John J. Kowalczyk, DO, FACOS

John J. Kowalczyk, DO, FACOS: There are unmet challenges in terms of management of urology, especially in California. I have to specify California because our HMO [health maintenance organization] system is unique compared with other parts of the country because we have independent physician associations [IPAs]. There are 3 things that I see as major challenges. The first 1 is the authorization process. I don’t mean prior authorization for medication. That’s still a pain in a certain part of the anatomy that all physicians and providers are dealing with. If there was an easier, faster, softer way to do that, then that would be great.

Our challenge is that we’re contracted. Let me give you an example. BlueShield HMO subcontracts with independent physician associations. Within our urban area, there are at least 20 other subgroups, called independent physician organizations, that have this BlueShield or even BlueCross HMO product. That being said, we can’t go to BlueCross BlueShield to request authorization for surgery because these are independent organizations that have their own processes. We have to go through them. They are the bypass for major corporations. We have to go to every 1 of these corporations. That means we have 20 different websites we have to go to on a regular basis to get authorization to do a procedure. Sometimes, that procedure is in the office.

If there was a way to integrate, link, or connect whatever process to make it easier, especially if it’s already preloaded into that patient, then that would be great. You get into that patient’s record and then, all of a sudden, there’s a link to their specific IPA. That way, you can have both screens open at the same time and process the paperwork. Right now, we have computers, for our authorization people, which they can use to log in to our system. Then they have to log into every independent physician association to get a request. Let’s say they have to request a cystourethroscopy CPT [Current Procedural Terminology code] 52000. You’d have to do that. If I saw 20 patients this morning¾that would be a slow day, by the way¾and each needed a cystoscopy, and each came from a different IPA, then my authorization person would have to log in to 20 different IPAs to request the CPT 52000 on their next visit.

The second thing I see as a challenge is that we still unfortunately use a paper system when we see our patients in the hospital. We’re getting a physical copy of patient demographics from the hospital. I’m mainly talking about someone who’s not an existing patient in our practice. We then have to have our billing and coding company submitted as an outside location or have our internal people create a document, which is time consuming. Then we submit the codes to the billing and coding service. You see, there are multiple steps which create multiple backlogs, which delays or decreases the speed of recovery for compensation.

The last challenge is trying to make it easier for non-English-speaking patients to access our communication in the portal system. It would be best if there was a way to integrate language. For example, our students will go in and take Google Translate into the room with them when they’re asking patients questions in their native tongue. Whether it’s Spanish or Armenian or Russian or Mandarin, they go in and communicate with the patient in that fashion. I wish there was a way for our patients to be able to communicate with us in a universal capacity.

These are my top 3 challenges. The first is the ability to better utilize our billing and coding systems. All of it comes back to billing and coding. Second, it minimizes the amount of time spent to complete authorizations for our hospital patients. We did a creative workaround for existing patients in which we’re able to create sites of visit. That’s a workaround, so it’s not ideal. The important thing is that it will persuade people in the computer engineering world to come up with a better mousetrap, if you want to call it that.

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A urologist practicing in California defines the remaining general and region-specific challenges he faces in managing his practice and his hopes for future solutions. 

Current Shortcomings in the Modern Urology Practice Management Landscape

John J. Kowalczyk, DO, FACOS: How might urology-specific integrative software impact our productivity and improve our practice management? Here are some of the features we’ve noticed. For the most part, our basic login system integrates our EHR [electronic health record] patient management and the billing tools. This has been the most significant impact. It has eliminated the loss of information and reduced the duration of paperwork completion to payment. It also promotes communication for those within our system, not with the patients. This is our own system. It’s instantaneous. We might get 60 to 100 intraoffice mails in a single day. Communicating now is different from the old days. I’m getting up there in my age. In my day, we would walk over to each other and have vocal communication face to face, and eye-to-eye contact. Now, it has become basic, quick, simple, instantaneous communication.

From that standpoint, the least important component of the integrated system for our practice would be the patient access to creating an encounter. I say this is for several reasons. Sometimes we’ve tried it and it’s not a service that would work for our population at this time. I’m not saying that it wouldn’t be useful in the future. The language barrier initiates the situation. When it comes to patients coming in for procedures, they’re scheduled in a very different fashion. That’s something that usually requires an MD [doctor of medicine] or another member of the team to help with the communication. This isn’t just putting in a date and time for an appointment. It’s completing the preparation that may involve something you can’t do or guarantee. Even if you had a pop-up on the computer that the patient would understand or even pay attention to, that pop-up is what expectations we may expect on our part for them to be ready for a procedure in the office.

We talked about streamlining our MIPS [Merit-based Incentive Payment System]. That’s 1 of the first components that our manager noticed. He came into the office, patted himself on the back, and said, “I can do this. I don’t need to go to our billing company.” We used to rely on our biller, and that would take weeks of waiting and lots of paper. I refer to our old billing system as the old-fashioned DOS [disk operating system]. We’d have to wait and wait and wait. The truth is that it really was a DOS-based system. Our previous biller has been around with me for a long time and is using a very old system of billing and coding. Those have been streamlined. We talked about the labs and ordering labs. Prescriptions is the same thing. I mentioned earlier that I’m usually catching up on prescription requests on a Friday evening or an early Saturday morning with my coffee. Those are some of the things that have improved our overall activities.

I still think our least important component is the self-scheduling of patients. On the flip side, for those who are computer savvy, the communications system in the patient portal is another groundbreaking platform for a lot of our patients. In all honesty, we have a very busy practice with a lot of phone calls coming in. We have to subcontract with people in India to help with our telecommunication. This way, a patient can get around to speaking with someone who isn’t necessarily from the office without waiting on the telephone line and listening to, “Please press 1.” Now, they just go in the patient portal and type a message. It pops up instantaneously. If I have a moment or 2, I’ll respond. An example would be when a patient this week was still traveling in the United Kingdom and ran out of a certain medication. There’s a similar medicine in the United Kingdom. The patient wanted to know if that would be OK until he or she came back. The answer was given instantaneously, even though we’re in 2 different time zones: Pacific time vs the time in the United Kingdom. It works out beautifully.

Those are the things we found to be very beneficial. At the same time, we have 1 or 2 things that we still need to work on. I don’t call it a challenge necessarily. It’s more a work in progress for us to better the ability of our patients to schedule their own appointments. Ideally, the best-case scenario would be to eliminate as many phone calls as possible. It’s been very cool to have people communicate directly through a system that I never thought would be as efficient as it is. I’ve been enjoying that part of medicine more than picking up the phone every time someone calls.

Dr. John J. Kowalczyk identifies the features of integrated, urology-specific software systems that have the largest impact on the management of his practice.

A Closer Look at the Impact of Integrated, Urology-Specific Software on Practice Management

John J. Kowalczyk, DO, FACOS: The conversations and other activities that we engaged in terms of making changes with our EMR [electronic medical record] systems evolved around the clinical side. A lot of the products that are out there would be great for administration or be fantastic for the front office. We finally found something that was acceptable and easy to use for both back office management and front office management. The actual day we decided to take on the challenge of Modernizing Medicine [ModMed], it was initially a big no from my management team. The manager in my office basically has full control of the purse. If I had control, we would lose control. The manager basically said, “No. That's it. You’ve spent way too much money on changing the EMRs 3 times in the past. We can't afford to do it again.”

The Modernizing Medicine representative came into the office with his iPad at lunch that day and walked around with 1 of the medical students. We have third- and fourth-year medical students that rotate with us. We had a third-year medical student who was a fantastic typist. He just types away. The student was actually functioning as more of a scribe for me when we got to the actual clinical component because of, again, certain built-in templates or other components of the software itself. We had just seen a patient and he was able to create and finish a note, while we basically emulated the exact same component on our EMR that we had at the time versus their EMR. The student was done with his note in less than 3 minutes. We actually timed it. Whereas, for the other note that we were still working on, we went way past the 5-minute mark in terms of the details that were required to fill in the blanks, etc. This revolution actually brought a few tears to my eyes. I went running into the manager's office, and I said, “This is going to save us money. I know it will.” As it turns out, that is the main reason we have stayed with the Modernizing Medicine component. I'm not trying to sound like a salesperson, but every time a question has risen as to a certain item that might be bothering us, we've actually had representatives come out. One of the things I just learned how to do is to create my own electronic request for a laboratory. Before our interview today, we had a patient that sent me an email asking if they could go to the lab for their PSA [prostate-specific antigen] level before they come in. I was able to just click 4 buttons and then submit the request to the laboratory. It's waiting for the patient to show up at any Quest Laboratory in his region and get his PSA level. Hopefully, the results will be ready for him by the time he comes to see me in 2 weeks.

How tech-savvy are my patients? I laugh because this is a never-ending problem in our patient population. They are not very savvy at all. Most of my patients are elderly. At least 30% of our patients are non-English speaking. This creates a barrier to using technology. We've come across a significant challenge as to how to get these people into our portal. Even trying to do telemedicine during the pandemic was challenging with some of these patients. Our strategy was to find a relative that spoke English and was a little younger so they were able to help work with them, at least to do the telemedicine visits. However, to answer the question of how tech-savvy my patients are, a third of them are not tech-savvy at all. It’s quite challenging. That creates a huge barrier for our communication and interaction with them.

Practice management concerns and considerations for clinicians intending to incorporate software tools into their practice workflows.

Identifying and Overcoming Challenges Associated with Implementing Software Tools 

John J. Kowalczyk, DO, FACOS: Historically, when EMR [electronic medical record] services first came out, we were 1 of the first groups to do something electronically. The reason why is because 1 of our hospitals was trying to get all of its incentives. They had established a few organizations that looked like they were going to go in the right direction and get their credits as well. Due to the many changes in congress and the differing expectations of the hospital, we decided to choose an electronic system.

One of the most detailed EMRs that we had prior to going to ModMed was a system called Greenway Health. Greenway Health was very complex and very detailed. I think our management team loved it more than our clinical team. The most frustrating component for me, although our younger members in medicine are more adapt at typing, is that I am a 1-finger typist. I'm not interested in going for typing lessons. So, basically, I spent my weekends catching up on notes. It would take hours. These weekends off were not really weekends off. The notes were amazingly detailed. I think the concept of templates was just being developed at that time. Even so, the templates required fill-in-the-blank fields. There are quite a few fill-in-the-blank fields on said templates.

The newer systems out there, for example, the 1 we are using now, allows us to use an iPad. I'm an iPad person for the most part because it works with 1 finger, and you can also use your thumb every now and then. We've learned how to use our thumbs on the cell phone; the iPad has been somewhat easier for me to use from that standpoint. Secondly, voice recognition on the iPad is relatively superior to the old technology. It actually recognizes what I'm saying. Because of the repetitive language that I'm using, it's actually catching and recording a lot of the medical terminology that I would have had to go back and edit with the old voice recognition systems. From a historic standpoint, we have gone from my spending a minimum of 6, 8, or more hours on a weekend catching up on notes to now. If I have notes to catch up on, with this new system, it would take maybe an hour at most. Then I would spend maybe an hour at most catching up on another tedious component of medicine: the electronic prescriptions that are being sent to us nonstop. That would be my 2 hours of duty on weekends now.

An experienced urologist provides an overview of useful niches clinical software tools can fill and how they can serve to boost efficiency in the practice.

John J. Kowalczyk, DO, FACOS

Articles

Current Shortcomings in the Modern Urology Practice Management Landscape

A Closer Look at the Impact of Integrated, Urology-Specific Software on Practice Management

Identifying and Overcoming Challenges Associated with Implementing Software Tools

Use of Clinical Software Tools To Streamline Practice Workflows