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The integrated practice: How integrating medical and financial information leads to a more efficient practice (Sponsored by IDEXX)


Progressive practitioners from around the country who have implemented an integrated system into their practices discuss how it has helped ensure the best healtcare possible for patients, made their practices run more efficiently, and increaed revenue.

The power of the integrated practice

Susan Warren: We're here today to discuss practice integration. You all have your own experiences. How do you define an integrated practice?

Dr. Buddy Fletcher: One in which you can see everything from one spot—which animals are checked in, their medical records, current radiographs or laboratory work, laboratory work from previous visits, pathologist or radiologist reports, referral surgeon reports, and so on. In an integrated practice, a doctor or team member can go to any workstation and see a complete patient picture easily and quickly.

The Integrated Practice: A roundtable discussion

Dr. Donald Earl: Business management info is also integrated into the same system. Financial and inventory data is all in one place and tracked automatically so you can see the complete practice picture too.

Dr. Jason St. Romain: We've integrated two locations. Everything that was just mentioned is available at both clinics, so we don't have to fax back and forth. We can do everything off a single screen and know what's going on at either practice.

Dr. Lynn Buzhardt: The biggest benefit for us is the ability to communicate contemporaneously between hospitals.

Kathy Bradfield: Practice integration has helped us communicate better with specialists because we can send records and radiographs to specialty hospitals faster.

Lynne Schroeder: This helps eliminate duplicate efforts and increases productivity.

Warren: So an integrated practice is one that can be both high-touch and high-tech?

K. Bradfield: An integrated system certainly adds a "wow factor" to your medicine, which is the high-tech part of it. Your clients can see what you are talking about right in the exam room.

Fletcher: I agree. The value of a dental prophylaxis, for example, is so much easier to communicate to clients. You can show the client before-and-after pictures, radiographs, and diagrams of teeth you treated right in the exam room. It increases the value of good medicine and makes the cost of dental care more palatable.

Case study: Snuffys emergency

Dr. John Bulovas: It also builds client confidence and loyalty. If they see that everything is working and organized, they feel assured that everything goes well all the time, even when they're not there. They develop more confidence in your ability and your recommendations.

Dr. Sarah Shull: The accessibility of data unifies the entire clinic and empowers the whole team by erasing any back office and front office boundaries.

Fletcher: Yes, but high-tech alone won't get the job done. It has to be high-touch, too, so you can create a bond with your clients and patients.

Case study: Seeing the complete picture

Warren: From my experience, one challenge has been getting staff members on board with offering the same level of care. If clients come in one time to see Dr. Jason and the next time to see Dr. Sarah, they should hear consistent messages. Has the integrated practice helped with that?

K. Bradfield: Everybody follows the same protocols because we now use medical templates. Integration has improved our medical records and our standards of medical care.

Transitioning to a paperless system

Warren: Why did you decide to change to a paperless system? What benefits did you anticipate?

Testimonial: Confidence stretched thin

Fletcher: The three most common words in veterinary medicine are "Where's the file?" Going paperless reduces a lot of frustration.

Bulovas: I had to watch expenses when I opened my practice, and going paperless gave me the benefit of having an account manager when I couldn't afford one. It gave me accountability. So much is automated, and staff members can't just go in and change prices—they need to check with me first.

K. Bradfield: Did your practice start paperless?

Bulovas: Yes, it did. However, I worked in a practice for two years where we tried to go paperless. It was like kicking a bad habit—there was always a reason you couldn't do it.

K. Bradfield: Our transition has really been worth the effort. For about a year, we still pulled records because there wasn't enough information in the computer. In March 2006, we quit using paper records and our revenue increased 24% during the next two months. It came from every aspect of what we do, especially the consistency of our diagnostic tests. We are an old practice to have that kind of growth. I'm so proud of that, and I attribute it to going paperless.

Earl: When you went paperless, did you already own in-house laboratory equipment?

K. Bradfield: Yes. We had two VetTest analyzers, two LaserCytes, two VetLyte machines, a digital CR unit, and a digital dental radiograph unit. Before, we were manually invoicing all in-house and outside lab charges, and some were missed.

Earl: That's where we are in the process, and a couple staff members can't let go of the paper.

K. Bradfield: We followed a step-by-step process during our transition (See Going paperless: Three simple steps). There are so many things to do at once.

Going paperless: Three simple steps

Dr. Tom Bradfield: The biggest step was setting a date.

K. Bradfield: Buddy and Tom, our practice owners, really set the pace and led by example. They had the worst records of anybody because either their handwriting was illegible or they didn't write enough in their notes. So they led the charge.

Trevor Lyon: I agree; you have to start from the top. If the big guns buy into it and are committed to it, then everyone else will be committed. That's the key.

St. Romain: We are taking the process slow and steady. We have been paperless for two years, but this week is our cut-off point.

Dr. Richard Maus: We went cold turkey with our previous system. My recommendations are to sell the doctors on it and do it cold turkey from day one.

St. Romain: We started off with a smaller software company, but we never trusted it enough to make the jump. We were scared of losing what we had put into it.

K. Bradfield: That's a really good point. You have to make sure you have a reliable backup in place. We installed the VetVault backup system at our practice.

Earl: At my practice, it used to take two receptionists 45 minutes a day to back up our files. The time it took equated to more than $1,000 per month just to back up our data. We switched to VetVault, and our backups are now automated. That gives me confidence. If anything crashes, I'll have a representative on the phone, and the system will be back up in a short period of time.

Warren: When did you set the time frame for implementation?

T. Bradfield: We set our time frame after designing our medical templates. That gave us the courage to take the first step.

K. Bradfield: Yes. We were lucky enough to have one of our own doctors set up those templates. The templates enabled us to move on, be consistent, and practice better medicine.

Buzhardt: The physical exam template feature helps us with consistency and prompts us not only to do a thorough exam, but to record the exam findings. The written exam record proves to the pet owner that we did a complete physical examination and therefore, validates the charges. Most clients don't understand the examination process. Veterinarians can palpate a cat's abdomen, and clients think they are just petting the cat. If we don't verbalize our physical findings during the exam, the pet report card provides a good explanation of what we did and what we found.

St. Romain: The system also allows us to print reports and instructions for clients.

Bulovas: That's right. If I treat a dog with a Demodex infection, I can print a three-page information sheet attached to the client's invoice. It prints automatically, so the technician or receptionist doesn't have to take time out and do it.

Buzhardt: We take that one step farther. Because you don't know if the person who brings in the animal is the primary caretaker, we send every client home with a health report—even if everything is normal. The physical exam template is an effective communication tool.

Lyon: I agree. Sending a report card home with clients adds value to what you do in the exam room. And being able to generate that report automatically makes a big difference and saves time.

K. Bradfield: We save our report cards in the system's documents section, which fills in the client's name automatically. We've also added a dental chart and a body chart to the report card.

Fletcher: I include a short summary at the bottom of the page that describes any abnormal findings or action points. I don't give clients the entire medical record.

Bulovas: But a paperless system allows you to accomplish what you want efficiently because the entire process is automated.

St. Romain: Yes. If the animal has otitis, I scroll down to the ears section in the system and click abnormal. The first thing on the list is otitis externa. In the general notes section, you type in what you want to send home. It takes me 30 seconds.

Buzhardt: To summarize, report cards are valuable for three reasons. Number one, they prove we did a complete examination. Veterinarians historically don't verbalize exams, so it serves as a good communication tool during the examination. Second, they are a communication tool at home for people who are not the pet's primary caretaker. Third, they act as an at-home tool that clients can refer to when they forget the things we told them in the exam room. One of our clinic mottos is, "No one leaves here without a piece of paper in his or her hands, and it needs to be more than just the bill."

Acclimating staff members

Warren: How did you over-come staff challenges during the transition?

St. Romain: Our staff members were ecstatic about switching to Cornerstone because we had been using such a difficult system.

Lyon: I saw tantrums and tears at first, but now they tell me that using Cornerstone is easy.

Bulovas: I hire my staff members because of their Cornerstone experience. Becoming Cornerstone-certified is worth the money.

Shull: If our team members get frustrated learning the system, we remind them how much time it used to take them just to determine if a pet was due for a vaccine. It no longer takes time to flip through eight pages of a record—just click, click, click, and you're done.

St. Romain: My handwriting is terrible, too. Now we don't have to worry about that.

Warren: Staff turnover is a large expense and one of the biggest challenges for practitioners. If we can enhance staff self-esteem and morale with a system that makes them more productive and efficient, it can definitely help us retain them.

Earl: Yes, having an integrated practice makes it much easier to retain and recruit staff.

Dr. Randall Carpenter: Our staff members smile and come in relaxed. They don't take phone complaints from clients who question them. It is a totally different environment, and the integrated practice gives us the opportunity to do that.

Lyon: In general, our support staff is always willing to change—especially if we give them an incentive to make a change. It is on their behalf that we try to make sure things run smoothly. We put everything in place, and it's their job to make sure it works.

Shull: Our team members know that we made the change to an integrated practice not just for clients and pets. They know we also made these changes so their jobs would be easier.

K. Bradfield: The integrated practice makes everyone accountable, so you don't have to micromanage. All team members feel like an integral part of the practice. That's why they stay with us for so long.

Shull: And because you can work more efficiently and make more income, you can pay them more.

Medical benefits

Warren: What are the medical benefits of an integrated practice?

T. Bradfield: Continuity. In other words, you can make sure that everybody knows the status of each case in a multiple-doctor practice.

St. Romain: I like the cumulative feature for laboratory work. If you are testing a dog's blood urea nitrogen and creatinine levels, the system can plot all the dog's values for the last two years. This is a lot easier than flipping through each piece of a paper record.

Buzhardt: I can also access records at home, which is important for practitioners who take emergency calls.

St. Romain: The availability of easy-to-use, in-house laboratory work has made the biggest difference for me. We've seen a lot of animals that have been saved by quick laboratory results that we didn't have access to two years ago.

Buzhardt: I was actually opposed to in-house diagnostics three or four years ago based on cost analysis. But our surgeries were delayed while we waited for results from the outside laboratory. Now we perform laboratory tests in-house, and efficiency is enhanced. My opposition was turned into support for in-house diagnostics based on the efficiency factor. Being more efficient balances the increased cost per test.

Bulovas: And you can generate much more revenue with in-house tests. One very important thing for me is being able to use the integrated practice system to help diagnose a condition by following established protocols. I am able to provide quality medicine quickly and with great client service. All laboratory, radiology, and medical treatments are recorded very quickly—which saves time for me and my staff. This allows me to communicate quickly with the owners or specialist, and medical care is greatly improved because I have more time to focus on treatment and less time finding or compiling relevant information about a case.

Earl: Absolutely. Just a few hours into the workday, we can diagnose six animals. I wouldn't have dreamed of that three years ago. I used to tell clients that we'd need to run tests and hospitalize the patient overnight while we figured out what was wrong.

Shull: We are better able to track medical records, lab results, radiology results, and charges. In clients' eyes, we are organized, efficient, and accurate. Our office procedures are fast and accurate. The services we provide now are light years ahead of what was available in the old days.

Practice management benefits

Warren: Let's talk about the practice management benefits of the integrated practice system. How has increased efficiency and organization helped you develop your practice?

Schroeder: It has increased our productivity in so many different ways. We can look up patients by their phone number, so we know we are looking at the correct record when a client calls. When a client arrives, we generate an electronic check-in sheet, so technicians can be anywhere in the practice and know the client has arrived. We also don't have to use paper charts anymore.

Buzhardt: On the day we stopped pulling charts, our staff danced in the front office.

Bulovas: My mantra is that doctors should be able to do what doctors do—practice medicine. A paperless system lets doctors truly do that, and technicians can perform higher-level work, which is better for everybody. They are not filing paper anymore.

Fletcher: It also helps manage doctors. Clients receive information in all kinds of areas. When you put everything on the same form, such as a food recommendation next to a body condition score, everyone is informed and nothing is accidentally left out. When you institute good protocols, it puts clients on an equal footing about what they are going to get from every doctor. It creates more value for the practice.

Lyon: The support staff can start doing the things they are supposed to be doing without waiting for instructions from the doctors.

Earl: When we have a client come in for a yearly examination and heartworm test, the receptionist can enter the exam and test on the appointment scheduler. Then the system automatically populates the client's invoice.

Bulovas: You can also track and analyze all sorts of data. For example, you can track your 10 most productive classes by day, month, and year; track service sales vs. inventory sales and monitor the ratio; monitor the amount of discounts given; and compare sales data for an item.

Shull: Our practice is more efficient because we know the information given to us by our software package is accurate and believable. Reminder cards don't get sent out in error anymore. Statements don't get sent out with inaccurate balances either. Records don't get shifted to another client. No more back tracking and apologizing. And we can trust our figures and analysis.

St. Romain: Do you use your integrated system as a selling point with clients?

Bulovas: Yes, we sell the value of the entire facility. On our client tour, we show them our radiology room, the lab, the view into the surgery room from the outside window, and the practice management system.

Carpenter: We also give tours to our clients and walk them through every room of the practice. We'll show them a radiograph, and then zoom in on a bone tumor. Their eyes always widen.

Lyon: We burn a CD for all of our radiography patients. That definitely draws more people to the practice.

T. Bradfield: Our on-hold phone message describes what our practice offers.

Shull: Any time we get a new piece of equipment, our local newspaper loves to talk about it.

Schroeder: We publish a newsletter twice a year, and we always feature what we are doing to build confidence. We created a video for clients to view before their pet has surgery that explains every step of the process, shows them our hospital, and describes the dog's experience. Quite a few clients say, "Wow, you guys do that? That's what they do at a human hospital." It's quite an eye opener for them.

Earl: We have increased 27% on critical care cases in the last year because we jumped ahead of others in the in-house diagnostics area. Now with digital radiography, we have jumped another step ahead. We are now becoming known as the best practice in the area.

Bulovas: Integration lets you adapt and change rapidly.

Carpenter: The integrated practice is a huge tool, not only for recruiting new clients, but also for recruiting new veterinarians. I think we're not too far away from a time when practices will have difficulty recruiting a new graduate if they don't have digital radiography in their repertoire.

Benefits for your bottom line

Warren: What type of impact has the integrated practice made on your bottom line? Has the differnce been significant?

Bulovas: We've increased our animal boarding revenue from $8,000 to $16,000 per holiday. I don't get the headaches that I used to because when the client arrives, the patient is automatically checked in. The number of staff members that used to manage this process was significant. Now I'm realizing much more revenue from boarding, and it's because we can handle a larger number of animals efficiently in a much shorter period of time.

Warren: Have you audited your electronic charts?

Lyon: I double-check everything for our own compliance and to see what we are recommending to clients. We don't check the things that are automated.

K. Bradfield: I click on the appointment scheduler and spot check our medical notes to see if our staff recommended a diet, put in a recheck date, or entered a pain score. I'm happy to say that most of the time, they do.

Earl: I audit a little differently. I spot check 10 invoices a day to make sure I didn't make an error and mischarge anybody. I check for any discounts or canceled invoices— and nothing else can verify that.

Lyon: I check for discounts every day and make sure our credit cards balance out.

Buzhardt: Do you pick up a lot of charges that used to be missed?

Lyon: We used to, but not since we integrated our practice. We recently made a change in our protocol for pets with grade III or IV dental disease. I looked at our electronic records from last month, and of the 75 patients we saw that had grade III or IV dental disease, we failed to meet the protocol only two times.

Warren: IDEXX has performed almost 200 audits of practices that have not yet gone paperless, and we found an average of 15% in lost diagnostic charges and 6% to 8% in lost radiography charges. When you think about the dollar volume, that is pretty significant.

Earl: We recently changed to Cornerstone and integrated our practice. From one month to the next, our net income went up 14%. All I can contribute that to is lost charges—I wasn't practicing differently at that point. I had not done anything else.

Warren: Does anyone have any other comments to add?

K. Bradfield: I think it takes everyone in the practice to make the transition successful.

Warren: Thank you for sharing your experiences with us today. It is apparent that the integrated practice is a more efficient operating model for veterinary practices. The ability to have information where you want it, when you want it, benefits both the staff and the client. Integration puts the entire practice to work for you by linking and automating equipment, services, and data. That means you'll be able to ensure the best healthcare possible for your clients.

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Aaron Smiley, DVM
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