1 Jul
Practice management systems have come a long way since first emerging in the veterinary world 20 years ago. A plethora of systems now exist to choose from, offering a range of features, but some are more useful than others, as Oli Viner explains…
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Back in the early days, any practice management system (PMS) was a massive step forwards from paper record keeping.
Early PMSs started out as just the digitisation of clinical records, but they soon added billing and invoicing, then calendar management and, before you knew it, “modern” PMSs emerged, which essentially acted as a centralised hub of all digital data within the clinic.
Acting as the “brain” of your digital infrastructure, the modern PMS is expected to manage all the clinical records, billing, talking to lab equipment (internal and external), liaising with a digital imaging suite, underpinning online booking, handling reminders and much, much more.
One of the unusual things about writing an article on trends in PMSs in veterinary clinics is that the topic is really the antithesis of trending. PMSs are not cool, not sexy, and are rarely changed.
An old adage says that the one thing a vet clinic hates more than its PMS is changing it. It is exceedingly rare to find anyone who loves their PMS. Being a tool that is used daily, everyone has gripes and niggles, and no one system will ever be everything for everyone.
As practice management systems evolved, the need increased to talk to other systems, such as the aforementioned lab machines. In the first instance, this may have been plugging a cable into a server located under the receptionist’s desk. However, all it took was one accidental nudge and… no more lab data.
‘If your data resides on a physical server at a clinic, it is very hard to access that data anywhere else you may want to.’
Equally, if your data resides on a physical server at a clinic, it is very hard to access it anywhere else you may want to. This may be a clinician on a house visit, or it could be communicating with a third-party service for appointment booking.
Having all your “stuff” in one physical site has some advantages. That cable that you can run straight from your lab machine to your local network/server is pretty reliable, so long as no one accidentally unplugs it. And if all your work terminals are in the same building as your server, then it does not matter if a pigeon decides to chew through your telephone cable, you still have a functioning platform. For years, this resilience and reliability, along with poor quality broadband connections, meant on-premises local servers were preferred to using any off-site/cloud systems.
On-premises solutions do also have some pretty hefty disadvantages. Firstly, that accidental kick or wire pull can not only knock out your server, but it is possible you could suffer data loss. Fire or theft pose a much more significant risk when everything is in one physical location. I still recall the old days where the last receptionist to lock up would literally take the external hard disk that had been doing backups all day home with them “just in case”.
Secondly, if you need your data outside of the site where the server sits, it is not always straightforward. That may be a second branch, or access from home, but either way, you are reliant on the telephone infrastructure to your premises to keep your access intact.
Lastly, others can benefit you from having access to that data. This may be cloud backups so data is never lost, or it may be access that is granted to third parties to give clients the ability to book appointments. Either way, having your server on site is a disadvantage.
The solution, one embraced by most industries quite some time ago, is to move to a cloud solution. This means that your data now lives “in the cloud” – that lovely term that few people fully understand.
A very basic way of thinking about the cloud is as a series of large purpose-built data centres that hold some or all of your data. Usually, massive redundancy for loss or damage exists, as well as a whole infrastructure and teams of engineers working to ensure the data centre stays connected to the internet, come rain or shine. These same data centres can hold not only your data, but the application you use to access that data, too – the PMS. These PMSs have now shifted from programs running on a PC to web apps available anywhere.
No veterinary start-up nowadays is going to look to install an on-premises solution, and for existing clinics, the trend is to migrate from on-premises to cloud solutions.
Historically, web-based PMSs were not as fully featured; however, this is changing. Through more modern technologies and techniques, highly functional PMSs are now available that are totally web based. It can be slightly harder connecting to things like label printers, but it is vastly simpler for connecting multiple sites or integrating third parties. The big PMSs to look out for that are web-based are Ascend (Covetrus), Digitail, Merlin, Provet, VetIT and others.
Following on from having a tool that is cloud based is the ability to access the PMS from devices that are not just a static terminal. A web-based PMS may have optimised views for mobile or tablet devices, as well as possibly an internal app.
No huge advantage exists in having an app over the web-based approach nowadays, and the risk exists that having an app adds overhead for the PMS to maintain versus just a single web app, accessible on mobile devices.
‘The real power however comes from being a platform, and allowing other specialised companies to add value.’
A lot of interactions with the PMS do not require heavy text/data entry, and it is those use cases that are best done on mobile devices.
Being able to check notes patient-side, or record hospital billing at the point of use, can be much more efficient than being stuck with a few static terminals.
This does also open up the possibility of people being able to access the PMS remotely on visits, or even from home. While some work-life balance challenges possibly exist around this, if you are dealing with out-of-hours calls, for example, having the clinical notes available (and potentially being able to add new ones directly) is a huge positive.
It is possible to add “apps” on top of the base PMS that will improve the experience.
In the same way Apple used to have a totally walled garden and then found greater success through having an App Store, PMSs used to be a one-stop shop. They attempted to provide all the services a clinic would ever want, from the EMR (electronic medical records) through to reminders and even online booking and client communication.
An argument can be made, however, that a PMS cannot do everything, or at least certainly cannot do everything as well as a specialised third party could achieve.
I would go so far as to say that I don’t believe that a PMS should attempt to do everything. If you try to optimise for everything, you optimise for nothing.
PMS companies were historically small niche software providers, and just keeping your system alive and bug free for basic functionality was (and still is) enough of a challenge. Veterinary clinics kept demanding more and the response was for the PMS companies to try to build it in, and, to some extent, compete on features.
To think that a one-stop shop will improve your clinic and make life easier is, unfortunately, a fallacy.
The real power, however, comes from being a platform and allowing other specialised companies to add value. No PMS offers the depth of online booking functionality that VetBooker or Vetstoria offers, simply because, for the PMS companies, it was a box to tick. For the specialised providers, though, it is existential to provide the best booking experience possible for clinics and customers.
To use our Apple analogy, a huge number of people, myself included, use Gmail on our iPhones. I do not use the native mail app and that’s because Google offers me a better all-round mail experience. Famously, Apple does not even include a calculator with iPads because they just could not see a reason to, relying on third parties to fill the gap.
It can seem attractive for a clinic purchasing a PMS to be sold the idea of this one-stop shop. Having a single provider gets rid of all that administrative faff that using multiple providers can cause. However this is a false economy – choosing one provider that does multiple things poorly is worse overall than picking multiple specialised providers who truly solve the problem area they are focused on.
Unfortunately it is also easy for the specialised providers themselves to experience feature drift, too. In solving one particular problem, for example client communication, it can be easy to start to offer a wider service, such as health plans. What happens is that the core problem that was originally targeted to be solved sometimes becomes just another tick box.
Regardless, having a platform that allows specialised providers is key here, and at the very least provides optionality.
How can you identify a PMS that wants to act as a platform? It needs to have a broad and open API, and one that will allow anyone to integrate with it, with as few commercial barriers as possible. Even if you aren’t technical, this question can be asked of the provider, and any provider who has its API documentation freely available is likely to have an open API.
Even asking the question if you, as a clinic owner, can access all of your own data through an API is worth doing. I am increasingly encountering, even among some previously open PMS providers, more resistance to truly open integration. I can understand the dilemma here for the PMS providers: they see potential revenue loss as they used to be able to upsell products such as marked up SMSs, and they want to be able to recoup that by either taxing integrations or blocking some altogether.
This zero-sum game assumption is, in my opinion, short sighted: clinics end up spending more for a worse service and any lack of choice makes the PMS less sticky.
Innovation is stifled if new companies cannot integrate easily with PMSs, which is a negative for all involved. Clinics voting with their feet and selecting PMSs based not just on the surface offering or which features are ticked, but on their integration capabilities and commercial policies, would be a huge benefit to everyone in the long run. The trend to open APIs is happening – albeit slowly and with some steps backwards, as well as forwards. In the long run, though, I am convinced that it is those PMSs that have the most open APIs that will do the best in our industry, and be the best choice for any clinic.
A PMS is a tool, and how we interact with it can make a huge difference both to the well-being of those who use it, as well as the quality of the data created and used.
A lot of PMSs look like they were designed in the early 2000s, and for good reason – most were. While design paradigms have moved on and many of us use beautiful, intuitive software every day, veterinary systems’ user interfaces have not kept up.
Two ways basically exist that you can approach data entry in a PMS: top down and bottom up. Traditionally, we have done a top down approach: you perform a consult in person, then write up a visit and bill from a blank slate over the top of the visit.
Increasingly, though, we are seeing new-style PMSs come forwards with ways of generating billing and consult information through workflow-driven interactions. Instead of one big long list of fees to bill at the end of a consult, I may start the consult selecting one of a few choices, which, in turn, drive the next set of options on screen. Eventually, the billing is automatically taken care of from the options I had selected before, as well as a framework for my clinical history being created for the visit notes.
In the long run, this is an area where AI will likely start to offer some benefits, and probably sooner than we expect. Large language models, such as GPT-4, can be amazing at understanding text, but they can also be brilliant at creating more verbose outputs from quite limited inputs. My old clinical notes favourite of “BAR, NAD on PE, routine vac” could become several well-articulated sentences, linked to the processes of my clinic such that anyone could more readily understand them.
Moving from a blank slate, top down entry system to a bottom up, AI-driven work flow based interaction will not happen overnight, but it has already started. Shaving a few minutes off of each clinical interaction through better tooling may become a serious battlefield for PMSs that are looking to the future.
While it is easy to be caught up in gimmicks with this sort of new tech, PMSs that appear to be giving thoughtful consideration to these things are well worth considering.
Once again, an open platform of a PMS will allow innovators to come in and offer these tools as plug-ins into the existing base system, and allow those PMSs to advance much more rapidly than closed systems.