Health care professionals enter the field primarily to satisfy an urge to serve. In recent years, however, disaffection has set in among many, as they struggle to balance the satisfactions of the healing arts with increasing pressures of administration, economics and regulation on the business side. Some leave the field; most soldier on, trying to find ways to retain or restore the balance between the professional and the business side.
In the chiropractic sector, there seem to be more challenges than are experienced in the more traditional sectors of the health care field. Chief among these are third party payer and private payer challenges to treatment charges, the constraints of managed care, increasing regulatory demands, time-consuming report preparation, high transcription costs, insurance company and governmental requirements for ever more documentation, and uneven patient retention rates. From the consistent undercurrent of discontent, one would think that chiropractors would be leaving the profession in droves but, in fact, they are an adaptable crowd and they continue to find ways to adapt.
According to David S. O’Bryan, executive director of the Association of Chiropractic Colleges, his member institutions in the U.S. and Canada graduate about 2,500 new doctors each year, a figure that has remained stable over the last several years, even while the rigors imposed on the profession have increased. Meanwhile, the number of practicing chiropractors also remains stable, at an industry-estimated 65,000 doctors–this despite a trend in favor of more conservative health care approaches and an expanding population that should, in fact, signal substantial growth. The number of hours worked each week is on the decline, now averaging 30-40 hours per week as many transition from full-time to part-time practice. The net-net would suggest that, while many in the field do well, these are troubling times for others and that perhaps the field is not growing as fast as it could and should.
“People want to stay in the profession,” says National Board of Chiropractic Examiners Executive Director Donna Liewer. “It is a high-satisfaction field, highly personal to its practitioners.”
Exploring the issues
The problems are familiar to any doctor, whether new to the field or a practitioner of long standing. Among them:
• Regulatory issues: State and local agencies have a full menu of practice requirements, recently complemented by measures like the Health Insurance Portability and Accountability Act (HIPAA).
• Collection issues: Because chiropractic relies on enlisting the body’s natural healing propensities, it can be difficult to convince payers of the efficacy of chiropractic treatment versus traditional methods.
• Reporting requirements: Documentation is fundamental to tracking progress and, ultimately, to getting paid. Insurance companies increasingly demand more detail, including complete history and physical examination.
• Medical examinations: Outside payer consultants consume valuable time and often force compromises, particularly when documents such as a complete history, complete examination, treatment plan and/or diagnosis are missing.
• Administrative and transcription costs: These vary with the size and nature of the practice, but they can consume hundreds of dollars per month, often creating associated problems through errors and delayed deliveries.
• Image considerations: The image of chiropractic is improving, but there is room for improvement. We do this by seeking Cultural Authority.
• Patient acquisition: Growth is imperative for chiropractors, as it is for any other type of business activity.
The challenge here is coping with these issues in a way that is affordable, ethical, legal, and within the expertise range of professionals who may not be well trained in business.
Most of us are familiar with practice management systems which, in concept, are much like the back office software solutions used in commercial businesses. They are basically build-outs of accounting software systems, modified to accommodate specific requirements of health care organizations.
Unfortunately, most of these types of systems overlook the area of documentation and reporting, at a time when documentation must be more complete and more detailed than ever. It must also be accurate and compliant with all local, state and national laws. In Florida, for example, inadequate record keeping is the number one reason doctors are brought before the board.
According to a recent survey by the National Board of Chiropractic Examiners, documentation takes 18.9 percent of the typical practitioner’s time, while time spent on direct patient care has decreased from 62 percent to 52.9 percent in only three years. The rest of the time was absorbed by business management and patient education, at about 13 percent and 15 percent, respectively.
Current and accurate notes are critical at every stage of examination, diagnosis and treatment. Reports that detail the case once it has been completed, or at interim stages, normally require sometimes hours of dictation. Transcriptions can take days or weeks for delivery, cost $20.00 or more per hour, and can involve even more time and money if they require return for error correction.
Dictated reports remain ad hoc and extemporaneous, even though practiced and generally well-informed. They can be rambling or circumlocutious, and they can be difficult for payer analysts to comprehend, leading to detours, denials, and referrals to independent medical examiners. Precise detail is not an option, given the regulatory and reimbursement environments that now exist. According to the NBCE survey, only one-fifth of patients pay cash. Another one-fifth are covered by private, non-managed care plans, and yet another one-fifth by managed care contracts. The rest, more than one-third of all reimbursements, come from personal injury, Medicare, Worker’s Compensation and Medicaid. All scrutinize carefully any document that arrives requesting a payment.
Can a relatively simple and affordable software solution address all of the documentation-related problems outlined above? Automated hardware-software solutions, in general business, streamline back office processes and all but eliminate errors associated with manual activities. The same levels of results can be achieved both in front offices and examining rooms through the use of a dedicated reporting solution.
These solutions can exist side-by-side with practice management systems and complement them. One solution that I and a number of my associates discovered, RAPID EMR from ACOM Solutions, Inc. (www.acomemr.com) starts with a patient self-registration form that resides on a tablet computer and which the patient completes while waiting for the doctor. All the receptionist has to do is to start the file by entering the patient’s name and appointment information at the time of the initial contact.
The patient records the symptoms, reason for the visit, personal history and the rest of the information that might otherwise occupy a multi-sheet paper form. The information input by the patient is the first stage in the creation of an electronic file that builds automatically with each visit and treatment.
Documentation and Why It Can Ruin Your Life–or Save it
Documentation practices among chiropractors typically differ little from those of practitioners in other health care sectors. You interview the patient, make your diagnosis, record your notes continue to build the file and, when the case is resolved, create the necessary reports. This is the process that consumes 20 percent of the typical chiropractor’s time–one in every five working days.
Documents fuel virtually everything you do, from inaugurating and tracking treatment to submitting your bill and encouraging the continuation of a wellness program. Experience clearly demonstrates that timely delivery of documents that are consistently clear, comprehensive and well organized contribute positively to the financial health and the image of a practice.
Simplicity on the surface often conceals extreme complexity in the underlying structure and that is no less true with our case in point. When a patient arrives in the examining room, the doctor can review the information entered by the patient and then proceed through a succession of other screens, step-by-step, enlarging on the diagnoses as he or she explores the patient’s self-described symptoms.
For example, if pain is indicated at a certain point on the patient’s spine, the system allows you to summon a diagram and zero in precisely on the specific vertebra and/or muscle involved. By “clicking” on the spot, you can send a module of associated text automatically to the file. If elaboration is necessary, such as to establish duration or level of pain, you can call up a checklist that also has associated text for various timetables or levels and this, too, becomes part of the file. The solution allows the flexibility to randomize the respective text blocks, recast them in a doctor’s own words, or to modify them on the fly in order to avoid a “canned” appearance. Direct personal observations can be entered as handwritten notes composed right on the computer screen.
As treatment progresses or when it concludes, all of the information that has accrued automatically in the patient record–including such things as photos, X-rays, diagrams, etc., that have been scanned into the system–is available for the reports. The system offers several outcomes assessment reports as well as a final report format.
The Value Proposition
How does all of this apply to the professional and business problems mentioned above? There are several answers. Among them are timely submission; clarity and consistency; comprehensiveness; accuracy in diagnosis; freedom from errors; and coding and compliance confirmation, which is incorporated right in the software.
We are all familiar with rejected and disputed claims and, often, doctors are discouraged from fighting back. Sometimes disputes are the doctors’ own fault–such as when reports on which the claims are based are unclear, wordy and not to the point. In such cases, even if the claim is not rejected outright, it may be referred to a third party medical examiner, costing the doctor time and inconvenience.
With a good documentation and reporting solution, delayed submissions are in the past. Reports normally can be submitted the day treatment is concluded, and they are uniformly concise and clear. They are structured to guide the analyst through his/her process quickly and convincingly, leading to a much more favorable pattern of payment. And, with reports generated automatically from material in the patient file, most problems disappear…as do the costs and delays associated with farming-out the transcriptions or staffing the office to perform it internally.
The image of the chiropractor as a professional is always a consideration in cultivating referrals. Reports are reflections of the person creating then, especially when they are sent to other physicians, attorneys and payers. One chiropractor reported that, after she began using her automated reporting solution, she received personal phone calls from referring physicians commenting on the quality of her new reports.
The accuracy of your documentation may make the difference in whether you are allowed to continue care of your patients or not. One of the best ways to support the need for periodic revisits is through a clear and concise explanation of what went wrong, how the problem was dealt with, how treatment progressed, and what the prognosis might be. These factors are all covered well and clearly through a variety of outcomes assessment reports that the doctor can review with the patient.
This software system incorporates four separate outcomes assessment reports, including a Visual Analog Scale, the Revised Oswestry, the Roland-Morris, and the NPDI. These reports make it easy for patients and other concerned parties to understand the problem, the course of treatment and the prognosis.
Would I suggest that automated documentation processes are the answer to all of our profession’s ills? Not at all. Excellence in patient care comes before everything else. But any mechanism that makes us more professional, more visible, more effective business people and which improves our relationships with other professionals, our business associates and our patients is certainly going to support us better today and provide our foundation for tomorrow.
Documentation is a continuing problem throughout the health care field and one that shows no signs of going away. Automation of diagnosis, notes and reporting processes is certainly such a mechanism. It can save up to one-fifth of a DC’s professional time, improve cash flow and provide more time for recreation, family life and professional development.
A resident of South Florida, Dr. Hyde received his D.C. degree from Logan College of Chiropractic, after previously graduating from Florida State University. In addition to operating a successful private practice, he has held post-graduate faculty positions at several chiropractic colleges.
Dr. Hyde has served in various capacities with local, national and international professional, sports and educational entities and is a frequent presenter at professional conferences and seminars. He holds numerous honors from organizations within and outside of the chiropractic field. He can be reached at