Computer Consult

How we'll survive our next computer switchover

Forced into the 21st century, the author bought a new computer system—and learned much about himself, his partners, and his staff.

By Robert Levai, MD

Remember the "Y2K problem"? When warnings of potential disasters began seeping out during the mid-1990s, I scoffed at the notion that the wizards of Silicon Valley couldn't correct such a conceptually simple problem. After all, how could geniuses like Bill Gates not realize that after 1999, 2000 was sure to follow?

About a year ago, however, my smugness was shaken when Roy, the computer consultant for my three-doctor group, announced that our practice management software wasn't Y2K-compliant. Months earlier, he had mumbled something similar, but I'd ignored him. Who thinks that far ahead? But now, with doomsday fast approaching, I was forced to listen.

Roy gave it to me straight: We'd need to chuck our old computer system and purchase a new one. Not to worry, he said, the transition would be painless—except for the need to slice into our bank account. We'd require two higher-capacity computers and some upgraded hardware to run them on a network, plus Y2K-compliant software. The total price tag would be close to $20,000.

Hold it, an entire new system? Well, yes, Roy explained, incredulous that I hadn't realized this sooner.

Our current system had served our practice admirably for more than 10 years. Left to our own devices, we'd have maintained the status quo. But that wasn't an option, according to Roy. No upgrade was available for our DOS-based programs; these days, most programs are written for Windows. Besides, the software company was defunct. Technologically, we were orphans.

Training, Roy acknowledged, would be extra. He recommended five full days of instruction, but since our office staff was expert in the old system, I figured that mastering the new one would be a cinch. So we budgeted three days for training.

The status quo, it turns out, is not something you can change in three days. Converting to a new computer system was a long and difficult process—and it taught us as much about ourselves and our staff as about the new hardware and software.

Our key computer users were our three full-time staffers. Two of them were outstanding. Helen (I'm using fictitious names), the office manager, had 25 years of experience, more than 10 on computers. Anything she didn't know about running an office wasn't worth knowing. Granted, she tended toward rigidity, enjoying routine rather than innovation. But I assumed that she would enjoy mastering the new system after all those years of sameness. Wishful thinking.

Jane, a rookie, had joined us just six months earlier. But she was sharp, picking up office routine faster than an alcoholic grabs a glass of brew. Unflappable in the midst of disaster, popular with patients, she'd have no trouble catching on to our new technology, we figured.

We knew from the start that the technological leap forward would be tough on our third front-office worker, Rebecca. Hired years earlier, when the pace of medical office work was far slower, she'd had difficulty adapting to the managed care era. Her more versatile co-workers assumed some of her duties, a benevolence that ended when the new computer system overwhelmed them.

We weren't sure how much Rebecca would help or hinder us in the conversion process, so we limited her role in the new scheme of things. We took away the task of entering patient charges. All she'd have to do was enter patient demographics. But reducing her load meant more work for the others—at the worst possible time.

My colleagues and I were part of the problem, too. Rather than providing leadership for our Y2K project, we hoped to do an end run around it. Like many doctors, we're relatively ignorant about computers and too busy to learn. Instead, we counted on Helen to take the lead. She would learn the new system backward and forward, and we'd pick it up from her. At least that was the theory. Like trickle-down economics, it sounded great, but didn't live up to expectations.

Changeover day would be May 1, so training began several weeks earlier. It didn't take long for the flaws in our conversion plan to surface. Susan, our teacher, arrived as promised on a Monday morning, but since we couldn't put a "Gone Fishing" sign out front, the staff would have to perform its everyday duties and attend classes simultaneously.

Helen soon resembled a prisoner walking to the electric chair. She found the instruction too intense and confusing, but she was afraid to tell Susan that most of the material was over her head. Her customary cheeriness gave way to anger and withdrawal. Before long, Helen started to denigrate the new system to fellow employees: "This is almost impossible to use. Our old system was better." Worse, she had neither the desire nor the time to show everyone else the fundamentals of the new system; we had to learn largely on our own.

Susan wasn't accepting any blame for the debacle. She thought she was performing admirably. The fault, in her view, lay solely on the shoulders of our staff of computer illiterates.

When we started using the new system in real time on May 1, it was a case study in chaos. Every patient, even those we'd been seeing for 20 years, filled out a new, two-page demographic form that had to be entered on the computer before we could create his account and enter charges. The staff—particularly Rebecca—fell hopelessly behind typing in all this stuff, so visits weren't entered for days or even weeks after they occurred. Charges weren't entered, either, so bills couldn't be sent out promptly. The staff was too frazzled even to collect money from patients who offered to pay at the time of service. Our accounts receivable eventually ballooned by an extra $50,000.

A month or so later, while we were still foundering badly, Helen took a two-week vacation. Since she was the only one who knew how to perform such incidental tasks as sending out bills, the practice listed to starboard.

But Helen's absence was actually a blessing, because it forced me and my partners to familiarize ourselves with the new system. We became part-time office workers, generating statements, posting payments, and phoning insurers to ask what had happened to various claims. We hired a computer-savvy college kid to enter those aggravating demographics. He also was bright enough to help us teach the computer system to everyone else.

Four months into our new system, our confidence and cash flow were rising. We even began transmitting electronic claims to commercial insurers through a clearinghouse, reducing paperwork and speeding payments. Once we got the hang of it, we transmitted a batch of test claims to Medicare, which accounts for half of our patient visits. If we could automate Medicare claims, we'd achieved something major.

The test claims were accepted, so we went online with Medicare for real on Sept. 1. At first, we glowed with self-satisfaction. Throughout September, the Medicare money kept rolling in. Then, in October, it dried up. It seems all the money we'd been collecting from Medicare in September was for July and August charges, which were submitted as paper claims. They'd received nothing from us since Sept. 1.

Angry conversations crackled over the phone between the software vendor, Roy, and us. Finally in November, with our bank account close to zero, we got the problem fixed, and Medicare began recognizing us in cyberspace.

Our Y2K disaster gave us a jolt, but it also made us wiser. Now we know what it takes to implement a new computer system. You have to plan very carefully. And you have to understand not only how the machines work, but how people work. Here are some lessons we learned.

1. Do your homework. Read product reviews in computer magazines and talk with physicians who are already using the systems. I did none of that stuff last year, and I'm still not sure I bought the right equipment.

2. Assess the strengths and weaknesses of your staff. Who's flexible enough to master a new system and teach others? Who might become a human roadblock? Choosing the right individuals to lead the way will ease everyone's pain, but not eliminate it entirely. (Any vendor who tells you otherwise merely covets the sale, not your well-being.)

3. Consider cutting loose computer-illiterate employees before Changeover Day, because they'll stick out like sore thumbs, demoralizing everyone else. We eventually dismissed Rebecca, but we'd have been better off doing it before we switched systems.

4. Don't skimp on training. We should have sprung for at least five days' worth.

5. If possible, train key employees when they're not carrying out their regular duties. Hire extra hands if you have to. Otherwise, both job performance and computer education will suffer. Either train employees off site during the day, or pay them to take classes after hours.

6. The trainer should presume your employees know zilch about computers. Ideally, he should teach them individually. And when classes are over, he should be available for follow-up questions.

7. Computer literacy is helpful, but two traits are even more important: a willingness to learn, and the courage to make mistakes. Touching a wrong key will not disable your system.

8. Encourage open, honest communication among staffers, physicians, and consultants so that glitches can be smoothed out immediately. In our case, Helen kept me in the dark about the breakdown in the training process. I needed to know about it early on.

9. Set aside a stash of cash, because collections are likely to suffer as you implement a new system. Try to have at least two to four weeks' worth of collections on hand.

10. Most important, don't be a passive observer during the process. Take an active role; absorb everything you can. You can do it. You got through medical school, didn't you?

The author is an internist in Glen Ridge, NJ.

Bits and bytes

Edited by Robert Lowes

Yes, I scan: Recipes abound in the world of cookbook medicine—practice guidelines, algorithms, decision trees, you name it. They often appear in the form of a handy, one-page summary, compliments of a medical society, malpractice insurer, or health care publication. Yet studies show that droves of doctors fail to follow these recipes. One reason is logistical, says family practitioner David Bright in Stuart, FL: "The guidelines get lost in a pile of papers, or they're filed away and forgotten."

Bright keeps these guidelines at his fingertips by scanning them into his computer. The gear to do so is relatively cheap. "You can buy a flatbed or sheet-feed scanner for under $200, and the paper management software you need to organize the electronic documents in your computer costs less than $100," says Bright, who's launched a company called Doctors Desktop to help physicians exploit informatics technology. "If you're not organized in medicine today, you'll die."

Online office space matchmaker: Do you have a few empty rooms in your office that you'd like to rent to another practitioner? Or are you in search of an office to call your own? Check out Offices2share.com (www.offices2share.com), a new Internet real estate database that deals in medical space. You can list your available space or search for rental space on a state-by-state basis. It's up to you to contact the owner and close the deal.

Right now, you can advertise your property on the Web site free of charge. But later this year, company President Jeffrey Landers plans to ask for $49.95 per month per listing—a bargain compared with classified advertising in a newspaper, he notes.

Is this outfit a gamble? Healtheon/WebMD is vying to be the Internet solution to running a medical practice. But will it be around long term? And should your practice hop aboard? The company's recent binge of deal-making has caused Wall Street to wonder whether it is dangerously overextending itself.

From last December through March, Healtheon/WebMD spent billions in cash and stock to acquire, merge with, or partner with close to 20 companies. Big-ticket purchases included software maker Medical Man-ager; Envoy, a claims-processing company; and OnHealth Network, which operates a leading health care Web site for consumers.

On paper, Healtheon/WebMD game plan makes sense. Digitize every aspect of medical practice—patient charts, prescriptions, claims forms, patient education—and put it under one electronic roof. Efficiency up, costs down.

But stock analysts wonder whether enough doctors will buy the company's services. "Doctors are some of the worst technophobes out there," says Mark Mulcahy, senior research analyst for Pacific Growth Equities in San Francisco. "The company may be moving faster than its market."

Another question is whether Healtheon/WebMD will be able to integrate its acquisitions. "An already significant execution challenge just got bigger," says Stephen D. Savas, vice president of equity research at Goldman, Sachs & Co. in New York.

Though many Wall Streeters don't expect the company to turn a profit for at least two years, Mulcahy notes that Healtheon/ WebMD has enough cash to survive lean times—and the ability to raise more.

 

Robert Levai. Computer Consult. Medical Economics 2000;7:47.