Small Practice

Small Practice

Google Algorithm to Favor Websites That Work on Mobile Devices

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Screen Shot 2015-03-22 at 10.28.41 AM
In a major update, the search giant has announced that on April 21, the algorithm will be updated to favor websites that are designed to work on both mobile and desktop devices, now often referred to as Responsive Website Designs.

Does your practice have a responsive website?

Google has had multiple mobile initiatives, including the GoMo campaign where the company provided free tools to help small businesses build websites that worked on mobile devices without the dreaded pinching, resizing, and squinting. That campaign had limited success because the technology didn’t quite work as elegantly as possible, but just last week Google took its most aggressive approach yet by declaring that they were going to start penalizing websites that did not have mobile capabilities.

Once referred to as mobile-friendly website design, geeks refer to it simply as responsive website design now. So how does one get a mobile-friendly, er, responsive website?

How to Safeguard your Career in Treacherous Healthcare Times

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Michel AccadDear medical student,

I am honored by the opportunity to offer some advice on how to safeguard your professional career in a treacherous healthcare system.

I will not elaborate on why I think the healthcare system is “treacherous.”  I will assume—and even hope—that you have at least some inkling that things are not so rosy in the world of medicine.

I am also not going to give any actual advice.  I’m a fan of Socrates, so I believe that it is more constructive to challenge you with pointed questions.  The real advice will come to you naturally as you proceed to answer these questions for yourself.  I will, however, direct you to some resources to aid you in your reflections.

I have grouped the questions into three categories of knowledge which I am sure are not covered or barely covered in your curriculum: economics, ethics, and philosophy of medicine.

I have found that reflecting on these questions has been essential to give me a sense of control over my career.  I hope that you, in turn, will find them intriguing and worth investigating.

One more thing before we proceed.  Don’t be overwhelmed by the depth of the questions posed and don’t attempt to answer them today, in a week, or in a year.  In many ways, these are questions for a lifetime of professional growth.  On the other hand, I believe that the mere task of entertaining these questions in your mind will be helpful to you.

So here we go:

Independent Practice Equals Higher Satisfaction

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Tom Guillani

Thinking of starting a new practice?  Is the lure of independence calling to you?  There are more reasons than every why independent practice is a great option. Being your own boss is not only easier than it once was, it can actually make you happier.

Independent physicians have many more options available to help them today than they used to. Affordable technology has revolutionized private practice from EHRs to easy-to-use practice management and billing software, adding flexibility to staffing and simplifying paperwork needs. And, the increased availability and ease of outsourcing has further reduced the burden of running your own practice. Physicians can now choose to outsource inbound calls, reminder calls, pre-authorizations, marketing, and of course, billing. In addition, independent providers can transition to new agile practice models such as concierge and hybrid that can offer higher incomes and smaller patient census and reduce some of the headaches associated with traditional practice structures.

Added to the fact that starting and running a private practice is now easier than ever, is the higher level of happiness experienced by independent physicians. In fact, a study done by Medscape in March 2014 reported that 74% of self-employed doctors are satisfied in their practice and that of the physicians who left employment in favor of independent practice, 70% felt happier in their new practice while only 9% were less happy being self-employed. Seventy-four percent of these self-employed doctors also said that their opportunity to practice quality medicine met or exceeded their expectations.

There are many factors contributing to these high satisfaction rates in independent physicians but one of the biggest is the control these doctors have over their practice, their schedule, their treatment of patients, and their destiny. A survey in Hospital Topics on the impact of practice arrangements on physician’s satisfaction backs this up, reporting that physicians who work for HMO’s have much less autonomy and decision-making power than self-employed physicians. And, the report by Health Affairs found that 85% of doctors in private practice felt free to control their schedules compared to only 39% of HMO physicians.

Self-employed doctors also avoided the pitfalls of employment cited by the Medscape study while the doctors working for hospitals and group practices listed administrative headaches, added rules, and a more limited income potential as reasons for dissatisfaction in their careers. It’s easy to see why the 2014 Great American Physician Survey conducted by Physician’s Practice found that over half of independent physicians would do things the same way all over again. This isn’t to say independent providers done have regulatory challenges or administrative responsibilities. However, they have more control over the day-to-day operations and administration, eliminating frustrating bureaucracy.

Better, more affordable, easier-to-use technology, simple outsourcing options, greater autonomy and control, and higher levels of satisfaction…all of these factors make private practice a more attractive option than ever. So, if you are considering starting a new medical practice, now is the time. Just remember, doing it right from the beginning will save you from unnecessary stress, making the process of opening your new practice a much more enjoyable experience.

By joining the ranks of independent physicians, you will be in control of both your practice and your life. You will be free to set your own schedule, manage patient care to your standards, work with a staff of your choosing, and have the final control over your income potential. All new practices will face challenges along the way but you will find a wealth of resources to make your life easier and guide you to success in your new venture.

Tom Giannulli, MD, MS, is the chief medical information officer at Kareo. He is a respected innovator in the medical technology arena with more than 15 years of experience in mobile technology and medical software development. Previously, Giannulli was the founder and chief executive officer of Caretools, which developed the first iPhone-based EHR.

Doctors Going the Distance (In Education)

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We need more doctors.

Between older care providers retiring, and the general population shift that is the aging of the Baby Boomers, we are running into a massive demographic of more, older patients, living longer and managing more chronic conditions. This puts incredible pressure not just on the remaining doctors and nurses to make up the gap, but strains the capacity of schools to recruit, train, and produce competent medical professionals.

So how can schools do more to reach students and empower them to enter the healthcare field?

The increasing popularity of online programs (particularly at the Masters level, among working professionals looking for a boost to their career advancement) has called forth a litany of studies and commentaries questioning everything from their technology to their academics,compared to traditional, on-campus programs. More productive would be questioning the structure and measuring the outcomes of degree programs in general, rather than judging the value of a new delivery mechanism against an alternative more rooted in tradition than science.

In terms of sheer practicality, though, a distance education—yes, even for doctors and surgeons—makes a certain amount of sense. One of the hottest topics in the medical community right now is Electronic Health Records (EHRs) and the ongoing struggle to fully implement and realize the utility of such technology.

Patient-Centered Service

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flying cadeuciiAmerican healthcare has a customer service problem.  No, customer service in the US is terrible when it comes to healthcare.  No, the customer service in the US healthcare system is horrendous.  No, healthcare has the worst customer service of any industry in the US.

There.  That seems about right.

What makes me utter such a bold statement?  Experience.  I regularly hear the following from people when they come to my practice:

  • “You are the first doctor who has listened to me.”
  • “This office makes me feel comfortable.”
  • “I didn’t have to wait!”
  • “Where’s all the paperwork?”
  • “Your office staff is so helpful. They really care about my needs.”
  • “This is the first time I’ve been happy to come to the doctor.”
  • “It’s amazing to have a doctor who cares about how much things cost.”
  • “You explain things to me.”
  • “You actually return my calls.”

Calcium Scan and Subtractive Medicine

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Being a radiologist, I rarely speak to patients, but I was asked to counsel Mrs. Patel (not her real name, so calm down HIPAA totalitarians), who was worried about the risks of radiation from cardiac calcium CT scan. Because of her risk factors for atherosclerosis, her cardiologist wanted her to take statins for primary prevention, but she was reluctant to start statins. They eventually reached a truce. If she had even a speck of calcium in her coronary arteries she would take statins. If her calcium score was zero she wouldn’t. This type of shared decision making is the most frequent reason why cardiologists order calcium scans at my institution.

The Case for Case-Based Reasoning

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flying cadeuciiCase-based reasoning has been formalized for purposes of computer reasoning as a four-step process[1]:

  • Retrieve: Given a target problem, retrieve cases from memory that are relevant to solving it. A case consists of a problem, its solution, and, typically, annotations about how the solution was derived.
  • Reuse: Map the solution from the previous case to the target problem. This may involve adapting the solution as needed to fit the new situation.
  • Revise: Having mapped the previous solution to the target situation, test the new solution in the real world (or a simulation) and, if necessary, revise.
  • Retain: After the solution has been successfully adapted to the target problem, store the resulting experience as a new case in memory.

The complexities associated with programming and implementation of a knowledge management system based on case histories is both non-obvious and difficult, but ironically this is the actual process that an expert physician uses in his day to day clinical work.

A Doctor is a Doctor is a Doctor, Right?

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flying cadeuciiI am a foreign born, foreign trained doctor, serving many patients from an ethnic minority, whose native language I never mastered.

So, perhaps I am in a position to reflect a little on the modern notion that healthcare is a standardized service, which can be equally well provided by anyone, from anywhere, with any kind of medical degree and postgraduate training.

1) Doctors are People

No matter what outsiders may want to think, medicine is a pretty personal business and the personalities of patients and doctors matter, possibly more in the long term relationships of Primary Care than in orthopedics or brain surgery. Before physicians came to be viewed as interchangeable provider-employees of large corporations, small groups of like-minded physicians used to form medical groups with shared values and treatment styles. The physicians personified the spirit of their voluntary associations. Some group practices I dealt with in those days were busy, informal and low-tech, while others exuded personal restraint, procedural precision and technical sophistication. Patients gravitated toward practices and doctors they resonated with.

Will Independent Physicians Go Extinct?

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Richard Gunderman goodLife is tough for physicians in solo and small group practice.  The federally mandated introduction this fall of ICD-10 requires physicians and their staffs to learn a new system of coding diseases.  “Meaningful Use,” another federal program, requires physicians to install and use electronic health records systems, which are complex and expensive.  And PQRS, the Physician Quality Reporting System, is beginning to penalize physicians for failing to report individual data for up to 110 quality measures, such as patient immunizations, each of which takes time to collect and record.

Of course, such requirements are not being imposed solely on solo and small-group physicians.  In many ways, they affect all physicians alike.  Yet the burdens of complying are disproportionately high for small groups, which cannot spread out the costs of purchasing equipment, hiring employees and consultants, and training personnel over so large a number of colleagues.  Hospitals and large medical groups can afford to hire full-time specialists to meet these challenges, but such approaches are not economically feasible for a group that consists of only a few physicians.

Such challenges are not just raining down –  they are pouring down on the heads of physicians.  Some physicians fear they smell a conspiracy to drive solo and small-group practitioners out of business.  And the problem is not just the money.  It’s also the time.  Many physicians already work long hours and simply cannot afford to shop for such systems, negotiate contracts, and enter data.  We personally know physicians who report spending two hours each evening completing records that they did not have time to attend to while they were seeing patients.

Death By Documentation

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In my work with hundreds of over stressed and burned out physicians, one thing is constant. Documentation is always one of their biggest sources of stress.

In fact, if you ask the average working doctor to make a list of their top five stresses, documentation chores will take up three of the five slots.

1. EMR – especially if you use multiple EMR software programs that don’t talk to each other

2. Dealing with lab reports and refill requests

3. Returning patient and consultant calls and documenting them adequately and all the other places information streams have to be forced together by the sweat of your brow.

The average doc is walking the cliff edge of overload on a significant number of office days in any given month. Now comes ICD-10 and my biggest fear is the extra work of the new coding system will push many physicians over the edge into burnout.

How much more time will ICD-10 take?