My E.H.R. Experience: A 15-year Journey

I have been using an E.H.R. off and on since the mid-1990s.  At that time, I was using the VA Medical Center’s system, VISTA.  Few current commercially available systems today can compare to what VISTA had in functionality back in 1999.  It was truly a fantastic system and it became for me the gold standard by which all other systems would be compared.

From July 2001 to April 2006 I went back in time, leaving the electronic world for the world of paper charts and DOS based billing systems.   I think this experience—living in both the paper and electronic worlds--taught me that medical offices run best in a digital environment.   Medical practice is too data-rich and high volume data is best managed in a digital format.  It is just that simple. 

In 2006, I left the paper world and returned to the digital one.  When I opened my own practice, I wanted to be electronic from day one.  The only problem was that I could not afford systems.  In addition, like many members of this IPA, I did not see the value in paying up to $40,000 for software.  That just seemed crazy to me, and in a way it still does.  So I built my own homegrown EMR system

I can tell you that my homegrown system was terrific and better than any paper system I ever used.  I used templates and macros and electronic faxing.  I set up in-bound lab interfaces so I never had to scan labs into my system.  I could retrieve patient charts in microseconds, rather than the days it would take to locate a chart in my old practices that were still on paper.  And I could access my charts from home or away.  The cost was the best part: a couple hundred bucks.  All software was commercially available, off the shelf, and general use.   So why the hell did I change? 

By 2008, my practice had outgrown the capacity of my system.  What worked with a volume of 35 patients per week no longer worked at 65 patients per week.   I grew tired of tinkering with my homegrown system.  Not only was I the developer, I was the IT support specialist, trainer, network engineer, and troubleshooter all wrapped into one.  I really just wanted to be a doctor and to be able to focus on patient care and growing the practice.   Plus I was swimming in post-it notes and drowning in pharmacy related issues.  To add to the stress, 2007 saw the advent of the RAC era.  At a moments notice, I could receive via mail an audit request letter for coding and compliance and potentially be liable for tens of thousands of dollars.  My system was just not equipped for any of that.   Finally, I had an EMR system and a separate billing system and they could not “speak” with one another.  So it was difficult if not impossible for me to do the type of practice analytics I needed to do to grow my practice.  I needed professional solution and I was finally willing to pay for it.

In 2009 I went live on my EHR and have never looked back.  

My Facebook Advertising Experience

My Experience with Facebook Advertising

There used to be a bakery on Armitage Ave in Chicago that gave at free samples of bread.  The bread was amazing.  The bakery was in a great location and had tons of foot traffic.  The store was mobbed from opening to closing.   Ultimately the bakery closed.  Why?  I don’t know specifically but I suspect that people came to the store for the free bread but then never went on to buy a loaf.   In web parlance, the store got tons of clicks but few sales: few conversions. 

This is somewhat like my experience as a Facebook advertiser. 

II used to advertise on Facebook and may again someday but as for now, at least for what I do, I see their advertising model as flawed.  All in all, I spent a couple grand in total.  That was spread out over a number of campaigns beginning in 2010 and most recently in early 2012.   Website analytics indicated that Facebook was the number one referral source to my websites, www.schoorurology.com and www.longislandvasectomycenters.com.   I tried both pay-per click and pay-per impression and both were effective in driving traffic to my sites.   In fact, Facebook was more effective than Google in driving traffic to the site.  So sounds good, right?   Facebook would claim success and blame any failures on my website.  Perhaps they are right perhaps not. 

Let’s go a bit deeper.    Business owners care about sales.  While traffic may lead to sales, traffic in and of itself, does not help.  While both Google and Facebook will drive traffic to your website, in in effect you business, Facebook sends lurkers and window shoppers while Google sends determined customers.  My websites are fine, as evidenced by conversions of traffic to actually physical patients coming into the office.    

Big difference.      

A Guest Post: The Future of Obamacare if Romney’s Elected

Guest Post:

Title: 5 Tips for Physicians Preparing for the ACA

As election day approaches, the future of the Affordable Care Act (“Obamacare”) is a hot topic among politicians, healthcare professionals and politicians alike. However, the outcome of the 2012 Presidential Election is unlikely to have an impact on the ACA.

David Fried, contributor to Software Advice, argues a victory by either Obama or Romney means the ACA, in the most part, is here to stay. To help physicians he provides 5 ways to effectively prepare for the impact of the ACA.

1. Decide How to Address Medicare and Medicaid
The decision to accept Medicare and Medicaid patients becomes even more difficult, as the ability to offset costs becomes increasingly difficult for physicians. With almost a quarter trillion dollars in Medicare and Medicare Advantage payments expected, physicians should begin to act now rather than later and addressing how to accept new patients.

2. Consider Relocating to a Rural Area
Ever wanted to relocate away from the big city? Now might be the time. The ACA rewards physicians that serve patients in what it calls “underserved areas” in the form of loan repayments and doctor scholarships. This is a great option for young doctors considering where to establish a new practice, as well.

3. Prepare for Bundled Payments
Soon, government payers will be transition to the “bundled payments” system, rather than paying physicians, labs and hospitals directly. This means that to receive payments for a patient, you may have to work with the hospital billing staff, rather than Medicare directly. Another consideration is to look into Accountable Care Organizations, or ACOs. These groups of physicians coordinate group-care to bring down the cost of care for patients, for which the physicians receive half of the savings.

4. Take a Firm Stance on Electronic Health Records (EHRs)
If physicians are interested in receiving Medicare reimbursements and don’t yet have an EHR, they’ll need to move quickly. The ACA increases the requirements for patient reporting necessary to be compensated seeing government payers. Alternatively, physicians can decide to deny seeing these patients.

5. Extend Office and Practice Capabilities
The ACA will impact the number of patients that physicians will see in three ways. First, the ACA will extend coverage to 32 million additional Americans. Second, it requires insurance companies to cover more preventive care procedures. Third, it specifically prohibits insurance companies from denying coverage of pre-existing conditions. Thus, physicians could prepare to see more patients. One way they can do this is by extending hours. Another is by adding additional physicians to the practice’s staff.

Research for this post was conducted by David Fried and Software Advice.

EMR: A problem Solver

A re-post:  See below.

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

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

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

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


Message handling:  100% solved.


Handwriting issues: bye bye!


Filing/retrieving:  see ya.


Lab tracking: Bye bye.


I still have problems, but just not these problems.


A good thing.

Independent or Employed?

That is the question most doctors who have remained independent grapple with today. In today's environment only about 20% of US doctors are independent but that number is expected to drop even further. The reasons are financial and managerial: not enough of the former and too much of the latter. As a result, hospital employment is becoming an attractive option for many. But is it?
Hospitals face many of the huge economic burdens. Even though they get reimbursed at higher rates, they have enormous administrative costs. Even as hospital systems merge to increase market share, so do their costs. All this in a shrinking patient base that has pit health system against health system. Now some systems want to not just be the provider of health services, they aim to be the payers as well. This is an interesting turn of events. As provider your goal is to maximize payments but as payer it is to minimize payments. Who will be squeezed in such a model? Let's see?
The administrators? No way. They control the switch.
The nurses? Yes. They will need to work more for the same and less.
The doctors? Bingo.
Once you sign with a hospital, your practice is no longer yours. It is then only a matter of time before you get administratored, ie f@cked!
Hold out. Just hold out.
The IU
The last remaining independent urologist in my area.

Why are doctor's late?

This post is in answer to a recent KevinMD post on doctors and wait times. Here are the reasons why I can run behind, in no particular order:

1: seemingly simple patient condition turns out to be complex.
2: patient arrives late
3: the 2:30 patient arrives at 2:50. The 3:00 patient arrives at 2:45. The 2:45 patient arrives on time.
4: Patient needs more time on initial intake forms
5: Medical emergency I have to deal with
6: Hospital doctor on the phone. Needs me now!
7: Elderly patient needs more time
8: Unexpected diagnosis needs discussion
9: Patient complaint about copay.
10: "Oh yeh doc, and I also have ED".
11: patient calls for 3rd time, needs me on the phone now.
12: pharmacist on phone. Needs to speak to me now.

Note that what is not present in the list is my lack of respect for patients' time, my own time, or anyone else's time. Nor do you find any profit maximization motive.

So why do doctors run late? Because doctoring is complicated. So before you take the doctor to small claims court or trash him on Angie's List, cut him some slack.

And one more thing: If you need extra time or special care from me, you'll get it, even if it makes me fall even more behind.

Video Informed Consent

Using nothing but a webcam, some good lighting, and a script, you--the doctor--can video an informed consent discussion for any number of procedures you perform and show it to a patient when appropriate.  This way the patients get the information they need to make a decision, that information is complete, but you as the doctor get to save your valuable time.

Win, win.

The procedure video do's and don'ts

With extremely low production costs, almost anyone can make and distribute a video for both educational and promotional reasons.  While a very powerful tool, the video can also cause more harm to your practice them help it.  Here is what to avoid:

• don't be too graphic.
• don't be too long
• don't show too much blood
• don't show injections or needles
• don't show incisions
• don't show a sloppy work station

Do the following:

• edit
• use good sound quality
• use voice over
• use captions
• use transitions
• good lighting
• ask a lay person to review it

How to make it:

• iPhone
• iMovie
• iTunes
• iPhoto

i dun now.

Lot's on my mind. Lots.

I hate the phone

I hate the phone.  There I said it.

Have you ever noticed that everyone has a cell phone yet no one answers theirs?  There are a myriad of reasons why people don’t answer their cell phones; they don’t hear the ringer, they are on another call, the phone is in a no service area, they are busy with something else, etc.  I don’t answer my phone either.

People no longer even answer their home phones.  My own family never answers the phone.  The running joke in my house: if I ever find my self in jail and I get my one phone call, I’d better not waste it on calling my house.  The phone, which once was the most efficient means of communication ever, is now among the worst.

As a doctor I find this very annoying n many levels.  Patients have a right to get their test results in a timely fashion.   I have an obligation return patient calls and to contact them with test results.  It is more than that, however.  I have a desire to be able to connect with my patients.  The phone unfortunately no longer serves this need.  

Typically, here is how most doctor/office—patient calls go these days:

·      Patient calls for doctor—doctor is with patients—take message

·      Doctor call back patient—voice mail

·      Patient calls back—doctor unable to come to phone

·      Doctor calls back again—voice mail

And on and on it goes until either the call gets through or both parties give up.

Is there a better way?  Yes, for everyone else.

But not for doctors.

Why?  Because email is not HIPAA compliant. 

Yet email is the best means of communication ever developed and would serve both doctors and patients needs simultaneously with efficiency, thoroughness, and elegance. 

But email is not legal.  But secure messaging is.  Fortunately we live in America, the land of entrepreneurship and companies have moved in to fill the void and meet the need.   I have been using one such company, which is still in Beta, and have already dramatically reduced the phone call nightmare cycle.   I am happy.  Patients are happy.  And I can even return calls when needed with more ease because the sheer number of calls and call-backs are so dramatically reduced.

Embrace it. 

Lycopene: Good for prostate health

There is some decent evidence that suggests that diets rich in lycopene can protect against prostate cancer. Lycopene is found in tomatoes.

Coverage?

What is coverage? The answer is that it varies. To a surgeon in the OR it means having an assistant. To an attending at a teaching hospital, it means having residents take care of their patient in-house. To a private practice doctor, it means having someone take care of patients when you are away.
If you take ER call, coverage is very important. Coverage in this case enables you to take vacation once in a while.
If you are in a group, coverage tends to not be an issue, unless of course you are doing the majority of covering for your partners as they vacation. This can lead to bad feelings.
As a solo doctor, coverage is vital, yet in many ways easier to come by than when part of a group. In many areas, ER call is valuable, so it is easy to give away. This means as a solo doc you can get away when you want.
Technology has made coverage less vital as well. With cell phones and EHRs, mundane tasks like rx refills and lab checking are non issues. With several minutes a day at a netbook, you can keep up to date and avoid the dread of the first day back mile high chart build up.
Yeh, life is good.

How to Attest For Meaningful Use

I just attested, successfully, for 2012 EHR meaningful use.  I can tell you that this has been no small feat.  I started the process in January 2011 and was it took me almost 20 months to get it right.  And I am a savvy EHR user.  Attesting for MU dollars is a process.  First you must register, then you must report for a 90 day period, then you attest.  Oh yeh I forgot, first you use select a qualified EHR & learn how to use it in a meaningful way.

CMS, the Center for Medicare Services, has lots of documentation on there website regarding MU, attestation, EHR selection, etc.  Click here, https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms/32_Attestation.asp to be taken to the site.  I know you will find tons of information on the site, just not a bit of it helpful.  I don't know who developed the content for the site, but either they were oblivious to the needs of the people who use it or intentionally made the site confusing to make especially difficult to start and complete the MU process.

The real link, the one you need to get the $$$ is here: https://ehrincentives.cms.gov/hitech/login.action
I just don't think CMS wants you to know it.

Here is how to do it, step by step:

• Register for MU at the link above
• you must have a NPPES password to do this.  If you do not, you must get one.  If you cannot, you are SOL.
• Answer the questions asked
• Find your EHR number (ask vendor or search on the EHR incentive site.
• Complete MU reporting process
• Return to link, complete questions, hit submit.

Sounds easy.  Is not.

Good luck.

Commodity vs Superstar?

If you were a hospital or clinic administrator, and you were charged with hiring a new doctor, would you want a competent but no-named doctor or a superstar?

The no-name, of course.  He/she costs less and can be replaced easily with less disruption to the organization at large.

Of course it you are the doctor, your goal is to become the superstar because you cost more and can't be replaced so easily without disruption to the organization.

The administration, if they are smart, will have policies in place that in effect make it difficult to become a superstar.

Of course, in this era of social media, this can be problematic for administration.

Interesting eh?

Write book. Why?

Do you have information you want to give to the world? Do you want to write a book? Here's an easier way:
recorded what you know on video. Then convert it to a DVD and get it out there. Way more more reach.
Easier, faster, cheaper, better.

A great use for MMS

Here is a cool use of technology. I had a patient who needed to understand how to use an injectable medication. He was unable to come into the office for a demonstration in person. So I video recorded me showing him how to draw the medication into a syringe using the vidoe function on my iPhone. Then I MMSed the video to him. Technology; wonderful.

A vasectomy consult with Dr Richard A Schoor MD FACS

I had this video made for my vasectomy patients.

http://www.youtube.com/watch?v=Q6DlGNeQEZ4&feature=youtube_gdata_player

Richard A Schoor MD FACS
www.schoorurology.com

Spousal consent prior to a vasectomy?

Vasectomy Complications

Count your jewels

A jeweler, on the way home from a business trip runs into a merchant friend of his. The merchant has some diamonds he needs to sell to the jeweler. The jeweler, having just made a purchase, does not have much money remaining. But the merchant is really offering a good deal. So the jeweler looks through his wallet and decides that he can make the purchase, but he'll have to travel home coach, when he is accustomed to first class, luxurious travel.
On the way home, the jeweler sees another friend. The friend asks the jeweler why he is in coach and not first class. Has the jeweler fallen on hard times?
The jeweler responds that when he feels cramped and uncomfortable, and when his back and legs hurt, and when he is hungry, he gets his bag of jewels and counts them, and he feels better.
When is the last time you counted yours?

Richard A Schoor MD FACS
www.schoorurology.com

Make a business plan

Even if your practice is up and running it is probably worth while to look at your business plan. If you are just now planning to start a new practice, having a business plan is essential.
A formal business plan contains many parts. You can get a template free from the US Governments Small Business website. It is a great and free resource. The business plan is your chance to plan for as much contingencies as possible before you spend the money. Brainstorm all the what if's. List them all. Then add up how much money worst case will cost.
Then compute the upside--the most you can make with the business.
Is your business still worth the risk?

Behave!

If you work in the same community I'm which you live, you better behave. You never know that the person you are mouthing off to may have been a future client or patient or customer.
These things happen.

Who is your best worker?

Miguel was beloved. He was an icon. Over his tenure, he became an institution at my temple.
But Miguel was really a slacker. Raul, his underling. was the gem. When Miguel left. Raul rose to the occasion and has out shined his former boss in all respects.
Are you honoring your true gem?

Richard A Schoor MD FACS
www.schoorurology.com

Semen analysis: what is normal?

The WHO recently re-analyzed "normal" values for semen analysis. Without boring you with statistics, I think that the results can be summarized as follows:

More is better.

Let me elaborate.
10 million sperm is better than 5 million sperm and 20 million is better than 10 million. To go further, 50 million beats 30 million while 100 million beats 50 million. In other words, the probability that a couple will conceive within a year increases as sperm counts increase. Same with motility and morphology.

Do what is my job? My job as a male infertility specialist is to help you produce more and better quality sperm.

Order Sets

Order sets go by several names but essentially they encompass all the pertinent diagnostic and treatment options indicated for any given disease process. Any EHR worth its price will come hardwired with datasets and will also allow you to customize your own. Datasets should ideally come from evidence based medicine and your society's best practice guidelines.
Does your EHR have them?

The IU.

Patient Satisfaction Surveys

Collecting data on how your practice performs in customer service is important. But there is a right way to get the data and many wring ways.
Wrong way: leave surveys in the office and hope people complete them

Wrong way: embed survey in website and hope people complete them

Wrong way: mail patients surveys and hope they complete them

Right way: ?

The problem with all surveys is wether or not the information is useful and accurate and unbiased. Doing surveys the wrong way will get you inaccurate biased and useless data.

Do it right or not at all.

Richard A Schoor MD FACS
www.schoorurology.com

EHR Slow Down

Do EHRs slow down physicians? Yes and no. EHRs force docs to be more complete, more thorough. If that slows you down then perhaps you needed to slow down. Ultimately though, as the doctor masters the templates and the flow of the EHR, he or she can actually speed up yet remain thorough.
A win win.

Richard A Schoor MD FACS
www.schoorurology.com

Live close to work. Work close to life.

One day you may be tempted to get a job or take call at a hospital greater than 30 minutes from your house. If at all possible, don't do it.

You may make some more money but you'll miss life.

Richard A Schoor MD FACS
www.schoorurology.com

Remember this when things are slow

When the phone keeps ringing
When patients keep showing up
When you have to see yet another
When you have to return another call
When you have to sign off another lab
When. . .

Richard A Schoor MD FACS
www.schoorurology.com

What is your plan?

Now is the time to start planning for next year. How are you going to:

Increase revenue
Decrease overhead
Get more new patients
Decrease risk
Decrease staff turnover

Now is time to plan.

Richard A Schoor MD FACS
www.schoorurology.com

Adding labs

An in office lab runs at razor thin margins. Here is what you need to consider before adding a test.

Number if tests ordered
Cost per test
Reimbursement per test
Cost of controls per testing day
Cost of proficiency testing
Cost of interface with EHR
Staff Time required to run each test
Ease of use of instrument
Space requirement of instrument
Calibration costs
Aggravation factor

Add them all up then decide. Simple math. No emotion.

Richard A Schoor MD FACS
www.schoorurology.com

Consumer vs Pro

The temptation is to spend less money. Resist it. If you are deciding between the consumer vs the professional model for you practice, definitely go pro. Ultimately that decision will save you big-time.

Printers
Computers
Scanners
Software
Telephones

Consumer models just don't work in a business.

Good luck.

Richard A Schoor MD FACS
www.schoorurology.com

Meaningful Use: BS or Not?

To achieve meaningful use, EHR users must jump through a lot of hoops, at least 23 to be exact. Are the hoops just busy work or are they worthy in creating a safer medical environment for our patients? I have been an EHR user for several years, long before MU came to be. I have been a meaningful user, ie I do all 23 hoops, for the past few months. What do I think? I think some of the objectives are worthy and others are busy work. On the balance I think MU is good and worthy. Dr Schoor www.schoorurology.com

Stressed Out

I was talking to a colleague of mine today. She told ms she was stressed about all the non-medical stuff that goes along with being a doctor. What kinds of things I wonder?

Documentation
Coding
Billing
Risk management
Practice management

Yeh, lots of stuff. But why get stressed. The challenge is the fun part. Rise above it and enjoy the journey.

Richard A Schoor MD FACS
www.schoorurology.com