Cost Consciousness and Medical Practice

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



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

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

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

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

The world's cheapest full featured EMR-PM

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

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

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

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

MS Word & Your DIY EMR

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

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

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

The IU.

DIY EMR: The essential elements

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

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

Optional:

• Adobe Photoshop Elements
• Adobe Acrobat Standard
• OmniForm

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

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

The IU.

Going Green in Medical Practice

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

• Go paperless/EMR


• Set the computers to power saving mode


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


• Practice the judicous use of antibiotics


• Install water saving toilet flushers


• Develop creative scheduling that promotes decreased medical waste


• Do procedures with the lights off (joke)

A green medical practice.

The IU.

Some Mistakes I've Made

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

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

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

My letter to Senator Clinton

Dear Senator Clinton,

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

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

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

Sincerely,

Richard A Schoor MD FACS

Automate, Automate, Automate

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

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

And probably others.
Thanks for listening,
The IU.

On getting paid.

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

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

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

Thanks,
The IU.

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

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

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

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

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

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

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

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

Thanks,

The IU.

My VONAGE experience summarized

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

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

Here are some of the great features of VONAGE.

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

Here are the disadvantages:

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

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

Thanks for listening,

The IU.

A load of garbage

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

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

My lab has achieved prestigious accreditation

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

Threats from all sides

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

My threats include:

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

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

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

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

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

Have a problem? Talk it out.

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

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

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

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

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

Good suggestion, and you know what; it works.

Talking! Who knew?

Thanks,

The IU.

Sorry!

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

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

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

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

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

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

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

Anyway, just my thoughts.

I thank you for your time.

The IU.

Memory Lane

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

A band aid to the rescue

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

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

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

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

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

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

And all because I purchased a cart with wheels.

Thanks,

The IU.

Gone Digital? 6 Essentials of Back-up

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

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

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

Any other suggestions?

Thanks,

The IU.

A decent way to send and document certified letters

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

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

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

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

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

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

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

Let me know what you think,

The IU.