Orly Avitzur, MD, MBA

Your paycheck has fallen steadily over the past few years. Everyone is talking about the decline in reimbursements and the increase in overhead costs. Although it is frustrating, it is not surprising. But before going back to work with a business-as-usual attitude, consider this: While most practices are faltering, some are quite successful--that is, they are economically thriving. So what makes the difference?

Medical practices that perform well, even in rough economic times, continually evaluate their operations. They ask: How are we doing? How do we compare with others? Are we using the best practices? What can we do better?

To get the answers, practices focus on benchmarking--the process of analyzing indicators of business performance--and apply the information toward improvements. Nearly all businesses do this to evaluate productivity, utilization, financial status, and level of quality compared with peers and competitors and to monitor operations over time. Benchmarks can be applied to gauge a medical practice's success and critically evaluate its shortcomings.

 problems. Formal benchmarking often takes a structured approach, using reliable parameters against which a practice can be measured. The prospect of benchmarking may seem daunting at first, but it can be simplified with a stepwise approach.

Decide which process you wish to benchmark, and select the appropriate metric.

 It is important be clear about the process you want to analyze and the area of performance you hope to improve. The question that is most frequently asked of Nick A. Fabrizio, PhD, senior consultant for Medical Group Management Association (MGMA) in Englewood, Colorado, is: How many full-time equivalent (FTE) staff should I have per FTE provider in my practice? "If a practice is currently using 3.5 FTE staffers per provider for the front desk, but the MGMA median staffing ratio for the specialty is 2, it is often an indication that the staff is inefficient or that a systems issue is impacting the practice. The situation suggests that an operational assessment of the practice is warranted," Fabrizio advised.

MGMA provides detailed benchmarks, including breakdown of revenues, expenses, and provider productivity and compensation. Relevant practice data generally can be developed using the practice's management system software.

The AMA and the American Medical Group Association, as well as medical societies such as the American College of Physicians-American Society of Internal Medicine and the American College of Rheumatology, also can provide applicable benchmarking tools and information.

Conduct close evaluation of variances to detect existing problems.

 After collecting the data, use the information to determine your practice's strengths and weaknesses. Evaluate the variances and investigate their root causes. For example, higher-than-median staffing in one neurosurgical practice for which Fabrizio provided consulting services was traced to an antiquated practice management system that required the attention of an extra employee. Inefficient work flow, poor systems, or inept personnel can create additional expense.

"Practices tend to throw people at a problem when they don't have the right people on the job," said Fabrizio. When confronted with staffing in the medical records division of another practice that was 1.5 times the benchmark, Fabrizio found that an employee, who had redefined her role as manager, was not performing her assigned job. Rather than confronting the employee, the practice's administrator hired an additional employee to compensate for the other's lack of performance. This scenario is all too common, according to Fabrizio.

Compare your practice with "average" as well as "best" practices.

 To be successful in the current economic climate, it may not be enough to compare favorably with averages. You may want to make the comparison against top-performing practices in your specialty. Best-of-class benchmarking strives to improve business practices by reaching goals achieved by the most successful practices.

The MGMA report Performance and Practices of Successful Medical Groups quantifies the business practices of respondents to its Cost Survey for Single-Specialty Practices and analyzes differences between "better performers" and others. It shows that the most profitable medical practices use proven strategies to achieve success in a specific area. It is often advantageous to consult with other neurologists who have shown strong performance in the area you are seeking to improve.

Upstate Neurology Consultants was designated as a "Better Performing Practice" by the MGMA in the area of accounts receivable (AR) and collections in 2001 and 2003. William S. Henderson, the practice administrator, attributes Upstate Neurology Consultants' ranking to close tracking of payer performance.

"My goal has been to convert as many claim submissions as possible to electronic submissions and attain as low a rate of denials as possible," said Henderson. He compares the practice's AR with standard MGMA benchmarks as well as with practice data from month to month. He further breaks AR categories down by payer. "When we started to see a large number of denials for level 2 hospital consults from a particular insurer, we flagged that payer and soon discovered that the insurer was withholding payment for documentation,"said Henderson. He solved the problem by submitting paperwork along with the claims for 6 months, and the denials stopped. Henderson also drops payers with a high hassle factor and that are a drain on employee resources, and he keeps tabs on insurers who have disproportionately high percentages in the more-than-120-days collection bin.

Frequent delays in reimbursement from a payer may be an early sign of financial instability. This is a cause for immediate investigation; many practices have been taken by surprise by payer insolvency and suffered large losses as a result.

Include relevant staff in processes that will involve a change in work flow.

 Discuss various proposals with your staff, and develop an action plan. Set goals and adopt suitable policies and procedures for reaching goals. When Henderson recommended that the office update its practice management system and then move to an electronic health record (EHR) system, he sat down with all the neurologists and discussed the transition in detail. "Before we made the purchase, the neurologists agreed to invest the time in training and implementation and to even hold each other accountable for follow-through," he said. The product ultimately paid for itself within 12 months and has been saving the practice $60,000 in transcription fees annually. Integrating the practice management and EHR systems also has helped drive AR management down because everything is now submitted electronically and reporting functions have improved.

Conduct training needed to apply new technologies or services.

 Provide your staff with sufficient education and resources to implement the new processes. When Upstate Neurology Consultants hired a new doctor whose sole exposure to computers was limited to e-mail, Henderson in turn hired an on-site trainer to teach the new clinician how to use the program; the new doctor was brought up to speed within 30 days. Henderson also designated a tech-savvy neurologist as the physician champion for the EHR system so that those less comfortable with technology could benefit from his guidance. All of the doctors contributed to content for neurologic templates, which were then created by the practice's designated physician-expert to make the process faster and more efficient.

Identify barriers to change. Anticipate resistance and be prepared to meet challenges head-on.

 When Bruce Sigsbee, MD, chair of the American Academy of Neurology Audit Committee, took on the role of medical director for a 35-physician hospital-owned group, one of his initial goals was to maximize productivity. Because he anticipated that the physicians would resist the suggestion to see more patients, he restructured their compensation by designing incentive contracts. MGMA benchmarks for Northeast income levels and the associated work relative value units (RVUs) allowed him to create a formula by which the physicians receive additional remuneration for work RVUs above the base number. "The doctors more readily accepted the change. Now, if they work harder, they earn more," summed up Sigsbee.

One of the last things physicians want to do is spend time in evaluation and management (E&M) coding education classes, but neurologists who deviate from peers in their distributions of coding levels can be flagged as outliers and put their entire groups at risk for audit, particularly if their documentation fails to support the level of coding.

The Centers for Medicare and Medicaid Services provides data by specialty and by state, which are often purchased by organizations to assist physicians in applying benchmarks to their coding. "If you profile out, you need to ask why," advises Jennifer Bever, a consultant with KarenZupko & Associates. "If analysis of your documentation reveals over-coding, you are risking an audit; if it reveals under-coding, you are clearly missing out on justifiable income," she points out. Bever, who uses the E&M profile analyzer (Figure), says that when outlier physicians are given evidence of how they are skewing their groups' results and placing other members in jeopardy, they tend to be more willing to undergo coding education.

 Trends analysis reports, such as those created by Henderson, may be applied to charges, revenues, gross and net collections, and adjustments. Wide increases or decreases in numbers may flesh out areas that require review. Monitoring monthly changes in AR may provide an early indication of brewing trouble. More in-depth review, such as an increase in charge adjustments, may indicate that aged accounts are not being pursued aggressively. If more accounts are aging into the more-than-120-days category, you need to explore the reason. Have there been delays in submitting bills? If so, find out why. Correcting the problem at the outset, rather than waiting several months for revenues to reflect a dip, may prevent large financial losses.

If a practice finds that their aged AR are rising or are higher than the norm, it may be personnel-related, according to Fabrizio. "If a staff member is uncomfortable addressing patients with overdue balances, the aged AR can rise rapidly," he warns. "Collection is an area that requires a specialized skill set; it needs a person who can send the message that patients have financial obligations and assist them in setting up payment plans."

Internal benchmarking also allows for detailed comparisons of different practice sites. If a striking variance in one location is found, investigate the cause. An analysis may reveal that a satellite office is a money-losing venture. Review the expenses and revenues of the off-site office. Consider the alternative use of equipment that may be underutilized.

When Henderson suspected that one of his satellite offices was a potential source of lost productivity, he asked neurologists frequenting that office to record the amount of time they spent traveling between offices and the 5 affiliated hospitals. This information helped him demonstrate that the time taken to travel between sites added up to reduced productivity and subsequent economic loss. "I calculated the revenue being forfeited and presented the data; although a few of the doctors were reluctant to abandon their ties to this community [served by the office], the numbers didn't lie," Henderson said.

Measure results and continuously evaluate progress.

 Evaluate the expenses and drawbacks as well as the resultant benefits and rewards. Monitor quality to make sure improvements in performance are maintained, and work toward continuous improvement.

Allen L. Gee, MD, PhD, managing partner at Frontier Neurosciences in Sheridan, Wyoming, uses sophisticated Web-based practice management software, athenahealth, which has been endorsed by many state medical associations. "The greatest benefit I have realized from the athenahealth revenue cycle management program is the immediately available, up-to-the-second reports and benchmarks," said Gee. The program, Live Benchmarks, includes charge entry lag and hold lag time for claims in need of correction before submission. His average office-charge entry lag time has declined from more than a day to less than 0.1 day.

He also has been able to tighten up his documentation lag for submissions requiring records such as workers' compensation claims. He finds that the most critical benchmark is the revenue realization rate-how long it takes to collect what is realistically expected. Monthly monitoring of this rate has identified delays in the collection process. "I have been able set alarms for claims that exceed expected days in AR, allowing my staff to follow up on these delayed claims sooner and ultimately improve collections," said Gee. Initially, he found that it took up to 6 months to achieve a greater than 95% revenue realization rate, but by applying continuous adjustments, the time is steadily decreasing.

is a practicing neurologist and a medical news commentator in Tarrytown, New York.

Articles

Everyone is talking about the decline in reimbursements and the increase in overhead costs. While most practices are faltering, some are quite successful--that is, they are economically thriving. So what makes the difference?

How Does Your Practice Compare? A How-To Guide to Practice Benchmarking

Managed care has a new angle to contain physician costs: physician profiling to select or exclude clinicians from tiered networks. It was no surprise to me last month when I received 5 insurance spreadsheets detailing my practice profile. In essence, I was given a breakdown of treatment costs for my patients (compared with those of my peers) in the hope that I would change my management and referral habits.Of course, I had known for some time that claims data were being mined. But what came as a shock was that most of the expenses associated with the episode of treatment group (ETG) methodology applied to my practice were attributed to charges that were not under my control. For example, an MRI scan of the brain-which cost the insurer an average of $391.11 per study on my patients-was 186.78% more expensive than the average $136.38 per study for patients going to other Metro New York-area neurologists. Data like this are now being studied by managed care companies to determine which providers are least cost-effective and to discourage patients from going to them. In some cases, the doctors to whom they are redirected are dubbed as providers of "higher quality of care." As this strategy is tested in various parts of the country, many physicians are wondering just how valid is this information, and how such ratings will affect their patients.By developing tiered networks-insurance products that select out "efficient" providers-health care insurers are hoping to create panels of physicians who will help them control costs. It's an idea, certainly, that worked for pharmacy benefits. Differential copayments steered beneficiaries toward lower-cost drugs. Insurers quickly applied the strategy to hospitals, with less clear results. Most recently, they have set their eyes on the physician market, with new programs poised to spread across the nation. For some payers, profiling is part of a concerted shift in health care toward pay-for-performance (P4P).Tiering of any kind, however, is built on erroneous assumptions-that all products are the same and that differences in costs are attributable to differences in efficiency. For example, in Aetna's Aexcel Specialist Network, which includes neurologists and neurosurgeons, physicians are stratified based on database information that identifies episode costs. Aetna decides who can join the network by measuring a minimum of 20 "episodes of care" over a 2-year period. An episode of care includes medical treatment for outpatient and inpatient care as well as related costs. Aexcel, which expanded into 20 US markets as of the beginning of this year, focuses on specialists because it has determined that specialty care is the greatest cost driver.Average Cost Per EpisodeIn my case, as a neurologist with a high proportion of referrals from orthopedic surgeons, the largest of my "treatment pattern comparisons" groups was for "joint degeneration localized, without surgery." For this category, largely composed of neck and back pain patients, Aetna determined that the average cost per episode for my patients was $1485.09, compared with $826.54 for all designated providers in my urban market. In other words, my "efficiency index" for this category was much worse: 1.42 compared with 0.76.This was attributed to increased use of inpatient visits (even though I do only outpatient work) and increased use of ambulatory facilities, other physicians, radiology, and laboratories. Where was all this coming from? Under this new math, if I refer a patient for imaging and those charges per service exceed the average, I am held responsible. If my patients' physical therapists bill for more "therapeutic exercise" codes per episode (in my case, 6 per episode) and do so at a higher cost per service (in my case, 120.55% higher), I am doubly "inefficient." It turns out that the biggest "total dollar impact" to Aetna was in this line item, with MRI facility bills close behind.None of Aetna's data were wrong. So why was the resulting profile so inaccurate and misleading? Consider, for starters, the size of the numbers that composed the snapshot. The highest number of episodes in any of my ETGs was 29 compared with 828 aggregate episodes (from an unspecified total universe of ETGs) in Aetna's pool of designated providers, and 9 of my 14 ETGs had only 1 or 2 episodes each. My total efficiency score for general neurologic conditions was 0.70-much better than the mean-but included only 60 episodes of care. Yet, it made my total average-1.01-look average. Imagine if other health care decisions-say, evaluating the effectiveness of the latest drug for stroke-were to ride on such sketchy confidence figures.And what of the many hidden issues that do not get factored into a profile but most assuredly affect ranking? Providers who care for the sickest patients, for example, are not going to profile well because those patients require care at "inefficient" levels. Patients suffering from many concurrent illnesses also will skew results for the physicians who care for them. Finally, while Aetna says it considers quality, there was no evidence that it incorporated clinical guidelines or outcome measures in the data that I reviewed.Neurosurgeon James R. Bean, MD, is concerned that most payers are focusing on tiering without a sound measurement of quality. The American Association of Neurological Surgeons treasurer is also president of a 350-member multispecialty Independent Practice Association. His concern as a neurosurgeon is that such profiles miss the most important parameter of all: how well a patient does after surgery.He added, "The system fails to differentiate between patients who have already had conservative care and have been pre-screened for surgery and those presenting at onset of their conditions." For example, he pointed out, a back surgeon who is referred patients who have already failed physical therapy or epidural steroid injections will be penalized for having a higher relative surgical rate than his or her peers. Bean summed up, "Profiling is an artificial administrative measure that is misleading or, frankly, exclusionary."Methods QuestionedWilliam Thomas, PhD, has been studying quality and economic profiling for some time. A health policy analyst working on a study about tiered networks with funding from the Robert Wood Johnson Foundation, Thomas is concerned about the dearth of research on important methodologic issues that can influence the accuracy of physicians' economic profiles. He's also uneasy about some of the methods being used to judge physicians' quality-of-care performance. "Reasonably strong evidence has been around for a good deal of time that the popular risk adjusted outcome measures-mortality, readmissions, and complications-are often not valid indicators of quality performance. Yet few employers and few health plans know that they're invalid," he said."This issue and others, including attribution methodology," explained Thomas, "need to be researched at greater depth." In some cases, an ETG is assigned to a physician responsible for the majority of professional fees associated with an episode and not necessarily the majority of prescribing or ancillary costs. Under this system, a surgeon may be given the attribution for an ETG even though a primary care doctor is managing the case, including referrals. An even bigger problem, said Thomas, is that conclusions are being drawn based on small sample sizes.Health plans involved in profiling do not know what sample size should be used because researchers haven't yet given them any guidance, Thomas explained. "As a result," he added, "they choose a number and hope it works." The problem they run into, he said, is that choosing too low a minimum number, like 10 (which incidentally, Aetna said it used with me), leads to unreliable tier assignments. He added, "Large percentages of physicians are shifted from one tier to another each year, and that's not just a problem for physicians, it's a problem for health plan members, too, and therefore for the plan itself."Aetna, of course, is not the only insurer experimenting with such plans. In the past few years, PacifiCare, Premera Blue Cross, and UnitedHealthcare all have rolled out tiered networks. UnitedHealth Premium's Web site tells members "UnitedHealthcare is providing you with important information on physicians, so that you are empowered to make more informed choices on where to receive care-you can rest easy knowing that you are receiving care from a physician that has met UnitedHealth Premium's strict quality standards."Negative IncentiveTo further push consumers into choosing physicians in tiered networks, insurance companies hit those who go to physicians outside the network with higher co-pays and deductibles. Aetna's Web site boasts that compliant members "benefit from expected lower costs in medical care as well as the value of having information to make better health care decisions." Since when, however, has lower-cost care proved to be better care? Enlightened consumers might perceive, instead, that a provider has incentives to spend less money in finding out what is wrong with the patient. Misdiagnoses lead to less effective treatments-and that's hardly better health care.Physician groups such as the Medical Group Management Association, the AMA, and the American Academy of Family Physicians (AAFP) have expressed strong doubts about current insurer performance measures. AMA trustee John H. Armstrong, MD, said, "The AMA does not regard tiered networks as quality improvement programs, and we certainly don't see how they help patients. These networks merely represent that latest insurer effort to economically credential physicians and cut costs."The AMA is very concerned, said Armstrong, that such initiatives put a barrier between patients and their doctors and restrict access to care. "How can 20% of physicians care for 100% of all patients?" He believes that there is no correlation between the tiered network efficiency ratings and clinical outcomes. "Any ratings must focus on clinically relevant performance measures that measure what matters to improve patient care," he noted. Once such performance measures are defined, the data must be collected and analyzed. "When it comes to data collection, the source of that data matters," he emphasized. "Claims data, while accessible, do not reliably capture the clinically relevant elements necessary to measure performance. Further, to collect this volume of data and facilitate data analysis, we need a robust information technology infrastructure, which is simply not yet in place."Some believe that physicians need to help create a common set of measures. Bruce Bagley, MD, medical director for quality improvement at the AAFP, conceded that while the programs are cost-motivated, a few, like United's, take an important step toward assessing and possibly motivating better performance. "Some see these plans as a ploy to steer patients to doctors who spend less money on patients," Bagley reflected, "but we need to move from judging physicians based on pedigree to making decisions based on actual clinical performance." Once such measures become available to primary care physicians who are making referrals, Bagley predicts that specialists will be chosen on a whole new set of criteria.Those with the most potential influence to choose are patients themselves. Gail Wilder, MD, who has been a medical director for 8 years, including 6 years with Aetna, said, "While conceptually, tiered networks are attractive to managed care organizations, they are very hard to implement because patients want to go to their own physicians." Wilder believes that it is useful to incorporate quality standards in physician profiles, but inappropriate and misleading to use rankings based on cost-efficiency alone.She pointed out that certain sought-after physicians who have a level of expertise and experience in their field above and beyond the ordinary may already have negotiated special fee contracts with managed care companies as a condition for agreeing to join the network. Said Wilder, "It would be ironic if these same physicians are later tagged as inefficient because of higher cost and, as a consequence, deselected out of a special tier." Moreover, what are the ethical implications of offering care to people based solely on cost and not quality? She reflected, "Persons may be unable to access the most proficient providers because they are the most costly."What's To Come Of It?For now, specialists feel it's a rigged game as to who is selected for referral and why. Daniel B. Hier, MD, MBA, a University of Illinois neurologist, said he was not offered an opportunity to participate in his United Healthcare profile. "I doubt that any quality data was reviewed," said Hier, who questions the methodology. "It is very hard to compare neurologists unless you analyze performance at the level of a specific diagnosis with access to detailed clinical data-and even then it is quite difficult."In P4P programs, insurers review claims to see whether doctors meet certain criteria such as prescribing medications that have been shown to reduce risk of illness or ordering screening tests such as mammograms. Right now, physicians may decline to participate in P4P.AMA sources said, however, that in another pilot by United Healthcare, physicians who have been selected for both quality and cost efficiency in Atlanta, Cleveland, and Chicago will be offered higher fee schedules. This essentially converts their current tiered program into a P4P program. And if profiling-in which physicians' participation is involuntary-is any indication of the future of managed care, P4P is not likely to remain a choice much longer. Then, we may be looking at an environment that will encourage practitioners to prescribe care regimens based not on what is best for patients, but on what will boost a tier ranking.In that scenario, only the payer wins.ORLY AVITZUR, MD, MBA, is a practicing neurologist in Tarrytown, NY.Part I: Tiered NetworksIn Part II, Bruce Sigsbee, MD, will discuss current pay-for-performance initiatives and their role in the future of medical practice.

P4P, pay-for-performance, tiered networks, insurance

Profiling and Pay-for-Performance: Is It Quality or Cost That Matters?

Stephen M. Sergay, MB, BCh, saw the promise of medical practice Web sites early on. Five years ago, when Salu Inc. began to promote its mission of building neurology Web sites through NeuroHub, Tampa Neurology Associates (www.tampaneurology. com) became one of its first beta sites. "More and more people were coming to the office with information they had downloaded from the Internet, and when we ran an informal survey, we found that large numbers of patients were indeed sophisticated Web users," he said.

Sergay, who is president-elect of the American Academy of Neurology (AAN), placed a computer terminal in the office waiting area and was pleased to find patients using it regularly. "It gave them an introduction to our practice and made us more accessible," he said. "Salu provided the design template and health information for neurology patients, adding value and making it easy to create a Web site. We started to schedule appointments and acquire patient registration data. It saved us time and the cost of mailings."

But NeuroHub, which by early 2001 had an enrollment consisting of 45% of the office-based neurology market, was ultimately unable to sustain its business model and, by March 2004, had shut down. Its final announcement to physicians offered assistance with switching to alternative Web hosts whereby patient data and other practice material could be transferred. Some subscribers switched to neurologychannel (www.neurologychannel.com), a product of Healthcommunities.com (HC) Inc. Tom Lund, director of business development at HC, said, "We were able to extract unique practice information from the NeuroHub Web sites and place it on the practices' new Web sites. Each practice then worked with an assigned Web site manager to individualize and develop it further. Contents were customized to those areas or subspecialties important to each physician." Initially, the sites were supported by various sponsorships, but the company now uses a monthly subscription model: $95 per month for the first year and $65 per month thereafter.

Associated Neurologists in Danbury, CT, has grown from a 2-physician practice in 1971 to a practice consisting of 9 member neurologists and 13 midlevel providers. The commensurate increase in communication needs has prompted the group to look for solutions that improve efficiencies without compromising patient care. Joyce Peters, director of business development for the group, oversees their neurologychannel practice Web site, www.associatedneurologists.com, which was launched in 2000.

"The major benefit is being able to provide patients with convenient access to relevant information 24/7 from the privacy of their home," Peters said. "We feel that this helps patients get to know us before their visit--through provider bios, photos, explanations about how our phone menu works, directions, and photos of our offices. It also allows them to complete forms in advance of their appointment, saving time and postage money. We have found that providing alternate ways to communicate with the office reduces phone call volume. To further promote the site, we periodically create a 'statement stuffer' describing convenient features such as the appointment request form."

She added, "Since patients can find answers on our Web site, our costs have lowered and patient satisfaction has increased due to greater convenience and consistency. For example, patients in the office frequently comment that they like being able to get our forms online. We've discovered that many of our geriatric patients have Web access. We try to always ask a simple question: Do you have Internet access?If so, we give them a flyer with our Web address and examples of useful content. Our site provides links to relevant--and validated--content, including AAN content."

The Division of Epilepsy and Electroencephalography in the Department of Neurology at Long Island Jewish Medical Center in New Hyde Park, NY, is another of the nearly 150 neurology practices that use HC services. For the past 3 years, patients logging on to www.epilepsylongisland.com have been able to download forms in preparation for their office visits, get answers to questions about epilepsy, and preview what the center has to offer. "In epilepsy, one of the frustrations is that if patients are not aware of treatments such as surgery, it is difficult for them to find [information on] such options on their own," explained Division Chief Alan B. Ettinger, MD. The site contains links to various sources of information on patient care, including the book, 

 by Ettinger and Deborah M. Weisbrot, MD. Also included is a section about seizures that was created by neurologychannel and links to sites about other neurologic conditions.

Some physicians choose to develop their own Web sites from vendors who provide Internet services. For the past 21 years, Damon M. Fellman, MD, a neurologist practicing in Hackensack, NJ, has used Network Solutions. With its tools, he recently created the practice Web site www.hackensackneurologygroup.com for his group of 7 neurologists. "I downloaded a template, which the company provided, and it was very user-friendly. The cost was very reasonable, about $150 per year. Our initial goals were simple," Fellman explained. "The most sought-after feature by members of the group was a 'Directions to Our Office' page, saving telephone time for the staff and reducing the likelihood that the patient will be late for the appointment. We also wanted links to professional sites that provide information about neurological disorders. We wanted to be able to help patients to select Web sites that we feel are most useful and accurate from the enormous amount of information and misinformation that is available on the Web."

Fellman posted instructions for the first visit, including reminders to bring referral forms and material about participating insurance plans. He created biographies of the neurologists in his practice so that patients could become familiar with practitioners other than their usual physicians in the event that, for instance, a certain physician was covering for another. Finally, he ordered business cards that display the name of the Web site in large letters. Fellman, a Web design novice by his own admission, exclaimed, "It took me very little time to manage, and I enjoyed the experience."

Brian D. Loftus, MD, however, an engineer in his life before neurology, is clearly an expert. He has been with the Diagnostic Clinic of Houston for the past 11 years since his residency. His site, www.loftusmd.com, began as a way to educate patients about their treatments. "Most of my practice patients have migraines and epilepsy, and the Web pages serve to answer questions about these diseases that I do not have time to answer during my first patient encounter. New patients are referred to the Web site to review this information before their second appointment," he explained. Loftus does all of his own Web design with Dreamweaver on his Macintosh computer. He said, "To help nonpatients find my Web site, I put in Meta tags--little bits of HTML code that provide information about a site--for keywords and description, but I depend on search engines to do their job and find the most relevant listings. I do better on some search engines than others. Some will not list you without your paying an annual fee, and these I avoid."

Steven A. Reid, MD, has had a practice Web site, www.brainsurgeon.com, for the past 10 years. He also personally designs, programs, and maintains it. His site is highly ranked in a Google search for the word "neurosurgeon." "I tried to anticipate the search engine ranking schema and was fortunate to have the foresight to select brain surgeon as my domain name, but this was also just dumb luck," he said.

Although the right Web address can certainly help potential visitors find the site--more likely when the Web address matches the name--there are other ways in which sites can ensure traffic. According to Yahoo, for example, search engines typically rank results based on a complex formula that considers keywords, number of links, page contents, site size, and other elements. Also, search engines change their formulas regularly to ensure that Web site owners are unable to elevate their rankings artificially by manipulating one or more of these criteria.

As Loftus described, adding Meta tags--which usually include a page title, description, and keywords to index the page--helps determine ranking in relevant search results. However, even this has changed. Soon after Web site owners began to insert misleading words about their pages and to use repetition of words in the hope of tricking searchers about relevancy, its weight in the ranking equation dropped. Experts now advise that the best ways to direct traffic to a site--referred to as search engine optimization--are to build a quality site and update it frequently; use noncompetitive keywords and include them in page titles, content, headings, and descriptions; and exchange links to other similar sites. Of course, for those who invest in advertising, paid listing services generally guarantee top results. According to searchenginewatch.com, a site that provides tips and information to site owners trying to improve their ranking, paid listings are an option that should be explored by those who wish to quickly build visibility.

Neil A. Busis, MD, Webmaster of Neurosciences on the Internet, www.neuroguide.com, has been maintaining the site--one of the very first neurology Web sites--since 1994. "Web search optimization à la Google is a link popularity contest--they see how many sites link to you, and the more the better. If you get all sorts of sites to trade links with you, your site will rise in the ratings. It is not about hits, but incoming links. If all neurologists linked to each other, all neurologist sites would increase in rank," Busis explained.

Lund says that many of his subscribers like to monitor their monthly traffic reports, information that includes numbers of hits, pages viewed, unique visitors, time of day, and referral source. Neuroguide, for example, gets 5000 to 8000 unique visitors each week. Peters' practice received 5724 page views and 1531 visits in July 2005. Other business-savvy practices have used this data to track the efficacy of newspaper, electronic, and other marketing programs by examining their traffic patterns in the period after each release.

The interest by neurology practices in developing Web sites seems to be growing. "Neurologychannel comprises the second largest group in HC," Lund said. "There is definitely a trend for neurologists to invest in developing an online presence."

At times, the investment is supported by hospitals or physician organizations that assist member physicians in creating a Web platform for their services. For instance, the Yale Brain Tumor Center (www. yalebraintumorcenter.org) uses the IT services of the Yale Medical Group. Joachim Baehring, MD, assistant professor of neurology and neurosurgery and a neuro-oncologist with the group, said, "It is difficult to judge since we're not tracking the information, but we certainly have seen many 'self-referred' patients who are specifically interested in the clinical studies posted on our Web site. We keep an active trial list that is continuously updated so that the information is available for physicians as well."

As with other technology initiatives for medical practices, it often takes a single visionary member of the practice to lead other busy and overworked physicians in a new venture. Fellman, who had asked members of his practice to write their own professional biographies, was frustrated by a delay in response. "Tired of waiting and perhaps impatient to go online, I eventually went ahead and wrote the bio for one member myself, which he later read and approved," he said.

Not all marketing ventures are ultimately successful, as Loftus noted: "The Web site has had minimal impact on clinical trials. The site needs major design changes to benefit these. Part of this is due to the time-sensitive nature of trials and the time-insensitive nature of the Web. There seems to be about a 3-month delay from the time a new article is posted on the Web site to significant listing on search engines. Since clinical trials enroll only over a few months, this limits its effectiveness."

Furthermore, just because a site has a feature does not mean that patients will necessarily want to use it. Peters has found that very few patients use the prescription refill request form, for example. The practice she serves plans to implement an electronic health record (EHR) by March 2006, so the Web site will evolve to include interactive and secure tools. As Sergay noted, "The ideal site will be integrated with a full EHR, electronic prescribing, and electronic messaging."

As always, medicolegal experts suggest that advice be provided to patients about the limitations of electronic information, particularly for interactive Web sites that include e-messaging. Loftus' site, for example, adds the following disclaimer: "This site is not intended for diagnosis but rather to offer information to make a better informed patient. Discuss any medication changes with your physician prior to making any changes." Although HC also provides an extensive disclaimer, including warnings that it is not a secure site, Peters reflected, "Some patients use the Web site to communicate protected health care information in spite of our disclaimers."	*

ow often do patients find their physicians by searching the Internet? It is getting more frequent. According to the May 2005 Pew Internet and American Life Project "Health Information Online," 8 in 10 Internet users have looked for health information online. After a tough time getting answers from several doctors, Kenna Bobber found her neurologist by searching Google for a "Houston neurologist." She said, "Dr Loftus was the first physician listed in the natural search, and I liked his Web site for its straightforwardness. I also liked that it wasn't slick. The most compelling piece of information on his site was a note stating 'If you are a new patient and you are told there is more than a 2-week wait until you can be seen, please email me.'"

Bobber added, "After visiting his site, I felt hopeful that there was a doctor out there [who] was going to listen to me and possibly even help me. The impressions I formed after reading Dr Loftus' Web site were consistent with what I discovered when I met him a week later. His most valuable trait is his compassion for his patients, reflective of the sense of warmth and safety conveyed on his site. Within 2 weeks of my first appointment with him, he confirmed the diagnosis of myasthenia gravis and recommended an aggressive treatment plan that totally took my needs and desires into consideration."

Physician Practice Web Sites Growing in Numbers

When Jeffrey H. Oppenheimer, MD, a neurosurgeon in suburban New Orleans, was a member of a group practice, one of his partners found piles of unopened explanations of benefits (EOBs) stuffed in a billing clerk's desk drawer. So, when he started his own practice, he wanted to be sure that he was as protected as possible from employee error and negligence. After searching for an office practice management system that would give him peace of mind, he decided to subscribe to athenahealth (www.athenahealth.com), a Web-based vendor that provides billing and collections services for physician practices.

Oppenheimer, who has been in solo practice for 5 years and has been using athenahealth for the past 3 years, said, "The best thing is that this system is embezzlement-proof. Insurance checks are deposited directly into a third-party lockbox. I can then wire-transfer the money into the bank once it is posted. The streamlined process frees up billing employees to deal with more urgent matters."

Oppenheimer also has taken other steps to prevent reimbursement losses. He does his own coding and, along with members of his office, attends the coding courses offered by the American Association of Neurological Surgeons (AANS) on a regular basis. "We need to be good coders ourselves and to educate our staff. If we delegate all this responsibility, there will be all kinds of errors," he said.

Manual diagnostic coding leaves much more room for human error than automated systems. Numbers scribbled on an encounter form, circled from a truncated list, or written in text form and subject to random interpretation by billing staff may end up looking very different from the intended diagnosis. Most payer claims processing systems contain claim adjudication features that reject incongruent International Clinical Disease-9 Clinical Modification (ICD-9-CM) and Current Procedural Terminology (CPT) codes. For example, when procedure codes for electromyography are automatically checked against diagnostic codes during processing, a simple numeric transposition error that changes 354.0 (carpal tunnel syndrome) to 345.0 (generalized nonconvulsive epilepsy) automatically triggers a denial. Without a vigilant staff or a computerized system that alerts physicians to error, payment for services may be delayed or left unpaid.

"No one but the doctor seeing the patient really knows the details of the diagnosis," said Laura B. Powers, MD, chair of the American Academy of Neurology (AAN) Medical Economics and Management Subcommittee. She shares a group neurology practice in Knoxville, TN, with 7 colleagues and has been teaching coding courses and speaking on behalf of the AAN for new diagnostic codes and clarifications and improvements to the current codes for the past 12 years.

"Unless the doctor writes the entire description required to choose the fourth and fifth digits for many of our diagnostic codes, the office personnel choosing the ICD-9-CM code will have to either come back to get more information or use a nonspecific code, which may be denied," she said. "Either outcome can cost the practice money."

"I have always spoken against superbills [charge slips with evaluation and management (E&M) codes and ICD-9-CM codes]. . . . They are fine for subspecialists who see only a limited number of codes and can have a list of all the possible codes on 1 sheet. But for general neurologists, there are just too many codes used in the office to list on 1 sheet, or even 2. There are also long-term economic implications for using the most precise codes possible," Powers added. "ICD- 9-CM is used for morbidity and mortality data. Using the right code can help us justify the need for financial assistance to further the treatment of neurologic diseases and help neurologic researchers get reliable data on the US population."

Most experts agree that automating the coding process reduces error. When Craig T. Williams first stepped into his role of administrator/director for the Departments of Neurosurgery and Neurology at the Brigham and Women's Hospital 3 years ago, he discovered that the departments had lost 1 month's worth of in-patient billing in a manual system that required doctors to jot down all their hospital visits on index cards. The physicians had to rely on recall to document their daily rounding activities. "Some could not remember very much at all," observed Williams, who realized immediately that a more reliable approach was necessary.

"To avoid filling out information again, the doctors tended to keep their cards until the patient was discharged, sometimes delaying claim submissions for 30 days and adding up to thousands of dollars in delays," he explained. "Moreover, when the cards were brought back, they were held up further by office staff tasked with matching the patient in-house days for concordance with length of stay. Then, they were sent across town in an interoffice envelope where they would sit in a bin until they were keyed into the billing system. In addition to cards never being turned in, imagine all the places along the way for them to get lost."

To avoid lost charges, Williams began using PatientKeeper (www.patientkeeper.com), a mobile charge capture application that the department's neurologists use on a Pocket PC Hewlett Packard Ipaq HX2750. After 1 year, he has seen an increase in in- patient charges of 20% and a 50% decrease of days in accounts receivable. "The census is uploaded onto the handhelds so that when neurologists are making rounds, their patient lists are readily available. They can then look up patient prescription information, recent laboratory reports, and radiology images. The first time they see a patient, they create a charge and select the appropriate E&M code from the system, which has been preloaded with the most common CPT and ICD-9 codes. The ICD-9 system has already been configured from the billing records to display those patients' most recent diagnostic codes. The efficiency is even greater the next day, when only follow-up codes need to be selected," he explained. Currently, the information needs to be synchronized at a base station, but Williams plans to use a wireless network that will allow the charges to upload automatically to their billing system, IDX.

Williams, the current secretary of the Business and Research Administrators in Neurology Society (BRAINS), which is affiliated with the AAN (for information, go to www.aan.com/about/sections/ brains.cfm), is dedicated to improving practice reimbursement. Hoping to achieve an even greater reduction in bill-processing time in the accounts receivable department, he is currently piloting a trial period in which residents have been supplied with the PatientKeeper system, thinking that the residents will be comfortable with the technology later on. He anticipates that their experience and ultimate buy-in will help prevent lost charges even more. Williams also notes that the application's built-in intelligence feature is able to prompt physicians when they inadvertently omit information or make a mistake. For example, it may ask, "Do you want to add a modifier?" or "Is this part of the surgical global period, or are you evaluating the patient for an unrelated complaint?"

Oppenheimer also appreciates the value of having a product with a rules engine. "Athenahealth tells you if you are making a mistake as it is running," he said. "Over time, the software accumulates payer rules, and as it evolves, it 'learns' from denials and improves its performance. When rejections do occur, it offers templates for rebuttal letters." In addition, the system checks eligibility information, referrals, and reimbursement requirements and flags problems for the office staff to review. It tracks claims, posts payments, notes nonpayments, and immediately follows up on unpaid claims.

In larger groups, it is often difficult to convince all member physicians to adopt new technologies at once. Laurence J. Adams, Jr, MD, a neurologist working in a combined neurology/neurosurgery group with 9 physicians in Colorado Springs, CO, began to use a new integrated practice management and electronic medical record (EMR) program, eClinicalWorks (www.eclinicalworks.com), a few months ago. "I am able to easily choose the right diagnosis code and billing level after I complete my note," he said. The E&M coder prevents underbilling by analyzing the documentation and recommends the appropriate visit level. The system is then able to reconcile patient encounters systematically to ensure that all charges have been recorded for all visits. Likewise, such tools can help prevent overbilling--and risk of audit failures and fines--by pointing out areas of deficiencies in documentation and allowing providers to add information omitted from the record.

"The cost of this integrated product is less expensive than our previous practice management system alone," Adams noted. A self-proclaimed technophobe who does not even own a home computer, he admits, "I am extraordinarily pleased with the results. . . . By using voice recognition for our notes and getting rid of our transcription fees, we have been able to save about $6000 per month." His practice manager estimates an additional savings of $3000 per month in postage, paper supplies, and equipment.

Adams' enthusiasm quickly attracted the interest of his associates; after 1 year, "seven others are using the system fully and the eighth is coming along," he said. Like athenahealth, eClinicalWorks PM is a Web-based application that allows practices to submit claims electronically; it also soon will confirm patient eligibility and determine which services will be covered. The system includes a scheduling program, scanning and document management module, prescribing application, and handheld capability to chart at the point of care. Since Adams' practice is now e-filing claims, it has seen a significant improvement in the revenue stream because claims can be turned around in as little as a few days, rather than weeks or months, which was the case when they were filed by hand.

William Henderson, the practice administrator for Upstate Neurology Consultants in Albany, NY, has seen a marked improvement in efficiency since the practice adopted new information systems. His 5-physician neurology practice uses Intergy software from WebMD (www.intergy.com). One application that translates into big-time savings has been document scanning and storage capabilities. An increasingly popular digital solution, document imaging and management systems (DIMS) provides a way to consolidate information from unmanageable quantities of paper to easily accessible electronic files for future viewing.

"All explanations of benefits are scanned by date posted. Not only has this saved considerable shelf space, it is now possible to search for an EOB within seconds," he said. "Billing staff can view the exact statements that patients receive when they need to discuss payment issues with them. And by using electronic billing features with Envoy's clearing house, staff can see claim rejection reasons on the Internet and resubmit the bills directly from those Web pages."

The quest for the right billing and practice management system requires planning and patience. When Bonnie A. Francisco, administrator for a large neurosurgical practice in Minneapolis, began her search, she engaged in a 1-year study of the vendor market, reviewing her practice needs and specific products. She checked whether applications were compliant with various current regulatory requirements such as those of the Health Insurance Portability and Accountability Act. She narrowed her search to vendors who provided local support, concerned that out-of-state support would be less accessible.

After approaching all departments in the neurosurgical office and asking them to create a wish list of functionalities that would improve their individual tasks and make them more efficient, she created a request for a proposal. Defining her practice requirements in writing ultimately forced vendors to respond to a consistent set of questions. Francisco invited 3 vendors to perform in-house demonstrations for various departments and asked the departments to rate the products' capabilities. She then took key staff members, including operations managers, business office managers, and department heads responsible for transcription and medical records, as well as medical secretaries and front-desk personnel, on site visits to investigate systems. They asked tough questions about product functionalities, user training experience, ease of the conversion process, and satisfaction with customer support.

They ultimately decided that their practice would benefit from a product that would be fully integrated with an EMR, one that demonstrated ease of reporting functions, provided prescription tracking and telephone messaging, and included a scheduling module with all providers' appointments-at-a-glance, insurance card scanners, label printers, and direct-fax capability. They selected NextGen (www.nextgen.com), a product that most closely matched their needs. The due diligence displayed by Francisco during this project earned her the "better performer" distinction in accounts receivables and collections from the Medical Group Management Association (MGMA) for the second year in a row. Like many practice administrators who are dedicated to improving operations, Francisco uses MGMA benchmarks and other resources.

Several consulting firms specialize in advising medical practices in their search for office systems. KLAS enterprises (www.healthcomputing.com), for example, supplies performance reports for many practice management and EMR systems. Its online database classifies products by category of function and practice size and reports on a standard series of vendor and product performance measures. It relies heavily on user experience and translates the feedback into rating scales and report cards. It allows practices to screen prospective vendors and review peer-generated reports to narrow selections to those vendors performing at a required level. With literally thousands of practice management products available--and many of them destined to fail--independent consulting firms provide resources through which practices can make more informed decisions about their purchases.

Barbara P. Hurlbert, CmpE, who has worked in health care management for 34 years and has served as practice administrator for Lyerly Neurosurgical Associates in Jacksonville, FL, for the past 9 years, has seen a great evolution in billing, a transition from paper ledger systems to computerized products. She has experience with more than a dozen practice management systems and believes that technology should be adopted incrementally. She said, "It is not something that should be done overnight but is best undertaken in baby steps."

Hurlbert is the president-elect of the Neurosurgery Executives' Resource, Values and Education Society (NERVES), established by the AANS and the Congress of Neurological Surgeons (CNS). She has been actively involved in the business education of AANS and the CNS member physicians and staff. In a presentation delivered at the 2005 AANS annual meeting in New Orleans in April titled "A Neurosurgery Administrator's Journey to EMR and Digital Technology," she advised, "Your vendor will not baby-sit you during an installation with a practice management system or an EMR. To get the best results, you have to tailor the product for the needs of your practice, and that requires a high level of sophistication from managers."

Lyerly uses the Misys Tiger Billing System (www. misyshealthcare.com) with the interfaced software that has a correct coding initiative built in. Lyerly physicians do the coding themselves before charge data are entered. Like most practices that have sought to achieve a seamless workflow, Lyerly uses an integrated billing and charting system.

For those who have not yet interfaced their systems, several Web-based resources can help with diagnostic coding. Powers recommends the "Official Guidelines for Coding and Reporting," found at www.cdc.gov/ nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm, and says that it is a quick read. The AAN offers a search engine for ICD-9-CM codes that includes an alphabetic search, a numeric search, and a stroke appendix for the rather difficult-to-navigate cerebrovascular disease section (www.aan.com/professionals/coding/coding.cfm).

Most practices today are struggling with higher overhead and working longer hours to maintain the bottom line. It is more essential than ever to ensure that each encounter is correctly billed and properly reimbursed. As Oppenheimer said, "The majority of us already take discounted fees from payers. It is criminal not to collect money that is rightfully ours."	*

software,coding,reimbursement,billing,practicemanagement,electronicmedicalrecord

Computerized Tools: Taking the Mystery Out of Coding, Billing, and Reimbursement

When Gordon R. Kelley, MD, was called to the ICU in Kansas City, Mo, to evaluate a deteriorating patient who had apparently overdosed on methadone, he was puzzled. CT and MRI scans revealed an obstructive hydrocephalus associated with abnormal signals throughout the cerebellum, basal ganglia, and hippocampi. He knew that these findings were not consistent with a typical cerebrovascular injury, but he and other treating physicians were unsure of the cause of the findings. Reaching for his handheld computer, he entered several key words into his favorite program, NERVLINE: cerebellum . . . heroin . . . leukoencephalopathy.

Within seconds he found the first of a series of papers describing symmetric lesions in the cerebellar and cerebral hemispheres of illicit drug users who heat heroin on tinfoil and inhale the thick white smoke, a technique dubbed "chasing the dragon." Kelley read that the syndrome was first described in 1982 as an epidemic of 47 patients in Amsterdam, and that the prognosis was poor for advanced cases.

 Although the syndrome has been reported sporadically since 1982, Kelley found a report published in 

 in 1999 that described 3 cases that occurred in New York.

 The report suggested a link between the toxicity and mitochondrial dysfunction. The authors, who included Arnold R. Kriegstein, MD, PhD (currently director of the Program in Development and Stem Cell Biology at the University of California, San Francisco, School of Medicine) and a team from Columbia University in New York City, reported treating 2 patients successfully with antioxidants, including coenzyme Q. So, when Kelley's patient awoke and admitted to smoking heroin, he was treated with the same regimen and made a remarkably good recovery.

Kelley raved, "NERVLINE helped me rapidly recognize and successfully treat a typical presentation of a rare disease that had previously been unknown to me. It was fast, slick, and nothing short of remarkable." NERVLINE

 one of a variety of digital reference tools available today, performs searches of 25,000 core clinical neurology articles to form diagnostic relationships between key words and produce relevant citations and abstracts. For many clinicians seeking help at the bedside, handheld references have replaced manuals, textbooks, and a variety of written note systems.

Personal digital assistants (PDAs) have given us the ability to get the information needed to provide patient care at virtually any time or place. As we purchase more devices, our demand for applications is growing. Traditional texts and reference materials are being ported to platforms that can be used as handheld references and are capable of being searched rapidly. Skyscape, for example, offers 270 references for handheld devices and segregates medical content by specialty. It transforms text, tables, and algorithms into formats that are easy to read and scroll through. Its smARTlink feature cross-indexes material in a logical manner that allows users to search multiple sources easily.

For Steven A. Reid, MD, a neurosurgeon in Gainesville, Fla, the reference source of choice for the past 3 years has been Epocrates, a provider of drug and clinical information. He uses the handheld version and pulls up the system an average of 5 times a day on his Sony Clie. "It saves me a lot of time confirming medication dosage regimens and identifying potential adverse interactions," he said. "I've noticed a trend recently, disturbing actually, for primary care physicians to prescribe a panoply of medications. Some of my patients routinely take 15 or 20 meds daily. Epocrates helps me sort these out, and educates me on unfamiliar meds. I am also able to screen all my post-op orders on the polypharmacy patients."

Many physicians who have become accustomed to Epocrates feel much like Jan H. Mashman, MD, a neurologist in Danbury, Conn, who said, "I can't live without it. It provides me with the ability to list the various medications the patient is taking, run a check of interactions, see which are acceptable in pregnancy, and get details such as dosages of drugs that I use rarely." He added, "Like most practices, our providers have a wide range of technical skills, so we consider the use of PDAs a key step in getting all our providers more comfortable and proficient with technology as we progress toward an electronic medical record [EMR]."

Reid and Mashman are 2 of approximately 170,000 active physician users of Epocrates in the United States; an estimated 4000 are neurologists. In a January 2005 survey sent to 250 neurologists who were active users, 40% responded within 36 hours and 91% of them agreed that the program helps them avoid 1 or 2 adverse drug events per week. Similar estimates were obtained from 1240 responders across 13 specialties. All responders also believed that Epocrates saved them time; 43% estimated daily time savings of between 11 and 30 minutes, and 25% estimated daily time savings of between 31 and 60 minutes.

Not only do software preferences vary; hardware preferences differ as well. The gamut of mobile computing devices ranges from large laptop computers to tablet PCs, ultraportable sub-notebooks, handheld computers, and mobile phones with additional capabilities (so-called smart phones). As these appliances shrink in size, the processor power, screen size, and the ability to support traditional desktop PC business applications decreases. All current mobile computing technologies have advantages and disadvantages. Some physicians dislike the limitations of the smaller handheld devices: small screen size, short battery life, slow or clumsy writing capabilities, low processing power, and operating systems in which the applications that can be used are limited. Others prefer the more capable laptops and tablet PCs, but they are bigger, heavier, more expensive, and more fragile.

Trade-offs exist in the methods of getting the information to and from the device. Wireless local area networks and the Internet have become more readily available but typically suffer from slow data transfer, poor security, competing standards, and in some cases, electromagnetic interference with medical equipment. Data synchronization through cradle and cable is simple and secure, but it is hardware-specific and can only perform batch data updates.

Most handheld devices run on the Palm OS or Pocket PC operating systems. Until relatively recently, most Palm OS devices were smaller and cheaper, had a longer battery life, had more applications, required less memory, and were easier to use, whereas Pocket PC devices had better integration with enterprise applications (such as Microsoft Office), more security, more computing power, bigger screens with nicer displays, and more standardization. Much of this is changing now, and more devices are being seen that have similar desired features.

Given all the available choices, what is the best device for today's practicing physician? "As with any technology purchase, the answer is, 'It depends on what problems you are trying to solve,'" advises Neil A. Busis, MD, a neurologist in Pittsburgh, who teaches about handheld devices and other technologies at medical society meetings, including the annual meeting of the American Academy of Neurology. "The hardware that offers the features and applications that best address each individual's greatest needs is the best one to buy." He continued, "For example, if a physician's most indispensable desktop software can only link with Pocket PC but not with Palm OS devices, the Pocket PC would be the mobile platform to select. If e-mail or Web brows-ing is a user's top priority, a smart phone may be the best solution."

In fact, many experts are tout-ing these latest gadgets--smart phones--as the devices most suitable for physicians. In addition to the standard functions, the Treo 650, for example, has a digital camera that captures video, Bluetooth technology that allows the user to connect wirelessly to printers and desktop computers, and even an MP3 player. Moreover, when convergence devices are combined with greater bandwidth, such as Cingular's high-speed data network EDGE, the user is able to experience faster synchronization times and handle more robust applications. For example, such a device can accommodate the PatientKeeper clinical application suite, test results, drug databases, and reference material. With a smart phone, a physician can be out at a ball game and answer a patient's telephone call, pull up a medicine list, retrieve up-to-date laboratory reports, or look at references.

"My Treo 650 takes all the pressure off being on call," said Alida F. Griffith, MD, a movement disorder specialist and solo neurologist for a hospital practice in Woodinville, Wash. She explained, "I use it in lieu of my pager, because I don't see the point of carrying both a pager and a cell phone. It accepts text messages from my answering service and holds all of my essential information, such as business addresses and my DEA number. It also weighs far, far less than the smallest laptop, so is a pleasure to bring on business trips. I can be out biking in the middle of nowhere and yet easily look up medication doses or even search PubMed."

Indeed,PubMed, the Internet site perhaps most widely visited by physicians, is now available for Web-enabled handheld devices. It allows users to search medical literature, browse journal abstracts, and compare different forms of treatment and desired outcomes through a new feature called Patient, Intervention, Comparison, Outcome. The developers also are creating other enhancements, such as a spell checker and a query tool called askMedline through which health care providers can ask natural-language, free-text questions.

Some veteran users find it inconceivable to practice without mobile computing. Randy M. Rosenberg, MD, a neurologist in group practice in Huntington Valley, Pa, uses a Dell Axim v50 with wireless capabilities that operates on the Pocket PC system. He depends on a wide variety of resources from his handheld, including Mobile MerckMedicus, which provides him with free journals; several drug databases, including Epocrates; MedCalc 3000

 a clinical calculator; Pocket Consult, a mobile version of MD Consult; and Medformulas, to calculate medication dosing.

He reflected, "I first came to realize the power of having information at my fingertips several years ago when I was called by a remote hospital to provide urgent orders on a potential tPA [tissue plasminogen activator] patient. I connected my handheld to the telephone using it as a dial-up modem and faxed an order set to the ER within the 3-hour window." Rosenberg believes that Palm OS systems eventually will become obsolete, however. He explained, "The nature of medicine will require a Windows-based environment that does not have to use third-party software to go back and forth between handheld and PC."

At the Neurosurgical Intensive Care Unit of the 800-bed Hartford Hospital, director Marc D. Palter, MD, also relies on a Dell Axim v50. "Most physicians prescribe about 200 drugs; the problem is that we all use a

200 drugs," he said. "My drug database, Lexi-Comp, allows me to do quick checks for drug interactions and look up less familiar meds. Furthermore, the material gets updated right away so, unlike the paper counterparts, they are always current. For instance, the minute that Vioxx was taken off the market, it was no longer available on the handheld."

He continued, "Our ICU, like many others, often has to accommodate medical boarders with problems that are not typically neurosurgical. Mobile references become truly useful in taking care of patients that are not our native population. For example, we recently admitted a patient with sudden dyspnea who was found to have methemoglobinemia. We looked it up on the handheld Washington Manual and found a relationship to hurricaine spray [a local anesthetic] and indeed, it turned out that the patient had self-administered so much that this potentially lethal condition had developed."

Palter's device also includes Outlines in Clinical Medicine, Pocket ICU, PocketChart, PatientKeeper, and numerous other applications, such as EPERC's end-of-life care treatment guidelines. "The vast majority of practitioners at Hartford Hospital uses PDAs and, at times, there is a race for information with everyone pulling up stuff on dueling handheld devices. Partners also routinely beam sign-out lists of patients to each other. The hospital is in the process of rolling out wireless connectivity, so while walking from the ICU to the floor, I can sync and update my device. Eventually, this will be done every time I turn it on," he said.

Although desktop computing offers capabilities that far surpass those of handheld devices, even terminal-rich hospitals such as MidState Medical Center in Meriden, Conn, do not necessarily support physician use. "Firewalls so restrict access that I am unable to connect to local networks or even use the Internet," said Ron Nath, MD, a solo neurologist in Wallingford, Conn. Nath refers to his Palm Tungsten T3 to look up medical information while on rounds. He uses the 5-Minute Neurology Consult, ICD-9-CM, and Stedman's Medical Dictionary from Skyscape, as well as Epocrates. He said, "I don't like filling up my pockets with books; I even find it inconvenient in the office. There is no better tool than a handheld for when I-need-the-information-right-now."

Nilay R. Shah, MD, 1 of 6 neurologists working at Crystal Run Healthcare, a large multispecialty group in Middletown, NY, believes that no single solution will appeal to every doctor. "Each physician has his or her own work style and workflow; there really is no one-size-fits-all gadget," he said. In fact, for his own computing preferences, he uses a combination of tools. He favors his HP Jornada 568 Pocket PC for mobile computing at the nursing home and hospital. The small machine with built-in Wi-Fi and Bluetooth technologies uses wireless connectivity, allowing him to incorporate parts of his in-patient records onto his Pocket PC. He prefers the larger tablet PC (about the size of a clipboard) for his office practice, which includes charting using an EMR.

Michael Segal, MD, PhD, a child neurologist and the founder of SimulConsult--a Web-based support tool that helps clinicians identify inherited and congenital neurologic diseases--also uses a tablet PC. "I have been very impressed, particularly with the dictionary-based handwriting recognition. For our software, we have a file with terms that users can add to their tablet dictionary, which then recognizes the medical terms used in the software extremely well," he said. But for the most part, the adoption of Tablet PCs has failed to meet expectations. Although screen size is larger, the current weight, fragility, and expense of these devices, as well as their awkward input methods, have been viewed as obstacles by many physicians. Newer mini-PCs--which are the size of PDAs, run on Windows XP, and easily connect to keyboards and full-size monitors--may attract some physicians, but they are still limited by short battery life and, for now, high cost.

For those physicians who are contemplating use of a PDA, many experts advise an incremental approach. "Start using it as an organizer and a date book first," said Nath. "Once you are comfortable with backing up and other basic functions, you can add medical applications."

As always, some are waiting for the ideal device that will do it all: function as a telephone, retrieve e-mail, run all necessary software, integrate seamlessly with PCs, and communicate quickly with all external sources of data. Griffith mused, "One day they will make the ultimate machine, which will consist of a heads-up display that fits into my glasses, voice-activated commands that make typing unnecessary, and is able to seamlessly transition between Wi-Fi hotspots and wireless dial-up. Until then, the Treo 650 does a pretty good job of keeping me connected."	*

1. Wolters EC, van Wijngaarden GK, Stam FC, et al. Leukoencephalopathy after inhaling "heroin" pyrolysate. 

2. Kriegstein AR, Shungu DC, Miller WS, et al. Leukoencephalopathy and raised brain lactate from heroin vapor inhalation ("chasing the dragon"). 

 is a practicing neurologist in Tarrytown, NY.

Neil A. Busis, MD, answers the question: What can PDAs do?

DAs started out as simple electronic organizers with only 4 canonical functions: a calendar, address book, memo pad, and to-do list. Now they are real computers with a universe of applications and have the ability to communicate with other computers and the Internet. Three capabilities of PDAs make them ideal devices to support medical decision making: PDAs think, sync, and link.

 PDAs literally put information at your fingertips. Examples of information that can be accessed include medical references, drug information databases, and clinical calculators. Requirements:

 PDAs synchronize their information with information on desktop or laptop computers either by wired (the PDA is placed in a cradle attached to the desktop computer) or by wireless mechanisms. Synchronization can be achieved either manually or automatically. Examples of synchronization include personal information management (calendar, address book, memos, to-do lists), charge capture, and electronic prescribing. Requirements:

* Information server (desktop or laptop computer)

 With wired or wireless modems, PDAs can connect to the Internet and access e-mail and the World Wide Web. They also can connect to private networks, such as hospital networks, and access patient data in real time. Requirements:

When Gordon R. Kelley, MD, was called to the ICU in Kansas City, Mo, to evaluate a deteriorating patient who had apparently overdosed on methadone, he was puzzled. CT and MRI scans revealed an obstructive hydrocephalus associated with abnormal signals throughout the cerebellum, basal ganglia, and hippocampi. He knew that these findings were not consistent with a typical cerebrovascular injury, but he and other treating physicians were unsure of the cause of the findings. Reaching for his handheld computer, he entered several key words into his favorite program, NERVLINE: cerebellum . . . heroin . . . leukoencephalopathy

Author | Orly Avitzur, MD, MBA

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