My favorite American tradition.

Happy Halloween.
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How to document an encounter quickly with an EMR

Electronic medical records have many advantages over traditional pen and paper charts. Speed of documentation, however, is not one of them. I have been live now on my high end electronic health record for 6 months. My first encounter on the system took place in February 2009 and took me 45 minutes to document on the system. Obviously, I would need to improve upon that. Now I do things differently, more efficiently. Here is my work flow:

1. Schedule patient, office staff gets some clinical information
2. Appropriate clinical templates are pre-loaded by me or staff into notes prior to patient arrival
3. I review the templates and pre-order labs, studies, and prescriptions as I see fit
4. When patient arrives, I perform the encounter and do my doctoring
5. I then determine if pre-ordered tests and prescriptions are still appropriate
6. Finally I complete the documentation, sign note, and on to the next patient.

The entire process now takes under 5 minutes and is much less stressful.

When you get an EMR, you must change your work processes to adapt.

Are meetings worthwhile?

As reimbursements continue to decline for many of us and we are forced to remain in the office longer and longer to make up the lost income, our attendance in meetings has taken a back seat in importance. This is a shame and you may wish to re-think this cost-cutting strategy.

Meetings are very, very important. You'd be better off cutting out some othe expense.

Meetings allow attendees to re-charge their batteries and return to the office energized and more productive than ever. Only through meeting with colleagues face to face can doctors forge new relationships that are important for networking and business development. While we may be able to learn new techniques and advances in our field through online CME courses, we learn best in person where the dialogue is 2 way and we have access to non-verbal communication.

Meetings are not cheap. Flights, hotel, registration, and time away add up to thoudands of dollars. However, if you choose your meeting wisely, increased revenue will offet the costs many times over. All it takes is learning one new CPT code or one new modifier or a new profitable procedure and you will payed back in triplicate, at least.

I just think this is not an option for cost cutting.

Wow, you can bill Medicare for waiting room magazines

From 2 posts on a listserve to which I subscribe:

" There are codes for magazine loss/replacement:
CPT: 9999a- replacement of magazine, identical issue
9999b- replacement of magazine, similar topic matter
J codes: 80% of magazine cost"

Also, since the governement is so interested in our education, here are some other codes you can use:

"Recent governmental efforts to encourage literacy among the poplus has lead to CMS's request for physician offices to voluntarily report, via PQRI, on appropriate utilization of magazines and reception area reading materials. Qualifying providers will be eligible for a 2% bonus of their annual CMS billings. These G-codes for PQRI measure 9999 are: G9990 - Educationally meaningful magazine provided at reception area G9991 - No educationally meaningful magazines provided at reception area G9992 - Some or all educationally meaningful magazines made available were lost due to theft or damage Eligible providers must successfully report on at least 80% of pts on Medicare seen in 2009 to qualify. The exact definition of educationally meaningful is still being debated, and won't be released until early December 2009."

I believe that most of this information came out on April 1st. I am not sure I recommended trying these codes just yet.

Hat tip to http://www.sunriseurology.com/ and Dr Ernie Sussman, famed urologist in Las Vegas. Hope you enjoyed.

GET WITH THE PROGRAM!

Doctors are resistant to upgrading technology. Most claim cost as the main obstacle to adoption of E.H.R technology. For others, overcoming inertia and resistance to change prevents them from committing to advanced information technology.
I say get with the program.

The technology is here.
It is good.
It is affordable.
Patients will demand it.
Payers will demand it.

I have several supermarkets near my house. One is less than a mile, but I shop at one 3 times the distance. This market has adopted technology that makes my life easier. In turn, I choose to spend my food dollar here. The image you see is of a scanner. I use the scanner to scan the bar codes of my food purchases. The scanner is tied to my card. After I am finished shopping, I simply hand the scanner back the clerk, my credit card is charges, and I am on my way.
I demand technology.
So will your patients.
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EMR vs House: Words of wisdom from a practice managment guru

Rick Rutherford, a practice management guru with the American Urologic Association, has a great analogy for EHR selection. I have published it, with his permission, in its entirety.

"The biggest fallacy in the process of selecting an EHR system is that too many folks think that there must be ONE systematic, accurate approach to making a good choice. There isn’t. To me, it is more similar to buying a house than a car. You can buy a car, drive it for three or four months and decide it is a lemon and go trade it in for a different one in a single day. Sure you lose some money, but beyond that, it is an easy transaction. When you buy a dwelling, there are many more considerations and sometimes, if you make a mistake, you just have to live with it. EHR systems are the same way. Why? Consider the following (substitute the word “house” everywhere you see the acronym “EHR”):

A whole group of people have to use the EHR so all of them should have input into what is important.
You can buy a modest EHR or a extravagant EHR depending on which things are most important to you.
When you start to use your EHR, you discover that almost every pattern you have developed must be changed or you will waste a lot of time and energy.
Over time, you become more and more comfortable with the EHR and appreciate (or hate) nuances you never saw when you did your first walk-through.
There are lots of financing options for an EHR. The government may give you money, the hospital may give you money, the bank may give you money. However, the financing should NEVER be the reason why you choose one over another.
You can spend money any time you choose to enhance the features of your EHR. Sometimes you have to spend money because of unexpected circumstances that you didn’t plan for.

The biggest difference between houses and EHRs? There is no residual value in an EHR. So take your time, be sure about what you want, talk to as many other people that use it as possible and read every single word of the purchase contract. Negotiate every item. Finally, once you commit, do everything within your power to make it make your life better.
With warmest regards, Rick Rutherford"

So true indeed.
Thanks for the words of wisdom, Rick.

The IU.

Time vs Money

There are only 2 variables that can be manipulated when determining compensation in a medical practice; time and money. There are many ways to divvy up either.

Some practices compensate all partners equally as long as the relative work performed by each doctor is equal. As long as the doctors work as hard clinically as each other and take the same number of nights on call, then the pay will be equal, though the details of this arrangement is certainly more complicated than that.

In an equal pay type of set-up, the easiest variable to manipulate is time. In a medical practice, time is spent in the following ways:

• Clinic hours
• Rounding/Hospital work
• On-call
• OR and procedure schedule
• Administrative

The hours spent performing these necessary functions must be allocated amongst the doctors. There all all kinds of ways the schedule can be configured for someones advantage, which by definition, is someone else's disadvantage. Time in a medical practice is spent as follows:

• Hospital rounds on Mondays vs Tuesdays vs Friday etc
• Monday morning office hours versus Thursday evening hours vs Friday afternoon hours
• Monday on call vs Tuesday on call vs Wednesday on call etc
• On call Christmas versus New Years versus Thanksgiving
• Having a first start case in the OR versus to follow cases
• Going to administrative meetings versus working in the clinic

All these things have value. Perhaps not the same value to each individual but value nonetheless. If more than one person comes to view Monday call is more labor intensive than Tuesday call--which it is statistically--or a 7:30AM start time as more desirable than a 1PM start time, grievances will arise. You can bet that conflicts will emerge over the schedule and the manipulation of time. In fact, the person who controls the schedule becomes the most important member of the team. . .often the most hated.

I want to say one more thing about time and money. As someone ages, money tends to become more abundant than time and this often influences a person's economic decision. For example, a person with lot's of money but little time will think nothing of purchasing the most expensive plain ticket if this gets them to their destination fastest. A college student on break, with all the time in the world but no money, will usually purchase based on price rather than time.

Conversely as time becomes more scarce, money becomes more important. If time cannot be manipulated in these cases, then people start to demand variations in compensation.

Then comes conflict.