling patients and Revenue Cycle Management. By 2001, we had outgrown our second UNIX system and were looking to replace it with new hardware and software. Our choice was whether to purchase a new system with the “old” server and software setup, or to look for an Internet based Application Service Provider (ASP). ASPs, currently referred to as SaaS were just making significant headway into the practice management and medical software market, and I began looking into them earnestly. An Internet based platform seemed to be the permanent solution that we had been looking for over the past seven years.”

Revenue Cycle Management is a sizeable opportunity for performance improvement, and Dr. Blythe knew that he wanted to seize this advantage with his new Cloud-based EHR. “I was very honest about Revenue Cycle Management. I talked to everybody about every aspect of claims entry and clearinghouse. We have a group that manages our practice. They oversee our financials and run a monthly report and tell us how we are doing. When we were looking at making this final change we really didn’t have anywhere to go but down as far as money because we were so very efficient. Our accounts receivable was 28 days. We were collecting 98% of expected collections after contractual write offs. When we started talking to each individual EHR company, I said, ‘The bar has been set high. We are going to change, but if our numbers go down and we become less efficient financially, we’re going right back,’” said Dr. Blythe.

Emphasizing that he was attracted to the claim submission for HCFA 1500 (which is currently CMS 1500) data entry, Dr. Blythe said, “Many practice management software firms and companies build an interface so you enter data on their website, which populates that information to a HCFA 1500. Instead, the system we choose allows you to enter the information on the HCFA 1500. For years we filled out the HCFA 1500. Now we are more efficient. You can just pull up the form if you want to look at a claim or any submission. It’s great that you no longer have to do this through a company’s interface or via an individual’s interpretation.”

Before he leaves the operating room, the bill for Dr. Blythe’s procedure is at the clearinghouse that is integrated with his EHR. “I do all of my own billing. When I do a surgery, for example, a tonsillectomy, before I ever leave the OR, I create a surgery note and enter the patient’s charges into the system. My protocol is: I do the surgery, I dictate, I write orders, I enter the patient’s data, I create a surgery note in my system and I talk to the family. I can do a lot of that all at one time and it takes me one minute. Before I leave the OR the bill for the procedure is already at the clearinghouse. It’s ready to go. It’s fast. Before a patient reaches our front desk office, visit claims are already at the insurer. We got really efficient at that. Most patients’ claims are in real time as opposed to the old days where we created a super bill and a front desk person would enter those claims and then we would review them at night, batch them and they’d go out the next day and surgery charges would go out a week later after we had a chance to code them. Now it’s all instantaneous,” said Dr. Blythe.

E-prescribing with a cloud-based platform is yet another great opportunity for performance improvement. Dr. Blythe states, “Connecting with patients via the patient portal is the future of healthcare. When patients come to the office, the front office staff makes sure they have the patients’ proper email address. If patients went online prior to the appointment to update their medical information, they are seen immediately. We reward them. The reward is their time. If a patient calls in and says, ‘I have a bad sinus infection,’ and we’re booked out weeks in advance, they can email me to tell me what’s wrong and I’ll double book and see them. People are grateful that a doctor emails them personally. We try not to punish those who don’t email because a lot of underprivileged people in Alabama don’t have a computer. We’re trying to build the future. I explain that the other patient gave information online. It just requires a lot of work for us to enter the information. We don’t mind doing it, but you have to wait if we enter the information for you.”

Moosa Jaffari, M.D., owner of his eponymous Lakewood, NJ-based ENT practice has experienced firsthand the frustration of a failed EHR implementation. “It became clear that the Electronic Health Record was very cumbersome and it was affecting our productivity. We really didn’t use it for too long. While in the implementation stage, we found that it is not suitable for my type of practice.”

With his second cloud-based EHR, Dr. Jaffari took advantage of numerous opportunities for performance improvement. One of these opportunities was using the EHR’s patient portal to provide educational material for the common problems he sees in his practice, such as sinus problems, dizziness and hearing loss. “We can put all of this patient information on the portal and they can access it and they will be more educated about their condition and be more satisfied with their care,” said Dr. Jaffari.