Monday, November 26, 2007

Cost Consciousness and Medical Practice

An interesting article in the NYTimes on air travel reminded me of what has become of the experience of seeing a doctor. Basically, the article talked about levels of service on airlines and who gets what type of service and why. In the airline business, the overwhelming majority of travelers chose carriers based solely on cost. I include myself in this category. As a result, we have become loyal to the price of the seat, rather than to the airline itself. The airlines know that our loyalty and our business come only with low fares, and that our business will leave with higher fares, and they have determined that keeping us happy is no longer important. Now, the airlines can cut out perks that once made flying enjoyable, or at least tolerable. The fact that we complain privately and publicly is not important, since they can always get our business back by running a special deal. On the otherhand, people who are willing to pay for business or first class get treated like royalty. Wine, no lines, chateau-braind. Very nice. While both coach and first class passengers arrive at the destination at the same time, the high paying customers have a better experience.

Like the airline industry, people that can afford better care, either on their own or via the best of the best insurance plans, get better treatment. They can be seen without referrals, go to out-of network providers, and get any medication the doctor prescribes. They can even go to a concierge model physician practice. This is like flying business or first class. For the rest of us, we have to fly coach.

The costs associated with running an airline have risen dramatically over the years. So has the cost of administering health care or purchasing health insurance. In the airline industry, at one end of the spectrum low cost carriers exist that cater only to the cost conscious traveler. At the opposite end of the spectrum is the corporate jet industry that caters to the high end, low volume traveler that cares solely about convenience and comfort. In the middle, we have the typical airline company, like United Airlines or American, that have first and business class for the "out-of-network" travel and coach for the rest of us in-network only customers.

Comparing the airline industry to the medical profession is easy. Flying low cost only carriers is like going to a clinic. You'll get to your location, or get your care, but it won't be pleasant. Flying business class or first class is like going to a concierge medical office or a medi-spa. Not only will you get to the location, you'll have a great experience on the way. Flying coach on a major carrier is like going to the typical doctor. It used to be nothing fancy, nothing great, but pleasant enough. Now it is horrible. As the airlines get squeezed, and as the doctors get squeezed, and as we the consumers let everyone know that we care only about cost, the experience is becoming less and less tolerable.

I don't have a solution for any of this. It is just my observation. I suppose that if you want premium medical care, like air travel, you will have to pay for it yourself. Otherwise you can join the rest of us in the coach section of modern medicine.

Sunday, November 18, 2007

The world's cheapest full featured EMR-PM

Since my last post on my DIY EMR, readers have given me tips on how to make it even less costly. How does $0.00 sound for the software. Here's how:
This list ought to get you going and leave enough cash left over to pay the insurance bill.
Good luck.
The IU.
Disclaimer: While I have tried some of these programs, I vouch for none of them. I have no affiliation with any of these products and can not attest to their functionality or security.

Friday, November 16, 2007

MS Word & Your DIY EMR

Here are some features of MS Word 2007 that make it so attractive for a homegrown EMR:
  • Insert signature line: once inserted, you can sign it with the stylus. The program then locks the document to prevent any changes.
  • Built in PDR conversion tool: No need to buy acrobat. PDF is a great format for an EMR for a variety of reasons.
  • Insert inbedded files: The user can easily insert inbedded files, like bitmaps, with things such as illustrations, photos, notes, etc.
  • Change tracking: This feature is also on older Word versions. Allows the user to make changes with cross-outs, rather than erases. Makes for good transparency, ie spoliation accusation resistant.
  • Can easily create templates and record macros.
  • Phrase finishing: user can train program to complete phrases and sentences. Useful when documenting encounters quickly.
  • User friendly: very little training required.
  • Ubiquitous: Is pre-installed on most computers, and is compatatble with google documents and MAC OS.
  • Inexpensive.

In other words, it is an excellent tool for the homegrown EMR. AND, from what I've seen from many vendor sold EMR's, the basic platform that they use in their products. Kevin's right: why pay so much more?

The IU.

Thursday, November 15, 2007

DIY EMR: The essential elements

It's been almost 2 years with my homegrown EMR. Works great. For any of you in the 'sphere who might want to do as I have done, here are the essential or helpful elements:
  • Tablet PC with Windows XP Tablet edition
  • MS Office Suite 2007
  • Adobe Acrobat Reader
  • Efax Pro
  • Canon Multifunction F80 scanner/copier etc with included software or other brand
  • Cardscan business card scanner with included software
  • Linksys VPN manager
  • MySecureDoc encryption software
  • 1 DVD writer
  • 1 external hard drive
  • 1 off-site automatic back-up facility
  • Your own courage to go for it!
  • Adobe Photoshop Elements
  • Adobe Acrobat Standard
  • OmniForm
All the above is off the shelf, inexpensive (relatively so) and easily customizable and scalable. Each of the above programs are also very powerful and user friendly.

Give it a whirl. Let me know what you think.

The IU.

Wednesday, November 14, 2007

Going Green in Medical Practice

With all the talk about the environment, I was wondering how one could "go green" in a medical practice. Here's how.

  • Go paperless/EMR

  • Set the computers to power saving mode

  • Recycle shredded paper (even a paperless office has some paper!)

  • Practice the judicous use of antibiotics

  • Install water saving toilet flushers

  • Develop creative scheduling that promotes decreased medical waste

  • Do procedures with the lights off (joke)

A green medical practice.

The IU.

Saturday, November 10, 2007

Some Mistakes I've Made

Mistakes are part of life and cannot be avoided. As my grandfather, Pop Pop, used to say with his thick Russian accent, "Vichie, my mistake column is longer than my good decision column." Here are some mistakes I made over the last 18 months.
  • Makler Chamber: These are counting devices for semen analysis. $500 bucks each. Too labor intensive with regards to cleaning. I haven't used them in over 1 year.
  • Olympus Cx41 microscope: reticle counting grid compatibility issues with microcell counting chambers. Better to have gone with scopes used by RSofNY.
  • Overhead light source/OR light: waste of money $1200. Should have gone with a $50 lamp from Bed Bath & Beyond.
  • Bayer Automated Urine Anlayzer: $800 with 2 bottles of Multistix Pro dipsticks. Bad investment. Multistix Pro not reimbursed at higher level, except by M'Care. Lost money.
  • Phone system: $3000. On retrospect, still don't need it and could have gone cheaper with Cisco VOIP phones.
  • Cidex trays: Used for disinfection. $300+ dollars. Really glorified plastic trays. I don't know that I could not have just gone tupperware for much less.
And other still in progress and yet to be discovered. I will say before I go, however, that at the time, those purchases were well thought out and good intentioned, they just turned out to be wrong.
Hey, at least I didn't start a war by mistake!
Hope you enjoyed this post.
The IU.

Friday, November 09, 2007

My letter to Senator Clinton

Dear Senator Clinton,

Please accept my apologies in advance for interrupting you from your campaign for President of the United States with this letter, but I feel impelled to do so. I am a solo practice urologist in Long Island who sees many patients with Medicare. As you may be aware, the costs of practicing medicine in Long Island are high and proposed cuts in Medicare reimbursement would have detrimental effects on my ability to remain in business. Please vote against them so that I may continue to practice the profession that I love and to serve the people who have served our nation.

Our nation faces many challenges both domestically and abroad. Perhaps the struggles of our nation’s urologists seem petty and provincial when compared to the struggles faced by our military, our citizens without any health insurance, and our economically pinched working and middle classes. But urologists are vital members of any community. As employers and business owners, we give much back to the society that gives to us. Please vote no to Medicare cuts that would hurt urologists in general but solo urologists like me disproportionately.

Again, please accept my apologies for interrupting you on your campaign trail and I wish you the best of luck in the race. I certainly have been and will continue to be a supporter of you.


Richard A Schoor MD FACS

Wednesday, November 07, 2007

Automate, Automate, Automate

Automation is key, I've come to realize. Automation makes things go better. It allows for the staff and management to concentrate on things that require a human brain, such as judgment calls. At first glance, it may appear that a medical practice is not a great fit for automation. Certainly an auto plant lends itself better to robotic processes, but if you re-analyze your own medical practice, you can find processes that can be automated, and can thus become mindless and effortless. Here are some things that can, and should be automated.
  • Data entry: Forms can be scanned with an OCR reader and the data can be extracted and imported into PM software, all with a key stroke.
  • Communications management: Macro software exists that can reduce complex, redundant tasks to a simple mouse click. Items that come to my mind in this category are call forwarding, voice mail retrieval, and fax management.
  • Document management: This is where an EMR really helps, but even without one the process itself can be automated, only the robot must be a person.
  • Laboratory services: automated lab analyzers exist and are reasonably priced for good ROI. These devices can be run be someone with only a high school degree.
  • History taking: forms, whether they are digital or paper, can assist in data capture that is consistent, accurate, and efficient. Patients can complete the forms themselves or with assistance from doctor or staff. Forms can be automatically imported into the EMR with a simple mouse click.
  • Back-up: of course
  • Billing: charge codes (ICD-9 and CPT) can be captured directly from the digital encounter form and can then be exported automatically into the PM software to be submitted electronically and effortlessly to the clearance house.
  • Bill pay and EOB-check depositing are all ripe processes for automation.
  • Payroll, a no brainer
  • Savings: automated, continuous forced savings. Slow and steady wins the race.
And probably others.
Thanks for listening,
The IU.

Friday, November 02, 2007

On getting paid.

Occasionally patients just don't want to pay. Insured patients don't want to pay the co-pays. Self-pays don't wish to pay anything. "Why should I pay, you only talked to me." I don't understand this. As professionals, we make our money by dispensing advice, ie by talking.

It can be difficult to convince get someone to pay you. We are doctors after all, and people can tug at our heartstrings so that we "do the right thing." They'll give us all sorts of sob stories, and your staff will wish to waive your fees or to "bill them later." Resist this temptation. You have bills and obligations and are in no position to waive anything. If staff wishes to lower fees for a particular patient, they can take it out of their own salary rather than yours. Just my opinion. Here is how to minimize getting stiffed from patients.
  • Take credit cards
  • Have pay plans through outside companies (eg CareCredit)
  • Get the co-pay before the the patient is seen
  • Unable to verify coverage equals no coverage equals money up front
  • Unsure of benefits equals no coverage equals money up front
  • Don't be afraid to play hardball, which includes collections and litigation
The IU.