Sunny Sanyal is CEO at T-System of Dallas, TX.
Tell me about yourself and about T-System.
T-System was formed in the early 1990s by a couple of ED physicians who essentially wanted to get through the day. They would work all day and then stay back for hours after work trying to figure out what they did all day so they could document all that and get paid correctly.
These two ED docs said, “Can we just take all the stuff that we do in the ED and organize that with some taxonomy in a way that all all this clinical content can be streamlined? So that we can document while we’re with the patient and very quickly get it all done in not more than two to three minutes and be able to support optimal coding and billing, be able to stand up to scrutiny in case of a lawsuit, be clinically accurate, and support all of our performance and quality and regulatory needs?
That’s how it started. One sheet of paper, front and back. By the way, Dr. Rick Weinhaus did a really good job on this article about why T-Sheets work. I owe him some thanks. We couldn’t have said it better.
The company all along has had a combination of both clinical and financial orientation. We’ve kept that alive in our products and services throughout.
I joined the company three years ago when the company was going through a transition and was acquired by a private equity firm. It was an opportunity for me to be a CEO. I had an appreciation for T-System, having seen it as a competitor in my past life. I jumped in because I saw a tremendous opportunity to do some great things in this space.
What are the most pressing issues that EDs are facing?
We call this the unscheduled care space. That’s a combination of emergency care, freestanding ED, hospital-based EDs, freestanding EDs, and urgent care centers. The macro demographic systemic issues are hitting all of these in the same way, but perhaps they’re feeling them differently.
I will clarify that. Largely speaking, they are all seeing an increase in volumes, rising volumes in the ED. At the same time, while volumes are growing, they are also seeing an increase in self-pay. Historically, we associated self-pay as people that didn’t have insurance. You’d have a hard time collecting from them. But more and more self-pays are coming from people on high-deductible plans and HSAs that we call insured self-pay. That’s making collections very, very difficult.
Add to that that reimbursement levels aren’t going up. They are just getting tougher. Productivity demands from people staffing the ED are going on.
This space is under a tremendous amount of pressure. Doctors are struggling, frankly, to keep up with being able to provide the right services, the right quality of the clinical services, while they’re getting paid less to do more and having to deal with more and more regulatory pressures. The whole system is under a lot of pressure.
At the same time, what we’re finding is in order to get away from some of these pressures, some physicians are leaving the ED as a practice and going to urgent care centers, where they don’t have some of those regulatory challenges. That further exacerbates the pressures in the EDs because now all of a sudden you’ve got staffing shortages. It’s difficult to find doctors, particularly in rural areas.
ED as an environment in general is under siege and we don’t see it getting better. We see it getting worse in that regard because all of the regulatory changes that are in the horizon make it tougher for the ED. If health reform adds more patients, those patients are unlikely to have access to primary care. It’s more likely that they will show up in the ED than not. If there are further reimbursed changes and modifications in the reimbursement programs and reimbursement gets cut then it will hit the ED even harder.
There is a tipping point here that the volume of beds is not increasing while the patient volumes are increasing. All of the changes in the horizon appear to be negative from an overall impact of the ED perspective.
I like that term “unscheduled care.” Is there any hope at all of reducing utilization of ED as a non-urgent care provider?
Absolutely. If there is a significant shift in the reimbursement models, then you will see hospitals taking steps to reduce ED utilization. Those patients fall into few different categories. Patients that are habitual ED users that don’t need to be at the ED can be redirected somewhere else or they can be educated to not seek care. That’s one option. Patients that do need urgent care but they don’t necessarily need to be at the ED can be redirected to urgent care facilities. I think there’s an opportunity to redirect the patients away from the ED.
However, the real problem is that while there may be habitual abusers, the vast majority of them will need access to care. That is why we coined the term unscheduled care. We’re seeing entire segment growing dramatically. Five years ago, you might have seen a few urgent care centers across any town or city, but today you see a lot of urgent care centers, The volume of urgent care visits today is estimated about 150 million a year. That volume is coming at the cost of other settings of care, maybe ambulatory.
That’s why this unscheduled care segment, which in some ways was nonexistent many years ago, has become this in-between segment. You have scheduled care, which is hospital and physician offices, and then this massive unscheduled care segment. Not all of it is bad. What we want is for patients not to over-utilize the ED services or something where there’s a better, cheaper setting of care.
I do think that there will be redirection and education and other care coordination — patient navigation services that will redirect the patients to lower-cost settings — but it’s going to be more likely to be the freestanding EDs or the urgent care centers.
Everybody expected a huge influx of newly insured patients with the Affordable Care Act. With the ACA having somewhat of an uncertain future, what do you predict the ED business is going to do?
The patients that need care that don’t have access to care, if they are uninsured, they are showing up in the ED today. I think they will continue to show up. I think the difference perhaps is that with the Affordable Care Act, they were going to get some level of insurance, and that was good for hospitals because rather than receiving nothing and having all these uncollectible or very low levels of collections, they at least get some low level of insurance guarantee that they’ll get some money for it.
I think the situation is not going to get worse than it is today. That’s my take. I think hospitals would miss an opportunity to collect from these patients. I’m not anticipating that ED volumes would change one way or another, go up or go down, if the Affordable Care Act doesn’t pass.
Hospitals complain about their ED volumes and the burden of servicing these volumes, yet they advertise their ED wait times. Are they trying to market selectively or are just confused about whether they do or don’t want the business?
That’s a great point. They don’t see the ED as a problem. They see the ED as a front door to their hospital, and more and more hospitals are using the ED to change their patient mix.
I had a hospital CEO tell me that, look, 80 years ago when my hospital was built in this downtown location, it seemed like a good idea. Today, it’s not such a great idea. I can’t help that I’ve got this huge bricks and mortar here, but but what I can do is two things: put my urgent care clinics in the residential areas where I have a better payer mix, and I can do my advertisements on billboards in those areas. Over time, I’ll gradually shift my patient mix and attract a larger percentage of the targeted patient mix into the hospital.
That we see them doing. The person that knows how to use the iPhone to go find the right ED and get to the right wait times or the person that has a car is driving on the highway … chances are they belong to probably a better payer mix. We think this is a conscious effort at shifting the mix. I know they have a volume problem, but by getting better payer mix and with care managers and other triage mechanisms ED, I think their hope is that they can manage that volume better as long as they can get favorable payer mix.
T-System has expanded the product line beyond the core business of ED documentation. Explain why you did that and how.
Even though T-System started out as a clinical documentation company, the founders of the company had reimbursement in mind all along. They wanted to get paid for the work that they did. They wanted to spend as little time as possible to get through the documentation. Even though as a company we have been a clinical company all along, revenue cycle was in our DNA.
We looked at the market landscape. We looked at what was wrong with the space or what the opportunities were. We were telling our customers if you use T-Sheets or T-System electronic EDIS, you will get reimbursed optimally. But we found that it’s easy to say but harder for hospitals to implement and sustain because over time, even though they’re using a system, chances are they’re not keeping up with training. Chances are they are not keeping up with upgrades and performance. There’s also the chance that performance would degrade and they’re not getting the outcomes that we thought they should get or they could get.
We said a better approach might be to tell our customers that if you use T-System solutions, we will get you paid better, rather than giving them the promise of that they might get reimbursed better. We say, “Use our software and services and we will get you paid better.” Talking about the outcome versus the potential for an outcome as they do it was the difference in changing our strategy. We decided to become a technology-enabled services company. Going forward, we’re applying that philosophy pretty much for every solution line we introduce.
For example, we have a care coordination offering. Rather than just offering software, we want to say, here’s our software that allows you to plan your care transition at the point of discharge well. But then, here’s a set of services where we can help you with that or we can do that for you as well. That’s the approach we’re going to take pretty much in every solution that we roll out. It will be a combination of both the technology and services.
Are you feeling any pressure as a best-of-breed vendor among the Epics and the Cerners out there to cast your net a little wider within your own specialty to make sure that you stay competitive even as their offerings become attractive because they’re fully integrated?
A couple of enterprise vendors have viable ED solutions. Several of them are very far behind. You can see in the recent KLAS study there’s a pretty big gap between the enterprise block in general and the best-of-breed block in general. There’s some natural selection that happens upfront when institutions decide whether they’re going to best-of-breed or enterprise. What we are seeing is that when someone makes a decision now to go best-of-breed, that’s a long-term decision. They’ve decided for certain reasons that that’s the path they’re going to take. It is a fairly stable decision.
We’ve seen this in other departments, where over time when all the systems have been shaken out and interoperability-related issues have been resolved,. Which by the way, each year as Meaningful Uses raises the bar on interoperability, what we find is that it’s becoming easier to have the conversation around how data will flow from the ED into the enterprise.
Given that, you look at other environments like radiology. It used to be that you needed an integrated RIS-PACS system in order to be able to run a radiology department effectively. Over time, that settled into the RIS in some ways being replaced by enterprise order entry, enterprise results supporting, and enterprise scheduling. PACS drives the physician workflow in the department. There has been a settling down where the co-existence of best-of-breed and enterprise has already occurred. You’ve seen that in several other places – cardiology, potentially oncology.
We think similar model is evolving in the ED as well. A good example for us would be Memorial Hermann. They’re a Cerner site. The ED uses Cerner for the enterprise workflow. For the physician documentation or physician workflow, they use T-System as the best-of-breed and the two co-exist in that environment. That’s how we see the space evolving between the enterprise and the best-of-breed.
How do you see the impact of Meaningful Use, especially the future stages, impacting your business?
The more there is an emphasis on interoperability, the better. That’s good for the industry, good for everyone, good for us as well. We hope that ONC will continue to drive that dimension harder. Secondly, Meaningful Use in general has accelerated the adoption of systems, which has been good.
Now what we’d like to see is that at some point, more emphasis be based placed on optimization of these systems. For example, in the ED there’s measures around documentation. Physicians don’t have to document in an electronic system. If the intent was to capture discrete data, if the intent was to get physicians to use the system, just stopping at physician order entry is not adequate.
We’d like to see the data capture portion also be included in some of the future Meaningful Use standards. That would be good for the industry to accomplish what it started out to achieve, which is to gather discrete data and have data codified to electronic format. That would be good for vendors such as for ourselves, because that’s what we do really well.
What are your priorities for the company for the next five years?
If I break that down into short-term and long-term, T-System made this transition to becoming a technology-enabled services company. We started that with revenue cycle. We acquired a few companies last year and we’re in the midst of integrating those companies and we’ve made pretty good progress there.
Short-term priorities are to continue on with the integration work. Our vision was that technology in the front office and service in the back office … if you combine the two together, you can move the back office component to the front office and become more efficient that way.
Our vision is that a locked ED chart ought to be a coded chart. Our investments are going in that direction. We’re making investments in products and technologies to move our products and services towards that vision.
Secondly,making investments in the businesses that we’ve acquired to add in new platforms. You might have seen the announcement that T-System is putting in NextGen system as our enterprise practice management system across our entire company. We’re introducing new technologies for point-of-service collections. That’s a real big problem in the ED. Patients leave without paying anything and there’s really no good approaches. We’re going to deploy some POS technologies to improve collections. We’re continuing to make technology investments in automating as much of the coding and billing process, as well as then integrating the coding platforms into the core EDIS.
I’d say in the next two-year, three-year timeframe longer term, we will continue to evolve the company into other service areas. For example today, patients are discharged from the ED. It’s a handshake at curbside. We think that’s wrong. It ought to be a warm handoff to that next caregiver and the transition should be coordinated. We have solutions to do to care transition.
We believe that where the industry is headed, care coordination, care transition, and helping patients navigate through the system is going to be important. As a company, we will make products and services available in that area. There are other areas within the ED where T-System, with the software systems that we used in the ED and the access to data that we have, we think we can make an impact in areas such as utilization management. We will continue to evolve our capabilities in that direction.