Are you feeling pressured to upgrade or change your software system? The mere thought of doing so may cause visions of conversion chaos to race through your mind. Spending more money on the computer may seem unthinkable. But practice demands continue to increase and change, requiring more of your computer system. At the same time, doctors like you have many options, depending on your specific needs. That’s why it can be hard to find a resource that will help you determine which way to proceed.

As practice development specialists who have helped many offices upgrade and use computer systems, we’ve put together this functional guide to help you modernize your software and hardware. No matter what your needs may be, you’ll find some helpful answers here.

Most offices are currently upgrading either their hardware system or software applications. The most publicized reason is the infamous Y2K "bug," which has caused many software companies to revise their software or to discontinue the sale and support of their products. (See "Your Most Neglected Patient," page 42 of our August issue.)

Another reason lies in the many changes in the way you file claims and collect reimbursements, which have created a need for more sophisticated software applications. Many of the early data management systems could barely track a managed care claim, payment and adjustment, let alone efficiently handle a capitation payment.

Because of these inefficiencies, practices are forced to revert to manual tracking systems, which can hamper productivity. Practices are wasting precious office time and money maintaining obsolete software programs that can’t produce the meaningful reports and information you need to make profitable business decisions in the current health care market.

A third reason for upgrading is the possibility of interfacing your practice management system with diagnostic equipment, optical shops, satellite offices and ambulatory surgery or refractive surgery centers. Technology is booming, and automation at the clinical level is more available than ever.

By choosing equipment wisely, you can greatly enhance your office productivity. Interfacing with your billing system will move you yet another leap forward.

Luckily, many new and upgraded software applications are available to address most of your practice needs. The challenge is choosing the right application for your business with an eye towards future growth. Here are some tips, tactics and strategies that will help you analyze your needs and identify priorities, so that you can make the right decisions. We’ll also outline the process of converting your old data into the format of your new software system and tell you what expectations are realistic during and after the conversion.

The functions we’ll describe are part of an "ideal" software program, representing many of the possibilities in the market. You probably won’t find all of these functions in any one program, so you’ll need to buy one that provides the functions that you consider to be your highest priorities.

First, assess your practice needs and evaluate the performance of the new software application that you’re considering. Look at your current needs, as well as your expected needs for 2 to 5 years from now. Involve your staff in this critical process. (See "How Your Staff Fits In".)

Keep in mind that automation can be a wonderful boost to productivity for your practice if your staff is of above average computer literacy. Yet automation can be disastrous if too many new systems are added at once while your office and clinical staffs are in the process of their technology education. Layering is the key. You’ll need to know the abilities and limitations of your staff and add new systems accordingly.

Here, we’ll examine the overall system features you should consider as you prepare for a software upgrade.

• Make sure your new software will work with your current platform.
For example, your current platform may be UNIX, Windows 95/98, Windows NT or Novell. Another thing to remember is that most new computer technology, including diagnostic equipment, is heading in the direction of a Windows operating system. If one of your practice goals is to interface clinical equipment with your new management system, this will become a crucial point.
• Confirm Y2K compliance.
As obvious as this sounds, the old adage "Buyer Beware" applies here. Ask to see a compliance statement.
• Make sure you can accommodate multiple providers and sites, if needed
. This could easily become an issue in the future, even if it isn’t right now.
• Look at the "reports" module of the new application
. The production of meaningful reports is important. You must have a reliable way to gather and analyze accurate data so that you can make sound business decisions. (This capability continues to be the common link among the most successful and profitable practices. )

Here are the computer-generated reports you should inquire about before choosing your software:

• Accounts receivable (A/R) analysis
. This report should show open account balances aged 30, 60 and 90 days by payer, by patient, by provider, by unpaid insurance or by patient balances. Configurability -– the ability to run the report in many different ways – is crucial.
• A day sheet (also often called a day journal or day ledger).
This report lists daily financial totals (charges, payments and adjustments, in detail) and is used to balance totals at the end of the day. The report should have the capability of organizing data by provider, site or overall practice.
• Charges, payments and adjustments for any period
. These should be listed for the overall practice, or by provider, site or payer. The report should be highly configurable. The best systems will supply distribution graphs or charts to accompany these reports.
• Insurance analysis and utilization reports
. These will help your administrator further determine the profitability of your insurance plans. The ability to quickly identify a non-profitable insurance plan and take action is of vital importance. If you use relative value units (RVUs) to determine the cost of providing services, then you must make sure that your new system can incorporate them into this report, which should also be highly configurable.

On a general note, keep in mind that all reports should have the capability of running by date of service or by posting date to ensure report consistency. You should also be able to export all report information to other applications (such as Excel) for manipulation and analysis.

Now let’s review specific software functions by module. As you go through this list, mark a number of 1 to 5 in each of the blank boxes, with 1 representing your highest priority and 5 representing your lowest priority. After going through this process, you should settle on a system that has at least all of your 1s and 2s.

Now that we’ve reviewed the billing, appointment scheduling and patient information modules, let’s focus on an equally important issue: clinical interfacing capability. You’ll need to choose software that interfaces with the systems you own, or plan to buy. A realistic target may be moderate automation that’s comfortable for both the skill level and pocketbook of your practice. Consider these issues:

• The full hardware system requirements list.
This is the list that you’ll use to buy hardware and check for compatibility of diagnostic equipment. Ask for a detailed list of compatible diagnostic equipment.
• A support program that meets your needs.
Discuss response time for common scenarios. How will you reach the company? Via telephone (toll free)? What are the support hours? Are they compatible with your time zone? Does support come via fax, the Internet or on-site visits?
• Types of training and continuing education programs that are ideal and affordable
. Are they available on-site, via the Internet or through manuals? Are upgrades included in the initial software price? How are they installed and delivered?
• Expandability.
What is the cost and process for adding workstations and users?
• Ability to support an optical shop module
. This may or not be important to you, depending on your needs and your future plans.
• References
. How is this system working for others? Ask for a list of current customers in your area. Make sure to call and visit at least one of these offices.

Once you’ve chosen the ideal software for your office, you must decide on how best to transfer your existing database into the new application’s database format.

If you currently work with a manual system, you’ll have to build your database manually. (Also, consider building it manually if your old computer handles fewer than 1,500 patients.)

First, we recommend that you have your staff input data for patients who currently have open balances, and then enter data for new patients as they come in for their initial appointments. In many ways, this is a better way to convert, because electronic conversions can be unpredictable and can deposit years worth of unwanted data into a brand new, clean database.

However, if you have a large patient base (more than 1,500 files), we recommend that you do an electronic transfer. When making this transfer, you should at least be able to convert patient demographics in order to justify the expense of the conversion process.

Frankly, an electronic conversion can be a "crap shoot," depending on the nature of the two systems. You may need to double-check and adjust your database after the conversion.

To minimize conversion errors, carefully review the process with your new software vendor until you clearly understand what information you can and can’t convert.

Here are some tips and tactics to enhance the conversion process:

• Determine whether electronically transferring balances is worthwhile.
Find out exactly how balances will transfer. Sometimes, balances won’t transfer according to provider, making it difficult to distribute payments to the appropriate physician. If your office compensates physicians based on payments, this can be disastrous, especially if your old system is no longer operational. Consider manually transferring accounts receivable (A/R), so that you can distribute the open balances by provider, if needed.
• Make sure only one person interacts with the vendor
. This will prevent confusion and communication breakdowns.
• Anticipate problems associated with fields that affect the daily operations of the practice.
Numeric filing systems are a good example. If your chart number is 10 digits long and the new field permits only four digits, you have a problem.
Ask the conversion team to point the old chart number into a miscellaneous field to use as a reference while the new system assigns new four digit chart numbers.
• Before the conversion, perform a thorough A/R audit
. Write off old and small balances, re-bill claims and run statements. Purge all unwanted information from the old system. For example, eliminate files for deceased patients and duplicate accounts. There’s no sense in wasting computer memory on useless data.
• Ask the vendor’s conversion team to check data thoroughly.
You should expect the team to review your A/R (if it’s transferred) and individual patient information before it sends your new database to your office. Provide the team with A/R reports and patient information printouts. If basic information is missing, you should insist on the team reconverting the data.
• Review implications of switching from individual to family billing
. When converting from a system that lists individual patient accounts to a family billing system, you’ll need to know what to expect. How difficult is it to consolidate families? Is it better to manually convert?
• Consider the special contractual requirements of physician employees.
So-called "flags" may be needed to track their patients before the new system is operational.
• Don’t eliminate your old system immediately
. For reference purposes, try to keep it up and running for at least 6 months after the conversion.

We hope the detailed advice in this article will help you and your administrators in your quest for a computer upgrade that works for your practice.

Remember that the key to increasing profits in the new millennium is investing in the proper balance of automation in your office. By fully using the functions of the software application you select, and avoiding excessive automation, you can reach the maximum productivity level necessary to maintain and increase profit levels.

You have no reason to feel like money is flying out of your pocket when it comes to computers. As with any major purchase, you should come out ahead if you do your homework and choose the system that works best for you and your staff.

Don’t assume that a new application will have all the billing functions that you like in your old system. Look for and inquire about the following features:

• Charges, payments and adjustments that can be posted independently.
Each can be posted without the other. For example: You may want to write off an uncollectible balance. You shouldn’t have to post a $0 payment to make the adjustment. Some systems will let you configure instances when automatic payments and adjustments occur, as in capitation contracts.
• The ability to post payments or adjustments organized by line item charge
. This linking feature lets your billing staff easily see a running account balance for each procedure.
• The ability to track routing slips
. This is accomplished by assigning unique numbers that are prompted at the time your office posts charges. The software should generate a list of all missing routing slips, eliminating unposted charges caused by walkouts or office errors.
• The ability to post a charge to any site or provider
. Your data entry staff needs this level of flexibility if you have satellite offices or if you perform surgery in a hospital or ambulatory surgery center (ASC) setting. You should also be able to post a charge to the responsibility of either the patient or the insurance company – or post a portion of the charge to each.
The best systems use the posting of the charge itself as the trigger to batch or print an insurance claim. This eliminates unsubmitted or lost claims, in case the data entry person forgets to generate the claim at the time the charge is posted.
• Fields to facilitate coding
. A procedure code field should accommodate the "add-on" codes commonly used in ophthalmology. You’ll also need a modifier field that can accommodate at least three modifiers – preferably more, because ophthalmologists use more modifiers than any other specialists.
• The ability to post charge, payment and adjustment notes by transaction
. For example: "balance remaining was applied towards your deductible." The system should also be able to print these notes on patient statements, if desired.
• A security feature that only permits staff assigned to billing functions to access the billing module
. The computer should also show a user identification code field in the line item transaction that identifies each user’s work.
• An easy way to correct errors and retain the corrections
. This will help you form an audit trail that’s identifiable by user code.
• Multiple fee schedule capability
. It’s more important than ever to manage and analyze multiple fee schedules by payer, site or provider. When designed properly, these functions should calculate the patient’s portion, calculate contractual write-offs and withholds, and insert the expected insurance payments. It’s through this function that the billing staffers will know what the insurance reimbursement should be for the procedure, enabling them to make the needed follow-up calls if the payment amount is less than expected. You should know exactly what the normal reimbursement is for each procedure, so you can challenge the payer on the most frequently used codes if you discover constant discrepancies.
• Special functions for capitated contracts
. Make sure you know how your new system will handle charges, payments and adjustments. If bogus charges and adjustments are used to offset the bulk cap payment, make sure you understand how these will affect your system’s A/R and productivity reports. We’ve seen some offices try to manipulate capitation charges, payments and adjustments without actually understanding how this information would report.
• Convenient access to information
. Your staff should enter a minimal number of screens in order to answer the most commonly asked billing questions.

As you proceed with your review of the billing module of the new software, remember to also get the answers to these key questions:

• Can the system process both electronic claims and paper claims
? The system should generate claims by batch (which can be tracked by number) or individually (at time of service, if desired, or for secondary claims).
• Can your system generate claims in groups
? For example, can it group claims by provider, site, payer? Also, will the system track the claim history of each patient by line item and batch number?
• Can your staff check claims before submission according to office-specific edits
? This capability will let you "clean" claims in the office before sending them to a clearinghouse or sending them directly to the insurance company. This drastically reduces the number of claim rejections you’ll receive.
• Can you batch print patient statements
? Besides printing them by batch (which can be tracked by number), you should be able to print them individually (at time of service if desired, or for patient inquiries). In addition, the program should block out statements for groups of patients who shouldn’t be billed. The ability to track patients’ statement histories is also important.

Your practice may also benefit from the ability to sort patient statements by various categories, including city, state, zip code, last name, or even diagnosis. Having this ability will make it possible for your staff to insert brochures and marketing materials into various groups of statements.

One of the most dramatic boosts to productivity and profitability is the addition of appointment scheduling. If you’re in a busy group practice, ask your receptionist how many times a day she or he says, "Can you hold please, someone else is using the appointment book."

With computerized appointment scheduling, you can eliminate that scenario and serve patients better. Your clinical staff can even help schedule appointments, lightening the load of the overburdened front desk staff. The scheduling module of a software program should be simplistic and work faster than making a manual appointment, once staff get past the learning curve.

Look for these functions in an appointment scheduling module:

• The ability to generate appointment related reports
. They should include the number of new patients, number of canceled patients, number of no-shows, etc. Your system will also need to generate multiple views of schedules and chart pull lists as well.
• Many search levels for finding appointments. This function will locate the desired appointment, based on criterion given by the patient, such as "next available," or "on Wednesday with Dr. A, only after 3:30 p.m."
• A master view of all appointments scheduled at all sites by all providers
. This overall practice view helps you zero in on unproductive times, sites and providers.
• Extra features, which are important
. Look for medical alerts, recall links, patient notes links, waiting lists and appointment confirmation tags.
• Bells and whistles
. A system should have a lot of these for when staff is booking appointments in closed time periods. Additionally, the system should warn users if they’re appointing providers who don’t offer a scheduled service or who don’t participate with the scheduled patient’s insurance plan.
• Ability to archive appointment schedules
. This will help you meet record retention regulations and save paper schedule storage space.

This module is the foundation of your computer database. When a patient joins your practice, your staff enters basic demographic information, such as first name, last name, middle initial, address, city, state, ZIP Code, etc. This builds your patient files.

All crucial patient insurance information is stored

here as well. This can be used by the claims component of the billing module to pull out the patient and plan identification numbers required by insurance companies for claims processing.

Your staff must have a quick and easy way to search and edit this patient information. Most systems will let you search by last name, Social Security number, account number or chart number (if used). When examining this module, look for these functions:

• Chart number search
. If you currently use a numeric chart filing system and change to a system that can’t reference or store these numbers, your staff will find it difficult to pull charts after your conversion. You can alphabetize your charts but, for larger offices (with 12,000 charts, for example), alphabetizing charts may be impractical.
• Ability to configure registration fields as "required fields."
This one function will save staff from having to look up information that’s crucial for "clean" claims, such as Social Security number, date of birth, policy and group numbers, etc. A common scenario in larger offices lacking this software function is that staff members responsible for submitting claims and doing crucial A/R follow-up spend many unnecessary hours completing patient registrations before claims can even be generated.
(Entering all patient information while the patient is still in the office is much more efficient; it’s worth the extra few seconds. Another tip: Patient intake/registration forms should reflect the order of data entry.)
• Patient information entry aids – the more, the better
. Examples include automatic area code defaults, a zip code entry that completes city and state fields, automatic capitalization of first character and ability to copy information from one account to another.
• More than one primary insurance section
. Many patients have both primary medical insurance and a primary vision plan. There should also be a section for workers compensation and no-fault information.
• Ability to track primary care physician (PCP) referrals
. This can be an important function to have if you participate in a lot of managed care plans. Look for a section that tracks referrals by date, PCP, number of visits – and that links to both the billing module and the appointment scheduler.
For a patient who needs a referral or whose referral is expired, the system should prompt the user to ask the patient to bring a referral at the time the appointment is being made.
• A method of archiving inactive insurance coverage as well as the ability to submit claims to inactive plans
. This will let your staff follow up for payment of services that were covered under now-inactive plans.
• Fields that track and report on referral sources
. This function – whose trackable sources should include physicians, patients and other marketing efforts (ads and brochures) – will give your office an excellent picture of the effectiveness of invested marketing dollars.
• A recall system
. Such a function is crucial to the lifeblood of your practice. Look for a system that permits a configurable recall system and is linked to the appointment scheduler and insurance tables. If a patient makes an appointment too early, the computer will warn the user that the insurance may not cover the visit. Staff can then alert the patient before he or she walks in the door. The system should print labels and/or postcards, saving staff from the need to hand-write them.
• Letter merge capabilities, with template letters
. Already formatted, these letters, along with merge capability, will enable your practice to have more patient communication and marketing flexibility.

To identify most of the top priority issues that your new software should address, circulate a questionnaire to your data entry staff. (Feel free to use copies of the main story for this.) Look for common complaints or compliments about your current system and keep them in mind when selecting a new one.

Communicate to the software vendor the limitations of your existing system, plus the expectations you and your staff have for the new system. The software company needs suggestions from customers to develop the best upgrades possible.

Involve your staff in the upgrade process. Office leaders who will spearhead the upgrade, as well as data entry assistants, should meet and communicate with the vendor’s support team, especially on technical aspects of the software.

The vendor should provide all staff members with a support manual and should carefully prepare everyone for the conversion process. Now is also the time for you and your managers to re-evaluate your current information intake procedures with your staff. Don’t let bad habits carry over to the new system.

Staff training is essential after an upgrade. Schedule the trainer from the new software company to fully train your key staff members. If training is done on-site, you’ll need to create down time to accommodate the training. If you don’t do this, you’ll only have to spend more money on follow-up training, because the staff will experience too many distractions to master the information during the initial training.

Schedule a follow-up visit from the trainer about 1 month after you go on line with your new system. Many offices try to save money by skipping this important part of the training process. We’ve seen offices fail to send batches of claims because of a simple training error. By the time someone figures it out, the claims are uncollectible because they’ve aged past filing limits.

Keep the education of your staff moving forward after the upgrade. At the very least, invest in the continuing education of one staff member who can then train the remainder of the staff. At best, all staff members should have a working knowledge of the system as it relates to their jobs.

At least two staff members should have advanced applications training. The person responsible for interpreting financial reports must understand the interrelationship between the report and the field from which the information has been pulled. Without this understanding, he or she won’t be able to properly communicate important information to the data entry staff.

Finally, have your administrator spot-check the system as needed, to ensure quality data and proper use of the new system.

Remember to shop for both an affordable price and good support when you’re looking for new hardware.

Software companies that offer hardware usually have an exclusive agreement with a national vendor, which means the mark-up on the hardware can be extremely high. To get the best price, you may be better off buying directly through the national vendor. Or consider local hardware vendors, who are somewhat competitive with national companies. Local vendors may also make up for their extra cost with dependable support.

When assessing the quality of companies’ hardware support programs, ask them to describe their typical response times for various scenarios that might develop in your office, such as printer problems, back-up unit issues and network shutdowns.

Vendor response time can be critical. For example, if your network goes down, and you use an application with appointment scheduling, you’ll need help right away. Most vendors will use a "triage" approach, as follows:

• Problems with printers, back-up units, or downed network terminals should elicit a response within 4 to 8 hours.
• Full network failure should warrant a response in no more than an hour. (We’re currently working with a vendor whose head technician’s pager interfaces with all of their clients’ servers. It automatically pages him in the event of a crash. The technician is required to stop all other tasks and respond immediately to the emergency.)

The price of hardware support programs can vary widely, so evaluate this aspect of your purchase carefully. Unless yours is one of the few offices that employs a computer or networking whiz, invest in a comprehensive support program. You won’t regret it.

One last note on hardware: Buy for future growth. For example, if your 2-to-5-year plan calls for a fully automated eight-lane paperless office with an optical shop, a satellite office and a refractive surgery center, make sure to purchase a large enough server to support such growth. Even if you’re not planning to have work stations in each lane, cable each lane and office for voice and data. Dollars will be well spent here.