William R. Pupkis, CMPE


Published 6/1/2012

Best Practices for Orthopaedic Practices

AAOE members weigh in on office technology

Recently, AAOS Now asked representatives from the American Association of Orthopaedic Executives (AAOE) to participate in a roundtable discussion on technology best practices in the orthopaedic practice setting. Moderating the discussion was George D. Trantow, FACHE, of Aspen Orthopaedic Associates (Colo.), which has 10 orthopaedic surgeons and 55 full-time employees. Joining him were the following practice managers:

  • James P. Kidd, CMPE, of St. Peters Bone & Joint Surgery, Inc. (Mo.), a 4-surgeon, 27-employee musculoskeletal practice
  • William R. Pupkis, CMPE, of Capital Region Orthopedics (N.Y.), a 28-surgeon, 128-employee multispecialty practice
  • Barbara Sack, MHSA, CMPE, of Midwest Orthopaedics, PA (Kans.), a 4-surgeon, 22-employee single-specialty practice
  • Sam Santschi, JD, with Diana L. Kruse, MD, a solo orthopaedic surgeon in Wisconsin
  • David Schlactus, MBA, CMPE, of Hope Orthopedics of Oregon, a 14-surgeon, 150-employee, single-specialty practice

James P. Kidd, CMPE

Barbara Sack, MHSA, CMPE


David Schlactus, MBA, CMPE

Mr. Trantow: Although every one of our practices uses some type of practice management system, the largest group and the smallest group represented today do not use an electronic medical records (EMR) system. Why haven’t you adopted that technology?

Mr. Pupkis: In our practice, the difficulty has been finding a technology that doesn’t slow down the doctors. In my opinion, most EMR systems are built for primary care doctors—not orthopaedic surgeons. By missing this year, we’ll pass up $18,000 per physician of incentive payments, and we’re willing to give that up because it won’t offset the loss in productivity. We do E-prescribe.

Mr. Santschi: We’re a solo practice with a doctor in the twilight of her career so being an early adopter of EMR was not our goal. We’ve taken the steps to do E-prescribing so we’re not getting penalized, but we’re obviously not participating in the bonus program.

Mr. Trantow: The issue of dictation versus a point and click to create a note faces every practice. Anyone want to comment on the use of voice recognition or transcriptionists to create the EMR note?

Ms. Sack: Our physicians do dictate despite having an EMR system and having qualified for meaningful use in 2011. We have an exceptionally productive transcriptionist who works by the hour and not by the line, and the physicians believe that dictation enables them to be most efficient and productive.

Mr. Kidd: Our physicians use smartphone technology for dictation. The phone is populated with the list of patients to avoid missing or deleting any dictations. We are also investigating the use of scribes.

Mr. Santschi: Our hospital has technology we use for hospital dictation. We outsource all our in-office dictation.

Mr. Trantow: And we are also dictating and it goes into the EMR from a transcriptionist. I think that’s a pretty popular model at this point. Among those practices that have adopted EMR technology, what’s been your return on the investment? How long did it take to pay for itself?

Mr. Kidd: We’ve had an EMR system since May 2004, and although we did not achieve the vendor’s promised return on investment, we did get our money back within the first 3 to 5 years, based on the improved processes we could implement.

Ms. Sack: We have not done a true return on investment analysis because so much of the return is difficult to quantify. It has to do with time and efficiency. For example, it’s simplified recordkeeping. Every report or interpretation used to come in via paper, was reviewed and signed by the doctor, and then filed in the chart. That process could take days. Now they come in via the fax server, are immediately messaged to the doctor, and simultaneously filed in the chart. We no longer spend time tracking down “missing” reports for a patient.

The doctors have seen an improvement in their lifestyle and they enjoy the ability to manage issues remotely. So the benefits may be difficult to quantify financially, but we believe that the investment has been well worth it.

Mr. Trantow: We paid off the first document management system we had (2003) in just about 3 years. When we switched systems, it was more difficult to achieve a return quickly due to the initial savings in staffing achieved with the first system.

What about electronic claims submission, auto remittance, and checking on patients’ health insurance benefits?

Ms. Sack: Eligibility verification is critical. We try to verify eligibility and benefits prior to an appointment, so we know what kind of copayment to expect. Does the patient have a high deductible? How much can we collect? Do we need to set up financial arrangements? Although we have a plug-in for our practice management system, we continue to struggle with it. We have to go to each payer’s website, which is much more time consuming.

Mr. Pupkis: We recently decided to return to our old practice management system so that we can verify eligibility, identify plan type and deductible, and establish a secure patient portal for credit card information and payment plans. At least that’s our hope!

Given today’s high deductible plans, practices need to know how much of the deductible has been met. Because payments for specific services may be dictated by contracts, you can tell the patient what a service will cost and determine whether a payment plan is appropriate. This changes how we do business.

Mr. Trantow: That’s a great point. We struggle because we don’t have that information from every plan. But having the information will enable us to give the patient a proper bill, without over or under collecting.

Ms. Sack: I think that portals are going to come with that kind of functionality. It’s critical to the survival of orthopaedic practices that we can ensure that we’ll be paid for what we do. We’re constantly trying to keep up with what is available, what it can do for us, and what we need to remain competitive.

Mr. Trantow: Our practice has two portals, one through the website for financial transactions that we constructed and one through the EMR system. On the EMR system, I think that transparency will be key in the future. I think patients will be able to log in, review their planned treatments, and download the notes so they have access to their full medical record.

Ms. Sack: We have a portal that does financial transactions; it also allows patient registration data to be imported directly into the practice management system, through a dashboard interface that enables us to check the data before accepting. Automating that process can eliminate some staffing requirements.

Mr. Kidd: I think the challenge will be getting the patient’s involvement. We opened a patient portal in January 2011 and the buy-in is probably still well under 15 percent. So now we’re gathering data when the patient calls to make the appointment and including it in the encounter note so it’s all documented prior to the visit.

Mr. Santschi: Our patient demographics are heavily Medicare and rural to semirural. These patients have neither the aptitude nor the desire to do that ahead of time on a computer.

Mr. Trantow: I have seen a couple of specialty practices that mandate that patients go online and register before the appointment. For my staff, who are medical and computer savvy, that’s not a big deal, but very few patients use the website even when we tell them. How do we make it easy?

Ms. Sack: We’ve seen an increase in the number of patients who go online, and I think that part of it has to do with how it is presented. Our practice management system will send the patient an email with an invitation to go online, register, and enter all their information. We tell patients that if they do this online, they only have to show up 5 or 10 minutes prior to their appointment. Otherwise, we ask that they come in 45 minutes early.

Mr. Trantow: You brought up a good point on reminder calls. We now collect patients’ preferred method of communication. With some automated reminder call systems, the message can be sent via email, test, or a call.

William R. Pupkis, CMPE
Sam Santschi, JD
George D. Trantow, FACHE

Ms. Sack: We use an encrypted email for appointment reminders. We have used texting in the rare instance when a physician has to cancel clinic for the day, asking the patient to call the office. That enables us to reach patients quickly to get things rescheduled without putting out protected health information.

Mr. Kidd: We have started collecting email addresses from our patients, which we use for marketing and survey purposes. At the end of each week, every patient who’s been in gets a reminder email to go online and complete the survey for a chance to win a $50 gift card.

Ms. Sack: I love that potential for patient satisfaction surveys via email.

Mr. Trantow: We are doing patient satisfaction surveys on Kindle Fires in our office. It’s live data, inexpensive, and you get real-time feedback. It actually alerts us if patients complain about wait times, which enables us to address it that day and do some service recovery. Is anyone else doing an automated patient satisfaction survey?

Mr. Schlactus: We are. We get the patient’s email addresses and send them a survey after the office visit. The survey is simple and short; it only takes 5 minutes to complete. The scores and written feedback are then instantly available. The system also identifies patients who were seen in the last 90 days, so they don’t get a second survey.

Now, we’re struggling with what to do with this interesting information. Are we really going to change to reflect the areas where we need to improve?

Mr. Trantow: That’s a great point. Has anyone had the success in that area? How do you take information on patient satisfaction and convert it to a change in behavior?

Mr. Kidd: I download results monthly, tally the scores, categorize positive and negative comments, and calculate the percentage of new and existing patients who responded. Then I send the information and comments to the physicians so that they know how the patients are responding.

Later, I strip out any identifying information and share the results with the staff. We talk about it on a quarterly basis, so it’s an educational tool for providers and staff.

Mr. Pupkis: We found that if you display the information, no one wants to be at the bottom of the heap. As long as the physicians see that the data are valid, you definitely can get movement and an upward creep in improvement over time.

Mr. Schlactus: Another aspect is the culture of your group. In our practice, if the physician misses an all-doctor meeting and was physically in town, he or she gets fined $250—and they all make the meeting. We’re looking at putting some dollars to patient satisfaction scores, and we expect that those scores will go up.

Mr. Trantow: Anybody experimenting or having any success with social media?

Mr. Pupkis: We’re about to go into that. We’ve had a website now for years, which we’re revamping. In addition, we’re getting a Facebook page, and a Twitter account. We’re going to start updating these pages with articles written by our physicians. Several of the younger doctors are excited; they plan to post incision photos—without any patient identification—or possibly even short film clips. From what has been described to me, it should be quite successful, but I have no proof.

Mr. Kidd: We recently set up a Facebook page, but we don’t have a Twitter account. I heard recently that for a medical practice, a good Facebook presence is an average of 100 followers per physician. We are about to embark on a major integrated marketing campaign directly to patients, using all these tools.

About 6 months ago, we signed up for iTriage, which is a free app that drives patients who are looking for an orthopaedic doctor to our physicians. The app also enables patients to find an urgent care center or hospital or ask about drug interactions.

Ms. Sack: In our group of 4 orthopaedic surgeons and 2 physician assistants (PAs), the thing that has held us back on social media is that someone has to keep it updated—me. With everything else on my plate, Twitter and Facebook are being elbowed to the bottom of the heap.

Mr. Schlactus: What about iPads, tablets, and handheld devices?

Ms. Sack: We have been using iPads for almost 2 years. The doctors love it, and it has completely taken the place of notebook computers.

We originally started with notebook computers for picture archiving and communication systems (PACS) because the exam rooms were not wired for monitors. When one of the doctors brought in his iPad and tried it using a remote desktop application, he said, “I’m never using a notebook again.” The PACS images are not as large as they would be on a monitor, but they’re much better on an iPad than on a notebook computer.

Mr. Santschi: We’re not using iPads, but we do have access to images and records through the hospital PACS. We have a monitor in one of the three exam rooms.

Mr. Schlactus: We have high resolution monitors in every exam room because we run our PACS through it. However, several physicians and PAs have iPads with voice recognition software for notes or dictation. Increasingly, doctors and PAs are using iPads to interface with the EMR system.

Mr. Pupkis: We’re a Microsoft house and iPads don’t always work well in a Microsoft environment. I’m not sure if they’re ready for our marketplace yet.

Mr. Trantow: What about using electronic or other devices to communicate with staff? We have texting in our EMR so the doctor can tell the nurse to go to room 2 and put a short arm cast on the patient there or tell the x-ray technician to go to room 3 and get a 3-view spine x-ray.

Ms. Sack: We have implemented an internal instant messaging program so we can instant message within the practice. You can also create custom messages to let people know you’ll be on a conference call or whatever. We can also send messages via the EMR system.

Mr. Trantow: We’ve had great success with online training. Staff can train at their own pace. The system keeps track so you know you’re compliant. I think that it’s one technology any size group should explore. But now, switching topics, what would you like to see developed?

Ms. Sack: I’m hoping for an add-on system that enables you to ensure that you are getting paid correctly. But the upfront workload to get everything into the system and all the fee schedules loaded is huge.

Mr. Santschi: I’m looking for reliable voice recognition software for dictation purposes.

Mr. Schlactus: I want to get our patient portal to work seamlessly. We have to find new ways to provide care in a cost-effective manner and an effective patient portal that is easy to use can be a long-term solution. We have not adapted our model of care to match the advent of technology, so I’d like to see a patient portal that can effectively help us come up with some options to change how we do what we do.

Mr. Kidd: A health data interchange that’s not that deficient, that’s not government run, that’s accessible and usable, and that will help us reduce the cost of health care.

For more information on orthopaedic apps for iPADS and tablets, see “Tablet Orthopaedics Increasing in Popularity.”