The phrase "This page intentionally left blank" is a paradox. It's a paradox that most chiropractors have read if they've taken a national board exam. We know the obvious meaning: We're meant to know that the blank page is not an accident. Otherwise, you might worry about it while sitting for a big exam. A paradox is one of those funny things that appears false even thought it's actually true. In this example, although the page states it is blank, the statement itself is on the page, so of course, it is not blank after all.
There are other paradoxes with which we are familiar, such as: "The more things change the more they stay the same." These everyday phrases communicate truth about life. They catch us off guard, make us laugh and often get us to nod along in agreement.
There is also a paradox in the digital clinic: The less the doctor does in the clinic, the more they accomplish. Seems impossible doesn't it? But ask users of true electronic health records (EHRs) and digital documentation if it's true, and I guarantee most will agree. In fact, I can give you the names of many doctors who would completely agree with this paradox now that they've gone digital. It's a spin on that old "less is more" paradox. If you want to see the truth of this statement, keep reading.
A corporate management guru named Peter Drucker once said, "Efficiency is doing things right; effectiveness is doing the right things." This statement is another play on words, one less known than a paradox. It's called a chiasmus. A chiasmus rearranges words to put more power behind the meaning. Think of John F. Kennedy's "Ask not what your country can do for you, but what you can do for your country." That's a chiasmus.
Drucker is communicating something powerful that relates directly to the concept of doing more by doing less. Let's unpack what he's trying to say and analyze both parts of his quote. Both have to do with the concept of clinical efficacy. First, let's analyze the statement: "Efficiency is doing things right." Typically, efficiency is defined as being able to accomplish a task with a minimal amount of time and effort. Drucker answers the question that pops up after establishing that definition: How do you do things with the minimal amount of effort? Do things right, Drucker says, and you'll have efficiency. So far so good, right? Wrong.
The problem with efficiency alone is that you're not guaranteed to be doing the right thing. You could be doing the wrong thing with the minimal amount of time and effort. You can be very efficient and be wrong at the same time. Efficiency is great when you're doing the right things. But it's actually harmful if you're not. What does this look like in practice?
The Dark Side of Efficiency
There are any number of examples of doing the wrong thing efficiently when it comes to chiropractic practice. Some are more controversial than others. But since postpayment reviews are on the rise, let's start with behaviors that flag audits to be initiated.
Billing for a 97140 manual therapy like trigger point or myofascial release combined with a CMT service is legitimate as long as it is not associated with the spinal area. Without the -59 modifier and proper documentation designating the separate and distinct services, as well as the necessity for that service, the effort to provide this care can go unpaid and cause an audit when claims are recognized for repetitive billing of these codes together. Carrying out these services may be efficient, but not effective for the end result of getting paid if the coding and documentation are not properly performed.
Speed-dialing your favorite treatment through your billing department is another way to be efficient. After all, if every patient is getting the same therapeutic services, some doctors wonder, why not code it ahead of time and be done with it? Minimal time and effort are involved, and you get your billing done faster. Efficiency is good, so no harm, no foul, right?
You might see these actions as clinical efficiency, but auditors see them as red flags that suggest abuse of the health care system. Your front desk might be saving time by missing a few copayment submissions during your evening rush, but Medicaid only sees you waiving copayments for an elite group of patients, which isn't allowed. Likewise, even if you're proving medical necessity for every patient to get your favorite therapeutic service, you're raising the red flag with some practices. If that means an audit in the future, being efficient hasn't helped you at all.
Doing the Right Things
The second half of Drucker's statement is, "Effectiveness is doing the right things." As you can see, he sets his statement up so there is a contrast between efficiency and effectiveness. If efficiency is doing things right so they can be done with minimal work, then effectiveness is to be valued because it means doing the right things from the beginning.
Personally, I believe Drucker is expressing why efficiency is overrated and why effectiveness, though noble, has its drawbacks. Efficiency doesn't mean effectiveness, especially if you're doing the wrong thing efficiently. Likewise effectiveness isn't always efficient. In fact, doing the right thing can be painfully slow. You may get the results you want, but the lost energy and time essentially rob you of the value in being effective in the first place.
Of course, there are plenty of examples from chiropractic practice. In my travels, I've heard many statements from chiropractors in practice that sound something like this: "I wish my documentation were more effective (faster and compliant)," "I wish my patient education were more effective (referral generation and better compliance)," or "I wish I could be more effective at collecting from third-party payers the first time I submit a claim (accurate, detailed submission and alerts for correct coding matching documentation)."
So, what do we mean by being more effective? It means having everyday tasks turn out more favorably for your practice. Effective documentation captures the essentials of what was said and done to the patient in a way that makes it easy to communicate to other health care providers and reviewers, and to earn payment for services properly rendered. Effective patient education gives patients the information they need to value their care and commit to the treatment plan in a way that excites them and encourages compliance. Effective billing claims win a favorable response from third-party payers the first time, without room for nickel-and-dime mistakes that delay payment.
Effective clinical tasks sound so easy on paper. Some chiropractors achieve everything listed above. They are effective clinicians and managers. Yet there are few who do all of it well with sustainable efficiency. Breakdowns happen even in well-run offices.
Effectively Efficient
What if we could add a third phrase to Drucker's statement? It would then read something like this: "Efficiency is doing things right; effectiveness is doing the right things; efficacy is doing the right things at the right time the right way." In other words, efficacy is doing effective things efficiently.
For anything to be effectively efficient in the clinic, it means having the ability to do the right clinical thing with minimal time and effort. Now, most people judge whether something is effective by its ability to achieve a desired result. Something is effective because it achieves greater results than another method. It does more or offers greater return. This brings me back to the concept of less is more. If you can achieve more with minimal time and energy, aren't you getting more by doing less? If you are being efficient and more effective, then less truly is more.
What could this look like in chiropractic practice? Well, how about avoiding the dark side of efficiency by streamlining billing and coding, including Medicare copayments, without attracting auditors? How about actually creating documentation that captures the essentials plus telling the whole story of the patient visit, which earns better returns on claims and approval for extended covered care? Or what about consistent patient education that wins better compliance and more referrals?
Here's the catch: You aren't going to achieve this unless you give up systems that are no longer meeting the demands of the third-party reimbursement world and the less-efficient paper processes in our offices; in other words, unless you have the kind of efficacy offered by true EHRs, compliant digital documentation, and digital integration of your clinic departments. Going digital is the only way you can do the right thing and actually minimize your work to do it. It's also the only thing that will make you safely efficient, provided your system has the right security and controls. It's effective efficiency that requires the right technology.
