Important Clarification Regarding CCGPP’s : Development of Clinical Guidelines and Algorithms

:dropcap_open:I:dropcap_close:t has come to my attention that yet another small group of individuals in our profession is hard at work spreading misinformation amongst their colleagues, this time in regards to CCGPP’s formulation of acute and chronic care guidelines and treatment algorithms. Since these previously published guidelines were developed for the sole reason of successfully helping the profession and its individual doctors, I would like to explain how these guidelines and subsequent algorithms came about.

Guideline Development:

workinjuryclaimformThe Council on Chiropractic Guidelines and Practice Parameters (CCGPP), was formed in 1995 at the behest of the Congress of Chiropractic State Associations (COCSA) and with assistance from the American Chiropractic Association (ACA), the Association of Chiropractic Colleges (ACC), the Council on Chiropractic Education (CCE), the Federation of Chiropractic Licensing Boards (FCLB), the Foundation for the Advancement of Chiropractic Sciences (FACS), the Foundation for Chiropractic Education and Research (FCER), the International Chiropractors Association (ICA), the National Association of Chiropractic Attorneys (NACA) and the National Institute for Chiropractic Research (NICR).

The CCGPP’s mission is to provide consistent and widely adopted chiropractic practice information, to perpetually distribute and update this data, as is necessary, so that doctors, consumers and others have reliable information on which to base informed health care decisions. CCGPP was also delegated to examine all existing guidelines, parameters, protocols and best practices in the United States and other nations with a chiropractic lens. Participation and process has been as transparent as possible and a major goal is to represent a diverse cross-section of the profession on the projects that CCGPP has been involved in.

While CCGPP initially had no interest in guidelines, a request was made by the state of California (where one out of 6 DCs in the USA reside) to develop an acute care guideline, since existing guidelines, and guidelines being considered by the state’s workers’ compensation system were developed primarily by medical physicians and were overly restrictive towards care rendered by chiropractic physicians. Clearly, there was a need for a guideline developed with a chiropractic lens and honest evaluation of the literature versus biased medical-driven interpretations of the literature. As a result, Delphi panels were formed to develop initial acute care and later chronic care guidelines which included widespread representation from all corners of our profession. It was an inclusive and very transparent process. In the end, our profession did something very historic. We reached over 80% consensus on both guidelines and greatly expanded the recommendations compared to virtually all other guidelines currently in use by most payors in the United States (which were developed with little, if any, chiropractic input and were very medically-biased).

CCGPP’s acute care guideline recommends approximately 25% more care than the widely used ODG (Occupational Disability Guidelines). ODG actually incorporated CCGPP’s acute and chronic care recommendations in the “current research” section of their guideline. CCGPP’s chronic care guideline recommends up to 1-4 visits per month to help “control” those patients suffering chronic pain. Again, this recommendation is far better than any other guideline of which we are aware. CCGPP’s acute and chronic care guidelines provide clear direction on how to document complicating factors, response to care, etc. to help explain why care may extend beyond the initial recommendations proposed. CCGPP spends a great deal of time reminding payors, consultants, and other interested parties on the “proper” use of guidelines and reminds everyone that guidelines are just that, “guidelines”, not cookbooks for care.

The Delphi Process:

The purpose of the Delphi process is to elicit information and judgments from participants to facilitate problem-solving, planning, and decision-making. It does so without physically assembling the participants. Instead, information is exchanged via mail, FAX, or email. It is structured to capitalize on the merits of group problem-solving and minimize the liabilities of group problem-solving. The Delphi technique requires a facilitator/director to organize and conduct the process, manage the information, and ensure that procedures are followed correctly. Dr. Cheryl Hawk served in this position.

:dropcap_open:In analyzing the responses, the median response was calculated for each item.:quoteleft_close:

Representation of all stakeholders is essential, and the group should represent both topic-specific academic/research expertise and a cross-section of the profession. Multidisciplinary input is also sought from our affected stakeholders. CCGPP sought nominations from COCSA and also sent a request to an extensive list of chiropractic organizations, including ACA, ICA and WCA, as well as their business partners and associates, to ensure adequate representation.

In making nominations, the organizations were asked to take the following factors into account in order to form a group that provides clinical expertise and represents the profession accurately and with diversity: geographic location (state/region), urban/suburban/rural location, chiropractic college of graduation, high volume/low volume practice, technique, manual only/manual plus modalities, scope of practice (broad/focused), experience in reading and evaluating the literature (demonstrated by advanced degree, post-grad work, publications, teaching), at least 5 years of experience in full-time clinical practice, currently licensed and practicing in the USA.

Panelists were first provided with background documents, including summaries of current guidelines in common use and recent relevant articles from the scientific literature. Three Delphi rounds were conducted, with the seed document revised as per the panelists’ responses between each round.

In analyzing the responses, the median response was calculated for each item. Medians, unlike means, take extreme responses into consideration and so will better ensure that each participant’s response will have an impact on the total. Agreement was present only with 80%+ consensus.

Algorithm Development:

checkupDespite how well-written the acute and chronic care guidelines are, we realize that a great many doctors simply have not taken the time to read them and, consequently, we are currently embarked on an initiative to simplify the contents for the average field doctor via the creation of visual “algorithms”. Unfortunately, an individual inappropriately released the DRAFTS of these documents, without any accurate explanation as to the clear benefits, intent, or use of the algorithms and has inappropriately been discussing and voicing concerns regarding these. Please be aware that the algorithms being developed contain NO NEW information, but are merely visual treatment algorithms based entirely on papers that were already published. Our goal is simply to help doctors in their cognitive flow regarding clinical decision making and treatment of patients in their offices for acute conditions and for chronic conditions. We are NOT setting standards for the profession. Anyone who read the acute and chronic care guidelines already realizes the difference between benchmarks for care, proper use of guidelines and standards.

The individuals who are spreading misinformation are claiming that these algorithms were never reviewed by the profession, even though one of their own board members was on both Delphi Panels and thus part of the process of developing the guidelines. They confusingly also claim that the algorithms are restrictive, should not contain numbers, and should not have been disseminated, despite the fact that they were already published in a peer-reviewed journal after an extensive and transparent Delphi process. Doctors across the profession recommend treatment plans to their patients that are based on numbers of visits per week, followed by re-evaluations. Many insurance companies and managed care companies use their own visit frequency and duration guidelines that are often very restrictive, because they do not use quality literature or use very biased medical interpretations of the literature. Often guidelines are based on uncomplicated case, versus the reality of what we deal with in our offices every day.

The bottom line is that, either our profession develops guidelines for ourselves or others outside the profession, who have no interest in the care of patients, will develop or have already developed them for us. The recommendations in our documents merely provide benchmarks for care in order measure the response to treatment, but are not prescriptive and do NOT represent limits for care. They take into consideration complicated and chronic cases and even cases that will never fully resolve. It is important to understand that these algorithms are for spine-related pain conditions only. They are not designed for other clinical objectives such as subluxation-focused care, postural care, wellness care, etc. and the introductory paper makes this clear.

randdPlease keep in mind that the original published guidelines and the subsequent pictorial description of the guidelines in algorithm form are based on the current level of scientific evidence. That is not to say that other forms of care may not work. CCGPP is only reporting on what we know, based on the highest level of scientific evidence to date. As more clinical research becomes available, CCGPP will update the guidelines and algorithms to support the most current knowledge base.

CCGPP is anxious to get these algorithms out to the profession and into the hands of as many organizations, schools, student doctors and field practitioners as possible. Before we do that, however, we intend to subject the algorithms to the same rigorous Delphi process and then publish the outcome. Once that is done, these guidelines will no longer be our property.

There has been some concern that CCGPP’s primary objective is to make money. CCGPP does not personally own the copyright of our published products. CCGPP funds the work through donations, sponsors and membership dues. CCGPP only recently agreed to give its board chairman a small stipend to compensate for the extraordinary amount of time it takes to fill this position. No one else on CCGPP’s board receives any compensation; in fact our board members pay dues to the organization, so these dedicated and hard-working doctors are paying to do all this work for free. Ironically, the members of the organization that is leveling this criticism are paid to sit on their board.

:quoteright_open:CCGPP funds the work through donations, sponsors and membership dues.:quoteright_close:

So, why is there a need for guidelines to be produced by our own profession? As previously stated, if we do not produce these, someone else will. In fact, a number of insurance companies have already done this. Would you prefer to be held to the recommendations / guidelines of ASHN, Optum Health, ACOEM, Milliman and Roberts or ODG? At least with CCGPP’s evidence-based guidelines, which do stand up to scientific scrutiny, doctors of chiropractic have a fighting chance to defend their care, to fight back against unjust denials, and to fight back against bad consultants.

:dropcap_open:Please ensure the message that is being delivered is accurate and if it is not, please do your part to correct the perpetrator of any misinformation.:quoteleft_close:

CCGPP is responsive to any requests we receive for support and information through our Rapid Response Team and we have a group of the profession’s top scientific minds at our disposal to help research and answer many of these questions. The fact is, CCGPP has always been and will continue to be here to help you as a doctor or to help your association or other chiropractic organizations. CCGPP is not here to restrict you, to express any strong biased statements or sentiments or to team up with the insurers against doctors. CCGPP exists for the following reasons: to help every chiropractic doctor make evidence-based clinical decisions and to be able to confidently and successfully defend his or her care, as well as ultimately improving patient outcomes.


1) Please go back and read the papers CCGPP published in JMPT. These should be close at hand on every doctor’s shelf, 2) Please go to our website at (this is undergoing a dramatic restructure that will make it much more useful and user-friendly) and get copies of the Acute and Chronic care guidelines. Read these and become familiar with the guidelines, 3) Keep your eyes open for the Treatment Algorithm tools and get these as soon as they become available, 4) Now you know the facts. If one of the individuals spreading the misinformation about CCGPP, the guidelines and the algorithms approaches you, you are now armed with the truth. It is every DC’s responsibility and every chiropractic organization’s responsibility to be accurate about the intent and actions of CCGPP for the benefit of the profession. Please ensure the message that is being delivered is accurate and if it is not, please do your part to correct the perpetrator of any misinformation.

CCGPP will continue to work hard to help the chiropractic profession.

Thomas J. Augat, DC, MS, CCSP, FASA is the chairman of CCGPP.  He is past president of the Northeast Chiropractic Council and the Maine Chiropractic Association.  He graduated with academic and research honors from Palmer College – Davenport.  Dr. Augat has practiced 24 years in Brunswick, Maine.  Contact CCGPP at [email protected].

Pediatric Risk Management Demands Extraordinary Caution, Communication and Documentation

:dropcap_open:T:dropcap_close:he laws of all jurisdictions in the United States authorize the provision of chiropractic care to patients of all ages.  No state places any limitations or conditions on chiropractic care based on age.  Doctors of chiropractic, indeed, provide clinically effective, safe and appropriate care to hundreds of thousands of children of all ages each year in the United States.  The provision of health care services to children by any health care professional does, however, raise the risk management bar for a number of significant reasons.  Doctors of chiropractic need to be constantly aware of the need to handle all cases involving children with exceptional attention to detail in analysis, communication with parents or guardians and, above all, in documentation.

gavellargeHow Real is the Chiropractic Pediatric Malpractice Risk? The exceptional safety record of chiropractic across all categories of patients extends, thankfully, to the child patient population as well.  While chiropractic pediatric malpractice claims are rare, especially by comparison to medicine, the reality of exposure should not be minimized.  This is especially true given the highly emotional nature of issues related to children and the damaging nature of any implication that a health care professional may be at fault. 

There are obvious situations where red flags present themselves, especially in situations where emergency or trauma-related care is sought, where parents are being less than forthcoming as to the exact nature of the child’s condition or where medication or substance-related issues may be present.  These situations require careful, cool and exact thinking on the provider’s part and will frequently call for a widening of the pool of professionals involved in such cases by a prompt referral and direct follow-up communication with one or more other classes of providers.  The record shows that there is a direct correlation between the sense of crisis and emergency on the part of the parent of a sick or injured child and the possibility of claims of malpractice, regardless of the real merits of such claims.

Exact current data on pediatric malpractice across all health professions is limited, but a detailed study of 2004-2005 data from the federal National Practitioner Data Bank showed that 14% of payments made during that two-year period involved pediatric cases, with $1.73 billion paid in settlement of malpractice cases involving children.  That same study revealed that “failure to diagnose” was the basis of 18% of all pediatric malpractice cases.  Delay in diagnosis and “improper performance” were the next two main reasons for pediatric malpractice claims, at 9% each.i

Whatever the statistics, a concentrated program of pediatric malpractice risk reduction is in the best interests of all doctors of chiropractic who have even one child in their practice. 

Communication: Communication in cases involving children, especially small children, is inherently complicated by the fact that the ability to communicate on their part is limited.  The ability of a child to describe their complaint(s), relate the exact details of an injury or trauma incident,  describe what substances they may have consumed or been exposed to, the duration of a problem and other key factors is limited.   In the case of infants, it is absent completely. You often must rely on your evaluation of the patient and the narrative of the parent or parents.

Even in the cases where on intake your initial assessment is that a child is an uncomplicated case, take a few extra moments to ask those extra questions of the parent to seek to identify any significant or extraordinary facts involving the child’s history of incidents and injuries, changes in patterns of behavior including eating and sleeping and other variables that may raise questions about the state of the child’s health that might not otherwise be immediately revealed.

Extra care and clarity is also required in your communications back to the patient and/or the patient’s parents or guardians.  This is especially the case where a referral to another provider is made or follow-up procedures are indicated.  The Institute of Medicine has noted that half of Americans, even among the well educated, do not understand basic health information.ii  Other research shows that many Americans lack good reading, listening and concentration skills, especially where unfamiliar health care terms are involved.  Some experts have advised that all verbal instructions should be simple, clear, concise, and repeated until the patient/parent acknowledges understanding.  Some have even advised that all written material provided to patients should be written at the eighth-grade level. Records of such communications on behalf of child patients must be included in the patient’s clinical record.

A child’s health status and prospects are sensitive and often highly emotional issues with parents.  Some added sensitivity and patience may, at times, be required in dealing with pediatric cases.  Parents can sometimes feel themselves responsible for a child’s injury or condition, and there may be rare instances where this is the case.  Child abuse situations apart, which require the strictest and most immediate implementation of the reporting requirements of your jurisdiction, your help in assessing at-home safety procedures, care patterns and such issues as how a child sleeps or is routinely carried may merit your serious attention and dialogue with parents.   Be careful in how you respond to such situations, as you never want to be in a position of being quoted as saying that any activity, care pattern or environmental situation is “OK” when the exact details might be incomplete or the information provided misleading.

Documentation: The clinical record through which all aspects of a pediatric case are documented is, as with all other categories of patients, the practitioner’s first and best line of defense.  In cases involving children, there is an added level of documentation required including annotation and inclusion of copies of or details on information provided to parents, answers to questions asked and other issues discussed.  Being able to document the information provided parents at the time of care, especially any positive findings, clinically indicated follow-up care needed and/or referral advice can be key elements in defending a malpractice claim.

:dropcap_open:Expect the Unexpected: Children can be mobile, unpredictable, fearless and not aware of risks and dangers.:quoteleft_close:

It is also essential to document negative findings and the results of any instrumentation or physical tests and observations since failure to diagnose is a reason for malpractice claims.  An analysis of pediatric malpractice court cases has shown that the provision of any clinical measurement, diagnostic imaging (which is problematic for most pediatric chiropractic cases on safety grounds) laboratory results or other quantified study or instrumentation finding carries significant weight in defending care decisions and will significantly help in outweighing the opinion of an opposing expert.   As well, incomplete, inadequate, un-timely or inappropriate documentation is what allows so many non-meritorious claims to proceed so successfully.

It is important for practitioners to always extend the same security and HIPAA confidentiality procedures to children’s files and to be aware that the statute of limitations and state-established requirements to maintain those files almost always extends to a period of years after the child has reached the age of legal adulthood.  It would be time well spent to find out what the specific requirements for record maintenance for child patients are in your jurisdiction.

Referral: Doctors of chiropractic can strengthen their clinical defenses, especially in complex or problematic cases, by referring the parents of a child patient to another professional for evaluation and/or additional care.  Where children are involved, the promptness of such referrals and on-going communication and follow-up with both the professional to whom the referral was made and the parents almost always strengthens your defensive position.  Where medication errors, unforeseen consequences of medication, substance abuse or infectious diseases are suspected, such referrals become urgent.  Nothing in any referral should be means to imply that you are releasing the child patient permanently from chiropractic care and should only imply that the skills of other professionals are in the best clinical interests of the patient at a specific time 

Clinic Environment and Physical Safety Issues: Starting with physical layout and patient safety issues, you will want to carefully survey every square foot of your clinic from a child’s eye point of view. You will want to look for loose tiles or carpet, cords and wires that might have found their way into walkways, sharp corners on tables, desks, filing cabinets and any other physical items into which patients might easily bump, trip over or fall on. Also, don’t forget to look at anything with which your patients come into contact, including the coffee machine if you have one, making certain that it is up far enough so that it is out of reach of children, and likewise check any water cooler, making sure that it is stable and not easily tipped over. Please don’t forget to look at the outside of your clinic, including parking facilities and your doors and sidewalk.

The next category of items and issues you should review relates directly to your professional activities, and starting with the adjusting tables, make sure that all are stable, in good repair and functioning as they were intended to function. Don’t minimize the importance of keeping your tables in tip-top shape. Injuries to patients because of faulty equipment are 100 percent preventable, and, especially when heavy, power-driven lift tables are in use, represent an important risk management area.

The wiring of tables is of special concern regarding child safety.  In June, 2011, in Minneapolis, Minnesota, an 18-month-old toddler crawled under a chiropractic table to which his mother had been strapped and immobilized and hit the control button, causing the table to lower directly on top of the child.  Despite an almost instantaneous response by the clinic staff to the mother’s cry for help, the infant died of his injuries.  Sadly, this is not the first incident involving the death of a small child by an electric table on which the switch was activated by a crawling child.  Safety switches that cannot be causally or accidentally activated are essential.

There is also a behavioral element to such kinds of risks.  Allowing small children to move freely about clinic areas unattended means that unexpected and unintended incidents can and do happen.  Policies and staff support that minimize any unsupervised time can certainly help.  Be thoughtful and cautious in asking patients not to bring their children with them when they come in for care, as a family-friendly environment is a powerful asset both to the strength of the practice and the healing nature of the clinic’s environment. 

Expect the Unexpected:  Children can be mobile, unpredictable, fearless and not aware of risks and dangers. It makes sense to do all you and your staff can to make your clinic a safe, welcoming and healing environment for all patients, however small, and the people who bring them in.  To be constantly on watch when children are present just makes good sense.  To always act at the highest professional standard in patient analysis, care delivery and documentation is your obligation, not just for children, but for all patients.



  1. Kain, Z.N, MD, MBA, FAAP, Caldwell-Andrews, Allison, A., PdD, (August 1, 2006). What Pediatricians Should Know About Child-Related Malpractice Payments in the United States.  Pediatrics, 118(2), 464-468 (doi: 10.1542/peds.2005-3112).
  2. Institute of Medicine, Committee on Health Literacy (2004). Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press..

Should You Go Cash or Insurance?


“The insurance companies are getting harder and harder. They pay less and less. Soon, insurance will not pay for chiropractic care anymore. I think about going cash only. My friend was audited and he had to give $100,000 back to the insurance company.” Have you heard something like this lately? For myself, I have been hearing this for over 20 years. Does this really happen? Yes and no. Yes, because, over the last 20 years, insurance companies have improved their ability to audit chiropractors and have implemented rules to keep control over their spending. Can we really blame them? If it were your company, you would probably manage the same way. And no, because, from a business standpoint, insurance companies can’t really go away. Private insurance companies are selling a product and they have competition. Covering chiropractic care is an added value for the consumers. Insurance consumers are looking to get the most for what they pay, just as we do when we shop around. What insurance carriers want is to avoid insurance fraud at any cost. They want to make sure doctors provide all the care they claim and make sure chiropractic care is really what the patient needs. Insurance control will keep improving in the future.

As an example, one of the requirements for a software being certified and qualified for the stimulus package is to have an audit log. This means that any change you will make in your computer system will be recorded. This may trigger alarms to the auditors. You may be asked questions like: Why have you added this information to this patient file? Why have you changed or added this to the SOAP note? The new log file for certified software may be just another step up for auditing. Not only they can see what was changed or added, but they can easily find out when the change was made. So, if you ever buy a certified software in order to get some stimulus dollars, you will have to keep all your patient files very accurate. But this is fine. You should do this anyway, stimulus or not. You do your work right, you will get paid right. If you document everything you do correctly during each visit, provide the necessary number of treatments but not more, show a health improvement in your documentation and only claim services which the insurance covers, you are all set. You will get paid easily.

Does this really happen in real life? Absolutely. I know hundreds and hundreds of chiropractors who are very successful with insurance. They just do it the right way and they have no problem with any insurance carriers. I am not saying “no” to go cash, if you want to. I know hundreds of very successful chiropractors who work with cash patients only. What I am saying here is going cash is not necessarily a solution, if you are having a hard time with insurance claims.

The solution is to take a step back and get well organized to manage insurance. You have tools available to make your insurance management very easy. Some management software have cool billing and documentation automated features. After you enter detailed SOAP notes (pressing only a few buttons), the patient and insurance billing will be generated automatically and accurately. Copay, deductible, maximum will all be adjusted automatically. So, you have accurate real time SOAP documentation and insurance billing at the same time. Auditors are welcome to your office at any time.

Now, some E.H.R. software providers will provide you full insurance claim support. Knowing you and your staff have an instant and constant support for your insurance claims is a huge pain relief. And guess what? You will be back fully focused on what is really important for you: providing great care to all patients; not on being scared of auditors or thinking why you have not been paid, etc. One thing we tend to forget is that accurate SOAP documentation is not only for insurance auditors. It is also for yourself, for lawyers, for your chiropractic boards, etc. Accurate notes are required at all times, no matter if you claim insurance for your patients or if you operate your office mostly in cash. Managing insurance or going cash with your patients should be directly related to your personality. In both cases, it is difficult to talk health and money at the same time to a patient. You have two bad and one good news for the patient. The bad news is the patient has an important health problem and there is a bunch of money needed to fix it and the good news is that you can give him back his health.

:quoteright_open:Accurate notes are required at all times, no matter if you claim insurance for your patients or if you operate your office mostly in cash.:quoteright_close:

This is when your personality for insurance or cash comes into play. How easy is it for you to say to the patient, “Here we do not accept insurance. You pay us at every visit and you have to claim your personal insurance yourself.” Or, it could be, “Here, we accept insurance. You will be responsible for an insurance deductible, a copay amount and, from there, we will be taking care of your insurance.” For the financial part of your operation, there is no magic solution. Both insurance management or cash office can work very well for you. It is up to you to have a plan in place, use the tools and support available and do it the right way. And, truly, in my very personal opinion, in 20 years from now, we will still hear, “The insurance companies are getting harder and harder. They pay less and less….”


Claude Cote is an expert in EHR systems, insurance bill- ingandchiropracticclinicmanagementfor22years. Hehas installed EHR system in 17 countries over 5 continents and nationwide in USA. He is the President and Founder of Plati- num System C.R. Corp ( For comments or questions, please email to [email protected].

How to Evaluate the Real Cost of an Electronic Health Record System?

moneyclock:dropcap_open:I:dropcap_close:f you are shopping for an Electronic Health Record system, chances are you will follow this path: You will choose to call 4 or 5 companies you have heard the most from other fellow chiropractors, or you have seen in chiropractic seminars or magazines. At this point, they are all the same for you. They all claim they have the best service, the best system and the lowest cost. So, you will ask for a demo, online or live at the seminar. As a bonus, you just find out the system is free and in the process to become certified for the Stimulus incentive package. So, you automatically become eligible to receive 44,000 dollars from the government. Wow, what a deal! That was easy…. You are almost ready to make your final decision. Let’s go fast because the government may have given all his Stimulus dollars to the fastest decision maker and maybe there will not be any dollars left for you. Hurry up; let’s buy some computers and go for it! Decision made…done deal!

Stop! No…don’t do that; it will not happen like this. The real cost of an EHR system has to be established with a lot of diligence. Let’s rewind the tape for a moment and proceed much differently. Let’s take the business approach instead of emotion. Choosing the automated EHR system you will be using for approximately 2,000 hours per year needs a serious analysis. Your analysis needs to be well structured with priorities well defined. Act as a good business person.

Free or Not Free

I will start this discussion with a big statement: “Nothing is free in life.”  It is not any different for chiropractic EHR software. “Free” will cost you a lot of money. You need to find what’s under the hood. In every software category, EHR or not, free is to get you aboard with something that does the very minimum and, most of times, less. Then they sell you applications (apps) or modules. You need to find out what will be the cost of these applications. What will be the cost for the service on these paid apps afterwards? Free or not free, you have to make a good evaluation of how much it will cost to maintain your EHR software over a 5-year period minimum. You may also hear, “Expand your EHR as you grow.” The word “expand” simply means spend more money on other applications later on. Some other providers will have specific functions and tools to help you grow, which is a much different and interesting approach. Do not hesitate to ask an EHR provider, “Please show me how I can grow my practice with your system,” or “Show me how your system will save my staff time and how it will make my life better.”

Hardware Cost

Computer prices have gone low. This is good news. You may think, since you will be using 5 or 6 computers in your practice, you need a strong dedicated server. If you use a dedicated server and it fails, you have no more access to any data file and cannot work anymore. These servers can cost up to $2,500 and are not necessarily needed for all EHR software. You can save a substantial amount of money with an EHR system that does not require a dedicated server. Since these systems can use just about any computer in your office to act as a file server, you may use any other computer as an emergency file server and get the system back in 5 minutes or so. This can be the difference between closing your office for the day or remaining open and treating every patient for that day.

:dropcap_open:Choosing the automated EHR system you will be using for approximately 2,000 hours per year needs a serious analysis.:quoteleft_close:

Time Savings

Do you agree that “Time is money”? Then you can make good money by saving time and using this precious time at your discretion. All systems are about the same speed on an online demo. They run on a single computer with near empty databases. The real speed test comes when you have 7 computers networked together, with 5,000 patients, 100,000 appointments and 200,000 transactions. It can be very slow, if your data is stored on internet somewhere. It is well known that internet is the slowest network, while a local network is so much faster. Make your own calculation: If, because you have a fast EHR system, you save 2 minutes per patient/visit and you see 200 patients per week, you will save over 333 hours per year, which represents more than 8 weeks of free time. Have you ever realized this amazing statistic? How much money this time saver is worth to you? The 2 minutes is not achieved only on hardware speed but also on how the information is accessible on one screen, how the system can automate all the billing, manage care plans, if you have any, etc.

Cost of Service

You will also have to pay for service because, like in any other business, help agents and trainers do not work for free. How much, in terms of money and quality, will you get back from that service contract? Will they answer your calls instantly when you need help or will you need to wait for a call back? Will they support you if you have some hardware issues? Do they have an emergency plan for you to make sure you can keep adjusting your patients if your server fails? If you are storing your patient data on internet and internet gets down on you, what is the plan if it takes 24 hours before you get it back? It can be very costly, if you have to cancel all your patients for a day or two. If you do have some insurance claims rejected, the money recuperation obtained from efficient software provider assistance can be huge at the end of the year.

The Stimulus Package

If you put the $44,000 Stimulus in the equation to do your EHR final choice, you will probably have to redo your budget at some later time. First and most importantly, no chiropractic software is fully certified for all the required meaningful use. Installing partially certified software will not make you eligible for one single penny from the stimulus. You would have to buy one or multiple other software to meet all the requirements. This would be a financial disaster for you. Be very careful about the stimulus package before you include it as criteria for your cost.

As a business person, the goal is to turn the EHR overall expenses into an investment. The return on your investment will be in office growth, time savings, better collection, and better overall control with less or no downtime at all. The real cost of an EHR software is much more than the acquisition and the monthly service fee and your investment return will make the entire difference between failure or success.

Fortunately, 99% of chiropractors I have personally seen installing an Electronic Health Record system has turned it to a great investment. Over the years, out of thousands of doctors I have witnessed installing such a system, I can recall only one who has returned to paper operation. This amazing statistic explains why EHR systems are so popular these days.

Claude Cote  is an expert in EHR systems, insurance billing and chiropractic clinic management for 22 years.  He has installed EHR system in 17 countries over 5 continents and nationwide in USA.  He is the President and Founder of Platinum System C.R. Corp (  For comments or questions, please email to [email protected].

How to Do More with Less

filespicture:dropcap_open:A:dropcap_close:s Doctors  of Chiropractic, as well as business professionals managing a practice, we are bombarded with solicitations to better our practice, improve our equipment, update our technology, and incorporate the “next best thing.” The economic realities of today, however, demand that we not add more and more “stuff,” but rather that we find a way to do more with less.  The road to efficiency is paved with streamlined operations, discarding what’s unnecessary, automating processes, and simplifying what remains.

Doing more with less sounds wonderful, but at times it can seem like an impossible goal. At first, it may seem difficult to imagine how you can actually better your practice by cutting things out, and it often feels counterintuitive, especially in a “more is better” culture. However, the best practices are the ones without all the bells and whistles—they are the practices that have gone through the process of simplification, and found that they can actually accomplish so much more by using less.

Achieving efficiency while increasing effectiveness consists of three steps: get rid of what you can, automate what you can’t get rid of, and simplify what you can’t automate. Again, though it sounds counterintuitive and, in some cases, downright impossible, your practice will be better for it, and you will be able to use less overhead to accomplish more.

Get Rid of What You Can

This represents a problem for many doctors, since the idea of getting rid of something seems both hard and unnecessary. However, ruthlessly going through your practice and getting rid of the “dead weight” is the first and most important step in getting your practice to the point where it is running at a higher capacity with a lower level of effort.  Placing too many people in a boat will ride it too low, slowing it down and making it difficult to operate. In great economic times this is passable, but these are stormy days. If we can’t get a bigger boat, we must make better use of the space we have. This principle applies to both equipment and staff. Consider what items in your practice are truly necessary, from procedural equipment to the office supplies on your receptionist’s desk.

If something is redundant, gets in the way, contributes to clutter, or simply does not provide an irreplaceable, evident and genuine use to your practice, it needs to go. You may be surprised by how much you can actually cut out this way, and how uncluttered and streamlined your practice will look afterwards.

Unfortunately, this principle also applies to staff. It is hard to follow through with cutting excess when it comes to real people but, if someone is not contributing to your staff, then it’s time to consider letting them go. Staff is one of the primary costs of any practice, and even small reductions in unnecessary time in this area can save you a lot of money.

Automate What You Can’t Get Rid Of

:dropcap_open:The issue of chiropractic documentation is a prime example of something that must be automated for an office to function properly.:quoteleft_close:

The wonderful thing about technology is that it allows you to automate necessary processes, and also generally performs them better than a person could. This is especially true in areas like patient reminders and chiropractic documentation. Granted, there are some things that require a personal touch, but the best offices are increasingly making use of the innovative chiropractic EHR systems and software to streamline their processes.

The issue of chiropractic documentation is a prime example of something that must be automated for an office to function properly. Besides all the physical space taken up by stacks and file cabinets full of chiropractic SOAP notes and other documentation, consider all the lost time and inefficiency that a paper-based system produces. If you choose only one aspect about your practice to automate, it should be the notation and storage of chiropractic documentation. Investing in a good chiropractic EHR system will save you tons of money and time almost immediately.

The same applies for things like patient reminder calls. There really is no reason to have a person making those calls, since the majority of them go unanswered anyway. By automating the process, you save literally hours of time, lower your phone bill, and free up your staff to do other things. Just as investing in chiropractic software will save you time and money when it comes to patient records, investing in automated reminders and online intake forms will keep your staff from wasting time on busywork, and allow your practice to accomplish the same purpose with a fraction of the cost.

Simplify What You Can’t Automate

Now that you’ve cleaned out the clutter, gotten rid of ineffective staff members, and automated your office as much as you can, it’s time to simplify those things that can’t be automated. This applies to everything from patient intake to the way you perform your procedures. Though technology does play a large role in this, a lot of it comes down to common sense. The key here is to keep a system that accomplishes the most with the least number of steps. Make use of the PEEP principle to keep your office simplified in the long run—a Place for Everything, Everything in its Place. Nothing is more frustrating than going through all the time and effort to simplify and automate your office, and then have you and your staff’s old habits slide back to the way they were within a month.

The Takeaway

The most important thing to remember about doing more with less is that it is a process. This is not a one-time change, but rather a long-term process of change in your procedures, habits, and service mentality. And, as anyone who has been through this process can tell you, it’s not easy, especially at the beginning. However, the way your practice runs after you go through the process of getting rid of what you can, automating what you can’t get rid of, and simplifying what you can’t automate is truly astounding. You can accomplish more than you ever dreamed with less effort, equipment, and overhead costs than you would have thought possible, and from then on…it’s smooth sailing.

Seven Deadly Business Traps

roadsignbusinesstraps:dropcap_open:T:dropcap_close:he following are traps that many doctors, as business owners, fall into and, if you can avoid them, you could make a lasting change in your business.

Most doctors are very proud of being true to their philosophy of healthcare and being a chiropractor, but doctors aren’t trained or naturally talented in all aspects of business, although, the amount of money many owe in student loans could fund a startup business.  However, a very good doctor may not invest in the time, funding and implementation of important aspects of his or her business. As doctors, we have to be business people, out of necessity. Just take a quick assessment of your own office and see if you can give yourself a good grade for avoiding the following business traps:

1. Slipshod Accounting:  Correct accounting can diagnose what is right and wrong with your business.  You can produce an income statement in a matter of minutes from any accounting software. That is, if you have input the data.  This shows if your formula for making money is working.  Do you understand your ratios of expenses to sales?  Yes, as doctor, you have sales.  This is what makes you profitable.  You must have an understanding that you must gross X$ amount to see X$ amount of net profit.  It is not going to work to say, I hope I can make $300,000 this year.  Slipshod accounting will get you into trouble and worse is having no accounting at all.  You must have a grasp on all your costs, including components such as computer upgrades and other orphan costs.  Then you can fine tune profits.  Accurate accounting can correct aimless direction.  A doctor doesn’t have to know all the answers to all the questions, but he or she does need to know all the questions and employ someone who can help achieve the answers, i.e., a good accountant and bookkeeper.

2. Fear of Fees:  Discounts on fees really increases your “Cost of Sales”, and you must keep that in mind.  Free offers for examinations, X-rays and first adjustments have costs associated with them.  There are the costs of the doctor’s time, patient confidence and income lost from “free offers.”  And you are acquiring additional liability for which you have not been compensated. You need to truly understand your costs, and pricing your fees too low is a significant sign of your own feeling of value and can transfer into patients’ lack of confidence in the doctor.

3. Ignorance in Hiring:  It is valuable to have a prospective employee interview with someone else in addition to the doctor.  The additional interviews can even be done via telephone or Skype.  It is amazing what others may detect while interviewing.  Busy doctors may want to hire someone pre-trained from another doctor’s clinic.  Key question, “Why aren’t you still with Dr. Bob?”  You need to take the time to call their references and learn how to ask the right questions.  We all want to hear that the prospective employee is wonderful and could return to their previous job, if they wished.  However, do we really want an employee from another doctor’s office?  Are we taking on another doctor’s bad habits and preconceived ideas that may not click with ours? I believe an employee must have some fundamental qualifications, but I do not want to hire from another doctor’s office.  I want to indoctrinate my own employees.  I have found that personality testing can provide great insight into what motivates a person and makes an employee tick.

4. Hanging onto Employees: No one wants to let an employee go and, unless you are the only one left to do the job, delegate it to a reliable employee or even a spouse, if available. Along with the delegation to another should be instructions of exactly what to do and say.  The simpler the better and just saying while handing the employee a short, nice severance letter, “This was a decision recommended by the accountant or management” could be the best approach.   Keeping an employee because of your own fear—fear of time it takes to advertise and interview and the fear of the time it takes to train—can hold you hostage.  If you have even a “gut feeling” about an employee, you should monitor this feeling closely.  It can be amazing how statistics can improve when the wrong employee is out of your office.

5. No Standards or Controls:  How much deviation from your standards can you tolerate and how do you know?   Chiropractors offer healthcare services; so where do standards come into play?   You, personally, are a well-trained doctor and your care and reports are fine and up to standards. Yet, how about standards in your paperwork?  Do all your forms that are given to a patient look crisp and clean with your logo, address, telephone number and website address?  Is your website up to standard?  So many people now research using the internet and, if a page of your website is “Under Construction” or there are major misspellings and grammatical errors—let alone just darn hard to navigate—all this turns people away. Make and meet standards in your office appearance and employee appearance. If you don’t have any standards, how can you have any control?  Implement what you want to see in your office and, of utmost importance is to be clean, orderly and consistent from room to room and employee to employee.  The doctor must appear well-groomed and look like a doctor.  I believe in wearing a lab coat, dress shirt and a tie. This is a topic that merits much more dedicated interest by many doctors.

6.  Poor messaging:  This applies to the way both you and your staff communicate with your patients. Messaging starts with the first telephone call from the patient to the Report of Findings and then on to communicating with patients all the way through care.  You need to trim out the fluff and have a message that is focused and easily understood. Poor messaging also means not anticipating what information a patient needs to know.  As an example, during the first telephone inquiry, the majority of a patient’s questions should be answered prior to being asked.  Another way to message poorly is not distinctly branding yourself and your clinic as an expert. What you need to remember is, whether it is good or bad, we are marketing and branding ourselves every day in multiple ways.

7.  Confusion about who you work for:  Do you work for your patients or the insurance company?  Are you afraid to offer best healthcare practices rather than best insurance practices?  Why not work for the patient and place payment responsibility on the patient by having a cash-only practice.  This will do away with third-party billing and waiting for reimbursement of a discounted, contracted rate.  The cash-only model allows the doctor to receive fair and reasonable reimbursement, and it emphasizes that the contract is between patients and their insurance companies and not between their insurance companies and the doctor.  Patients understand it; they get it that insurance companies dictate care, slash fees and are not focusing on meeting the needs of the individual, unique patient.

These are all correctable traps and, with this being the start of 2011, you can start fresh.


Dr. Richard E. Busch III is a nationally recognized Doctor of Chiropractic, author, and speaker. He has successfully treated thousands of patients for chronic and severe disc conditions that traditionally would have required surgery.  Dr. Busch developed the DRS Protocol™, utilizing spinal decompression technology. He has served as a national consultant for the continuing development of this technology and the DRS Protocol™. Dr. Busch has published a recent eye-opening book *Surgery not Included: Freedom from Chronic Neck and Back Pain. You can visit his website at or or call 1-866-662-2225.

Begin With the End in Mind to Ensure Financial Ease

phone1:dropcap_open:A:dropcap_close:lmost every new patient encounter will begin with the phone call that potential new patient will make to schedule their initial visit.   Setting the financial tone of the relationship with that potential patient as early as the initial phone call lays the groundwork for a healthy partnership in the years to come. In the same manner that we might not go to the mall and purchase a new outfit without first taking a peek at the price tag, most new patients will want to know the costs associated with their care before they begin. Communicating this information effectively without scaring the patient away is a finely tuned dance that requires confidence, knowledge, and effortless ease.

We’re frequently asked, “How much do we talk about finances on the very first, new patient phone call?” The answers to this question are as varied as the reason for them. Some feel that any discussion of finances leads a potential new patient to believe that all we are worried about is the finances.  While we don’t want money to be the main focus of our list of questions for a potential new patient, some discussion of the finances is vital to ensure that your process is smooth and orderly. You must know if they plan to use some third party insurance to assist with payment of their bill. You really can’t answer the all important, “How much does it cost to see the doctor?” question if you don’t know about their insurance. We can apply patterns and our experience based on other, similar patients, but the truth is we never REALLY know until we verify the insurance.

By asking the patient, “Is there some type of insurance coverage you would like our assistance with?” we imply that our job is to assist, but the ultimate responsibility remains that of the patient. There may be certain responsibilities required of the office, such as mandatory billing for a program like Medicare, but setting this tone with a patient early on that you are assisting, and not being solely responsible, is most useful. While the conversation may naturally turn to questions about network participation, policies relative to noncovered services, or any cash discounts that you may offer, minimizing these on the telephone is preferred. It is helpful to have a “cheat sheet” at the front desk or near the phone to have standardized answers to some of the more difficult questions asked on a new patient phone call. Some commonly asked questions to be prepared for include:

:dropcap_open:Communicating this information effectively without scaring the patient away is a finely tuned dance that requires confidence, knowledge, and effortless ease.:quoteleft_close:

“Does the doctor participate in my insurance network?”  If you do not participate, but offer other patient friendly payment plans, appropriate scripting will help ensure the appointment is secured.

“How much does it cost to see the doctor?”: Knowing how to think on your feet and explain your fees whether cash or insurance, will ensure that the patient gets in for the first visit where you can explain in greater detail.

Verifying a patient’s insurance benefits before they are seen by the doctor can significantly reduce financial concerns and confusion later. Sometimes this seems like a potential waste of time when they’re not even our patient yet.  The benefits far outweigh the negative effects of any potential time wasted if the patient does not come in for an initial visit. The ability to collect properly on a first visit because you have already verified the insurance lends itself to the very effective financial policies you are able to enforce on visit one.

Collecting on the first visit allows that patient to establish good financial habits and patterns with your office. Often, patients are used to the type of benefits their insurance may have in a primary care physician’s office, such as a flat copayment. Frequently, chiropractic benefits can be complicated and could even include patient responsibility for each and every different service rendered in the visit. Unless the patient has used these benefits before, it can create sticker shock. Therefore, when you are able to discuss benefits on the first visit, even in a limited way, you are further setting a great financial tone for that patient relationship.

:quoteright_open:It can seem like financial matters are the elephant in the middle of the room that nobody wants to talk about.:quoteright_close:

Many chiropractic practices use the procedure of explaining full benefits and patient financial responsibility on a subsequent visit after the doctor has laid out a treatment plan with the patient. This is the perfect time for a financial report of findings. Patients want to know what to expect in order to budget their expected financial contribution. Conducting this financial consultation is a tremendous habit to adopt. One of the primary reasons patients drop out of care is lack of a clear understanding of financial liability or the perceived inability to pay. Most practices have policies that allow the patient to make payments toward their responsibility and reinforcing this in a financial report of findings tends to keep the patient on track and not so ready to drop out over simple financial matters. The financial report of findings should include a review of the doctor’s treatment plan, explanation of the patient’s responsibility, and their options for making payments. Insuring that no one leaves this meeting without a clear understanding of that responsibility will go a long way toward laying a strong foundation with this patient.

It can seem like financial matters are the elephant in the middle of the room that nobody wants to talk about. However, the practice that addresses patient finances head on, in a matter-of-fact conversation, alleviates these concerns before they crop up. By discussing finances when the patient calls for their initial visit, at the first visit and again when laying out a treatment plan, the financial aspects of their treatment encounters in your office tend to not be a patient’s primary concern. With their mind set on getting better and not focused on financial issues, the patient is a happy and productive practice member.


Kathy Mills Chang is the founder of her own consulting firm, assisting doctors with finding financial and reimbursement ease in practice and helping them to make and keep more money. She specializes in coding, documentation, Medicare, billing and collections and patient finances.  She can be reached for service and questions through her website at or by email at [email protected].

More $ from Uncle Sam

clipboardchecklist:dropcap_open:O:dropcap_close:ur Federal government keeps coming up with ideas to give all of us more money!!! At least that is what they claim. If you use certified Electronic Health Record (EHR) computer software and demonstrate meaningful use of that EHR, then you may qualify for up to $44,000.00 in bonus payments from Medicare. The bonus is NOT based on the cost of the EHR program. The amount of the bonus is determined by the amount of money Medicare pays you. Medicare sets the bonus at about 75% of what they normally pay you. So if your annual Medicare payment is only $1,000 you will get a bonus check for $750; if the payment is $25,000, your bonus check will be $18,000. Should you qualify for the maximum bonus each year for 3 years in a row, your bonus checks will total $44,000.

In order to demonstrate meaningful use of your EHR system, you must utilize the Physicians Quality Reporting System (PQRS) codes. And according to the government, any doctor that uses the PQRS codes correctly will have his/her payments increased by 2%. This means that for every $100 you would normally receive from Medicare, you will get a total of $102 by using PQRS. It may not be a lot, but it is better in your pocket than staying with the government.

PQRS consists of codes that most of us have never heard of. There are CPT I codes, CPT II codes and G-codes. And each code must match up with something else on the claim form. That something else may be an ICD-9 code, a regular CPT service code, and/or some aspect of the patient’s demographics. Each PQRS code must have only one diagnosis pointer. And when PQRS is used, your CMS1500 must be completed in a very specific manner.

:dropcap_open:In order to demonstrate meaningful use of your EHR system, you must utilize the Physicians Quality Reporting Initiative.:quoteleft_close:

The good news is that PQRS is being automated in some EHR systems. This programming development provides you with the benefits of PQRS without having to master every aspect of its technical requirements. However, you should make it a point to understand the concepts behind PQRS so that you will be able to respond to claims examiners or auditors when asked why you used it.

An example of the PQRS codes shows what needs to be reported regarding back pain. Back Pain Measures Group consists of 4 measure specifications:

1. PQRI measure #148 back pain initial visit–includes pain assessment, functional status (assessment form in patient file, signed by patient), history noting presence/absence warning signs, assessment of prior treatment and response, and employment status. Use CPT II code 1130F. The pain assessment and functional status should be completed by the patient using standard functional assessment forms such as Oswestry, Rand, Pain Disability Questionnaire, etc. Note that Medicare requires proof that the patient completed the form, so the patient’s signature MUST appear verifying that he/she answered each question and completed the form.

2. PQRI measure #149 back pain physical exam–straight leg raise test and a neurovascular exam showing presence/absence of findings. Be sure to note all positives and negatives. If you only record positive findings and do not record the negatives, an auditor will claim that you made a false or fraudulent claim. Use CPT II code 2040F.

3. PQRI measure #150 back pain advice for normal activities–advice to maintain or return to normal activities. Use CPT II code 4245F.

4. PQRI measure #151 back pain advice against bed rest–patient counseled against bed rest of 4 days or longer. Use CPT II code 4248F.

If ALL these items are to be reported, then a single composite G-code G8502 can be used. Note that PQRI codes must be reported correctly. If errors are made, you do not have the ability to correct them and simply loose the benefits of PQRI.

Currently there are 179 PQRS codes. It is incumbent on you to go through the list and see which ones apply to your practice. Make sure those items are in your EHR system. It is critical that you look up each code individually and know when it should/should not be used. Keep in mind that the PQRS codes are evaluated and revised every year, so from one year to the next you may need to revise your list.

:quoteright_open:Various software companies are passing the tests and getting their EHR systems certified.:quoteright_close:

The government has authorized 3 companies to test and certify EHR software. Many EHR programs are passing the tests and getting certified. The overwhelming majority are medical systems. There are a few Chiropractic specific EHR systems that received certification in November 2010. Only a handful of Chiropractic specific software companies qualified for certification before the end of 2010. And you had to have certified EHR in place before the end of 2010 to qualify for the Medicare stimulus calculation beginning in January 2011. Otherwise, the earliest you can qualify for the stimulus bonus is April 2011. So if you are planning on getting EHR computer software for your practice, find out if the system you are looking at is certified or will soon have certification. If it is not, then select another software program that is or will soon be certified.

Using PQRS is the tool that demonstrates meaningful use, and therefore qualifies you for up to $44,000.00 in bonus payments. It also gives you a 2% bonus just for using PQRS.

Make sure that you get the greatest amount of payment from the government that you possibly can. This will be one of the rare occasions when you will be able to recoup some of the money you paid to the tax man.


Dr. Paul Bindell, a 1975 Palmer graduate, has been in practice in Rockaway, NJ, since 1976. He lectured on Chiropractic in Brazil and Israel and is a past Chairman of Public Relations for the Northern (NJ) Counties Chiropractic Society. The Chiropractic Answer produced by Dr. Bindell in the 1980’s was a cable television program, a newsletter, and a newspaper column.  In 1991, Dr. Bindell and his family began Life Systems Software so Chiropractors would have computer programs based on real practice. As a consultant, Dr Bindell is the expert in assisting the profession and individual Chiropractors to improve and succeed. Numerous articles have been written by Dr. Bindell and have appeared in several Chiropractic journals. Dr. Bindell is available to speak to your group or organization and can be reached by email at [email protected], or you can call Life Systems Software at 1-800-543-3001.