230- An EHR for Evidence Based Chiropractic Care

Welcome to the Evidence Based Chiropractor where each week we deliver the latest chiropractic research and marketing strategies all in the time it takes to get to your office. Now here's your host, Dr. Jeff Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I am your host, Dr. Jeff Langmaid. And on today's episode, you're gonna have the opportun to listen in to a conversation that I recently had with Dr. Scott Munsterman. He is the founder and CEO of Best Practices Academy, which dives into compliance. Super, super important, but a lot of time that we spend today we're talking about his other project, which is Echiro ehr. He's doing some really interesting things in the EHR space. You're going to get a little bit of research, a little bit of compliance, a little bit of EHR, and even a little bit of marketing. In today's episode, I want to thank some Scott and please be sure to check out Best Practices Academy and Echiro EHR@echiroehr.com without further ado, here's my conversation with Dr. Scott Munsterman.

The EHR space. I gotta lead off by asking you what gave you the motivation to start Echiro ehr?

Yeah, that's a great question, Jeff. And it started with pain points. We were involved with a practice recognition program from the National Committee on Quality Assurance. They had a practice recognition program that they provided for the medical community. And we felt that chiropractic could achieve those same recognitions. And so we got a group of practices together. There was about 21 DCs total within our state of South Dakota that went on that project. And we achieved the practice recognition through the NCQA called the Patient Centered Connected Care. And then later on one of those out of that group became a PCMH Patient Centered Medical Home, which achieved a top national recognition status among the top 25 medical clinics in the nation last year. What we wanted to do is bring chiropractic to the peak and we were able to do that with our organization. However, during that process, it was very painful for those doctors because there were six different chiropractic EHR systems that were used and none of them, none of them met the requirements that we needed in order for them to achieve that recognition. And so we had to do all kinds of workarounds. And so it was that experience, that painful experience that led us to the point of looking for an EHR system, not building our own. Because again, I didn't wake up one morning thinking I had this brilliant Idea that I was going to build an EHR system. So we went looking for a partner that had integrated care in the forefront, that it was a full fledged EMR system. And of course we found that partner in Ipatient care.

I love that. And let me peel it back. I want to dive into some big time details on that, but I want to peel it back to a couple of years before that and say, let's get a feel for what inspired you to become a chiropractor.

Oh, gosh. Well, the pain point to your point again was when I was a junior in high school and I was wrestling and I was in a tournament and I came out of it fine, I won it, but I couldn't walk afterwards. And so I came home and told my mom and she said, well, you're going to the chiropractor. And I said, what? I'm going where? I didn't know anything about chiropractic, but I knew that my parents and my grandparents and my great grandparents used chiropractors as just part of our healthcare, but I personally had never experienced it. Well, long story short, within a couple of adjustments I was back in the wrestling mat. And so I always tell people that I'm a fifth generation chiropractic patient. Okay. And that's the truth because it goes way deep in my family heritage that we have been chiropractic patients. It's been a natural part of our health care. And of course I have grandchildren and so on and so forth that experience chiropractic care as well. So it's just become a long standing part of our healthcare and our family.

I love that. It's so interesting how different people are brought into the profession. And certainly in your experience, there's the sports aspect and I've just seen such a big uptake in that sports aspect in evidence based practice as defined over the last few years. I noticed you use some of that terminology on your website as well. Bringing it back there for the evidence based chiropractors that are listening. How do you define that and what have you built into the software that. To help that provider type?

Yeah. So for me it's been 35 years in the profession. February 4th of 1985 is when I actually put my stake in the ground and start a practice. And ever since that point, even through college, I was always along the lines of, okay, what does the evidence tell me? Even though we didn't talk about evidence based way back then, but it was always about how do we back this up? You know, in Essence. And so taking that philosophy and that intent moving forward, that's exactly what we did with the Echiro EHR system is that we built out an evidence informed, evidence based note. We go right to where the references are that tell us what the prediction rules are for myelopathy. It tells us what the best likelihood ratios are for the different ortho tests. That in terms of a diagnostic clustering of what's going to tell us that we have pyramidal compression or not some of those things and even diagnostic prediction rules, when it comes to X ray, does it make sense to take an X ray? Well, what does the literature tell us? We get into the mode sometimes of doing things because a payer told us or because a payer is only doing this or doing that. And we don't get into asking ourselves as clinicians what's the clinical indication, you know, and what is, what does it tell us? And so it's bringing those pieces together inside of the, inside of the note taking system. And we've done that with E Chiro ehr. And so as we think about our diagnosis of that patient and we're going to get that through a comprehensive history, all right, and examination leading up to that point of making that diagnosis while our treatment plan is contingent upon what the diagnosis is. And so right now there is a big focus on the treatment plan, whether it's Medicare or third party payers, auto whatever. But the question will soon become is that diagnosis accurate and what is the evidence for that diagnosis? And that's where the evidence, informed exam history, all of that comes into play to make sure that we have that in place on that initial visit and any subsequent reevaluations. And so we're, you know, we're looking ahead somewhat from a compliance perspective and also saying that hey, we want to do the right things. It's all about, you know, what does the evidence tell us is going to be the, you know, the right diagnosis for this particular case? There's a lot of great information out there that I know you're aware of, Jeff. And what we're trying to do is just be a sponge to that and say, okay, how do we apply this in clinical practice and what is the tool through this EHR system that we can deliver it effectively for the clinician and come alongside of them as a business system essentially within the clinical environment.

Yeah, it's such a balancing act. Right. You want to make sure you have give docs the availability to have the customization tools, but you also want to make sure that you're doing everything you can to help guide them towards what may be in their best interest along the way. And, and with that, that makes me think of some of the notes, templates, et cetera. I think that those can be such a huge time saver for docs, and especially from what I hear from you, when they're almost reverse engineered, when they're built off of what's the terminal point? Well, the terminal point is being compliant and getting paid and then working backwards potentially and saying, hey, what are the steps that would lead you to those things? Because that's going to be probably a pretty darn good direction to bring your patient and your practice along the way. Tell me a little bit about your thought process behind note templates where you've seen a lot of success. Maybe the docs that use the service have really given you good feedback. Just talk to me a little bit about notes templates, because I think that's something docs are always do I use it?

Do I not?

How much do I need to customize? How much? Don't I? What are your thoughts on the background there?

Yeah, there's two key thoughts I'm going to come down to the foundational element of compliance. All right. And what are we trying to do with our notes? I mean, what we're trying to do is to provide the most accurate story for the patient. And that doesn't matter if it's the first visit or the fifth visit or the 20th visit. It doesn't matter because that encounter has to be specific. And so one of the downfalls and one of the blessings of an EHR system template is that you can carry over what you did from the last visit. Right. But the downfall of that is that it needs to be encounter specific. Matter of fact, if it's not encounter specific, then it's not medically necessary care, and it's called cloning. And that will become fraudulent behavior if it's repeated. And it's being looked at upon by the Department of Justice and other groups. Other agencies are beginning now to be very critical about EHR systems. And it's not so much the EHR system template as, again, it's more about us clinicians and how we use that and to make sure that we bring that new information for that encounter into that template. So that's very key from a compliance per second perspective. But secondly, Jeff, to answer the other part of your question is that templates need to be our guidance, be able to kind of give us the path. It's kind of like when you're going down the road and you've got these, I'm forgetting the terms now, but kind of the guidelines or the guideposts, the rumble strips and some of those things keep you from going off the road. And even in some of the new cars they've got some guidance that will keep you in the lane and we want to try to stay in our lane. And that's how the templates need to be developed and that's how we developed them in E. Cairo. It's to make you think about all these different aspects and then give you the opportunity to be able to create a note that will provide changes since the last visit. And when we're talking about a subsequent visit, that's very key. Asking the patient, what changed since the last visit? What changed with your pain, what changed with your function? When you go to palpate that patient, you're asking yourself, well, what's changed since the last visit? You look at your note, oh, that spasms. I'm going to rate it differently than I did last time, whatever the case may be, making sure that we have a good, vibrant, updated, encounter specific note and that the template allows you and helps guide you in that clinical decision making process. And so that's how we've developed our template, but from a standpoint of clinical appropriateness to make sure that that note is encounter specific. And it's up to the clinician to make sure that they get that done no matter what EHR system that they happen to be in.

I think that's such a key component. And the first part of your answer really was devoted towards guiding the patient and making sure that the patient experience is really where it be. And that makes me think of the patient portal that you've developed and tell me a little bit about what's entailed in a patient portal. I've seen some that are awesome. I've seen some that left some things to be desired. And how does it improve the patient experience? Maybe even more importantly what's included in the patient portal. But what's your thought on how it helps the patient experience in a provider's office?

Yeah, well, there's so much to that from a technology perspective when I say that a portal needs to be that to provide a patient that ready access into their EHR system. But even more than that, we need to be able to have the capability for that patient to give information to the system that could be through patient monitoring devices. And we see this just taking off like crazy. There's even from the standpoint of understanding the socioeconomic and demographic aspect of a patient. Now, for instance, our system actually has developed to where we know what some of the downfalls could be of where a patient lives and that that can pull into the equation as to your past family, medical, social history, part of it. You know, social determinants of health are becoming widely known. And as clinicians, we need to pay attention to some of those things. Well, that information that can come from a portal, from recognizing where a patient lives, maybe where a patient works, you know, the social environment that we have data on from a county and state perspective can bring and inform that clinician. But that patient engagement, to your point, and the experience of being able to have ready access, provide data feedback into the system, be able to communicate with the clinician securely, those are all important features. And that they can have ready access to, let's say for instance, vital signs, or maybe intake forms can be brought into it, or that they can just have a virtual visit. Those are all areas that this is just going to continue to lead us into having more real time interaction with patients and not just like face to face in the office. And you kind of. I always thought about that years ago about how that would work someday. Telemedicine, how would that work someday with chiropractic clinicians? And I think we kind of sell ourselves short a bit. I mean, we think, okay, I need to use my hands to help people. Well, we have a lot of knowledge up here in our head that we can give some great advice for patients. And so we need to be thinking a little bit out of the box and how we can expand what we do and how we do it. So yeah, I think that it's wide.

Open, Jeff, when docs first start using echiro, what are some of those things that they fall in love with? What's the feedback that you get because you just named off a couple different aspects that we haven't even touched on yet that are critically important to really having a successful practice. And I would say for most practices, the EHR system is the foundation of things. It can either help you get somewhere or it can certainly hold you back. When docs first start using echiro, what are some things that you hear? They just really love about it and really saves them time, energy, money, etc.

Yeah, they come to us because they want to do a good note. They want a compliant note. They want one that somebody will look at and say, wow, that's, that's the type of docs that we're having come to us. And so number one, is the EHR system that we built out that we already kind of talked a bit about. The second thing is more of a secondary, maybe blessing in disguise for them. And that's the practice management system itself and the ease of using it from a scheduling perspective. And then the billing side of it. I mean, there aren't any deep dark holes that you lose claims in. You know, it's. And the way that it's done, it's very meticulous in the reporting system and all that. By far the best practice management system I've ever seen. And again, I've been in Chiropractic for 35 years. Okay, that just is what it is. I mean, I'm still amazed by how well it's put together and how well it manages a practice. And then the third part you mentioned earlier, and we already talked about it, is the patient portal. I mean, that outreach and, and to the patient in that interaction that we've already talked about.

So with a practice management component, what are a few critical items that either you guys have that you're really proud of, or maybe the docs listening that don't use Echiro yet are thinking to themselves, gosh, let me see if what I'm using has this. What are a couple critical elements that you see in that system?

Yeah, well, a couple of things. I mean, keeping track of patients is important, and, and the statistical analysis that you want to keep track of in a practice on a daily basis, on a weekly basis, and a monthly, quarterly, semiannual, and then the reporting side of it from a financial class perspective, and keeping track of claims and making sure that money is posted directly to that specific data service. And so practice management systems out there that are, in current systems that many doctors use don't have the level of finite detail that this system does. It doesn't lose anything. It doesn't lose any claims, doesn't lose any money in the system. And I think docs that have been around the block a few times know exactly what I'm talking about because it happened to me in practice. And so having we live and die on reports for our practice and keeping track of, you know, what's coming in, what's going out, any hiccups. And so we've built the system around that to help train doctors on what to look for coding, you know, being able to do comparison studies of codes that you're using from one quarter to the next quarter and just seeing if there's areas, especially if you have a large group practice or even two or three in Your group, managing those other doctors. You know, you need systems around you to be able to do that effectively. And so, you know, we have practices coming into our system that have bigger clinic systems because they just need a better management system to help them. There's those features and many more from the practice. There's over 300 preferences, Jeff, in this system that you can tweak it the way that you want it, reminders the way you want them and all of that.

That's a really key component because I find so many docs out there, either they don't have great reporting or they don't use the reporting that's given to them. So a lot of what I'm hearing from you and what I like, what I'm hearing is again, taking it back to where we started. Hey, this is really, to a certain extent, reverse engineering. How do we get paid, how do we stay compliant, how do we give great patient outcomes and then making sure that every step of our system leads us to those places. Because I think that's where we all want to be. We want to have profitable practices that have happy patients coming out of and we don't want to be stressing out on how we got there along the way. A critical portion of that, a key portion of that is the reporting that goes in. Being able to set up preferences, being able to know where you're going to get to. And certainly what you described, not having gaps and lags in data is just so critically important because you can't have great reporting if you have shoddy data. So making sure that your system really is keeping a close eye on the patient throughout their journey in your practice. And where I'm going with that is that that also delves into, and I'd love to hear your thoughts specifically regarding outcome measures and where that fits into compliance and ehr. There's a whole multi hour conversation there. And for those that don't know, you are also a compliance expert, if that hasn't been made clear in a conversation for another day. But in regards to an EHR system, tracking patient outcomes and staying compliant, what are the thought processes that you look through that prism with? Echiro.

Yeah. So two things, Jeff. Number one, I mean, we've gotten pretty good as a profession at using outcome assessment tools, which is great. And I think there's always a place for those validated tools. However, and I'm going to throw you a curve ball. Okay. When it comes to designing a treatment plan, we need three things in a treatment plan. We need specific goals. All right? We need duration of care outline, which would be for the whole episode of care for that active treatment. And we also need frequency of care. How many total treatments will it take to get that done? So let's focus on the goals though, because this is where we're going with. With what you're talking about patient specific goals. How long can sal. What. What functional activities have been limited by Sally, specifically Sally, the patient? Well, maybe sitting, maybe standing, maybe sleeping, maybe whatever, walking. And it's putting a metric on that, you know, while Sally could sit for two hours without pain before she slipped and fell, now she can only sit for 20 minutes. It's aggravated by sitting. Well, great. We have a goal then Sally, we want to get her to two hours of sitting without pain. She's at 20 minutes. We have to, in our treatment plans get very specific and have our goals get specific. And what's not accepted in a treatment plan when we talk about goals is that we're going to decrease Sally's revised re pain questionnaire from 75% to 30% or by 50% or whatever. And the reason that doesn't work from a goal perspective is why? Because it's not measurable, it's not specific, it doesn't tell us specifically what we're doing for Sally. And so again, validated tools, they're great. We need to keep using them because I think it just shows that we know that that's an important element to rate from a 30,000 foot view perspective. But in our treatment plans, from a compliance perspective, we've got to drill down and be very specific about our pain. What's our pain goal? What are our ADL goals? And we should have two or three of those if they are there for the patient. And then thirdly, even looking at objective, maybe range of motion goals or that type of thing, but those are three key categories from a goal perspective. And so we need to, to your point, those tools are important and we track those in E chiro, by the way, so that they can be put into E chiro and then they're tracked and you can show it on a nice graph, you know, the improvement. But aside from that, from a compliance perspective and documenting perspective, we need to drill into those patient specific goals. And that's very key. And of course we learn from those outcome assessment tools, you know, that they are having trouble with sitting or standing or whatever the case may be, but we have to drill further than that.

Yeah. And let's talk about those goals a little bit and how it fits into a note and really how it fits into a plan. I find that docs get a little bit nervous when they're like, well, what if I don't reach the goal that I set out for? And to me it's like, well, that's why it's a goal, right? You just want to make progress along the way towards it. And, you know, healthcare is nonlinear. Our bodies are dynamic and our healing processes are that way. But I find that a lot of docs get a little bit of ants in their pants when they have to be nailed down on a specific goal because they hate to fall short. I guess from a documentation perspective, whether in echiro or maybe even a little bit from a compliance perspective, does docs need to be concerned about stuff like that? I mean, what are some of your thoughts and tips for how to set great goals? I know it depends on the patient and what you're shooting for, but what are some basics that you'd give the docs out there for advice on goal setting?

So when we're across from a patient, and I mean, it can be a wide range of things going on with that patient, be something very simple, or it could be a patient that's had complexity, they've got degenerative changes, maybe a lot of comorbidities or whatever the case may be, they could have the same diagnosis, but they could have certainly different treatment outcomes, no matter how good you are. So as we begin with patients, the thing that we have to be realistic about is that we're going to bring this patient down one or two paths or at the end of the path, it's going to be one of two outcomes. Number one, hopefully we can have the goal that we want to bring them through their pre incident status. So if Sally could sit two hours before she fell, she can only sit 20 now. You know, hey, let's, let's shoot for the two hours, right? And I think a lot of us may feel that way, or it could be where we have a patient that does have a lot of baggage, clinical baggage, I'll call it, going on. And maybe we're not going to be able to get that patient back to their pre incident status because there's some permanent impairment, potentially, whatever. And so we want to bring that patient to a point of what? Maximum therapeutic benefit. Right. And so either way, as we start out from the starting line, we may be thinking that, you know what, I'm an idealist by trade, and so I'm always a pre. Let's reach a pre incident status level. Sally. All right. But if we move along and we do our progress evals when we need to be doing them, and we're seeing like a plateau in that patient's progress, then we need to begin to clinically ask ourselves, okay, is there anything more that we need to do different with this patient? Is there any other team members we need to get other colleagues, medical or otherwise involved in this case? And then finding out if that patient has reached a plateau, then they may have reached a point of maximum therapeutic benefit. Okay, and so maybe Sally can't get to two hours of sitting, but we got her to one, you know, without pain. Okay, well, all right, then maybe that's where Sally's at. And then at that point we have to ask ourselves, okay, we're going to go ahead and release that patient to a trial of therapeutic withdrawal. And if Sally can self care, self manage herself and keep it that one hour without pain, great. If Sally has maybe a reoccurring episode, something happens and it started to come back. She comes back into the office, we treat her a few times, she reaches her maximum therapeutic benefit level again, we release her. Kind of a catch and release, if you will. Great. But then the third part of that would be that if Sally, just through normal activity of daily living, starts to regress and she's back in, in two weeks or three weeks or whatever the case may be because of the chronicity of it, and she can't maintain herself at that maximum therapeutic benefit, well, what do we run into there? Well, Sally, you'll probably need maintenance, therapy or supportive care, whatever you want to call it. So we as clinicians, we have to start out at the starting line somewhere. And again, I'm an idealist. The starting line is going to be pre incident status for me. But as we get into the reality of that case, we have to be flexible in our thinking and we have to say, okay, for whatever reason we've hit this plateau, we've done this, we've done that. It looks like this is where Sally is going to be. Now let's see how Sally does in these three areas. Can she manage herself or is this going to be where I'm just going to see her periodically? Because there's some permanency to this situation or chronicity. The key here, though, is that we do our job at cutting that pain of journey, that journey of pain short. When it comes to chronic pain, we need to do our job as clinicians to help that patient manage that pain, get to a point of maximum functional improvement and performance, and it becomes all about how do we improve their life from that point moving forward? And if we can keep that patient from getting into more of a chronic pain or chronic pain syndrome, we've done them a world of good in their life. A world of good. And if we can maintain them at a good, healthy, high quality status, whatever that means to them, then we've done our job at the end of the day. So tell your doctors to relax a little bit and not be so hard on themselves, but to go after it in a manner that you're going to find out what the sweet spot or what the best is for that patient because they're all different.

I'm going to ask you a couple fast and furious E chiro questions as we come towards the conclusion here. Cloud or server based and why cloud based?

I was kind of the older generation, if you will, that was a little nervous about that five, ten years ago, but not anymore. Cloud based is the way to go from a compliant, from a security perspective and the redundancy backup perspective and all of that. And then the ease of being able to access it wherever you're at. You don't have to worry about upgrading your hardware systems or servers going down or some of those things. Just got to make sure you have good bandwidth and of course a good cloud based system with the backups and all that.

Cool. What is the one thing that Echiro does for your clients docs out there that they didn't expect?

Well, number one would be the note system. They're proud of their notes and they weren't proud of them before, matter of fact. And secondly, I've had doctors say that they're sleeping better at night, not worth it. So those are the two biggest things.

That's great. And what's something. What haven't I asked you about Echiro or what do you think docs need to know in the EHR space? You can go either direction with it that we haven't touched on today.

Yeah, I would just say that when we went, your first question is what was the pain point that brought me into this whole thing? Because I didn't wake up one morning having this great idea kind of thing about getting into EHR business or whatever. It boils down to selecting an EHR system that is actually robust. And of course, with the iPatient Care platform, they have over 70,000 users worldwide. It's an EMR system inside of hospital systems and medical clinics and all of that. And the reason I say that that's important is because it's been able to win awards and Stay ahead and do a lot of testing for Medicare and in different areas and all that. It's right on the forefront. And what we've been able to do is just harness that, be inside of that, and build out our niche inside of that Note, which works extremely well. And so choosing a partner has been big. It's kind of like the analogy of the elephant and the mouse crossing the bridge, and the mouse looks back after they cross the bridge. Boy, we sure shook that thing, didn't we? I'm the mouse. I am just the mouse. Having partners really defines who you are and where you're going into the future. That is huge for us.

I think that's super important and it's something that this is the first I'm hearing of it, so that's exciting. Anytime that I love it, that's where I look towards maybe the marketing world in my niche, where I say, what are the biggest players out there doing and how does it apply to what we can do within chiropractic? It sounds like your thought process has been really parallel to that in the documentation and specifically in the EHR space and docs listening right now, they're saying, gosh, I've heard all this awesome stuff about Echiro. Where the heck do I go to learn more? Where would you direct docs to go to learn more about yourself and or E. Cairo as well?

Yeah, well, it's not about me. Just type in Echiro ehr. Google it, you'll bring it right into the website and we've got a team there that will be able to help you get a demo set up. Happy to get you a demo. And then you just make a decision.

Awesome. Scott, I really appreciate our time here. I think you've given me a ton of information regarding what docs can look for in their EHR systems, what they should have, if they don't have already, and really how it intertwines. The most important thing to me, how does it intertwine with patient experience and compliance? And that sounds like the crux of what you've really been solving for over the past X amount of years. And I commend you on it. And I think that's been very, very critically important for chiropractic practices today. You want to be compliant, you want to have good reporting. You don't want to do that at the sacrifice of your patient experience. You want it to be enhancing the patient experience. And it sounds like E Chiro is right in line with what I'm thinking. So I'd encourage everybody listening if you're watching this, click the link below. If not, type in as Scott had said, echiro ehr and you will find it, do a demo, see if it's right for you, and and kind of take it from there. Scott, I really appreciate our time today.

Yeah, same here. Jeff. Thank you.

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