What's a tipping point? Here's a hint: It has nothing to do with dining out and calculating 15 percent of your bill. Tipping points are those abstract factors that marketing gurus and practice-management groups want to manipulate to get their clients more attention and profits. Tipping points explain why the market chose VHS over Betamax, and why one day, everyone had a cell phone, including 12-year-olds. And in chiropractic? We definitely need to figure out what's going to create our tipping point among health care consumers - but that's a topic for another day.
Today, the question is: "When will electronic health records (EHRs) tip?" It's a question that's definitely on the minds of people who follow documentation trends. And although it's a question that may not weigh heavy on your mind, it probably will soon. For us self-proclaimed EHR "geeks," it is not a question of if EHR is going to tip, but when. When will that point in time come that the perceived value of EHR overcomes fears about its application. And that "when" is going to have consequences on the way every chiropractor practices, cares for their patients and pays their bills.
While this message isn't new to this column, the way I'm addressing it is. It's new because I'm going to tell you the truth about things you think you already know about chiropractic practice, but place them in the context of the drive for digital documentation. Let's call them "three myths revealed." Keep reading as I lay out my predictions for EHR, and ultimately its relationship to your practice. I guarantee you're going to ask, "Why didn't I see it earlier?"
Myth #1: HIPAA Is About Privacy
If I asked most of you what HIPAA is about, you would say that it's about privacy. And on the surface, that would make sense, because every hoop HIPAA makes us jump through seems to be about protecting our patients' right to privacy. But this is a myth, and it persists because a lot of us haven't taken the time to read the law in all of its dry legalese. Let's remind ourselves what HIPAA actually stands for: Health Insurance Portability and Accountability Act (1996). Sure, privacy is there, included in the notion of accountability. The key word here is portability. What does that mean? According to information provided by our own version of nationalized medicine, Medicare/Medicaid Services:
"Adopting these standards [HIPAA] will improve the efficiency and effectiveness of the nation's health care system by encouraging the widespread use of electronic data interchange in health care."1
That's right. HIPAA is ultimately about moving from paper to digital in order to increase the ease of access to a nationwide health-record database. Right now, HIPAA may seem most effective in delaying loved ones' access to their family member's medical records. However, that's just an unfortunate side effect of its ultimate purpose, which is to make us comfortable with the idea of our medical information floating through cyberspace.
Back in the mid-1990s, the idea of sending health information electronically would have sent most people into a panic. Cell phones were still large in size, the Internet was not in every single home, and wi-fi hotspots were almost places from science fiction. Now, 10 years later, we find that people are very comfortable banking online with a financial institution that isn't even located in their state. We've turned the corner with our acceptance of digital data. As long as there's a little lock in the corner of the Web browser, we're pretty confident our online purchases, taxes and vacation reservations are being handled safely.
In the world of health care, HIPAA has become that little lock consumers look for to know their data is safe. It may be an annoyance to them, but it's also a security blanket. There's actually a reason that HIPAA wants you to log and verify every electronic transaction you have that includes your patients' health care information. There's also a reason it took more than 10 years to phase in every aspect of the HIPAA law. The government was preparing us for the everyday demands of being able to guarantee our patients' data, and setting national standards for all the power players in the health care data-flow process.
Myth #2: The Concept of 24 Patient Visits Is Based on Evidence
Why do only a few third-party payers allow 24 patient visits a year to the chiropractor? Is it about evidence or about best practices? Actually, it has little to do with either one of those reasons. Our patient visits stand at 24 for some of the more open carriers because it costs less for third-party payers than it does to request and review the records associated with the claim. If you do the math, the average patient-visit collection is $58 around the country, which means it costs more than $1,300 to double-check our records after all the departments "touch" or initiate the transaction. It's simply cheaper to pay us or deny payment for improper coding than it is to review the merit of individual claims. I almost wouldn't believe this myself, except the president of a large third-party pay program told me in person. This inefficiency is actually allowing many of us to get paid $1,300 for some patient cases of more than a year - some with quite a few glaring holes in their documentation standards.
The cost of moving, storing and securing paper records is one of those few variables that the government and the health care industry know they can control. They can't stop two-thirds of Americans from becoming overweight. They're limited in raising cigarette taxes. But they can dramatically reduce the cost of health care by automating it through digital documentation. The process is simple:
Suddenly, it's not about paying for 24 visits because that was the cheapest option. It's about having digital access to the evidence justifying patient visits for every interaction. It's about saving lots of money. In the next few years, that 24-visit allowance will be gone, replaced by shorter increments with immediate electronic evaluation. Does your documentation hear me now?
Myth #3: We're Decades Away From Mandatory EHR
As of right now, Medicare requires all chiropractors with more than 10 employees to submit every Medicare billing claim electronically. Not many of us have more than 10 employees, so this information hasn't quite sunk in yet. Nevertheless, it's true. Digital has already become the standard for one of the largest government pay programs. And the most interesting part of it is that you can't opt out. If you have 10-plus employees and are seeing patients age 65 or older, then you're submitting digitally, and you don't have an option.
Mandatory EHR is not decades away; it's already starting. As of right now, 25 percent to 30 percent of us are already successfully participating in electronic billing. The question that immediately arises is: What's stopping the other 70 percent? Legislators and third-party payers know that all it will take for health care providers to go electronic is to start penalizing those who don't, by limiting their reimbursement to the method they choose to submit claims and documentation.
It's my personal opinion, and one shared by others in the profession, including college presidents and other profession leaders I've conversed with, that we're only five to 10 years away from a health care system that will expect a digital note submitted with every claim. While each note won't necessarily be reviewed on the spot, a daily SOAP note on file within a database will become a condition of payment. This is just a new format for an old idea. Those of us who take personal-injury and workers' comp cases know we have to submit our records just to get paid.
Preparing for the Tipping Point
It isn't yet known when and how EHR will tip and become the predominant form of documentation and billing. But I'm convinced the tipping point is just around the corner. I offer these three shattered myths as support for the coming change in our offices, to show how HIPAA and Medicare are leading the way. The question is not if, but when. Where will we be when it comes time to make that change? I'd like to believe we could lead the way in this shift in health care. We could lead a health care revolution by elevating our documentation standards and the way we record the practice of chiropractic, rather than regretfully changing when everyone else has determined the rules of the game.
HIPAA is ultimately about digitizing health records, and that means digitizing our clinics. So we can continue to write by hand and scan every paper in our office into a computer file in order to get paid, or we can meet new challenges head-on and adopt a paperless-clinic model. I'd rather it not be the act of some legislator to get us to follow where everyone else has already gone. My hopeful prediction is that a majority of our profession will embrace the digital practice revolution and begin to enjoy the clinic of the future. Maybe we could even contribute to the precipitation of this tipping point.
Reference
Many relevant diagnostic signs are not performed deliberately by the examiner or by the patient at the examiner’s direction. They are observed as the patient reacts to their condition. Fortin’s finger sign, Minor’s sign, and Vanzetti’s sign are three examples of this principle.
On Feb. 1, 2024, two more legislators – John R. Carter (R-Texas) and Robert “Bob” Good (R-Va.) – co-sponsored the Chiropractic Medicare Coverage Modernization Act of 2023, bringing the co-sponsor total to 155, two more than the total achieved over the entire two-year congressional cycle in which identical legislation last appeared (2021-22).
While working at the Lovelace Medical Center in Albuquerque, N.M., one of the primary care physicians stated that imaging every patient prior to receiving chiropractic was not medically necessary. It was at that point I reconsidered the need for the imaging of every patient to avoid malpractice.
