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- 1. Academic Journal<br />e-MDs<br />Melvin Young<br />BIO 337N: Practicum<br />Summer 2010<br />Week 1: Jul 12-16, 2010<br />Mentors: Michael Smith, Jennifer Pritchard <br />Monday, Jul 12<br />What I did:<br />Today was a short day, only involving a 3 hour orientation. Mike <find last name> took us on a tour of the facility, which had been previously owned by a prosthetic limb manufacturer. More importantly, was the sheer amount of branches e-MDs had, each with specified tasks. We visited thirteen different divisions, including implementation project managers, training, and even a mock clinic. Theyre being extremely flexible in where were assigned, allowing all of us to get a taste of everything on a rotating schedule. Several of the divisions sent speakers explaining the details of their department to us. I requested rotations between training, billing services, and the team developing their next-gen software scheduled for release in the future. Lastly, we were given four forms to sign, mostly variations of non-disclosure agreements. In addition, we will not be allowed internet access during the practicum. Hopefully they keep us busy enough so that wont be an issue. <br />What I learned:<br />I learned that one of the most difficult aspects of coordination for a vendor is keeping all the groups running in sync. I look forward to seeing how they do that as I go through my rotations. Seeing the number of non-disclosure forms let me see how seriously e-MDs is taking HIPAA regulations and other privacy and security issues. I can also infer how competitive this industry has become. They were emphatic in telling us not to post our activities on social websites, and if we saw others doing so, they asked us to emphasize positivity. <br />Tuesday, Jul 13<br />What I did:<br />Today I was assigned to shadow Michael Smith in the training department. When I came in, he was in the middle of an online / telephone training on patient portals. Jennifer brought a splitter so that I could listen in on the sessions. In between online sessions, Mike discussed with me his impressions on the solution series, and his take on issues with the health care system. The first session I got to listen into was about Crystal reports. During this session, the client, who was an office manager, complained about the lack of automation in the billing module. She was, however, impressed with some of the AR reports available. The second session I was supposed to listen into was canceled. The client, a doctor, claimed they had finished the necessary training. Mike spoke to the project manager in charge of their implementation, Lana, and informed her of training cancelling. This was notable because they still had 10 hours of online training scheduled in the next week. <br />What I learned:<br />The trainers connect with the clients through Ciscos WebEx, similar to remote desktop except it allows easier connectivity via the internet. Their ticketing system is done through Parature. Mike accessed Parature to check the notes of the trainers who had done the previous online training sessions with the doctor who canceled the sessions. He discovered that they had received 8 hours of training instead of the 6 hours the project manager had thought. In addition, by going through the training session notes, he was able to see that they had indeed gone through the required training, although both Mike and Lana were worried that they had not spent enough time to acquire the fundamentals. <br />Wednesday, Jul 14<br />What I did:<br />Today, I spent the morning with Mike again listening to the online training sessions. Today, he did a session on RxHub. Mike told me that RxHub and patient portal training was becoming extremely common because the advent of meaningful use. However, this training session ran into a great deal of issues. First, there were issues connecting via WebEx; the client, an office manager, had to switch computers multiple times. Secondly, the Surescripts website had changed overnight, and Mikes old instructions were no longer valid. Thirdly, the installation of Solution series on the clients server was missing files, and Mike was unable to setup the automated tasks required for RXHub. <br />In the afternoon, I spent the afternoon in the classroom, listening to Jennifer teach clients in the classroom. Today they were going over scheduling. The topics they went over included access levels, dashboard organization, setting up defaults in fields, and Codelinker. Whenever an issue came up during training, Jennifer jotted down the problem to forward to IT after the session to have it fixed as soon as possible.<br />What I learned: <br />The first thing that became apparent to me was that even with RxHub implemented, its usefulness was relatively minor. The reason for this is because of how few insurance companies and pharmacies were fully participating. Typically, Mike would have to go through three or four patients to find one that had the requirements to get the data. However, once he did, the usefulness of RxHub was easily apparent. For example, one patient on four different medications had two which were not covered under their insurance; RxHub quickly identified alternative generics which were covered, which would clearly save the patient a lot of money. <br />In the class, I saw how thoroughly Jennifer went through each piece of data. I also saw how much better it would have been if we had the opportunity in the CEC to follow the presentations on workstations that had the vendor software on it. The reaction of the clients seemed to be most positive when dealing with Codelinker, which allowed office managers to link visit reasons with instructions. They quickly saw how this could facilitate implementation of guidelines per condition, lowering error and raising efficiency. <br />Thursday, Jul 15<br />What I did:<br />Today was a full day listening to Jennifer and Mikes training class. This morning focused on billing, something which we had little exposure to in the CEC. Some of the topics today included overall management of the practice finances, avoidance of red flags which represent non-billable codes, and customization of fee schedules. <br />The afternoon focused on dealing with insurance such as posting and co-insurance. Mike took over since Jennifer had a doctors appointment. There were some confusing issues such as duplicate insurance due to separate addresses to file different types of claims. He taught them to use internal labels to overcome these issues so the staff would know where to send. He also taught them to update their payer IDs directly from their clearinghouse. The information on the cards wont likely list the proper ID. <br />What I learned:<br />Theres a strong sense of antipathy against insurance companies. The client complained about difficulties on getting proper fee schedules. Mike talked about how the insurance companies used to have policies of discarding every 10th claim regardless of the content. Also, he made a point to tell the class to type out the full name of the insurance company when typing up claims. Not only does it promote consistency, but they might even reject the claim if there were only an acronym. Consistency is a key to all claims filing. He even suggested having only one person input all insurance company information. Interestingly enough, he also suggested the person inputting should manually type in the insurance tags and class since there were far too many in the drop down box. Another issue was legacy codes which he taught them to ignore; because old customer still utilized them, development couldnt remove it, but training taught clients to ignore them. It is clear why the entire company is looking forward to their next big software release as it will allow them to use software initially designed for meaningful use. <br />Friday, Jul 16<br />What I did:<br />Today was a full day attending Mikes training class. In the morning, Mike spent quite a bit of time teaching the class about quirks in the billing interface. He taught the class that although the goal was to automate as many tasks as possible, manual manipulation of many field in billing was essential. There was general emphasis on setting things up properly to prevent future issues, such as properly labeling claims to ensure insurance companies couldnt deny them. Mike explained to the class current issues with reason codes and group codes for posting. He emphasized to the class about how automation was dangerous when dealing with secondary claims due to potential inaccuracies. Another issue he explicitly explained was that the Other Adjustment field would be better labeled as Remaining Balance. The posting process was overall represented as somewhat ugly and convoluted with general blame again directed against insurance company policies and administration. <br />The afternoon continued with its focus on the billing system on topics such as reversing charges and reversal of payments. Mike was particularly pleased with the Audit Report capability of the Solution series. He told the class that this module took 3 months of QA and was one of the most heavily requested features. Mike spent some time pointing out a recent change in the interface that could throw old users of the Solution series off. After that, Mike went through several important reports, such as Prepayments Collected and Till Reconciliation. <br />What I learned: <br />A few days ago, Mike told me in his opinion, the billing portion of the Solution series was its weakest facet, and I was able to see why. He told about how he reported to development about a booby trap within the program, which was basically an improperly configured field which could easily disrupt workflow. However, developers simply said that it wasnt high enough priority, so trainers were forced to simply inform clients of the issues and how to work around them. These types of issues are likely a large reason why e-MDs is eager to migrate to their next generation software as soon as they can. Its interesting how client driven EHR products are; with vast amount of alternatives, all vendors must strive to please clients as much as possible. This is evident in what William from the marketing department said the first day. He said that although e-MDs customers accessed the web as the first point of contact, the majority of purchasers were from word of mouth. A happy client is a client that will recommend their product. I also wonder if theres a bit of disconnect between the training and development team. There were multiple features or changes which Mike seemed a little bit exasperated about. More than likely though, this is just an issue of prioritization of resources. <br />Week 2: Jul 19-22, 2010<br />Mentors: Wendy Pilgrim, Alicia Wagner, Nikki Thompson, Paul Spock<br /> <br />Monday, July 19<br />What I did: <br />This week I was assigned to the billing services department. It was decided that I would rotate through different roles of the service through the week. Today I was assigned to Wendy Pilgrim, who was posting claims and building invoices. Although Wendy normally deals with AR issues, this past week she has been taking on this additional role while someone was on maternity leave. In the morning I watched her take care of one of the practices she was assigned with. I was told this practice was particularly messy and difficult to deal with; roughly 1/3 of the patients had issues that had to be dealt with before sending the compiled invoice as an e-file to the scrubber. The scrubber sends back a report within about 30 seconds at which point the issues in the report must be fixed. Finally the modified e-file is the sent to the clearinghouse. In the following days, a report from the clearinghouse will be available containing potential problems that must be repaired. In the afternoon I was allowed to do the claims and invoice processes hands-on for another clinic with Wendy giving me instructions when required. <br />What I learned:<br />I learned various things about the workflow required to post claims and build invoices. It was also great to actually see how e-MDs used the scrubber and gateway. The billing specialists also have a customer service role since they deal directly with the customers for the practices they do the billing for. The actual billing module of the solution series felt a little bit flaky; several times Wendy showed me workarounds for particular issues for a certain clinic. For example, one clinics fee schedule was not properly implemented, so occasionally codes with no charges would appear. Wendy had to force the charge to reacquire a fee schedule manually each time. <br />Tuesday, July 20<br />What I did:<br />Today I was mentored by Alicia Wagner who was handling posting payments. First though they were having a monthly meeting with one of the four clients the team was assigned with. The time until the meeting was spent doing as much research as possible on the current state of the practice in order to answer any questions or issues the provider might bring up. I was told this provider in particular was very on top of things in his clinic and would require them to be on the ball. The meeting went pretty smoothly with the provider and office manager stating their questions and issues, then e-MDs billing team went through their own. The provider seemed demanding, but was also very willing to do make changes on his end to help the overall process. The major focus of the dialogue was on rejections with a small sidebar into general financial trends. <br />The rest of the day was spent doing Alicias primary job, posting payments. The majority of the focus was on. Each clinic Alicia was assigned to had a receivables tracking spreadsheet. There she would keep track of the live checks posted at e-MDs, the live checks posted at the practice, and those that were done electronically via EFT or ACH. All the data in the EOBs had to be posted manually during this process. <br />What I learned:<br />The meeting with the client let me see how closely e-MDs has to work with providers in order to streamline the process as much as possible. Because one person on the team was out on maternity leave, there was a problem with an issue she had been assigned with that she neglected to report about to others in the group. Therefore the problem had to be researched on the fly in order to discuss with the provider and office manager. This underscores the importance of communication both within the team and with the practice. <br />During the posting, I saw how the greatest frustrations involved patients with secondary or tertiary insurance providers. Sometimes the primary wouldnt send on time, or the secondary would overpay. Another major issue was the variance in EOBs. Although the required data was always there, they were always labeled different and located in a different area. This could cause great confusion with the biller if they were not yet familiar with the insurance companys methods. <br />Wednesday, July 21<br />What I did:<br />Today I shadowed Roniqueca Thompson, or Nikki, as she did her work in AR. Out of all the roles in billing so far, Nikkis work seemed to be the most focused as she worked solely on appeals and denials. From morning to afternoon, her time was spent doing brief research on the reason for a denial before contacting the insurance company to deal with it. Today was spent going through a work-list of 230 items of a specific clinic. I was also given the opportunity to handle some of the more simple issues and handled four claims today. <br />What I learned:<br />I learned just how important each step of the process was today. All issues not resolved during the building of claims and invoices or posting payments required work on the staff in charge of AR. Also, the majority of issues seemed to be along the lines of lost paperwork; there were a lot of issues that were potentially solved with a resubmission of information or of a form. There was also a technical issue that caused Cigna to mail checks to an old address for months, forcing Nikki to request that they cancel the payment and resubmit to the new address. <br />Thursday, July 22<br />What I did:<br />Today was a slow day because the majority of senior personnel went to the AT&T conference center for the e-MDs sponsored User Conference. I decided to check out implementation project management instead of my assigned space in billing. I spoke with Paul Spock about the various roles in his job while he was dealing with a process called conversion. Conversion is required when the practice adopting e-MDs has existing EHR or practice management software. Instead of the 2 or 3 hours required to input required defaults and initialize the solution series, up to a week is required to ensure all data is properly migrated. When not dealing with specific projects like conversion, Pauls main assignment was dealing with immunizations / vaccination interfaces. I also spoke with other HIT students regarding their experiences at e-MDs. <br />What I learned:<br />From Paul I learned about how those at IPM were the face of e-MDs to their clients. As such they get a disproportionate amount of both praise and especially praise. Paul seemed to relish his role of being the hub and dealing with people more than technology. He said one of the biggest issues during implementations was clients not knowing their limits and not listening to the advice of the IT support team or training teams. Paul seemed to be slightly exasperated at the tedium of conversions and was hoping something more efficient like electronic entry by clients could be adopted. From the other HIT students, I learned that their experiences at e-MDs had been as positive as mine. The staff was very friendly and accommodating, doing their best to make our experiences as beneficial as possible. <br />Week 3: Jul 26-27, 2010<br />Mentors: Michael Rickman, Nina Heeren<br />Monday, July 26<br />What I did:<br />Today I attended a couple meetings at the development group. Unfortunately the development teams were dedicated to establishing a tasks and timetables, so those of us here saw no actual development work. I mostly spent my time observing how they did things and methods of organization. Due to the non-disclosure agreements, those of us shadowing the next-gen development team must be vague in our journals. <br />What I learned:<br />A lot of time spent planning in the beginning will likely save time by preventing potential issues from occurring during development. There were two separate development teams along with QA which had to be coordinated. They were trying to organize several hundred development hours between each other, and there was quite a bit of discussion to figure out what things they should take responsibility for. They mentioned it was very important that they didnt overreach as it could slow down development if they took too large a part. Therefore several large sections were left as open so that development teams could take further responsibility if their progress was favorable. <br />Tuesday, July 27<br />What I did:<br />This morning most of the HIT students attending e-MDs participated in thanking the staff by handing out boxes of donuts to those who mentored us. I visited all my mentors with the exception of Mike Smith; as a trainer he was out of town. It was gratifying to thank everyone personally and marked a positive ending to an excellent experience. For the remainder of my time at e-MDs, I split my time between software support and IT support. At software support, I was mentored by Nina Heeren. I was able to listen in to a few of her support tickets and calls. At IT support I was mentored by Michael Rickman. He gave me a 90 minute long lecture on the type of work he did while introducing me to multiple internal modules of e-MDs.<br />What I learned:<br />Today I learned about the multiple layers of support and how they were organized. There were two layers of software support, with IT support being the third layer and interface support as a fourth layer. Software support dealt with the specific issues within the e-MDs software, such as difficulty using a module or issues with the GUI. IT support brought it a step further as it included support with SQL server configuration, fax server issues, and other issues with the setup and deployment of the Solution Series. Although I didnt see the interface support personally, I was told they focused on interfacing e-MDs Solution Series with other applications. <br />