Sunday, August 31, 2008

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!

Friday, August 29, 2008

After the Open

Corona Park at Sunset.

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

Think about it.
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Wednesday, August 27, 2008

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.


Tuesday, August 26, 2008

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.

Monday, August 25, 2008

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?

Thursday, August 21, 2008


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.
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Tuesday, August 19, 2008

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.
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?

Tuesday, August 12, 2008

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.

Thursday, August 07, 2008

Can't get affordable insurance? Start your own company.

Four years ago, an emergency medicine physician in south Florida was asked to pay liability premiums that represented greater than 1/3rd of his entire revenue and he could simply no longer afford it. Rather than flee the state, grin and bear it, or bitch and moan, this physician studied the issue and came up with a solution. He started his own insurance company. Fours years later EMPAC, the company founded by that physician, has become a very successful and profitable liability insurance company-RRG that underwrites emergency medicine physicians only.

2 years ago, a urologist, Ernie, in Nevada became fed up with double digit increases in his premiums that made it difficult for him to simply remain in business. Rather than flee the state for a more hospitable environment, he drove himself to the offices of the Nevada Department of Insurance and "ranted and raved." He wanted answers. He wanted solutions. A persistent individual, Ernie was not about to give up until he had a solution. Ultimately, an official in Nevada's insurance office gave him a name of someone in Florida who started an RRG for emergency physicians.

Ernie called him. And he called him again. And again. And again.

Over an 8 month period Ernie would not go away and he would not take no for an answer. After 8 months, Ernie had convinced this person in Florida to help him start a new company with him. The new company was to be called SCRUBS. Ernie's Florida contact was the founder of EMPAC; the man who started that company out of his own necessity.

Ernie and the EMPAC founder along with his EMPAC founding partner, personally risked $500,000 to fund the cash reserve requirement needed to obtain an insurance operating liscence in Nevada. They hired outside consultants to administer the plan and they flew around the country to meet with urologists and urology administrators and to promote the new product. In order to operate as an insurance company, SCRUBS would need at least one policy holder. Ernie risked once again and dropped his traditional policy to become SCRUBS first and only policy holder. The entire company, all 3 or them, prayed that Ernie would not get sued.

Both Ernie and SCRUBS survived that first year and looked to grow the company in 2008. The 3 managers of SCRUBS knew that New York's urologists were ripe for the taking and they concentrated promotional efforts on this group. SCRUBS' management obtained a list of practicing urologists in New York and elsewhere and sent a flier.

While the 3 SCRUBS managers worked on their problems, I had problems of my own and was facing the double digit increases in insurance premiums that most of my urology colleagues faced. At these 15% rates of increase--compounding of course--our premiums were to double every 3 years and would have crossed the $100,000 threshold by 2010. At the current rate, many of us had to work without a paycheck for 3 to 4 months just save enough for July's premium, its increase, and any additional surcharges that often accompanied them. By 2010, I'd be done without intervention from Albany or elswhere.

In February and March and I attended medical staff meetings and joined grassroots efforts to effect change at the capitol. I became an activist, I pleaded with Albany and begged "them", to not let us doctors go under.

But there is no "they", and what "they" there is does not care about "you"; well certainly not about me.

In mid-April 2008, I recieved a flier from a company called SCRUBS, an RRG that only underwites urologists. Fed up with "them" and "they" and and a future that in the absence of course-change, would lead to certain demise 4 to 5 years hence, I responded to the letter and sent in an application. Several weeks later my life changed, or at least my outlook changed. SCRUBS had answered me. SCRUBS had agreed to underwrite me at considerable savings now, stable premiums into the future, and the possibility of premium reductions as the company grew.

In July 2008, I joined Ernie and became SCRUBS second policy holder, and the first in New York. As of today, I am one of 45 urologists across the nation who decided to take a chance and change course; to take control of our destinies. Our future is still uncertain, only now it is hopeful.

Wish us look and good fortune.

The IU.