Steven J. Kraus, DC, DIBCN, CCSP, FASA, FICC, is Founder and CEO of Future Health Software ―the technology leader for chiropractic-specific EHR/practice management software. He is an acknowledged expert in Health IT, including EHR and the up-to-$39,000 ARRA incentive program to implement EHR. Dr. Kraus serves on numerous ACA committees and regularly travels to Washington DC to meet with policy makers on the subject of documentation and electronic health records. He lectures to state associations and at industry events regarding EHR and the relationship to documentation. He presents monthly webinars on how EHR usage will impact doctors of chiropractic. For more information, visit www.FutureHealthSoftware.com or call Toll Free 1-888-919-9919, ext. 616.
Doctor Confidence: Now a Software Feature?
:dropcap_open:C:dropcap_close:hiropractic works. Chiropractic is powerful. Chiropractic is fun and rewarding. On a good day, many chiropractors would say all of that, but would they say the same thing about their chiropractic software?
Can chiropractic software be powerful, rewarding, fun, and, most importantly, work in such a way that it actually boosts your confidence as a doctor? If software helps you document exams more accurately, provide detailed care plans to better manage patients, and create encounter-specific daily notes in a way that is compliant, accurate, and leads to saving money while increasing efficiency, then yes! Software can be a source of confidence for any doctor.
Here are the top three ways EHR and documentation software can build your confidence.
#1: Improve your focus on your patients
How do you enhance your focus on patients and not simply go through the same old motions? Some doctors might use meditation or mind techniques before seeing patients. Others might use a subtle mental cue to remind themselves to be consciously present in the moment for their patients. Of course, many doctors try to delegate tasks not directly related to patient care to an assistant, as long as they can afford the hire and find someone they trust with the tasks.
Using technology to decrease the demands of multitasking is perhaps one of the most overlooked ways to shift focus from your “busy-ness” or the business of practice over to your patients. Rather than allowing technology to create more work for you during patient-care hours, you should demand that your software makes focusing on patients easier. How can software make you a more focused doctor?
The most powerful way to free you to focus on patients during patient-care hours is by simplifying your exam and daily visit documentation. Documentation is the one task that is difficult to delegate. It is also best to complete documentation at the time of service for greater accuracy and compliance—as Larry the Cable Guy says, it simply is better to “get ’er done.” It feels great to know that at the end of the day, your notes are compliant, detailed, and complete, especially if it’s all done by 6 p.m.
Relieving you of any irrelevant steps in an exam or SOAP note may be the most effective way to keep you focused on patient care, as long as you are not sacrificing the quality of documentation. This is a hard balance to achieve for any documentation program. A customizable yet chiropractic-specific design helps to ensure that every doctor has his or her favorite exam flow, list of tests, performance order of procedures, or codes included. However, this design also creates focus-stealing distractions if it does not allow you to filter out what you do not need. For example, if you do not utilize ultrasound or muscle stimulation, instrument adjusting, or take x-rays, why would you want to have to manually bypass those software screen options every time you create a new note? Being forced to mentally filter out 10 options on your EHR screens that you do not use becomes a source of distraction when you multiply this self-filtering over tens of thousands of notes.
Electronic documentation software that is pre-loaded with chiropractic nomenclature, clinical findings within your scope of practice, and procedures that you actually employ in your clinic will save you time over handwritten notes. To improve your focus, though, it is best if you have the option to choose how best you move through the documentation, including eliminating distracting options.
When software helps you do your job more efficiently and with greater accuracy, you will have more time to deliver care instead of thinking about everything that goes into the care you deliver. Software that revolves around your style of practice using your vernacular and your methods will feel right and empower you to practice your way, quickly, efficiently, and accurately.
Step 2: Eliminate any worry about compliance or oversight
No doctor wants to have the practice’s records scrutinized by anyone. Having a case reviewed by an independent medical examiner, an insurance company claim reviewer, or Medicare auditor is never a pleasant experience, especially when reimbursement for services already rendered are on the line. While it may never be fun to open your clinic records to a third party, you can gain confidence and worry less when it does happen with the right software that helps you create the best notes possible.
With the software that fits your practice, you should be able to reduce your multitasking, focus on your patients, and improve your compliance with the demands of your state board and third-party payers. You should not have to trade accuracy and consistency in your documentation with less time for patient care, or less family and personal time for you.
:dropcap_open:If you need a little extra help, custom buttons on specific screens to help you raise documentation and coding compliance may be possible depending on the program.:quoteleft_close:
How can software help you raise your level of compliance, especially when different third parties want to see different items in your documentation and care plans? First, electronic health records can provide you with a template that contains all of the elements of compliant documentation so that you are always prompted to “cross your t’s and dot your i’s” right there on the spot. Second, electronic health records can provide chiropractic-specific alerts and reminders to encourage you to provide the proper criteria required or to better manage your patient. If you need a little extra help, custom buttons on specific screens to help you raise documentation and coding compliance may be possible depending on the program. You should note that chiropractic-specific alerts and templates for chiropractic-specific criteria are not going to be found in medical-based electronic health records. You may not be able to expect the same efficiency or compliance in this case.
The best part of improving your documentation quality with the right software is the ability to create documentation compliance immediately at the time of service. There is nothing that creates more confidence than knowing that your documentation is complete and above scrutiny—and not hanging over your head for another day. Having a system that helps you track completion of your notes is important at the end of the day. Should someone be interested in reviewing your records, you also waste little time wondering if you have left yourself exposed.
Step 3: Raise your efficiency while, keeping money in your pocket
Would you feel more confident as a doctor if you left less money on the table due to incomplete exams, or documentation vulnerable to nitpicky reviewers? What if your software could help you increase your chances of being paid consistently for the care you have already delivered? Would you feel greater confidence knowing that the evidence for your care (and therefore your reimbursement) was complete, robust, and just a few seconds away—available at the touch of a few buttons rather than recalling all the criteria from scratch or having to dictate from an empty slate?
When the compliance and quality of your documentation improves, so will your ability to explain your care to third-party payers in the language they understand. With better documentation, you will be able to use and justify higher code values (when appropriate) instead of automatically devaluing your care with a lesser code while hoping to fly under the radar. You will have the confidence to use appropriate billing codes and will be more likely to defend it, which will raise your chances of leaving less money on the table.
The right software should also increase your ability to actually bill for services you are already rendering. The reality of the clinic environment sometimes creates holes in communication where services are improperly coded or not even coded at all. Doctors are often surprised to learn that they lose thousands of dollars every year by simply failing to code services rendered, either in their documentation or in the billing process. Lost or dropped codes mean lost or dropped dollars.
Nothing can raise your confidence like the ability to raise your level of efficiency while saving you money.
Confidence, the next software feature?
Knowing that your documentation and daily notes look professional, legible, complete, detailed, compliant, and specific to the patient’s encounter is a powerful accomplishment and feeling. You will feel more confident knowing that your notes are not fluffy, verbose for the sake of lengthiness, or masquerading as detailed notes by using a lot of words to create a faux filled note. Can chiropractic software actually help boost your confidence as a doctor, which helps you, in turn, become more successful in practice? If confidence can come from eliminating distractions during patient care so you can focus on your patients, then yes. If confidence can come from not fearing any scrutiny over your documentation, then, again, yes. And if confidence can come from leaving less money on the table from incomplete or inconsistent documentation and coding, then yes. Make sure that greater doctor confidence is a main feature in your next software investment.