Have a nice weekend

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Happy Mother's Day

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A picture is worth 1000 words

The easiest way to teach your medical assistant how to set up for a vasectomy or any other procedure is to show her a picture.
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A reason to get involved

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

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

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

I'll keep you posted.
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Five ways to decrease call-backs

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

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

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

Is your practice compliant with Red Flag?

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

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

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

Feel free to contact me if you have any questions.
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Some observations about urology

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

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

So I wish them luck.

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

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

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

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

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

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

Poster session at the AUA

Good stuff, good stuff.
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My junior resident

Dr Dan Williams MD

Male Infertility Expert, University of Wisconsin at Madison.

Northwestern Urology Alum.

Nice job buddy!

Good morning from Chicago

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

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

DIY EMR vs The Big Boys

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

EMRs do some things really well. Some of these things benefit the doctor. Others benefit bean counters. Other's benefit patients. A few of these things benefit doctor, payer, and patient simultaneously. I think this is an unintended consequence of an EMR, to be honest.

1. EMR's handle prescriptions really, really well, and that is regardless of an eRx module or not. The good EMR's have built in prescription writing software--actually the software is from a third party vendor--that simplifies the new and refill process so much that a medical assistant with a little bit of training can do it without mistake. This helps doctor, payer, and patient through efficiency and accuracy. My little DIY EMR was terrible at this.
2. EMR's handle coding very well. The good products have CMS coding rules pre-programmed. When the doctor sees an encounter, the system can suggest an accurate level of coding that reflects the documentation. This helps doctor and bean counter at the same time, though it does not help the patient at all. My DIY EMR was not sufficient in this regard, but I could have made it so if I had the knowledge then that I have now.
3. EMR's handle documentation extremely well. Notes are well written and chock-full of information and free from handwriting issues. This helps the bean counter though not the doctor or the patient as much as you might expect. You see the notes seem to lack the essence of what was on the doctor's mind. I find them difficult to sift through, to be honest. In fact I just got documentation faxed from a local urologist to whom I referred a patient. The computer note was difficult to interpret, albeit beautiful. Had the urologist not called me in addition to the fax, I'd have not known what he was planning. I found that quick, short, scribbled notes (typed even better) provided the best form of documentation from a pure patient care perspective. Ironically, my little DIY EMR was superior in this capacity.
4. EMR's enhance billing processes. Good EMR's can seamlessly merge EMR data with billing data and facilitate claim generation and turn-around time. Coding, ie programming, requirements for this were light-years ahead of my little DIY EMR. This feature of an EMR helps doctors only.
5. Correspondence: Good EMR's facilitate correspondence with providers. Ironically, this might not really help the receiver, since these systems tend to inundate them with paper. I have had a number doctors mention this to me with regard to my system and other popular systems. Perhaps this is just a customization issue. In this regard, looking back, my little DIY EMR was superior.
6. Document management: When properly interfacted with participating labs and radiology centers, document management with a good EMR is a snap. These interfaces don't come cheap, however, and if your EMR and local lab/radiologist etc cannot work together, you are screwed. My little DIY EMR was vastly superior in this regard since it worked with everyone, cheaply. There were no interface issues.
7. Intra-office communication: Good EMRs, though probably even cheap ones, have secure email features for intra-office communications. I have found this feature, even in my small office, to be a huge improvement over my previous way of doing business. If I was a better software designer, I could have configured my little DIY EMR to do the same thing. But I didn't.
8. Customization: Good EMR's can be customized and programmed to reflect "best practice" guidelines. My little DIY EMR did not do this. I actually see a sinister motive in the government's and industries pushing this "best practice"agenda. Ultimately, the powers-to-be will use this to empower midlevels and pay doctors less.
   

All in all, my little DIY EMR was damn good. Not perfect, but nothing is. If I was cash only practice, I'd still be using it. But in the RAC, HIPAA, P4P era, it no longer was sufficient for my needs.

Still, not bad at all.

Dr Schoor MD FACS

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

Happy Passover

Be thankful for your freedom and wish freedom for those without it.
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The 5 P's of EMR

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

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

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

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The Paradox of EMR

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

Like a marriage, a very complex relationship indeed.

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The Capitol Dome

Wow
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Capitol Urinals

Don't have BPH here. There are only 2 of these.
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Enough

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

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An evening out with the girls

Nice break from my EMR hassles, etc
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Not bad daddy

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

My father daughter trip begins
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Make good use of your time

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

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

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

Yes, it was time.
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A new generation of bloggers

I have some competition now.
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MY FIFTH EMPLOYEE

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

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

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

My fifth employee doe not make mistakes.

My fifth employee is very organized.

My fifth employee can write prescriptions.

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

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

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

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

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

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

That is a good way tolook at an EMR investment.

Email back-up

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

In back-up, it is the ability to restore that matters.
Good luck.
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Mobile Ideas

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

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

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

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

Just my cynical observation made for your convenience.

In a rough economy, give patients value

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

You may want to try the following: have patients come in to discuss results

• . . .and have a repeat physical exam.
• . . .and have a urine culture
• . . .and have a blood draw
• . . .and have a ultrasound
• . . .and review radiologic studies in their presence
• . . .and draw diagrams for them
• . . .and complete forms

etc.

Just something I've figured out over the years.

From Idea to Implementation: 5 Steps

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

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

Good luck with your endeavor.

My respite.

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

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

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

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

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

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

Again, sorry for the respite.

Sad

This is a mother of 2 girls the same age of 2 of my 3 kids. She frequents a bread line in South Florida.

From the NYTimes:

Megan Brown, standing in line with her well-dressed daughters, Kayley, 2, and
Sydney, 4, had come because she feared the worst. Her husband still had his job,
she said, “but things are getting more and more tight.”

Scary and sad times indeed.

How an EMR changes you and your practice forever.

Forget everything about how you used to do things.  Just let it go!  When you adopt a high-end EMR product, you'll find that business as usual is over, and forever. 

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

Ahhhhhhhh!

The IU.

Are we next?

Employment lawyers have seen a sizable increase in wrongful discharge claims.  Are we next?

I've always thought so.  It seems to me that claims of all sorts would rise during tough economic times.  For doctors, I think this is especially true.  Any adverse outcome that results in lost time from work or out of pocket expenses could quickly change a good doctor-patient relationship into a bad one and result in a claim of medical negligence.

I'm not sure what to do about, other than make sure you dot your "i's", cross your "t's", and make every effort possible to manage risk in the office.  Perhaps now is not the time to increase risk by adopting new techniques and procedures in the office.

I don't know.  Scary stuff!

The hiddden costs of any marketing campaign

Marketers are very quick to sell you on the upside of any campaign, whether it is TV, radio, print, email, or direct mail.  Skilled marketing companies can even supply you with data on conversion and response rates and how much return on investment you can expect.  But beware of the hidden side to any marketing modality.

The TURN OFF FACTOR!

Newton's third law of motion states that for any action there must be an equal but opposite reaction.  While in marketing, the opposite-than-intended reaction may not be equal, it is present and you ought to be aware of it.  Lets use a mailing as our example.

Let's say you send 2000 newsletters to your established patients.  Conservatively you can hope for the following:

• Cost of the mailing ~$2500
• 1% positive response rate, max = 20 patients who call to come in and be seen
  
• Each encounter  = $150 = ROI of 120% or the campaign paid for itself + $500.

Sounds good, right?

Now lets factor in the turn off factor.

• Of the 2000 mailings, you annoyed 1% 20 patients
• 20-60 patients x $150 = $3000 in lost revenue for those patients who decide to hopefully just leave you.
• Factor in an additional small percentage of really mean people who will use the mailing as a reminder to bad-mouth you to others.
  

Obviously, this is an extreme example, but the turn off factor is probably in the 0.1 percent range, or 2 patients out of 2000 = $300 plus any additional bad-mouthing damage that they may do.

Just think about all the possible outcomes before you do a mailing, or any other brand of unsolicited, in-your face, type marketing campaigns.

Good luck,

Dr S

Clueless? Design the Front End First

Let's say you wanted to start a web-based business but did not have any web design, programing or software engineering experience, you might think that it would be impossible to proceed with your plan.

You'd be wrong.

Using simple and inexpensive software, such as Balsamiq or even MS Publisher, you can actually build your site from the front end first, ie from the experience of the user. Then, you just have to find a coder to build you the site and then find someway to pay for it all.

If you are going into a new, solo medical practice, you can adopt this type of backwards planning strategy to achieve your ultimate goal even if you lack the knowledge to see the all the details involved in the project.

For example, perhaps you want to leave a group practice to start your own one, but have no experience with the business aspects of medical practice, you can use your knowledge of how you want to experience life in your practice and then step by step find out how to accomplish the seeming impossible. You may know that you want to see 20 patients a day, take insurance, do in-office procedures, major surgery in the hospital, and have a lab. Using this knowledge, you can back-step the route to the goal.

This strategy takes some practice, but you'll be amazed at what can be accomplished by using it.

Good luck and let me know how it goes.

The IU.

Solo Practice Amidst A Huge Team

Whether you are in solo or group practice, you work as part of a large team.  You rely on yourself and your employees to get stuff done, but you also rely on other people who you may never have met to act on your behalf and that of your patients'.  When I schedule a surgery in the OR, for example a penile implant, at least 7 people are involved in the process, not including the patient.  If anyone of them fails to do their little-but-critical part, the process comes to a halt, or worse.

It is a wonder that the system ever works at all.

Here are some things that we do so that we can trace the course of an order through the multiple levels that have become our health care system.

• Save fax confirmations
• E-prescribe
• Take notes
  
• Send letters by certified mail
• Document, document, document
  

. . .and really we question everything and take it to the next level when something is not quite right. 

Modern medicine is a team endeavor whether you are solo or not.  Anything you can do to make it easier for someone else to do their job will ultimately make it easier for you and your patient.

Who else is listening?

Have you ever had the nagging feeling that your words are being recorded?

Recording a phone conversation in which you are not taking part, ie between 2 other people, is wiretapping. This is illegal without a court order. Recording your own conversation, even without the other conversant's consent, is legal and done frequently.

Sometimes, I get the feeling that I am being recorded. I don't mind when this happens, because I tell the truth in the presence or absence of any recording devices, but I do question the motives of the person who records me surreptitiously. Are they building a case against me?

Here are some tell-tale signs that you are being recorded by an amateur on the QT.

• They keep on asking you to repeat yourself.
• They really try to pin you down to a guarantee on success or a particular outcome.
• The caller seems preoccupied with some of the technical aspects of the call.
• The caller says they just want someone else to listen in, yet there is no one there.
• The caller tries to manipulate the conversation so that you say something they may want to hear.

Of course, an expert can record your conversation without you ever knowing or suspecting it. But most people are amateurs.

And also, most of the time any recordings will pnly go in your favor in the case of a civil action since it will support you in the typical he-said-she-said game.

Good luck.

Is it time for a contrarian approach?

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

Then I saw something amazing.

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

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

It was a nice day on the beach!

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

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

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

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

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

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

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

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

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

Dr S

A new blog.

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

Check it out: The Andrology Blog.

My New Years Business Resolution

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

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

Anything else that I'm missing?

Dr S

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

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

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

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

Good technology can well worth the cost of implementation.

Dr S.

The 5 Key Elements of Any Business Plan

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

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



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

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

Good luck,

The IU.

Size Does Matter: Go Small

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

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

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

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

Dr S

Going Solo? The Turnkey Medical Practice: 2.0 Style

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

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

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

Good luck.

Dr S

A New Car--A Vas Reversal

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

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

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

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

Kind of like when we see our vas reversal patients.

Dr S

December Goals

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

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

Good luck and have a good December.

The IU.

Happy Thanksgiving!

From Portraits 11/27/08 1:02 PM

Selection Criteria for an EMR-PM Purchase

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

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

And then layout the big bucks!

Good luck.

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

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

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

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



The IU

THE ANGRY JUROR

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

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

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

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

And it was awesome!

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

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

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

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

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

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

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

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

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

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

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

The IU.

Pay Cuts, Again!

I am not happy either!

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

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

Oh Oh!

In rough times, every little bit counts.

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

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

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

The IU.

Some things I've been thinking about.

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

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

Exciting times, indeed.

The IU.

The Ultimate Low Cost Specialist Office

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

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

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

If anyone has tried this approach, let me know.

Destroyed in Seconds

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

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

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

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

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

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

Leaving a practice? The Essental List

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

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

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

Good luck,

The IU.

The Copay Sign

In this day and age, every dollar matters.

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

Joe the Plumber vs Rich the Urologist

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

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

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

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

Good luck Joe the plumber,

Sincerely,

Rich The Urologist.

How it Works: Getting Paid That Is.

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

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

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

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

1st: Insurance: yes or no

• No: Straightforward fee for service, just like restaurant

2nd: Yes, Insurance

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

3rd: Patient in office

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

4th: After physician sees patient

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

5th Billing

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

6th Payment

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

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

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

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

And that is a whole other discussion.

Physical Networking in a Virtual World

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

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

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

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

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

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

Thanks and good luck,

The IU.

I stand corrected

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

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

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

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

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

The IU

Fall

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

Not bad!

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

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

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

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

Thanks for the help.

Still waiting for a "minion."

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

What is regulated medical waste?

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



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

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

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

So please, give me a hand.

Considering an EMR? Look Into VISTA.

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

And it still is.

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

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

DIY

Text Messaging Consultants: I'd Like It.

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

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

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

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

5 Ways That Unfaithful Men Get Caught

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

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

So be forewarned and keep your pants zipped.

Going Solo? 10 Pearls For Success

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

In no particular order:

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

Good luck.

The Key To e is C

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

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

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

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

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

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

Good luck.