The pMD Blog
POSTS BY TAG | Charge Capture

As a software engineer at pMD, I get to straddle the cutting edges of two very different industries: health care and technology. I’m familiar with how quickly the technology world moves -- developers jumping on a new front-end technology every other day, “sprinting” through “agile” hoops at the speed of light. But I’ve been surprised to learn how thoroughly the health care environment is also evolving. I’ve learned that over the next few years, physicians will be facing fundamental changes in the way they see and treat patients. It has been one of the most interesting parts of my job to not only learn about these changes, but to help providers transition to the health care environment as it transforms around them.

With value-based health care on the horizon, providers will need to bring the patient into the center of their care. For the more than 100 million Americans with chronic illnesses, for example, the occasional face-to-face encounter with a provider might not be enough. Obviously, for those types of patients, providers must think beyond the 30 minute annual checkup; with constant management of medication, treatment, and services. In today’s day and age, providers often have difficulty bridging communication gaps, leading to inconsistent data, increased expenses, and poorer outcomes for their chronically ill patients.

We are trying to solve that problem at pMD, and to help providers proactively coordinate their patients’ care. Every new feature we are working on supports providers as they take on this new paradigm shift. One of the simplest ways we help providers is by showing them how they can get reimbursed for adapting to this new, patient-centric health care model. For example, since 2015, Medicare has reimbursed providers who offer at least 20 minutes a month of non-face-to-face medical care to patients with two or more chronic diagnoses, through CPT code 99490. For our providers -- who have been using pMD's charge capture tool to record services outside of face-to-face encounters like medication reconciliation review and care coordination, and may soon start to use pMD for patient education -- this could prove to be a fruitful change that helps them transition to tomorrow’s health care system.

As I mentioned in a previous post, almost every EHR vendor out there has some sort of mobile component to their offering. This tool is typically a useful extension of the EHR for every physician using the system, from primary care providers to specialists. Try to envision a car that will satisfy the needs of every person in America. It needs enough seats to fit a large family, and don't forget about good gas mileage and passenger comfort. If you're building a car for everybody, it would probably look like a minivan. Similarly, the mobile component to most large EHR systems is the minivan of mobile software. You sacrifice performance for the ability to do something for everybody.

Now imagine that you're a consultant for a large health system that just spent millions dollars and thousands of man hours implementing a cutting-edge EHR across all of their facilities and clinics. Sure it was expensive and took a few years, but since it's such a comprehensive offering the health system only has to work with a handful of vendors instead of a hundred. Your job as the consultant is to help them determine which vendors will comprise that handful. Some of the physicians have mentioned an app they currently use called "pMD," so you've started investigating the EHR's mobile offering. Doctors can use the EHR’s mobile software to look up patients’ clinical information and order medication refills without logging into a desktop environment. You start wondering what it can't do and schedule meetings with doctors to discuss your findings.

In your meeting, primary care physicians and specialists rejoice! The EHR's mobile app, as you would expect from a minivan, offers utility for nearly everybody. 70% of the doctors are satisfied and head home. But the specialists hang around and keep asking you questions. The cardiologist is wondering if it can work offline. The critical care doctor asks how quickly she can capture hospital charges for 30 patients on her iPhone. A hospitalist asks how fast he can take over his partner's patients and view handoff information in the app. What is this "pMD" thing they keep mentioning? Although these specialists only comprise about 20-30% of the physician headcount, you know they command a huge percentage of the health system's revenue.

So what's going on here? You just tried to replace somebody's race car with a minivan. The minivan can go farther and fit 8 people with all of their luggage. A race car can't do that, and frankly it's not all that comfortable to drive. But how fast is the minivan? What if somebody is extremely busy, and their primary need is to get from Point A to Point B, on a paved road, disgustingly fast? The number of passengers, luggage capacity, comfort, and all-around capabilities take a back seat to speed.

These specialists need the race car of charge capture because they are insanely busy. They usually spend half of the day seeing patients in their clinic and the other half driving around to around to various hospitals rounding on another 20-30 patients. They are up before the sun and still working on documentation at midnight. The math on an extra few seconds or clicks on a per patient basis adds up quickly. This is why they can't use a minivan for charge capture. If you give them the minivan, they will wait until they have time to use it: at the end of the week or at the end of the month. And where does this revenue reside between weekly or monthly submissions from the specialists? On paper.

A significant amount of the revenue these doctors generate, and therefore a significant percentage of the health system's revenue, is generated outside of their office clinic, so this can be hugely detrimental to the health system's business. At best, it slows down a large amount of revenue. Worst case, the paper (and revenue) goes missing entirely.

EHR mobile solutions and pMD Charge Capture are not mutually exclusive for the same reason that you might keep a minivan alongside your race car in the garage. The minivan is the clear choice for taking the family to a tee-ball game, but it would be absurd to show up in a minivan for some track time at the local raceway. The EHR's mobile solution is built with every physician in mind, and pMD is purpose built for specialists. Although a user may never be able to articulate why, they can definitely tell you that using pMD for charge capture is insanely fast. I can't fault them; I can't clearly explain the excitement of driving a race car with words, but I sure can tell you I love the feeling of such raw power and performance. What is it about pMD that doctors love so much? I've worked with doctors that use pMD all across the country and I'll do my best to articulate why on the next post. Cheers!
Apple will report their Q2 FY15 Earnings on Tuesday, April 27th, so it’s time for us to ever-so-loosely hypothesize how Apple market share has fared based on the technology trends among our niche of physician Apple users.

Q1 was a record breaking quarter for Apple, who posted the biggest profit in corporate history largely due to the success of iPhone sales. Last quarter we saw a mild increase from Android physician users despite Apple’s phenomenal iPhone growth. This quarter, Android users again showed slightly more net growth than Apple, climbing up 0.12 percent.

Apple’s earnings from Q2 should indicate just how successful the iPhone 6/6 Plus phones have been performing, as well as the adoption of the new MacBook that was released this quarter. Let’s take a look at what’s been happening with the iPhone growth by model among our users this past quarter.

Users are finally turning in their iPhone 4 and 5 devices and investing in newer models, which is great for Apple. Given the substantial increase in iPhone 6/6 Plus devices over the past quarter, both from upgrades as well as new users, we’re anticipating that Apple will post sound Q2 earnings with a resulting uptick in stock value. We’ll call it more of a hunch. Apple just released pre-orders for their Apple Watch with orders nearly topping 1 million, so we’re likely to see the impact of this innovative new gadget in Q3 earnings. Until next quarter!
At pMD, we wear many hats. When I describe my job to friends, they often ask "Aren't you a programmer? Why are you doing so many other things?" They, at most, have two major responsibilities at their companies and they assume my other tasks are bothersome. But having those extra responsibilities isn't a burden at all! Instead, I see them as a badge of honor. What I find often overlooked is the fact that hats translate to trust. Being given multiple hats to wear means the company is entrusting you with those responsibilities. They view you as having the ability to own these tasks and to execute them at a high level. Essentially, the company believes in you! And having different responsibilities means no two days are the same, which makes work fun and allows me to avoid the repetitive. Here's a snapshot of one of my developer days at pMD:
pMDers love Porsches, but I wouldn’t say that we have a company full of car enthusiasts. I learned a lot about Porsches when I first started working at pMD because we do have some car enthusiasts. pMDers love Porsches because the “Porsche Principle” resonates so deeply with the way we operate:

“The underlying principle is to always get the most out of everything. From day one, we have strived to translate performance into speed – and success – in the most intelligent way possible. It's no longer all about horsepower, but more ideas per horsepower. This principle originates on the race track and is embodied in every single one of our cars. We call it ‘Intelligent Performance’.”

We share a similar philosophy for the mobile charge capture and secure messaging products that we design, implement, and support at pMD. So why have I never come across a single person using the Porsche BlackBerry in our office?

Our weekly device breakdowns don’t even acknowledge Porsche (or BlackBerry) as having a horse in the race! This is probably because Porsche should stick to what they excel at: building legit sports cars. I will continue giving Apple my money because they consistently deliver the high-end sports car of smartphones to my pocket, and I need cutting edge mobile technology to stay productive while traveling across the country.

Similarly, pMDers are fans of Epic. Judy Faulkner’s motto of “Do good, have fun, make money” certainly resonates with me. It is truly amazing what they have accomplished in the medical industry. With that said, I can’t tell you how many times I have been asked how pMD is going to survive competing with a juggernaut such as Epic.

“Epic does everything! They have a mobile app!”

At first these statements were a bit disconcerting, especially for my cat since she’s somewhat dependent on pMD’s ability to stay in business for her kibble. Epic has a mobile app. pMD has a mobile app. The cat has nothing to worry about. Porsche isn’t competing with Apple. pMD isn’t competing with Epic.

This isn’t unique to Epic. Almost every EHR vendor out there has some sort of mobile component to their offering. Epic comes to mind because we happen to have quite a few mutual clients that have been asking me about this. pMD’s relationship with some of those mutual clients started when an Epic client acquired a medical group that was already using pMD. During the transition phase, Epic replaces many of the products that the newly acquired medical group was using. The physicians draw a line in the sand when they come across pMD.

This is usually the beginning of a two year evaluation process that begins and concludes with happy doctors using pMD. After spending thousands of dollars on a team of consultants, internal projects, meetings and demonstrations, our client comes to the conclusion that pMD is a complementary service that enhances the physician experience for specialists.

During one of these evaluation cycles we were introduced to an Epic expert at one of these consulting firms. Our mutual client asked us to work together to understand how pMD compares to Epic’s mobile offering. At our first meeting, the consultant very candidly admitted that he was tasked with replacing pMD with Epic’s mobile product. Oddly enough, this was good news! Instead of wondering where the overlap might be, we were able to collaborate with him and develop some concrete answers about how pMD would (or wouldn’t) fit in at an Epic site.

Every one of our mutual clients goes through this evaluation sooner or later. This process is expensive and takes a long time. It’s not a good use of health care dollars and certainly doesn’t help patients or our client’s profitability. But since we know the cycle begins and ends with happy pMD users, I’m hoping to help educate the market and our customers going through this transition by writing some blog posts about what we’ve learned working with the Epic expert.

Porsche has not released a smartphone that competes with the iPhone. That’s seemingly obvious. Working with the Epic expert helped us understand why pMD is the sports car of mobile charge capture, even at an Epic site.

Stay tuned to to find out why.

My dog, Irwin, and I share many common interests, including playing frisbee, going on trail runs, eating good food, and participating in hardcore coding sessions. OK, maybe that last one is just me, but when I do dive headfirst into a serious software development task, I try to take some inspiration from my canine friend.

When Irwin puts his mind to something, he is focused and persistent. For example, when we play fetch at the park, he makes it his mission to retrieve his favorite ball and return it to me as quickly as possible, and he ignores all of the other dogs around us. Normally, he’d be interested in socializing with his doggy buddies, but fetch time is fetch time, and nothing gets in the way of that.

I try to take a similar approach to my coding sessions. I do everything I can to eliminate outside distractions during these focused times. Working as a developer at a fast-paced charge capture and secure messaging company means that there is always a lot to be done on a number of different fronts. However, to be able to tackle tough software problems, I need my entire brain to be concentrated on the task at hand. Much like Irwin, I ignore for a while all the things around me that I’d normally engage with, and throw all of my energy at my code.

There is a lot of research out there, including a study reported by the BBC, which argues that multitasking of any kind makes us less productive. I personally believe that there are certain times when multitasking is OK and even necessary to get the job done. However, like Irwin, I know that certain tasks are just more productive, more efficient, and more fun when I devote my full attention to them. My coding sessions rank highest on this list, which is why I like to refer to my approach to software as Dog Driven Development.

When I was asked to man the pMD booth at the ACC/Medaxiom Cardiology Conference in Orlando last week, my immediate reaction was "COOL!" followed by a sense of confusion. I'm a programmer, not a sales guy. Shouldn't someone from the sales team do this instead of me? What was I going to get out of this exactly? I eventually would come to learn the real benefits of having a developer at a conference - especially for myself.

Working with our customers every day, I’m exposed to groups who are already using pMD charge capture or are in the process of implementing our solution. During this conference though, speaking with potential customers was definitely eye opening.

At the booth, many doctors and practice managers came to talk to us. Some knew about our product and wanted to learn more, while others wanted to know "How DOES pMD make doctors happy?" And some just wanted some handmade candy that we were giving out. It was fun to speak with people who have a real need for our solution. As one doctor spoke to me about his paper charges, I could just see the frustration in his face as he discussed his day to day process. Another doctor brought up his grievances with his current electronic mobile solution. Reliability, or lack there of, was killing him. As I spoke with each new potential customer, I started to empathize more about their plight. They went to school to be a doctor, to help the sick, not to figure out how to bookkeep their activity. Seeing that pain versus just hearing about it was a big difference for me.

As a programmer, it's important to see and hear about how the work I'm doing is actually being used. Working at a defense contractor in the past, I can tell you first hand how dull and painful it is to wait a year to see your work finally do what it was intended to do. At the conference, we had a few of our own customers in attendance. When they came up to us, I had never met them before, but they were so open and willing to speak to the folks around us about how happy they were to use our product. It gave me that sense of accomplishment that I otherwise would not have gotten from behind my desk.

Speaking about the technical aspects of our application, interfaces, and overall utility I seemed to get an extra nod from those around me. My sales partner, Ryan, was more than equipped to speak about our software, but folks seemed to find an extra bit of worth in my words simply because I introduced myself as a developer. After the conference, Ryan expressed his joy at directing the technical questions to me. People just seemed to trust the technical answers from the technical person.

It was a great experience and I'm glad I did it. It was fun! As a developer, you work hard behind the scenes and it's difficult at times to remember the real life struggles that your product aims to solve. It’s reinforcement from all these doctors, directors, and nurses telling me about the pains of their existing system - paper, emails, and most interestingly to me, non-reliable software. I'm able to take this experience back with me with a rejuvenated sense of focus. I recommend to any developers out there to take a trip out to a conference. Not just to get out from behind your desk, but to meet the users that would or could benefit from your products. My sole regret from this trip was not being able to go to Disney World when I was only steps away!
In high school, I wrote my programs first on paper before typing them out. It was a habit that came from writing all of my english essays in a notebook. Whether the topic was Shakespeare or Binary Search, paper and pencil somehow helped me organize my thoughts better than a text editor. Over the years, my instincts on when to step away from the computer have continually evolved, but I’ve continued to wonder why different mediums had such a big impact on my thinking.

These days I still use paper to initially sketch out my code when I can’t just Google for a solution. The result is usually some flowchart, pseudocode, and more importantly, a clearer understanding of the problem. The paper makes the problem feel more tangible and concrete, a physical entity that can be held and inspected.

If the problem’s big enough, I don’t quite start typing away at my keyboard right after the paper and pencil phase. In college, I discovered that the visual size of my writing had an ability to get me unstuck somehow. Math proofs that felt insurmountable in my trusty notebook seemed to get a second chance on a large whiteboard. It still puzzles me why the size of the writing makes such a difference. I’d like to think it’s the act of making ideas human-size that helps me see them from a new perspective, and increases the chance of serendipity and insight as you walk past it throughout the day.

There are times however, when I forgo all of the above. Sometimes speed, legibility (I have terrible handwriting), and the ability to cut and paste text quickly is the best choice. In these situations, my text editor excels. The choice of what medium to use isn’t always clear cut. Sometimes I find myself internally debating the pros and cons of going to my notebook, whiteboard, or editor first. Other times, if I take shortcuts and skip the natural progression dictated by a problem, I usually regret it.

A growing volume has been written about “slow programming” and hammock driven development, and I think the common theme is that picking the right medium and slowing down your process (not your thinking) has significant benefits. Bret Victor recently gave an illuminating summary of his recent work in a talk titled “The Humane Representation of Thought.” In it, he attacks the shackles of static representations of thoughts and communication as great inhibitors of our full potential. We are seeing glimmers of this approach with Chris Granger’s Light Table and most prominently Apple’s Swift language with its Playground. How far these ideas can go and provide alternatives to notepads and whiteboards is an open, and exciting question.

At pMD, we’re building out big new functionality in secure messaging, coordination of care, health information exchanges, and charge capture, and we’re facing a lot of interesting engineering challenges. Using the right medium to think about and discuss problems is more important than ever.

“I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.”

“I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.”

“I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.”

Doctors begin their careers with The Hippocratic Oath, swearing to uphold moral and ethical standards for the wellbeing of the patient. But the attitude among many doctors has evolved into a modern day version along the lines of "I'll do what I can for the patient, unless it puts myself in jeopardy." There is an ideological shift happening in medicine, and it is keeping doctors from providing the most complete care possible.

Doctors are becoming victims of a litigious society that is changing the way they communicate about patient care. Even though there has been a rise of advanced, secure communication platforms in health care technology, there is an emerging phobia of all information becoming discoverable. Doctors are having to censor their communication lest it resurface in a malpractice lawsuit.

I was recently working with a doctor during a mobile charge capture training for pMD, and he echoed an all too familiar mantra in the industry. He generally doesn’t record anything that he wouldn’t want the world to see. At some point in his career, he had taken a strong stance of never recording any information in his EHR around patient care that could potentially be used against him, even if sharing that information meant helping the patient. Yet the alternative, sending sensitive information in non-secure texts or writing it on pieces of paper or not sharing it at all, is far worse. This reaction points to the hesitation that exists in the health care community to record any kind of informal, candid information about patient care, stemming from a larger “Big Brother” paranoia. So what are doctors not saying that could be jeopardizing patients (and breaking the Hippocratic Oath)?

Advanced communication platforms for sharing health care information are being developed to improve care coordination among providers, allowing them to stay involved in up-to-date patient information more fluidly. The unintended consequence is that providers are becoming more cautious about sharing certain medical information and fostering trust issues with the system at large. Communication is imperative in medicine, and it’s an uphill battle against many different forces to improve and increase the communication in the patient + doctor + administrator intersection.

Doctors pledge that they will apply all measures necessary to care for their patients and gladly share knowledge with each other. It's time that "Big Brother" backs off so doctors can start using technology as it’s intended - as a resource used to save patients rather than avoiding it to save themselves.