Monday, December 28, 2009

Miniature Circus

If the Medicare cuts go through, I am going to run away and join the miniature circus.
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Friday, December 25, 2009

Come on, come out, Sun.

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Thursday, December 24, 2009

Using an EMR to Solve Problems

If someone came to you with a solution to 3 out of the 5 biggest problems you face, you would probably take it--or at least listen to their proposal, right?

Imagine if someone said to you, "you know that persistent problem you have with your filing system, I found the perfect solution and you'll never have to deal with that again."  I don't know, I'd be all ears.

Every doctor has problems.  Filing and retrieving, lab tracking, order tracking, prescription refills, handwriting issues, messaging handling; these just name a few.   I certainly had my issues.  Many of them are now past tense issues.

Prescription issues:  99% solved.  On rare occasion I forget to initial a narcotic script or my rx printer malfunctions.

Message handling:  100% solved.

Handwriting issues: bye bye!

Filing/retrieving:  see ya.

Lab tracking: 90% better.  I am still learning my EMR's functionality.

I still have problems, but just not these problems.

A good thing.

Sunday, December 20, 2009

Saturday, December 19, 2009

Early Praise for My Book, Suddenly Solo

Rich's book is excellent I am going to have my office manager read it too.  Nice to codify philosophy of self made "man". . .

Dr A.G.
Urologist  NY, NY

You can get your copy FREE.  Just click the cover.

Friday, December 18, 2009

An Excerpt from Suddenly Solo

Imagine being safely ensconced in group practice one day, just going through the motions, but nonetheless enjoying your day—talking with colleagues, consulting with patients, maybe even enjoying lunch, driving home, talking over your day with a friend or your spouse, and then walking into work the next morning, only to find yourself out of a job—fired.
Or, if that doesn’t gut you enough, imagine coming to work one day to find that not only do your keys mysteriously no longer work, but a security guard bars you from entering the building, where all your files are locked away.
Here’s another dream scenario: Imagine returning from a long-overdue, much-anticipated, relaxing vacation to find that your partner has conspired with another and has effectively stolen your practice. . .

. . . . . . . . . . . . .

If you want to read more, just click the cover on the sidebar and register for your free e-book copy.

And good luck!

Dr Schoor

Monday, December 14, 2009

My Book, Suddenly Solo, is finally ready for publication

Three years in the making, perhaps even more.

And you can have it free, for a limited time.

Just complete the following webform and the e-book version of Sudddenly Solo: A Physician's Guide to Surviving & Thriving in Your Own Medical Practice will be emailed to you.

I hope you enjoy it!

Dr Schoor

Sunday, November 29, 2009

Not Everyone Needs High Tech Toys

Sometimes you can't beat the old fashion.
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Monday, November 16, 2009

My presentation milestone

I am a big believer in software as a service, despite its pitfalls. Today I gave a presentation at my hospital's tumor board. In the past, I'd have had to bring either my laptop or a thumb drive with powerpoint talk and ope that everything would sync ok. This time, I just had to make sure they had a computer with internet access. They supplied that, no problem. I just brought a url. Worked great.

Gotto love technology

EHR is not a panacea, Mr President

From the AUA Daily Scope

"Study finds little benefit to date in electronic patient records.
The New York Times (11/16, B3, Lohr) reports that a study to be presented Nov. 16 at a medical conference "comparing 3,000 hospitals at various stages in the adoption of computerized health records has found little difference in the cost and quality of care." Researchers from the Harvard School of Public Health conducted "a follow-on study to a survey of hospitals' adoption of electronic health records, published this year and financed by the federal government." The authors found that "differences...were 'really, really marginal,'" and suggested that "government policies should focus on helping physicians, hospitals, and the public health system use the technology more effectively." "

Frankly, I am not the least bit surprised.

The IU

Wednesday, November 11, 2009

Tuesday, November 10, 2009

A death spiral in evolution

It is truly fascinating to witness a corporate death spiral firsthand.  Here's how one just unfolded in my presence.

  • Company A, a software as a service (SAS) solution lands big client, Company B, an EMR company.
  • The arrangement flourishes.
In business--and life--the only constant is change.  In this case change produced:
  • Increase in demand for company B's SAS solution
  • Company A needs to invest in infrastructure to support Company B's plans.
Credit Crunch or bad Management?
  • Company A unable or unwilling to accomodate Company B's plans
  • Company B finds SAS vendor that will
The death spiral begins.
  • Company B signs with Company C, the new SAS provider
  • Company A makes lay offs of technical employees
  • Service declines at Company A
  • Company B gets tons of complaints
  • Company B pulls remaining clients from Company A
  • Company A has problems.

Could this have been avoided by Company A.  In this economy, who knows?  Probably not.  I wish them luck.

Dr Schoor

Sunday, November 08, 2009

Where an EMR helps and hinders in medical practice

EMR are very useful tools, just not for everything.  If you think about about all the processes that take place in your medical office from the moment a person calls to book an appointment to the moment you get paid, you can determine where the EMR will help and where it will hinder.  Here are some places I think these programs help.
  • Scheduling
  • Prescribing
  • E&M Coding
  • Charge Entry
  • Claim Submission
  • Payment Posting
  • Acounting
  • Auditing
  • Ordering
  • Document Management
  • Clinical Trend Analysis
  • Coordination of Care
  • Patient Compliance
  • Communication
  • Information Flow
  • Documentation*
Of course, not all processes are streamlined with an EMR.  The main example of this, and perhaps the only example, is the physician's encounter.  It takes longer for the doctor to document a patient encounter with an EMR.  And the doctor has to expend more effort to document the encounter.  Both the effort and time required to document improve over time, however.

Also, EMR generated notes are more cumbersome to read, which can make it more difficult for the doctor to get at the "essence" of his/her prior encounter.  Of course, this can overcome by adding memory joggers into the document.

On the balance, EMRs are improvements over business as usual for the small independent medical practice.

Dr Schoor

Saturday, October 31, 2009

My favorite American tradition.

Happy Halloween.
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Thursday, October 08, 2009

How to document an encounter quickly with an EMR

Electronic medical records have many advantages over traditional pen and paper charts. Speed of documentation, however, is not one of them. I have been live now on my high end electronic health record for 6 months. My first encounter on the system took place in February 2009 and took me 45 minutes to document on the system. Obviously, I would need to improve upon that. Now I do things differently, more efficiently. Here is my work flow:
  1. Schedule patient, office staff gets some clinical information
  2. Appropriate clinical templates are pre-loaded by me or staff into notes prior to patient arrival
  3. I review the templates and pre-order labs, studies, and prescriptions as I see fit
  4. When patient arrives, I perform the encounter and do my doctoring
  5. I then determine if pre-ordered tests and prescriptions are still appropriate
  6. Finally I complete the documentation, sign note, and on to the next patient.

The entire process now takes under 5 minutes and is much less stressful.

When you get an EMR, you must change your work processes to adapt.

Sunday, October 04, 2009

Are meetings worthwhile?

As reimbursements continue to decline for many of us and we are forced to remain in the office longer and longer to make up the lost income, our attendance in meetings has taken a back seat in importance. This is a shame and you may wish to re-think this cost-cutting strategy.

Meetings are very, very important. You'd be better off cutting out some othe expense.

Meetings allow attendees to re-charge their batteries and return to the office energized and more productive than ever. Only through meeting with colleagues face to face can doctors forge new relationships that are important for networking and business development. While we may be able to learn new techniques and advances in our field through online CME courses, we learn best in person where the dialogue is 2 way and we have access to non-verbal communication.

Meetings are not cheap. Flights, hotel, registration, and time away add up to thoudands of dollars. However, if you choose your meeting wisely, increased revenue will offet the costs many times over. All it takes is learning one new CPT code or one new modifier or a new profitable procedure and you will payed back in triplicate, at least.

I just think this is not an option for cost cutting.

Thursday, October 01, 2009

Wow, you can bill Medicare for waiting room magazines

From 2 posts on a listserve to which I subscribe:

" There are codes for magazine loss/replacement:
CPT: 9999a- replacement of magazine, identical issue
9999b- replacement of magazine, similar topic matter
J codes: 80% of magazine cost"

Also, since the governement is so interested in our education, here are some other codes you can use:

"Recent governmental efforts to encourage literacy among the poplus has lead to CMS's request for physician offices to voluntarily report, via PQRI, on appropriate utilization of magazines and reception area reading materials. Qualifying providers will be eligible for a 2% bonus of their annual CMS billings. These G-codes for PQRI measure 9999 are: G9990 - Educationally meaningful magazine provided at reception area G9991 - No educationally meaningful magazines provided at reception area G9992 - Some or all educationally meaningful magazines made available were lost due to theft or damage Eligible providers must successfully report on at least 80% of pts on Medicare seen in 2009 to qualify. The exact definition of educationally meaningful is still being debated, and won't be released until early December 2009."

I believe that most of this information came out on April 1st. I am not sure I recommended trying these codes just yet.

Hat tip to and Dr Ernie Sussman, famed urologist in Las Vegas. Hope you enjoyed.

Sunday, September 27, 2009


Doctors are resistant to upgrading technology. Most claim cost as the main obstacle to adoption of E.H.R technology. For others, overcoming inertia and resistance to change prevents them from committing to advanced information technology.
I say get with the program.

The technology is here.
It is good.
It is affordable.
Patients will demand it.
Payers will demand it.

I have several supermarkets near my house. One is less than a mile, but I shop at one 3 times the distance. This market has adopted technology that makes my life easier. In turn, I choose to spend my food dollar here. The image you see is of a scanner. I use the scanner to scan the bar codes of my food purchases. The scanner is tied to my card. After I am finished shopping, I simply hand the scanner back the clerk, my credit card is charges, and I am on my way.
I demand technology.
So will your patients.
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Monday, September 21, 2009

EMR vs House: Words of wisdom from a practice managment guru

Rick Rutherford, a practice management guru with the American Urologic Association, has a great analogy for EHR selection. I have published it, with his permission, in its entirety.

"The biggest fallacy in the process of selecting an EHR system is that too many folks think that there must be ONE systematic, accurate approach to making a good choice. There isn’t. To me, it is more similar to buying a house than a car. You can buy a car, drive it for three or four months and decide it is a lemon and go trade it in for a different one in a single day. Sure you lose some money, but beyond that, it is an easy transaction. When you buy a dwelling, there are many more considerations and sometimes, if you make a mistake, you just have to live with it. EHR systems are the same way. Why? Consider the following (substitute the word “house” everywhere you see the acronym “EHR”):

A whole group of people have to use the EHR so all of them should have input into what is important.
You can buy a modest EHR or a extravagant EHR depending on which things are most important to you.
When you start to use your EHR, you discover that almost every pattern you have developed must be changed or you will waste a lot of time and energy.
Over time, you become more and more comfortable with the EHR and appreciate (or hate) nuances you never saw when you did your first walk-through.
There are lots of financing options for an EHR. The government may give you money, the hospital may give you money, the bank may give you money. However, the financing should NEVER be the reason why you choose one over another.
You can spend money any time you choose to enhance the features of your EHR. Sometimes you have to spend money because of unexpected circumstances that you didn’t plan for.

The biggest difference between houses and EHRs? There is no residual value in an EHR. So take your time, be sure about what you want, talk to as many other people that use it as possible and read every single word of the purchase contract. Negotiate every item. Finally, once you commit, do everything within your power to make it make your life better.
With warmest regards, Rick Rutherford"

So true indeed.
Thanks for the words of wisdom, Rick.

The IU.

Tuesday, September 15, 2009

Time vs Money

There are only 2 variables that can be manipulated when determining compensation in a medical practice; time and money. There are many ways to divvy up either.

Some practices compensate all partners equally as long as the relative work performed by each doctor is equal. As long as the doctors work as hard clinically as each other and take the same number of nights on call, then the pay will be equal, though the details of this arrangement is certainly more complicated than that.

In an equal pay type of set-up, the easiest variable to manipulate is time. In a medical practice, time is spent in the following ways:
  • Clinic hours
  • Rounding/Hospital work
  • On-call
  • OR and procedure schedule
  • Administrative

The hours spent performing these necessary functions must be allocated amongst the doctors. There all all kinds of ways the schedule can be configured for someones advantage, which by definition, is someone else's disadvantage. Time in a medical practice is spent as follows:

  • Hospital rounds on Mondays vs Tuesdays vs Friday etc
  • Monday morning office hours versus Thursday evening hours vs Friday afternoon hours
  • Monday on call vs Tuesday on call vs Wednesday on call etc
  • On call Christmas versus New Years versus Thanksgiving
  • Having a first start case in the OR versus to follow cases
  • Going to administrative meetings versus working in the clinic

All these things have value. Perhaps not the same value to each individual but value nonetheless. If more than one person comes to view Monday call is more labor intensive than Tuesday call--which it is statistically--or a 7:30AM start time as more desirable than a 1PM start time, grievances will arise. You can bet that conflicts will emerge over the schedule and the manipulation of time. In fact, the person who controls the schedule becomes the most important member of the team. . .often the most hated.

I want to say one more thing about time and money. As someone ages, money tends to become more abundant than time and this often influences a person's economic decision. For example, a person with lot's of money but little time will think nothing of purchasing the most expensive plain ticket if this gets them to their destination fastest. A college student on break, with all the time in the world but no money, will usually purchase based on price rather than time.

Conversely as time becomes more scarce, money becomes more important. If time cannot be manipulated in these cases, then people start to demand variations in compensation.

Then comes conflict.

Friday, September 11, 2009

Craziness or Opportunity

I needed medical records from a patient's recent hospital admission for continuity of care purposes. I recieved the records today but they were sent not by the hospital itself, which is 3 miles from my office, but from a 3rd party operation located in North Carolina, approximately 800 miles away.

IOD, Inc.

Crazy, right? Why can't the hospital just send me the records when I request them?

Well the answer is that due to the complexity of federal privacy laws, the hospital has decided to outsource the management of the release of health information. The hospital pays this company and the company assumes the liability associated with a violation of HIPAA. Other than slight inconvenience to me, patient privacy is assured, the law is followed to the letter, and some entreprenurial person makes money. Win, win, win.

What can this teach us? For one thing, you can view regulatory change as a pain in the rear or as an opportunity for improvement or even new business.

Since the business and regulatory world are always changing, I recommend that you embrace the change and and use to your advantage.

Thursday, September 10, 2009

Fighting Murphy: what are your checks and balances?

People can slip through the cracks easily.
  • Patients can walk out of the office with their encounter forms or charge slips.

  • The office staff can forget to give them a follow-up appointment.

  • Patients can call to cancel an appointment, intend to re-schedule, then forget to do so.

  • Patients can no-show.

  • Staff can forget to put the patient on the recall list.

  • Staff can put the wrong patient on the recall list.
  • The doctor can get forget to write the order for the test or the follow-up.
  • The doctor can forget to click on the order or the request for follow-up.
  • Handwriting can be illegible.
  • The computer can crash.
  • Murphy can and will show up.

In a doctor's office, this can be dangerous.

The only way to prevent Murphy from walking into your medical office is to have multiple and redundant checks and balances.

How do you do it?

Wednesday, September 09, 2009

Information Management: The True Essence of Medical Practice

Twenty five, 30 years ago, doctors could keep track of their patients on index cards. I know some of these retired docs. They tell me that in some instances a 30 year patient relationship could be held on a 4-6 index card, front and back.
Seems insane in these information rich times.
Medicine, the business of medicine, that is, has become if nothing else, information heavy.
Clinical data, billing data, legal & compliance data, laboratory data; it could fill a warehouse if stored in paper format.
What is the best way to handle this mountain of data?
Either purchase the system or develop it yourself, but get a system that can store and more importantly manage information digitally.
You’ll be much better off for it in the future.

(Reprinted from:

Tuesday, September 08, 2009

Cost Containment: A Post Worth Revisiting

With declining reimbursements, the only way to to remain viable is through revenue generation coupled with cost containment. I'd like to talk a bit about costs, and some obvious--and not-so-obvious-ways to minimize them.
Fixed Costs: These are items like rent and insurance. While you probably have little negotiating power in this area, with regard to rent you can keep costs down the following ways:
Maximize productive use of space. I pay $26 per square foot, and use all of it productively. An EMR helps here, because I don't need to dedicate several hundred square feet to chart storage. Also, mobile units, such as portable sonogram machines, client computers, and portable lab equipment, also helps. And of course, I have VPN, because it essentially converts my house or Starbucks, or anywhere with an internet connection into an extension of the office.
Maximize revenue generation areas of the office. These areas include exam rooms, your office, and the lab. Back office functions, such as insurance claims submissions and billing work, can be virtual, via your VPN, yet remain "in-house" as opposed to being outsourced. With a well networked office, exam rooms can serve as exit offices while you go to the patient in the adjacent room.
On-demand Supply Ordering and Smart Storage: Closets = Square footage = $$. With some thought and planning, shelving, exam tables, cabinets, and closet space can be used for maximal storage at minimal square foot usage. In addition, I order supplies as needed, since my vendor, PSS Worldwide Medical, always delivers next day.
Variable costs: These include costs for items such as medical supplies, payroll, utilities, stamps, etc, and can be determined by examining the profit-loss statements prepared by the accountant. here are some ways to keep variable costs down.
On-demand supply ordering. DELL Computers uses this concept. I do as well, just make sure you don't run out of Foley drainage bags after you've already placed the Foley.
Part-time employees: Simple. They cost less than full time employees, plus no overtime.
On-demand staffing: I staff heaviest on the busiest days. Plus, since I am capable and willing to pick-up slack on days that we are inadvertently short staffed, this method works out well. Busy days or light days, open or closed, phones are always!!! staffed.
Amortization of utility payouts. Most utility companies will estimate a fixed monthly cost for you to pay based on a prior years consumption. I like it for cash-flow management.
Have your phones (VOIP), cellphones, & internet on fixed plans, so that costs do not soar with usage. Get the maximum minutes for cell phones, since the incremental costs of the plan are much less than overage payments. VOIP is cheap, plus never varies with usage. On the balance, I've been happy with it, yes, even for the "mission critical" functions.

Fax. Why snail mail when you can fax the referral letter. Not only is it faster, more efficient, and trackable, it is cheaper. I love my fax. Yeh, yeh, yeh, I know, HIPAA. But it can be done and still be in compliance
Direct costs: These are costs that are directly involved in patient care. Here's how to minimize these costs.
Everyone does everything. MA's do data entry, answer phones, clean rooms etc. The docs answer phones (if they are not seeing patients) when needed, clean rooms, order supplies, schedule patients, e-file labs. Again, an EMR and a VPN helps here as well.
Part time employees and on-demand staffing: see above.
Creative patient scheduling: Figure out which works best for you; clinic, open access, proportional, or wave scheduling, and then determine minimal staff requirements for your office hours.
Ergonomic room design. I have rigged my rooms so that I can do a many procedures without an assistant present. I learned these skills as a surgery resident in central line clinic. In fact, I can prep with my left hand, place the scope with my right hand, and simultameously do a UA with my toes (kidding!). If you have 2 hands, a brain, and a Mayo Stand, you can make it work as well, and in the mean time, you'll free up staff to answer phones and book new patients or enter claims.
Training and process management: Training employees well and developing efficient processes of doing business will allow you and your employees to work smarter and with less mistakes and to get the job done right the first time. This simply saves money. Also, keep your employees happy. Turnover is very expensive and disruptive.
Indirect costs: These costs cover non-patient care activities, such as back-office staff and billers. Here's how to minimize these costs.
See direct costs.
Remote working

Embrace technology
Training and process management

Consider outsourcing when appropriate.

Saturday, September 05, 2009

PQRI in 10 Steps

I finally figured it out, PQRI that is.  After several courses and months of procrastination because of PQRIs seeming complexity, I got it and am going to give it to you. . .free.

No strings attached.

Here it is:

  1. Pick your measures (you'll have to look them up or contact me)
  2. Right them down on a piece of paper as a cheat sheet or see step 3
  3. Enter them into your EMR templates as appropriate
  4. Tell staff to mark all encounters on pure Medicare (only) patients with a big red mark
  5. See patient as normal
  6. Circle or click on PQRI code on your encounter slip or your EMR
  7. Tell biller to insert those CPT codes on line 2 of the HICFA 1500 form
  8. Submit claim
  9. Let Medicare do the rest
  10. Or. . . you can outsource the whole process to a third party, approved vendor.
That is it.  Once you put the processes into place, simple.  And I just gave you the process.


The IU.

Thursday, September 03, 2009

A follow-up protocol for non-compliant patients and busy offices

Patients no show and are not compliant and their lack of compliance can be blamed on you.  Here are 5 steps you can take to prevent a patient from slipping through the cracks:
  1. Impart onto patients the importance of follow-up then. . .
  2. Give all patients a follow-up appointment or place them on a recall list, and if they fail to show up. . .
  3. Run a no show list. . .but if your staff forgot to give them an appointment, you'll catch them by . . .
  4. Running a diagnosis/procedure list periodically, and if all else fails, hopefully you'll get them with a. . .
  5. Random Audit
Crazy, but very important.

Any other suggestions?

The IU

Monday, August 31, 2009

What is your donut?

I was talking to my father-in-law the other day about a client of his who is a baker. This baker used to make lots of fancy and expensive items, such as cakes and tortes, but now he makes mostly donuts. He did not always do this. He began to do it out of neccessity. Donuts, you see, are high profit margin products.

Dunkin Donuts only makes donuts and coffee and guarentee them to be fresh anytime. Dunkin Donuts can do this because donuts are so cheap to make and they have such a high profit margin, that the store can afford to throw away items that have gone stale.

Urology has high profit margin procedures. Vasectomies and cystoscopies are 2 examples. Larger, maga-groups have radiation therapy for prostate cancer, which for now has a high margin. Laboratory work is low margin. Major surgery in the hospital is low margin.

In your practice, what has a high margin?

Sunday, August 30, 2009

A great use for an EMR

Everyone has no-shows. It is just a way of life in medical practice. Effective no show management can add to your bottom line. An EMR can help here.
Set your EMR to automatically run a no show list or even better, a no show letter, once per month, at least. Then you and staff get these patients back into the office.
One, you'll recoup income. Two, you'll practice good medicine.
Win, win.
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Tuesday, August 25, 2009

It's a tough life

Tennis is a very rough way to make a living. Only about 100 of the world's best make a decent living solely through winning matches. Of those, only about 50 make what a cardiologist makes with the top 25 making wall street figures.
What amazes me, year after year, is how much the draw changes. Only 2 to 3 players from last year have returned this year. Maybe one made the big show, but the rest have done worse.
At my urology meeting, I saw all my old colleagues and everyone was successful. My dad was right. Play as an amateur, be a professional.
Good advice..
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That time of year again

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Saturday, August 22, 2009

Who's your role model?

I was watching tv the other day, flicking through the channels. I came across Bill O'Reilly first and listened to him and Dennis Miller. Entertaining? A bit, Angry? Very. Inspiring? Not at all.
Then I flipped to C-Span and a speech by Muhummud Yunnis, the Nobel Peace Prize winner for microfinance. Microfinance is a great concept; lend a woman 100 dollars so she can start a business, grow it, and eventually take herself and her family out of poverty. His concept has taken 40 million people in Bangledesh out of poverty. Here in New York, his microfinance program, which is not welfare, has allowed thousands in Jackson Heights Queens to ascend out of poverty.
Muhummud Yunnis: truly inspiring.
Who inspires you?

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Thursday, August 20, 2009

Information Flow

One of the best aspects of a good and integrated EMR and PM system is the rapidity with which information can flow through your practice. A patient phone call can result in action within minutes, even seconds, after the phone call is made. The same with the doctor's orders or a staff member's questions. Processes just get done with speed and efficiency.

Information at the speed of thought, to paraphrase Bill Gates. Truly amazing.

Wednesday, August 19, 2009

Automation and the demise of doctoring

Doctors will always be needed. So will carpenters and iron workers and all skilled laborers. However, as technology advances, it allows for high labor intensive jobs to shift down the labor intensity curve. While we still need carpenters for custom jobs, the vast majority of carpentry is done by machine, not man. Very few carpenters, as a result, can command high incomes.
Medicine is going in this direction as well. Information management and science will enable thought leaders to produce efficient and accurate algorithms that automate the very process of patient care. As a result, most medicine will be delivered by non-doctor entities, perhaps even machines.
The need for doctors will diminish, as will income levels. This may take 20, 30, or even more years, but it will happen.
What will you tell your kids to do when they grow up?
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Monday, August 17, 2009

Long day

Good day

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Sunday, August 16, 2009

To consult or not to consult

The definition of a consult by CMS is unclear. At a conference yesterday, about 300 of us spent almost an hour parsing this one word.
In the US, medicine is easy. Coding is challenging.
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Saturday, August 15, 2009

How to use free in your office to make money

Free can make the good business person a lot of money. Here are some ways to convert free into dollars in your own practice:
The path might not be direct, but it will get there just the same.
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Friday, August 14, 2009

Who is driving?

I sometimes wonder who is driving all this lunacy in health reform.
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Saturday, August 08, 2009

Want to find in-efficiencies? Make a flow chart.

I serve on my hospital's performance improvement commitee. I enjoy it and I learn from it. Here is something I learned from my hospital's PI committee.

If you want to find sources of error, flow-chart your processes. It can go something like this for a small office like mine.

Let's say you want to find a weak spot in your diagnostic test ordering and resulting process; FLOW IT OUT
  1. Patient needs "blood test."
  2. Complete requisition (paper for sake of argument)
  3. Give requisition to MA to facilitate

  4. She draws the blood, processes it, ie centrifuge, and places it in the pick-up box with requisition attached

  5. Lab recieves, runs the lab

  6. Results are faxed and mailed to office (partials first, then finals)

  7. Result placed on doctors desk for review and signature
  8. Result then given back to staff for placement in chart, unless doctor needs chart pulled to interpret test
  9. Patient informed
  10. Chart re-filed

If you go through this simple list of steps, you can see lot's of inefficies. For example;

  • Step 2: WARNING: MAJOR SOURCE OF ERROR HERE: handwriting issues and duplication of data: an electronic ordering system can correct this. Contact your labas they may be able to install one for you at no charge, even.
  • Step 6: Duplication of results, wasted time and effort as doctor needs to sign-off on the same lab multiple times. Plus cost of tonor, printer/fax usage, staff time,and doctor frustration factor, there is a better way. Simply ask the lab to only send complete reports and better yet, ask them to automatically download those results from their server to yours and to notify you when done. Most good labs can do this easily and at no charge to you.
  • Step 7: Automating step 6 makes steps 7, 8, and 9 obsolete.
  • Step 9: Normals can be mailed to patients using a form letter.
  • Step 10: Electronic records obviously elliminates this step plus step 8 as well.

You can do this for almost, if not every, process that takes place in your office.

Try it.

Sunday, August 02, 2009

I aced my lab inspection

My information management system, to the rescue.

My COLA CLIA inspection went very well.

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Monday, July 20, 2009

Camp Doc For A Week: Old Fashion Medicine.

From Camp Doc 2009

My wife and I spent the past week as doctors for an overnight summer camp in the Adirondaks of New York. If you ever get a chance to visit this part of the country, I recommend it highly. The Adirondaks are New York's Alps. Though this trip was not my first to the region, I was once again blown away by its beauty, its charm, and its wilderness; a true jewel only a 3-4 hour drive from New York City.

Being a camp doctor was an interesting experience, to say the least. In many ways, doctoring in the camp environment exemplified many of the reasons why I chose this profession in the first place. For many of us, the art of medicine has been replaced by the assembly and bottom-line apporach that has become modern medicine. As a camp doc, all I had was the art: history, physical exam, judgment, compassion, and a shingle. I felt like Marcus Wellby himself.

From Our Photo Blog

Wonderful indeed!

During the week, my wife an I saw many campers with a variety of ailments. Lots of campers and staff alike had bug bites. These we treated with Calamine lotion and some antihistamine.

From Camp Doc 2009

One camper had severe swelling around the eye and another on the hand. We gave these 2 campers some prednisone along with the antihistamine, and they both got better. Lots of kids had foot ailments for some reason. The nursing staff liked to soak everyones' feet in a betadine and peroxide solution.


From Camp Doc 2009

I sent one child to the emergency room with a a suspected nasal fracture. Actually, the child's father insisted on the ER visit and I just complied with his request. In the ER, the child had a facial x-ray performed which did not show a fracture. Of course, no x-ray can ever truly be negative, so the ER ordered a confirmatory CT scan. Fortunately, the CT was not done, at the father's request, out of the concern of radiation.

I sent 3 other people for diagnostic imaging. Onea 15 year old, was complaining of back pain for 12 days. Though I knew a back x-ray would be negative, I sent him for it anyway. It was negative. Another person, a staff member, hurt her thumb 2 weeks prior and still had pain and decreased mobility. I sent her for a hand x-ray. This was my last day in camp, so I don't know the outcome. The 3rd was a counselor with fevers to 103 and cough. I actually heard rales which prompted me to order a chest x-ray that showed pneumonia.

Not too shabby for a urologist, eh?

From Camp Doc 2009

From Camp Doc 2009

The camp had a "health center". The center consisted of a small house with a great front porch. The main room was an evaluation and treatment room plus office combined. We would see the "patients" here, document the encounter on an index card, and if necessary, call the parents. There was a smaller room to the side and this room doubled as the medication dispensary and computer room. Campers who took routine pills--which was about a third of the camp's population--would present themselves to this window and get their daily ritolin or advair or atarol or zoloft.

From Camp Doc 2009

I found this "medicalizing" of what seems to be a generation sad, to say the least.

The health center had one "isolation room" and an infirmary area with 6 beds; a small hospital really. We used the "isolation room" to house our potentially infectious campers or staff. Influenza struck fear into the hearts of staff and parents. Some camps had severe epidemics of flu this summer and were forced to send home 40 to 50 campers with the illness. The camp where I spent my week did not want this to happen, so contagion control was paramount. I could not help thinking what camp must have been like during polio's reign of terror.

We had 2 patients in the isolation room at various times during my week, both counselors. One was the young man with pneumonia that responded quickly to zithromax. The other patient, a suave British, self-proclaimed male-model-turned-counselor, had a viral upper respiratory infection. He spent five days in the isolation room, though he made many trips to the front porch for some fresh air and conversation. Treated round the clock by a diligent staff of nurses and nursing students, the Brit whose accent rivaled James Bond himself, recovered nicely on a prescription of bed rest, hot meals delivered to his room, movies, wireless internet access, and--though I can't confirm it--a sponge bath from one of the nubile nursing students afore mentioned.

This guy was good. Real good. Ultimately the threat of deportation seemed to clear up his chest congestion just fine.

In the clinic, as we called it, we had only 2 diagnostic tests at our disposal. One was a rapid strep test and the other was a flu test. All other diagnostic testing required scheduling at an outside facility, which was difficult to obtain, and it required that the camper lose valuabe--and expensive--camp time. The funny thing about diagnostic testing is that if you have it available and it is easy to order and perform, you'll use it. If testing is difficult to obtain, you make due without it. We did at least 50 flu tests that week and a similar number of strep tests as well. All were negative. I only sent 5 or so people for outside diagnostic testing, though if an x-ray or CT scanner was more readily available, I'd have probably utilized that technology.

I enjoyed the week, all in all. I found myself smiling inside as I looked into an ear canal or the fundus of an eye. I palpated, auscultated & perscussed. I heard rales, looked for egophany, and, yes, sought after the illusive physical exam finding of whispered pectriloquy. I felt Sir Williams Osler's blood course through my veins. I had fun.

Thursday, July 16, 2009


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Tuesday, July 14, 2009

A doctor owns this house!

Holy molly. He must see lots of 99214's
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Sunday, July 12, 2009

What medicine is supposed to be like

This week, I am camp doc. More to come.

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Saturday, July 11, 2009

The start of a long deserved VK

On the Pt Jeff Ferry

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Friday, July 10, 2009

Long Time, No Post

It has been a long time indeed, several weeks, since my last post. Here's what I've been doing.
  1. I have been tweaking my EMR
  2. I have been improving my office workflows
  3. I have been working om my iLabTQM project
  4. I have been working on several internal based marketing campaigns
  5. I have been adjusting my adwords and some other external marketing campaigns
  6. I have been playing tennis
  7. I have been spending more time with my family
  8. I have been working
Hopefully I'll get re-inspired to blog.

Wednesday, July 08, 2009

Monday, May 25, 2009

Fw: The time has come: Medicare for all, and now!

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From: Health Justice
Date: Sun, 24 May 2009 20:06:38 -0600 (MDT)
To: <>; <>

TO: The White House Office of Health Reform, Senator Edward Kennedy, Senator Max Baucus, Speaker Nancy Pelosi and Senator Harry Reid.


Dear President Obama and Legislators:

You want a "uniquely American solution" to the health care crisis. So do I. Fortunately, we already have a uniquely American solution. It works. It saves money. It's called Medicare. It's the most popular social program in history.

I want expanded and improved Medicare now. For me. For everybody. Just like in Rep. Conyers' bill, HR 676.

Health insurance is not the same as health care. Insurance is for accidents. Health care is not an accident. I want health CARE, not health insurance.

Insurance company flacks and high-paid lobbyists twist the truth about Medicare. It's not "socialized medicine." Medicare is publicly financed, privately delivered health CARE. I have heard the nonsense about "government bureaucrats practicing medicine." The insurance companies paid Harry and Louise to twist the truth in 1994 and spout half-baked "facts" to defeat the Clinton plan. That tactic won't fool me again.

Medicare works for Americans over 65. It will work even better for healthier younger people. Quit looking for a solution that gives the insurance companies more money. Use what works. Give Americans under 65 the same right that seniors have - the right to guaranteed affordable health care with free choice.

Medicare for me. Medicare For All. Everybody In, Nobody Out. Now.

Please do the right thing for our kids, our nation, our economy, and vote for expanded Medicare for all.


Richard Schoor ,, zip code 11787

Sunday, May 17, 2009

Beyond the call of duty

Waiting in line to buy dance recital tickets, some people got here at 5AM.
Is it me or is it them?
I have an idea, sell the tickets online.
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Friday, May 15, 2009

Have a nice weekend

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Sunday, May 10, 2009

Happy Mother's Day

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Saturday, May 09, 2009

A picture is worth 1000 words

The easiest way to teach your medical assistant how to set up for a vasectomy or any other procedure is to show her a picture.
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Thursday, May 07, 2009

A reason to get involved

I used to shun service on committees. I saw it as a waste of time. Now I volunteer for them. I've come to view this type of service as valuable on many levels.

Currently I serve as my hospital's PI committee. PI stands for Performance Improvement. We review adverse events and try to learn from them in order to become better. One tool we use is the RCA: the root cause analysis.

I've started to apply lessons I have learned in PI to processes in my own practice. I am now in the process of developing a repeatable system of PI, based on the hospital's, for my own office. When lab's don't make the chart or a patient is upset over a delayed returned phone call, I do an RCA. So far the initial results have been encouraging.

I'll keep you posted.
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Sunday, May 03, 2009

Five ways to decrease call-backs

In a medical practice, phone calls are money pits, essential though they are. Doctors don't get paid for phone calls and the more calls a practice gets, the higher the costs. However, missing calls is even more costly, so the key is call management. Practices that manage phone calls well can benefit. Here are somes things you can do:

1: Track when calls come in and staff accordingly.
2: Track why calls are made and adjust operations accordingly.
3: Decrease call demand by use of e-Rx, printed materials, and an instructive website.
4: Manage patient expectations.
5: Use a patient web-portal.

While employing some or all of these tactics may not eliminate repeat calls, it will reduce them by 10 to 20 percent and free your time for more productive and pleasant pursuits.

Wednesday, April 29, 2009

Is your practice compliant with Red Flag?

Beginning May 1, all medical practices must take steps to ensure compliance with "the red flag" rule.

In essence, we have been deemed creditors and must have policies in place to prevent identity theft. You must identify risk areas, address them, then develop policies to minimize the risk. Failure to do can result in thousands of dollars in fines.

While HIPAA may not have had teeth, my understanding is that Red Flag will, since it is the FTC that enforces it.

Feel free to contact me if you have any questions.
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Tuesday, April 28, 2009

Some observations about urology

Many urologists with whom I spoke are doing very well, yet our collective ill-ease is palpable. Fears over increasing government intrusion into our lives pervades our thoughts. As always, our Sisyphean battles with commercial payers continue.

Of the hundreds of urologists that I spoke with, only a handful are in solo practice. I guess I am bucking a big trend. I do not know if I can survive or not, but I do feel that my survival will be in many ways tied to success of lobbying efforts by large groups.

So I wish them luck.

Over the years, technological advancements have made the AUA meeting more user friendly. Courses, sessions, and lectures are now available on DVD, continuing medical education credits can be downloaded from the Internet, and the AUA now keeps track of the CME credits using bar code scanners.

Many, if not most, practices have EMRs. All have problems with their products and expressed frustration to me. However, all those that use EMRs see the benefits of the technology and just need to learn to successfully implement it.

Many of my friends and acquaintances are in academic practices. Most seem happy. Academics produces 3 types of doctors: the superstar, the worker-bee, and the former academician. Superstars have busy clinical practices, serve on committees, and give courses and lectures. They teach others and make policy.

Private practitioners in general do not serve in that capacity. I think this is because they are not invited to participate in policy making committees. This is a shame and a disservice to the very same urologists affected most intimately by policy changes.

I call upon the AUA to include us in the process.

Today is my last day in Chicago, a city that I love. All things considered, I find that Chicago is the best US city. I am glad that the AUA comes here very few years. My experience at the AUA meeting has been positive. I have learned a great deal, networked, and re-charged my drained batteries. Though costs of attendance at the AUA can get a bit pricey, the benefits far outweigh them.

Monday, April 27, 2009

Poster session at the AUA

Good stuff, good stuff.
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Sunday, April 26, 2009

My junior resident

Dr Dan Williams MD

Male Infertility Expert, University of Wisconsin at Madison.

Northwestern Urology Alum.

Nice job buddy!

Friday, April 24, 2009

Good morning from Chicago

In town for the AUA, a urologist's version of the Oscars.
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I am in Chicago for the annual meeting of the American Urological Association. I arrived on Thursday so I could attend the practice managers meeting Friday and Saturday. Here are some things I learned, business-wise:

  • Urologists are public enemy number one and targeted for cuts on all-ends.
  • e-prescribe will be mandatory by 2011, after which practices that do not e-prescribe will lose 1 to 2% of Medicare reimbursements.
  • PQRI requires participating doctors from any specialty to enter data on 80% of appropriate cases or forfeit all bonuses.
  • e-prescribing needs to only be done on 20 or 25% of cases to meet criteria.
  • MGMA data suggest that higher operating expenses translate into more profit for doctors, so long as the expenses are in ancillary services, health information technology, and staff.
  • Medicare Advantage Plans are run by commercial payers arrangement costs the taxpayer an extra 13%, on average, over straight Medicare.
  • Medicare Advantage Plans are not required to follow Medicare's rules and are not under state jurisdiction.
  • The speaker recommended that urology practices avoid the Medicare Advantage plans.
  • A physician's most valuae resource is his time.
  • For efficiency's sake, doctors need to delegate everything that can be to employees or non-physician providers.
  • The speaker, a professional consultant, stated that practices should answer phones at times that patients are likely to call, ie during lunch, before work, after work, etc.
  • Practices need to understand performance metrics and adjust accordingly.

Thursday, April 16, 2009

DIY EMR vs The Big Boys

Here are some of my thoughts on this whole EMR business , now that I have "upgraded" to one of those products worthy of a government seal of approval.

EMRs do some things really well. Some of these things benefit the doctor. Others benefit bean counters. Other's benefit patients. A few of these things benefit doctor, payer, and patient simultaneously. I think this is an unintended consequence of an EMR, to be honest.
  1. EMR's handle prescriptions really, really well, and that is regardless of an eRx module or not. The good EMR's have built in prescription writing software--actually the software is from a third party vendor--that simplifies the new and refill process so much that a medical assistant with a little bit of training can do it without mistake. This helps doctor, payer, and patient through efficiency and accuracy. My little DIY EMR was terrible at this.
  2. EMR's handle coding very well. The good products have CMS coding rules pre-programmed. When the doctor sees an encounter, the system can suggest an accurate level of coding that reflects the documentation. This helps doctor and bean counter at the same time, though it does not help the patient at all. My DIY EMR was not sufficient in this regard, but I could have made it so if I had the knowledge then that I have now.
  3. EMR's handle documentation extremely well. Notes are well written and chock-full of information and free from handwriting issues. This helps the bean counter though not the doctor or the patient as much as you might expect. You see the notes seem to lack the essence of what was on the doctor's mind. I find them difficult to sift through, to be honest. In fact I just got documentation faxed from a local urologist to whom I referred a patient. The computer note was difficult to interpret, albeit beautiful. Had the urologist not called me in addition to the fax, I'd have not known what he was planning. I found that quick, short, scribbled notes (typed even better) provided the best form of documentation from a pure patient care perspective. Ironically, my little DIY EMR was superior in this capacity.
  4. EMR's enhance billing processes. Good EMR's can seamlessly merge EMR data with billing data and facilitate claim generation and turn-around time. Coding, ie programming, requirements for this were light-years ahead of my little DIY EMR. This feature of an EMR helps doctors only.
  5. Correspondence: Good EMR's facilitate correspondence with providers. Ironically, this might not really help the receiver, since these systems tend to inundate them with paper. I have had a number doctors mention this to me with regard to my system and other popular systems. Perhaps this is just a customization issue. In this regard, looking back, my little DIY EMR was superior.
  6. Document management: When properly interfacted with participating labs and radiology centers, document management with a good EMR is a snap. These interfaces don't come cheap, however, and if your EMR and local lab/radiologist etc cannot work together, you are screwed. My little DIY EMR was vastly superior in this regard since it worked with everyone, cheaply. There were no interface issues.
  7. Intra-office communication: Good EMRs, though probably even cheap ones, have secure email features for intra-office communications. I have found this feature, even in my small office, to be a huge improvement over my previous way of doing business. If I was a better software designer, I could have configured my little DIY EMR to do the same thing. But I didn't.
  8. Customization: Good EMR's can be customized and programmed to reflect "best practice" guidelines. My little DIY EMR did not do this. I actually see a sinister motive in the government's and industries pushing this "best practice"agenda. Ultimately, the powers-to-be will use this to empower midlevels and pay doctors less.
All in all, my little DIY EMR was damn good. Not perfect, but nothing is. If I was cash only practice, I'd still be using it. But in the RAC, HIPAA, P4P era, it no longer was sufficient for my needs.

Still, not bad at all.

Dr Schoor MD FACS

Urologist and Owner of iLabTQM, a CLIA compliance software company.

Wednesday, April 08, 2009

Happy Passover

Be thankful for your freedom and wish freedom for those without it.
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Sunday, April 05, 2009

The 5 P's of EMR

I have now had my new one for 6 weeks. Here's my advice for success with an EMR conversion.
1: Persistence: The process does not come easily but takes lots of work.
2: Patience: See above, plus time.
3: Patients: The EMR conversion is best done in a live environment, under real life conditions, with real patients.
4: Paranoia: You can't put blind trust in the EMR to dot all I's and cross all t's. You still need a brain.
5: Payment: The good ones don't come cheap, at least not if they have good support. Be prepared to cough it up.
Good luck, and a 6th "P" for the Stimulus plan--Please--reimburse me for my investment.
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Sunday, March 29, 2009

When customer service matters

Taking money is easy. Providing good service, well that is more of a challenge.
And critical to the long term success of any business.
As a doctor, this means being available to patients 24 7.
Same for an auto insurance company when you have car trouble.
As a write this I sit on the LIE with a flat tire but help is on the way.
I am thankful for good customer service.
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Good luck

A high end men's shoe and socks shop in a high rent space in the village.
Better sell a lot of shoes.
Good luck.

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Thursday, March 26, 2009

The Paradox of EMR

I love my EMR. . .and I hate it.
With my EMR, my efficiency has improved, yet I have difficulty staying on time.
My biller can easily submit claims, yet I think the system under-codes me.
My notes have amazing detail, yet it is mostly non-pertinent stuff.
I think it facilitates patient care, yet I tend to look at the computer more than the patient.
I can easily correspond with other doctors, but I risk inundating them with paper.
My staff likes it, perhaps because my payrole has increased, rather than decreased.
The ability to customize has me in awe, yet it is a pain in the ass to do it.
The organization is flawless, yet paper charts are effortless to thumb through.
Typed templates are great, yet handwriting gets to the essence of the encounter.
ICD-9codes are always in plain site, but I think in human-speak.
I marvel at aspects of the system, then curse it in the same breath.

Like a marriage, a very complex relationship indeed.

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Monday, March 23, 2009

The Capitol Dome

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Capitol Urinals

Don't have BPH here. There are only 2 of these.
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Sunday, March 22, 2009


Do you have to go Paris or the Islands or somewhere exotic to get away?
Of course not!
A weekend with your family in an inexpensive hotel in a nice locale within several hours drive is enough to re-charge and re-energize.
And as a busy, self-employed practitioner, this type of get-away won't hurt the practice either.
I'd rather do 10 of these mini-VKs than take 1 long but exotic trip.
Just me and perhaps just for now, but the truth.
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Nice day

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An evening out with the girls

Nice break from my EMR hassles, etc
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Saturday, March 21, 2009

Not bad daddy

My name inscribed in a plaque.
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Road trip with the girls.

My father daughter trip begins
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Saturday, March 14, 2009

Make good use of your time

Using time wisely has become more important than ever.
EMRs help here, as they make the most out your precious minutes with a patient.
Tablet PCs can save time as well, since you can use them as both paper and computer.
Electronic faxing saves time by preventing printing problems and scanning issues.
Mobile devices allow me to blog while waisting valuable time at Costco.
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Saturday, March 07, 2009

Why now?

Why choose the EMR now? Well, why make any decision at any point in time?
Because I identified problems that needed solving.
Here were my problems:

Too much scanning.
Too difficult to send correspondence
Too many refill and rx issues
Too many documentation problems
Too many scheduling mishaps
Too many remote access disruptions
Too much effort with back-up
Too much paper
Too much effort
Too much work
Too much wasted time
Not enough reward

Yes, it was time.
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A new generation of bloggers

I have some competition now.
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Thursday, March 05, 2009


I currently employ 4 people, including myself.  I have 2 MA's and a part time biller.  All 4 of us make more than $600 per month.  My fifth employee is my EMR system.  It cost me $600 per month, +/- a few.

My fifth employee works 24/7 and never takes a sick day or personal day.

My fifth employee never forgets to do what I ask of it.

My fifth employee doe not make mistakes.

My fifth employee is very organized.

My fifth employee can write prescriptions.

My fifth employee can file labs efficiently. . .and retrieve them with equal efficiency.

My fifth employee can submit claims. . .at 2AM if I ask it to.

My fifth employee can generate letters to referring doctors. . .and deliver them. . .24/7.

My fifth employee is a great employee, my electric one.

Even at the hefty price tag I paid for it, my EMR when viewed as a fifth employee is cheap. . .very cheap.

Here's the thing: people expensive/robots cheap.

That is a good way tolook at an EMR investment.

Wednesday, March 04, 2009

Email back-up

I just had to do a massive re install of the OS on my Tablet PC. I do back up daily so I lost nothing, but I do have a warning regarding Outlook back-up. You need to take an extra step to insure that all emails are saved. I just hit the folders I want saved, hit ctrl A, save as a text file onto you back-up drive.
Then all emails are easily restorable as text files than can easily be read.

In back-up, it is the ability to restore that matters.
Good luck.
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Sunday, March 01, 2009

Mobile Ideas

Sometimes, in fact often, I find myself in car with sleeping child. There, alone and in piece and quiet, I often come up with my best ideas. Many blog posts, many practice decisions, even iLabTQM, my new CLIA Compliance Solution, have been launched from my Honda, with sleeping child aback.
I always keep pen and paper handy for such occassions, though now I have a Blackberry, so when idea comes, I compose it into an email or MMS and blast it off.
Makes for a good use of time--my alone time.
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Friday, February 27, 2009

"For your convenience. . ." Who are they kidding?

Beware when a company changes its operations "for your convenience. . ."  For your convenience actually means for their convenience.  While you may be helped by the change, that is mere coincidence.  The change in operations was made for cost savings. . .or increased profit, etc.  But certainly, it was not made primarily for your betterment.

When the customer service department notifies you that service queries must now be made on-line rather than by phone--"for your convenience"--it probably means that you'll have to wait longer to get help.

When statements can be sent by email, rather than mail, the company benefits by saving money on postage and envelopes.

Just my cynical observation made for your convenience.

Thursday, February 26, 2009

In a rough economy, give patients value

In this challenging and down economy where insurance companies and Medicare attempt to remain viable by raising premiums and co-pays, patients may balk at having to come to the office merely to "discuss lab results."  Now I know as well as you do that the cognitive aspects of medicine are important, valuable, and worthy of pay.  Even the insurance companies recognize this fact.  But patients, on the other hand, get pissed off when they are asked to pony up $50 when you don't "do anything."  While I disagree with the patients on this one, I do understand their gripe.  As a result, I try to offer something "of value" to them on every visit.

You may want to try the following: have patients come in to discuss results
  • . . .and have a repeat physical exam.
  • . . .and have a urine culture
  • . . .and have a blood draw
  • . . .and have a ultrasound
  • . . .and review radiologic studies in their presence
  • . . .and draw diagrams for them
  • . . .and complete forms

Just something I've figured out over the years.

Wednesday, February 25, 2009

From Idea to Implementation: 5 Steps

My friend Steve once told me, "ideas are cheap."   He was right.  They are cheap.  The real challenge is taking an idea from concept phase to market place, or FROM IDEA TO IMPLEMENTATION.  After you have come up with the idea or have identified a problem that needs solving, here's how to begin.

  1. Commit the idea to paper.  This gives it life.
  2. Develop a revenue model around the concept, ie subscription, advertising, affiliate, etc.  If the idea survives this test, proceed to step 3.
  3. Write a business plan.  This converts the idea, which is really just a 1 cell embryo, into a 6 week old fetus: you may not tell anyone else about it, but you are starting to get excited.
  4. Do research: Nothing fancy needed here, but some gentle field research, Google searches, informal focus groups may let you know that the fetus can develop into a baby or perhaps it can not.  But you'll discover it's fate before you invest more time and money into the project.
  5. Speck-it out: Build a mock-up version of the business.  In-expensive software can help here, or pen and paper works as well.  Be as detailed as possible.  Re-visit, re-work, & re-imagine the project often.  Try to poke holes into it.  Pick it apart.  Because the next step is either. . .
  6. Abandon or commit.
Good luck with your endeavor.

My respite.

In case you have not noticed, I've been inactive for the past few weeks on the blog. Lots have been going on, good stuff, just lots-o-it.

I am in the midst of an EMR conversion and this eats up an enormous amount of time and energy.

I have been very busy in the office, knock on wood.

Insurance companies, in general, seemed to have slowed down their disbursements to me. From comments on various list-serves, this seems to be a national trend. BASTARDS! But working claims has become a team approach.

I have developed software that automates and facilitates the quality assurance and CLIA compliance processes in my lab. Since it has worked so well in my office, I have decided to turn it into a business. Beta-testing will start soon for interested practices. Very time consuming indeed, and exciting. Here is the link:

I'll start posting again a bit more frequently soon.

Again, sorry for the respite.

Monday, February 09, 2009

Saturday, February 07, 2009

How an EMR changes you and your practice forever.

Forget everything about how you used to do things.  Just let it go!  When you adopt a high-end EMR product, you'll find that business as usual is over, and forever. 
  • Workflow: Old way: front desk staff checks in patients, then doc takes the entire history.  New way: patients can check themselves in and staff takes the majority of the history, such as the PMH, Allergies, Social History etc.  Doc reviews, completes, and cognates.
  • Back-end: Old way: complete charge sheet, give it to back end staff, they enter charges, submit claim.  New way: after the encounter, doc completes the note, signs, and voila, off it goes to the clearinghouse.  Billing staff now freed up to "work" the claims.
  • Scheduling: Old way: patients call, overload phone lines, and staff assists in booking while waiting room fills up.  New way: patients book themselves on-line, enter their own information, doctors phone lines freed up, staff freed up.
  • Precriptions: Old way: scribble, give to patient, often gets lost or handwriting issues, leads to call backs, refills, torture.  New way: click on favorites, click on med, click on pharmacy, click.
  • Coding: Old way: document as much as you can given time and hand-cramping restraints, stay within the bell curve for your specialty, then hope you don't get audited.  new way: predesign your templates with appropriate level of E&M coding, see patient, hit enter, next.
  • Lab and study tracking: Old way: give patients requisitions and hope they go and hope you get lab and hope lab is filed correctly and hope you don't miss anything bad.  New way: select tests from check boxes in template, hit enter, system flags non-compliant patients, all results come to you automatically, electronically, effortlessly, and if you want it, graphically.
  • Practice patterns: Old way: "this is how I do it."  New way: pre-program best practice guidelines from professional organizations into your templates, then all appropriate tests and studies are orderd automatically, effortlessly.
  • Coordination of care: Old way: dictate, wait for transcription, mail.  Call doc, wait on hold, disturb.  New way: select letter template, recipient, hit enter.

The IU.