Friday, June 29, 2007


I finally decided that enough is enough with VONAGE and have decided to phase it out slowly. Here is my plan.

I desperately do not want to lose my phone number or have a major disruption in service. So, I am going to add 2 additional optimum voice lines for a total of 3 lines in a call hunt grouping. Call hunt, for those who don't know, allows incoming calls to jump from busy line 1 to busy line 2 then to open line 3. I now have 3 VONAGE lines. The main line, 631-326-6035, will jump to line 2 when busy. I actually do not know the phone number for line 2. My 3rd VONAGE line is at home, and I use this line to make and receive patient related phone calls after hours. This line is not part of my call hunt sequence, but after hours, calls made to 631-326-6035, my VONAGE line 1, will forward to this home line. Interestingly, this phone line has never dropped a call, though it's call volume is negligible.

I have one Optimum voice line, which I use as a private line for outgoing calls and as a fax line for outgoing faxes. Incoming faxes come in via EFAX. This line has been very reliable, though again, with a lower volume of calls, so who can really say? For some reason, this line's phone number is listed in the yellow pages--the free listing. Why do I mention that? Because, in April and May of 2006, when former patients of mine tried to look me up in the book, they found my listing and called the Optimum voice number, which rang and rang and rang. Fortunately, my patients are my greatest assets and they told me about the problem, which I corrected by forwarding Optimum Voice line 1 to VONAGE line 1. Voila, solved. Crisis averted.

So here is what I plan to do now that VONAGE has caused my hairline to recede to the apex of my skull. I am going to keep VONAGE line 1, but forward it to optimum voice line 1. Optimum voice line 1 will then call hunt to lines 2 and 3. VONAGE line 2, the number I don't know, I plan to use as a back line and outgoing fax line. VONAGE line 3, the one in my house, I will keep as is. If after several months, everything is working fine, I'll probably start to pear back the system, and screw everything up.

Now I just need to figure out which phone jacks receive their signals from which phone number. And for this, I need to go pro, at $85 per man per hour, not including parts.

Did you ever think a phone could be so complicated. Well they can be. Any suggestions from the 'sphere.

Thanks, the IU.

Why I won't be getting an Iphone.

I want an Iphone. I really, really want an Iphone. They look cool. They look fun. They all kinds of cool features. It looks like a really fun toy.


I don't purchase toys for my practice. If I had a need to surf the web on my phone while seeing patients, I'd buy an Iphone. If I became lost in my 1100 square foot office, and needed GPS, I'd buy an Iphone. If I became bored when consulting with a patient and felt like listening to some music, I'd buy an Iphone.

But there is one thing I could use te Iphone for: email. Of course, I don't need an Iphone to do mobile email. But perhaps that is a good enough reason to justify the purchase. . .

Wednesday, June 27, 2007

Vonage: A Biopsy Story

You know I have a love-hate relationship with VONAGE, my VOIP phone service provider. Well, the other day I was in the process of telling a patient about his biopsy results. Here's how it went.

"Hi, it's Dr Schoor. I'm calling with your biopsy results."
"Oh, thanks doc, I'm really stressing over this."
"OK, the biopsy was" click.

Dropped call.

Somehow, I don't think that that'll end up in one of their commercials. Though I still, on the balance, have liked VONAGE.

Thanks, The IU

Sunday, June 24, 2007

The 4 types of urologists

I was having a discussion this weekend about the nature of private practice vs academic practice on my way back from the city and I'd like to share my thoughts with all 4 of my readers, plus mom.

As I see it, there are 4 types of urologist--or any physician for that matter. The 4 types may be classified as follows:

1: The academic hot-shot: this is the superstar academic physician. This doctor has NIH money as well as pharma dollars and is a consultant for many companies, either pharma or medical device or both. This doctor does very well financially and has a very secure future, since he or she can take their credentials with them wherever they go. These docs are the leaders of the specialty and influence, for better or worse, how the rest of us practice.

2: The typical academic physician: this physician sees the patients in an academic urology practice. They can get some pharma dollars or serve as consultants to medical device companies, but this is really not a significant source of income for them. These doctors are the worker bees of the academic practice, and to an extent, support the galavanting superstars. This type of typical academic physician serves at the whim of the chairman and/or board of governors and can be canned quite easily and mercilessly. These doctors grumble quite a bit.

3: The typical private practitioner: The most common type of urologist. Very hard working and very competent, these doctors roll with the punches and constantly adapt to the changing market place. They will always do well, yet they never feel in control, and complain quite often. The react to changes in the medical marketplace, though some react faster than others. Many, someplace along the line, lose their passion for the field and consider their specialty as a job. Que' lastima!

4: The private practice superstar: This is the go to guy, the urologist's urologist. This doctor sees only people on an out-of-network basis and commands high fees, yet has high volume as well. This type of urologist/doctor has extraordinary vision, foresight and business saavy. They have the ability to develop a practice that seems impervious the problems that plague the rest of us. These docs do very, very well.

5: The doc who thinks he/she is the superstar and yet is not. Of course, this is the largest of the categories.

Just some food for thought.


Thursday, June 21, 2007

How to ask for the co-pay...and how not to.

Getting co-pays is critical for your practice. Your cash flow depends on it. In general, patients have no problem ponying up the co-pay. They do it gladly. However, there are certain methods of asking for the co-pay that can increase--and decrease--whether or not you get it that day. Here is how to ask for co-pays if you DON'T want to collect them the day of the visit:

  • "Would you like to pay your co-pay now or later?" 5/5 will say, "later."

  • "Would you like to pay your co-pay now, or should we bill you later." 4/5, in my experience-->"bill later."
  • "How would you like to pay your co-pay?" Too open ended. Open ended questions are great during a medical history, but not when you are trying to collect money.
  • And of course the worst way is to see the patient first and then say, "Ok thanks" and then just send the bill for the co-pay. Oh, yes, this happens in many offices because the staff is just too busy and does not understand the importance of the co-pay.

Here is how to ask for a co-pay:

  • "I see that your co-pay is x-dollars. Will that be cash or check today." And of course, it is collected BEFORE the patient is seen.

That is the best way.

Of course, we don't deny people service because they can't pay the co-pay right then and there, but it does serve to let the patients know that we take co-pays seriously and that they will receive a bill in the mail, and that they will be expected to pay it.


The IU.

PS: How would you like to pay for this practice management tip, bank check or credit card?

Tuesday, June 19, 2007

Email and the solo doc

Email is a great way for a doctor to communicate with patients, despite it's drawbacks. In my practice, patients have been using email more and more frequently, and I think it is a good thing and welcome it. It makes me more accessible to my patients and is less intrusive on my own life. For example, in Father's Day, 2 patients had quick questions for non-emergent conditions and sent me emails. Since I have a habit of hitting "send/receive" every time I pass my MAC, i got the messages promptly and replied. No biggy. As I said, I like communication with email.

Here is how I deal with emails.

Patients are given the option to communicate by email, but they must sign an email consent form first. The consent discusses all the possible negative consequences of email communication and If you'd like mine, just shoot me an email.

When patients send me emails, I reply, then I save the initial question and my reply in the patients folder under correspondence. I save the email as a text file and date the file as well.

And that is it. Nothing fancy. Totally simple.


The IU.

Monday, June 18, 2007

More on EMR's

I have been having discussions recently, with knowledgeable people, on one of my favorite topics: the EMR. One person, a patient of mine, was an EMR purchaser for a major hospital, so I think she may know something. Here are some salient points we came up with that you may want to consider before committing to an EMR.

  • Up-front cost: Of course this is important and obviously so, yet people still get mesmerized by the bells and whistles of a system and the vendor's claims of "ROI." Here's the real deal. If you are a primary care physician who makes, on average, $35 per encounter, you will need to see an additional 4285.7 patient visits to offset the cost of the $150,000 EMR featured in this NYTimes article. In other words, a primary care doc will need to see 12 additional patients per day x 7 days per week just to pay for the initial EMR cost.

  • Up-grade costs: Have you ever wondered why Windows keeps changing it's perfectly good operating system, for example from XP to Vista, every couple of years. Windows does this to make money. Of course, when you have a personal computer, you are under no obligation or professional stress to up-grade, plus, as a consumer, the up-grades are relatively inexpensive. Now consider your EMR that you purchased for $5000 to $150,000, up-front. Every 6 to 12 months, without question, the vendor will hit you for an upgrade. Perhaps upgrades in the first year or 2 will be free, but they won't be free forever. Sooner or later, they'll get you for possibly thousands per year in upgrade costs. And what are you going to do; not pay it and let your system crash? Will you switch to another vendor and start again? I don't think so. You will be held hostage!

  • Service contracts: Have you ever called, for example Dell Computers. If you don't have a service contract, they can charge $100 per 15 minutes. Dell has great customer service and their setrvice contracts are cheap: ~$250 per 3 years. Now consider this; have you ever seen anything "for medical use" be cheap? Absolutely not! Service contracts for EMR's typically start in the $500 per 6 month range and go upwards. I know of one that costs $12,000 per year. That is more than some docs pay for liability insurance. And you have to pay this because the systems break down--even the "good" ones.

  • Reliability: I'm actually talking about the vendors now. EMR sales are expected to skyrocket in the next 6-7 years, so we are in a sort of gold rush, with the EMR vendors being analogous to the prospectors of 1848. Many vendors, in fact most, will not survive. Now I want you to imagine that you select an EMR for $5000--cheap for EMR's--and the software comes with free upgrades and service for 12 months. You convert everything to electronic after hours and hours of effort and money, and then the company stops answering their phones when you need them. Now what do you do? You have all this critical information that may or may not be transferable to another EMR program. In other words, choose your vendor carefully and if possible, get psychic powers.

  • Ownership: Some companies are promoting use of their own EMR online services. These services are cheaper as there is no expensive software or hardware to purchase upfront, and there are no installation costs, but I have some concerns. One major concern is: who owns the records; me, the patients, or the vendor? You better read that contract carefully, or better yet, get a lawyer to read it. You may surprised. Medical charts--paper ones--that were stored in Iron Mountain Storage after a California HMO implosion in the early 1990's cost millions to retrieve, and some charts were lost forever. Personally, I don't see a difference between electronic vs paper storage. Storage is storage and physical possession is everything.

  • Work-flow: Most EMR's that I have used or demo'd force the user to alter their own typical work-flow routine to fit that of the computer program, rather than vice-versa. Now this may not be a bad thing, but I know many very excellent physicians who can crank out patient visits and still leave the office on-time, with charts completed at the end of the day. For these docs, which I believe are the silent majority, EMR's would actually add inefficiency.

There, I have said my peace. And I am a staunch believer in EMR's. But they are just too expensive and if they are supposed to benefit the payers, as Senator Clinton points out, then let the payers purchase them for us. Until that happens, proceed with caution.

Hope you enjoyed the post.

The IU.

PS: Thanks SeaSpray for the Father's Day Wish.

Wednesday, June 13, 2007

EMR: Toys vs Tools

In an earlier post I wrote about the difference between toys and tools. I recently came across an article in the NYTimes regarding a 3 physician group who purchased a $140K dollar EMR with $50K in service contracts. In the article, the doctors state that the advantages of their system gave been largely non-economic: they have been able to downsize staff by 3 and have saved somewhat on transcription costs, but otherwise it has been a loss.

I can understand why. They spent too much and must not have really run the numbers. I think they purchased a very expensive toy, rather than a tool.

When buying an EMR, running the numbers and doing the analysis is everything.

More later/

Wednesday, June 06, 2007

Going solo? Have phone drills.

I overheard 3 recent phone call encounters. Here's how they went:

So my question was, what the hell was going on? I decided to ask the receptionist, one of the new hires, what the phone calls were about.

  • Call 1 was from someone who asked for our address, but she did not enquire as to who was calling or for what purpose.

  • Call 2 was from a person who asked if we take credit cards, but my receptionist did not know who called or why they wanted to know whether or not we take credit cards.

  • Call 3 was from a person who wanted their records sent to someone, only the receptionist did not ask for the patient's name or to whom they wanted the records sent or why.

Well, that is certainly not how I want my phones answered, and I could get angry at her, but the anger should really be directed at me. See, one can not assume that someone would or could know how you want the phones answered and what information they need to get from the caller. Some training was needed and I dropped the ball. No doubt in my mind, call #2 was from a new patient, so I lost some potential income. Serves me right!

Since the phone is the life's blood of a practice and the first, and perhaps most important, encounter that people have with you and your practice, phone training is essential for new hires. I knew that, and didn't do it. Now we drill the new hires with a variety of phone scenarios. As a mystery caller, I call my own office and ask the following questions.

  • "Hi, is this Dr Kim's office?"

  • Is this Suffolk Urology Associates?"

  • "What is your address?

  • "Do you accept United Health Care?"

  • "Do you do vasectomies?"

  • etc

The answers to the above questions are not simply yes or no. Instead, I have trained my staff answer those questions with questions and to try to elicit from the callers their names and the reason for the call and if it turns out that the caller is a new patient, to get them in the front door.

Poor phone skills can cost money. Lots of it. Phone training is critical!


The IU.

Monday, June 04, 2007

Another reason to answer the phone: word of mouth

I answer my phones after hours. Other doctors say I'm nuts to do this and tell me that one should never give out personal cell phone, home numbers, etc, to patients because the patients will abuse it.
Wrong, wrong, wrong!
I have been doing exactly that for 15 months and not one patient has ever abused it. What has happened is that word of mouth regarding my availability to speak on the phone and my reach-ability has spread like wild fire and my practice has grown. Patients and their families consistently say things like, "I've never seen any other doctor be so reachable." And then they volunteer, "I'm going to refer you to my friends."
Music to my ears!
Maybe one day I'll get tired of it, but I doubt it because it really is no big deal, patients like it, and not only does it cost nothing, it makes me money. Placing less barriers between you and your patients, while counter intuitive, is actually better for everybody; patients, referring docs, and you.
The IU.
ps: the above picture was taken by me at Robert Moses State Park, about 15 miles from Smithtown.

Sunday, June 03, 2007

Minimize phone lines-Maximize phone power.

The phones are your practices life's blood. You must keep the phone lines open for callers, yet your staff must be on the phones for a variety of important reasons, such as to confirm patient appointments or call insurance companies regarding claims. Thanks to VOIP and PC calling, you can have relatively few expensive phone lines, such as from Verizon or ATT, etc, but have a several PC phones on every computer. I use a service called SKYPE. SKYPE used to be free--100% free--but due to its popularity, it began to charge a whopping $29 per year--YEAR!!!--for unlimited PC to phone calls anywhere in the USA and Canada. SKYPE to SKYPE, anywhere in the world, is still free, and will always be free. I use SKYPE in my office frequently and have it on each computer. My staff and I use SKYPE to make all outgoing calls to insurance companies and doctors offices, any place where you may be placed on hold for a long time.

Just a little pearl of wisdom from the IU to U.

Friday, June 01, 2007

More on answering the phone after-hours.

I know I risk sounding like a broken record, but it seems that 2-3 times a week I am rewarded just for answering the phone. Here are 2 of the latests successes:
  • Last night a woman called at 7:45 PM to enquire about getting her husband an appointment for a vasectomy. The call was forwarded to my vonage line at home, which I anwered while trying to put my girls to bed, and booked the patient.
  • A patient was given the numbers of 2 urologists for a vasectomy, me and another, established urologist. The patient called the established urologist first, but they did not answer the phone. He then called me, we answered, and I did the vasectomy yesterday. Not only that, he had such a good experience in my office, he let me know that he would tell others to come to me.

Answer the phones. It is really that important.

The IU.