Marketing, Compliance, and Patient Care: How Your EHR Impacts Everything

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 reevaluation.

Scott, I really appreciate you coming on. And most entrepreneurs start businesses due to a personal pain point. Chiropractic. You know, it's mostly somebody gets hurt, the family member gets hurt, then they see great results, they go into chiropractic in 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 Career. 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. So 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 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. It was 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. And 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 kind of defined over the last few years. And I noticed you use some of that terminology on your website as well. So kind of 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 started 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, you know, does it make sense to take an X ray? Well, what does the literature tell us? You know, 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 does it tell us? And so it's bringing those pieces together 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 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 for you, when they're almost reverse engineered, when they're built off of, you know, what's the terminal point? Well, the terminal point is being compliant and getting paid and then working backwards potentially, and saying, hey, you know, 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. So 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, so there's two key thoughts, and 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. You know, 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. You know, I'm going to rate it differently than I did last time, whatever the case may be. And so 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 should 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, so 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. And 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. And so 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, and you brought an interesting thought to my mind when you started to discuss, I mean, certainly the telehealth component, but also the kind of the wearable component. And you know, as time goes on, it is, it's such an evolving. It's evolving. It's Moore's Law, I guess, right? Every two years it doubles or whatever, 10 X's, whatever the case may be, it's accelerating the technology and the application of the technology is accelerating at such a crazy pace right now. How do you see the individual, the physician, the wearable device and the ehr? How do you see that mix playing out throughout time? If you had a crystal ball, what would you love to see? And what are some, maybe some things docs should look out for with their ehr or questions that they might ask to make sure that they're going to be set up for success in the future? It's evolving. We know it's early, but it's getting there. What are your thoughts around some of those topics?

Yeah, well, we have to think of the EHR system as the hub of information, the coordinator of information for our patients, and not just what we put into it. I mean, that's obviously very important, but it's all about the interaction and having that communication like we talked about. Eventually it will get to the point where people will be using portals more. And that's going to be such a key component to have that loop around. But EHR systems need to be the place where we can go to find out what's going on with our patients. I just think it's going to be that hub, the other part of it, it's kind of a. I'll not go down the rabbit trail very far, I promise you, Jeff. But it's all about health information exchange in addition to that. So it's getting records from patients and understanding where have they been. One of the number one downfalls that we have as chiropractic clinicians is that we have a tendency to not pay attention to, number one, the past family, medical, social history and sometimes review of systems. I mean, it's one of those areas that we can just get so focused on the regional exam and the history of present illness, chief complaint that we kind of forget about, well, where have they been? Or take stock in one needing to know more about that orthopedic neurology visit, maybe even an endocrinology visit that they had years ago. Well, within our platform coming out now this quarter is an HIE health information exchange capability that we will be able to connect with the EPICS discerners through a large platform system. And so by two or three clicks, you'll have all of your patient records from wherever they've been, if they've been inside of those other EHR systems. We play with the big boys, Jeff. Okay. And this is a capability that the doctor of chiropractic really needs to have at his and her fingertips to get the full awareness of what that patient is all about and who that patient is. So again, this system needs to be the hub of information for that patient and our communication with our patients. And it's where we live. It's where we should live. Absolutely.

Those integrations, I'll commend you and I'm glad I didn't have to do the work. I'll commend you and your team for doing the work to get those set up. Because I know a lot of times getting in the backend, so to speak, and making sure it's compliant and really talking with other systems can be an absolute logistical challenge to like the 100th degree. So I'll commend you guys certainly on making that happen, because I've never heard of anybody else. It probably exists, but I've never heard Anybody else really say it the way you just did, that there is a technology solution that chiropractors have in their ehr that can connect to those systems. And that I think is important from two different aspects. Right. Number one is making sure that you have the best and most accurate information on your patient that you have in front of you so you can help guide them the best way possible. Second aspect is, I would assume, I love the fact of what you're saying, hey, me as a clinician, I don't need to do all the coding. I can make a few clicks and that can save me a heck of a lot of time making sure that I have a really robust and complete record by being able to access what they've already done. And it's so crazy in our system that many, much of the time we just rely on a verbal interaction of a couple minutes, just duration maximum or the patient hopefully brought a scribbled note of what they had done somewhere else. And we're relying on that to help give a clinical direction on a patient. Now thankfully, again, most of the time with what we see as chiropractors, it's non emergent. Right. And that's a good thing. So it gives us a little bit more latitude. But I don't think it should not give us ability to sit back and say not our problem. The, the more information that we have with our patient, the better clinician we can be and we can start to become more of the quarterbacks of their case. Which in my opinion is really where we should be. There's friction in chiropractors. Chiropractors don't see 99% of the population, we might see 15. So if somebody chooses to come in to see a chiropractor, that's a big deal. By and large they are a minority of individuals and with that that's put so much trust in us as providers that we should be doing everything we can to, to make sure we're guiding and directing them based upon that trust. But I'm going to pull it to the now instead of the future and talk about text because text has become such a ubiquitous platform of communication to me a critical part of a modern practice and anyone that's not using it arguably could be missing out. What's your take on text? Where have you seen successes and what does even chiro ehr do in the text communication space today for the individuals that are a member of a chiropractors practice?

Yeah. So number one, from a compliance perspective, text messaging is not secure.

Okay. We're getting some good stuff here.

So again, Jeff, I'm going to bring you back to the foundational element, which really is okay, what's right and what's wrong. And it's kind of what brought us into evident being evidence based, evidence, informed clinicians, because we want to know that. And so bottom line is that texting is not compliant or it's not secure. And what's important, if you are currently texting and using that as an option with your patients, better make sure that you've got the appropriate disclosure authorizations from the patient that you can communicate to them via text, via email, but that they have to know that it's not secure and that you have protected health information that anytime a clinician and patient talk and if it's clinically relevant, that's phi. Okay, so number one, first and foremost, that has to be done. And so within the Echiros system, what we've done is we've held back on allowing that text messaging to occur inside of our EHR system for that particular reason. But we do have capabilities to be able to do emails, to be able to do the appointment reminders and calls and all of that. But we take the approach that we want to make sure that we don't lead people in the wrong direction and to misuse something that could be easily misused, which I think today, and maybe you'd agree or disagree, but I think there's a lot of misuse of text messaging today and at least the patient's not knowing that it is not secure, a secure way of doing it.

Let's go down there. Let's go down that a little bit farther because I think you brought up a very, very interesting point. There is a difference between text reminders, appointment reminders, and making sure that you are guiding the patient's journey and having what I'll just refer to as a, a medical healthcare conversation. I think that what you're describing is exactly where I was going, which is the ability to remind your patients of appointments, being able to potentially follow up if they've missed an appointment. These are really critical components because it's so real time as opposed an email is great and imperative, but the patient might not see it for a few hours and is what you've seen with the text. I'm just thinking about it from a pragmatic point of view. Hey, patient's late, you text them. There's, I'm going to assume, I'll let you tell me, a substantial increase in their ability to either reschedule or say, you know, darn it, I forgot, I'm on my way right now, as opposed to an email which might have a longer lag period. Is that sort of what you've seen?

Yes, that's exactly right. And so, and just a real quick point is that even when you use it for appointment reminding services, it's important to get the disclosure. So, but that aside, everything that I've read, Jeff, is that it increases by 20 to 30% those missed appointments, you know, and so you're going to, if you've got, let's say, 10 missed appointments a day that you're averaging, or five, or whatever the number is, you can expect 20 to 30% of those to be in that day because they were reminded, and then the other ones just plain need to be rescheduled because life happens. Right?

That's wild.

It's so important to have that as a business component. And what we've done at Echiro is we've created clinical business systems that help guide the clinician around their EHR practice management system, from the billing aspect of it to the reporting aspect to key activities like that. I mean, something very small that can be a big deal to the practice.

And let's go there a little bit. So 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. So 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, et cetera?

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 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 the way that it's done. It's very meticulous. And 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, I'm. 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 to the patient and that interaction that we've already talked about.

So what 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 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 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 that money is posted directly to that specific data service. 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 what's coming in, what's going out, any hiccups. And so we built the system around that to help train doctors on what to look for coding, 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 need systems around you to be able to do that effectively. And so we have practices coming into our system that have bigger clinic systems because they just need a better management system to help them. So, yeah, there's those features and many more from the practice. And there's over 300 preferences, Jeff, in this system that you can tweak it the way that you want it, you know, 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, you know, reverse engineering. How do we get paid, how do we take a client, how, 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. And so a critical portion of that, a key portion of that is the reporting that goes in. So 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 complex 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 when it comes to designing a treatment plan. We need three things in a treatment plan. We need specific goals, 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 what you're talking about, patient specific goals. How long can Sally, 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 while Sally could sit for two hours without pain before she slept 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 Western pain questionnaire from 75% to 30% or buy 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, 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 echiro 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 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, or 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 will 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.

Yeah, I think the most ironic part about that is I worked in a few surgery centers and you see the surgeons and they're man, I Hope we get 30% reduction in pain. And then you see the chiropractor, that's a surgery that costs you x hundreds of thousands of dollars. And then you see the chiropractors that are like, but if I fall short of my 80% reduction in pain by 5%, I'm a little bit anxious about that. And so it's definitely all a matter of perspective. And I guess if you were to again, I'm going to ask you to take back out that kind of crystal ball. What are some of the big challenges that you see chiropractors facing potentially in the next five to 10 years? Could be documentation related, could be compliance related, could be. I want to talk a little bit broader healthcare with you because of your background experience that we haven't really talked about yet. But what are some of the greatest challenges that you see chiropractors facing in the next five to 10 years?

Well, we just need to keep bettering ourselves and we have to be open to working with teams and collaborating. This whole opioid crisis situation, it's going to take decades to unwind. This whole habit of getting a prescription for your pain, it's been ingrained in our society for years. But we have to be at the forefront in understanding that we are the non pharmacological alternative. That's great news. Right. But there comes with that a responsibility and accountability to ourselves to be evidence, informed, evidence based, which your audience is. And that's great. I mean that's how I practice for 35 years. And that's, that's the way we need to be moving forward. But we have to embrace and be flexible as to working with other providers. We don't have all the answers, but we have a part of the answer. And a lot of times we do have the answer to many different types of things that are within our scope and within our specialties. So staying in our lane, our swim lane, working with others is going to be part of the challenge because we're used to being by ourselves and we're used to being the entrepreneurial, spirited that we've had to be to be in this profession in the first place. You know, secondly is keeping up on the literature and keeping up on, you know, how do we take care of these more complex cases and be a part of that team we have clients that are in federally qualified health centers. And if you want to see a sick patient population, you should go there and watch some of these chiropractic clinicians work inside of these integrated teams. They're doing great work. But again, we are only exposed to a certain level of population. To your point earlier, the other 85% that are out there, there's a lot of sick folks out there. And so we have to be ready to engage and hopefully be a part of their lives as well. And then thirdly, and you reference this from a compliance perspective, I mean, that's a big part of how I'm finishing my career off the next 15 years, is to help practices understand what regulations that they are under in their clinics, whether it's hipaa, whether it's osha, whether it's the Medicare OIG aspect of it. Federally, there's so many business decisions that chiropractic clinicians make that go out of bounds of some of those things. And they don't know. We didn't learn it in school. The other thing we didn't learn in school is that we didn't learn how to run a business in school either, did we? And so those are some of the things that we have to get under our belt. And they are challenges. They may not be surfaced that most doctors can see it, but that is the underlying challenge is to shore up these small businesses that our chiropractic clinicians are in, to get them viable so that they will stand the test of time as we enter into this whole new opportunity that we have in the healthcare delivery system. Huge opportunity in care delivery for us and how we think and what we do. But we have to be flexible. We have to back away, be a team player is what I mean by back away and say, okay, I have my opinions, but I need to listen and let's work with other people as we move ahead.

Yeah, that's something that I've definitely taken on my mantle as well, is how do we work with other providers? And, and the best way for the patient, there is enough room for all of us. And again, it's almost the irony of it is that we have the smallest utilization yet. We have quite often, in the absence of red flags, the most effective, the most cost effective, the safest care. But hey, while that's great, that can almost be a challenge in terms of the other side also. And the gist of it is there are plenty of people on planet Earth, there are plenty of people struggling with issues, and it's really all about the patient. But I want to touch on something that you just said, and I want to drill into it just a little bit. What's the number one compliance issue that chiropractors need to know about and or are dealing with today?

Well, the one that they need to know about or the one that they may be aware of.

Let's go with each.

Okay. The one that they may be aware of has to do with documentation, you know, so the OIG Office of Inspector General, they are the watchdog for Medicare trust fund dollars, you know, and it's not just our profession. They're looking out, they're looking at everybody, and they're crossing T's, dotting I's. They want to see that documentation was there to support the level of billing and all of that. So we have that level, and I think a lot of our clinicians and our colleagues know that that's going on and all of that. Underlying that, though, many think that they might be compliant with HIPAA because they bought a policy 10 years ago that's sitting on their shelf. And by the way, some of it's in shrink wrap. I've had, actually, doctors tell me that, and they're not doing what the policy says they're going to do to meet those regulations. And so the underlying issue that we have as a profession is shoring up to the regulatory environment. We're in a highly regulated environment. This healthcare delivery system we're in, we're not out of that, we're into that. And so we have to understand what are the rules that we need to know. Well, most doctors are oblivious to that. They don't really have any idea. You know, they maybe understand HIPAA a little bit, but they don't understand, you know, the 45 different policies they need to have. And how does that relate to their practice and what are they doing in their practice to make sure that they're complying to it, and how are they monitoring and auditing their systems and all of that. So, I mean, just basically having a compliance program. Jeff, what I do is I'll. When I'm speaking on this particular topic, I'll ask doctors, how does your compliance program work today? And I see your eyes, I see your eyes, and that's exactly what I get. They kind of like, okay, well, I've got a policy on my shelf, but it's not, like working for me. It's sitting there. And that's the whole idea, is that actually it's a work plan and it needs to have some key activities. But we'll take that subject matter another time, I think. But the point being is that that's the part that they don't really understand or know about is that. And then the other side of it, and we touched on it, is just the clinical business systems understanding. What does it take to run a clinical business? And so we talk about coding, we talk about billing, we touched on the reports. Well, it's great to have an EHR system like we have built now for the profession that's robust and will take you into the future big time. But then it's all about understanding how do I use it and why do I need to use it and how do I use that to effectively run my business, my clinical business. And that's what we have brought around, the docs who are within our system is that know how, which we didn't get in school. So loaded question, you know, what does everybody know about? Well, the documentation thing, what don't they know about? Well, it's basically compliance and maybe what they don't know about business that they should know. And some of them readily admit I just don't know much about business. So there you go.

Yep, I can understand that. So I want to ask you, I'm going to ask you an easy one and a fun one. You have a hundred million bucks to spend on health care and no red tape. How do you spend that money?

100 million bucks? I probably would. Okay, so let me ask you this to preface the question. I can spend it however I want, wherever I want.

That's correct.

Well, what I would probably do then is I would find organizations like the foundation for Chiropractic Progress and I would sit down with them and say, you know What? I got 100 million bucks. I need some ideas. Because the bottom line is that we need to get our message out about who we are. I would look at university systems that we have within our profession. I would align it with more of the evidence informed based approach. You know that I think there are some that are way there now, some that are working their way towards that area. I would do everything that I could to try to drive our profession more towards the ideals that we've just spent time talking about, Jeff. So however that would look. But it would go into chiropractic, there's no question about it. Yeah, 35 years working with patients has taught me a lot about this profession. And it just, you know, it's just a great profession and it's for people.

I could, I could not, could not agree more. So I'm Going to ask you a couple fast and furious E. Cairo questions as we come towards the conclusion here. Cloud or server based and why cloud based?

And 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?

Ah, well, number one would be the note system. You know, they're proud of their notes. I mean, 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. That's a good thing, you know, 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, you know, when we went, you know, your first question is what was the pain point that brought me into this whole thing? You know, because I didn't wake up one morning having this great idea, you know, 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 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. And that is huge for us.

I think that's super important. It's something that, this is the first time 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? And 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 E Chiro. Where the heck do I go to learn more? Where would you direct docs to go to learn more about yourself and or eciro as well?

Yeah, well, it's not about me, so go just, 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 and happy to get you, you know, 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 very, very critically important for chiropractic practices today. You want to be compliant, you want to have good reporting and you don't want to do that at the sacrifice of your patient experience. You want it to be enhancing the patient experience experience. And it sounds like Ecaro is right in line with what, with what I'm thinking. So I'd encourage everybody listening. You know, if you're watching this, click the link below. If not, type in as Scott had said, E. Cairo EHR and you will find it, do a demo, see if it's right for you and kind of take it from there. Scott, I really appreciate our time today.

Yeah, same here, Jeff. Thank you.

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