Not likely. But amazingly, that is the situation some of your peers find themselves in today — doctors who ignore the opportunities presented by technology. Challenges, of course, vary from practice to practice, but broadly, they fall into five general categories, none of which are going to go away:

WHY DOCUMENT?

There are two critical aspects to documentation and reporting. The first is the need to document diagnosis and treatment to assure that cases are handled systematically and that there are clear indications of required treatment and patient progress.

The second is the requirement for a variety of reports, most prominently to insurance companies and other third-party payers, and secondarily to attorneys, referring physicians, employers, and perhaps others.

Records and charts have always been part of healthcare treatment. Notes are normally made during or following the patient visit. Typically, practitioners prepare their reports after patients and staff have all gone home — often during evening hours and at other times that should reasonably be devoted to family time and recreation.

Instead, they devote hours to analysis and dictation, sending tapes off for transcription. The transcriptions must be returned for correction frequently. Errors are not an option and the process can consume days or weeks.

Assuming a successful transcription at $20 a page (or more), the report goes to the payer, and you cross your fingers and wait. Ideally, your rationales make sense to the claims analyst and a check is forthcoming.

But, you may face alternative scenarios: outright denial; contested charges; or a visit from a third party medical examiner. You are on the defensive, and defense takes time away from the practice and from your financial comfort level.

Regulatory issues also come into play at this point. Rule-makers in the healthcare profession are in abundance. They range from the federal government down to the local government, with professional associations contributing their guidance and control structures along the way.

Finally — your patients. Where do they come from, where do they go, and why?

Your reputation is probably the most powerful marketing tool you have available, and referrals are often the most effective way to build your practice — although various types of advertising can also be successful.

Where do referrals come from? Satisfied patients are one good source. Others are people you send your reports to — attorneys, physicians in other healthcare disciplines, companies, schools, hospitals, and others.

In your work you touch a broad spectrum of the public and the professional community and the quality image that you project through your documentation can have a mighty impact on whether or not you are on the receiving end of referrals. Aside from direct patient care, which is a highly personal encounter, your reports and documentation are the most immediate contact you normally have with the various audiences that impact your practice — whether to get paid, to stay in compliance, to breeze through a medical exam, or

A BETTER WAY TO DOCUMENT

If you continue to prepare your documentation meticulously in the time-honored, time-consuming manual tradition, you’ll probably be all right. But if you want growth, greater financial success, and more life and leisure, you need to follow the lead of general business practitioners and explore the value of automation.

In fact, software is available that introduces greater and lesser degrees of automation to every level of your practice, from initial patient registration through diagnosis to final reports.

Software allows you to do:

• Patient self-registration. Consider, for example, handing an arriving patient a tablet computer with an interactive self-registration form on it that, when filled out and saved, actually opens the patient file.

• SOAP notes. The same tablet computer can serve as the platform for diagnosis and recording of SOAP notes, with interactive helpers — diagrams, interactive charts, and checklists that simplify both diagnosis and notes by linking to descriptive text that automatically enters the patient file with a simple tap on the screen. If handwritten input is necessary, it can be done on the screen as well, again going straight to the file.

• Outcomes assessment reports. The file builds, visit-to-visit. Periodically, both doctor and patient want to gauge physical response, and this can be ascertained precisely through the use of a choice of outcomes assessment reports: a set of visual analog scale sliders that enable you to be extremely precise regarding grade of pain and the rate of progress.

For neck disability, a questionnaire enables you to generate a report with a graphic representation. Another questionnaire covers the Oswestry index to establish current level of disability. A fourth is comprised of the 24 Roland-Morris questions that measure improvement from the first day and from the last visit.

Finally, a set of standard helpers assist you in preparing the final report: recommendations, professional opinion, permanent or correctible injury, and so on. You can modify these helpers to your own preferences and use them repeatedly.

All of this information transfers directly to the patient file. As you generate the final, you retain the ability to change it, since all reports and letters are generated in Microsoft Word.

• Selective reporting. When it is time to submit the report, all you have to do is select the patient file, select the type of report you require, and print it. The system itself collects and formats the information, including text, graphics, and photos, if any, generating a clear, concise document that is consistent with all rules, supports coding and compliance requirements, and gets you home in time for dinner. Wide open, it lets you customize and personalize to your heart’s content.

When you use software appropriately:

1. You can prepare reports automatically;

2. You satisfy the rigid requirements of the payers;

3. You save money;

4. You anticipate likely challenges to your claim for payment;

5. You observe all of the caveats, rules, and regulations (they’re programmed into the software); and

6. You have clear documentation to provide to referral sources and patients so that they continue to refer with confidence, and patients understand easily when and if we suggest that they set up an ongoing program to sustain their physical well-being.

Best of all, you don’t have to stop there. You can link all of the information developed by this professional office software seamlessly with front office and financial management software, further streamlining your operations.

Gregory T. Church is vice president of ACOM Solutions, Inc., Healthcare Business Division (www.rapidchiro.com). He can be reached by e-mail at gchurch@acom.com.