Not Everyone Needs High Tech Toys

Sometimes you can't beat the old fashion.
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My presentation milestone

I am a big believer in software as a service, despite its pitfalls. Today I gave a presentation at my hospital's tumor board. In the past, I'd have had to bring either my laptop or a thumb drive with powerpoint talk and ope that everything would sync ok. This time, I just had to make sure they had a computer with internet access. They supplied that, no problem. I just brought a url. Worked great.



Gotto love technology

EHR is not a panacea, Mr President

From the AUA Daily Scope

"Study finds little benefit to date in electronic patient records.
The New York Times (11/16, B3, Lohr) reports that a study to be presented Nov. 16 at a medical conference "comparing 3,000 hospitals at various stages in the adoption of computerized health records has found little difference in the cost and quality of care." Researchers from the Harvard School of Public Health conducted "a follow-on study to a survey of hospitals' adoption of electronic health records, published this year and financed by the federal government." The authors found that "differences...were 'really, really marginal,'" and suggested that "government policies should focus on helping physicians, hospitals, and the public health system use the technology more effectively." "

Frankly, I am not the least bit surprised.

The IU

My chief resident: a famous LA urologist on MTV

The Hills - MTV Shows

Hat tip to Dr Adam Weiser

A death spiral in evolution

It is truly fascinating to witness a corporate death spiral firsthand.  Here's how one just unfolded in my presence.

• Company A, a software as a service (SAS) solution lands big client, Company B, an EMR company.
• The arrangement flourishes.

In business--and life--the only constant is change.  In this case change produced:

• Increase in demand for company B's SAS solution
• Company A needs to invest in infrastructure to support Company B's plans.

Credit Crunch or bad Management?

• Company A unable or unwilling to accomodate Company B's plans
• Company B finds SAS vendor that will

The death spiral begins.

• Company B signs with Company C, the new SAS provider
• Company A makes lay offs of technical employees
• Service declines at Company A
• Company B gets tons of complaints
• Company B pulls remaining clients from Company A
• Company A has problems.

Wow!

Could this have been avoided by Company A.  In this economy, who knows?  Probably not.  I wish them luck.

Dr Schoor

Where an EMR helps and hinders in medical practice

EMR are very useful tools, just not for everything.  If you think about about all the processes that take place in your medical office from the moment a person calls to book an appointment to the moment you get paid, you can determine where the EMR will help and where it will hinder.  Here are some places I think these programs help.

• Scheduling
• Prescribing
• E&M Coding
• Charge Entry
• Claim Submission
• Payment Posting
• Acounting
  
• Auditing
• Ordering
• Document Management
• Clinical Trend Analysis
• Coordination of Care
• Patient Compliance
  
• Communication
• Information Flow
• Documentation*

Of course, not all processes are streamlined with an EMR.  The main example of this, and perhaps the only example, is the physician's encounter.  It takes longer for the doctor to document a patient encounter with an EMR.  And the doctor has to expend more effort to document the encounter.  Both the effort and time required to document improve over time, however.

Also, EMR generated notes are more cumbersome to read, which can make it more difficult for the doctor to get at the "essence" of his/her prior encounter.  Of course, this can overcome by adding memory joggers into the document.

On the balance, EMRs are improvements over business as usual for the small independent medical practice.

Dr Schoor

My favorite American tradition.

Happy Halloween.
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How to document an encounter quickly with an EMR

Electronic medical records have many advantages over traditional pen and paper charts. Speed of documentation, however, is not one of them. I have been live now on my high end electronic health record for 6 months. My first encounter on the system took place in February 2009 and took me 45 minutes to document on the system. Obviously, I would need to improve upon that. Now I do things differently, more efficiently. Here is my work flow:

1. Schedule patient, office staff gets some clinical information
2. Appropriate clinical templates are pre-loaded by me or staff into notes prior to patient arrival
3. I review the templates and pre-order labs, studies, and prescriptions as I see fit
4. When patient arrives, I perform the encounter and do my doctoring
5. I then determine if pre-ordered tests and prescriptions are still appropriate
6. Finally I complete the documentation, sign note, and on to the next patient.

The entire process now takes under 5 minutes and is much less stressful.

When you get an EMR, you must change your work processes to adapt.

Are meetings worthwhile?

As reimbursements continue to decline for many of us and we are forced to remain in the office longer and longer to make up the lost income, our attendance in meetings has taken a back seat in importance. This is a shame and you may wish to re-think this cost-cutting strategy.

Meetings are very, very important. You'd be better off cutting out some othe expense.

Meetings allow attendees to re-charge their batteries and return to the office energized and more productive than ever. Only through meeting with colleagues face to face can doctors forge new relationships that are important for networking and business development. While we may be able to learn new techniques and advances in our field through online CME courses, we learn best in person where the dialogue is 2 way and we have access to non-verbal communication.

Meetings are not cheap. Flights, hotel, registration, and time away add up to thoudands of dollars. However, if you choose your meeting wisely, increased revenue will offet the costs many times over. All it takes is learning one new CPT code or one new modifier or a new profitable procedure and you will payed back in triplicate, at least.

I just think this is not an option for cost cutting.

Wow, you can bill Medicare for waiting room magazines

From 2 posts on a listserve to which I subscribe:

" There are codes for magazine loss/replacement:
CPT: 9999a- replacement of magazine, identical issue
9999b- replacement of magazine, similar topic matter
J codes: 80% of magazine cost"

Also, since the governement is so interested in our education, here are some other codes you can use:

"Recent governmental efforts to encourage literacy among the poplus has lead to CMS's request for physician offices to voluntarily report, via PQRI, on appropriate utilization of magazines and reception area reading materials. Qualifying providers will be eligible for a 2% bonus of their annual CMS billings. These G-codes for PQRI measure 9999 are: G9990 - Educationally meaningful magazine provided at reception area G9991 - No educationally meaningful magazines provided at reception area G9992 - Some or all educationally meaningful magazines made available were lost due to theft or damage Eligible providers must successfully report on at least 80% of pts on Medicare seen in 2009 to qualify. The exact definition of educationally meaningful is still being debated, and won't be released until early December 2009."

I believe that most of this information came out on April 1st. I am not sure I recommended trying these codes just yet.

Hat tip to http://www.sunriseurology.com/ and Dr Ernie Sussman, famed urologist in Las Vegas. Hope you enjoyed.

GET WITH THE PROGRAM!

Doctors are resistant to upgrading technology. Most claim cost as the main obstacle to adoption of E.H.R technology. For others, overcoming inertia and resistance to change prevents them from committing to advanced information technology.
I say get with the program.

The technology is here.
It is good.
It is affordable.
Patients will demand it.
Payers will demand it.

I have several supermarkets near my house. One is less than a mile, but I shop at one 3 times the distance. This market has adopted technology that makes my life easier. In turn, I choose to spend my food dollar here. The image you see is of a scanner. I use the scanner to scan the bar codes of my food purchases. The scanner is tied to my card. After I am finished shopping, I simply hand the scanner back the clerk, my credit card is charges, and I am on my way.
I demand technology.
So will your patients.
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EMR vs House: Words of wisdom from a practice managment guru

Rick Rutherford, a practice management guru with the American Urologic Association, has a great analogy for EHR selection. I have published it, with his permission, in its entirety.

"The biggest fallacy in the process of selecting an EHR system is that too many folks think that there must be ONE systematic, accurate approach to making a good choice. There isn’t. To me, it is more similar to buying a house than a car. You can buy a car, drive it for three or four months and decide it is a lemon and go trade it in for a different one in a single day. Sure you lose some money, but beyond that, it is an easy transaction. When you buy a dwelling, there are many more considerations and sometimes, if you make a mistake, you just have to live with it. EHR systems are the same way. Why? Consider the following (substitute the word “house” everywhere you see the acronym “EHR”):

A whole group of people have to use the EHR so all of them should have input into what is important.
You can buy a modest EHR or a extravagant EHR depending on which things are most important to you.
When you start to use your EHR, you discover that almost every pattern you have developed must be changed or you will waste a lot of time and energy.
Over time, you become more and more comfortable with the EHR and appreciate (or hate) nuances you never saw when you did your first walk-through.
There are lots of financing options for an EHR. The government may give you money, the hospital may give you money, the bank may give you money. However, the financing should NEVER be the reason why you choose one over another.
You can spend money any time you choose to enhance the features of your EHR. Sometimes you have to spend money because of unexpected circumstances that you didn’t plan for.

The biggest difference between houses and EHRs? There is no residual value in an EHR. So take your time, be sure about what you want, talk to as many other people that use it as possible and read every single word of the purchase contract. Negotiate every item. Finally, once you commit, do everything within your power to make it make your life better.
With warmest regards, Rick Rutherford"

So true indeed.
Thanks for the words of wisdom, Rick.

The IU.

Time vs Money

There are only 2 variables that can be manipulated when determining compensation in a medical practice; time and money. There are many ways to divvy up either.

Some practices compensate all partners equally as long as the relative work performed by each doctor is equal. As long as the doctors work as hard clinically as each other and take the same number of nights on call, then the pay will be equal, though the details of this arrangement is certainly more complicated than that.

In an equal pay type of set-up, the easiest variable to manipulate is time. In a medical practice, time is spent in the following ways:

• Clinic hours
• Rounding/Hospital work
• On-call
• OR and procedure schedule
• Administrative

The hours spent performing these necessary functions must be allocated amongst the doctors. There all all kinds of ways the schedule can be configured for someones advantage, which by definition, is someone else's disadvantage. Time in a medical practice is spent as follows:

• Hospital rounds on Mondays vs Tuesdays vs Friday etc
• Monday morning office hours versus Thursday evening hours vs Friday afternoon hours
• Monday on call vs Tuesday on call vs Wednesday on call etc
• On call Christmas versus New Years versus Thanksgiving
• Having a first start case in the OR versus to follow cases
• Going to administrative meetings versus working in the clinic

All these things have value. Perhaps not the same value to each individual but value nonetheless. If more than one person comes to view Monday call is more labor intensive than Tuesday call--which it is statistically--or a 7:30AM start time as more desirable than a 1PM start time, grievances will arise. You can bet that conflicts will emerge over the schedule and the manipulation of time. In fact, the person who controls the schedule becomes the most important member of the team. . .often the most hated.

I want to say one more thing about time and money. As someone ages, money tends to become more abundant than time and this often influences a person's economic decision. For example, a person with lot's of money but little time will think nothing of purchasing the most expensive plain ticket if this gets them to their destination fastest. A college student on break, with all the time in the world but no money, will usually purchase based on price rather than time.

Conversely as time becomes more scarce, money becomes more important. If time cannot be manipulated in these cases, then people start to demand variations in compensation.

Then comes conflict.

Craziness or Opportunity

I needed medical records from a patient's recent hospital admission for continuity of care purposes. I recieved the records today but they were sent not by the hospital itself, which is 3 miles from my office, but from a 3rd party operation located in North Carolina, approximately 800 miles away.

IOD, Inc.

Crazy, right? Why can't the hospital just send me the records when I request them?

Well the answer is that due to the complexity of federal privacy laws, the hospital has decided to outsource the management of the release of health information. The hospital pays this company and the company assumes the liability associated with a violation of HIPAA. Other than slight inconvenience to me, patient privacy is assured, the law is followed to the letter, and some entreprenurial person makes money. Win, win, win.

What can this teach us? For one thing, you can view regulatory change as a pain in the rear or as an opportunity for improvement or even new business.

Since the business and regulatory world are always changing, I recommend that you embrace the change and and use to your advantage.

Fighting Murphy: what are your checks and balances?

People can slip through the cracks easily.

• Patients can walk out of the office with their encounter forms or charge slips.


• The office staff can forget to give them a follow-up appointment.


• Patients can call to cancel an appointment, intend to re-schedule, then forget to do so.


• Patients can no-show.


• Staff can forget to put the patient on the recall list.


• Staff can put the wrong patient on the recall list.
• The doctor can get forget to write the order for the test or the follow-up.
• The doctor can forget to click on the order or the request for follow-up.
• Handwriting can be illegible.
• The computer can crash.
• Murphy can and will show up.

In a doctor's office, this can be dangerous.

The only way to prevent Murphy from walking into your medical office is to have multiple and redundant checks and balances.

How do you do it?

Information Management: The True Essence of Medical Practice

Twenty five, 30 years ago, doctors could keep track of their patients on index cards. I know some of these retired docs. They tell me that in some instances a 30 year patient relationship could be held on a 4-6 index card, front and back.
Seems insane in these information rich times.
Medicine, the business of medicine, that is, has become if nothing else, information heavy.
Clinical data, billing data, legal & compliance data, laboratory data; it could fill a warehouse if stored in paper format.
What is the best way to handle this mountain of data?
Digitally.
Either purchase the system or develop it yourself, but get a system that can store and more importantly manage information digitally.
You’ll be much better off for it in the future.

(Reprinted from: iLabTQM.com/blog

Cost Containment: A Post Worth Revisiting

With declining reimbursements, the only way to to remain viable is through revenue generation coupled with cost containment. I'd like to talk a bit about costs, and some obvious--and not-so-obvious-ways to minimize them.
Fixed Costs: These are items like rent and insurance. While you probably have little negotiating power in this area, with regard to rent you can keep costs down the following ways:
Maximize productive use of space. I pay $26 per square foot, and use all of it productively. An EMR helps here, because I don't need to dedicate several hundred square feet to chart storage. Also, mobile units, such as portable sonogram machines, client computers, and portable lab equipment, also helps. And of course, I have VPN, because it essentially converts my house or Starbucks, or anywhere with an internet connection into an extension of the office.
Maximize revenue generation areas of the office. These areas include exam rooms, your office, and the lab. Back office functions, such as insurance claims submissions and billing work, can be virtual, via your VPN, yet remain "in-house" as opposed to being outsourced. With a well networked office, exam rooms can serve as exit offices while you go to the patient in the adjacent room.
On-demand Supply Ordering and Smart Storage: Closets = Square footage = $$. With some thought and planning, shelving, exam tables, cabinets, and closet space can be used for maximal storage at minimal square foot usage. In addition, I order supplies as needed, since my vendor, PSS Worldwide Medical, always delivers next day.
Variable costs: These include costs for items such as medical supplies, payroll, utilities, stamps, etc, and can be determined by examining the profit-loss statements prepared by the accountant. here are some ways to keep variable costs down.
On-demand supply ordering. DELL Computers uses this concept. I do as well, just make sure you don't run out of Foley drainage bags after you've already placed the Foley.
Part-time employees: Simple. They cost less than full time employees, plus no overtime.
On-demand staffing: I staff heaviest on the busiest days. Plus, since I am capable and willing to pick-up slack on days that we are inadvertently short staffed, this method works out well. Busy days or light days, open or closed, phones are always!!! staffed.
Amortization of utility payouts. Most utility companies will estimate a fixed monthly cost for you to pay based on a prior years consumption. I like it for cash-flow management.
Have your phones (VOIP), cellphones, & internet on fixed plans, so that costs do not soar with usage. Get the maximum minutes for cell phones, since the incremental costs of the plan are much less than overage payments. VOIP is cheap, plus never varies with usage. On the balance, I've been happy with it, yes, even for the "mission critical" functions.

Fax. Why snail mail when you can fax the referral letter. Not only is it faster, more efficient, and trackable, it is cheaper. I love my fax. Yeh, yeh, yeh, I know, HIPAA. But it can be done and still be in compliance
Direct costs: These are costs that are directly involved in patient care. Here's how to minimize these costs.
Everyone does everything. MA's do data entry, answer phones, clean rooms etc. The docs answer phones (if they are not seeing patients) when needed, clean rooms, order supplies, schedule patients, e-file labs. Again, an EMR and a VPN helps here as well.
Part time employees and on-demand staffing: see above.
Creative patient scheduling: Figure out which works best for you; clinic, open access, proportional, or wave scheduling, and then determine minimal staff requirements for your office hours.
Ergonomic room design. I have rigged my rooms so that I can do a many procedures without an assistant present. I learned these skills as a surgery resident in central line clinic. In fact, I can prep with my left hand, place the scope with my right hand, and simultameously do a UA with my toes (kidding!). If you have 2 hands, a brain, and a Mayo Stand, you can make it work as well, and in the mean time, you'll free up staff to answer phones and book new patients or enter claims.
Training and process management: Training employees well and developing efficient processes of doing business will allow you and your employees to work smarter and with less mistakes and to get the job done right the first time. This simply saves money. Also, keep your employees happy. Turnover is very expensive and disruptive.
Indirect costs: These costs cover non-patient care activities, such as back-office staff and billers. Here's how to minimize these costs.
See direct costs.
Remote working

EMR
Embrace technology
Multi-task
Training and process management

Consider outsourcing when appropriate.

PQRI in 10 Steps

I finally figured it out, PQRI that is.  After several courses and months of procrastination because of PQRIs seeming complexity, I got it and am going to give it to you. . .free.

No strings attached.

Here it is:

1. Pick your measures (you'll have to look them up or contact me)
2. Right them down on a piece of paper as a cheat sheet or see step 3
   
3. Enter them into your EMR templates as appropriate
   
4. Tell staff to mark all encounters on pure Medicare (only) patients with a big red mark
5. See patient as normal
6. Circle or click on PQRI code on your encounter slip or your EMR
7. Tell biller to insert those CPT codes on line 2 of the HICFA 1500 form
   
8. Submit claim
9. Let Medicare do the rest
10. Or. . . you can outsource the whole process to a third party, approved vendor.

That is it.  Once you put the processes into place, simple.  And I just gave you the process.

Gratis.

The IU.

A follow-up protocol for non-compliant patients and busy offices

Patients no show and are not compliant and their lack of compliance can be blamed on you.  Here are 5 steps you can take to prevent a patient from slipping through the cracks:

1. Impart onto patients the importance of follow-up then. . .
   
2. Give all patients a follow-up appointment or place them on a recall list, and if they fail to show up. . .
   
3. Run a no show list. . .but if your staff forgot to give them an appointment, you'll catch them by . . .
   
4. Running a diagnosis/procedure list periodically, and if all else fails, hopefully you'll get them with a. . .
   
5. Random Audit

Crazy, but very important.

Any other suggestions?

The IU

What is your donut?

I was talking to my father-in-law the other day about a client of his who is a baker. This baker used to make lots of fancy and expensive items, such as cakes and tortes, but now he makes mostly donuts. He did not always do this. He began to do it out of neccessity. Donuts, you see, are high profit margin products.

Dunkin Donuts only makes donuts and coffee and guarentee them to be fresh anytime. Dunkin Donuts can do this because donuts are so cheap to make and they have such a high profit margin, that the store can afford to throw away items that have gone stale.

Urology has high profit margin procedures. Vasectomies and cystoscopies are 2 examples. Larger, maga-groups have radiation therapy for prostate cancer, which for now has a high margin. Laboratory work is low margin. Major surgery in the hospital is low margin.

In your practice, what has a high margin?