Monday, October 29, 2007

The MRSA Panic: This time, it's real!

My wife and I were having a discussion this weekend about the MRSA scare. We are both physicians, so we tend not to panic over these things.

We are also parents, so we tend to panic over these things.

In addition, as physicians she and I have had patients who are panicked. She asked me how I deal with their questions. I answered that I like to put the scare into perspective. Here's how I view it.
  • Fall 2007 MRSA
  • Fall 2006 Bird Flu
  • Fall 2005 Influenza, with no available vaccine
  • Fall 2004 SARS
  • Fall 2003 Mad Cow
  • Fall 2002 Anthrax
So in other words, the media for some reason that I just can't seem to understand, likes to scare us, in a public service sort of way.

In my view, the most significant impact of the MRSA scare has been on the cost-per-click amount for the keyword phrase MRSA. 1 week ago, I could have had my google adword banner shown for 10 cents per click at the top of the page. Now I am priced out of the market. In 3 weeks, after the media moves on to the next story, the keyword price will return to its usual levels. But by that point, MRSA profits will have dried-up.

So here's my take. If you have lots of money tied up in an anti-MRSA counter-top spray and you can't cash-out, panic. Otherwise, you have little to fear from MRSA.


The IU.

Saturday, October 27, 2007

My VONAGE experience summarized

I finally switched from VONAGE, my VOIP phone service provider, to Optimum Voice, a local Long Island company and branch of Cablevision. In the end, I switched because my 2 office VONAGE lines went dead and VONAGE customer service was unable to remedy the problem. I think the lines died because of incompatibility issues with my VPN router, but this is just my own, admittedly ignorant, speculation. Since I use the VPN router daily for billing purposes, and reconfiguring the router's settings would cost me hundreds of dollars, I decided to switch to Optimum Voice.

But please do not misinterpret my impression of VONAGE, which is this. It is an absolutely fabulous system. If I had to do it all again, I would pick VONAGE again, and again, and again. In fact, I kept my third VONAGE line, which I have in my house as another office line.

Here are some of the great features of VONAGE.
  • Cost: cheap
  • Simulring: I found this feature indispensable. As far as I know, only VONAGE has it.
  • Portability: Just re-locate the router
  • Caller ID: many phones have this, but not as good as VONAGE's. Trust me.
  • Call tracking: ALL inbound and outbound calls are logged. Other's services have this as well, but not quite as good as VONAGE.
  • Voice Mail-Email notification: This came in handy once in a while.
  • Network availability: great feature. If your internet goes down, VONAGE automatically forwards to a number of your choosing.
  • Others that I did not need, but are really cool. Go to the site.

Here are the disadvantages:

  • Unreliable: let me add a caveat. It is really only unreliable if the VONAGE routers are in line with other routers and switches, in my experience. My home VONAGE works fine.
  • Technical support: Only by phone, so if you have a major issue, your SOL. For minor issues, their phone support is OK.
  • Dropped calls: I had lots, but I think this had to do with my set-up, and not really with VONAGE per se. My home VONAGE phones does not drop.

That's it. In summary, I liked VONAGE and still do. I can contribute lots of my success to their ingenuity. Over 19 months, I never missed one call. Not one. I would recommend them to any small business.

Thanks for listening,

The IU.

Thursday, October 25, 2007

A load of garbage

I was surprised to see this headline on MSNs search page: Healthy Outlook. The article talks about an economic boom in the healthcare industry. Jobs a plenty.

There's only one problem: No money, horrible hours, difficult work environment. I wonder who sponsored the article?

Wednesday, October 24, 2007

My lab has achieved prestigious accreditation

Great news! My lab achieved the prestigious accreditation from COLA, a major accomplishment. In order to become accredited, a lab must adhere to strict standards of quality control and quality assurance. The accreditation process took 18 months, involved an on-site survey, completion of a 20 hour lab director course, and continuous commitment to quality laboratory processes.
Not easy, but well worth it.
The IU.

Friday, October 19, 2007

Threats from all sides

Recently someone recommended that I do a SWOT. A WHAT? A SWOT. In other words, an analysis of my practice's Strengths Weaknesses Opportunities and Threats, ie SWOT. I enjoyed doing the S and O portions of the SWOT, but the T was very disturbing, both in raw number and in ratio form with the O. In other words, my T/O ratio appears out of whack. Not good.

My threats include:

  • rising insurance costs
  • rising rent
  • rising payroll
  • rising administrative costs
  • increasing oversight
  • increasing regulation
  • declining reimbursements
  • litigation threats

Then yesterday, KevinMD ran a link the following post:

Damn! I guess I now need to add that to my SWOT list. What if I just bought product A then United Health Care demands I buy product B, then Blue Cross demands I buy product C? Then what? Sheer craziness. I suppose it is legal for them to do that, but it strikes me as problematic.
In any case, I'll add it to the T's, which now vastly outweigh the O's.

Most of my threats are similar to threats to other doctors. Some may find some perverse comfort in the fact that we are all on a sinking ship together, but not me. I believe that when the bow of the ship goes under water, and the stern rises into the air, it'll be every man for himself. And it won't be a pretty picture.

Threats from all sides. How will it end. . .?

Wednesday, October 17, 2007

Have a problem? Talk it out.

My MA has been causing me some aggravation. As I said, she is fresh out of school--in school actually--and is doing her externship with me. She is a blank slate. Blank slates are good for many things, but they cannot be relied upon to send urine specimens to the lab.

As a urologist, I see many people with UTI's, or UTI related symptoms. I send many urine specimens to the various labs for culture. For my first 1 1/2 years on my own, our accuracy in sending patient specimens to the correct lab at the correct time was 100%.

Now that accuracy has fallen, and with that my headaches have returned. What am I to do?

Well, only one thing in my experience works with people, and that is talking. I asked her, "What can I do to make your job easier and improve your accuracy?" 60 minutes later she walked into my office and asked "Can I make a suggestion." Absolutely.

Her suggestion was to keep a running tally of the patients seen and the specimen to be sent, and at the end of the day she and I would spend 5 minutes confirming that patient A needed a urine culture, patient B needed a cytology, and patient C needed only a UA, ect.

Good suggestion, and you know what; it works.

Talking! Who knew?


The IU.

Tuesday, October 16, 2007


Much has been written, recently, about the positive effects of apologizing. Some risk managers tell us to say "I'm sorry" when we mess-up. They believe that these words can prevent a law suit from being brought forth, and thus recommend that we do it. Maybe. To that effect, every so often I read in the paper about a plaintiff who said something to the effect of, "Had the doctor just apologized, I would never have sued." Yeh, yeh right! At the risk of seeming cynical, which I am not, I believe that these people do not understand forgiveness.

I believe that we, as people, apologize because it makes us feel better. And sometimes it gets us off the hook. I think we learn this as children.

I do believe that the recipient benefits from an apology. Namely it makes them--the recipient--feel better. Most importantly, the act of forgiveness is very therapeutic to the forgiver, rather than to the person who is apologizing. It is simply unhealthy for people to hold onto anger and internalize it. So lets say that I am a big believer in the power of the apology. I'm just realistic about it what an apology can accomplish and when it ought to be used.

For example, should people be absolved of their wrongs simply because they apologize? I don't believe so. Recently, in NY, a woman had a bilateral mastectomy due to lab error. I don't think an apology would suffice in this case. Moreover, the error was the result of short-cuts taken by the technician in the lab. Something tells me, that his apology to the boss found deaf ears, as it should have. The technician may have been fired, but the owners of the lab may lose their livelihoods over this incident. No, I don't believe that an apology means much in this case.

In my own office, I had a receptionist download a file sharing program on the office computer. I discovered it instantly. She immediately apologized, but I fired her on the spot. Her contrition would not have corrected the many problems her act could have caused, such as data loss, data theft, or an RIAA lawsuit. Her apology meant nothing to me.

Two years ago, my 4 year old pushed my 1 year old, who fell down a step. The 4 year immediately apologized, because she saw that I was angry. I responded, "I don't care that you are sorry" and then I explained to her that her apology does not undue the pain she caused on her sister. The 4 year old--an exceptional 4 year-old--understood, and she has never pushed her younger sister again.

I think we need to re-learn the purpose of "sorry." If you find yourself apologizing for personal gain, you are doing it for the wrong reasons. The goal ought to be for healing. If the goal is for healing, and healing alone, then it'll be accepted.

Anyway, just my thoughts.

I thank you for your time.

The IU.

Friday, October 12, 2007

Memory Lane

I just found this picture.
My first day of surgical internship at Northwestern Memorial Hospital.
July 1994.
I was 26 years old. Bright eyed and bushy tailed. Eager and energetic.
I am holding up my rounds list, the first of many.

A band aid to the rescue

Sometimes your organization can be in such disarray that you need major surgery to fix it. Other times, a band aid is all you need. Recently, I applied a band aid to my own practice. I purchased a cart.

The cart is stainless steel, has 3 shelves, and sits on 4 wheels. It is approximately 24 inches wide by 36 inches long, and 36 inches high. I keep my portable sono unit on the top shelf and I keep the various probes on the middle shelf. On the bottom shelf I keep the phlebotomy kit, fully stocked, and the power cord for the sono unit.

I do a lot of scrotal sonograms for male infertility in addition to performing pelvic/bladder sonograms for post-void residual urine assessment. Often I have to change probes several times per day, or I need to re-charge the portable battery on the unit at random times. Because evrything sits on the cart, I can do these chores quickly and effortlessly "on the fly."

When I have a vasectomy, I place the sono unit on the middle shelf, then drape the entire cart in a sterile drape. I then place the vasectomy instruments on the spacious top shelf. I usually begin my vasectomies on the patient's left side, then I move on to their right side. I just wheel the cart along with me.

Within arms length of the cart, on the right side, is the counter top. On the counter top I leave open the paper wrap from the sterile gloves. As I use up the sharps, I place them on the paper wrap to my right side. At the end of the vasectomy, all that remains on the cart is non-sharp garbage, the soiled vas instruments, and the vasa themselves. Within 1 minute after completing the vasectomy, I can have the used instruments in the sink, the vasa in the specimen bottle, the sharps in the sharps container, and the remaining waste--wrapped in the sterile drape--in the garbage can. Voila! Done.

No wasted motion. Efficiency. And as far as a vasectomy can be, a thing of beauty.

And all because I purchased a cart with wheels.


The IU.

Tuesday, October 09, 2007

Gone Digital? 6 Essentials of Back-up

Though I'm no computer expert, I have an EMR, and I have had crashed drives and lost data. I've learned the hard way how to prevent data loss. Here are 6 crucial elements for back-up systems.
  1. Automatic: Your system should back-up without your needing to ask it to do so.
  2. Redundant: You must not leave all "eggs in one basket." This way, you will never lose your data.
  3. On-and Off-site: What if you have a fire or flood in the office?
  4. Daily: If you see more than 5-6 patients per day, you will not be able to remember encounters, let alone billing details.
  5. Versioned: If files are corrupt, versioning will prevent the corrupt file(s) from being propagated to subsequent back-ups.
  6. Recoverable: Back-up is only as good as your ability to retrieve the lost data.

If you have an EMR, you need to back-up.

Any other suggestions?


The IU.

Tuesday, October 02, 2007

A decent way to send and document certified letters

Remember Mad Libs, those funny word games available when we were kids. They were basically stories in which the critical verbiage, adjectives, or nouns were left blank, to filled in by you. Depending on your own creativity, it was possible to create some pretty funny things.

Sending certified letters to non-compliant patients is not funny business, but can be made easier by applying a Mad Lib approach to it, only without the funny adjectives, adverbs, and nouns.

Before I had an EMR, I had to dictate the letter, have it transcribed and printed, then I'd have to review it, make any necessary changes, then repeat above process. That is how I used to do it when I was part of a group. Worked well so long as you can afford a huge staff.

Now that I'm solo, I'm more frugal, and I have an EMR--a home grown one--but an EMR nonetheless.

Here is how I did it until recently. I created a template letter with the date, patient name, DOB, and Dear SoAndSo fields left blank. When generating a letter, I would simply insert the above information, print the letter, sign it, scan a copy back to chart, and send the original. Of course, we would save all the USPS documentation for proof.

Now I think I have even improved the process some more. Currently, I simply print out the blank template letters, have my staff write, by hand, the name, date, and etc onto the letter. The staff then brings the letter to me. I sign it. The letter goes back to staff, who then scans it into the patient chart, places it in the envelope, and then mails it with certified forms attached. We retain USPS forms, which are scanned into the patient charts as well. Takes about 10 seconds per letter, if that. Scanning time for the staff, with an automatic document feeding scanner, is only slightly longer.
My system certainly lacks the prettiness of what you'd expect from an expensive EMR, but what it lacks in style points, it makes up for in efficiency.
Let me know what you think,
The IU.

Monday, October 01, 2007

Can't sleep? Audit yourself.

Are you certain that your documentation is good? Are you sure that all labs have been received and filed correctly? Have all your bladder cancer patients had their cystoscopies and cytologies?

Well, though I'm sure you pride yourself on your recall systems, documentation, audit proof EMR's, and lab follow-up processes, despite the best of intentions, things will slip through the cracks. So if you are worried, and you should be, do an internal audit before someone else does it. You'll be surprised at what you find.

  • Do your consults have associated referral letters
  • Do your no-shows have documentation regarding attempts to contact them
  • Are all the ordered labs and studies in the charts
  • Are certified letter documents in the charts
  • Do all encounters have written notes
  • Are informed consent discussions documented
  • Are phone conversations documented
  • Are all email communications saved in the chart
  • Does the documentation fit the coding level

I know that good EMRs can do lots of this for you, but I still believe that random audits are warranted. We do them and find things frequently. I recommend it.

The IU.