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New Program Trains Physicians In Health Informatics Basics

Posted on January 18, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

A new program has emerged to help physicians make better use of the massive flow of health information they encounter on a day-to-day basis. With any luck, it will not only improve the skills of individual doctors but also seed institutions with clinicians who understand health IT in the practice of medicine.

The Indiana Training Program in Public and Population Health Informatics, which is supported by a five-year, $2.5 million award from the National Library of Medicine, focuses on public and population health issues. Launched in July 2017, it will support up to eight fellows annually.

The program is sponsored by Indiana University School of Medicine Richard M. Fairbanks School of Public Health at Indiana University-Purdue University Indianapolis and the Regenstrief Institute. Regenstrief, which is dedicated to healthcare quality improvement, supports healthcare research and works to bring scientific discoveries to bear on real-world problems.

For example, Regenstrief participates in the Healthcare Services Platform Consortium, which is addressing interoperability issues. There’s also the Regenstrief EHR Clinical Learning Platform, an AMA-backed program training medical student to cope with misidentified patient data, learn how different EHRs work and determine how to use them to coordinate care.

The Public and Population Health training, for its part, focuses on improving population health using advanced analytics, addressing public health problems such as opioid addiction, obesity and diabetes epidemics using health IT and supporting the implementation of ACOs.

According to Regenstrief, fellows who are accepted into the program will learn how to manage and analyze large data sets in healthcare public health organizations; use analytical methods to address population health management; translate basic and clinical research findings for use in population-based settings; creating health IT programs and tools for managing PHI; and using social and behavioral science approaches to solve PHI management problems.

Of course, training eight fellows per year is just a tiny drop in the bucket. Virtually all healthcare institutions need senior physician leaders to have some grasp of healthcare informatics or at least be capable of understanding data issues. Without having top clinical leaders who understand informatics principles, health data projects could end up at a standstill.

In addition, health systems need to train front-line IT staffers to better understand clinical issues — or hire them if necessary. That being said, finding healthcare data specialists is tricky at best, especially if you’re hoping to hire clinicians with this skill set.

Ultimately, it’s likely that health systems will need to train their own internal experts to lead health IT projects, ideally clinicians who have an aptitude for the subject. To do that, perhaps they can use the Regenstrief approach as a model.

Ophthalmologists Worry That EHRs Decrease Productivity, Boost Costs

Posted on January 16, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

A new study has concluded that while EHR use among ophthalmologists has shot up over the last decade, most of these doctors see the systems as lowering their productivity and increasing their office costs, according to a survey published in JAMA Ophthalmology.

To conduct the study, the researchers emailed surveys to 2,000 ophthalmologists between 2015 and 2016. The 2,000 respondents, whose responses were anonymous, were chosen out of more than 18,000 active US members of the American Academy of Ophthalmology.

The researchers involved found that the EHR adoption rate for ophthalmologists, which is about 72.1%, was similar to rates among other specialties. Nonetheless, it’s a big jump from 2011, when only 47% of the 492 respondents reported using EHRs in their practice.

Most respondents were devoted solely to ophthalmology and had an average of 22 years of practice. They had an average of 5.3 years of EHR use, but nearly the entire group had previously used paper records. Eighty-eight percent of those currently using EHRs had been present for the transition from paper records to digital ones, researchers found.

Not surprisingly, given typical EHR acquisition and maintenance costs, the mean number of ophthalmologists in a given practice was higher among those with an EHR in place than practices without one. Researchers found that when practices were part of an integrated health system, a government health system, the higher the odds of their having adopted an EHR.

While the adoption rate has increased, ophthalmologists actually seem less happy with EHRs than they had been before. For example, many reported that they felt EHRs were undermining both their productivity and financial situation.

For example, more than half of respondents in 2016 reported that their patients seen per day had fallen since adopting EHRs. That’s an unfortunate change in perceptions since in 2006, more than 60% of ophthalmologists saw an increase in productivity after their EHR system was implemented.

Meanwhile, respondents were ambivalent about the impact of EHR use on revenue, with 35% reporting that revenue had remained the same after adoption, 41% a decrease and almost 9% an increase.

Despite concerns that EHRs were undercutting practice productivity, researchers reported that three previous studies of academic ophthalmology practices found no change in patient volume after EHR adoption.

There also seems to be a disconnect between what ophthalmologists think their patients want technically and what they want.  While 76% reported that their patients felt mostly positive or neutral toward EHR use, 36% of ophthalmologists would return to paper records if they had the chance.

That being said, ophthalmology practices do seem to see the benefits in keeping their EHR systems in place. For example, despite the fact that 68% saw paper documentation as faster, 53% of respondents felt their EHRs were generating net positive value.

All told, it seems that ophthalmologists’ concerns about EHR use are working themselves out. However, it also seems as though the doubts we see documented here are deeply rooted and may not go away quickly.

Big Gap Exists Between Wearables Hype And Physician Use

Posted on January 12, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Not long ago, I wrote an article describing some major advances in wearables and health tracking technologies. Standout technologies included Grail, a cancer detection startup, Beddit, which makes sleep tracking technology, and Senosis Health, which developed apps using smartphone sensors to monitor health signals.

In the article, I argued that we’re past the question of whether wearables are valuable and that it’s time to focus on what we want to do with next-generation of superpowered health tracking devices instead. I was driven by stats like the ones produced by the Consumer Technology Association, which asserted last year that by 2020, physician use of patient-generated data will reach critical mass. It noted that wearables are being used more often in clinical trials and that some health insurers offering free wearables to patients, trends which it predicts will cause the market to explode.

But at least to some extent, I think the CTA (and I) were both wrong. As impressive as the new patient trackers are, they won’t be that valuable if nobody on the frontlines of medicine uses them. And even if trackers are being used in clinical trials or given away by health insurers, that doesn’t mean physicians are on board. The issue is not just whether devices work well, but whether doctors can actually use them in their daily care routine.

Recent stats suggest that few physicians actually use patient-generated data in their practice. In fact, the Physicians Practice Technology Survey found that just 5% of respondents reported that they use such such devices as part of their care routine.

I’m not surprised by this research. My own informal discussions with physicians suggest that the number of practices that actively use patient-generated data may be even lower than 5%.

Why are so few medical practices leveraging patient-generated data? The reasons are fairly straightforward:

  • Few of devices offer measurements that are consistent, predictable and valid
  • Vanishingly few are FDA-approved, which does little to inspire clinicians’ confidence
  • In most cases, the data produced by wearables and related devices isn’t compatible with practice EMRs

For what it’s worth, I do believe that many physicians — especially those with an interest in health IT– know that patient-generated health data will eventually play a valuable role in their practice. After all, in principle, there must be ways that such data could inform patient care.

But right now, the simple devices patients own aren’t sophisticated enough to serve practice needs, and most of the advanced patient tracking devices are at the idea or testing phase. Until patient tracking devices become more practical, and offer reliable, valid, usable data, they’re likely to remain a dark horse.

AI Project Could Prevent Needless Blindness

Posted on January 11, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

At this point, you’re probably sick of hearing about artificial intelligence and the benefits it may offer as a diagnostic tool. Even so, there are still some AI stories worth telling, and the following is one of them.

Yes, IBM Watson Health recently had a well-publicized stumble when it attempted to use “cognitive computing” to detect cancer, but that may have more to do with the fact that Watson was under so much pressure to produce results quickly with something that could’ve taken a decade to complete. Other AI-based diagnostic projects seem to be making far more progress.

Consider the following, for example. According to a story in WIRED magazine, Google is embarking on a project which could help eye doctors detect diabetic retinopathy and prevent blindness, basing its efforts on technologies it already has in-house.

The tech giant reported last year that it had trained image recognition algorithms to detect tiny aneurysms suggesting that the patient is in the early stages of retinopathy. This system uses the same technology that allows Google’s image search photo and photo storage services to discriminate between various objects and people.

To take things to the next step, Google partnered with the Aravind Eye Care System, a network of eye hospitals based in India. Aravind apparently helped Google develop the retinal screening system by contributing some of the images it already had on hand to help Google develop its image parsing algorithms.

Aravind and Google have just finished a clinical study of the technology in India with Aravind. Now the two are working to bring the technology into routine use with patients, according to a Google executive who spoke at a recent conference.

The Google exec, Lily Peng, who serves as a product manager with the Google Brain AI research group, said that these tools could help doctors to do the more specialized work and leave the screening to tools like Google’s. “There is not enough expertise to go around,” she said. “We need to have a specialist working on treating people who are sick.”

Obviously, we’ll learn far more about the potential of Google’s retinal scanning tech once Aravind begins using it on patients every day. In the meantime, however, one can only hope that it emerges as a viable and safe tool for overstressed eye doctors worldwide. The AI revolution may be overhyped, but projects like this can have an enormous impact on a large group of patients, and that can’t be bad.

Clinicians File Class Action Suit Against eClinicalWorks

Posted on January 9, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

EMR provider eClinicalWorks has been hit by another class action lawsuit, this time a suit led by clinicians, raising questions as to how much legal trouble the vendor can survive.

The new suit is the latest of a series of dominos falling on eCW. Its legal problems began in May of last year, when it was forced to settle a suit filed by the U.S. Department of Justice for $155 million. The suit contended that eCW got its Meaningful Use certification by misrepresenting its capabilities.

Then, in November of last year, eCW was slammed with a class action lawsuit, this one demanding $1 billion. The suit alleged that by lying about the capabilities of its software, eCW “failed millions of patients by failing to maintain the integrity of patient records.”

Now, eCW faces another class action suit, this time led by primary care doctors. The suit alleges that because eCW’s software didn’t meet MU standards as promised, they lost government reimbursement. The suit asserts the eCW gave the PCPs “no reason to suspect that [it] had made false statements to obtain its certification.”

All of this is interesting in and of itself, but it doesn’t address the bigger question: Can eCW survive the legal firestorm that has engulfed the company?

eClinicalWorks is a private company, so I can’t offer detailed information on its finances, but it reported revenue of $130 million for the third quarter of 2017. If that’s a representative number, the company generates roughly half a billion dollars a year.

That’s a lot of money, but it’s not an infinite supply. The $155 million settlement has to have hurt (though I suppose it might have been covered in part or entirely by business liability insurance).

The other two lawsuits could prove more deadly. While it’s hard to predict whether a suit will go anywhere, there’s at least some chance that eCW will face a $1 billion judgment. Of course, even if it does lose the case, it will take effect only after several years of legal wrangling. Nonetheless, it seems likely that such a conclusion could bankrupt the company.

The other key question is whether eCW can hold onto its customers as lawsuit after lawsuit is filed. It might seem to some that eCW has been punished enough for its indiscretions, and that the additional lawsuits are largely part of a feeding frenzy. On the other hand, one might suggest that if eCW lied to all of its customers, it deserves to be forced out of business. It’s a flip of the coin at  this point.

Regardless, the suits do suggest that EMR vendors had better keep their noses clean. If they try to fool customers – or the feds – the results could be catastrophic.

Doctor on Demand Stats Offer Insight Into Telmedicine Trends

Posted on January 5, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Recently, direct-to-consumer telemedicine provider Doctor on Demand released some statistics on its performance in 2017. While some of the report was self-congratulatory, I still think the data points are worth looking at, especially for clinicians.

For starters, it’s worth noting that the company now considers itself a fully integrated medical practice. For example, it’s begun offering lab testing services through Quest Diagnostics and Lab Corp. as part of a program to control chronic conditions such as diabetes, high blood pressure and high cholesterol levels.

Another factoid the stats offer is that its physicians are generally in their mid-career; apparently, Doctor on Demand’s average physician has 15 years of experience. The company doesn’t offer any perspective on why that might be, but it suggests to me that clinicians who participate are both confident that they can manage care remotely and comfortable with technology.

Why is that the case? My guess is that this work may not be attractive to younger doctors, who might feel uneasy managing patients online given their lack of experience. It also suggests older physicians, some of whom still consider telemedicine to be a poor substitute for face-to-face care, probably aren’t engaging with telemedicine either.

Other data provided by Doctor on Demand includes the top reasons for visits included treatment of cold and flu, prescription refills and infections, which isn’t surprising. It also notes that mental health visits climbed 240% over 2016, with anxiety, depression and stress being the most common symptoms treated. This is more interesting, as it suggests that among other problems, consumers feel they aren’t getting their mental health needs met in real life.

Meanwhile, when it comes to the company’s self-reported benefit statistics, I’m taking them with a large grain of salt, but I found them to be worth a look nonetheless. The company says it saved its patients nearly $1 billion in healthcare costs and saved over 1.6 million hours that would otherwise have been spent in doctor’s waiting rooms. These results were allegedly generated by a base of 1 million patients, according to the San Francisco Business Times.

I’m not writing this to suggest that Doctor on Demand is better or worse than other telemedicine companies and video services offered by privately-employed physicians or hospital telemedicine services. Still, I got a kick out of learning what trends a well-positioned telemedicine service was seeing in the marketplace. While Doctor on Demand’s results may not reflect the market as a whole, they certainly offer food for thought.

Supercharged Wearables Are On The Horizon

Posted on January 3, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Over the last several years, the healthcare industry has been engaged in a rollicking debate over the value of patient-generated health data. Critics say that it’s too soon to decide whether such tools can really add value to medical care, while fans suggest it’s high time to make use of this information.

That’s all fine, but to me, this discussion no longer matters. We are past the question of whether consumer wearables data helps clinicians, which, in their current state, are under-regulated and underpowered. We’re moving on to profoundly more-capable devices that will make the current generation look like toys.

Today, tech giants are working on next-generation devices which will perform more sophisticated tracking and solve more targeted problems. Clinicians, take note of the following news items, which come from The New York Times:

  • Amazon recently invested in Grail, a cancer-detection start-up which raised more than $900 million
  • Apple acquired Beddit, which makes sleep-tracking technology
  • Alphabet acquired Senosis Health, which develops apps that use smartphone sensors to monitor health signals

And the action isn’t limited to acquisitions — tech giants are also getting serious about creating their own products internally. For example, Alphabet’s research unit, Verily Life Sciences, is developing new tools to collect and analyze health data.

Recently, it introduced a health research device, the Verily Study Watch, which has sensors that can collect data on heart rate, gait and skin temperature. That might not be so exciting on its own, but the associated research program is intriguing.

Verily is using the watch to conduct a study called Project Baseline. The study will follow about 10,000 volunteers, who will also be asked to use sleep sensors at night, and also agreed to blood, genetic and mental health tests. Verily will use data analytics and machine learning to gather a more-detailed picture of how cancer progresses.

I could go on, but I’m sure you get the point. We are not looking at your father’s wearables anymore — we’re looking at devices that can change how disease is detected and perhaps even treated dramatically.

Sure, the Fitbits of the world aren’t likely to go away, and some organizations will remain interested in integrating such data into the big data stores. But given what the tech giants are doing, the first generation of plain-vanilla devices will soon end up in the junk heap of medical history.

An Example Of ACO Deals Going Small And Local

Posted on January 2, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Until recently, ACOs have largely focused on creating large, sprawling structures linking giant providers together across multiple states. However, a news item that popped up on my radar screen reminded me that providers are quietly striking smaller local deals with hospitals and insurance companies as well.

In this case, cardiologists in Tupelo have begun to collaborate with Blue Cross & Blue Shield of Mississippi. Specifically, Cardiology Associates of North Mississippi will with Blue plan associate Magellan Health to create Accountable Cardiac Care of Mississippi.

It’s easy to see why the two agreed to the deal. The cardiology group has outpatient clinics across a wide region, including centers in Tupelo, Starkville, Columbus, Oxford and Corinth, along with a hospital practice at North Mississippi Medical Center-Tupelo. That offers a nice range of coverage for the health plan by a much sought-after specialty.

Meanwhile, the cardiology group should get a great deal of help with using data mining to deliver more cost-effective care. Its new partner, Magellan Health, specializes in managing complex conditions using data analytics. “We think we have been practicing this way all along, [but] this will allow us to confirm it,” said Dr. Roger Williams, Cardiology Associates’ president.

Williams told the News Leader that the deal will help his group improve its performance and manage costs. So far it’s been difficult to dig into data which he can use to support these goals. “It’s hard for us as physicians to monitor data,” he told the paper.

The goals of the collaboration with Blue Cross include early diagnosis of conditions and management of patient risk factors. The new payment model the ACO partners are using will offer the cardiology practices bonuses for keeping people healthy and out of expensive ED and hospital settings. Blue Cross and the Accountable Cardiac Care entity will share savings generated by the program.

To address key patient health concerns, Cardiology Associates plans to use both case managers and a Chronic Care program to monitor less stable patients more closely between doctor visits. This tracking program includes protocols which will send out text messages asking questions that detect early warning signs.  The group’s EMR then flags patients who need a case management check-in.

What makes this neat is that the cardiologists won’t be in the dark about how these strategies have worked. Magellan will analyze group data which will measure how effective these interventions have been for the Blue Cross population. Seems like a good idea. I’d suggest that more should follow this ACO’s lead.

EHRs Could Be Causing Patient Harm More Often Than Expected

Posted on December 26, 2017 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Why did the healthcare industry invest so heavily in EHRs in recent years?  Obviously, one major reason is the payoffs that became available under HITECH, but that’s not all.

Another important objective for spending heavily on EHRs and other HIT options was to protect patients from needless harm, including everything from clinical decision support to finding grand clinical patterns among patients with similar conditions.

Now, nobody’s saying that none of these benefits have been realized. But according to one researcher, we haven’t paid enough attention to the ways in which these technologies can actually cause harm as well. In fact, some researchers say that HIT-related mistakes are not as minimal or easily managed as some think.

So how do we get a grip on how often HIT tools and EHRs are a factor in patient care errors? One way is to examine the role HIT has played in malpractice claims, which, while not offering a comprehensive look at how such mistakes occur, certainly gives us a look at where some of the biggest have taken place.

For example, look at this data from the Journal of Patient Safety, which dug into more than 300,000 cases from an insurance database to see what role HIT played in such cases. Researchers found that less than 1% of the total malpractice claims involved HIT, more than 80% of that 1% involved problems of medium to intense severity.

The researchers found three major reasons for EHR-related suits:

  • 31% involved medication errors, such as the case when a baby died from a drug overdose that took place because a handwritten order was entered in the computer inaccurately
  • 28% involved diagnostic errors, as when critical ultrasound results ended up being routed to the wrong tab in the EHR — which in turn led to a year-long delay before a cancer patient was diagnosed
  • 31% of cases were related to complications of treatment related to HIT errors. For example, in one case a doctor was unable to access emergency department notes, and the lack of that knowledge prevented the doctor from saving the patient

Unfortunately, if you’re a physician group member working within a hospital — particularly as an on-call clinician with little say about how HIT system should work — your group may be vulnerable to lawsuits due to technologies it doesn’t control.

Still, it doesn’t hurt to learn about common errors that can arise due to EHR and HIT malfunctions. When it comes to delivering patient care, the fewer surprises the better.

RCM Tips & Tricks: Shortening Length of Claims In Accounts Receivable

Posted on December 21, 2017 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

There’s little question that health insurers do little to help your medical practice collect the reimbursement you’re due.  Not only that, ongoing changes in federal laws make improving your collections levels even more difficult.

As a result, physician practices need all the help they can get in shortening the days claims spend in Accounts Receivable, including the seemingly obvious challenge of collecting payment in full from payers, which don’t even honor rates set forth in reimbursement contracts in some cases.

Given these challenges, medical groups need all the help they can get in improving A/R. Here are some tips from medicalbillersandcoders.com:

  • Find claims which might be rejected ahead of time before submitting them to payers. Claims not paid when first submitted are far less likely to ever get paid.
  • Identify such claims using software that can track and respond to rules and regulation changes by payers. This software should also take into account the rate of denials by a given payer for all doctors.
  • Use software (such as practice management tools) to track all payments, and make sure that your practice is paid based on the terms the payer has agreed upon. Insurers pay less than promised for roughly 10% of claims.
  • Create a detailed system to address the aging of receivables, then track those claims by payer, as various payers might have different payment schedules and different procedures for addressing late reimbursement.
  • Make sure you follow up on unpaid claims as quickly as possible, as the sooner your practice follows up with health insurers the more likely you’ll get paid, and the less likely the claim will end up lost or ignored.
  • Using electronic tools, see to it that your A/R workflow is efficient, or your group may endure errors in documentation which slow down reimbursement. Practice management software can be helpful in addressing this problem.

Practices with a large budget may be able to invest in sophisticated, expensive tools which can perform in-depth claims analysis. This can help such practices improve time in A/R for claims.

However, if your practice is smaller and its budget can’t absorb high-end analytical tools, you can still improve your collections by being thorough and having a good workflow in place.

Also, it’s smart to make sure everyone on your staff is aware of your A/R goals. Even if they don’t have direct contact with collections or A/R, they can be the eyes and ears which help the process along.