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Tag: practice management

Rob’s New Economics of Practice Management

It has always been my assumption that my new practice will be as “digital” as possible. No, I am not going into urology, I am talking about computers. [Waiting for the chuckles to subside]

For at least ten years, I’ve used a digital EKG and spirometer that integrated with our medical record system, taking the data and storing it as meaningful numbers, not just pictures of squiggly lines (which is how EKG’s and spirometry reports appear to most folks). Since this has been obvious from the early EMR days, the interfaces between medical devices and EMR systems has been a given. I never considered any other way of doing these studies, and never considered using them without a robust interface.

Imagine my surprise when I was informed that my EMR manufacturer would charge me $750 to allow it’s system to interface with a device from their list of “approved devices.” Now, they do “discount” the second interface to $500, and then take a measly $250 for each additional device I want to integrate, so I guess I shouldn’t complain. Yet I couldn’t walk away from this news without feeling like I had been gouged.

Gouging is the practice of charging extra for someone for something they have no choice but to get. I need a lab interface, and the EMR vendor (not just mine, all of the major EMR vendors do it) charges an interface fee to the lab company, despite the fact that the interface has been done thousands of times and undoubtedly has a very well-worn implementation path. This one doesn’t hurt me personally, as it is the lab company (that faceless corporate entity) that must dole out the cash to a third-party to do business with me.

Doing construction in my office, I constantly worry about being gouged. When the original estimate of the cost of construction is again superseded because of an unforeseen problem with the ductwork, I am at the mercy of the builder. Fortunately, I think I found a construction company with integrity. Perhaps I am too ignorant to know I am being overcharged, but I would rather assume better of my builders (who I’ve grown to like).

Yet thinking about gouging ultimately brings me back to the whole purpose of what I am doing with my new practice, and what drove me away from the health care system everyone is so fond of. If there is anywhere in life where people get gouged or are in constant fear of gouging, it is in health care. Continue reading…

Progress


Finally.

I can finally see progress in what I am doing.  Above is a photo of the front page of my new practice website (visit http://doctorlamberts.org).

There still is a little “Lorem ipsum” here and there – like having labels you missed on a shirt you are wearing – but I am very happy with the look.  The pictures of the sepia photos with the iPad making it color were the genius of my web developer (with some suggestions from me), giving a perfect image of the use of technology to accomplish “old-fashioned care made new.”

I’ve spent good portion of the past few days writing the content (replacing most of the “Lorem ipsum”).  Of what I’ve written, the strongest was in the section “Why It’s Different,” where I compare life in a traditional practice to what I intend to do.  Here are a few examples:

“I Need an Appointment”

Traditional Practice

· Call the office, hear a message about calling 911, get placed on hold or leave voice message (after navigating automated attendant).
· Get called back to find out the reason for your appointment.
· Appointment is made around what is open for the doctor.
· Take time away from your schedule to meet doctor’s schedule.

Our Practice:

· Log on to portal and directly make your own appointment to fit your schedule.
Or
· Call the office and tell a human being that you need an appointment.

Continue reading…

Questions and Answers

Things have been crazy.  It’s much, much more difficult to build a new practice than I expected.  I opened up sign-up for my patients, getting less of a response than expected.  This, along with some questions from prospective patients has made it clear that there is still confusion on the part of potential patients.  So here is a Q and A I sent as a newsletter (and will use when marketing the practice).

About My New Practice

Q. Why did I do this?

A.  I get to be a doctor again (perhaps for the first time).  I got tired of giving patients care that wasn’t as good as it could be.  I got tired of working for a system that pays more for bad care than for good.  I got tired of forcing patients to come in for care I could’ve given over the phone.  I got tired of giving time that should be for my patients to following arduous regulations.  I got tired of medical records not meant for actual patient care, but instead for compliance with ridiculous government rules.  Making this change gives me the one thing our system doesn’t want to pay for: time devoted for the good of my patients.

Q. How can I afford to do this?

A. I have greatly decreased my overhead by not accepting insurance and keeping my charges simple.  My goal is to have 1000 patients paying the monthly fee, which will limit the number of staff I need to hire.

Q. When will it open?

A.  My office will open in January, 2013, but the exact date is still not set.  I had initially hoped to be already seeing patients, but things always are harder than they seem.

Q.  What makes this better for patients?

A.  The main advantage is that I am finally able to give them the care they deserve: care that is not hurried, not distracted by the ridiculous complexity of the health care system, and not driven by the need to see people in person to give care.  This means:

  1. I don’t ever have to “force” people to come to the office to answer questions.  This means that I will let people stay at home (or work) for most of the care for which I would have required an office visit in the past.
  2. I will be able to give time people deserve to really handle their problems
  3. I won’t have to stay busy to pay the bills, so I can take care of problems when they happen (or when they are still small), rather than having to make people wait to get answers
  4. Patients won’t get the run-around.  They will get answers.
  5. I won’t wait for patients to contact me to give them care.  I will regularly review their records to make sure care is up to date.
  6. I will help my patients get good care from the rest of the system.  Avoiding hospitalizations, emergency room visits, unnecessary tests, and unnecessary drugs takes time; I will have the time to do this for my patients.  This should more than make up for my monthly fee.

Continue reading…

Scaling is Hard. Case Study: athenahealth

There are many companies that are competing to be the “operating system” for small businesses. The theory is that with the advent of the cloud in the digital age, small businesses can leverage a suite of services from a technology vendor to manage all aspects of their work – from payments to record-keeping to marketing to customer communications.  Among those competing for this vision are PayPal/eBay, Square and Groupon, with each struggling to pull together pieces of the equation and, importantly, reach the small business in a cost-efficient manner at scale.

One company in Watertown, Massachusetts has been executing on this vision for over a decade with a winning approach for one vertical slice of the small business market:  physicians.  Although this is not typically how athenahealth is described, it is one way to describe what they are doing that mainstream members of the technology community might understand.  I have found it pretty amazing that so few people in the tech community know their story or understand the scale and scope of what they have achieved.  That is why I’ve chosen athenahealth for the third in my series on scaling (following Akamai and TripAdvisor).

Founding Story:  A Pivot

Athenahealth version 1.0 was a complete failure.  The company was originally founded in 1997 by Jonathan Bush (1st cousin of George W.) and Todd Park, a pair of Booz Allen consultants, as a physician practice management company for obstetrics.

Continue reading…

Med School: It’s Not What You Think It Is


I am so tired of seeing statements like these:

– Nutrition is not taught in medical school.
– Pain management is not taught in medical school.
– Practice management is not taught in medical school.

All three of those statements, and the vast majority of others bemoaning the shortcomings of medical education just because “XYZ isn’t taught in medical school” are right, but oh so wrong.

“Nutrition” is not taught in medical school. What we learn is biochemistry, metabolism, gastrointestinal and endocrine anatomy and physiology. We may not learn “nutrition” per se, but we learn what we need to know to understand nutrition in a more fundamental and comprehensive way than can be gleaned from any course in “nutrition”. This also means we understand nutrition differently — and more completely — than anyone without that same level of medical education can, however much they’ve read about nutrition.

“Pain management” is not taught in medical school. What we learn is neuroanatomy, pharmacology, behavioral psychology, and neurophysiology, so that we have the basic knowledge to understand pain management. Narcotics dosing, epidural steroid injection techniques, rehab protocols and so on are learned in residency. I agree that pain is often not well managed, but not because “it’s not taught in medical school.”Continue reading…

The Stunning Shift Toward Employed Physicians

By DAVID E. WILLIAMS

I’m amazed at just how quickly physician employment has swung from small independent practices to hospital-based employment. I’ve heard about it anecdotally from medical societies and malpractice carriers who are seeing their constituents shift, and have certainly observed the shift from individual physicians, but I’m still surprised how fast it’s occurring. A new report from recruiter Merritt Hawkins tells the clearest story I’ve seen:

  • In the last 12 months, 56% of physician search assignments have been for hospital jobs, whereas 5 years ago it was just 23%
  • Just 2% of assignments were for independent, solo practice docs compared with 17% 5 years ago

Doctors are becoming more like regular wage earners, albeit high paid ones. There are some strong drivers of this trend including the need to support health information technology, comply with regulations and deal with health plans. There’s also a desire on the part of a younger, increasingly female physician workforce to have a better balance between work and home life. If anything the forces pulling physicians into hospital employment will strengthen in the near term with the arrival of Accountable Care Organizations and other forms of deep integration.

Yet when a pendulum swings it tends to swing too far. Especially considering how quickly things have moved, I do expect that there will be some backlash to the rush into employment. It’s really not all that much fun having a boss, especially when that boss is a big, bureaucratic hospital with other things on its priority list besides MD satisfaction and career development. Patients may not like it so much either. I know I’d rather see a physician who’s not too tightly tied to a hospital.

So what will the reversal look like? I don’t think it’s going to be doctors rushing to put up their own shingles or buy practices of retiring docs like in the old days. Instead I expect to see a new breed of physician employers who recognize what’s needed to make docs happy, treat patients well, manage compliance, and still make money. One example is so-called direct primary care practices such as Qliance. Time will tell what other forms develop.

EHRs in Surgical Practices

I was recently asked to offer advice about implementing EHRs in surgical practices.   Here are the lessons learned from our Massachusetts EHR rollout experts.

1) . Surgical practices are challenging in general because they frequently use dictation and the most obvious benefits of EHRs do not apply to them.  They do not have substantial amounts of structured data to enter and they do not have a high fraction of recurring patients so a large fraction of records are “new” records. The highest benefit areas for them require interoperability, which takes time to accomplish. A significant fraction of the information they need for documentation comes from hospital operative notes, referrals/consults are the biggest element of workflow, and they rely on electronic lab and imaging test results.

2) . The most successful workflow change approach requires shifting more responsibility to mid-levels so that basic structured data entry (like vitals, history, etc) and billing related entry do not fall on surgeons who can be resistant to doing that type of documentation.  Unfortunately shifting practice roles/responsibilities is not easy.

3) . Working with the practice to build structured procedure templates in advance of go-live and setting up voice-recognition to allow surgeons to continue to dictate are key workflow/adoption steps.

4). Some EHRs such as eClinicalWorks have templates for Operative Notes as well as SOAP notes, which are key to EHR adoption.

5). Interoperability should be implemented as quickly as possible:  diagnostic results delivery (especially imaging results) and hospital document push (operative notes, discharge summaries) should be  integrated into workflow during implementation.

Continue reading…

Losing Patients With Insurers

We are losing patients.  Certain insurance companies are trying to “play hardball” with doctors, unwilling to negotiate with us over their outlandishly low rates.  We have lost patience.

So the signs went up in the exam rooms today:

As of the start of the year, we will only accept X, Y, and Z Medicare advantage plans, and we are presently negotiating with A and B insurance companies.  Please consider this when enrolling in plans.

It is highly likely we will drop one of the insurance plans altogether, and we are one of the last practices in our town to accept them.

Patients are distraught.  Some of them who have seen us for years are now going to have to go elsewhere, while others that just joined our practice because their previous doctors dropped out of the plan will once again have to find a new doctor.  Patients aren’t mad about this, just sad.  The conversations go like this:

“So you are dropping X insurance?”

“We will if they don’t change.  They are paying us significantly less than other plans.”

“That’s crazy.  We just left a doctor because of the same thing.  Now we have to move on.”

“Yeah, I am very sorry about that.  I just want to see patients; I don’t want to do this kind of thing.”

“Well, I don’t blame you.  They pay $1000 for an ER visit for an ear infection, and they won’t pay you what you charge?”

Continue reading…

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