Alphabet soup - that's what the current discussion of practice guidelines sounds like to many of us. We're too busy meeting the demands of our day to consider what kind of impact these long acronyms (used to describe guidelines) will have on our practices. Most are probably going to wait to see how the rest of the profession responds before figuring out how to adapt. A few, however, have not waited. What they've learned can be instructional for the rest of us. These "early adopters" stand as case studies in how our practice might be affected. And what are the early adopters telling us? Some of them are saying that we should prepare for the future now by adopting electronic health records (EHRs). One group in particular says that the combination of guidelines and the digital clinic is an absolute necessity.
The Early NCQA adopters
When I say "early adopters," I'm talking about chiropractors who have voluntarily signed on to the National Committee for Quality Assurance (NCQA) back pain guidelines. The NCQA is a nonprofit patient-advocacy organization that offers physicians the opportunity to show the public that they're meeting health care quality standards. So far, more than 100 physicians have signed on to NCQA's Back Pain Recognition Program (BPRP), many of whom are chiropractors. The BPRP is just one NCQA program, built on the recognition that back pain is a multibillion-dollar industry that is often mismanaged and ineffectually treated by health care providers. The BPRP is an attempt at getting these costs and ineffectual management under control. It's a strong example of how evidence-based health care is being used to influence patient management in order to lower health care costs.
This NCQA program is voluntary, but many of the guidelines that are in place in the BPRP also may make their way into chiropractic guidelines in the future. Here are a few examples of what the NCQA is asking providers to do: The doctor will make sure that patients receive a mental health assessment when appropriate; advise on proper exercises and activities of daily living; counsel against bed rest for back pain; promote smoking cessation; and provide timely reassessment of patient progress. The point of all of this is to improve patient outcomes and, ultimately, limit health care costs. Research literature has shown that these measures improve back pain outcomes in some way. Of course, much of the cost controls will come from the way the NCQA guidelines limit medical doctors in the use of steroid injections and back surgery.
Why the NCQA?
In return for voluntary agreement with the NCQA guidelines, the participants gain sponsorship and endorsements from the NCQA. As a Washington, D.C.-based organization, the NCQA has a board of directors that includes members of the insurance industry, prestigious medical schools and medical associations. More or less, the NCQA seal of approval is much like a Consumer Reports endorsement or the Better Business Bureau seal of approval.
From a practice-management perspective, the NCQA endorsement is meant to show both patients and third-party payers that the doctor in question is above the board in patient management. The endorsement is expected to lead to better collection percentages and greater referrals from colleagues and the public. There is talk of the BPRP participants actually getting more dollars per reimbursement, although this part of the plan hasn't been adopted universally.
Why Not the NCQA?
When reading just a few of the requirements placed on providers, the answer to the question, "Why not join the NCQA?" should be obvious. The program means committing to extra work for every patient in a way many of us can't handle. And when I say extra work, I'm really not considering counseling patients, showing patients exercises, or even having patients fill out a health questionnaire. These are the kinds of things most of us are already doing for many patients without giving it much thought. I say these guidelines cause extra work because they ask us to do all these important tasks with every patient, and properly document all of it. This is the extra work - documenting all of these things we normally do. Detailed documentation is something many chiropractors are unable to do in their current practice-management model.
A story from one group of early NCQA adopters will help shed some light on the demands of guideline documentation.
The Rochester Group
What do you do when you realize your commitment to voluntary guidelines requires you to document more efficiently? You change the way you are managing clinic documentation as soon as possible. This is exactly what some chiropractors did when they committed to being part of the NCQA initial study for the BPRP. Dr. John Ventura and Dr. Brian Justice are the founders of a multi-clinic practice in Rochester, N.Y. They're active in the profession and in their communities, and are strong ambassadors to the medical community for the importance of chiropractic care. Both have been involved in building integrative relationships with a medical school and several local hospitals. After reading their curricula vitae, you can understand why these chiropractors would sign on to a program that would validate chiropractic management of back pain patients. Being NCQA early adopters fits their mission.
They will tell you that NCQA participation required more than just a desire to be recognized for superior patient management. It required being able to prove their patient management on every patient visit, with proper documentation that would pass NCQA scrutiny, all while not upsetting their established practice flow. That's a tall order to fill. Drs. Ventura and Justice knew that paper records weren't going to cut it in the long run, so they started exploring electronic health records.
Three Letters: EHR
What I find exciting about the Rochester Group is their ability to anticipate the future and adapt. Ask these doctors about adopting EHRs into their practice, and they will tell you the decision became a "no-brainer." Others with the same practice experience might have tried making it work with paper, but Drs. Ventura and Justice saw the writing on the wall. If they were going to grow through adopting guidelines, they knew they were going to step up their documentation consistency. That meant being able to document smarter so they could accomplish more in less time.
So, why did they choose an EHR-based clinic management system? The Rochester Group learned that a digital note isn't synonymous with a fully portable and protected EHR. They wanted more than just a digital version of their current notes. A digital note would still require them to adapt their records individually for each of their NCQA patients. What they needed was an EHR they could customize to their own established workflows, as well as offer them electronic documentation instantly portable and written specifically for their NCQA guidelines. They did some searching and found what they needed.
What the Story Tells Us
What can we learn from the experience of the Rochester Group? In short, it's this: The NCQA may not be in your future, but a similar guideline by another name will be and it's going to alter the way you manage your practice.
Whether it comes directly from an insurance company as a dictate to all providers or through your state licensing board, stronger adherence to practice guidelines is in our future. While buzzwords such as "evidence-based care" and "patient-centered care" will continue to be thrown around, the reality is that the market is demanding practice guidelines. Insurance companies have their own customers they have to satisfy - the small and large American enterprises that offer benefits to their workers. Treatment guidelines offer a relief valve for corporate concerns about wasted health care dollars. They're also great PR for insurance companies. While we may think of guidelines as just another hoop through which to jump, American business is happy to see that we're being asked to tell smokers to stop smoking and give obese patients simple nutritional advice. And that we're being asked to document it and prove it. After all, they're footing part of the bill.
Prepare for the Future
I've talked a lot about how the law is moving us toward EHRs. This column shows that more detailed documentation is going to require it, for the simple reason that sticking with paper is going to get too cumbersome. So, you're probably wondering, what can you do? Start going digital? Of course, my answer is yes, but let me give you three pieces of advice:
- Regardless of where guidelines might come from (NCQA, CCGPP, ACN, ASHN, etc.), you need to make sure your documentation company understands the seriousness of these guidelines and will help you adapt to them.
- You need to find an EHR system that is automatically customizable to these guidelines so your practice can remain diverse enough to meet the requirements of more than just one of your third-party payers. You need the option of customizing it yourself or, preferably, having it already done for you.
- Finally, you also need to find a system that will grow with your company; one that keeps track of chiropractic trends and is able to offer upgrades that match these changes for today and in the future.
If you don't do all three of these things, you may find yourself buying a new system to replace one that didn't upgrade with the times. Be sure to ask any EHR company how it's going to protect your investment and help you adapt to practice changes.
Start Exploring
Today, we discussed a voluntary NCQA back pain guideline. In a short time, we could be talking about mandatory guidelines from major players in the insurance industry. In other words, the future is rapidly approaching. Even if you plan on going digital when the law finally makes you, there's always the possibility that paper will be made obsolete by the number of documentation requirements placed on your practice. My recommendation: Start exploring the world of EHR. Take stock of the inefficiencies you face in your practice and find out how a digital practice can help you solve them. You may just find out, like the early NCQA adopters, that EHRs are a no-brainer for your practice. Start preparing for your clinic of the future - today.
