Academic Journal

e-MDs

Melvin Young

BIO 337N: Practicum

Summer 2010

Week 1: Jul 12-16, 2010

Mentors: Michael Smith, Jennifer Pritchard

Monday, Jul 12

What I did:

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. They’re being extremely flexible in where we’re 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 won’t

be an issue.

What I learned:

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.

Tuesday, Jul 13

What I did:

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.

What I learned:

The trainers connect with the clients through Cisco’s 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.

Wednesday, Jul 14

What I did:

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 Mike’s old instructions were no longer valid. Thirdly, the installation of Solution series on the

client’s server was missing files, and Mike was unable to setup the automated tasks required for

RXHub.

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.

What I learned:

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.

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.

Thursday, Jul 15

What I did:

Today was a full day listening to Jennifer and Mike’s 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.

The afternoon focused on dealing with insurance such as posting and co-insurance. Mike

took over since Jennifer had a doctor’s 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 won’t likely list the proper ID.

What I learned:

There’s 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 couldn’t 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.

Friday, Jul 16

What I did:

Today was a full day attending Mike’s 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 couldn’t 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.

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.

What I learned:

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 wasn’t 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. It’s 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

there’s 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.

Week 2: Jul 19-22, 2010

Mentors: Wendy Pilgrim, Alicia Wagner, Nikki Thompson, Paul Spock

Monday, July 19

What I did:

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.

What I learned:

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 clinic’s

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.

Tuesday, July 20

What I did:

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.

The rest of the day was spent doing Alicia’s 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.

What I learned:

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.

During the posting, I saw how the greatest frustrations involved patients with secondary

or tertiary insurance providers. Sometimes the primary wouldn’t 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 company’s methods.

Wednesday, July 21

What I did:

Today I shadowed Roniqueca Thompson, or Nikki, as she did her work in AR. Out of all the

roles in billing so far, Nikki’s 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.

What I learned:

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.

Thursday, July 22

What I did:

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, Paul’s main assignment was dealing with

immunizations / vaccination interfaces. I also spoke with other HIT students regarding their

experiences at e-MDs.

What I learned:

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.

Week 3: Jul 26-27, 2010

Mentors: Michael Rickman, Nina Heeren

Monday, July 26

What I did:

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.

What I learned:

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 didn’t 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.

Tuesday, July 27

What I did:

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.

What I learned:

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 didn’t see the interface support personally, I was

told they focused on interfacing e-MDs Solution Series with other applications.