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.
Sent via BlackBerry by AT&T

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