Is it time for a contrarian approach?

I spent last week in Florida. One fine day on the beach, I witnessed an interesting natural event. Some beach goers began to toss bread into the air and immediately 30 to 40 seagulls flew over to get some food. It was a frenzy and the birds seemed to be fighting each other over food. It reminded me of life as a doctor in NY.

Then I saw something amazing.

One bird--and only one bird--stopped participating in the melee and instead flew in the opposite direction toward the sea. Once there, beyond the cresting waves, this bird hovered and then made several dives and pulled out a fish. While his competitors were fighting over crumbs and hand-outs, this contrarian bird went solo and came out ahead.

It got me thinking. Do I fly with the other birds and fight like mad for some scraps. Or do I go the other way, beyond the cresting waves, so I can feed in the blue waters of no competition.

It was a nice day on the beach!

To send to collections or not, that is the question.

The decision to send people to collections or to simply write off bad debt is a difficult one to make and should not be taken lightly.  You and your managers need to balance the difficult economic times that we all face with the business's own needs for cash flow.  In addition, sending people into collections is unpleasant and I think it just feels wrong.  As a human being, I can understand that difficult choices that many people face in deciding where to spend their hard earned yet meager wages.

Despite these challenging times, most people pay their bills conscientiously and feel ashamed at not
having the ability to do so.  Even people who can not pay the bill in full are eager to pay in installments, even if it is a small amount per month and others are happy to accept a settled amount and pay it on the spot.  Most people just don't like to "stiff" another person. 

However, there are others, a very few, who brazenly withhold
payment as if they can do it with impunity.  They answer their phones and simply refuse to pay or they say they'll call back some other time and then never do.  Others say that the check is in the mail when it is not.  A very few even write bad checks.

They are the deadbeats and
these type of people plague every business, even
medicine.

I recently, 2 years and 9 months into my own practice, have decided to outsource my deadbeat accounts to a collection agency.  This was prompted by several events:

• I have been seeing a patient I know to be a deadbeat around town, eating out in restaurants and having Starbucks coffee.
• I have had several people simply refuse to pay their co-insurance because I did not "do anything"--other than provide them with information and advice.
• I've had a few people become very belligerent to my staff as they tried to collect moneys.

In my practice, deadbeats owe me in excess of $10,000 dollars.  That is a lot of money.  I need that money to pay my staff and my vendors and my bills.  Though I only came to this decision after several years and some glaring examples of "how not to act when you owe money", I have finally come to grips with the notion that sometimes you just need to resort to a collection agency.

I just never thought I'd have to do so.

Dr S

A new blog.

I just started a new blog at WordPress on andrology. I want to see how long it takes me to get it noticed by the organic search engines.

Check it out: The Andrology Blog.

My New Years Business Resolution

Someone in the Enteprenwur Group ask the question about business plans for next year. Here is my answer.

• reviewed and revised my business plan for 09.
• upgraded to EMR-PM system
• Hired coding consultant
• Hired lab consultant
• Plan to expand lab test menu
• Improve marketing: email, direct mail, targeted mail, blogging, adwords, twitter
• Increase referral base
• Outsource collections for deadbeats
• Improve collections: check scan, cc's, EMR-PM, cash
• Answering phones 24/7
• Making it easy for new patients to book and be seen

Anything else that I'm missing?

Dr S

Disney's use of technology and what a doctor can learn from it.

I spent the past few days at Disney World and among other things, I was amazed at how they have improved their technology usage since my last visit, only 3 years ago. While I have no doubt these improvements did not come cheap, I also know they enable Disney to make money more easily and efficiently. Here are just a few that come to mind immediately.

• Smart room keys: your room key doubles as a charge card and park entrance pass
• Biometric scanning: upon entrance, adults have to scan their index fingers which get matched to the park pass and to the kid's entrance passes
• Photopasses: photographers line Main Street and Hollywood and Sunset taking pictures of guests. Image numbers are infrared scanned onto cards which can be usd by guests to purchase the pictures on line
• Ride-photography: at the end of roller coasters and flumes, guests are shown pictures of themselves during the "big drop" and the pictures can be purchased right there
• Remote card processors: all vendors, even the portable street ones, accept credit cards, room keys, or any sort of electronic form of commerce, as payment

So how can doctors learn from this. Technology that enables more efficient billing, verification, and documentation will help you save money and make money.

Good technology can well worth the cost of implementation.

Dr S.

The 5 Key Elements of Any Business Plan

Whether you plan to open a bagel shop or a solo medical practice or to attempt to advance your own career while an employee within an established group, you must develop a business plan.  Here are the key elements to a good business plan:

Revenue Sources
Operational Costs
Capital Requirements for Start-up
Critical Success Factors
Key Risk Factors



Think about each of these 5 elements and brainstorm as much about them as possible.  You'll find that with this disciplined approach, you'll avoid making some costly mistakes and maximize your chances for success in the venture.

If you don't understand or have the time to make a plan yourself, you can use a number of resources, such as The Entrepreneurial MD, et.al. 

Good luck,

The IU.

Size Does Matter: Go Small

Everyone wants a large office.  I think that is an ego thing.  For me, I'll take too small rather than too large anytime.  Larger offices, like larger houses, have costs that smaller spaces just don't have. 

• Rent--most of us pay per square foot.  Obviously, the more square footage, the more you pay.
• Cleaning--larger offices cost more to clean that smaller ones.
• Heat--see cleaning
• Cool--see cleaning and heat
• Wallpaper--see above
• Carpet--see above
• Clutter--more space = more clutter = decreased efficiency

The only exception to this rule is if the office does not have sufficient working space to maximize patient flow.

If in doubt, in my opinion, go smaller rather than larger.

Dr S

Going Solo? The Turnkey Medical Practice: 2.0 Style

I know I have written previously about how to start a practice from the embryo stage on up, but here it is again, parred down to its bare essentials:

1. Get or develop a detailed business plan that will serve as a blueprint.
2. Get a mentor or coach or other such trusted adviser.
   
3. Get credentialed with insurances, hospitals, et al.
4. Get professional liability insurance.
   
5. Get a phone number.
6. Get a web-presence.
7. Get office-space; sublease, lease, or purchase depending on your unique situation.
   
8. Get a good EMR-PM system.
9. Get a payroll service (also does statutory insurances for small businesses).
10. Get an employee.

That is the list. Easier said than done and each step has many and multiple sub-parts. Still, just 10 steps.

Good luck.

Dr S

A New Car--A Vas Reversal

I recently traded in my Honda Accord with 114,000 miles for a used, mint condition, 2005 Accord with 26,000 miles. What could have been a difficult and cumbersome transaction was smooth and pleasant because all parties involved assisted each other and were motivated to make it happen.

My experience int the car dealership got me thinking about the differences between exceptional medical practices and typical ones.

• In a typical practice, staff is harried and just wants to push you through the system with as little effort as possible.
• Exceptional practices provide assistance and encouragement with all aspects of the experience and go the "extra mile".
• The typical practice just wants patients with good insurance; i.e. insurance plans without much hassle factor.
• Exceptional practices want cash paying paying patients.
• The typical practice is not equipped, psychologically or operationally, to handle cash pay patients and the challenges that this type of patient brings to the business.
• The exceptional practice has developed the skills, techniques, and mechanisms that make it easier for patients to WANT to pay out of pocket.
• The typical practice adds little added value to the encounter.
• The exceptional practice does little things that add value for the patient, and in turn the patients--or their insurance carriers--are willing to pay extra for them.

Essentially, my experience a the dealership taught me that when all people involved are motivated to make the sale or provide the service, business gets done.

Kind of like when we see our vas reversal patients.

Dr S

December Goals

Thanksgiving is over and December is upon us.  December can be a slow month.  Do you have plans to turn it around?  Here are things you can try.

1. Send a mailing to all your existing patients, either as a holiday card or a flyer.
2. Make a newsletter and send that to your existing patients and referring docs.
3. Update your website.
4. Blog and then blog some more.
5. Review your online marketing campaigns.
6. Send "thank you baskets", etc, to your good referrers.
7. Invite your best referrers to dinner.
8. Send something useful to your referring docs, like an article or hyperlink.
9. Keep your phones on and manned.
10. Open extended hours.

Good luck and have a good December.

The IU.

Happy Thanksgiving!

From Portraits 11/27/08 1:02 PM

Selection Criteria for an EMR-PM Purchase

I suppose that these criteria--the ones that I used--are as good as any out there.

1. Listen over a 2 year period to see what others are using and what their experiences have been.
2. Check the KLAS reports.
3. Check the CCHIT lists
4. Check the state medical society lists.
5. Define your own needs.
   
6. Call the top 10 vendors and see who answers the phone.  If they don't even answer for a sales call or get back to you promptly, you can forget about customer service and support.
7. Set up appointments to demo the systems.
8. Get references.
9. Contact the references and ask what they don't like about the systems.
10. Pull the trigger and make the purchase or continue the search.

And then layout the big bucks!

Good luck.

How to Convert an EMR From A Cost into a Profit Center

Good EMRs are very expensive. I am about to upgrade my homegrown system into one of these very expensive yet equally powerful programs. In order to justify the expense, I've brainstormed some ways to convert the EMR from a cost center into a profit center. If I were to use the system in the following ways, I think I could actually increase my revenue in the coming years.

1. Increase contact with referring MDs and patient providers.
2. Use the system's data mining capabilities to augment marketing to specific patient groups.
3. Improve my practice's operational efficiency and then market that.
4. Automate time consuming and error prone processes and then free up staff time to market for me.
5. Use the software to more efficiently evaluate practice patterns and then transition into more profitable areas.

I'd love to hear from others about additional ways to make an EMR a profit center.



The IU

THE ANGRY JUROR

I had jury duty today. Essentially, it was easy and relaxing and a nice break from my otherwise very hectic schedule. If I was an employee of a big company or a school district or some public job, I'd have even loved to serve on a jury. However, in my case every day out of the office is lost income so I was a bit nervous at the possibility of having to serve on a 3 week trial. Knowing my luck, I'd be sequestered in some motel for 9 weeks.

Fortunately for me, I was excused relatively early in the process.

Every one seems to have advice about how to "get out" of jury duty. I was told everything from "tell the judge your a doctor" to "tell the judge your a racist." One guy seemed to have listened to some of this advice. Let me tell about him.

I first noticed him early in the day. He was in his mid-50's, gray haired, and he seemed very annoyed about having to serve in this way, on this day. For the entire 4 hours we were in the room, he was pacing and mumbling loudly. Apparently, he thought it was "bullshit" that we had to wait past noon only to be excused anyway. At 1:30PM, I overheard him telling some other men about his jury-dodging strategy. One or 2 hours later, I watched him try to pull it off.

And it was awesome!

About 100 of us prospective jurors were called into the court room at 2:30PM. This was a criminal case and present in the court were the judge, the prosecutor, the defense attorney and the accused. The judge thanked us for our time and then had us swear to be honest. Now here is where the angry juror's plan commenced.

"Your honor" he said with a very bold voice. "I do not swear to be honest." He was trembling imperceptibly, but I was so close to him I noticed it.

"Excuse me", the judge said. Then the judge added, "then we can have you affirm the oath." I guess "swearing" might somehow be religious while an affirmation is not and the judge was trying to assuage the man on these grounds.

"No" the angry man persisted "I will not be able to be honest." Then he added, to my utter amazement, "I just wanted to be honest with you, you honor."

My eyes were bulging out of my head: what gall! This guy was something else.

The judge seemed for a moment taken aback, but was not about to lose this argument. "Well then, sir, we just need you to sit with the court officer outside, and after these proceedings are finished, we will talk again. And then he added. "what is your name" and then the judge directed the stenographer to record it into the record.

The angry man was shaking, only now visibly. Seconds later, he as escorted out of the court room by an armed court officer.

10 minutes later, the judge excused about 50 of us for a variety of mundane reasons, no questions asked, and by 3:00PM I strolled past the angry man, who appeared to be in some kind of "jury-jail", and I received my certificate of appreciation and proof of service, and then I left the building.

I wonder what happened to this guy, the angry juror. Obviously he listened to some bad advice.

In any case, if you get called, don't sweat it. It is not painful. It is interesting. And it does make one feel good about our legal system.

And for Christ's sake, just take the oath.

The IU.

Pay Cuts, Again!

I am not happy either!

I just read this on KevinMD. I thought the cuts were tabled for 18 months. Wrong?

Physician reimbursement. Medicare is soon scheduled to cut physician payments in excess of 20 percent and cash-strapped states are slashing Medicaid reimbursements. At a time when the costs of running a practice are increasing, this blow would cripple many practices. Linking physician pay to patient outcomes, so-called pay for performance, is one often-discussed approach to mitigate the payment cuts. This has been controversial as the reward in payment is not commensurate with the costs of implementing the systems to measure performance.

Oh Oh!

In rough times, every little bit counts.

These are difficult economic times.  People are losing their jobs, their homes. . .everything.  For many others like me, "country club" dreams have vanished and mere survival has become the goal.  In times like this, times that I think are only going to get worse before they get better, every little bit counts.  As a solo physician, here are some things you can do to maximize your chances at surviving through the coming months.

1. Answer your phones 24/7.
2. Invest money or time in smart, cost effective marketing techniques.
3. Invest in technology that enables you and staff to work smarter and less.
4. Be in-network.  People just don't have the money now for out of network providers.
5. Focus on what you do best and refer out or outsource the rest.
6. Do CME, learn new things, and incorporate them into your practice.
7. Know your metrics inside and out.
8. Re-examine your long-range vision & refine your short term goals.
9. Back-word plan to achieve goals.
10. Keep staff happy and turnover low.

Good luck and let me know if you have any other suggestions.

The IU.

Some things I've been thinking about.

My mind has been full these days with lots of important decisions that must be made.

• I am in the final phase of a decision to go with a specific EMR vendor.
• I am combing through my P&L statement with a fine-toothed comb looking to cut any extraneous costs.
• I am looking at ways to partially outsource my phone systems during overflow periods.
• I am looking to hire a technical consultant to assist me with laboratory regulations and management.
• I am looking for more economical ways to spend marketing dollars.
• I am simultaneously shifting and tightening focus for my practice goals so that I can continue to thrive in a changing environment.

Exciting times, indeed.

The IU.

The Ultimate Low Cost Specialist Office

With costs rising for all of us physicians, cost containment has become more important than ever. I've been thinking about how to keep costs super-low without sacrificing services. I've brainstormed some solutions. Here they are:

• Sublease office space from another office.
• Share office personell. You can use someone else's front desk staff to check in your patients. Of course, you must provide this staff, which technically is not your own, with your own workstations with your own PM-EMR system and teach them how to enter data into the system accurately. And you probably ought to augment their salaries with your paychecks so that they work for you, rather than someone else, and are thus loyal to you. You can even share the other doctor's office manager and pay them, then make them oversee the front desk staff.
  
• Purchase a good EMR-PM system. You may wish to consider an ASP model--or internet based model. These have no upfront costs to you and are payed on a monthly basis. Plus, the vendor manages all the technical aspects of the technology, such as back-up, upgrades, and interfacing.
  
• Outsource your phones. Phone systems can get surprisingly expensive if one considers the cost of the systems themselves, the line-fees, maintenance, and the salaries + benefits of the people who answer the phones. Check out this site for an alternative approach to phone managememt.
  
• Outsource your billing & credentialing functions. Sure, there are pro's and con's to this approach, but with the right company and proper over site from you it could work. Alternatively, with some of the better EMR-PM systems, you can do your own billing.
  
• Use only automated laboratory equipment should you choose to provide some lab services in your office.
• Any imaging equipment, such as ultrasound units, and of course your workstations must be portable, lightweight, and networked to your central server.
• Outsource some marketing functions, like direct mail advertising or email advertising.
  
• Make your own basic website and do your own basic SEO.
• Outsource payrole services, pension fund management, accounting, and book keeping (make sure the book keeper is bonded).
  

With this approach, you can function quite well and grow significantly with only one employee, ie a medical assistant. Your costs can be half that of a tradiotional solo doctor's without much sacrifice. If planned correctly and executed well, this approach could work well for even a specialist.

If anyone has tried this approach, let me know.

Destroyed in Seconds

There is a show on the Discovery Channel called Destroyed In Seconds.  Essentially, the program shows video footage of disasters that seem to have come out of nowhere.  In one episode, the viewers could enjoy a helicopter crash that happened with shocking rapidity.  In another episode, a speed boater loses control of his craft and in an instant is gone.

In medicine, good relationships can evaporate in seconds as well and we seldom see it coming.  In this first episode of "Destroyed in Seconds: Urology Edition" I am going to present some instances where a perfectly good doctor-patient relationship can get "destroyed in seconds."

• A previously passive patient receives an unexpected bill and calls the office ranting and raving about it: relationship destroyed in seconds.
• A patient receives an unexpected phone call regarding the need for additional pre-surgical testing and is inconvenienced.  His frustration and vehemence gets turned upon staff and you and the relationship is destroyed in seconds.
• A patient being followed for rising PSAs is told by a "friend" that he should have been biopsied and he accuses you of negligence: relationship destroyed in seconds.
• Above patient has biopsy done by you and is negative for cancer: relationship restored in seconds.
• Above patient has terrible complication from above biopsy that you initially advised against and relationship destroyed in seconds.

Medicine is a crazy business.  We walk a fine line between hero and goat. 

And any doctor patient relationship can be "Destroyed in Seconds."

(Disclaimer: the above examples are fictitious and do not represent actual encounters.  Any similarities are purely coincidental."

Leaving a practice? The Essental List

Sometimes the group thing just does not work out and people find themselves with no other option than going solo.  Follow these essential rules and you'll land on your feet.

1. Determine your short term intermediate, and long term goals and list in backwards order how you plan to attain each of them.
2. Leave your old practice on good terms, this will only serve to help you in the future and trust me, you WILL need them in the future.
3. Develop a plan to attract your old patients, so long as it does not ruin your relationship with the old office, and separate plan to attract new patients.
4. Organize all credentialing material and higher someone, even per diem, to assist you with credentialing.
5. Look for an office or sublease on a temporary basis.
6. Go electronic, even a web-based ASP model for an EMR and PM/scheduling system.
7. Get a website, just don't pay a lot for it.
8. Get a blog and start posting to it.
9. Look for staff (personally, I recommend Craig's List.)
10. Get a phone and answer it 24/7.

If you follow these 10 steps, you'll be up and running in no time flat.

Good luck,

The IU.

The Copay Sign

In this day and age, every dollar matters.

While I find that 99% of people pay their copays without problem or complaint, 1% will ask for it to be waived. We simply direct them to sign above and that answers their questions succinctly, forcefully, yet with some humor.

Joe the Plumber vs Rich the Urologist

I did a vasectomy today on a plumber from Long Island.  Like Joe, the plumber from last night's presidential debate, this plumber is in business for himself.  As I was performing the vasectomy on my patient, I was talking to him about his business.  Here's what I learned from my "Joe the plumber."

• Plumbers are not licensed by the state but by the town in which they do business. 
  
• Each town in which the plumber works requires the plumber who owns the business to be licensed.
• Each town in which the plumber does work requires the plumber to be insured.
• Plumbers in Long Island must carry 1 million dollar policies per occurrence.
  
• Most towns require the plumbers to carry an additional million dollar policy in order to get a permit for any specific job.  This extra-policy protects the town in case a civil action is brought upon the plumber and threatens the town as well.
  
• In Long Island, the plumber's first insurance layer--the initial 1 million--costs $12,000 per year.  The second layer--the one each town needs--can add as much as $7500 per year onto the plumber's yearly overhead.  Thus on Long Island plumbers pay $19,500 per year in liability insurance.  Urologists in Long Island pay as little between $22,000 and $57,000 depending on the policy type and the urologist's loss history.
• Plumbers must pay workers compensation and unemployment insurance as well.
• If the plumber has employees, they may wish to carry employer liability insurance as well, which covers for things such as harassment law suites and wrongful termination suits.  This costs ~$2500 per year.
• Some plumbers are in business for themselves yet contract with larger, national companies, so that they can get more business.  The national companies take hefty commissions from the local plumbers who actually do the jobs.
• Some plumbers are W-2 employees of these larger companies and are paid salaries, yet they must still carry and pay for their own liability insurance.
• When a plumber's work results in a person's bodily injury, law enforcement typically investigates the incident and files criminal charges.
• In Long Island, a plumber who offers health insurance to his employees shells out $12,000 per year for family coverage, $6000 per year for single coverage and is often forced to pass an increasing percentage of this cost onto the employees.
• On Long Island, the plumber must bring in at least $1000 per day in revenue to survive.

Now Rich the Urologist.  My overhead is similar to Joe's in all respects yet I think I have a higher earning potential.  In addition, my licensing requirements are statewide rather than town by town.  Like Joe and his town permit requirements, each hospital in which I work requires that I carry $1 million of insurance and be credentialed, yet they don't (yet) make me purchase additional insurance per procedure or admission.  Like Joe, I can either be an employee or self employed and can contract with larger corporations for an increase in business.  Like the plumber, contracting with these companies (insurers) comes at a price.

That's it.  Joe's got it rough, even rougher than Rich the Urologist.

Good luck Joe the plumber,

Sincerely,

Rich The Urologist.

How it Works: Getting Paid That Is.

When you go to a restaurant, you order the food, eat, the bill comes, and you pay for the meal either with cash or credit card.  If you use an accountant, they do their work, send you a bill, and you send them a check.  If you purchase a sweater on-line,  you supply the merchant with your credit card or paypal information, hit submit, and then the merchant processes the order.  In general, the process is pretty straightforward and transparent.

In most medical practices, the process is much more complex, less transparent, and more open to error.

In medical practice, from the instant a patient calls to make an appointment, a cascade of events gets initiated that results several weeks to several months later in a payment into your bank account. 

Here's the steps that follow the "I'd like to make an appointment with Dr Schoor" phone call:

1st: Insurance: yes or no

• No: Straightforward fee for service, just like restaurant

2nd: Yes, Insurance

1. Determine type
2. Referral needed
3. Verify eligibility
4. Give appointment

3rd: Patient in office

1. Obtain insurance ID card
2. Determine copay amount
3. Determine method of payment, ie cash (great), cc (OK), check (risk of bounce)
4. Give receipt
5. Room patient

4th: After physician sees patient

1. Determine diagnosis codes (ICD9)
2. Determine procedure codes (CPT)
3. Determine level of visit (1-5)
4. Manually or automatically via EMR/PM charges and codes are sent to biller/billing software

5th Billing

1. ICD9 and CPT codes are entered (manually or via computer) and a claim is generated
   
2. Claim is edited either manually or via PM program to make sure that all demographics are correct, NPIs are correct, PTANS of present, if needed, and ICD9 and CPTs match, and more.
3. Claim is then either printed on a HICFA 1500 form and mailed directly to insurance company or submitted electronically to a clearinghouse (middle man)
4. Clearinghouse adjuticates claims (further processing for all above) and then either rejects claim or forwards it onto the pertinent insurance company either electronically or on paper.
5. Insurance companies review claims and either: authorizes claim "as is" and remits check for contracted amount, down codes encounter and remits check for lesser amount, or does nothing (which then requires you to track down the claim).
   

6th Payment

1. Payment comes in the form of an EOB, or explanantion of benefits and a check.
2. Checks can either be attached to the EOB (paper) or issued via ETF (electronic transfer of funds).
3. Check amount must be verifed against EOB.
4. Practice can then either accept payment "as is" or re-submit claim with a dispute.

And that is for a simple office visit.  The process varies a bit for things like hospital consults and procedures or for procedures performed in any out-of-office setting.  In addition, each payer and each plan, within the plan, within the plan, has slightly different rules, policies, and procedures, and these can muck up the reimbursement's timeliness and accuracy for the doctor. 

And what about copays?  I have not even dealt much with this easiest part of the whole thing, that is the copay.  Some people have them and some don't.  Some plans have a flat copay amount for all visits, while others have different amounts depending on the type of visit, e.g. primary care, specialist, ER, hospital, lab, etc.  To make everything even more complex, not all ID cards indicate the copay that fits the particular situation.  In this last instance, the only way to know the copay amount is get it off the EOB in the box that reads "patient responsibility."  Then you must, contractually, go after the patient.

Going after the patient, for even as little as $3, is not always easy.  Even though the majority just pay with no fuss, some patients get very upset at receiving a bill for any amount.  For all patients, the practice must send statements, ie bills, and this costs 41 cents, plus envelope, per bill plus staff time for each patient per statement period.  When the patients return their payments, the cycle is complete. . .unless they have secondary insurance. 

And that is a whole other discussion.

Physical Networking in a Virtual World

It used to be that doctors socialized with each other.  This is no longer the case.  The practice of medicine and its economic realities have made it difficult for doctors in a community to get to know one another and become friends.  In the recent past, circa 1990's and before, one could go into the doctor's lounge and immediately find colleagues, engage them in debate or small talk, or even hold an impromptu journal club about someting innane written in the NEJM.  Specialists could put names to faces of their primaries, and vice-versa.  If a physician needed a quick consult or simply a pep talk, he could find it in the lounge. 

Until recently, the hospital itself served as the hub of all social activity amongst physicians.  The yearly hospital galas in those days were part prom for the doctors and their wives and part fundraiser for the hospital and its board.  Though these galas still exist, doctors can no longer afford the $500 per person ticket price for admission and few attend.  I have been to one or two of these myself--on someone else's dime--and I was amazed at how few doctors were in attendance.

Not so long ago, outside the hospital doctors would socialize with each other at the local country club or tennis club.  Their wives would become friends and so would their kids.  It was nice time; a time that I only glimpsed from the outside during my medical school days and that subsequently vanished while I was still in training.

No doubt due to abuses to the system during a bygone era, the pendulum has swung way over to the other side with PHARMA having eliminated the only remaining locally held social activities available to the community doctor; the drug dinner and the sponsored grand rounds.     

The demise of this important social network has had some profound implications for the business side of medicine, some for its betterment and some for its detriment.  I suppose that a strong social network prevented the development of Medicare until 1965 and I can almost see doctors in the lounge working each other up to a tizzy about the "red evil" that was coming in the form of socialized medicine.  On the other hand, the network probably served as a catalyst for doctors' acceptance of commerical payers, especially as their colleagues, one by one, signed onto the plans.  On a more personal note, it has become difficult, to say the least, for young doctors to meet other young doctors and establish new lines of referral and make friends.  Since networking goes hand-in-hand with business development and practice building, the absence of this network system makes it more challenging to grow a practice. On the flip side, with few in-roads available for networking, well thought out and skillfully excersised networking tactics can produce significant positive results.

Networking still exists and is as important as ever, but it is no longer conducted as much in the physical world as in the virtual one.  Your trick, as a solo doc, is to find a way to use the virtual network community to augment your own local, personal network group.  It can be done.  Just ask some of the people who have done it.

Thanks and good luck,

The IU.

I stand corrected

Minyan is a quorum. Minion is "a servile follower." Thanks to Kishkes for the correction.

October is upon us and it is time for some Q4 planning.

Tomorrow is the last day of the 3rd quarter of 2008.  Wednesday marks the first day of the last quarter in 2008.  I never really understood the significance of quarters until I went into solo practice, but now I do.  For business owners, the 4th quarter means planning and preparation because Uncle Sam wants his money and $10,000 on December 31 is worth only ~$6000 on January one.  Unfortunately, the $10,000 insurance bill remains $10,000 and the $2500 rent remains $2500, and even goes up due to tax increases.  So I recommend planning and preparing.

• Pay January bills in December
• Hold check-posting reimbursements in the last few December week's until January
• Max the 401K
• If no 401K, you have several weeks to start a Simple IRA and the rest of the year to max it out
• Pay off high interest debt with profit
• Invest in new equipment now
• Invest in that marketing project you have been considering before years end
• Pay down some of your business line of credit
• Of course pay off credit card debt
• Make any office capital improvements that are needed between now and December 31

And the rest, take in profit and pay Uncle Sam-->Wall Street.

The IU

Fall

Looking forward to the change of seasons and the final quarter.

Not bad!

15 people responded to the quiz and 11 of the respondents had a similar understanding of regulated waste as my own.

Essentially most items belong in regular trash. The only exceptions are gauze or gowns that drip with blood, body tissue, and sharps. While this may vary by state and locale, the results of my quiz suggest there are some national standards.

Of course with an n of 15, my study lacks any power and we must accept the results with caution.

I will place the pole on the side bar and see if we can get some more responses.

Thanks for the help.

Still waiting for a "minion."

I am still waiting for a sufficient number of people to respond to my queary to provide the results. In the meantime, check out a new post and pole at http://schoor-urology.blogspot.com/.

What is regulated medical waste?

If you ask 5 people "what is regulated medical waste?" you'll likely get 5 answers. Everyone knows that sharps are regulated and they belong in a sharps box. But how about the following?



Let me know, so that I may know. After I have "a minion" of responses, I'll post my understanding based on discussions that I've had of late with experts in medical waste management.

Knowledge of where waste rightfully belongs is important for 3 reasons:

• Safety of the environment
• Safety of the public
• Cost to you, the business.

So please, give me a hand.

Considering an EMR? Look Into VISTA.

I spent much of my urology training at Chicago's Lakeside VA Medical Center.  This was in the 1990s and EMRs were in their infancy.  At that time, the VA had it's own proprietary system, called VISTA.  And VISTA was amazing: simply the best EMR ever made.

And it still is.

VISTA is free.  You can get it from the VA Medical Center's Website.  It requires a MUMPS platform to run, and this requires a license, or it can run for free on a LINUX system.

So basically, to have the best EMR is the world you can rent space on a VPS (Virtual Privacy Server) that runs LINUX, get a techie to configure it for you, and then you have the best EMR in  the world

DIY

Text Messaging Consultants: I'd Like It.

Last week I had a patient in the hospital who had to stay 24 hours longer than I thought she needed to stay because it was difficult for nursing staff to contact all the doctors that were providing her care and clear the discharge home order. Essentially, I came in to make rounds and the patient wanted to go home. She was eating, having BMs, and was in no pain, and she felt that she would get better rest at home. I reviewed her chart and agreed with the patient that she could go home. However, I wanted to coordinate her care with all the other consultants who had helped on her case, such as pulmonary, ID, hospitalist, and general surgery. Aside for writing an order "d/c home if OK by pulm, hospitalists, ID, and general surgery services" I had no efficient way to convert the order to action.

To make a long story short, it took 18 hours to contact all the consultants and to finally get an OK for the discharge and then another 6 hours to make arrangements to actually get the patient home.

I have a better way. Doctors or their services ought to use SMS. I could then send one text message to all 5 consultants-or their services--and then the doctor could simply reply "yes" "no" or "?" to me and then I'd give the order, or not. I think it would save time and simultaneosly improve care to patients and communication amongst consultants and primaries.

Ain't gonna happen, but it would be nice.

5 Ways That Unfaithful Men Get Caught

Men in high profile positions, such as governors, presidents, and senators, get discovered cheating on their wives in very dramatic ways. These men get outed by the media or during a special prosecutor's investigation. Most men, however, get caught by much more mundane reasons. Most men get caught because they contract a disease. If you cheat, here is how you will get caught.

1. Herpes: condoms don't always protect against herpes. As one can imagine, this might be difficult to explain to your wife. A herpes infection is forever.
   
2. Warts: see herpes, but in honesty it is possible, though not probable, that an HPV infection can remain dormant for 20 years. So tell her you must have contracted it from the last woman you dated, 20 years ago.
   
3. Gonorrhea/Chlamydia: men have an encounter, then develop symptoms of pain and discharge and come in for evaluation. The problem is that in the interim between the sexual encounter and the medical treatment, the man had sex with his wife.
   
4. Abnormal pap smear: of course men don't get pap smears, but our wives do. Typically a wife with 20 years of normal pap smears will have an "abnormal one" and the man will come into my office, look very sheepish, close my door, then spill the beans.
5. Fractured penis: yes, that right,fractured penis. Usually the man is on a business trip, has vigorous sex with a woman and oops, the penis pops out of the vagina, then gets thrust upon her pubic bone. It then bends when it is erect and snaps. This is a medical emergency and I suppose it could be difficult to explain the penile bandage to your wife when you return home.
   

So be forewarned and keep your pants zipped.

Going Solo? 10 Pearls For Success

Now that I have been solo for 2 1/2 years and feel that I have traversed the valley of death successfully, I can look back with some perspective and understand some of the important decisions I made that enabled me to get to where I am today.

In no particular order:

1. Start small: preserving capital is critical. Most businesses fail because they run out of money before cash flow starts to take over.
2. Develop a business plan: this will serve as your road map and guiding vision and will help you make important decisions when the future is uncertain.
   
3. Go EMR: whether you purchase one or make your own, these systems have major advantages for small sized practices.
4. Build up a nest egg: For most of people, the decision to go solo is made over years, not days. This should give you enough time to build up a cash reserve that can get you through the first 6 to 8 months. If you can't save it, then getting adequate loans in important. best of all, save it yourself, then take out a loan and use the bank's money.
5. Surround yourself with good employees: staff turnover is lethal. When you find good people, reward them and retain them.
6. Invest into the practice: as money starts coming in, rather than take a vacation, invest some of it back into the practice, say, for new billing software, new equipment, advertising, etc.
7. Network: This is not only important as a good source of referral business, but you can learn from others who have "done it" and have overcome challenges that you now face.
   
8. Study: read business books and do your homework. It will pay off dividends.
9. Get on the web. Web presence is critical.
   
10. Have fun: if you don't enjoy the process, you will certainly fail.

Good luck.

The Key To e is C

Though I went electronic a few years ago, I finally figured out the key to e.  It is simple: just go with the flow.

Most EMR or e-Rx modules have a certain "flow" of their own.  The programs seem to force users to adopt to how they are written rather than to how the doctor herself might do things with pen and paper.  Many of these electronic flows, or e-flows, seem to follow a different logic, a different algorithm, than we as doctors are used to, say, from being human or from having been practicing for many years prior to the software's development. 

While many vendors try to engineer the software to be intuitive and analogous to a typical doctor's doctoring "process", the software really can't be everything to everyone.  Most of us will have to change in order to use an EMR to its maximal efficiently.  And that is a good thing.   Just because an EMR forces a user to adapt, does not make it a bad product.  In fact, if the change improves accuracy and completeneness of data collection, promotes mistake proof ordering and prescribing, and allows for efficient data review, then I am all for it.  If adaptation promotes survival, it is a good thing.

E-prescribing for me has been difficult to adopt because writing a prescription on a traditional pad is quick and easy.  Traditional prescribing works like this: I see patient-->discuss treatement options-->recommend medication-->discuss side-effects-->write prescrion-->hand it to patient.  The whole process takes minutes.  E-prescribing requires significantly up front more time and effort for me and I simply cannot do it while the patient sits in front of me in my office.

However, I have found that e-prescribing results in so much less aggravation on the back-end that it is really worth the time and effort to do it.  I just had to change my methods to fit the new technology.  Now that my metomorphosis is complete, I find that I am more efficient overall than I was before the change.  I can see more patients, more easily, and with less aggravation.  Things like, "Oh doctor, can you do 90 pills instead of 30" just don't happen to me any more.  I have successfully found a method to e-prescribe that works for me and now I like it.  Like my grandfather said when he got an answering machine as he turned 89, "Vichie, how did I ever live without one."

So if there are any managers out there frustrated because docs are resistnant to change, maybe try to convince them that once they adapt, they'll be amazed that they ever survived without the technology.  Tell them that the key to e is C(hange).

Good luck.

Protect Your Online Reputation: 10 Steps

One of my employees has a doctor that she worships, so one day I Googled the doctor's name.  He had several listings, but all were from sites such as Ucompare, Healthgrades and some other local doctor rating sites.  I pulled up one of the free reports and found two ratings; one glowed while the other seethed with anger and hate.  And that was all that this outstanding doctor had to represent him to the online world.   

In these days, doctors must be proactive in managing their online reputations.  Any person with an ax to grind and access to a computer and internet can really damage your hard earned reputation.

Here are some things that I do and I recommend you do to manage your online reputation:

1. Blog and blog often.
   
2. Have your own website, even if you are part of a group.
3. Link your blog and website.
4. Publish articles, such as review articles, in medical journals and periodicals.
5. Post comments on other peoples blogs and allow them to post on yours..
   
6. Get your name in the media via interviews (see blogging and blogging often).
   
7. Google yourself on a regular basis.
8. Contact content providers that allow subscribers to post malicious writings about you and request that that they remove the comments.
9. Have a lawyer contact the content services or the offenders themselves with threats of litigation.
10. Seek help from online reputation management experts (yes they exist).
    

So protect your online reputation and remember that no one has a right to malign you unjustly and falsibly.  The first Amendmant does not protect people who do this from civil damages.  Do not be afraid to enforce your rights and fight for your reputation.  Your very livelihood could depend upon it.

Good luck.

Tau Epsiilon Phi 1990

My fraternity brothers 1990.
Life, uncomplicated.

A Weekend With The Boys

I'm taking the weekend off and I'm going to my Alma Mater, The University of Maryland College Park. The weekend plan seemed to come out of nowhere, but actual was made possible by Facebook.
Beginning in August, someone from my college mentioned this weekend as the TERP reunion weekend on Facebook and due to speed of information dispersal over the net, over 100 guys that I went to school replied, excitement grew and the party is going to be tremendous. It's going to be a great time.

As a solo urologist, I have some challenges to overcome so that I can go. One, I had to get coverage. This was easy and I arranged it with a local urologist whom I cover on a prn basis.

The next challenge is how to balance being in touch with being away. I plan to use voicemail and email as my predominate means of communicating; text message as well.

The next challenge is family. This was more difficult than office coverage and well, costly.

See ya next week.

How to do an Operational Manual for a Practitioner's Office

You really ought to do a "how to" type guide for things you and your staff "do" in your business.  Basically, what you ought to have is an operational manual.    An operational manual is very important for a business to have as it can enable the business to continue to function after you or any particular staff member has left the business.  A good one essentially makes the business larger than any one particular individual, including you.  But you don't have to do it all in one day, or even one week, month, year, or decade.

The concept of "Operational Manual" can be intimidating.  When I think of one, I see a huge binder with thousands of pages of documents that makes for the most boring reading material ever.  Of course, after you've worked on your manual for several years, it'll hopefully look just like the boring one I just described.

You could and should do your manual piecemeal: a little at a time.  And you may wish to include the staff in the process.  Since they are the ones that do most of the actual work that is detailed in the manual, the staff are probably the people most qualified to write it.  I had my technician write down for me the exact steps that she takes when she does a semen analysis.  I then reviewed the steps with her and found ways that could make her more efficient and accurate.  Conversely I discovered--through her--methods to improve the process of semen analysis; the same with urine analysis.  Writing the operational manual with my MA/tech has been an educational process for both of us. 

In my offices, we have documented the processes for digital back-up & recovery, disaster plans, instrument prep and sterilization, specimen collection and handling, phone triage and etiquette, scheduling procedures, copay collection and even how to use the credit card processor.

My operational manual has been a work in progress that started one day in February 2006 as I sat in the The Smithtown Library and planned my new practice.  Over the past 2 1/2 years, I have added to it, subtracted from it, revised parts of it, and learned from it.  The manual has a paper form, but really it has been converted to more of a digital format.  The original document still resides on the shared drive on my office computer but now I keep copies of all the documents and all the newer documents on my Google documents site.  This way, I can revise them from anywhere, at any time.  In addition, with Google documents, you can give staff "collaborator" priveledges and you can adjust settings on the documents site so that it will notify you whenever a change was made by the collaborator.  I don't do this, but you could and I can see the benefits of it.

Also, you can also buy an operational manual from a commercial site, such as the MGMA.  But I don't recommend this because the process of writing the manual is what makes you, your staff, and your practice better.

So start today and after several years, you'll have created something pretty impressive.
Let me know how it goes.      

Solo vs Group: The Pros and Cons

For me, solo practice has been just the cure for what ailed me in my professional life. Several years ago, I suffered from low morale, poor outcomes, and desperation. I felt that I had had made a drastic mistake in my career choice and was in a mental prison. I was part of a group, an excellent group, in fact, and I had nice and competent partners. I was making some money and was living comfortably. Yet I was miserable. Perhaps I did not truly know how unhappy I was then, because I had no basis of comparison and know template for what how a good fit was supposed to feel. For me, solo practice is simply more compatible with my core values.

Solo practice has some advantages over group practice. . .for the right person. As a solo practitioner, you run the show. You must have knowledge in some basic business principles, such as accounting, marketing, human resource management, information technology, quality control, and business strategy. Or you better acquire this skill set quickly. Oh, yeh, and you have to be a good doctor as well. . .and be home for your family. . .and make time for your one outside interest, such as tennis. So as you can see, solo practice can be very demanding.

Personally, I enjoy all the business and medical aspects of solo practice,but here is the best part of it. Only solo practice really allows you to pursue ALL of your entrepreneurial dreams and goals. Only solo practice allows you to have hope in a future for you that is brighter than today. And that is truly the best reason for going solo.

Group practice is good too. As part of group you will simply make more money than as a solo doctor,at least at the beginning of your career. You'll have partners for emotional and professional support, and you'll more easily be able to leave the job behind you when not on call. In fact, you'll view it as just a job; not bad! You can focus simply on doctoring and pursue outside interests more easily. Perhaps you have a passion for wine and reading about military history and you play tennis. In group practice, you'll have time for it all.

So the bottom line is that there are many trade offs in the solo-group dichotomy. By defining your core values you can then get a better insight into what will be a better long term fit for you.

Goos luck,

The IU.

No ID, No I See: Some good reasons to require photo IDs from your patients

I have a strict policy in my urology office:

No ID, No I See!

I have developed the policy over the years because,well, I've been screwed on several occasions. Here are some good reasons why you may wish to adopt the No ID No I See Policy.

1. Fraudulent Health Insurance Cards: In this case, the best situation will be that you only deliver free care. However, I have had instances where insurers have paid me only to demand refunds. Then I have to go after the patient. Good luck tracking them down!
2. False Names: Drug seekers can use a fake name to get narcotics from you and dead beats can elude collection attempts with a fake name.
3. Bad Checks: See above, and yes I have had patients give me bogus checks.
4. Wrong address: This makes collections difficult if you have no proof of address.
5. The Photo: I find the photos helpful in jogging my memory of the patient and their story.

So in my office, NO ID, NO I SEE!

The Independent Urologist Blog To The Rescue

I just had a patient call. He claimed to be a patient of mine when I was employed by another group. He told my staff that he just left the hospital and has a kidney stone. He said he was a self-pay, did not ask for the fee, and said he'd be right over. He did give his name.

When my staff told me about it, my own mental alarms began to sound. First of all, the name he gave me was a name I remembered from my past and it was the name of one of my old, arch-enemy drug seekers. Four or 5 years ago, this guy got me good with several 2 and 3AM phone calls for refills or new narcotics prescriptions and a feeling as if I had been victimized.

As per our usual custom with ER patients, we called the hospital, the one in which this man reported having spent the prior evening, and the hospital in turn reported having no record of his visit.

Now my alarm bell was sounding in full force.

Several minutes later he showed up. . .and my staff recognized his face. They called me and I recognized him as well. I had seen him within the past year or so. While I have trouble with names, I rarely forget a face. I remembered this man as someone whose behavior prompted me to write a blog post about drug seekers. But I could not recall his name now.

My staff began to rifle through our new patient records, but we have way too many new patients to locate one by shear memory. We needed a time reference as to when he was here as a patient.

So I used to blog search feature on Google blogger, typed in "drug seeker", found the post and the date posted, went to that date in the book and voila, I recognized the name. Moments later I had his medical record opened and found that the drug seeker in March was the very same person as the man who was standing now in my waiting room.

Everything was crystal clear.

Needless to say, I sent him away empty handed.

GALL !!!

How to use email to imrove your bottom line.

While using email for medical type communication may be risky, email should be used in your office as it is a very powerful form of communication between your office and your patients. On top of that, you can use it to improve your bottom line.

Email is a cheap, actually free method to communicate with people. All that you need, lest you be considered a spammer, is to get the patient's permission, and that is easy to obtain. Just ask for it.

I have an email sign up form mixed in with the new patient demographic form, the ABN form, and the HIPAA form. Basically the email form explains what for and why I like to use email, and what types of information is not email appropriate, ie for protected health information. The majority of my patients sign it readily. In the past year or so I've added about 700 names to the list.

I use email to keep my patients informed about my practice. I think it works well for things such as:

• Out-of-the-office alerts, eg vacations
  
• Changes to office hours, such as Saturday or Evening hours
• Events, such as the opening of another office or a prosate cancer walk, etc.
  
• New additions to the office,such as doctors, staff members, etc
• New procedures or diagnostic tests that are offered, such as urodynamics
  
• Newsletter distribution
• Warnings; for example to keep hydrated during a heat wave to avoid kidney stones, etc
• When I have updates to the website that I'd like to share with patients
• New policies/procedures in the office, such as e-prescribing, changes in insurance pars, online booking, online contact forms, etc

And others.

So how does this add to the profits I see. Easy. Every time I send an email to my patient base, I get a spike in new and follow-up patient business. Think about the psychology of people. You may have done a vasectomy on someone 2 years ago. He has since forgotten your name and even that he had a vasectomy and he probably does not know what a urologist does, aside for vasectomies. When his wife mentions to him that she has been suffering from incontinence, unless you are fresh in his mind and he has been informed about what you do in addition to vasectomies, he will be unlikely to refer his wife to you. For another example, let's say our vasectomy patient sees blood in his urine and gets flank pain and decides that he needs a urologist. Would it not be nice if he remembered you and called you instead of someone else? It may make the difference of who he calles if he had just received a recent email about a new doctor you hired or on an update to the website via his email.

And again, email communication costs nothing.

So try it out and just remember to BCC your patients instead of CC'ing them, for privacy reasons and unsubscribe people who request it.

Good luck and have fun.

The IU

A cool trick for getting someone a copy of an insurance card

Here's the scenario: you are tryingto book a patient for a procedure at a hospital or surgery center and they request a copy of the patient's insurance card. With a paper chart, you'd have to locate the chart, xerox a xerox of the original, and then fax the xerox of the xerox. Well, you can imagine that the card is basically worthless when it arrives at its destination.

Here's a better way. All you need is a business card scanner and associated software.

1. someone asks for the insurance card, ie hospital
2. pull up the card image in card scan
3. alt print screen to take a picture of the computer screen
4. open ms word blank document
5. paste
6. save as
7. efax
8. drink coffee

Total time: 2 minutes.

Want a web presence? It's easy.

A urologist friend called me the other day. He's from Jersey and he wanted some advice. Comcast, his ISP, wants to sell him on a package that involves website design, website maintenance, and SEO (though my friend did not actually know what SEO stood for). Comcast wanted $200 per month for the Website and SEO + $50 per month for website "maintenance". Actually the price could and would vary based on the number of clicks and hits, etc, to is site. Total cost per year: ~$2700.

Now here is The IU DIY way:

1. Go to www.godaddy.com or 1and1.com and register domain name, ~ $2 to $7 per year
2. Google.com-->blogger-->create blog
3. Point domain name to blog (easy to do)
   
4. Write post #1: Something like this, "Hi I'm here and I do x,y,z."
5. Go to page layout, then add gadget, then add stuff to the sidebar like phone number, contact information, bio, even a form (available on Google documents)
6. Write something else, like "Hello,still here and I still do x, y,z" as post #2
   
7. Get a google adwords account-->start an ad campaign-->pick some key words, for example x,y,z--->bid on the cost per click (CPC--google can help determine how much the key word phrases cost)-->set daily or monthly max budget-->give AMEX card
8. Write something more provocative for post #3, like "insurance companies suck" or "working in the ER is cool. . .and bloody" or "The lawyer who deposed me was H-O-T hot!", & have the post picked up on KevinMD then see your readership start to flourish.
   
9. Have fun-->feel pride in the new skill set that you have acquired, and make money.
   

Total cost: ~$5 per year + whatever your adword campaign costs, not to exceed your own pre-determined max budget.

Or just hire some 13 year old kid to do it for you!

Have fun.

The IU.

The case against an answering service.

Have you ever called a doctor, perhaps for yourself or your child, and experienced the following:

Ring ring ring. . .ring ring ring...ring ring ring. . ."please hold". . .hold hold hold. . .hold hold hold. . .hold hold hold. . .hold hold hold.

"Hello, doctors' service."

"Yes I need to talk to the doctor, my child has 107 fever."

"What is your number, he'll call you back."

First of all, what is this "Doctors' service"? Dr Who? Can it be any more impersonal? And second of all I find the whole thing so annoying as a patient.

I have learned over the years that doctor's answering services are no longer an essential element to practice. I am going to make the case, a balanced case, against answering services for doctors.

1. Barriers: Services place barriers between you and established as well as new patients, neither of which is good for the practice. In addition, answering services place barriers between you and referring doctors; never a good thing.
   
2. Control: Unless you own the service, you have no control over the voice at the end of the line.
3. Impersonal: Services tend to be bland, rather than unique. You are looking for unique.
4. Obsolete: With current technological alternatives, there simply is no longer a need.
5. Annoying: I find them annoying, since they only take messages. This gets me to my next critique:
6. Purposeless: Most of them only take messages and either contact the doctor immediately or send a message to the office next business day, but they don't actually do anything. (some top-end services do function as extensions of your business)
   
7. A Waste of Time: How many times have you called a service and it has taken 5, 10, or even 20 minutes just to get through. No thanks.
   
8. Expensive: Price varies per package, but it can really add up. Plus, you still need all your other communication tools.
   

Here are some of the positive elements of a service:

1. Professional: Many people, especially baby boomers and older, equate doctors with answering services and find it "unprofessional" for a doctor not to have one.
2. Barriers: Sometimes I think it would be nice to have a barrier placed between me and, for example, an irate patient or one who simply decides at midnight to cancel an appointment.
   
3. Reliable: You will never miss a phone call with a service.
4. Human: Sometimes it is nice to have a human element or to give the appearance that you have a big staff.
5. Cost effective: Some of the better services can function as an extension of your own staff and behave in a seamless manner that gives the impression that you are larger than you are in reality at a price that is affordable, though not cheap.
   

So, as in anything, there are pros and cons to having an answering service. But for us small guys who are tech savvy, I don't see the utility of an answering service.

At least not a standard one and at least not yet.

The IU.

Keeping Track of Your Patients? Here's a method.

Another re-print of a previous post, with some modifications. Now that I have ~2000 patients, how am I supposed to keep track of them all? Here is part of how I do it.

Have you ever sent a patient for a test or study only to have them not have it done? Have you ever had a patient lost to follow-up? Do you ever lose sleep at night worrying about what positive cytology result is floating around in the ether, unknown to you or your patient, waiting to give the patient--and you--a problem? I used to, but no longer. And that is because when I went solo I was able to really analyze in a comprehensive way how patients get lost to follow-up and why they don't comply with orders and then my staff and I developed a system to counteract this problem. We call it The No Worries Log, and here is how it works.

When I finish seeing a patient and have formulated my plan, I tell my staff to enter my orders into the outbound referral section of my practice management software. This section is really designed for something else; to keep tabs on referrals from a primary care doc to a specialist, but I have customized it easily to fit my own needs as a specialist and a rapidly growing solo practice doc. For example, if I order a CT scan without contrast and a cytology on patient Richard Cockworthy, I tell my staff and they enter it like this: CT I-, cytology. If I send patient John Smith to a surgeon to rule-out a hernia, we log that as hernia ref to Dr J. You can accomplish the same thing with a log book and paper and pencil or with an Excel Spreedsheet, but that results in lots of wasted time and effort due to data entry duplication. Since our patient's data is already in the PM software program, there are no issues regarding repeat data entry, and the date of the log entry is automatically noted by the program. Once a week my staff goes though the list and checks off all the labs that have returned and I have signed. We then contact the non-compliant patients and gently prod them to get the tests that were ordered. Of course, we document these phone calls in the medical record.

The patients think its magic; they think that we are omniscient. We are not! They really think we are on top of things. We are! It's easy. We are simply using our existing software to its fullest extent.

This way I sleep well at night with the knowledge that I have minimized my liability risk by maximizing my power over a patient's non-compliance. It also makes for outstanding patient care and does not cost anything extra. Moreover, I can check the log from my laptop computer, while in bed at home, using a secure VPN connection, and can call the non-compliant patients from my Vonage office line that happens to be plugged in to my router at home. The caller ID that the patients sees says Dr Schoor's office.

Technology. It's wonderful!

After the Open

Corona Park at Sunset.

A good day, made possible bacause I am my own boss.

Think about it.

How to talk on the phone while watching a tennis match and not piss people off!

Solo practitoners face challenges that are unique to our breed. Coverage is always an issue and we must continuously balance self-time with availability.

Yesterday I spent the day at The US Open watching tennis. My office remained open and staffed and the phones, as always, went answered. My staff are non-medical types and will never answer medical questions. They simply take messages, prepare e-scripts for me to finalize, schedule patients, and track down claims. When doctors or patients need to speak with me, my staff knows to contact me immediately. But when I am court side at the US Open, cell phone etiquette often makes doctoring problematic.

Here's how I did it:

• Phone set to silent mode
• Staff sends text messages with pertinent information
• Blue tooth in ear enables talking on the phone in an inconspicuous manner
• Text messages back to staff with instructions on how to respond

Easy stuff. When I become the USTA touring urologist (Billie Jean, if you are reading this post, consider it my application for the job), I'll get an i-phone so I can be even more connected, yet more remote.

Fun.

Why a Professional EMR is better

A very smart urologist makes a good argument for a commercial EMR.

In his words:



I commend you for using the home-grown medical documentation system with Word. Advantages of a fully integrated EMR from a "vendor" are numerous. Here are a few: 1. FULL integration instead of piecemeal programs to do multiple tasks. 2. No need to redundantly enter pt demographics / name when you start a new encounter. 3. Electronic charge capture and being able to document within one program and send the charges to the PM side. 4. ONE page summary of just your A&P automatically generated and faxed to PCPs. 5. FULLY INTEGRATED eRx module, instead of having to use a separate system OUTSIDE of the "EMR". 6. Ability to completely mine your EMR database. For instance, I can find all male pts with LUTS over the age of 65 who have not had in-office microwave who also don't have bladder or prostate cancer and who are not on anticoagulants, as well as post an automatic pop up reminder into every one of those pt's electronic charts. 7. Intra-office messaging and integrated patient messaging. 8. Full document management system built-in to handle all incoming and outbound faxes. 9. Auto-documentation of any/all documents generated out of the EMR, including date, time, who generated the doc, and how it was output, including which printer. Accountability and transparency! 10. Requirement to change password according to HIPAA best-practice policies. Word documents are easily hacked. 11. Ability to standardize training and have a program to teach new employees / new hires. I can go on, but you get the idea. To me the price paid for a commercial EMR is completely worth it.

I agree with the above. I do have several caveats.

• Upfront costs: This is the least of my concerns
  
• Ongoing costs: every 6 months the vendors get you for upgrades, maintanenance, etc. All these are very necessary, but you are a captive audience since changing vendors is almost impossible
  
• Necessity: do you need all the functionality mentioned. Only you can answer that question. I would suspect that if you have a predominantly insurance based practice in a market place where you can use the data to find leverage, than yes. In my case, with a large cash base and no leverage to negotiate, I am not certain it would help.

But thanks for the back and forth.

The DIY EMR: Revisiting an earlier post.

This post was previously published by The IU, but due to recent contacts from readers, I thought I re-post it.

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?

Inspirational!

Ball Girl. 2008 US Open

Urologist vs Professional Tennis Player: Revisted

Someone on the way up and someone on the way down

Congratulations to the victor!

Once again, the US Open comes to NY and I love it. I go every year, both to the qualifiers and to the main draw. It is my favorite time to be in NY.

Personally, I think the qualifiers is better than the main draw, at least the first week of the main draw. Aside for the lack of crowds, you get very excellent tennis matches with lots of drama. You see players on the way up, and some on the way down. Most are never-wills. You also get to sit and talk to coaches and parents and player entourages in a way that is simply impossible during the main draw. You can learn some things and see that life is tough all over!

Players in the qualifiers must win 3 matches to make the main draw. Winning only once or twice during this week results in a big fat zero payout. If theplayers win all 3 matches, they make the main draw. Just being in the main draw, even with a first round loss, is worth a couple grand. Most, if not all qualifiers will lose in the first round. So 16 players will work for a solid week--and work very hard--and make only 3 or so grand. Factoring the cost of travel, lodging, coaching, food, clothing, rackets, stringing,etc. . .they don't do so well. The remaining 112 players, those that lost during the Q week, do even worse. They make nothing.

The 2 players in the picture up top are Victor Estrella and Xavier Malisse. Victor, the player on the left, was the victor. He is a young Brazilian on the way up. Xavier, the other player, was a former top 50 player who was considered a real contender at one time. He was a media darling as well, in his younger days, and had long hair and a flamboyant persona. Unfortunately, his career did not turn out as he, and others, had hoped it would, and he has been struggling. I guess his short hair is a symbol of his new-found-focus. Perhaps it is to little to late. I wish him well.

I did peruse the draw and roster of competitors from this years tournament and I did not recognize any players from this year that played last year. Maybe that is good sign and means that all of last years players made the main draw this year.

I doubt it.

I did recognize one name in the Q-tournament draw, Nicholas Massu. He is a former Olympic Tennis Gold Medal winner in 2004 and top men's player. I wonder what happened to him.

In urology, most of my own colleagues are still practicing and most urologists in my area can report higher incomes than last year because of a stregic merger of competing groups. I don't know of a single urologist that has left practice in Long Island due to the competition or external factors such as rising costs of living.

Recently Medicare has not been paying in a timely fashion. I know of one urologist that sees 95% Medicare patients. He has only received $1700 in reimbursements in 2008. For the rest of us urologists who see a mix of patients from a mix of payers, 3 days of work brings in considerably more money than the majority of qualifiers earn in a similar work week.

During Q-week, I watched the qualifiers struggle. I witnesses intense happiness with victory and devastation upon defeat. I saw several players at the end of their careers; no doubt faced with the question that I faced several years ago; "what next."

For me, as I watched the qualifiers compete, I felt comfort in my own situation. I am my own boss and my outlook is positive. I call my own shots. My wins are mine alone, as are my losses.

I think I am better off as urologist than a professional tennis player, aside for the fact that I really not very good at tennis. As a pragmatist, I know my earning potential, even with the current reimbursement landscape, is better than for 99.999% of tennis players.

So for now, I practice urology by day and play tennis by night.

And go to The US Open every August. . .the best show in NY.

What do you do with all those radiology CD-ROMs?

In the past, doctors, especially surgeons, would request radiologic images on films and would review them on light boxes in their offices. However, in the past 5-7 years, actual films have become somewhat of a rarity. Instead, CT scans and other images can be viewed either over a secure internet connection or via a CD-ROM that contains the images and the software necessary to view them. Personally I have found this changed approach to the viewing of radiological studies as a huge plus, with one exception.

What are we supposed to do with all the CD-ROMs that patients hand to us?

When I had paper charts, I used to simply staple the jacket that contained the disk to the patient's file. This worked ok. But now I have electronc charts. So now what?

Here's how I do it now.

1. Place the disk in the drive
2. Go to My Computer and open it up
   
3. Right click on the icon for the image viewer in the DVD-CD reader
4. Click Explore to open the files on the CD-ROM
5. Select ALL, then Copy
6. Create and label a new folder in the pertinent patient's folder
7. Paste the files into the new folder

And now you have the images saved and you can shred the CD-ROM.

Alternatively, you can ignore the CD-ROMs since you are under no obligation to save them in your files. The radiologist is the one responsible for ensuring that the images remain available for the time period specified by state laws.

However, I find that when comparing old studies it is nice to have images saved in a location that allows for rapid and effortless recall.

The "Green" Consent: Consent Foms On-Demand

I have developed a simple method to get written informed consent from patients in way that completely eliminates paper waste and ink usage while simultaneously maximizing efficiency and the "wow" factor.

Here's how it works.
I composed 5 or 6 consent forms for the various procedures that I do in my office. These procedures include cystoscopy, prostate biopsy, testicular biopsies, and penile duplex scans. I developed the consent forms myself and worded them in English rather than legal-ese. Since I am neither crazy nor stupid, I did have them approved by an attorney.

I keep the consent forms in a directory called "CONSENTS." The documents are MS Word 2007 files. Word 2007 has a great feature: it enables documents to have multiple signature lines. In my consent forms, the documents have 2 signature lines. One line is for the patient to sign and the other line is for me to sign.

After the patient and I have our informed consent discussion, I copy and paste the consent form from the "CONSENTS" directory into the patient's folder. I then type in the patient's name and date and then here comes the cool part. I swivel the tablet PC so that I can use it like it's a piece of paper and I slide it across the desk to the patient. He/she then reads the document right on the Tablet PC and if he/she agrees and understands it, they sign it. Then I take the tablet back and sign it as well.
After my signature is completed, the document locks so that no further changes to it are possible.
Done.
5 goals have been thus accomplished:

1. A necessary legal consent form has been obtained.
2. The consent has been placed in the chart forever.
3. The process was done efficiently, inexpensively, and with considerable "cool" factor.
4. It was accomplished with off-the-shelf software.
5. Not a shred of paper was used!
   

I like it. How about you?

Want to negotiate with insurers? You better have these characteristics.

I had a conversation the other day with an expert on negotiating insurance contracts on behalf of doctors, groups, and hospitals. Here is what she told me:

"I am going to be brutally honest doc, because I don't want to just take your money, but you don't have a chance in hell."

Essentially, what anyone needs to successfully negotiate is leverage,which is what doctors in NY-metro just don't have. There are simply too many of us in every specialty. In fact, this woman told me that the panels are over filled already and that she spends most of her time just getting new doctors accepted into the plans under any terms. While it is not impossible to get a better-than-average contract, it is difficult. Essentially, you need to be special to do so. Here are some of the key elements as I interpreted them based on my conversation with the negotiator.

1. Unique: If you are the only one of your specialty in a 20 or so mile radius, you may have some leverage.
   
2. Efficient: If you can save the insurer money by operating at a lower cost to them, such as by doing in-office procedures, or with less errors due to an EMR, you may be able to make a case for the insurer to cut you a piece of the action in return.
3. Desirable: If you are one of few doctors who does something that people want or need and will pay more to the insurance company for it in the form of premiums or plan selection--then the insurer may cut you into the action as well.

Notice that large size is not on the list. Size can work for you if your group becomes so large that it controls the market place. In a larger market place, such as NY, reaching this critical size can be difficult if not impossible. In addition for most large groups, lets say a 50 person group or larger, operating expenses become so high that they can become unable to sacrifice a contract worth 20% of their revenue. They simply could not survive the acute loss of revenue. Well managed groups, ones that know their numbers inside and out, may be able to determine if they can play hardball with an insurer and survive for the year or so that is needed to recoup the lost patients that will follow the lost contract. So know your numbers!

Finally, if you do successfully negotiate, don't brag about it: that could cost you the contract. . .and more. Most plans make their "special" docs sign strict confidentiality agreements with draconian penalties for non-compliance. So the next time you hear a doctor in the lounge bragging about his great negotiating skills know that he is either crazy or full of crap.

Therefore, don't feel like you are the only schmuck on the block that takes whatever contract is offered you. If you live and practice in an over saturated market and don't have one of the big 3 characteristics in my list, you simply must sign on the line and work like a dog.

Good luck.

The IU.