A urology-eye view of an earthquake

I first learned of the earthquake after returning from a hike in which I was out of cellphone contact. The first emails from my urologist and practice manager colleagues were of the "did you feel that " nature. The quake occurred during office hours for most practices. A colleague in Indiana felt the quake. So did one in Staten Island and another Rhode Island. My own office I'm Smithtown Long Island shook for 3 minutes. My staff evacuated. I was not present.
I wonder is there were any surgical mishaps caused by the quake.

Richard A Schoor MD FACS
www.schoorurology.com

From up here it all seems so silly

Important skills for a physician-manager

Collect copays
Get deductibles
Correct coding
Streamline work flow
Automate what you can
Optimize staff work

Richard A Schoor MD FACS
www.schoorurology.com

EHR Success-5 Tips

A successful EHR adoption is within everyone's reach. Just do the following:

Master the templates
Tweak the templates
Adapt your workflow
Connect to lab and instruments
Stick with it

The benefits are simply amazing.

Richard A Schoor MD FACS
www.schoorurology.com

Patient Portals

Do patients want online access?

I offer it.

Very few take me up on it.

I'd prefer it.

The patients seem to prefer the phone.

Online is efficient and inexpensive for me.

Perhaps the phone is efficient and inexpensive for them.

I guess people call when they have time, ie from their cell phones while driving.

Dr Schoor

www.schoorurology.com

3 things that gave me happiness today

A good sushi meal
A busy day in the office
Watching my daughter play tennis

Richard A Schoor MD FACS
www.schoorurology.com

Still Kicking

After a long break from blogging, I think I have found my voice again. Why is that? Well I think that I am inspired by hardship, difficulty, and challenge. Being in solo practice in 2011 in the USA, I have all 3 of those things in abundance.

Currently, I am confronting:

high rent
high insurance
high payroll
high technology costs
low reimbursement
Many doctors have either joined forces and formed large single or multi-specialty groups or have given up their independent practices to be part of a hospital setting.

I remain solo.
I remain independent.

For me and my situation, no white horse is coming.
I am on my own.

What I do have on my side is:
very effective system of new patient acquisition
a great reputation in the community
a solid existing patient base
a very efficient E.H.R. system
a good office and dedicated staff
a devoted and loyal wife and family
incredible drive to succeed
What is the long term outlook for us "so-low" doctors? Don't know.

Revised Prostate cancer screening guidelines

revised guidelines say

Because of these complex issues, the American Cancer Society recommends that doctors more heavily involve patients in the decision of whether to get screened for prostate cancer. To that end, ACS's revised guidelines recommend that men use decision-making tools to help them make an informed choice about testing. The guidelines also identify the type of information that should be given to men to help them make this decision.

ACS recommends that men with no symptoms of prostate cancer who are in relatively good health and can expect to live at least 10 more years have the opportunity to make an informed decision with their doctor about screening after learning about the uncertainties, risks, and potential benefits associated with prostate cancer screening. These talks should start at age 50. Men with no symptoms who are not expected to live more than 10 years (because of age or poor health) should not be offered prostate cancer screening. For them, the risks likely outweigh the benefits, researchers have concluded.

As in earlier guidelines, ACS recommends men at high risk—African-American men and men who have a father, brother, or son diagnosed with prostate cancer before age 65—begin those conversations earlier, at age 45. Men at higher risk—those with multiple family members affected by the disease before age 65—should start even earlier, at age 40.

For men who are unable to make a decision about screening after these conversations, ACS recommends the doctor make the call based on his or her knowledge of the patient's health preferences and values.

For men who choose to be screened after discussing the pros and cons with their doctor, the new guidelines make the digital rectal exam (DRE) optional and offer the option of extending the time between screening for men with low PSA levels.

Above from: http://www.cancer.org/cancer/news/news/revised-prostate-cancer-screening-guidelines

Happy New Year

EMR securuty

Switch To EHRs Raising Some Privacy Concerns.

I don't think the concerns below are warranted, really.  Paper is much less secure than electronic communications which can be password protected and given user level security. 

The Fort Worth Star Telegram (12/19, Branch) reports, "As the transition from paper to electronic medical records gains momentum, so have concerns that more confidential patient information will fall into the wrong hands. Privacy advocates warn that without proper safeguards, digital records could make large caches of personal medical data vulnerable to theft or improper use, such as discrimination by employers." Psychiatrist Dr. Deborah Peel, who is also the "founder of Austin-based Patient Privacy Rights and an outspoken critic of how digital records are being implemented," said, "The security issues are extreme. .. Some of these systems are very poorly protected, and you are going to have patients without control over who is looking at their health information."

A new pediatric urgent care establishment opened in Smithtown, not far from my urology office.  I saw some things I liked. . .and some I did not.

I liked:

• Ample parking
• Nice building
• Electronic medical record system
• Advanced "feel" to the office

I did not like:

• Unfriendly staff

Will all the good outweigh the one negative?

We'll see.

The case for an answering service

I finally did. I got an answering service. Almost 5 years since I opened my doors and probably 1000 calls answered myself, I hit the wall. I am too tired of answering my own phones.

Unfortunately it was not until after I ticked off a patient and was fired as their doctor.

Need to Train Staff-Make A Video

It is just easier.

Don't even try to compete

Another practice's website can be slicker than yours.
Another's can be prettier than yours.
Another's can be cheaper than yours.
And another's can be faster than yours.

But does your site do what you need it to do?

Make it easy for people...
. . .to pay
. . .to schedule
. . .to refill
. . .to get results
. . .to give your name out

Do things things, and you'll do OK.

Middle-ware: The Independent Way

For those of us with EMRs, one common challenge that exists is how to interface in-office lab analyzer data with your EMR software.   Basically, there are 4 ways to get lab data into your EMR:

1. Manually: Inefficient, slow, error prone.  DO NOT do it this way.
2. Scan results: Time consuming, error prone 
3. Middle-ware: If you are fortunate to have an analyzer that interfaces seamlessly with your specific EMR, this is the best solution.
4. Customized software: If your analyzer outputs data in a digital format, you can develop a solution easily and inexpensively, even if you have no programming knowledge yourself.  I recently developed one for my semen analyzer.

Your goal should be to efficiently and automatically get data into your EMR where you can sign off on the result and act accordingly.  Electronically is the best way to do this.

Good luck

Dr S

Tips for staying sane and viable through the tough times

This is one challenging economy.  Here's how you can manage to stay in good shape.

Avoid these pitfalls:

• Over-extending: good times don't last forever
• Over-contracting: neither do bad times
• Panicking: don't jump at your first rescue option, it may not be the best one
• Putting your head in the sand: the payment system is changing.  You'll need to adapt or die.
• Second guessing: too much wasted energy better spent on planning and acting.

Good luck,

Dr S
s

Why Do I Use a Different Pool Guy Every Year?

I have a pool--which I don't recommend.  The house came with it.  I maintain but have a service open and close it for me.  Every year it seems we use a different service.  Why is this?  For the most part, it is because the pool companies have not been following up with us through the winter.  We lose their numbers and forget their names and have to look up another one every May.
Crazy!  And in this economy.
Don't run your medical office like that.  Reach out to your patients, the active and the inactive ones on a routine basis.  Doing this is neither difficult nor expensive.
Just do it.
Dr Schoor

A Cost of Woking for Someone Else

These doctors assumed someone else would take care of their insurance needs.

I've said it before.  I'll say again.

Your practice, your problems, even if you work for someone else.

Dr Schoor

5 Key Practices to Help You Through This Recession

This is a tough recession--the worst I've been through certainly.  Only the fittest will survive this one.  Here are some survival tips that you can use:

1. Focus on collections: Obtain deductible information prior to seeing the patient and collect up-front if your contract allows.  If not, use a service like this. 
2. Scutinize all costs: Trim some and expand others--cost center vs profit center.
3. Smarten up your office hours: Avoid overtime while maximizing office visits.  Use your data to figure when patients "want" to be seen and staff heavily at these times, light at others.
4. Leverage technology: EHR, smart phones, VOIP, webforms, sms, etc
5. Answer your phones

Good luck.
Dr Schoor

Miami Urologist takes a stand

This urologist's patients are welcome in my office!

http://www.nytimes.com/2010/04/03/us/03doctor.html?ref=health

History

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History in the making

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21% Cuts: The perfect storm?

If you have had your head in the sand or too immersed in patient care issues, our fearless lesaders have let the Medicare's SGR proceed and with it a 21% cut in Medicare reimbursements to doctors across the board.  Whether you take Medicare or not, no matter what your payer mix may be, this affects you dramatically.  For many, if not most of us, our private payer contracts are tied to Medicare rates.  So  in essence, you can expect a 21% cut in gross payments while the private insurance companies have just recieved a 21% windfall.

Do you have chest pain yet?

How will you survive?

Well, you may not.  This may reresent the perfect storm, the trifecta of bad luck that has befallen the American doctor: rising liaility inurance rates, falling reimbursements, a severe recession. 

Or you could try some of the following:

1. Stop seeing Medicare patients.  Not out of protest, but because these patients are too sick and labor intensive to care for and still make money.
2. Increase volume.
3. Go ou of network with some private plans.  This works better if you are a primary care doctor or a specialist that sees emegency room patients.
4. Re-negotiate your contractswith the private payers.  Good luck with this one, but you never know.
5. Merge, merge, merge.  If the other strategies don't work, this drastic move may be the only viable approach. 

Good luck and let me know how it goes.

Dr Schoor

Well, the whole day is not lost!

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Prevent the Cuts!

Contact congress now.  If you live in Long Island, see these links.

Congressman Israel, from Huntington:  http://israel.house.gov/

Congressman Bishop, Smithtown and Brookhaven: http://timbishop.house.gov/

The Speaker of the House: http://www.house.gov/pelosi/

Senator Schumer, NY: http://schumer.senate.gov/

Senator Gillebrand, NY: http://gillibrand.senate.gov/


These people work for you!  Contact them and ask them to reverse these devastating cuts.

Dr Schoor

Never Back and Animal Into a Corner

With devastating cuts to Medicare looming to take effect March 1st, us doctors are taking our message to everyone.  We will not go down without a fight.  This is a letter I sent to ALL of my Medicare age patients.

2/23/2010

Dear friend,

MEDICARE is under threat!

Unless we take action now, congress will allow MEDICARE to drop reimbursements to all

doctors by 21.6% effective March 1st.  For most of your doctors, that would account for greater

than 20% loss of the practice's total income; income that we use to pay our staff, purchase office

supplies, pay for our equipment, care for you, and support our families and the local economy.

If the US Congress allows the drop to go through on March 1st, many of your doctors, like your

internist, family practitioner, endocrinologist, urologist, dermatologist, and others, simply will no

longer be able to survive and remain in practice.  Those that can weather the storm will be forced

to make drastic cutbacks in services to Medicare beneficiaries or drop out of Medicare altogether.

I implore you to contact your local representative to the US Congress and ask them to prevent

MEDICARE from proceeding with the devastating 21.6% cut to the physician fee schedule.

Feel free to contact me directly if you have any questions or would like to know who to contact.

You can email me at rich@drschoor.com.

Or visit www.theindependenturologist.com for links to members of congress.

Do it now!  Our beloved MEDICARE depends on our action.

Sincerely,

Dr Schoor

The End of an Era

I disconnected the last of my remaining VONAGE lines today, the phone that sat in my house and served as an office line, just one that happended to be in my house.

It feels a bit sad, nostalgic almost.  While VONAGE was the source of much of my telecom pain in the early and not-so-early days of my fledgling urology practice, it was VONAGE's then avant-guard service that enabled me to grow in those first critical months cheaply and mobily.

In many ways, it was VONAGE that put me on the map.  And for that, I thank them.

Ultimately, I outgrow its capabilities, however.

For the past few months, as I have been looking to cut cost whereever possible, VONAGE was always near the chopping block, but the off-site line still served a function, even though improvements in cell phone reliablity  at my house enabled me to make and receive calls from almost any room in my house.

Still, I held a special place in my heart for this little phone company that could, silly as it seems.

Then my VONAGE router died--just went kerplunk--and that was the catalyst.

Several minutes ago, I called and canceled my service.

Fairwell old friend.

Dr Schoor

Dwindling Down My Paper Usage

I am down to two!  Pieces of paper that is.  Everything else is the glorious e.

Patient records--electronic

Radiology reports--electronic only

Lab reports--electronic only

Patient intake & demographic form--electronic (actually, I don't even have one.  I got rid of it.)

HIPAA acknowledgement form--electronic, signature and all!

Consents--electronic

Patient statements--electronic.  They are actually mailed on paper, just not be me or my staff.

ABN (Assigment of benefits) consent form--you guessed it, electronic.

That is it.

So what is still paper?

We still send claims for secondary insurance by paper.

My biller insists on continuing to use paper encounter forms.  Alright.  If it ain't broke. . .

Dr Schoor

Unintended Email Consequence

My staff has been getting email addresses from patients.  Over the past few months, they collected 212 emails--not too shabby.  Thanks guys!

Yesterday I uploaded the email addresses to my email management site and sent the patients a confirmation email (I don;t want to be a spammer, so the patients must opt-in again to confirm they wish to be on my email list).

Most people have opted in, but what I did not expect was the number of emails from patients regarding billing issues.

It seems I have awakened a sleeping dog.

I get it, I think.

I think I finally "get" Twitter.  Or at least I figured how I plan to use this seemingly inane service that millions love.

Twitter is best used when the tweeter draws attention toward someone else, rather than himself.

The "I'm at Starbucks" tweet is boring and useless.  On the other hand, the "check at this new gadget" tweet, well that might be interesting.

As in any form of marketing, the best type places attention on the other person, rather than the marketer himself.

Better to be "how can I help you?" than "how can you help me?"

New Years Resolutions

Try these on for size:

1: Go E.H.R.
2: Improve your E.H.R.
3: Start PQRI
4: Decipher "meaningful use"
5: See more patients or...
6: See less patients
7: Learn 10 new codes
8: Get rid of 1 piece of paper
9: Do away with 1 process
10: Write a book

Happy New Year

Dr S

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Miniature Circus

If the Medicare cuts go through, I am going to run away and join the miniature circus.
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Come on, come out, Sun.

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Using an EMR to Solve Problems

If someone came to you with a solution to 3 out of the 5 biggest problems you face, you would probably take it--or at least listen to their proposal, right?

Imagine if someone said to you, "you know that persistent problem you have with your filing system, I found the perfect solution and you'll never have to deal with that again."  I don't know, I'd be all ears.

Every doctor has problems.  Filing and retrieving, lab tracking, order tracking, prescription refills, handwriting issues, messaging handling; these just name a few.   I certainly had my issues.  Many of them are now past tense issues.

Prescription issues:  99% solved.  On rare occasion I forget to initial a narcotic script or my rx printer malfunctions.


Message handling:  100% solved.


Handwriting issues: bye bye!


Filing/retrieving:  see ya.


Lab tracking: 90% better.  I am still learning my EMR's functionality.


I still have problems, but just not these problems.


A good thing.

This Jewish guy likes Christmas.

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Early Praise for My Book, Suddenly Solo

Rich's book is excellent I am going to have my office manager read it too.  Nice to codify philosophy of self made "man". . .

Dr A.G.
Urologist  NY, NY

You can get your copy FREE.  Just click the cover.

An Excerpt from Suddenly Solo

Imagine being safely ensconced in group practice one day, just going through the motions, but nonetheless enjoying your day—talking with colleagues, consulting with patients, maybe even enjoying lunch, driving home, talking over your day with a friend or your spouse, and then walking into work the next morning, only to find yourself out of a job—fired.
Or, if that doesn’t gut you enough, imagine coming to work one day to find that not only do your keys mysteriously no longer work, but a security guard bars you from entering the building, where all your files are locked away.
Here’s another dream scenario: Imagine returning from a long-overdue, much-anticipated, relaxing vacation to find that your partner has conspired with another and has effectively stolen your practice. . .

. . . . . . . . . . . . .

If you want to read more, just click the cover on the sidebar and register for your free e-book copy.

And good luck!

Dr Schoor

My Book, Suddenly Solo, is finally ready for publication

Three years in the making, perhaps even more.

And you can have it free, for a limited time.

Just complete the following webform and the e-book version of Sudddenly Solo: A Physician's Guide to Surviving & Thriving in Your Own Medical Practice will be emailed to you.

I hope you enjoy it!

Dr Schoor

Happy Holidays

Make a Smilebox greeting

Not Everyone Needs High Tech Toys

Sometimes you can't beat the old fashion.
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My presentation milestone

I am a big believer in software as a service, despite its pitfalls. Today I gave a presentation at my hospital's tumor board. In the past, I'd have had to bring either my laptop or a thumb drive with powerpoint talk and ope that everything would sync ok. This time, I just had to make sure they had a computer with internet access. They supplied that, no problem. I just brought a url. Worked great.



Gotto love technology

EHR is not a panacea, Mr President

From the AUA Daily Scope

"Study finds little benefit to date in electronic patient records.
The New York Times (11/16, B3, Lohr) reports that a study to be presented Nov. 16 at a medical conference "comparing 3,000 hospitals at various stages in the adoption of computerized health records has found little difference in the cost and quality of care." Researchers from the Harvard School of Public Health conducted "a follow-on study to a survey of hospitals' adoption of electronic health records, published this year and financed by the federal government." The authors found that "differences...were 'really, really marginal,'" and suggested that "government policies should focus on helping physicians, hospitals, and the public health system use the technology more effectively." "

Frankly, I am not the least bit surprised.

The IU

My chief resident: a famous LA urologist on MTV

The Hills - MTV Shows

Hat tip to Dr Adam Weiser

A death spiral in evolution

It is truly fascinating to witness a corporate death spiral firsthand.  Here's how one just unfolded in my presence.

• Company A, a software as a service (SAS) solution lands big client, Company B, an EMR company.
• The arrangement flourishes.

In business--and life--the only constant is change.  In this case change produced:

• Increase in demand for company B's SAS solution
• Company A needs to invest in infrastructure to support Company B's plans.

Credit Crunch or bad Management?

• Company A unable or unwilling to accomodate Company B's plans
• Company B finds SAS vendor that will

The death spiral begins.

• Company B signs with Company C, the new SAS provider
• Company A makes lay offs of technical employees
• Service declines at Company A
• Company B gets tons of complaints
• Company B pulls remaining clients from Company A
• Company A has problems.

Wow!

Could this have been avoided by Company A.  In this economy, who knows?  Probably not.  I wish them luck.

Dr Schoor

Where an EMR helps and hinders in medical practice

EMR are very useful tools, just not for everything.  If you think about about all the processes that take place in your medical office from the moment a person calls to book an appointment to the moment you get paid, you can determine where the EMR will help and where it will hinder.  Here are some places I think these programs help.

• Scheduling
• Prescribing
• E&M Coding
• Charge Entry
• Claim Submission
• Payment Posting
• Acounting
  
• Auditing
• Ordering
• Document Management
• Clinical Trend Analysis
• Coordination of Care
• Patient Compliance
  
• Communication
• Information Flow
• Documentation*

Of course, not all processes are streamlined with an EMR.  The main example of this, and perhaps the only example, is the physician's encounter.  It takes longer for the doctor to document a patient encounter with an EMR.  And the doctor has to expend more effort to document the encounter.  Both the effort and time required to document improve over time, however.

Also, EMR generated notes are more cumbersome to read, which can make it more difficult for the doctor to get at the "essence" of his/her prior encounter.  Of course, this can overcome by adding memory joggers into the document.

On the balance, EMRs are improvements over business as usual for the small independent medical practice.

Dr Schoor

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.

Craziness or Opportunity

I needed medical records from a patient's recent hospital admission for continuity of care purposes. I recieved the records today but they were sent not by the hospital itself, which is 3 miles from my office, but from a 3rd party operation located in North Carolina, approximately 800 miles away.

IOD, Inc.

Crazy, right? Why can't the hospital just send me the records when I request them?

Well the answer is that due to the complexity of federal privacy laws, the hospital has decided to outsource the management of the release of health information. The hospital pays this company and the company assumes the liability associated with a violation of HIPAA. Other than slight inconvenience to me, patient privacy is assured, the law is followed to the letter, and some entreprenurial person makes money. Win, win, win.

What can this teach us? For one thing, you can view regulatory change as a pain in the rear or as an opportunity for improvement or even new business.

Since the business and regulatory world are always changing, I recommend that you embrace the change and and use to your advantage.

Fighting Murphy: what are your checks and balances?

People can slip through the cracks easily.

• Patients can walk out of the office with their encounter forms or charge slips.


• The office staff can forget to give them a follow-up appointment.


• Patients can call to cancel an appointment, intend to re-schedule, then forget to do so.


• Patients can no-show.


• Staff can forget to put the patient on the recall list.


• Staff can put the wrong patient on the recall list.
• The doctor can get forget to write the order for the test or the follow-up.
• The doctor can forget to click on the order or the request for follow-up.
• Handwriting can be illegible.
• The computer can crash.
• Murphy can and will show up.

In a doctor's office, this can be dangerous.

The only way to prevent Murphy from walking into your medical office is to have multiple and redundant checks and balances.

How do you do it?

Information Management: The True Essence of Medical Practice

Twenty five, 30 years ago, doctors could keep track of their patients on index cards. I know some of these retired docs. They tell me that in some instances a 30 year patient relationship could be held on a 4-6 index card, front and back.
Seems insane in these information rich times.
Medicine, the business of medicine, that is, has become if nothing else, information heavy.
Clinical data, billing data, legal & compliance data, laboratory data; it could fill a warehouse if stored in paper format.
What is the best way to handle this mountain of data?
Digitally.
Either purchase the system or develop it yourself, but get a system that can store and more importantly manage information digitally.
You’ll be much better off for it in the future.

(Reprinted from: iLabTQM.com/blog

Cost Containment: A Post Worth Revisiting

With declining reimbursements, the only way to to remain viable is through revenue generation coupled with cost containment. I'd like to talk a bit about costs, and some obvious--and not-so-obvious-ways to minimize them.
Fixed Costs: These are items like rent and insurance. While you probably have little negotiating power in this area, with regard to rent you can keep costs down the following ways:
Maximize productive use of space. I pay $26 per square foot, and use all of it productively. An EMR helps here, because I don't need to dedicate several hundred square feet to chart storage. Also, mobile units, such as portable sonogram machines, client computers, and portable lab equipment, also helps. And of course, I have VPN, because it essentially converts my house or Starbucks, or anywhere with an internet connection into an extension of the office.
Maximize revenue generation areas of the office. These areas include exam rooms, your office, and the lab. Back office functions, such as insurance claims submissions and billing work, can be virtual, via your VPN, yet remain "in-house" as opposed to being outsourced. With a well networked office, exam rooms can serve as exit offices while you go to the patient in the adjacent room.
On-demand Supply Ordering and Smart Storage: Closets = Square footage = $$. With some thought and planning, shelving, exam tables, cabinets, and closet space can be used for maximal storage at minimal square foot usage. In addition, I order supplies as needed, since my vendor, PSS Worldwide Medical, always delivers next day.
Variable costs: These include costs for items such as medical supplies, payroll, utilities, stamps, etc, and can be determined by examining the profit-loss statements prepared by the accountant. here are some ways to keep variable costs down.
On-demand supply ordering. DELL Computers uses this concept. I do as well, just make sure you don't run out of Foley drainage bags after you've already placed the Foley.
Part-time employees: Simple. They cost less than full time employees, plus no overtime.
On-demand staffing: I staff heaviest on the busiest days. Plus, since I am capable and willing to pick-up slack on days that we are inadvertently short staffed, this method works out well. Busy days or light days, open or closed, phones are always!!! staffed.
Amortization of utility payouts. Most utility companies will estimate a fixed monthly cost for you to pay based on a prior years consumption. I like it for cash-flow management.
Have your phones (VOIP), cellphones, & internet on fixed plans, so that costs do not soar with usage. Get the maximum minutes for cell phones, since the incremental costs of the plan are much less than overage payments. VOIP is cheap, plus never varies with usage. On the balance, I've been happy with it, yes, even for the "mission critical" functions.

Fax. Why snail mail when you can fax the referral letter. Not only is it faster, more efficient, and trackable, it is cheaper. I love my fax. Yeh, yeh, yeh, I know, HIPAA. But it can be done and still be in compliance
Direct costs: These are costs that are directly involved in patient care. Here's how to minimize these costs.
Everyone does everything. MA's do data entry, answer phones, clean rooms etc. The docs answer phones (if they are not seeing patients) when needed, clean rooms, order supplies, schedule patients, e-file labs. Again, an EMR and a VPN helps here as well.
Part time employees and on-demand staffing: see above.
Creative patient scheduling: Figure out which works best for you; clinic, open access, proportional, or wave scheduling, and then determine minimal staff requirements for your office hours.
Ergonomic room design. I have rigged my rooms so that I can do a many procedures without an assistant present. I learned these skills as a surgery resident in central line clinic. In fact, I can prep with my left hand, place the scope with my right hand, and simultameously do a UA with my toes (kidding!). If you have 2 hands, a brain, and a Mayo Stand, you can make it work as well, and in the mean time, you'll free up staff to answer phones and book new patients or enter claims.
Training and process management: Training employees well and developing efficient processes of doing business will allow you and your employees to work smarter and with less mistakes and to get the job done right the first time. This simply saves money. Also, keep your employees happy. Turnover is very expensive and disruptive.
Indirect costs: These costs cover non-patient care activities, such as back-office staff and billers. Here's how to minimize these costs.
See direct costs.
Remote working

EMR
Embrace technology
Multi-task
Training and process management

Consider outsourcing when appropriate.

PQRI in 10 Steps

I finally figured it out, PQRI that is.  After several courses and months of procrastination because of PQRIs seeming complexity, I got it and am going to give it to you. . .free.

No strings attached.

Here it is:

1. Pick your measures (you'll have to look them up or contact me)
2. Right them down on a piece of paper as a cheat sheet or see step 3
   
3. Enter them into your EMR templates as appropriate
   
4. Tell staff to mark all encounters on pure Medicare (only) patients with a big red mark
5. See patient as normal
6. Circle or click on PQRI code on your encounter slip or your EMR
7. Tell biller to insert those CPT codes on line 2 of the HICFA 1500 form
   
8. Submit claim
9. Let Medicare do the rest
10. Or. . . you can outsource the whole process to a third party, approved vendor.

That is it.  Once you put the processes into place, simple.  And I just gave you the process.

Gratis.

The IU.

A follow-up protocol for non-compliant patients and busy offices

Patients no show and are not compliant and their lack of compliance can be blamed on you.  Here are 5 steps you can take to prevent a patient from slipping through the cracks:

1. Impart onto patients the importance of follow-up then. . .
   
2. Give all patients a follow-up appointment or place them on a recall list, and if they fail to show up. . .
   
3. Run a no show list. . .but if your staff forgot to give them an appointment, you'll catch them by . . .
   
4. Running a diagnosis/procedure list periodically, and if all else fails, hopefully you'll get them with a. . .
   
5. Random Audit

Crazy, but very important.

Any other suggestions?

The IU

What is your donut?

I was talking to my father-in-law the other day about a client of his who is a baker. This baker used to make lots of fancy and expensive items, such as cakes and tortes, but now he makes mostly donuts. He did not always do this. He began to do it out of neccessity. Donuts, you see, are high profit margin products.

Dunkin Donuts only makes donuts and coffee and guarentee them to be fresh anytime. Dunkin Donuts can do this because donuts are so cheap to make and they have such a high profit margin, that the store can afford to throw away items that have gone stale.

Urology has high profit margin procedures. Vasectomies and cystoscopies are 2 examples. Larger, maga-groups have radiation therapy for prostate cancer, which for now has a high margin. Laboratory work is low margin. Major surgery in the hospital is low margin.

In your practice, what has a high margin?

A great use for an EMR

Everyone has no-shows. It is just a way of life in medical practice. Effective no show management can add to your bottom line. An EMR can help here.
Set your EMR to automatically run a no show list or even better, a no show letter, once per month, at least. Then you and staff get these patients back into the office.
One, you'll recoup income. Two, you'll practice good medicine.
Win, win.
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It's a tough life

Tennis is a very rough way to make a living. Only about 100 of the world's best make a decent living solely through winning matches. Of those, only about 50 make what a cardiologist makes with the top 25 making wall street figures.
What amazes me, year after year, is how much the draw changes. Only 2 to 3 players from last year have returned this year. Maybe one made the big show, but the rest have done worse.
At my urology meeting, I saw all my old colleagues and everyone was successful. My dad was right. Play as an amateur, be a professional.
Good advice..
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That time of year again

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Who's your role model?

I was watching tv the other day, flicking through the channels. I came across Bill O'Reilly first and listened to him and Dennis Miller. Entertaining? A bit, Angry? Very. Inspiring? Not at all.
Then I flipped to C-Span and a speech by Muhummud Yunnis, the Nobel Peace Prize winner for microfinance. Microfinance is a great concept; lend a woman 100 dollars so she can start a business, grow it, and eventually take herself and her family out of poverty. His concept has taken 40 million people in Bangledesh out of poverty. Here in New York, his microfinance program, which is not welfare, has allowed thousands in Jackson Heights Queens to ascend out of poverty.
Muhummud Yunnis: truly inspiring.
Who inspires you?

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Information Flow

One of the best aspects of a good and integrated EMR and PM system is the rapidity with which information can flow through your practice. A patient phone call can result in action within minutes, even seconds, after the phone call is made. The same with the doctor's orders or a staff member's questions. Processes just get done with speed and efficiency.

Information at the speed of thought, to paraphrase Bill Gates. Truly amazing.

Automation and the demise of doctoring

Doctors will always be needed. So will carpenters and iron workers and all skilled laborers. However, as technology advances, it allows for high labor intensive jobs to shift down the labor intensity curve. While we still need carpenters for custom jobs, the vast majority of carpentry is done by machine, not man. Very few carpenters, as a result, can command high incomes.
Medicine is going in this direction as well. Information management and science will enable thought leaders to produce efficient and accurate algorithms that automate the very process of patient care. As a result, most medicine will be delivered by non-doctor entities, perhaps even machines.
The need for doctors will diminish, as will income levels. This may take 20, 30, or even more years, but it will happen.
What will you tell your kids to do when they grow up?
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Long day

Good day

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To consult or not to consult

The definition of a consult by CMS is unclear. At a conference yesterday, about 300 of us spent almost an hour parsing this one word.
In the US, medicine is easy. Coding is challenging.
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How to use free in your office to make money

Free can make the good business person a lot of money. Here are some ways to convert free into dollars in your own practice:
Blogging
Seminars
Consults
Courses
Volunteering
The path might not be direct, but it will get there just the same.
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Who is driving?

I sometimes wonder who is driving all this lunacy in health reform.
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Want to find in-efficiencies? Make a flow chart.

I serve on my hospital's performance improvement commitee. I enjoy it and I learn from it. Here is something I learned from my hospital's PI committee.

If you want to find sources of error, flow-chart your processes. It can go something like this for a small office like mine.



Let's say you want to find a weak spot in your diagnostic test ordering and resulting process; FLOW IT OUT

1. Patient needs "blood test."
   
2. Complete requisition (paper for sake of argument)
   
3. Give requisition to MA to facilitate


4. She draws the blood, processes it, ie centrifuge, and places it in the pick-up box with requisition attached


5. Lab recieves, runs the lab


6. Results are faxed and mailed to office (partials first, then finals)


7. Result placed on doctors desk for review and signature
8. Result then given back to staff for placement in chart, unless doctor needs chart pulled to interpret test
9. Patient informed
10. Chart re-filed

If you go through this simple list of steps, you can see lot's of inefficies. For example;

• Step 2: WARNING: MAJOR SOURCE OF ERROR HERE: handwriting issues and duplication of data: an electronic ordering system can correct this. Contact your labas they may be able to install one for you at no charge, even.
• Step 6: Duplication of results, wasted time and effort as doctor needs to sign-off on the same lab multiple times. Plus cost of tonor, printer/fax usage, staff time,and doctor frustration factor, there is a better way. Simply ask the lab to only send complete reports and better yet, ask them to automatically download those results from their server to yours and to notify you when done. Most good labs can do this easily and at no charge to you.
• Step 7: Automating step 6 makes steps 7, 8, and 9 obsolete.
• Step 9: Normals can be mailed to patients using a form letter.
• Step 10: Electronic records obviously elliminates this step plus step 8 as well.

You can do this for almost, if not every, process that takes place in your office.

Try it.

I aced my lab inspection

My information management system, www.ilabtqm.com to the rescue.

My COLA CLIA inspection went very well.

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Camp Doc For A Week: Old Fashion Medicine.

From Camp Doc 2009

My wife and I spent the past week as doctors for an overnight summer camp in the Adirondaks of New York. If you ever get a chance to visit this part of the country, I recommend it highly. The Adirondaks are New York's Alps. Though this trip was not my first to the region, I was once again blown away by its beauty, its charm, and its wilderness; a true jewel only a 3-4 hour drive from New York City.

Being a camp doctor was an interesting experience, to say the least. In many ways, doctoring in the camp environment exemplified many of the reasons why I chose this profession in the first place. For many of us, the art of medicine has been replaced by the assembly and bottom-line apporach that has become modern medicine. As a camp doc, all I had was the art: history, physical exam, judgment, compassion, and a shingle. I felt like Marcus Wellby himself.

From Our Photo Blog

Wonderful indeed!

During the week, my wife an I saw many campers with a variety of ailments. Lots of campers and staff alike had bug bites. These we treated with Calamine lotion and some antihistamine.

From Camp Doc 2009

One camper had severe swelling around the eye and another on the hand. We gave these 2 campers some prednisone along with the antihistamine, and they both got better. Lots of kids had foot ailments for some reason. The nursing staff liked to soak everyones' feet in a betadine and peroxide solution.

Whatever.

From Camp Doc 2009

I sent one child to the emergency room with a a suspected nasal fracture. Actually, the child's father insisted on the ER visit and I just complied with his request. In the ER, the child had a facial x-ray performed which did not show a fracture. Of course, no x-ray can ever truly be negative, so the ER ordered a confirmatory CT scan. Fortunately, the CT was not done, at the father's request, out of the concern of radiation.

I sent 3 other people for diagnostic imaging. Onea 15 year old, was complaining of back pain for 12 days. Though I knew a back x-ray would be negative, I sent him for it anyway. It was negative. Another person, a staff member, hurt her thumb 2 weeks prior and still had pain and decreased mobility. I sent her for a hand x-ray. This was my last day in camp, so I don't know the outcome. The 3rd was a counselor with fevers to 103 and cough. I actually heard rales which prompted me to order a chest x-ray that showed pneumonia.

Not too shabby for a urologist, eh?

From Camp Doc 2009

From Camp Doc 2009

The camp had a "health center". The center consisted of a small house with a great front porch. The main room was an evaluation and treatment room plus office combined. We would see the "patients" here, document the encounter on an index card, and if necessary, call the parents. There was a smaller room to the side and this room doubled as the medication dispensary and computer room. Campers who took routine pills--which was about a third of the camp's population--would present themselves to this window and get their daily ritolin or advair or atarol or zoloft.

From Camp Doc 2009

I found this "medicalizing" of what seems to be a generation sad, to say the least.

The health center had one "isolation room" and an infirmary area with 6 beds; a small hospital really. We used the "isolation room" to house our potentially infectious campers or staff. Influenza struck fear into the hearts of staff and parents. Some camps had severe epidemics of flu this summer and were forced to send home 40 to 50 campers with the illness. The camp where I spent my week did not want this to happen, so contagion control was paramount. I could not help thinking what camp must have been like during polio's reign of terror.

We had 2 patients in the isolation room at various times during my week, both counselors. One was the young man with pneumonia that responded quickly to zithromax. The other patient, a suave British, self-proclaimed male-model-turned-counselor, had a viral upper respiratory infection. He spent five days in the isolation room, though he made many trips to the front porch for some fresh air and conversation. Treated round the clock by a diligent staff of nurses and nursing students, the Brit whose accent rivaled James Bond himself, recovered nicely on a prescription of bed rest, hot meals delivered to his room, movies, wireless internet access, and--though I can't confirm it--a sponge bath from one of the nubile nursing students afore mentioned.

This guy was good. Real good. Ultimately the threat of deportation seemed to clear up his chest congestion just fine.

In the clinic, as we called it, we had only 2 diagnostic tests at our disposal. One was a rapid strep test and the other was a flu test. All other diagnostic testing required scheduling at an outside facility, which was difficult to obtain, and it required that the camper lose valuabe--and expensive--camp time. The funny thing about diagnostic testing is that if you have it available and it is easy to order and perform, you'll use it. If testing is difficult to obtain, you make due without it. We did at least 50 flu tests that week and a similar number of strep tests as well. All were negative. I only sent 5 or so people for outside diagnostic testing, though if an x-ray or CT scanner was more readily available, I'd have probably utilized that technology.

I enjoyed the week, all in all. I found myself smiling inside as I looked into an ear canal or the fundus of an eye. I palpated, auscultated & perscussed. I heard rales, looked for egophany, and, yes, sought after the illusive physical exam finding of whispered pectriloquy. I felt Sir Williams Osler's blood course through my veins. I had fun.

IMG00257-20090716-1215.jpg

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A doctor owns this house!

Holy molly. He must see lots of 99214's
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What medicine is supposed to be like

This week, I am camp doc. More to come.

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The start of a long deserved VK

On the Pt Jeff Ferry

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Long Time, No Post

It has been a long time indeed, several weeks, since my last post. Here's what I've been doing.

1. I have been tweaking my EMR
2. I have been improving my office workflows
3. I have been working om my iLabTQM project
4. I have been working on several internal based marketing campaigns
5. I have been adjusting my adwords and some other external marketing campaigns
6. I have been playing tennis
7. I have been spending more time with my family
   
8. I have been working

Hopefully I'll get re-inspired to blog.

Making use of a slow day in the office

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Fw: The time has come: Medicare for all, and now!

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---

From: Health Justice
Date: Sun, 24 May 2009 20:06:38 -0600 (MDT)
To: <rich@drschoor.com>; <fax@health-justice.org>
Subject: (Fax Receipt) I WANT EXPANDED AND IMPROVED MEDICARE NOW

TO: The White House Office of Health Reform, Senator Edward Kennedy, Senator Max Baucus, Speaker Nancy Pelosi and Senator Harry Reid.

I WANT EXPANDED AND IMPROVED MEDICARE NOW

Dear President Obama and Legislators:

You want a "uniquely American solution" to the health care crisis. So do I. Fortunately, we already have a uniquely American solution. It works. It saves money. It's called Medicare. It's the most popular social program in history.

I want expanded and improved Medicare now. For me. For everybody. Just like in Rep. Conyers' bill, HR 676.

Health insurance is not the same as health care. Insurance is for accidents. Health care is not an accident. I want health CARE, not health insurance.

Insurance company flacks and high-paid lobbyists twist the truth about Medicare. It's not "socialized medicine." Medicare is publicly financed, privately delivered health CARE. I have heard the nonsense about "government bureaucrats practicing medicine." The insurance companies paid Harry and Louise to twist the truth in 1994 and spout half-baked "facts" to defeat the Clinton plan. That tactic won't fool me again.

Medicare works for Americans over 65. It will work even better for healthier younger people. Quit looking for a solution that gives the insurance companies more money. Use what works. Give Americans under 65 the same right that seniors have - the right to guaranteed affordable health care with free choice.

Medicare for me. Medicare For All. Everybody In, Nobody Out. Now.

Please do the right thing for our kids, our nation, our economy, and vote for expanded Medicare for all.

Sincerely,

Richard Schoor , rich@drschoor.com, zip code 11787

Beyond the call of duty

Waiting in line to buy dance recital tickets, some people got here at 5AM.
Is it me or is it them?
I have an idea, sell the tickets online.
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Have a nice weekend

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Happy Mother's Day

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A picture is worth 1000 words

The easiest way to teach your medical assistant how to set up for a vasectomy or any other procedure is to show her a picture.
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A reason to get involved

I used to shun service on committees. I saw it as a waste of time. Now I volunteer for them. I've come to view this type of service as valuable on many levels.

Currently I serve as my hospital's PI committee. PI stands for Performance Improvement. We review adverse events and try to learn from them in order to become better. One tool we use is the RCA: the root cause analysis.

I've started to apply lessons I have learned in PI to processes in my own practice. I am now in the process of developing a repeatable system of PI, based on the hospital's, for my own office. When lab's don't make the chart or a patient is upset over a delayed returned phone call, I do an RCA. So far the initial results have been encouraging.

I'll keep you posted.
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Five ways to decrease call-backs

In a medical practice, phone calls are money pits, essential though they are. Doctors don't get paid for phone calls and the more calls a practice gets, the higher the costs. However, missing calls is even more costly, so the key is call management. Practices that manage phone calls well can benefit. Here are somes things you can do:

1: Track when calls come in and staff accordingly.
2: Track why calls are made and adjust operations accordingly.
3: Decrease call demand by use of e-Rx, printed materials, and an instructive website.
4: Manage patient expectations.
5: Use a patient web-portal.

While employing some or all of these tactics may not eliminate repeat calls, it will reduce them by 10 to 20 percent and free your time for more productive and pleasant pursuits.