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EMR Doctor’s Blog: Ways to Save Money in a Modern Electronic Medical Practice: Part One

Posted on December 20, 2010 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.

As we all know from our efforts to save money and run a more efficient business, there are great ideas out there that we just haven’t discovered yet. With this in mind, I thought it would be fun and possibly helpful to discuss some tips I learned over the first year in private practice that have really added efficiency and productivity to my office.  I’m going to roll these out one at a time to keep the blog post size in check.

Tip #1. Use an electronic fax service tied to a dedicated fax email (electronic fax) account.

This allows you to download and attach any incoming old medical records that are faxed over ahead of time for an upcoming patient’s visit.  Any new studies that come in, such as labs or radiology study reports, can be treated in the same way.   It takes a few keystrokes and clicks of the mouse to get these into the patient records, and this saves all that paper and ink that used to go into paper charts.  We use a service called Metrofax.com, but there are a wide variety of services on the e-market, with different plans, bells and whistles, depending on what you need as the end user.  The baseline cost for Metrofax, which includes 1000 pages, is between $13-$15 per month, depending on whether you decide to have a local number or a toll-free fax number.  After the first 1000 pages, the cost is 3 cents per page.  Since we use about 2000 pages per month, the cost is somewhere around $35-40 per month.  Much better than paying for a fax machine that can eventually break and has ongoing service, paper and ink costs.

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.

John’s Comment: You need to be careful about which electronic fax service you use. I haven’t done a thorough study of Metro Fax, but many of the fax services out there aren’t HIPAA compliant. This said, when done right, an electronic fax service is a great solution and saves a lot of time and money. See this review I did of sFax’s electronic fax service.

Do I Need to Fire My EHR?

Posted on December 13, 2010 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.

In the late spring of 2009, I got this crazy idea of opening up my own practice as a solo practitioner. I was sitting in my Friday morning clinic block at Hopkins, seeing somewhere between 8-10 patients a week, when I came into a room to see an interesting young woman with slightly buggy eyes. Turns out, she was a specialty physician working in private practice for her thirteenth year in a row and she later in the visit would tell me private practice was the best thing she ever did. I, on the other hand was in my first year of junior facultyship at an academic pressure cooker and still trying to come to a conclusion about being overworked and underpaid compared with my private practice colleagues. But I will save the rest of that conversation for another day. My doctor-patient turned out to be a pivotal figure in my life and soon I was carefully planning to open my very own practice in downtown Washington.

One of the things my practice manager and I wanted to do from the very beginning was to get away from paper charts and all the pitfalls I had previously experienced. From lost charts, to missing test results, to needing to constantly refile charts after visits, our motivation was pretty clear. In August of 2009, we started combing through blog after blog and website after website trying to find that perfect combination of price, form and function. We finally settled on a moderately-priced, middle of the road model and signed the contract on the dotted line. A server was bought. Thin-client dummy terminals were installed. And life was going to be organized and GOOD without paper charts!But the best laid plans of mice and men are, of course, not always so easily pulled off. For three months from November 2009 until the beginning of February 2010, we struggled with unfinished training sessions, broken software links, and a multitude of things just plain not working. These issues were followed by an outsourced team in India telling us that all problems would be solved to our complete satisfaction. We tried to be patient, listening to the software vendor’s excuses and promises. Day after day of frustration went by, and soon it was up to month after month. At the beginning of February 2010, we decided to fire the company and go with a different one. We initially demanded all of our money back for product misrepresentation. Fortunately, depending on how you look at it, we had only paid half of the complete bill earlier on, citing that payment would only be completed when we had a completely functioning product. This never happened. And so we finally settled for a partial refund minus $2000. Talk about insult to injury! But we needed to move on as quickly as possible, and we had patients to see and take care of, after all. Could we have won in court? In a nanosecond.

As far the company we fired, we agreed to sign a gag order in order to get any money back, and so they remain carefully hidden in the shadows. But if you can read the details above, it probably won’t be difficult to stay away from this one. In retrospect, nevertheless, we should not have let our EHR disaster get so far. As soon as promises were made and not kept more than once, we should have read the writing on the wall and gotten out. Lesson learned!

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.

EMR Doctor’s Blog: Popular Misconceptions of Using an EHR System From a Provider’s Point of View

Posted on December 6, 2010 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.

I thought it would be fun to discuss the “real world” of what it’s like to use an EHR system. Here are a few misconceptions that, if you believe all the advertising and other hype, you might have about the benefits of using an EHR system. Although the promise is definitely there in terms of what should be feasible ideally, the real world often determines otherwise.

Misconception 1. “I walk out of the office at 5 PM with all of my notes done for the day.  Awesome!”

Maybe once every month I can do this, on a slow day. The fact is that all of the documentation that needs to be completed prior to signing a note usually cannot be done for all visit notes by the end of the day. There are a variety of issues. Patients throw you curve balls on the way out the door. Patients have complex issues that you need more time to research prior to finalizing your plans. Patients forget information that they want to call you back about later, e.g. missing medication names and doses, doctor’s names that they want you to cc:, etc. On busier days, when patients come in late and you end up juggling appointments to avoid refusing to see anyone (this is private practice with real cash flow needs after all!), or when the phone just ends up ringing off the hook with one urgent issue after another, signing all your notes by 5 PM becomes impossible.

Misconception 2. “It’s a breeze to electronically send all my prescriptions. I don’t need a scrip pad anymore!  Woohoo!”

Mail order pharmacies destroyed this one with all their forms. Three-quarters of the patients in this category need me to fill out a paper form to fax in. The other 25% need paper scrips written out, typically five to ten at a time, so that they can mail them in themselves. Auto-renewal requests come in by fax every day, needing to be filled out and faxed back. My personal revenge comes in the form of being able to fill most of these out using my PDF editor software prior to faxing them back without touching a single microdot of ink to paper.

Misconception 3. “I don’t have to dictate anymore.  Yippee!”

For all new patient visits, I end up dictating at least the history of present illness (i.e. “HPI”, the first paragraph or two telling the patient’s story for those of you unfamiliar with this terminology). Although I can eliminate paying for this service by using a free iPhone app (Dragon Dictation), I still have to go through the process of speaking and then editing the notes. The alternatives would involve me sitting there wasting huge amounts of time typing details into a paragraph or two for each patient, or I would end up doing what I see some of my referring docs do, which is to type in VERY brief notes that eliminate a lot of important details just to get by and move on to the next patient. Some contrarians might suggest that everything can be done through templates, which is partially true to some extent, but everyone’s story is unique and different, especially when you are dealing with subspeciality areas such as disorders of the thyroid and adrenal glands.  The last time one of my patients had run-of-the-mill chest pain that could be reduced to a series of templated checkboxes to adequately describe their story was … well… never.

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009. Check out all of Dr. West’s EMR Doctor’s Blog posts.

EMR Doctor’s Blog: When does efficiency in documentation become misguided and counterproductive?

Posted on November 29, 2010 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.

We have all seen medical records from an emergency department (my apologies to the blissful ignorant out there — you don’t want to know if you don’t already). Much like sausage, they come out pretty much all ground up, full of information that at first glance can be difficult to figure out. If you find yourself asking questions such as, “Where is the part about why the patient came in and what the doctor thought about their case?” then you just might have one of these notes. They’re actually one of my favorite types of “old medical records” to sift through for the purposes of “reviewing and summarizing”. This is because when you’re dealing with gobbledygook, well, there’s not much to summarize. It’s easy to flip through forty or fifty pages in no time and say that you have honestly reviewed and summarized the old records, which are full of near meaninglessness that doesn’t impact my decisions in the patient’s care much, if at all.

The ER notes (and many primary doctor visit notes nowadays) result from having programmers who don’t appear to understand the appeal of a well-written note in facilitating basic communication. Computer programmers who get their hands on the list of required information that must be put into a note to pass by insurance standards don’t always design good products. Unfortunately, this really only highlights the insanity of criteria for medical documentation to gain the golden eggs of insurance company reimbursements for providing medical services. I’ll save those crazy criteria for some other day. Nonetheless, the tax man and the gobbledygook cometh. If only they had the guidance of a practicing physician in the design process!

Unfortunately, as the gold rush for economic stimulus dollars ramps up, poorly designed systems will most assuredly continue to be thrown onto the market. I recommend to anyone considering incorporating an EHR system into your practice that you actually consider and request to review a sample of the output format. If it looks like something that would embarrass you to show your former mentors from the residency or fellowship program in which you trained, then I would posit that this is probably not fit for medical documentation. If no one wants to read what you wrote, then is it really worth doing? And please don’t be fooled into thinking that spending more money is the key to getting a better product. Ask the EHR vendors to put their money where their mouth is.

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.