Going solo? Use all your resources

This morning I was busy. I had 5 follow-ups, 1 scrotal sonogram, 1 penile duplex scan, and 3 semen analyses. The patients that I saw generated 3 new prescriptions and 2 refills. In addition, an established patient of mine moved and requested that her chart be sent to her new urologist.
In other words, a lot of grunt work.
Fortunately, my inexperienced staff can do the lion's share of it because of training and technology.

• My MA electronically queued all the prescriptions while I was doing the duplex scan. She made 2 mistakes, but the system will not allow her to actually send the prescriptions, so patient safety was never compromised. When I had a break, I pulled up the queue, made corrections, hit approve, and the prescriptions were sent to the pharmacies.
  
• My MA with no andrology lab experience was able to do the semen analyses for me on my automated system. I was able to verify their accuracies by reviewing the image and motility files. Plus, she calibrates the instrument daily and performs quality control on known samples. All this while I was doing a scrotal sonogram.
• My receptionist printed out the chart of the patient that was leaving us and placed it on my desk. I reviewed it to make sure that she printed out everything--which she did not--and then I signed it. She then scanned the signed copies back into the patient's chart into a sub-folder named "record releases", dated the entry, and then faxed the paper copies to the new doctor. All this while I saw the follow-up patients.

By 10:15 AM I was finished and on-time and all grunt work was done with accuracy and completeness. I then logged onto my blog, The Independent Urologist, and wrote the above.
Good morning!
Thanks,
The IU.

A Day Off

Took some time off today with the family.

More uses for technology in medicine

Today I:

• e-prescribed
• remotely completed medical records
• used a greenlight laser
• performed a TESE in conjunction with ICSI
• roasted a chicken
  

Good day

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My automated semen analyzer

I recently invested in a new and somewhat expensive technology to automate my semen analysis process. The instrument, called the Sperm Class Analyzer or SCA System is a very sophisticated software program that links by computer and camera set-up to my microscope in my in-office, COLA accredited andrology lab. The SCA System adapts to my methodology of semen analysis and quality assurance and is really a very useful adjunct to my lab. Aside for basic features such as concentration and motility analysis, the software can also analyze sperm velocity, progressive motility, morphology by Kruger and WHO criteria, and sperm DNA integrity. In fact, these cumbersome and complex analyses have become so easy that I have been able to train my MA to do them.

From a technology perspective, the system fits in well with my general electronic office design. I can access the system remotely and review the saved analyses from home, generate a report, and digitally sign it, all from the comfort of my home. I can even do it from the road via my lap top. If I have a doubts as to the accuracy of any particular report, I can even re-run the analyses, since the digital images and motion analysis data are archived.
I can then convert my reports to PDF files with a keystroke and fax them electronically to referring doctors.

Automated semen analysis has some advantages over manual analysis. Perhaps the biggest advantage is reproducibility of results and decreased inter-observer variability. Accuracy is not compromised in anyway, since the instrument is calibrated daily and verified manually for accuracy by a trained andrologist, a guy by the name of Dr Richard Schoor MD.

Apparently, I am the only lab in NY to have the system, though several of the largest IVF groups in the nation have recently adopted the technology for their own usage.

If you need a semen analyses, please contact me:

Thanks,

The IU.

My high tech snow day

Despite global warming, the weather brought snow today to Suffolk County Long Island, where I have my urology practice. Fortunately I had a slow day in the office and was not really disrupted much by the snow. My biller however, was unable to get into the office. No biggy. Here's what we did:

• Encounter forms were delivered to my biller by my MA, who lives in the same town as my biller. We could have faxed the biller the encounters or emailed them as well, though delivery was just as easy, and HIPAA compliant.
  
• My biller VPN'd into the network, entered the charges, and submitted the claims electronically, just as if she was at her post in the office.
• I left early as well and had phone calls forwarded to my cell phone.
• From my cell phone and blue tooth wireless, I called in a prescription for antibiotics while I drove and deposited checks in the Commerce Bank drive-through..
• When I arrived at home, I e-prescribed for another patient and electronically signed off on some labs via the VPN connection to the work station in my own office.
• At one point, I was on the phone with my biller, who was remotely accessing her workstation from her home while I was remotely on my work station from my own home.
• While I was at home, where I get little cell phone reception, I received a call from a local doctor's office. They called my office main line which forwarded to a VONAGE line in my home office. Had I been on the road, the VONAGE line would have simul-ringed on the cell phone. Since I was home, I simply picked up a cordless phone,and took down information on a new patient.
  
• I did miss one call, but the number was logged on VONAGE, and I easily returned the call.

Maybe mundane to you, but I think it is pretty cool.
Thanks.
The IU.

E-Rx: A Good Use for An i-Phone

I don't have an I-phone but I may get one soon since I just discovered a new use for it that would fit in well with my practice: e-prescribing. E-prescribing has some advantages over traditional paper prescription writing. To name a few such advantages, e-prescribing decreases Rx dosing errors and insurance formulary and tier-ing issues, not to mention handwriting problems. Though I'm still slow at it, I can see that e-prescribing willmake my practice more efficient.

In NY State at least—which is fast becoming the most physician unfriendly state in the nation—only licensed practitioners such as RNs and MD/Dos can call in prescriptions to a pharmacy on behalf of the doctor. As you might imagine, a busy doctor, especially a generalist, can easily become overwhelmed by prescription management. In comes e-prescribing. With this new high tech tool, my high school educated MA—or anyone else with no medical training for that matter--can queue up all the prescriptions and refills for me that come in throughout the day and then I can review, edit, and approve them with a simple keystrokes from anywhere. My MA does not need any specific training in prescription writing or drug-drug interactions and she really can't make a mistake that can get my patients and me into trouble. Yet she can do the lion's share of the work for me.

Beautiful and just what I need.

Here is where the i-Phone comes into play. I was in the OR today and forgot my Rx pads. I did several cases on patients, all of whom had different pharmacies and I had have to call in some scripts for them. Now with hold times and phone trees and formulary related call backs etc, calling in prescriptions to pharmacies can be a royal pain and not something that I relish. Instead, I asked to borrow my friend Mike's i-Phone. With it, I logged onto my e-RX network, located my patients' profiles, selected the meds and doses from drop down menus, selected their pharmacies, hit approve all and voila', done.

Not bad. I can see other nice uses for the i-Phone as well, but this one is among the best.

Now if I could only use an i-Phone to reach Governor Spitzer to beg him for relief from this ridiculous med-mal environment that Long Island's docs have entered.

As always, join me on legislative day in Albany, March 4^th.

The IU

Going Solo? Develop A Competitive Edge.

What makes you so special? Why would patients go to you over someone else? While it may be difficult to compete with an established group or a large group, you can try to level the playing field--or perhaps tilt it a bit in your own favor--by developing a competitive advantage the amplifies your strengths and exploits your competitors weaknesses. Having Saturday hours when others do not may represent one such competitive advantage. Here are some others:

• Have office hours others do not
  
• Offer a service others do not
  
• Learn a new procedure that others are not yet doing
  
• Treat diagnoses that others find undesirable or less profitable
• Answer your own phones, and do it 24/7

As you grow, you can adjust your practice's competitive advantages accordingly. That is the fun part of solo practice.
Good luck.

The IU.

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Tell me this is a joke, please.

From today's NYTimes: Congress is preparing for the switch, allocating money for 33.5 million $40 coupons to defray the cost of set-top converters, which retail for about $50-$70. Each U.S. household is entitled to request up to two coupons, redeemable at a certified retailer within 90 days.

 

Do the math: That is 2 billion dollars for health care—Oh I'm sorry, for digital TV.

Yeh, that is what we need in this country.

Am I nuts, or is that just bonkers? Someone, please tell, what am I missing.

The IU.

Where is Dr Carl?

Pillitieri Ob-Gyn has been delivering babies in Suffolk County NY for 50 years. The practice was started by Dr Pillitieri senior, and it was ultimately inherited by his sons, Carl and Mark, and his daughter Eileen, a nurse practitioner. I got to know Carl first, and then Mark, Mother's Day 2003, when I was on call for my urology group. Carl called me first and asked that I see his patient who was in pain from a kidney stone while pregnant. I said sure. About 30 minutes later, Mark called to ask where I was because his patient was in pain.

Who are these guys? And why do they torture me thus?

Several months later, when my wife became pregnant with our second child and we needed a new Ob-Gyn, the Pillitieri's were the first and only number that I called. I only knew them from that interaction and one or two more like it, but I could tell that these guys were patient advocates to the n'th degree. Their commitment to my wife and me from beginning to end confirmed my initial belief.

I have come to know Drs Mark and Carl, as they are called, and "Dr" Eileen, pretty well over the years. They send me patient referrals from time to time and in fact kind of supported me in my early years as a solo urologist in start-up. Their patients are nothing short of fanatical about them as doctors; almost cultish in their reverence for the 2 docs and nurse. On several occasions I have treated mother-daughter-baby combos all of whom were patients of Drs Mark and Carl. From an unassuming office, the Pillitieris practice outstanding patient care and safety combined with state of the art medical treatments. They are the real deal.

They are also dying.

Dr Pillitieri senior left practice in the 90's after being on the losing end of a multi-million dollar lawsuit. Dr Carl left practice after 15 flawless and lawsuit free years in practice to relocate to Maine, where his liability insurance premiums dropped by 66%. Dr Mark has remained behind in the Deer Park NY office, along with his sister Eileen. They are committed to the practice and the community that they love. Mark takes call everyday and has not had a single day off since Carl, left 2 years ago. Now that is devotion!

This year, Mark paid the standard rate for Ob-Gyns in Long Island, which happens to be $180,000. Unless legislative action in Albany intervenes, Dr Mark will be forced to pony-up another $56,000 in July 2008, in addition to his $180,000. If he cannot do afford the rate increase—and who really could—he will be forced to close his doors to new obstetrical patients.

There is a real human drama unfolding here on Long Island—a crisis in the making.

You have the ability to avert it. Contact your local state senator and assemblyman. Join me in Albany for legislative day on March 4^th.

What affects Dr Mark affects me and affects you.

Act Now!

The IU.

An Activist is Born

Liability rates in NY are rising dramatically. Many obstetricians in my own community, have already either given up OB or have left the state entirely. Who will deliver our children?

MLMIC, one of only 2 liability carriers in NY, paid $500 million dollars over a ten year period to defend claims that never resulted in a single payout to a plaintiff. The trial lawyers say that the defense bar is winning the war, but the cost of that war has been so high that the vitality of the entire health care system in NY State is in jeopardy. For the OB that delivered my Emma, legislative action that occurs in the next 6 months will determine whether or not he stays in business--and he is one of the good guys.

The trial lawyer lobby is strong, but ultimately they in are in-the-wrong. The citizens of NY need professionals that can provide obstetrical care, emergency cardiac and surgical care, and preventive medicine. I know personally several family practitioners in my community that subsidize their own practices with personal savings and debt just so that they may keep their doors open.

There is a misperception, perpetuated by the trial lawyer lobby, that there is no crisis looming; that the problem is the result of bad doctors, and that doctors and insurance companies are just greedy. This is simply not true. The overwhelming majority of doctors consistently do the right thing by way of their patients, and the days of the "country club life" for doctors has long since passed. From a financial perspective, most of us are simply trying to stay in business, provide for our families, and practice the professions that are our passions.

Help avert the impending crisis that WILL come in JULY 2008 unless legislative change happens immediately. Join us in Albany on March 4th for Legislative Day. Contact your local assemblyman and state Senator. Contact me, and I'll assist you in contacting your local reps.

Believe-you-me; when you or your child or your husband or wife or dad or mom is sick and in need of medical attention, you will turn first to your doctor and hospital, not to your trial attorney. You have the power to make sure that we are there for you.

Act now!

Thank you.

The IU.

Develop your long range plan

Medical practice is a business. Like any other business, a medical practice has 4 stages in its life cycle. Stage 1 is the embryonic stage. Like a developing embryo, the new business must develop the basic necessities of life, such as an office, a phone system, a computer system, etc. And like the wonder we feel towards our newborn infant, when we look at our new business, we feel awe and amazement over all that we've accomplished just so that we can open our doors on day 1.

Ultimately, the business will either die in the embryonic phase or will proceed to the next phase, the growth phase. The growth phase is like childhood. It starts out all fun and wonder, but becomes more challenging and stressful as maturity hits. The growth phase will morph imperceptibly into the next and longest phase of the life-cycle, the mature phase. It is during this cycle that the business continues to grow, but it grows at a more predictable level. Cash flow is somewhat stable and daily operations sort of take care of themselves but the stability is often interrupted by head-aches and fires that seem to sprout up out of nowhere. Finally, like life itself, all businesses ultimately die. Businesses end either in bankruptcy, or they get bought out, or they simply disband.

During each of these stages, you'll have outside forces that will push or pull your practice in one direction or another. The chance to make some "quick bucks" with some new equipment, the possibility of hiring a new associate, or perhaps the opportunity for a strategic merger with another group; these, and many more possibilities will avail themselves to you during your career. Since you will not have a crystal ball and will not truly know what to do when faced with these uncertainties, you will need something that can guide you in the right direction. And the only place that you can turn for guidance will be your long range plan.

The long range plan is your vision. It is where you see yourself in 10 years. It is your ultimate dream; the business or practice that you would want if nothing could ever get in your way. Your 10 year vision, or 20 year vision for that matter, is never too large or too ambitious. Nor should it be something that can be reached to soon, for then it would not be big enough.

Recently I have felt a strong pull towards a large group that has formed in my area. The temptation to reach out to them has been great. From all that I've heard, this group will achieve tremendous success and financial glory. They'll have their hands into everything and generate revenue hand over fist. Urologists around me are falling like dominoes and have been lining up—and paying handsomely—just to join. Should I try to get in as well.

My answer: no. To join that group right now would be incompatible with the long range vision that I formed for myself many years ago.

For now, I stay solo and grow on my own terms.

David vs Goliath.

Wish me luck.

The IU.

Business Acumen or Dumb Luck?

I am reading a terrific book now called, The Illusions of Entrepreneurship, by Scott Shane. I started it, and it has already inspired me to write this post. Rather than give advice that is based on anecdotal information, the author uses data to illustrate the differences that lead to success vs failure for a start-up. Here are some:

1. Stay in school: college grads do better that high-school grads. Education I have-a-plenty.
   
2. Don't start to soon: people who work for others, and learn on their employer's dimes, do better when they ultimately do go on their own and start-up. I did that.
   
3. Money matters: Having access to capital early on makes a huge difference. I had significant savings which I used a collateral to get loans.
   
4. Have a business plan. I did that, only I did not realize that I had.
5. Choose the right industry: urology is pretty good, infertility is even better. For me, pure dumb luck! In New York, a start-up OB would be almost doomed to fail. Derm is good!
   
6. Have the right motivation: are you doing it to make money or to have autonomy to "do what you want." If you goal is to generate revenue, you'll do what it takes--like answer the phones 24/7 or have evening and Saturday hours. I did those things because they seemed obvious to me. If your goal is to be able to take a vacation whenever you want, re-think your plan.
   
7. Buy someone else's business: I did not do this, but I guess you can't argue with the logic.
8. Focus on your strengths. I did this. Dumb luck.
9. Marketing: Successful entrepreneurs market their products or businesses early on. Caveat, do it smartly. I wasted a lot of money in my initial attempts.
10. Find unreached customers: I suppose that had I stayed in the same area as my former employers and tried to compete with them, I'd have lost. Dumb luck and restrictive covenant to thank here. If you are starting your own practice, try to identify patients that others are not seeing, such as patients who need weekend or evening hours or patients of certain ethnicities, disease states, insurance types, etc.
    

I'll keep you posted about others.

Thanks,

The IU.

What happens when physicians leave?

The Governor of Mississippi understands this simple fact: doctors are good for the economy. In his state, according to a KevinMD link, each doctor brings in about 20 jobs to a local economy. I don't know if that is or is not accurate, but in my community in Suffolk County Long Island, I believe that there'd be a ripple effect that would look like this after a physician exodus.

• Tough times for accountants
• Loss of revenue for restaurants
• Decrease big-screen TV sales, among other consumer items
  
• The demise of the local tennis industry
• A fall in house values
• Decline in school funding
• Displacement of at least 4 workers for every doctor who leaves
  
• Hospital closures
• Layoffs in law firms, both plaintiff and defense
• Layoffs in all medically related sales forces

On the economic scale, we are below the the high end technology sector and are above retail. We add jobs to a local economy and give people economic opportunities that would be otherwise unattainable.

Our political leaders must wake up and see it for how it is. It really is that simple.
You can't kill the goose that lays the golden egg.

Thanks,
The IU.

Are doctors worth $75,000 per year in income?

Some in Congress believe that the entire health care problem would be solved if doctors would "accept" salaries of $75,000 per year. Let's examine this figure to see if it is reasonable.

First, what do people make in other fields, on average?

    Call center analyst: $36,000

    Admitting director for a hospital: $80,000

    Retail store detective: $35,000

    Bricklayer: $70,000

    Risk Manager: $120,000

    Appraiser, residential: $36,000

    Advertising Account Exec: $70,000

So I suppose that the congressman believes that his personal physician's worth lies somewhere between his bricklayer and the admitting director of his local hospital.

Perhaps until he gets chest pain or shortness of breath or renal colic or a fracture or an elevated PSA .

Now what does it cost to become a bricklayer? Nothing. Bricklayers do apprenticeships.

What does it cost to become a hospital admitting director? The price of a college degree at a state school.

How about a doctor? $250,000, and 12 years minimum of training.

I don't know, but I just don't see it. $75,000! Am I nuts or is that unreasonable.

Thanks,

The IU.

 

 

    

Doctors ARE valuable members of society!

You can hear it the way they say provi-i-i-i-ders. You can sense it in the tone of their rhetoric. You can read it in the policy papers. And you can view it on TV during debates and on c-span. Doctors—I'm sorry providers—have become--in the eyes and minds of the policy wonks--drains on the economy.

I am not sure why this is. I simply don't see it this way.

In my little practice, sparsely 2 years old, I employ 4 people. I provide them with health insurance and a retirement plan. Neither the state nor federal government does this.

I pay payroll taxes for each employee and myself. I pay into unemployment insurance and workers comp insurance funds, as well as into the government mandated disability insurance fund. In fact, these "social" programs are not provided for us by our government but by us, the employers. They are simply mandated by the government and funded by business owners.

For every dollar I earn, 70 cents gets returned into the economy. The revenue that I generate—because I provide services that people want--supports medical equipment vendors, insurance personnel, billers, PHARMA sales reps, hospital employees, home health workers, lab personnel, marketers, lawyers, software vendors, hardware vendors, the cable company, the phone company, and others.

I get none of the tax subsidies that are commonly given to big retail businesses, such as Cabella's Sporting Goods or Walmart.

The income that my employees earn pays for consumer goods, which fuels our US economy. Thirty nine percent of my income gets returned to the federal government, and 7% goes to New York State. Ten percent goes to my retirement savings, and the rest is returned to the economy.

Please tell me, Mr Stark, or any other policy maker, how can you have such disdain for us? I just don't get it.

No, I don't see myself as a drain on the economy in any way. I give back, and I give back quite a bit.

I wish that our political leaders and policy makers would see it this way and stop viewing me as a cost center rather than what I truly am—a business owner and an employer and a valuable member of society.

Thanks,

The IU

How to become a stock broker

I spent last night at a superbowl party at a friend's house. He does very well and owns a brokerage house. We got to talking and I asked him, only half jokingly, how can one become a stockbroker?

"It's easy" he said, "you just have to take the series 7 test."

"How do you get to take that test," I asked.

"Simple" he said. "Just read some of the study material, go to a local testing center, pay 300 bucks, and take it. When you pass, you get a liscense."

"And then I could trade stocks?" I asked, incredulous.

"Yep, it is that easy."

"So theoretically, I could get study material from Amazon, read it this week, and by next week I could be a licensed stockbroker, work for you, and start making money?"

"Yes, only you don't even have to purchase the study material. I'll give it to ya."

Now that is un-@#$%-believable!

A family practice doc, who makes about as much as a mildly successful broker has to go through at a minimum the following difficult gates before he can earn a only a modest living:

• The MCAT (trust me, this test is very challenging). Your score--ie how well you do--determines if you can go to med school and where you can go.
• Step 1 USMLE-the first of 3 parts to our lisensure exam. We can take it only after 2 years of medical school have been completed--the most challenging years. I studied about as much as most students do, which was 15 hours a day 7 days per week for 6 weeks. Like the MCAT, the score means even more than pass/fail and can affect the economic outlook for the rest of your life! This is a very high pressure test.
• Step 2 USMLE-the second part of our lisensure exam. We take this one after we've completed at least 3 years of medical school. By the time you get here, you're pretty much home free.
• Step 3 USMLE-the final test for licensure. You take this test during your first or second year of residency training. Actually it is a difficult test, but for the most part one's score is irrelevant.

After our family practice doc completes 4 years of medical school AND passes all 3 USMLE parts AND completes an accredited residency program, only then can he APPLY for permanent state licensure so that he can start to treat patients on his own.

And there is one more hurdle for most of us, including our family practitioner. We MUST become certified by our respective specialty boards. This entails completion of all the above PLUS an application to simply be allowed to take the exam PLUS recommendations from practicing doctors that attest to our competency and character AND THEN you must pass the exam. And these tests ain't easy.

After all this is done, you have to send proof that you compeleted all the above and send it to the credentialing commitees of EVERY hospital you wish to practice in and EVERY insurance company you wish to participate with and EVERY state you in which you wish to be lisensed.

And you must update it every 1-2 years.

For our family practice doc, if he was to hit no road blocks along the way, the process would take him a minimum of 8 years and cost at least $100,000. For me, a specialist, the process began in 1988 when I began to study for the MCAT and it ended in February of 2003, when I passed by final test for certification by The American Board of Urology. Total cost ~$125,000 and only vague memories of my life outside the hospital between age 26 and 32, when I was a resident in urology.

So here's what I said to my friend.

"When can I start work?"

Good luck.

The IU.

If you want my business, answer your phone!

I need my microscope serviced and I need it serviced in the next week or so. Since I have a contact at Olympus, where I bought the scope, I called him for a recommendation. He gave me a name of a "great guy" named, ironically Guy, who works or owns a Massapequa Long Island microscope company. I was given the name of his company and told to look it up in the book. I never use the book, but I am typically preferential to "great guys", so I set to look up Guy's company on the web. No web site, no real web presence to speak of, but he does have a listing in some non-yellow book, non-yellow pages yellow page. I called it, and got a busy tone. I re-dialed, and now I got an answering machine. I called again, same result.

To hell with Guy!

Guy, if you want my business, answer your phone. It is really that simple.

So here's what I did. I Googled "microscope repair long island" and found ~10 listings on the side-bar, the paid listings. I chose one in the middle of the page that caught my eye because it said the word "service" in it. I clicked on the link and was taken to a nice website. On the index page of the site, I saw the phone number and location of the business, which was somewhat nearby to my office in Smithtown. I dialed the number and low and behold they answered…immediately. Suffice it to say that several minutes later I had an appointment scheduled for an in-office service by a guy named Raul and I was given Raul's pager number. The price was reasonable, though I'm sure that Guy would have done it for less, but he did not answer his phone.

I only do business with people that answer their phones before they have my money. If they don't answer when they want the sale, they will certainly not answer after they've made it.

If you want to compete and thrive, start by answering the phone and being reachable. It is really that simple.

The No-Show-ers

I have become somewhat obsessed with no-show-ers. Who are they and why? Are they rude or just forgetful? Do they think it is no big deal or do they know it's wrong & just don't give a crap? I think that no-show-ers can be placed into several categories and you can almost tell who will no show by examining the details surrounding the appointment booking.

Most—if not all--people who claim to be in pain, yet don't want to be seen that day, will no show. I don't understand this one, but it's true.

No show rates for vasectomies or infertility consults seem to double if the wife, rather than the husband, makes the appointment.

Self-pay patients no show more frequently than do insurance patients, unless it is an uninsured man who sees something on his penis. They always show up.

I have never seen a racial difference, but there is definitely a socio-economic difference; the very poor and the very wealthy no-show equally.

Young people no show more than the elderly. When an elderly patient of mine no shows, I start calling the hospitals!

Working people only no-show on Saturdays or in the evenings. . .or on holidays.

Retired people never no-show.

People who refuse to leave us their cell phone number typically no show.

People whose phone goes right to voicemail no show much more than do people who answer their phones.

People who return your calls never no show.

People that try to get a free consult over the phone while they are making the appointment will almost always no-show.

100% of people who ask for a free vas reversal consult will ultimately no show.

I noticed a trend, p value <0.05, that people who find me via the organic google rankings no show more than those who find me via paid listings.

Requiring intensive directions to my office predicts future no-showage. (And I'm on a major road in a big, well marked and well lit building)

Oh, I have a patient now. Thanks.

Geeze, I'd have figured that he would have no-showed. Oh well.

The IU.

 

My slowing blog post frequency

My favorite reader, SeaSpray, has asked several times why I have been posting with less frequency in recent weeks. Well, there are a variety of reasons for this, but basically, I write less because I feel there is less need for me to write.
When I first began to write the Independent Urologist blog, my experience with start-up was fresh and raw. Every day brought something new that needed to be published. For me, publishing was therapeutic, like a form a counseling I suppose. It helped me to collect my thoughts and to process the daily peaks and valleys that must occur in every start-up business and that certainly happened in my own business, big time! For me, my first 1 to 1 1/2 years as a solo practice urologist was the most exciting period of my life, far and away. I simply had to write about it or I felt I might explode. The fact that I had an audience made blogging that much more fun.
Fortunately, my practice is doing well now and I have settled into somewhat of a nice routine. It is not boring. Far from it. I just am no longer surprised when I get several new patients in a given day nor am I devastated when I don't. I have a schedule that is relatively constant from week to week. I have my typical busy days, slow days, late nights,and early mornings, and I drive my 3 1/2 year old to and from school 2 days per week, in between patient sessions.
Many of the challenges that I faced early on, such as getting my lab accredited and my office functional, I have overcome. I do a variety of in-office procedures, such a cystoscopies, vasectomies, and prostate biopsies, and I have developed such easy routines for preparing and doing these procedures, that they no longer cause me any stress, any heartache. Even scheduling patients for in-hospital procedures has become routine, automated, easy. Nothing more to blog about there, which is good.
From a staffing perspective, I have 2 people who have been with me from the beginning and a medical assistant, who I trained a few months ago, who are all excellent and loyal employees and they all plan to remain in their current positions indefinitely. As far as I know! So while I no longer have blog topics on staffing issues, I have stability, and that is better than blogging.
My homegrown EMR was a good source of blog topics for a while, but even that is just performing silently and bug-free in the background, as any good EMR should. I just don't feel the need to write about it any longer. With regard to digital back-up, I no longer need to expend mental energy on it, because I finally seemed to have come up with solutions that work for me automatically and effortlessly. It only took 21 months, but with regard to back-up, I have finally started sleeping at night, my infant not-withstanding.
Attracting new patient business, marketing, and practice building were a great source of blog post topics for a long while. Here, however, I have stopped writing for 2 reasons. One, I've become very adept at attracting new patient business economically and I no longer "need" to write about it from a therapeutic perspective. And two, I don't wish to share such valuable information with my competitors. It is that simple.
Medical malpractice is a favorite blog topic of many bloggers, but I never really got into that one. I guess that personal views on that topic are best kept personal. Just ask Flea. Enough said.
I do have much left to do in my still young practice and I plan to continue writing about it. But hopefully, I wont feel the need to write about it. I want stability and yes, even boredom. Those are 2 signs of a mature business, one with a future and in this regard, I feel that I have arrived.
Thanks for listening.
The IU.

On Making Decisions

Perhaps I made a mistake on VONAGE. Perhaps. Only when I Look back 21 months later, with the benefit of hindsight, am I not so sure that I would use this company again. But then again, 21 months ago I was in a bind and VONAGE was the perfect solution at the time. I had just left my old group and I wanted to capitalize on retaining any former patients of mine into my new, fledgling practice. I had no office and was unsure how long it would take me to get an office. Every day that I went without an office was lost money and missed opportunities. I was desperate to get new patients and was unwilling to miss a single one. With VONAGE, I was able to set up shop in my home and function as a business well before I had an office or an exam room or a staff. For me, back then, VONAGE was a key ingredient in my early success.

Some say that VOIP is not reliable for mission critical functions related to business. I disagree. Many businesses use this technology and it works very well. I have friends in the financial service industries—on Wall Street—whose firms have switched to VOIP. What is more mission critical than high finance? The problem has not been VOIP, but customer service at VONAGE. Their technology is fine. It is their service that fails.

It is very easy for people to criticize and second guess the decisions of others. It happens every day. What the critics fail to realize is that we make decisions with the circumstances and the best available information at the time, not years later. I believe the ability to have vision and then use it to analyze a situation, cull the data, and be decisive given incomplete information is what separates successful doctors, lawyers, politicians, and police officers, among others, from unsuccessful ones. Teddy Roosevelt understood this:

"It is not the critic who counts: not the man who points out how
the strong man stumbles or where the doer of deeds could have done better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood, who strives valiantly, who errs and comes up short again and again, because there is no effort without error or shortcoming, but who knows the great enthusiasms, the great devotions, who spends himself for a worthy cause; who, at the best, knows, in the end, the triumph of high achievement, and who, at the worst, if he fails, at least he fails while daring greatly, so that his place shall never be with those cold and timid souls who knew neither victory nor defeat."

Critics will always be out there in the ether doing what they do. My advice to another person who finds themselves solo and unsure of what to do: analyze and think, but don't be afraid to make the hard decisions. And to hell with the critics!

Thanks for listening,

The IU.

VONAGE bites me in the ass!

Several months ago I switched from VONAGE to my local VOIP phone provider due to reliability issues. I ported the number and everything seemed to work out well. I did test to see if the port worked by simply calling the number and voila', it rang in my office, call hunted, etc. Beautiful.
Yesterday I received an email from a former patient of mine. "Dr Schoor, are you still in business? Your phone number has been disconnected for weeks" went the email.
What? The phone had been working fine and was ringing off the hook that very morning. I called him.
Apparently he has a VONAGE system himself and when he called from his cell phone or any other non-VONAGE phone, the call placed successfully. But from a VONAGE phone, the caller would always receive a disconnected message. I called VONAGE.
"Oops, sorry, our bad. We forgot to release the number from our system. I'll do that now. It'll take 24 hours. Sorry for the inconvenience."
Holy shit!!! For 3-4 months, anyone that tried to contact me from a VONAGE phone would not have been able to do so. Un-!@#$%-believable.
Think of the missed opportunity costs. I estimate that I probably missed 3-5 prospective new patients who called, got the message, and went to the next urologist on the list. Being that new patients are worth, over the course of a year ~$400, I can estimate a loss of up to $2000, maybe higher.
Yeh, I'm pissed!
My recommendation: if you are a business, do not get started with VONAGE. Their customer support is just not adequate for a business's needs.

Goals for -08

My 5 Areas of focus, (not in order of imortance)

Process Sreamlining ---Revenue Generation---Cost Containment---Safety---Payer Shift

At the beginning of a new year I like to take stock in what I have accomplished and to focus on goals for the next year. The cycle above represents the 5 major areas that I will focus on most. All are interrelated and of equal importance. For example, streamlining processes will result in increased patient safety and efficiency and help to decrease costs. Revenue generation will follow based on an increase in word of mouth referrals and through acquiring patients with better paying plans and cash pay.
Wish me luck.
The IU.

Just Doing My Part

 

 

Take Action Now!

 

Dear Patients,

New York State is currently in a health care crisis that threatens all of our abilities as patients to get affordable healthcare. The threat comes from a tort system in New York that has run out of control. Jury awards have risen dramatically over the years and are often out of proportion to the nature of the injuries. The problem is only getting worse.

I support tort reform that retains our rights to seek reasonable compensation when injured by a negligent act, but the system must prevent excessively high awards for pain and suffering that is limited in intensity and duration.

I call on you to take action and contact your local representative in the state assembly and ask them to support liability reform. I have pre-printed, addressed, and stamped envelopes; all you need to do is sign.

Please become involved in this grass roots effort to save New York from an impending health care implosion and in doing so, help to lower health care costs for the majority.

If you have any questions, please feel free to contact me.

Sincerely,

Richard A Schoor MD FACS

Taking Notes From a Plumber

I just had a great experience with. . .a plumber! Yes, that is right, a plumber. And I paid $680. How is that. Well, I took notes. Not on his plumbing technique, but on how the business was run. Terrific from first contact to last. Let me tell you about.

We have a leaky pipe in the basement of our house. Though we have a contract with a plumbing service for our boiler and AC, I forgot their name and did not feel like looking it up. Plus, this pipe would not be a "covered" service anyway. As I was about to blow off the whole thing for another day, my wife handed me my 5 month old and a flier from a plumbing company. I get tons of these things, but timing is everything, right. I looked at it and liked the message: on-time service, up-front pricing, no surprise or hidden costs, all credit cards accepted, all work guaranteed in writing for 1 year (that's hell of a global), and a coupon. On the bottom of the flier was their phone number, clearly visible. I called—7:15AM—and, voila, they answered. Sold!

Over the phone, the receptionist had a friendly voice and she offered me a number of scheduling options, that day, or any other day. She had one of those great phone voiced that makes you feel like she is on your side. I should have offered her a job. Anyway, I took an appointment for the following morning, between 8 and 10AM.

At 8:30AM, the plumber arrived. He parked his truck so to not block my car, and when he entered the house, he had his own door mat with him. Nice: makes for good style points. I showed him the problem, along with several others that have been lingering, and after an inspection he came up with a solution, a guaranteed price, and the 1 year guarantee on the work. Plus, he turned off some pipes to the outside, gratis, and wore shoe covers so he would not dirty the rug. Again, nice style points and demonstrated that he was on my side and cared about details.

The work was completed quickly, but not too quickly. He made a soft up-sell on some biological cleaner, and I declined, and here's the kicker: when it came time for payment, we completed the transaction with a mobile, cellular credit card processor. Payment to him guaranteed. No accounts receivable. Not only relatively painless to me, a technological talking point.

Lessons for the doctor.

1: Answer the phones.

2: Hire excellent phone personnel and train them well.

3: Make the patient know that we are on their side.

4: Embrace technological advancements, especially when it comes to accounts receivable.

5: Attend to the details. They really matter.

Anyway, thanks for listening and if you want their number, send me an email.

The IU.

What Medicare cuts could mean

It looks like Congress will not intervene and that Medicare cuts of 10.1% on average are imminent. Urology is slated for an 11% cut. What does this mean in real dollars. Let's take a look.

 

Practice A sees 1200 patients per month = 14,400 visits per year x 25% Medicare = 3600 Medicare visits per year x average visit value of $150 = $540,000 reimbursed per year from Medicare x 11% = [$59,400 - $540,000] = $480,000 lost income if Medicare is dropped completely.

Practice A sees 1200 patients per month = 14,400 visits per year x 10% Medicare = 1440 Medicare visits per year x average visit value of $150 = $216,000 reimbursed per year from Medicare x 11% = [$23,700 - $216,760] = $193,000 lost income if Medicare is dropped completely.

 

Practice B sees 400 patients per month = 4800 visits per year x 25% Medicare = 1200 Medicare visits per year x average visit value of $150 = $180,000 reimbursed from Medicare x 11% = [$19,800 - $180,000] = $160,200 lost income if Medicare is dropped completely.

Practice B sees 400 patients per month = 4800 visits per year x 10% Medicare = 480 Medicare visits per year x average visit value of $150 = $72,000 reimbursed from Medicare x 11% = [$7,920 - $72,000] = $64,080 lost income if Medicare is dropped completely.

 

Practice C sees 200 patients per month = 2400 visits per year x 10% = 240 Medicare visits per year x average visit value of $150 = $36,000 x 11% = [$3,960 – $36,000] = $32,040 lost income if Medicare is dropped completely.

 

So as you can see, the numbers are large indeed whether a group or solo urologist keeps or drops Medicare. However, based on my calculations, a urologist or urology group would still do better remaining par with Medicare. Out and out dropping of Medicare would be tantamount to suicide for the business.

Though it is tough for me as a urologist to admit, Medicare has me by the balls.

Good luck to everyone else.

 

Speak of the devil.

The new HIPAA rules for practices such as mine.

Can't wait to read through them.

Results of my survey

I just sent a survey to an admittedly un-scientific sample of my patients, yet the results were interesting. The survey, sent to 24 patients selected at random, asked respondants 9 questions relating to the practice, the patient's experience here, and asked for suggestions for improvement. Here is a preliminary result that I'd like to share with you, as I find it interesting.

• 16 out of 24 respondants stated that email was their preferred method to communicate with the doctor or staff, and this was not age dependent.

• 24 out of 24 respondants stated that they had NO concerns regarding email security.
• 24 out of 24 would refer me to a friend or famlily member.

Interesting. I am not sure what it means, but I believe that:

• HIPAA is perhaps a bit overblown.
• People want to communicate by email.
• I'm pretty awesome.

I plan to send more surveys to try to get some real scientific data with hope of publishing it here on my blog.

Until then,
The IU.

The Paradigm Shaft

Several years ago a wise man said something to me that really impacted my life. He was a Pharma drug rep, but prior to that, he was an accountant for a financial service company. One day, during his old career, he had an epiphany of sorts when he was conversing with an investment banker. The accountant lamented to the banker, "How come you make so many times what I make?" The banker responded, off handedly, "Because I make money and you cost money."

"Because I make money and you cost money." Wow!

Several weeks later, this accountant left his company and went into sales so he could "make money."

He told me that story over dinner one night and I had epiphany of my own. There are 2 types of people in the world: those who make money and those who cost money. People that make money will always be worth more than those who cost money. Most of us fall into the cost money category. Think about it. The dichotomy really has truth to it. Movie stars, investment bankers, top professional athletes, even top doctors and lawyers, all validate their incomes because they produce wealth for others as well. They make money. Nurses, medical assistance, accountants, teachers, police officers, fire-fighters, in fact most of the rest of us, are in more of a support role and don't really bring in the bacon. Not to say that our jobs are not important. They are. It is just that we cost money, rather than make it.

Doctors used to be in the "make money" category. Throughout the 1960's, 70's, and 80's, doctors not only made money, we were seen as having the ability to generate wealth for others. The perception was that we made money. Beginning in the 1990's--though it's roots actually started under Nixon & Reagan--physicians came to be seen as cost centers rather than revenue centers. This shift in perception, a paradigm shift really, put us in the very precarious position we sit today. In fact, to the extent that there has been the downfall of doctors, this paradigm shift led directly to it.

People that make money are always worth more than people who cost money. It is really that simple.

Again, I don't have a solution for the problem. I only have the observation. I suppose that if you are a physician, you may benefit from re-tooling your practice so that you can be seen as a revenue generator, rather than a cost center.

Remember, 2 types of people exist in the world: those that cost money and those that make money. Try to be the latter.

Good luck.

The IU.

Why I Hate No-Shows

For most of us in the service industry, no-shows are a part of life. For most of us in the service industry, no shows are an exasperating and costly part of life. People that no-show don't think it is a big deal. Here's why they are wrong.

1: Lost revenue: I see patients sparingly on Saturdays, ie I reserve the day for people that really have a difficult time making it to my office any other day. This Saturday, I had office hours from 8-11, staffed by 2 people x ~$28 per year = $84, not including my time. I had 4 no-shows, each worth ~$50 x 4 = $200 lost revenue for that day. I saw 4 other patients, 2 new and 2 follow-ups = $350. Total income for this day was $350- $84- $200 = $66. Now it may be worth my time to come in to the office for $550 - $84 = $466, but not for $66.

2: Increased liability: Unlike people that no-show to a restaurant, established patients that no-show to a doctor's office can cause future problems for themselves and for the doctor. Even though they--adults all, mind you--no-showed, it is our—the physician's—responsibility to make a reasonable attempt to contact them. To do this, we have to pull their charts, review them, make phone calls to the patients, and send them certified letters. What does all this cost? It costs a lot if you factor in the following: chart review = 10 minutes per chart X 4 charts = 40 minutes x my time + staff time to call x 4 + certified postage $5.39 x 4. Plus, a no-show patient that is lost to follow-up yet resurfaces several years later with a tumor that "you missed" can bankrupt you. No, no-show's ain't cheap.

3: Increase in uncompensated work: All of the above work by the doctor is uncompensated.

4: Inconsiderate: I call to cancel reservations at restaurants and for haircuts. It's just the right thing to do.

Thanks,

The IU.

Damn December

December! Everyone loves it, right. The holidays, parties, joy, peace and love on earth.

Bahumbug!!

The holiday season can be a difficult time for many people. The depressed or lonely are the obvious people that come to mind. But I'm talking about the small business owners. Whether you are in retail, food service, or health care, the holiday season brings many challenges to your business. In retail, for example, experts project poor sales for this year, and owners, managers, and employees of retail chains and mom & pop stores alike may suffer the consequences.

Medicine, contrary to what I was told as a pre-med student, is far from recession proof. In medicine, we suffer right along with everyone else, minus the insurance execs.

I am not going to get into the economics of whether or not we are in a recession. We are, however, in a period of difficult economic times for many people. This economic downturn, in addition to consumer pressures that the holidays bring, mean less money spent on health care. i.e., we, the doctors, suffer.

Let's take the example of a typical patient of mine, a 35 year old man who wants a vasectomy. He works for someone else, most likely a big, faceless corporation or government agency, and his employer pays for his health insurance. His family income is $150,000 per year, which does not go very far in the New York metro area. Like everyone else, his co-pays or deductibles have risen dramatically in recent years. Far from being 5 dollars, now they are in the $35 to $50 range. His children, like my own, have had one cold after the next, after the next, and he has paid several hundred dollars in co-pays for his kids' pediatrician visits. His oldest daughter wants a new dance leotard and a Webkins doll for Christmas and his younger girl wants a Fiona doll and a Bella Dancerella video. Perhaps he and his wife agreed to not spend money on each other, but knowing that this really means "get me something," he buys his wife some inexpensive jewelry and plans to take her out for sushi. On top of all that, the pre-school/day care tuition for his toddler is due by Jan 1, or else, and that ain't cheap.

So how does this affect me? Well, he and his wife have decided that 2 children are enough and that he should have a vasectomy. Most likely, his insurance will cover it. But he still has co-pays. And I don't waive those. I simply cannot do that. Since he has all these other bills to pay, does not relish the idea of paying the 2 or more co-pays required for the vasectomy. In addition, he can't afford to take any time what-so-ever off from work, even though vasectomy patients recover quickly. He thus decides hold off for now on his vasectomy.

Multiply this times 20 vasectomies per month, times God know's how many other elective things that I do in urology, and you can see why December can be a difficult month for a urologist or any other doctor.

But Happy Holidays.

The IU.

Cost Consciousness and Medical Practice

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



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

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

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

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

The world's cheapest full featured EMR-PM

Since my last post on my DIY EMR, readers have given me tips on how to make it even less costly. How does $0.00 sound for the software. Here's how:

• EMR/PM platform: openEMR
• VOIP Phone system: YATE.
  

• PDF generator: PDF creator from sourceforge.
• Word Processor: For MAC users, Bean. For Windows users: AbiWord.
• E-faxing: Fax digits.
• Accounting software: Gnucash

This list ought to get you going and leave enough cash left over to pay the insurance bill.
Good luck.
The IU.
Disclaimer: While I have tried some of these programs, I vouch for none of them. I have no affiliation with any of these products and can not attest to their functionality or security.

MS Word & Your DIY EMR

Here are some features of MS Word 2007 that make it so attractive for a homegrown EMR:

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

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

The IU.

DIY EMR: The essential elements

It's been almost 2 years with my homegrown EMR. Works great. For any of you in the 'sphere who might want to do as I have done, here are the essential or helpful elements:

• Tablet PC with Windows XP Tablet edition
  
• MS Office Suite 2007
• Adobe Acrobat Reader
• Efax Pro
• Canon Multifunction F80 scanner/copier etc with included software or other brand
  
• Cardscan business card scanner with included software
• Linksys VPN manager
• MySecureDoc encryption software
  
• 1 DVD writer
• 1 external hard drive
• 1 off-site automatic back-up facility
  
• Your own courage to go for it!
  

Optional:

• Adobe Photoshop Elements
• Adobe Acrobat Standard
• OmniForm

All the above is off the shelf, inexpensive (relatively so) and easily customizable and scalable. Each of the above programs are also very powerful and user friendly.

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

The IU.

Going Green in Medical Practice

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

• Go paperless/EMR


• Set the computers to power saving mode


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


• Practice the judicous use of antibiotics


• Install water saving toilet flushers


• Develop creative scheduling that promotes decreased medical waste


• Do procedures with the lights off (joke)

A green medical practice.

The IU.

Some Mistakes I've Made

Mistakes are part of life and cannot be avoided. As my grandfather, Pop Pop, used to say with his thick Russian accent, "Vichie, my mistake column is longer than my good decision column." Here are some mistakes I made over the last 18 months.

• Makler Chamber: These are counting devices for semen analysis. $500 bucks each. Too labor intensive with regards to cleaning. I haven't used them in over 1 year.
  
• Olympus Cx41 microscope: reticle counting grid compatibility issues with microcell counting chambers. Better to have gone with scopes used by RSofNY.
  
• Overhead light source/OR light: waste of money $1200. Should have gone with a $50 lamp from Bed Bath & Beyond.
  
• Bayer Automated Urine Anlayzer: $800 with 2 bottles of Multistix Pro dipsticks. Bad investment. Multistix Pro not reimbursed at higher level, except by M'Care. Lost money.
• Phone system: $3000. On retrospect, still don't need it and could have gone cheaper with Cisco VOIP phones.
• Cidex trays: Used for disinfection. $300+ dollars. Really glorified plastic trays. I don't know that I could not have just gone tupperware for much less.

And other still in progress and yet to be discovered. I will say before I go, however, that at the time, those purchases were well thought out and good intentioned, they just turned out to be wrong.
Hey, at least I didn't start a war by mistake!
Hope you enjoyed this post.
The IU.

My letter to Senator Clinton

Dear Senator Clinton,

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

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

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

Sincerely,

Richard A Schoor MD FACS

Automate, Automate, Automate

Automation is key, I've come to realize. Automation makes things go better. It allows for the staff and management to concentrate on things that require a human brain, such as judgment calls. At first glance, it may appear that a medical practice is not a great fit for automation. Certainly an auto plant lends itself better to robotic processes, but if you re-analyze your own medical practice, you can find processes that can be automated, and can thus become mindless and effortless. Here are some things that can, and should be automated.

• Data entry: Forms can be scanned with an OCR reader and the data can be extracted and imported into PM software, all with a key stroke.
• Communications management: Macro software exists that can reduce complex, redundant tasks to a simple mouse click. Items that come to my mind in this category are call forwarding, voice mail retrieval, and fax management.
• Document management: This is where an EMR really helps, but even without one the process itself can be automated, only the robot must be a person.
• Laboratory services: automated lab analyzers exist and are reasonably priced for good ROI. These devices can be run be someone with only a high school degree.
• History taking: forms, whether they are digital or paper, can assist in data capture that is consistent, accurate, and efficient. Patients can complete the forms themselves or with assistance from doctor or staff. Forms can be automatically imported into the EMR with a simple mouse click.
• Back-up: of course
  
• Billing: charge codes (ICD-9 and CPT) can be captured directly from the digital encounter form and can then be exported automatically into the PM software to be submitted electronically and effortlessly to the clearance house.
• Bill pay and EOB-check depositing are all ripe processes for automation.
• Payroll, a no brainer
• Savings: automated, continuous forced savings. Slow and steady wins the race.

And probably others.
Thanks for listening,
The IU.

On getting paid.

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

It can be difficult to convince get someone to pay you. We are doctors after all, and people can tug at our heartstrings so that we "do the right thing." They'll give us all sorts of sob stories, and your staff will wish to waive your fees or to "bill them later." Resist this temptation. You have bills and obligations and are in no position to waive anything. If staff wishes to lower fees for a particular patient, they can take it out of their own salary rather than yours. Just my opinion. Here is how to minimize getting stiffed from patients.

• Take credit cards
• Have pay plans through outside companies (eg CareCredit)
  
• Get the co-pay before the the patient is seen
• Unable to verify coverage equals no coverage equals money up front
• Unsure of benefits equals no coverage equals money up front
• Don't be afraid to play hardball, which includes collections and litigation

Thanks,
The IU.

The MRSA Panic: This time, it's real!

My wife and I were having a discussion this weekend about the MRSA scare. We are both physicians, so we tend not to panic over these things.

We are also parents, so we tend to panic over these things.

In addition, as physicians she and I have had patients who are panicked. She asked me how I deal with their questions. I answered that I like to put the scare into perspective. Here's how I view it.

• Fall 2007 MRSA
• Fall 2006 Bird Flu
• Fall 2005 Influenza, with no available vaccine
• Fall 2004 SARS
• Fall 2003 Mad Cow
• Fall 2002 Anthrax

So in other words, the media for some reason that I just can't seem to understand, likes to scare us, in a public service sort of way.

In my view, the most significant impact of the MRSA scare has been on the cost-per-click amount for the keyword phrase MRSA. 1 week ago, I could have had my google adword banner shown for 10 cents per click at the top of the page. Now I am priced out of the market. In 3 weeks, after the media moves on to the next story, the keyword price will return to its usual levels. But by that point, MRSA profits will have dried-up.

So here's my take. If you have lots of money tied up in an anti-MRSA counter-top spray and you can't cash-out, panic. Otherwise, you have little to fear from MRSA.

Thanks,

The IU.

My VONAGE experience summarized

I finally switched from VONAGE, my VOIP phone service provider, to Optimum Voice, a local Long Island company and branch of Cablevision. In the end, I switched because my 2 office VONAGE lines went dead and VONAGE customer service was unable to remedy the problem. I think the lines died because of incompatibility issues with my VPN router, but this is just my own, admittedly ignorant, speculation. Since I use the VPN router daily for billing purposes, and reconfiguring the router's settings would cost me hundreds of dollars, I decided to switch to Optimum Voice.

But please do not misinterpret my impression of VONAGE, which is this. It is an absolutely fabulous system. If I had to do it all again, I would pick VONAGE again, and again, and again. In fact, I kept my third VONAGE line, which I have in my house as another office line.

Here are some of the great features of VONAGE.

• Cost: cheap
• Simulring: I found this feature indispensable. As far as I know, only VONAGE has it.
• Portability: Just re-locate the router
• Caller ID: many phones have this, but not as good as VONAGE's. Trust me.
• Call tracking: ALL inbound and outbound calls are logged. Other's services have this as well, but not quite as good as VONAGE.
• Voice Mail-Email notification: This came in handy once in a while.
• Network availability: great feature. If your internet goes down, VONAGE automatically forwards to a number of your choosing.
• Others that I did not need, but are really cool. Go to the site.

Here are the disadvantages:

• Unreliable: let me add a caveat. It is really only unreliable if the VONAGE routers are in line with other routers and switches, in my experience. My home VONAGE works fine.
• Technical support: Only by phone, so if you have a major issue, your SOL. For minor issues, their phone support is OK.
• Dropped calls: I had lots, but I think this had to do with my set-up, and not really with VONAGE per se. My home VONAGE phones does not drop.

That's it. In summary, I liked VONAGE and still do. I can contribute lots of my success to their ingenuity. Over 19 months, I never missed one call. Not one. I would recommend them to any small business.

Thanks for listening,

The IU.

A load of garbage

I was surprised to see this headline on MSNs search page: Healthy Outlook. The article talks about an economic boom in the healthcare industry. Jobs a plenty.

There's only one problem: No money, horrible hours, difficult work environment. I wonder who sponsored the article?

My lab has achieved prestigious accreditation

Great news! My lab achieved the prestigious accreditation from COLA, a major accomplishment. In order to become accredited, a lab must adhere to strict standards of quality control and quality assurance. The accreditation process took 18 months, involved an on-site survey, completion of a 20 hour lab director course, and continuous commitment to quality laboratory processes.
Not easy, but well worth it.
The IU.

Threats from all sides

Recently someone recommended that I do a SWOT. A WHAT? A SWOT. In other words, an analysis of my practice's Strengths Weaknesses Opportunities and Threats, ie SWOT. I enjoyed doing the S and O portions of the SWOT, but the T was very disturbing, both in raw number and in ratio form with the O. In other words, my T/O ratio appears out of whack. Not good.

My threats include:

• rising insurance costs
• rising rent
• rising payroll
• rising administrative costs
• increasing oversight
• increasing regulation
• declining reimbursements
• litigation threats

Then yesterday, KevinMD ran a link the following post: http://www.emrupdate.com/forums/p/10746/72642.aspx#72642

Damn! I guess I now need to add that to my SWOT list. What if I just bought product A then United Health Care demands I buy product B, then Blue Cross demands I buy product C? Then what? Sheer craziness. I suppose it is legal for them to do that, but it strikes me as problematic.
In any case, I'll add it to the T's, which now vastly outweigh the O's.

Most of my threats are similar to threats to other doctors. Some may find some perverse comfort in the fact that we are all on a sinking ship together, but not me. I believe that when the bow of the ship goes under water, and the stern rises into the air, it'll be every man for himself. And it won't be a pretty picture.

Threats from all sides. How will it end. . .?

Have a problem? Talk it out.

My MA has been causing me some aggravation. As I said, she is fresh out of school--in school actually--and is doing her externship with me. She is a blank slate. Blank slates are good for many things, but they cannot be relied upon to send urine specimens to the lab.

As a urologist, I see many people with UTI's, or UTI related symptoms. I send many urine specimens to the various labs for culture. For my first 1 1/2 years on my own, our accuracy in sending patient specimens to the correct lab at the correct time was 100%.

Now that accuracy has fallen, and with that my headaches have returned. What am I to do?

Well, only one thing in my experience works with people, and that is talking. I asked her, "What can I do to make your job easier and improve your accuracy?" 60 minutes later she walked into my office and asked "Can I make a suggestion." Absolutely.

Her suggestion was to keep a running tally of the patients seen and the specimen to be sent, and at the end of the day she and I would spend 5 minutes confirming that patient A needed a urine culture, patient B needed a cytology, and patient C needed only a UA, ect.

Good suggestion, and you know what; it works.

Talking! Who knew?

Thanks,

The IU.

Sorry!

Much has been written, recently, about the positive effects of apologizing. Some risk managers tell us to say "I'm sorry" when we mess-up. They believe that these words can prevent a law suit from being brought forth, and thus recommend that we do it. Maybe. To that effect, every so often I read in the paper about a plaintiff who said something to the effect of, "Had the doctor just apologized, I would never have sued." Yeh, yeh right! At the risk of seeming cynical, which I am not, I believe that these people do not understand forgiveness.

I believe that we, as people, apologize because it makes us feel better. And sometimes it gets us off the hook. I think we learn this as children.

I do believe that the recipient benefits from an apology. Namely it makes them--the recipient--feel better. Most importantly, the act of forgiveness is very therapeutic to the forgiver, rather than to the person who is apologizing. It is simply unhealthy for people to hold onto anger and internalize it. So lets say that I am a big believer in the power of the apology. I'm just realistic about it what an apology can accomplish and when it ought to be used.

For example, should people be absolved of their wrongs simply because they apologize? I don't believe so. Recently, in NY, a woman had a bilateral mastectomy due to lab error. I don't think an apology would suffice in this case. Moreover, the error was the result of short-cuts taken by the technician in the lab. Something tells me, that his apology to the boss found deaf ears, as it should have. The technician may have been fired, but the owners of the lab may lose their livelihoods over this incident. No, I don't believe that an apology means much in this case.

In my own office, I had a receptionist download a file sharing program on the office computer. I discovered it instantly. She immediately apologized, but I fired her on the spot. Her contrition would not have corrected the many problems her act could have caused, such as data loss, data theft, or an RIAA lawsuit. Her apology meant nothing to me.

Two years ago, my 4 year old pushed my 1 year old, who fell down a step. The 4 year immediately apologized, because she saw that I was angry. I responded, "I don't care that you are sorry" and then I explained to her that her apology does not undue the pain she caused on her sister. The 4 year old--an exceptional 4 year-old--understood, and she has never pushed her younger sister again.

I think we need to re-learn the purpose of "sorry." If you find yourself apologizing for personal gain, you are doing it for the wrong reasons. The goal ought to be for healing. If the goal is for healing, and healing alone, then it'll be accepted.

Anyway, just my thoughts.

I thank you for your time.

The IU.

Memory Lane

I just found this picture.
My first day of surgical internship at Northwestern Memorial Hospital.
July 1994.
I was 26 years old. Bright eyed and bushy tailed. Eager and energetic.
I am holding up my rounds list, the first of many.
Wow!

A band aid to the rescue

Sometimes your organization can be in such disarray that you need major surgery to fix it. Other times, a band aid is all you need. Recently, I applied a band aid to my own practice. I purchased a cart.

The cart is stainless steel, has 3 shelves, and sits on 4 wheels. It is approximately 24 inches wide by 36 inches long, and 36 inches high. I keep my portable sono unit on the top shelf and I keep the various probes on the middle shelf. On the bottom shelf I keep the phlebotomy kit, fully stocked, and the power cord for the sono unit.

I do a lot of scrotal sonograms for male infertility in addition to performing pelvic/bladder sonograms for post-void residual urine assessment. Often I have to change probes several times per day, or I need to re-charge the portable battery on the unit at random times. Because evrything sits on the cart, I can do these chores quickly and effortlessly "on the fly."

When I have a vasectomy, I place the sono unit on the middle shelf, then drape the entire cart in a sterile drape. I then place the vasectomy instruments on the spacious top shelf. I usually begin my vasectomies on the patient's left side, then I move on to their right side. I just wheel the cart along with me.

Within arms length of the cart, on the right side, is the counter top. On the counter top I leave open the paper wrap from the sterile gloves. As I use up the sharps, I place them on the paper wrap to my right side. At the end of the vasectomy, all that remains on the cart is non-sharp garbage, the soiled vas instruments, and the vasa themselves. Within 1 minute after completing the vasectomy, I can have the used instruments in the sink, the vasa in the specimen bottle, the sharps in the sharps container, and the remaining waste--wrapped in the sterile drape--in the garbage can. Voila! Done.

No wasted motion. Efficiency. And as far as a vasectomy can be, a thing of beauty.

And all because I purchased a cart with wheels.

Thanks,

The IU.

Gone Digital? 6 Essentials of Back-up

Though I'm no computer expert, I have an EMR, and I have had crashed drives and lost data. I've learned the hard way how to prevent data loss. Here are 6 crucial elements for back-up systems.

1. Automatic: Your system should back-up without your needing to ask it to do so.
2. Redundant: You must not leave all "eggs in one basket." This way, you will never lose your data.
3. On-and Off-site: What if you have a fire or flood in the office?
4. Daily: If you see more than 5-6 patients per day, you will not be able to remember encounters, let alone billing details.
5. Versioned: If files are corrupt, versioning will prevent the corrupt file(s) from being propagated to subsequent back-ups.
   
6. Recoverable: Back-up is only as good as your ability to retrieve the lost data.
   

If you have an EMR, you need to back-up.

Any other suggestions?

Thanks,

The IU.

A decent way to send and document certified letters

Remember Mad Libs, those funny word games available when we were kids. They were basically stories in which the critical verbiage, adjectives, or nouns were left blank, to filled in by you. Depending on your own creativity, it was possible to create some pretty funny things.

Sending certified letters to non-compliant patients is not funny business, but can be made easier by applying a Mad Lib approach to it, only without the funny adjectives, adverbs, and nouns.

Before I had an EMR, I had to dictate the letter, have it transcribed and printed, then I'd have to review it, make any necessary changes, then repeat above process. That is how I used to do it when I was part of a group. Worked well so long as you can afford a huge staff.

Now that I'm solo, I'm more frugal, and I have an EMR--a home grown one--but an EMR nonetheless.

Here is how I did it until recently. I created a template letter with the date, patient name, DOB, and Dear SoAndSo fields left blank. When generating a letter, I would simply insert the above information, print the letter, sign it, scan a copy back to chart, and send the original. Of course, we would save all the USPS documentation for proof.

Now I think I have even improved the process some more. Currently, I simply print out the blank template letters, have my staff write, by hand, the name, date, and etc onto the letter. The staff then brings the letter to me. I sign it. The letter goes back to staff, who then scans it into the patient chart, places it in the envelope, and then mails it with certified forms attached. We retain USPS forms, which are scanned into the patient charts as well. Takes about 10 seconds per letter, if that. Scanning time for the staff, with an automatic document feeding scanner, is only slightly longer.

My system certainly lacks the prettiness of what you'd expect from an expensive EMR, but what it lacks in style points, it makes up for in efficiency.

Let me know what you think,

The IU.

Can't sleep? Audit yourself.

Are you certain that your documentation is good? Are you sure that all labs have been received and filed correctly? Have all your bladder cancer patients had their cystoscopies and cytologies?

Well, though I'm sure you pride yourself on your recall systems, documentation, audit proof EMR's, and lab follow-up processes, despite the best of intentions, things will slip through the cracks. So if you are worried, and you should be, do an internal audit before someone else does it. You'll be surprised at what you find.

• Do your consults have associated referral letters
• Do your no-shows have documentation regarding attempts to contact them
• Are all the ordered labs and studies in the charts
• Are certified letter documents in the charts
• Do all encounters have written notes
• Are informed consent discussions documented
• Are phone conversations documented
• Are all email communications saved in the chart
• Does the documentation fit the coding level

I know that good EMRs can do lots of this for you, but I still believe that random audits are warranted. We do them and find things frequently. I recommend it.

The IU.