Making Better Medical Practice Decisions With Data: Talking to Nate Moore

Nate Moore is one of the great gurus of data in the place where healthcare begins - in the physician practice. We had a conversation recently to talk about the state of data in medical practices.

Mary Pat: Your first job in healthcare was with a radiation oncology practice as their CFO, and you wrote the practice's software yourself. What is your background that you were able to accomplish this?

Nate: I did write billing software. Rather than just trying to write software for billing, I wrote software to give me data about the billing. The number one priority when I joined the radiation oncologists was to recover from problems the practice had from outsourcing their billing the prior year. When I came to the practice, they’d purchased an inexpensive off-the-shelf billing software in an effort to start billing their own claims. I crashed the software trying to get information out of it. I wanted to know what most practices want to know – who’s sending patients, which insurance contracts were better, how many new patients were actually treated, that kind of thing. When I couldn’t get the information I needed, I wrote my own billing software that the practice used for the next 10 years. I used the new software to track down the old claims from the billing company and was able to collect $230,000 in old claims. The new software also allowed us to do data mining and analysis with Pivot Tables. Ever since, I’ve worn an Aloha shirt to work.

I’m a CPA with an MBA, and with familiarity with numerous other industries I was stunned at the lack of data practice executives have to run their practice and make decisions. My frustration with trying to get timely, relevant, easy to work with data in healthcare drove me to get to the source of the data, which in healthcare often means SQL Server. SQL Server is widely used and other industries use their data, so I was determined to find a way to use data my practice needed to do the right thing. The software I wrote used SQL Server, and most of the work I do today involves working with data in SQL Server.

Mary Pat: You are well-known in different communities as the "Excel Guy", the "Pivot Table Guy" and you told me your real job is Custom Data Mining. Who are you?

Nate: I’ve taught lots of classes around the country for organizations like MGMA, AAOE, ADAM, and AUA on how to use Excel in a medical practice, so lots of people know me as the Excel Guy. Many of those presentations are on Pivot Tables, and on YouTube, Facebook and Twitter I’m PivotTableGuy. Excel and Pivot Tables are great tools to start doing data analysis in a practice.

My real job is creating custom data tools using SQL Server. I connect a practice’s data in SQL Server to Excel tools like Pivot Tables and SQL tools like web pages, email, and dashboards to help practices see exactly what they need to see to make better business decisions. In most cases the data practices start with is in Excel. Many practices aren’t fluent in Excel because they can’t get the data they need to even use Excel to its potential. So training in Excel has been a necessary bi-product.

Mary Pat: You've spoken at many conferences - 17 times in 2013 alone - for MGMA and other groups. What themes did you hear this year from attendees about their struggles getting data out of their Practice Management/Electronic Medical Records systems?

Nate: Practices are frustrated trying to get actionable data out of their PM/EMR systems. Vendors are so focused on complying with Meaningful Use that meaningful reporting has taken a back seat. Practice managers are so busy running their practices that reports they’d like to look at every week end up being reviewed every month (or completely ignored) because it takes so much time and effort to download, clean up, and then organize their data.

Whether practices spent a big fortune or a small fortune on their PM/EHR software, almost everybody I talk to is frustrated trying to coax actionable information from the software. The most frustrating part for many of them is that they know the software has the information they need. They’ve spent a lot of time, effort, and money trying to get accurate data into the system. What they need is a simple way to get their data back out without a ton of effort.

Mary Pat: We discussed getting reports from PMs and EMRs and agreed there is a large disparity in what reports users can get from different systems. If the practice has their data on an in-house server, what can you do to help them get to their data? Can you help anyone whose data is on the cloud?

Nate: When the data is within the practice’s in-house server, I create the datasets in SQL Server and connect the datasets to Pivot Tables in Excel for analysis. Every time you open the spreadsheet, Excel refreshes the analysis with current data. You don’t have to download, clean up, and reformat the data and recreate charts and tables each time you look at the data. All you have to do is open the spreadsheet and the same analysis you had the last time you opened the spreadsheet is still there – with current data. My experience is that one well-designed Pivot Table can replace dozens of canned reports.

If practices control their own data, they’re in a terrific position to leverage that data. I often start by pulling just two or three datasets out of their PM system and connecting those datasets to Excel. For example, a billed charges dataset might have procedure codes, modifiers, charges, rendering providers, referring providers, primary insurances, and everything else submitted on a claim. That billed charges dataset could be analyzed to look at provider productivity (encounters/day, work RVUs/month, or charges/location, for example), E&M coding levels by provider, or a referring physician analysis (who is referring what insurance payers to which providers, by location, etc.).

Once the practice has several datasets going, I set up SQL tools to email exception reports, daily summaries, and monthly analyses to practices. I also set up web pages and dashboards so practices can get their data on demand.

There are lots of advantages to having data in the cloud in terms of lower IT costs and maintenance, but the challenge of having your data in the cloud is that the PM/EMR vendor now controls your data. You end up being at the mercy of the PM/EMR vendor’s reporting system for whatever reports you can get. If the information you want is not in a report, you’re out of luck. Most of the practices I help own their own data. They store it on site so that if the information they want isn’t in a canned report, I can access the data they need directly in SQL and report for them.

I have helped practices with data in the cloud. What we end up doing is getting a scheduled dump of data from the cloud. I then upload into SQL to take advantage of the Excel and SQL based analytic tools that are much more flexible and friendly than some of the canned reports PM/EHR vendors offer.

Mary Pat: It is clear that healthcare software vendors have been spending a lot of time and money recently making sure their systems can meet Meaningful Use requirements and ICD-10 requirements. Do you think that reporting has taken a back seat during the past several years?

Nate: Quite frankly, business level reporting has never been in the front seat for PM and EHR vendors. Their primary service is to capture medical billing, scheduling, and medical record documentation in what they hope is an efficient workflow for the end-user. The concept of providing a business intelligence level of reporting has not been a priority. In their defense, vendors have been hit with a wide variety of fairly involved requirements to meet Meaningful Use and ICD-10 will only make it worse. Meeting those requirements has to be a priority for vendors and generally it has been.

My experience is that not every vendor has sat in a practice manager’s chair and this is why we are lacking the essential tools we need to make better operational and strategic decisions. Some vendors have started to offer speedometers and thermometers with some data. But this is just a visually awkward way to look at your data and woefully inadequate. Vendors often don’t have the hands on experience to truly understand what savvy practice managers really need. The reports and the report tools are often more technical and less user-friendly than they need to be. As a result, I’ve worked with practices that have full time data analysts who spend way too much reformatting data in spreadsheets and not enough time deeply analyzing the data.

Mary Pat: You have a new book out. It is called "Better Data, Better Decisions: Using Business Intelligence in a Medical Practice." What can a medical practice learn from your book?

Nate: I wrote the book with my friend, Mona Reimers. Mona’s practice is a client in Indiana and we’ve done a lot of interesting things together customizing data analysis for their group. The book is very visual, with page after page of examples of how to use data in a medical practice. We both hope that managers will see their data as the asset it truly is. After decades of lowering their expectations after numerous disappointments in data mining, the time to get and use their data is finally here. And, in many cases the software and the data already belongs to the practice and simply needs to be used!

The first four chapters of the book introduce a model for analyzing medical practice data and a variety of tools that make that analysis faster, easier, and more effective. You’ll find an extended Pivot Table example that explains how Pivot Tables can make medical practice analysis much more efficient than canned reports do. The book was written to “plant the seed” with real-life experience implementing business intelligence projects in a busy practice. We specifically did not want a cookbook, but to get managers inspired and assure them that now (maybe for the first time ever) they can get to their data with a reasonable investment of time and money. There’s also a whole chapter on better ways to present data so that your charts, reports and dashboards say more in less space.

The second section of the book has chapters on accounts receivable, payer contracting, scheduling, prior authorizations, collecting at the time of service, appointment duration, lag days, billed charges, payments and adjustments, and claims management, concluding with a chapter on acquiring, valuing and retaining patients. Each chapter has suggestions on what data to gather, examples on how to present that data, and ways to manipulate the data to get custom reports that work for both small and large practices. The chapters are designed so that readers can take the book to their IT staff and say, “I want the report on page 127.” or, “Can we get a report like the example on page 80 from our software?”

Mary Pat: If practice managers don't have a good grasp of using Excel, what should they do to get up to speed?

Nate: I have almost 400 videos on how to use Excel in a medical practice on my website, www.mooresolutionsinc.com. The videos are all free and typically last three or four minutes. There’s an Excel Basics playlist that starts with Excel Video 201. About 80 videos later you’ll have a firm grasp of how to get your data in Excel, what to do with your data in Excel, and how get your data out of Excel.

Mary Pat: What resources do you have for practices on your website?

Nate: The videos section has all of the Excel Videos, but visitors will also benefit from the Learn Excel section. If you’d rather read about Excel than watch videos, the Articles area has copies of all of the articles I’ve written about Excel for HBMA’s Billing magazine and MGMA’s Connexion magazine. You can follow PivotTableGuy on Facebook or Twitter to be notified every time a new video is released or an article is published.

MGMA members should join the Excel Users Community. I moderate the community and members can ask questions about using Excel in a medical practice. You’ll get a response from at least one of more than 600 practice managers across the country who use Excel every day. It’s a great way to collaborate about Excel.

Mary Pat: Relative to using data, you said "Make it easy to do the right thing." What did you mean?

Nate: My co-author, Mona Reimers, says this a lot. Too often medical practices’ software and workflow is time consuming and cumbersome. Her goal is to make it easy for her staff to do the right thing, so we’ll do things like design an accounts receivable report sorted by the oldest, biggest claims that haven’t been worked in a certain amount of time. All they need to do is open the report and they’re working on the most important claims. And with a “double click” of the mouse, they have the necessary detail to call on a payer or patient. If getting the data is too hard or no faster than the “old fashioned way” your data projects will fall flat. There needs to be a fairly substantial improvement in the workflow of the end-user. This is often reducing the potential of errors and reducing key strokes. Morale goes through the roof when you make employees’ jobs easier and reduce or eliminate the potential for errors, no matter how big or small the error might have been.

We do the same thing with appeals. We give the appeals staff a report that shows open appeals sorted by the appeal due date, so it’s easy to see which appeals need to be worked first. We also automatically go through the data and present the staff with a list of all zero pay claims that haven’t been worked in a certain amount of time. I’ve done a similar thing for a practice I help in Texas. I give them daily emails telling them which patients didn’t meet a meaningful use requirement today or which patients coming in next week are missing demographic information, lab work, or need insurance follow up. The less time staff spend looking for things to work on, the more time they have to get their work done. Exception reports and alerts make it easy for staff to do the right thing.

We recently rolled out a report with information about narcotic prescribing that looks at the amount of medication, the last time the patient had a urine drug screen and so forth. The staff working with the doctors can receive an automated report every day for any patient scheduled to warn them of patients that may need attention in some way. Think of that workflow versus reviewing every patient’s record every time. The nurses’ job is significantly less time-consuming, the practice gets better results and the patients get better care.

Mary Pat: How can managers motivate doctors to get started with Business Intelligence?

Nate: The botched rollout of healthcare.gov combined with pressures from the ACA, lower reimbursement from commercial payers, higher costs, meaningful use, ICD-10, and more can leave providers and clinics reluctant to invest in technology. If you see the value of Business Intelligence but your providers need help, start small. Look for information you aren’t getting now that directly impacts the practice’s revenue cycle and the physician’s compensation.

For example, who is referring patients to the practice? What is the trend in provider productivity? Which payers allow the highest percentage of the practice’s most frequent and most profitable procedures? What appeals need to be worked before the appeal period expires?

After you have chosen your one issue that will directly impact your practice’s bottom line, make sure that the cost is relatively inexpensive and delivered in days and weeks, not months and years. In order for business intelligence to work (and in vetting any potential advisor) it must be delivered quickly. Granted your first pass may not be pretty and you WILL change your minds about what you want after you see it, but tweaking should add only another few days or weeks. Gather as much data as you can since providers are trained to evaluate and respond to data. Present the data in a concise, understandable format that makes acting on the data easy. Make sure the return on technology investment is visible, whether the return is fewer billing staff supporting more providers, better reimbursement, faster receivable collections, or increased practice profitability. Build on the small victory to tackle bigger challenges and more data.

Mary Pat Whaley is a Physician Advocate and Consultant who blogs at Manage My Practice; her LinkedIn Group by the same name is for those interested in healthcare management. You can contact Mary Pat atmarypat@managemypractice.com.