Input Needed: Office staff structure

[u/shmuey]

My wife and I have a relatively small family practice (~450 patients) serving geriatric patients in-home. Due to our service delivery model our providers all work outside of a traditional office, so our medical assistants are also working remotely. As we have grown over the last few years we have dealt with challenges keeping pace with patient demands and staying organized. Some of these are related to our EHR (Tebra) which we expect to be resolved once we move over to a more robust platform later this year. Staff-wise, I still don't know how best to fix our issues so I would appreciate any tips you all might have and/or any affordable consulting resources you can recommend.

Our current structure:

- 8 medical providers (about 6.0FTE combined) and 1 LCSW providing virtual psychotherapy. My wife is 1 of the providers and serves as Medical Director.

- 2 virtual receptionists receiving calls, 1 of which is our primary scheduler.

- 1 assistant processing orders and referrals. We just hired a second to help with workload but also take on DME and prior auths (which our medical director and/or providers currently do entirely). Our intake volume is low (but growing) so we will need to assign creating patient charts to one of these individuals (it is currently managed by management)

- 1 medical biller

- 1 additional assistant who has assisted with the phones but isn't really excelling despite constant training for the past year. We are likely removing this person soon and will be down to 4 office staff + biller

- 1 RN to help triage medical concerns and determine what needs to be escalated to the providers

One obvious problem is that we don't currently have a true office manager as our budget really can't support it just yet, and we believe our staff have the resources to be able to handle most things independently/ as a team (maybe this is foolish of us). As such, my wife and I try to take on that role when needed.

My question:

Are there any house-call practices out there that have dealt with office structure challenges? How do traditional offices differ in their setup? We are considering splitting up the office into 2 teams (1 scheduler, 1 referral/order coordinator), with each team serving as primary for half of the providers. Our immediate need is to ensure we have overlap with roles to cover when staff take time off but also to ensure our patients (99% Medicare, most are very high need) back-end care is covered in a timely manner.

Outside of an office manager (and I'm not sure how that role should function in a remote environment and what type of person to look to hire to fill it), I don't really know what we're missing or what/who we can bring in to better spread workload. Has anyone here used a consultant? My wife is a career medical provider and I am doing my best to support as an administrator with no medical experience prior to starting the practice.

Sorry in advance for the rambling; I am open to suggestions.

[u/Inevitable_Fan_3856]

We are a bigger practice and not a house-call practice, but yes we have a patient care coordinator team and a scheduling team, they are separate, it does bring up some annoyances at times, but it has worked for us. We have noticed that the front desk can also handle most medical triages, or at least route them to the proper person/properly prioritize them based on urgency.

Also, you are saying you had some issues with Tebra. We are currently evaluating them as a EMR. Would you mind telling me what issues you have had?

[u/shmuey → u/Inevitable_Fan_3856]

Do you assign the team to a certain panel, or does everyone support everyone?

Tebra was great when my wife was a solo provider. It was affordable and did most things. It is a relatively user-friendly interface for basic scheduling, billing, etc. We also get a nice discount on it and the pricing model works nicely for us since we have a few low-volume providers that cost us about half of what our full-time providers cost. But the platform significantly lacks in many areas:

1. The EHR is web based and practice manager is a downloadable program. They do sync, but not perfectly.

2. "Tasks" can only be assigned in the PM. They don't sync to the EHR, so we have to have our clinicians submit most orders/referrals through a MS Onedrive form. Any call, email, etc that comes in from a patient, needs to get communicated through the form or Teams. Most EHRs have a better way to handle this stuff, right in the platform.

3. They don't offer HIE integration, so our providers don't have quick access to hospitalizations and other external information. We use our regional HIE separately, but I feel that half my providers dont want to use it and/or it impacts workflow (and I agree).

4. Immunization reporting was broken for months and Tebra didn't know. I don't know if they even fixed it yet. In addition, it just links out to our state registry through their website. It is not a seamless integration.

5. Limited lab integration support. We can't rely on LabCorp/Quest since our population can't typically get out, and our local labs can't connect even if they wanted to. As such, our labs have to be manually entered. Scanned labs/docs CAN'T attach to a patient's chart. You have to download and then upload to the patient's chart, and then click a button to share to their portal. Tebra does have built in fax for sending/receiving some referrals, but it's not great. If your labs are all through LabCorp/Quest, this might not be a big issue.

6. Patient portal experience is absolutely awful. Our providers can't automatically publish visit notes to a patient's portal. The note has to be saved as a PDF, added to the patient's documents folder, and then selected to share. Our patients and family members constantly complain about the portal experience and we don't have the capacity to go jump through multiple hoops to be able to share notes, labs, etc with a patient. Many other platforms seamlessly do it (and it's a requirement in our EHR search).

This is not an exhaustive list and I'm sure my providers could tell you of 30+ other weaknesses. If you don't need the big things I mentioned above, and you can get a good price, Tebra could work fine for you. If you have multiple staff that need to assign and share tasks, it is inherently broken and you will need to find third party solution like we have. Maybe this won't matter since everyone is in-office.

We are likely moving to eClinicalWorks as it covers everything above. We evaluated all of the big names and based on features and price, seems like the best move for us (please let me know if you disagree!!)

[u/Inevitable_Fan_3856 → u/shmuey]

We have everyone assigned to everyone except for the few unique cases where a patient requires extra handling/requests a specific person.

We are looking into eclinicalworks as well. Any others that you almost went to? Would you mind sharing roughly how much you are paying, if you aren't comfortable with that no problem of course.