Progress Note: So, It Turns Out Starting a Business Is Really, Really Hard…

I am not sure if my lack of blogging is a good sign or a bad one. It’s been a week and a half since I started my new practice and I finally am getting this chance to come up for air. It’s been an über hectic and very draining time, but I am happy to report that the end of the week was significantly better than the beginning.

Here are some things I am learning.

1. Starting a business is really, really hard

I did my best to make my business as simple as possible, mainly because I understand my own deficiencies when it comes to business-related activities. Of course, being in a leadership role of a practice for the past 16 years helps me understand incredibly confusing concepts like accounts receivable, budgets, paying bills, and avoiding going to jail for spending all the collections on lottery tickets and reporting it as “research.” I purposefully designed the business to require as little accounting as possible, and in general I think I accomplished that. People come in to see me, pay me by swiping their card on the nifty card-reader on my iPhone, and I email them the receipt. That’s not the hard part (aside from people touching the “skip signature” button with their hand while they are signing).

The hardest part of starting a business for me is knowing what overhead items are necessary and what are not. Building the office took a month longer than I expected and cost twice as much. Yet I signed “yes” to all of the things that added cost. Some of them were necessary, like doing the things needed to comply with ADA, compliance with electrical code, and having furniture. But where to draw the line? I want the office to send a message of “professional, yet welcoming,” which means it can’t look cheap but doesn’t look posh either. I want the office to be consistent with my logo, a door opening that says “come on in,” and “welcome.” But everything adds cost, and mounting cost is tough when delay in opening means I am earning nothing.

Everyone is willing to give advice, but most of the advice given has little foundation in my reality. People say “it will all work out,” or “you’ll do great,” reassuring me that I don’t have to fret about things. It’s as if I can sit back and relax while things “work out.” The reality is that the reason they will work out is that I will spend most of my waking hours (and some while I’m not awake) working, worrying, thinking about details, and trying to plan for a very uncertain future.

2. EMR’s have gone over to the dark side

I wrote about it in an earlier post, about how hard I had to work to figure out my EMR system. Well, I never really figured that EMR out, so am in the midst of deciding where to go next. The problem I see is that instead of transforming health care by simplifying the process (what I imagined in the early EMR years), electronic records have been transformed by the system to add a complexity that was not possible without computers. ”The system” thrives on complexity and documentation of that said complexity in complex ways. It is job security to EMR vendors, hospital administrators, insurance and HHS employees, and the armies of medical billing staff over our great land. Computers can turn difficult tasks into easy ones, but EMR has taken easy tasks and made them incredibly complex.

This has been much clearer now that I don’t care about documentation for the sake of payment, and am not trying for “meaningful use.” I just want to document so I can give good care, using the EMR in a meaningful, useful way. Yet, to enable a seasoned veteran of EMR (16+ years of use) to simply document a visit required hours of training. After they bragging of the way I could send lab results to patient portal (complying with meaningful use) more than one vendor explained apologetically that they were unable to print a letter with those same results. Adding problems and medications is another simple task made complex, not to mention finding them on the list after they’ve been entered.

3. Walk, then run

I had a crisis last weekend. I was so frustrated that I wasn’t giving people the care I imagined. It seemed all the work over the four months prior to opening the practice amounted to a bunch of wadded up balls of paper around the trash can. I tried a lot of things that didn’t pan out. I learned a lot about what doesn’t work. While there is value in knowing what works (a lot of value, actually), it doesn’t help deliver the goods when it comes to actual patients. And the plans I made showed their flaws once they were put to the test, giving me the task of re-solving problems I thought already had a solution.

Upon further reflection (and common sense from a person willing to listen to my anxiety) I realized the source of my frustration: me. I wanted to have the practice working perfectly from day 1, something that my patients never expected. It turns out that it’s not the business with the best plan that succeeds, it’s the business that responds best when their plans are flawed. There was no way to predict everything that would happen when I saw actual patients, and so we’ve spent the first week and a half finding ways to make our practice fit reality, not trying to force reality to fit our plans.

So, what will this week bring? I think things are starting to fall in place and we are getting a system set in many areas. But I also think that I don’t know what’s coming. Some things that worked for the first 2 weeks will show their flaws and perhaps better solutions will appear.

The head count: 35 families, and 73 patients signed up so far. The total signed up or on the wait list is up to 250, and there are big prospects on the horizon. We are slowing down a bit this week, focusing on building the systems that will let us manage a bigger patient population. That’s what it comes down to: I left my practice because I felt like I was too busy to give good care. Now I need to resist the temptation to grow the business too fast. I want to make it worth the wait.

I explain to people when they ask about paying $30-$60 extra per month that if all they were getting was me as I was in the old practice, they’d be wasting their money. I intend to give them far more than that.

One of the high points of the week was seeing a person in their 30′s who has very high blood pressure, but was too busy with school and a job to get it taken care of. The hassle of calling a doctor, waiting in the office for hours, and getting very little time for the money paid kept them away from care they needed. I told about the $40 monthly charge and was greeted with a grin. The smile widened when I mentioned that the basic chemistry profile I was ordering would be an additional $4.50. I’ll do a follow-up this week, with an EKG, but there will be no charge for that and nobody’s had to use my waiting room yet. Perfect. It’s what this is all about.

Stay tuned…

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind)where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

17 replies »

  1. True. Being an entrepreneur is full of unpredictability as you get more experience things become easier. You have to make mistakes to learn like in anything else.

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  3. Hey Rob, thanks for the update on your progress. Starting a business sure can be hard.. Especially in such a regulated industry. I agree that many of the latest EMR systems are severely lacking in quality and ease of use. If you’re not trying to qualify for Meaningful, use you may want to consider a HIPAA-compliant document management system to store your EMR’s. For example, here’s a cloud solution based on a monthly subscription plan (you pay by storage amount so your storage bill grows with your business). Hope this helps and best of luck! http://www.dynafile.com

  4. Rob –

    Your story highlights the need to have financial reserves to cover cost overruns of building out your office space within reason and/or a longer than expected startup period for your practice.

    It seems to me that a practice like yours which allows you to spend more time with patients would be most valuable to those with one of the big six chronic conditions – CHF, CAD, COPD, diabetes, asthma and depression. I’m wondering what percentage of your ultimate patient panel is likely to have one of these conditions and can you give them better care for a flat fee than they could get elsewhere, still make a decent living and save money for the overall healthcare system by reducing referrals to specialists?

  5. “computers make the organization and transmission of data easier”

    But that is far from the sum of what being a good doctor is about. Analysis, synthesis, creative thinking, are all required; what many of us are objecting to is that EMRs are being used quite aggressively to turn us into nothing but data collectors, and that is a terrible loss for our patients.

    As someone who wrote his first computer program in 1966 at age 11, I do say that paper charts are better than the current perversions of EMRs that are being used.

  6. Amen to that! I am tired of the excuses.
    I sit here typing on the computer I built from scratch (with crossfired GPUs, Overclocked and unlocked CPU, and eyefinity display) while my son sits next to me on the computer he built, having learned that skill from me. I can fix any PC. My first PC displayed on a TV and saved code on a tape recorder and had 16kb of RAM. My first Harddrive weighed 10 lbs and was a massive 10 Mb. I have installed DOS and every version of Windows through 8 as well as LINUX. I installed and maintained Windows NT 4.0 and the network when I was using SOAPware. We have two PCs, two laptops, two tablets, smart phones, wireless routers, etc all maintained by me.
    But the point isn’t “wow, look at what I can do.” It is to point out the stupiidity of those who try to invalidate my opinion when I dare to criticize their precious EHRs.

  7. OK, Mike. I stand corrected. My reaction was tainted by your place in the line of commenters. A luddite is, in my view, a person who truly believes paper charts were superior simply because they are not computerized. I am now passionate in my criticism of EMR because of their huge potential for good that was unrealized because they were recruited to do the bidding of administrators, not clinicians. EMR’s are more about measuring doctors than giving good care, and that is an incredible waste.

  8. If your reply was to me then you misread my post. But calling someone who prefers paper a luddite? There are very valid reasons for keeping your notes on paper – that won’t prevent you from utilizing all the other wonderful technological devices. You can even fax paper to a computer to be incorporated into an EHR. That in fact, is about the only way that makes the “transmission of data easier” seeing as EHRs cannot after all these years ‘talk’ to each other in any meaningful way (ironic, given the goals of “meaningful use”)
    The point was that the only answer you get when you ask for a fully competent EHR is “at least its better than paper.” Yes it is better than paper, but not better enough.

    Dr. Mike, past user of Practice Partner, SOAPware, NextGen, Meditech, and current user of Practice Fusion. Yea, I know, a luddite.

  9. To those who REALLY believe paper charts were good things: why not find an accountant who uses paper instead of spreadsheets? Better yet, find a bank that doesn’t use computers but has filing cabinets full of your financial records? No, find one that uses no calculators, but does all the math by hand…or uses an abacus! Yeah, that would be real great, wouldn’t it?

    As the person who wrote this, a person who has gone from evangelist to critic of EMR, I do NOT think paper is better. That is utterly ridiculous. Why are you even commenting using these computing devices? Why not write a letter to the editor of your newspaper? Because computers make the organization and transmission of data easier. That’s how I am communicating with you right now. I am not critical of the idea of EMR; I am critical of the incredible lost opportunity for EMR to improve quality of care far beyond where it is today. I do think computers improved things (I can find results far easier and communicate with patients more efficiently). The problem is that they were co-opted into devices to produce copious over documentation. The payment system is what drove computers to this (and what has caused many lousy things about health care). Computers allow things to be done more efficiently, but unfortunately they don’t discriminate, allowing stupidity to be done far faster and in greater volumes. I will still use computers; I will just use them far better than I could in an EMR. Being freed from the payment system has given me the opportunity to use computers for actual care, not just documentation.

    PLEASE, don’t confuse what I am saying with luddite nonsense about the “wonderful era of paper charts.”

  10. If you find your EHR hard to use, well you know it must be your fault because EHRs are better than paper.
    If you find safety issues in your EHR, well you know at least its better than paper.
    If you find yourself less efficient because of your EHR, well at least you know its better than paper.
    If you find the specialist’s 5 pages of EHR generated paper sent by fax to be senseless fluff added by the EHR to increase coding complexity, well at least you know…er….wait.

    I wonder what excuse they are going to use when the new docs come round that have never seen a paper chart and they start complaining about the stupidities in their EHR. “Well at least its better than paper.” “Paper? what’s that?” LOL to you EHR apologists.

  11. “The problem I see is that instead of transforming health care by simplifying the process (what I imagined in the early EMR years), electronic records have been transformed by the system to add a complexity that was not possible without computers. ”

    There is always good old pen and paper. Did you see the February 7 Grey’s Anatomy Show, towards the end? Brilliant. Maybe someone could post it. My computer is too old for such modern processes.

    Health care has been transformed to grids and check boxes and silos.

  12. I am thrilled to hear that marketing is not a problem and that there is plenty of pent up demand. This usually spells success for any entrepreneur and lots of forgiveness for false starts and business process mistakes.

    I am also hopeful that all the disheartened primary care docs out there who are selling, sold, or considering selling to hospitals, take notice of this opportunity, and the same goes for new graduates choosing to become shift workers because they see no other alternative.

    May be not today, maybe not tomorrow but soon, and for the foreseeable future, this is how primary care will be defined…. 🙂

  13. That’s why I said it was the hardest part FOR ME. Marketing is not a big deal for this business (so far) as I’ve tried to avoid marketing to get overwhelmed with business. I have also had 2 businesses come to me (unsolicited) wanting me to be their company doctor. This would double the total number of patients, and it shows to me the pent up demand from businesses for a better solution to health care cost.

    Overall I think this has been a real good start to the business.

  14. “The hardest part of starting a business for me is knowing what overhead items are necessary and what are not.”

    Wrong! Hardest part is the marketing to bring in business to pay the bills. The rest is just housekeeping totally within your control.

    Since I understand you were able to bring a lot of your existing patients with you I think the marketing was already taken care of.

  15. Yep, being an entrepreneur is hard work. Ambiguity is something that as a physician you should be experienced with. Keep your focus on your goal…changing how YOU care for your patients. It will be your guiding star.

    What got me through the tough time of my business is remembering the sun comes up in the morning and my dog still loves me. Have patience and faith.