I have watched the electronic certificate of medical necessity (eCMN) frenzy with mixed emotions. I like technology, and anytime I can get rid of paper, I am all for it, but getting a messy paper process to electronic format seemed even more challenging than simply scanning and indexing our own documents. We decided to implement eCMNs only 1 year ago. While we were clearly not the first provider to sign up, it seems we are still considered a pioneer in the eCMN initiative.

Prior to considering electronic solutions, providers must walk through several steps to be sure they are ready. Just as we developed an assessment tool to see if physicians were ready for eCMNs, providers must do an internal assessment to see if they themselves are ready. I have seen many providers sign up for these solutions, get frustrated, and finally realize they are simply not ready.

For any provider, the documentation process is critical to overall success. Many times the accountability for getting CMNs and orders signed is un-clear. Is it sales and marketing, the bill-ing department, or perhaps the intake department?

Since the order is so closely tied to the intake component of any operation, there needs to be a clear tie to the intake- and revenue-incented roles. Placing account-ability as a back-end responsibility where there often is no physician to sign a CMN, or the patient does not meet the qualifications for a piece of equipment, does not make sense. Decide who has the incentive to make sure the order for the equipment is matched with the patient qualifying for the item—and a physician is willing to sign a CMN or written order.

The second step in self-assessment is to evaluate how the paper process works from the time the CMN or order prints. Where do the CMNs and orders print? Who evaluates them to be sure they are needed and all the necessary information is there? What is the process for getting them to physician’s offices?

For example, CMNs are printed in a branch location and staff members are required to evaluate documents to be sure they are needed (many software applications print documents that are not needed such as those for oxygen modality changes and different CPAP masks). CMNs are hand delivered to specific physicians and mailed to all others within two business days of printing. A sample follow-up process would look like: no response in 14 days; call placed to MD office; faxed if no record.

Electronic Solutions
Once the paper process is established, it is time to look at the opportunities for electronic solutions. Conduct a similar process review on how electronic options will integrate into existing operations. Will eCMNs be handled centrally and paper CMNs at the branch locations? Is this a short-term or long-term implementation strategy? This process development needs to be created with those individuals in the organization that know the paperwork process.

Now consider the sales and marketing aspects of electronic documentation. Is there competitive pressure in your area from others using eCMNs? If so, what applications are they using and what have they introduced to physicians in your area?

Even though we have options in the electronic documentation arena, our physicians will probably choose one, and if you are not the player introducing the technology in your marketplace, you may be stuck using what your competition chose. The goal is to choose the vendor based on what works best in your operation. Do you need an interface into your software application? Which vendor offers this technology? If you end up rekeying all of your CMN information created by one application into an eCMN application, you could find yourself having to add staff instead of saving costs by reducing full-time employees!

Internal Implementation Plan
Now it is time to define your internal implementation plan for electronic documents. First of all, who is leading the initiative? Often the mission is given to sales and marketing as a selling tool to get into physician offices, but this needs to go hand in hand with the whole CMN process. The sale is a combination of the operational process and sales and marketing.

Unless the sales and marketing personnel are currently responsible for getting orders and CMNs signed and they are successful, this approach will more than likely not work. Consider letting the operational area drive the process with sales and marketing. Often physician demonstrations involve detailed questions on the CMN process in general, and even though a salesperson may sign up an MD to use the software, the goal is utilization. Follow-up on use of the application and retraining are the keys to success.

At this point in the process, you are committed to the concept, there is defined accountability on the team, and the operational process for documentation is clear. Now what? I have found in many physician practices the use of technology ranges from no computers at all, computers and no Internet access, and full-blown electronic medical records.

This entire spectrum even varies from physician to physician in a large practice. Develop a physician assessment tool before you buy the lunch and spend your time and energy showing what can be done. See if they are even candidates. Track this information internally so you know what practices and physicians are even capable. As you roll out the eCMN initiative, refer back to this document. I have seen practices that refuse eCMNs because the office managers did not like computers, but once they retire, there is an opportunity to revisit the option.

Determine who you should target. This should be a joint effort with operational personnel who know which physicians have the highest volumes and which physicians and practices you should target from a sales perspective. Both groups can have a concentrated focus from marketing and operations. Many eCMN software vendors will visit physicians with you to help in this process. Engage these vendors when it is to your advantage.

They’re Signed Up: Now What?
Now that you have chosen your eCMN solution and signed up several practices and physicians, what is next? The answer is follow-up; are they using it? Is the office manager who you taught or worked with now gone? Do you need to revisit and teach the new MDs or personnel in the practice?

Determining if you should use eCMNs, selecting the product you want, and implementing it is just the first half. The second half is ensuring your time and efforts are successful and actually being used. We spend as much energy ensuring the process is working as we did getting it going. Expect to see practices and physicians come and go.

It is more important than ever that CMNs and orders remain efficient so you know when there is a problem and can proactively work with the practice to determine the issues. Otherwise, the bad paper process turns into an even worse electronic process.

Does it work? Absolutely, but it does not replace the need to follow up on orders and CMNs. I have found the return rate for problems with our electronic solution to run less than 2% of all electronic routed documents. On paper, many of us spend countless hours rerouting documents to resolve blanks (diagnosis and length of need) or the classic “this is not my patient.” You can’t lose eCMNs, so that is something to consider.

Ultimately, it is not simply a process you turn on—it takes thought and effort. The long-term goal is for the cost of eCMNs and E orders to be cheaper than the paper process. Consider activity-based costing to know what each transaction costs your company.

As we watch the average sales price reimbursement of aerosol medications, the Federal Employees Health Benefits Program cuts, and competitive bidding, it is imperative that we remove costs from our processes. This is the only way we will be able to compete over the next few years. DP

Kim Brummett is vice president of contracting and reimbursement for Advanced Home Care, Greensboro, NC. Along with additional consulting work, she is chairperson of the Region C Advisory Council for Palmetto GBA. Brummett serves on the Board of the North Carolina Association for Medical Equipment Services; is a member of the MED Group Reimbursement Advisory Council, the National Supplier Clearinghouse Advisory Committee, and the Regulatory Committee for AAHomecare; and was recently appointed to the National Uniform Claim Committee. She can be reached via e-mail: kbrummett@advhomecare.org.