Don’t Write Off E-prescribing

I may appear to be somewhat of a troglodyte, but I actually have  committed myself to learning to love technology.  I am the proud owner of a smart phone, have mastered my email, and actually use two different EMRs.  So, you see, this qualified me as an expert on EMRs and e-prescribing (wipe that smirk off your face!)

It was with interest that I read “Effect of Electronic Prescribing With Formulary decision Support On Medication Use and Cost” in the December 8/22 2008 issu3e of Archives Of Internal Medicineby Michael Fischer, MD, MS et al.  The authors describe a study in which physicians using e-prescribing with formulary decision support were compared with physicians using traditional paper prescriptions with respect to prescribing tier 1 medications.  When prescribing electronically, the physicians were more likely to choose the lower cost generic tier 1 medication.  There was a 3.3% increase in tier 1 prescribing, with a decrease in tier 2 and 3 prescriptions.  Fischer et al estimate that this would result in an $845,000 savings per 100,000 patients, based on the assumption that each patient filled one prescription per month.

I love saving money, but what was the cost of saving money?  According to the authors, “government estimates of approximate first year costs were $3000 per prescriber.”  In the study, Blue Cross Blue Shield supplied the software to the physicians, along with a free wireless device, access to a secure Web portal, licensing and wireless carrier.  So, the cost was not borne by the participating physicians.

I think as a first step toward an EMR, e-prescribing makes sense.  I do not think that every insurance company should provide physicians with it’s wireless device.  Can you imagine, five different devices for five different insurance companies?!

So what is to be done?  The federal government must mandate one SINGLE e-prescription system that we all should use, and insurance companies should bear the cost, based on percentage of patients enrolled in each plan.  Why should health insurance plans pay?  Because they are the ones that will enjoy the savings!  I think this would be an effective way to usher in the beginnings of an EMR.  Mr. Obama and Mr. Daschle, are you listening?

As physicians, we must look for ways that we can use e-prescribing efficiently and effectively.  We must commit to learning all the bells and whistles, and using it to our advantage.  So, stop hiding behind your prescription pad, and make way for what is inevitable.  Get out there and lobby for what should be done, rather than whining when we get handed the bill for something that will most benefit the health insurance industry!


Survival Tips for Primary Care: How to Save Money

Now that I have vented/ranted/opined on the demise of primary care, let’s move to some survival tips. Following are PookieMD’s two fundamental. most important, and most loathsome rules of survival in primary care medicine.

The money is in the numbers.

Time is money.

Yes, you have to see patients to  make money, and given today’s reimbursement you have to see a fair amount of them.  This is a given, a fact, a law.  If you don’t want to see 20 (or more) patients a day, go in to psychiatry.  If you are in primary care, you probably are looking for a way to make a dollar go a bit further.  Don’t laugh, you might spot something useful here!

  1. Get a set back thermostat.  No, these aren’t just for home use.  If you are paying your utilities, why are you heating the office at night? 
  2. Learn to be efficient.  I have previously blogged on being efficient.  Running yourself ragged to see more patients is a recipe for burn out (if you are not already there!)  Look for ways to become more efficient.
  3. Use your EMR to the fullest.  For heaven’s sake, if you bought the thing, use it!  Learn every bell and whistle it has, every dot command, every work around, every reminder system. .  It will make you more efficient. Reminder: USE the perscribing feature (CMS will be rewarding this, and then penalizing you if you DON’T use it!
  4. If you don’t have an EMR use preprinted check box forms when possible. Write in the extras but the check box forms will save you time, and are usually more legible.
  5. Have your receptionist call and remind patients of their appointments.  An empty slot in your day doesn’t generate revenue.
  6. Look at how you use your space.  Could you rent a spare exam room to a occupational or physical therapist?
  7. Consider extended or weekend hours.  You are paying the rent whether you are open or not.  Consider opening a half day on Saturdays for urgent care appointments.  Don’t let Walmart take away YOUR business!
  8. Consider using medical assistants during their internship.  Lots of local MA schools are looking for practices that will take on a student.  These students are usually in the later part of their training and can extend your man power for free!  Beware, your nurse or MA should supervise them.
  9. Make sure you are billing for in-office procedures.  Train your staff to check off ua’s, strep tests, pregnancy tests etc.  You should then double check when you are filling out the superbill. You are doing ’em, get paid for ’em.
  10. Shop at big ware houses, like Costco.  Get toilet paper, and office supplies at a discount.
  11.  Make sure you charge for vaccination admission and the vaccine itself.
  12.  Use those freebie exam table coverings.  (Yeah, I’m not fond of laying down on an exam table with a paper covered with Viagra logos, but hey, what a poor primary care doc to do?)
  13. Don’t buy new–buy used equipment when possible.  (Checked Ebay lately?)
  14. Consider remote deposit capture.  If you have a big enough volume of checks that come in, you can scan and electronically send the images to your bank to get instant deposits. Cash flow is king!
  15. Consider ancillary services.  See previous post on ancillary services.  See what you can stomach.
  16. Consider group appointments.
  17. Utilize your staff to the fullest.  See previous rants.  Yes, I’m talking to you.

Look, this stuff isn’t fun.  However, if you want to survive, your business (note, I didn’t say PRACTICE), must have revenues greater than expenses.  This is the law of keeping the doors open.  Maybe things will change for the better.  Maybe not.  But if you are doing primary care, it’s up to you how you handle your BUSINESS, and how you keep the doors open so you can see patients.

Wand Waving Part 2: Common Sense is Uncommon

Let’s jump right  into the second part of PookieMD’s dissertation on the Medical Home.   As you recall, I was reviewing the 10 rules of the medical home, as set forth by the National Committee for Quality Assurance.  The next three concepts are NOT new, and are, you guessed it, common sense.  (Why is common sense so uncommon?)

4.  Shared knowledge and the free flow of information. Patients should have unfettered access to their own medical information and to clinical knowledge.
5.  Evidence-based decision making. Patients should receive care based on the best available scientific knowledge.
6.  Safety as a system property. Patients should be safe from injury caused by the care system.

Let’s tack number 4 next: “Shared knowledge and free flow of information…”  I think this is a thinly veiled reference to an EMR.  I am completely for nationwide use of an EMR, but am dismayed at the piecemeal, haphazard free for all that has ensued.  The EMR needs to be accessible to health care professionals across all spectrums of care.  Therefore, the myriad of programs out there are not going to create a system of good access for providers and patients.  It has been proposed that there be a nation wide EMR for all health care providers to use.  I am hesitant in advocating this, as many tout the VA’s system as the model.  I am loathe to advocate anything the VA uses, as I would summarize my experience with all things VA using two words: “profoundly inefficient.”  However, a nation wide, user friendly EMR  would probably be the best option.  BUT,  it has been estimated that it will cost $36,000 per physician to implement an EMR.  Where’s the money coming from?  I don’t see a huge surplus (!) coming any time soon into our Nation’s budget.

5. “Evidence-based decision making.”  No argument here.  I believe this is the very foundation of modern medicine in the West. 

6.  “Safety as a system property.”  It scares me that this is a rule.  Didn’t we take an oath to “do no harm?”  It also scares me that the folks at my favorite institution, the CMS (Center for Medicare and Medicaid Services), have bungled their way in to making rules to keep the patients safe from bed sores, c diff and catheter infections through the “Never/Ever No Pay” rules.  (See post below.) 

So what’s so new and exciting about the Medical Home?  No much so far, just more costs to the physician, a slick new name and a lot of press.  I’ll tackle the next ‘rules’ the next post.

For more info on EMRs, visit Dr. Kevin Pho’s informative post at  For more on the technical aspects, see Dr. Josh Schwimmer at

Cheers!  Don’t let your hands cramp writing those SOAP notes!

Another One Bites the Dust: Dr. T. Leaves Primary Care

I received a disturbing email from one of the doctors in my group, Dr T.  My group is made up of internists and family practice physicians that fill in locally through out the large city we live in.  All the physicians are board certified and have been out of residency for five years or more.  Several of them have private practices and work with ExtraMD as a local locums to augment their salaries.

Dr. T. is one of my favorites.  He is in solo practice in a lower income area.  His office is comfortable, his receptionist kind and the atmosphere is homey.    He works with ExtraMD on his days and weekends off.   Dr. T. is leaving private practice.  He has been trying to make it for 5 years now, getting by with a single receptionist and his wife doing the books.  He just can’t make it work anymore. 

But why?  He has tried mightily to serve the working class poor in his area.  He does most procedures himself, runs a tight ship and economizes where he can.  He bought his equipment second hand, takes little time off and spends nothing on frills.  While working, he developed acute cholecystitis and was hospitalized.  His first thought was to let his patients know he wouldn’t be in and his second was to call me because he had a shift scheduled.  Not one word about how he was hurting.  In addition, his wife followed up with a call just to make sure I had gotten the word.  Sheesh, how many of us care that much?

He is leaving because he can’t deal with the constant financial hardship, of fighting with insurance companies, figuring out how to make the cash go further when the payers are late, and how to break even.  He takes medicare and medicaid, because in his neck of the woods, they are some of the best payers.  He is leaving because he can’t keep up with the endless fighting over claims, and can’t afford to hire someone to do it for him.  He is leaving because he can’t afford to hire someone else to beg insurance companies for pre-authorizations.  He can’t afford the mandated EMR, can’t afford the “team” approach required for the patient centered home, and he fears he will go bankrupt trying to follow other of  the latest government mandates. He can’t keep up with ICD-10.  He doesn’t want to be a manager of a ‘physician extenders’ but wants to practice medicine and help people. Dr. T feels as if physicians have “sold out.”

He is leaving, he says because of “the realization that there is no future for the kind of medicine I practice.”

Dr. T, you will be missed.  I will miss your honesty, integrity and caring.  Your patients will miss a force for good, a comforting presence, and a kind and competent physician.  We all mourn the passing of primary care into the hands of those that DON’T care.

Score: Medical Insurance Companies/Government Regulations: 1  Patients/Physicians: 0.

Good bye, Dr. T and Godspeed.

PookieMD Airlines: How aviation check lists apply to medicine

I am married to an electrical engineer that loves to fly around in a small airplane.  Because I hang out with him, I’ve been forced to observe the intricacies of not crashing into other planes and landing safely.  I’ve learned a lot.

Pilots have a check list for everything.  Plane manufacturers include an entire book of checklists for every contingency, from take off, to landing, to what to do if there is an emergency.  ( It is a BOOK, mind you!)  My husband straps the needed check list to his leg and goes through it every time we land or take off or preflight.  He actually LOOKS at the list, touches each instrument and taps on the applicable gauges.  It is not a passive process.  Hence my hubbie and I have logged over 1000 hours safely in the cockpit of our tiny plane.  (Don’t look at me.  I don’t know a dang thing about flying.  I just kiss the ground when we land.)

Why do we physicians not utilize more check lists as we go through our day?  The medical profession has been (reasonably) stubborn on adapting algorithms and treatment pathways, arguing that each patient is different and no one algorithm can apply to every patient.  But from a patient safety stand point, I will side with the check list every time.  When a patient goes to the OR a check list is utilized, and when a patient is transported in one of the hospitals where I work, there is a “ticket to ride.”  Why don’t we have some simple checklists for ourselves, listing important but (sadly) forgettable to do items for each patient?  Now, some hospitals have an EMR that will generate order sets, but they are usually not as robust as they could be, and frequently only cover one disease state.  These order sets are good, but incomplete, and  lead to “drop offs” on treatment plans.  Hence the need for the check list.

When one of the hospitals I work at transitioned to order entry, I had to develop a check list that I carried around with me, because going back and forth between multiple screens is onerous.  It included the following:

  • Order labs for next day (first screen)
  • Review current meds (screen #2)
  • order new meds (screen #3)
  • order radiology studies (screen #3)
  • make sure note is entered in the EMR (screen #4)
  • review labs (screen #5)
  • read other doctor’s notes (screens 6 and more, each note a different screen)
  • review radiology studies (screens 7 and 8, depending on if you actually looked at the image.)

It’s quite easy to drop the details we internists live for.  Seems silly, but given it was a new EMR for me, I had to develop a system to make sure my work flow was preserved and important information and procedures were addressed.  Most of us used check lists as medical students, and then gave up the habit as we grew more comfortable with medicine.   You don’t have to have a check list for everything, but it’s helpful when you are encountering a different situation then usual, like the new EMR I described. 

I encourage you to add to your history and physical check list the following things:

  • Prophylaxis: e.g. have you written for GI prophylaxis (if warranted) and DVT prophylaxis  (don’t forget that DVT is now one of the  medicare “no pays”)
  • “Treatment plan discussed with patient and family, and they are in agreement.”
  • Note the time spent with patient and coordinating care.  (A must, for billing.  Heck, have this tattooed on your hand if you can’t remember it!)
  • Pressure ulcer present/absent at _____________(location).  (I have a skin category in my physical exam and include the pressure eval here.  Pressure ulcers that develop during a hospital stay are another Medicare no-pay.  More on that in a later post.)

One of my hospitalist colleagues uses the following check list at discharge, necessitated because the EMR we use makes us go between several screens and logins:

  • write discharge summary
  • write discharge orders
  • send note to PCP
  • set up follow up
  • write scripts

Useful primary care check lists would be:

  • State of undress for each exam:  (female pap: the full Monty, male: off with the tighty whities for the prostate check, diabetics: off with their shoes and socks!)
  • Check list clipped to chart as to what screenings are done at what age, or in each room.
  • Check list on cabinet door detailing what items go in each cabinet.
  • Check list at discharge for assistant to review: does patient have scripts, referrals, test info, and know when to come back.
  • List of items your front desk staff needs to check at each check in (check address, insurance card, HIPPA).
  • List of items your assistant needs to check as they room the patient (chief complaint, allergies, meds etc.)

When I wrote this post,  I considered making a “write post” check list, which would include looking for typos.  It seemed like a good idea, but I wuz too bzy so I didn’t have tim to go threw my list witch wud have reminded me to make sur I didn’t have no tipos.   

We can learn a lot from the world of aviation.    Should we have a check list for Code Blue/COR-0?  Nah, we’re physicians, we know it all.  Besides, the guidelines will change in two years anyway.

Flaps up!

21 Primary Care Time Wasters

In my travels as the ExtraMD, I have seen many different practices, different styles and hundreds of ways practices waste time and annoy patients.  In my quest to help primary care physicians stay afloat, I will list my observations of time wasters that suck the joy out of medicine.  I will also include my incredibly astute suggestions for positive change.  Beware, you may even see your practice here.

1) The doctor checking the patient in while the medical assistant stands there.  (Really.)

2) The doctor calling every patient to tell them their labs were okay, while the MA stands there. (Is there a pattern here?)

3) Not having the patient undressed and ready for the gyn exam.  There I am, setting out the speculum, diving around for the gown, searching for the pen to write their name on the specimen cup, while trying to keep up the patter.

4) Not having the diabetic patient’s shoes and socks off. C’mon, it’s standard of care.

5) Spending a lot of time arguing with the patient.  Give your viewpoint, listen to theirs, and then agree to disagree.  You will not convert everyone into exercise zealots in a day!

6) Not having preprinted check off forms if you don’t have an EMR.

7) If you do have an EMR, not learning how to type.  Get a typing a program and stop with the hunt and peck!

8) Not telling patients when to come back–be specific!

9) Waiting for late patients.  Have a policy that you if the patient is more than 10 minutes late, you will reschedule them, or try to work them in.  Caveat: YOU MUST BE ON TIME!  (Guess what patients complain about the most?  Waiting for you!)

10)  Not having charts pulled when you return phone calls.  Document the phone call, or have your malpractice lawyer’s phone number handy if you don’t!

11) Not having notepads in every room, so you can write instructions down (legibily) for your patients.  How much do you remember sitting in a paper gown in your tighty whities?

12) Not having a stock phrase down, as in, “Mrs. Malady, which two problems would you like to focus on today?”

13) Complaining.  Oh puhleez, nobody wants to hear you whine.  If you want to whine, start a blog.  Better yet, be the change you want to see.  (Thank you, Ghandi.)

14) Not giving out educational material.  You look like the hero if you have some handouts, and it’s good medicine to boot.  Have info stocked in each room in a standardized fashion.

15) Not relying on your staff.  You’re paying ’em, and they WANT to be useful! Use them to make calls, double check medications and allergies, hand out educational info, and answer questions.

16) Losing stuff in your office.  Have a systemized approach to patient care, from check in to check out and follow up.  Your best approach is to go through a day with your staff, and see where stuff goes.  You will also gain a lot of insight into what everyone is doing.  You probably need to do this every quarter.  It is helpful to try to systematize every aspect of care delivery, so it is repeatable and reliable.  E.g.: all labs must have a physician signature before filing, all patients are asked to disrobe according to the exam, each room is stocked with the same supplies in the SAME places.

17) Sloppy hand writing.  ‘Nuff said.

18) Thinking you are superman/woman.  You need to allow other people to do their job, so you can do yours.  Even Batman had Robin.

19) Charts that aren’t.  I have seen (not fibbing here!) a simple file folder with everything stuffed in it, in random order.  As a locums MD, how easy do you think it was to find important info?  Most charts have tabs–use them.  And train your staff to file properly.

20) Not having your staff notify you immediately when the patient says the magic words, “Chest Pain.”  They should immediately mobilize the EKG and get you in the room.  So what if it’s NOT the big one–better to err on the conservative side then have some poor slob infarcting while waiting for you for 30 minutes to finish up with the fibromyalgia patient next door.

21) Chatting about yourself.  Patients just don’t care, and find it annoying.  There are actually studies demonstrating this.  (Who funded those studies?…)

Hope this helps.  Don’t be afraid to look at your practice as an experiment, change stuff, and then see what works out.  Most of all, enlist your staff.  You will be hugely surprised at how innovative and involved they will be!

What We Didn’t Learn in Medical School and Residency

One of my favorite rants is “What we didn’t learn…”  I remember finishing my residency in internal medicine, thinking I had learned everything I needed to go out and cure patients, save the world, and get paid while doing it.  Boy was I wrong.  It was just the beginning!  Some of the lessons have come harder than others: I have had to learn that medicine is really a business, and that no matter how hard you try you can’t know everything.  So I thought I would come up with a manifesto on what we REALLY need to know.  So with out further ado:

1) Medicine is a business.  Get used to it.  Know that if you can’t keep the doors open, you can’t see patients.

2) Insurers run the world.  Get used to it.  Know which insurers reimburse the least and lose ’em if you can.

3) Learn all you can about coding and billing.  You deserve to paid for the work you do.  Most physicians undercode.  (Yes, I remember the 3 minute lesson I received as a senior resident:  “if the patient is complicated, code higher.”  Not exactly what I needed to know!)

4) Constantly look for ways to be effective and efficient.  Go through your day, minute by minute, and see what you can do differently.  Just try it.

5) Computers and EMRS are your friends.  Embrace technology because it is here to stay.  Get used to it.

6) Decide what is important to you, THEN pick what you want to do.  If you want shift work, think urgent care or hospital medicine.  If you want autonomy, consider a micropractice, if you want a guarantee think large practice or HMO.   Learn as  much as you can about each practice.  Remember, if you don’t like something, you can always change it!

7) Surround yourself with good people.  Have a good bookkeeper, accountant and attorney.  The flip side is, never blindly surrender your business/practice to someone else.  Understand financial statements, cash flow and personnel issues.  Don’t become one of those sad physicians that tells you their bookkeeper/accountant/office manager/partner/medical assistant ran off with receivables.  Ignorance is not a good strategy.

8)  Constantly learn.  Look for ways to learn from patients, staff and the slow lady yapping on her cell phone in the “fast” lane.  Some patients are there to teach you patience, and sometimes the slow lady reminds you to go the speed limit!

9) Remember two rules of medicine  (Thanks to M*A*S*H!)  First, patients die.  Second, doctors can’t change rule number one.

10) Breathe.  It’s tough to be a doctor in the trenches today, with the health care mess, Wall Street madness and the litiginous climate.  However, you ARE doing good!

May at least one person thank you today, to remind you that being a physician IS a worthwhile profession!