The Ideal Medical Practice Model: Improving Efficiency, Quality and the Doctor-Patient Relationship by L. Gordon Moore, , and John H. Wasson,
Monday, August 31, 2009
More information on micro or ideal medical practices
Many names, the same idea: low overhead and high-quality care. NDs have always done it, MDs are looking to reclaim it. Here are two more articles about Doctor's retaking their business and their ability to truly care for their patients.
The Ideal Medical Practice Model: Improving Efficiency, Quality and the Doctor-Patient Relationship by L. Gordon Moore, , and John H. Wasson,
The Ideal Medical Practice Model: Improving Efficiency, Quality and the Doctor-Patient Relationship by L. Gordon Moore, , and John H. Wasson,
Tuesday, August 25, 2009
7 Strategies for Creating a More Efficient Practice, brought to you by Dr. Lynn Ho
Though this is written by an MD, it is applicable to any provider billing insurance and working on a small-office budget. Enjoy!
7 Strategies for Creating a More Efficient Practice
http://www.aafp.org/fpm/20070900/27seve.html
Simple, low-cost technologies and strategic outsourcing have helped this solo physician practice efficiently, even without any staff.
I opened a solo family medicine practice in Rhode Island in October of 2004. It's an ultra-solo, no-staff ideal medical practice, also known as a micro practice. Low overhead allows me to see fewer patients per day and spend more time with them, but it also requires that I optimize efficiency in order to accomplish all of the administrative tasks on my own.
Before opening my solo practice, I worked as a salaried family doctor for more than 13 years in an environment where I was completely sheltered from the practice management aspect of medicine. Although I wondered whether I would be able to manage the challenges of running my own practice, I was inspired to make the leap after reading about Dr. Gordon Moore's ideal micro practice in Family Practice Management1,2 and watching a colleague of mine set up a similar practice that has prospered.
The start-up process was relatively easy: I applied for insurance provider numbers, rented some office space, incorporated myself, bought used office equipment from a retiring physician, created a practice Web site (http://nkfp.familydoctors.net) via Medfusion (http://www.medfusion.net) and placed an advertisement in the local newspaper.
Believing that technology is a key to efficient practice management, I also decided to purchase an electronic health record (EHR) system (Amazing Charts; http://www.amazingcharts.com) and billing software (EZClaim; http://www.ezclaim.com) that interfaced with my EHR. (Total cost for hardware and software at the time of purchase was less than $4,000.) To supplement my income while I developed my practice, I found a part-time job for 12 hours a week at a college health service. Then, in October 2004, I opened the door to my office with a few patients (fewer than 10) who followed me from my previous practice.
Hook, line and sinker, I had swallowed the ideal medical practice bait. I was and remain convinced that ideal medical practices can deliver what patients want and need through the medium of a sustainable and enjoyable practice setting for physicians. However, at the 18-month mark of my new practice, I noticed that although my practice engaged me and provided a level of professional satisfaction that my previous employment had not, I was spending way too much time on my work. I was routinely bringing home billing and notes that had not been finished and phone messages that had not been attended to. Burnout was imminent.
It was clear I needed to fix a number of key workflow processes to achieve greater efficiency in my practice.
Seven interventions
From June to December of 2006, I tested and implemented a number of solutions to hone my office efficiency. Through this process, I discovered one of the most delightful aspects of a micro practice: its responsiveness to change. When I decide to change something, it simply gets done. No one needs to be convinced or trained. The results are immediate and dramatic.
I've listed below the changes that were the most helpful in my workflow redesign:
1. Offer online appointment booking. I use http://www.appointmentquest.com for $14.75 per month. Now, when patients want to make an appointment, they simply go to my Web site and follow the prompts. I am gradually training my patients to use the system as I see them, or while they are on the phone with me. After I go through the steps with them once, they realize it is easy, efficient and convenient, and they take over. It saves them and me lots of phone time.
2. Delegate history-taking to patients. In September 2006, I started using Instant Medical History (http://www.medicalhistory.com), which allows patients to enter their own history into their chart. I use both a Web-based version that patients can complete from home and an office-based version that patients can complete in the waiting room. To implement this, I had to rearrange my office and set up a desktop computer for patient use, but it was worth the effort. More than 80 percent of my patients participate. The system has many benefits. It produces a more complete note than I would have, which allows me to bill at a higher level than I might otherwise be able to; saves me time; helps patients think about the reason(s) for their visit before they see me; keeps churning out histories of the same quality even at the end of the day when I am fatigued; has made obsolete all the paper rating scales I used to use to evaluate patients' pain, depression, etc.; and helps me finish the note in the exam room. Plus, at $50 a month, it's much cheaper than a nurse or medical assistant. (For more information on this topic, see "Improving Care With an Automated Patient History," FPM, July/August 2007.)
3. Use free tools to measure how you're doing. How's Your Health? (http://www.howsyourhealth.org) is a free online tool that collects patient-entered data regarding their health status and their perceptions of the care they have received, and it provides a summary to the patient and to the doctor. I can even export the data electronically into DocSite (http://www.docsite.com), a Web-based patient registry that helps me track and manage patients' chronic, complex and preventive health needs. Patients can complete the HowsYourHealth.org survey at home or on the computer in my waiting room. It gives me an instant practice database that helps me identify my patients' needs and measure how I'm doing.
4. Use e-mail to convey laboratory and X-ray results to patients. E-mailing provides a written record to the patient, is fast (particularly if you use templates) and is free, assuming you already have e-mail set up in your practice. I also use Updox document management software (http://www.updox.com), which allows me to attach items such as lab orders, prescriptions and even Web pages and save the information to the patient's EHR file as I'm sending the e-mail.
This approach is much more efficient than traditional communication methods. Conveying results by mail is neither fast nor free. Calling patients with their lab results often sets you up for, "Oh, by the way, doctor, I wanted to ask you about [insert any new problem]," which can consume your time.
5. Don't be afraid to let the answering machine pick up. During office hours, my message machine states, "I am currently with a patient or otherwise unable to get to the phone; please leave a message and I will call you back as soon as I can." Interrupting the work I am currently engaged in is highly inefficient, whereas handling messages at a time of my choosing is much more effective. Because I return calls promptly, patients don't object.
6. Use electronic billing. Electronic billing through a clearinghouse is easier and faster than paper billing, and the clearinghouse scrubs my claims and identifies those with problems. (I use EClaims, http://www.eclaims.com, which costs about $65 per month after setup.) The "easy" rejections can be fixed in a day or two, as opposed to disappearing into my accounts receivables. Electronic billing also provides proof of the date of submission, which I didn't have with my paper system, and electronic remittance advice, which makes it easier to produce the explanation of benefits in question when arguing with insurance companies about payments.
7. Hire a poster/biller. I gave up on the pure ultra-solo/no-hired-help model, mostly because I hate posting and billing. Successful physicians seem to know how to play to their strengths, and billing is simply not one of mine. I now pay a medical biller approximately $100 every one to two weeks to argue with insurance companies about claim rejections, submit claims to patients' secondary insurers and produce patient statements, and I find it liberating.
How's it working?
While my practice is by no means perfectly efficient, the above changes have made my practice sustainable over the long haul. The pace, the quality of my work, the reward of running my own practice and the capacity for making lasting and significant changes within my practice are addictive. I would never go back to the high-patient-volume, high-overhead model.
| Amazing Charts | Electronic health record |
| Appointment Quest | Online appointment scheduling |
| DocSite | Online patient registry |
| Eclaims | Electronic claims clearinghouse |
| EZClaim | Billing software |
| How's Your Health? | Online health survey tool |
| Instant Medical History | Documentation tool |
| Medfusion | Web site creation |
| Updox | Document management system |
Even if you are not planning to open your own micro practice, many of the above changes in workflow and processes are applicable to any practice setting. For example, you may want to explore online scheduling, patient-entered histories or e-mail-based results reporting.
For those interested in practice transformation via the ideal medical practice model, join the online discussion group "practiceimprovement1" at http://www.groups.yahoo.com. It will connect you with like-minded physicians and give you information on how to nudge, nurture and shape your practice as it evolves to its truly "ideal" form.
Send comments to fpmedit@aafp.org.
1. Moore LG. Going solo: making the leap. Fam Pract Manag. February 2002:29-32.
2. Moore LG. Going solo: one doc, one room, one year later. Fam Pract Manag. March 2002:25-29.
Wednesday, August 12, 2009
OBNE Meeting, Aug 3, 2009
I was unfortunately late to this meeting because they started earlier than usual.
I was not present for the disciplinary presentations.
Continuing Education Discussion:
There was considerable discussion about how to word OAR 850-40-210. When a final version is provided I'll link it to the site.
SB 355: Fees for being able to prescribe pain meds. All active licensees will be required to pay a $25 annual fee to help pay for the Pain Management Program, which will provide more oversight of pain med prescribing. Apparently this exists in more than 30 states, but Oregon’s new program is the best.
Formulary Meeting Summary:
SB 327 Passed and was signed by the Governor! This is HUGE. OBNE has been working on this legislation for several sessions and many years. This says a lot about how far we’ve come, but more about how hard the board and OANP has worked to promote the profession. This should change a lot for NDs in Oregon, and eventually the US.
With the removal of restrictions (starting Jan 1, 2010), NDs will have prescription power for all meds they can safely prescribe, except that extra education will be required to prescribe chemotherapy meds, and anti-psychotics.
The Formulary council intends to include all of the drugs in the US P&F, all FDA approved substances, all drugs included in the Drug Facts and Compendium, the AAHFS, or any comparable and authoritative source.
OAR 850-060-226 (dividing drugs by ND classification) was removed from the ND OARs, and OAR 850-060-225 was clarified to better reflect the change. The question arose of what role the formulary will take on now.
Legislative update:
HB 2009 which create a Healthcare Authority Board/ Health Policy Board has apparently passed. This is one of Senator Greenlick’s measures. The Board would like to sugest and ND join to keep the ND voice alive in this board. The fear is that it will try to become and “umbrella” organization for all health-care boards which is disapproved by OBNE.
Next Meeting: Sept 28th, 2009.
Public Comment:
Vanessa Esteves is involved in a committee to try to achieve parity for NDs in traditional medical settings: hospitals, integrative clinics, community health clinics, etc. Now that SB 327 has passed, putting NDs on par with MD primary care providers, it’s time NDs were welcomed in these settings, should they choose to apply for employment there. This is also key for banks. Apparently, banks are more likely to loan NDs on par with aestheticians rather than MDs in order to build their business. This affects the amount of money NDs can borrow as well as the terms and conditions of such borrowing. If you are interested in getting involved in the effort to achieve equality in this manner, contact Vanessa info@dresteves.com.
OBNE Public Meeting, June 1 2009
My apologies for the late posting of this meeting. Some of the business is now somewhat outdated, but my summary is here nonetheless. I am not an official minute keeper, so please note that there may be an occasional error as I do not have the opportunity to double check this with the board.
Opening Business: Minutes of previous meeting approved, typos corrected,approved addition of OAR 850-060-225 and 226: Formulary Compendium and classifications.
Non-ND/ND investigations: The public is not meant to know who these people are, only a small degree of the circumstances. If an investigation leads to formal discipline, only then will the person names become public.
09-00-ON-1: Complaint regarding and advertisement of ND services where the ND had left the business. They were notified and addressed the problem promptly and the board dismissed the complaint as simple oversight. Dismissed with no action.
N08-09-20N: Closed case, overlapped with the medical board.
N09-05-11N: Other board licensee was selling supplements and diagnosing medical issues, investigation open
N09-05-12N: individual claiming to be an ND selling supplements. Investigation open.
09-02-04, 05, and 06: issued proposed discipline
08-08-18A: issued proposed discipline
09-00-ON1: Motion to close with no action
08-09-11N : Motion to close with no action
Bill Report:
SB 131: The Governor signed SB 131 changing the name of the Board from the Oregon Board of Naturopathic Examiners to the Oregon Board of Naturopathic Medicine. Look our for the OBNM this January!
SB 132: At this time was awaiting a vote on the House floor to increase the civil penalty maximum amount to $5000. This civil penalty amount is used by the Board to discipline licensees. (This was signed by G. Kulongoski on June 18)
SB 327A: This is the monumental bill that allows NDs to prescribe in accordance with their training rather than according to drug structure. At this time was passed by the Senate, 22-7, and awaiting a vote on the House floor. The initial bill was an exclusionary bill, meaning that it was going to be a short list of medications NDs couldn’t prescribe. Though Pharmacists and Nurses supported this, DOs and the OMB protested and requested an inclusionary bill as a compromise. This was adopted in the end, so a lengthy list is being compiled of all the drugs NDs can prescribe rather than a very short, simple list of all the drugs NDs can’t prescribe. (G. Kulongoski signed this into law June 18th!!!)
The Formulary council will tentatively be meeting September 11th, for those interested in weighing in on this process.
Continuing Education discussion:
A doctor/professor at NCNM proposed increasing the CE requirements to relate to and likely exceed those of MDs in Oregon. The goal is for Oregon to be a leader in the country as a state of quality alternative medical care. Additionally, it was brought up that by 2014 all practitioners will be required to use electronic medical records. There was a considerable discussion about how much to increase the hours by and across how many years. The Board was sensitive to the concerns that it would be cost-prohibitive to new practitioners and looked into options to make it easier. The recommendations will be transformed into rules for the next meeting.
Ended up with:
35 Hours Next year
50 hours the following and thereafter
No restrictions on subject areas, except 3 must be in ethics
10 hours must be “in person.” Virtual presence is not “in person.”
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