Doctor’s Digest’s Practice Tips from the experts!

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Becoming a 5-Star Practice

The solo practice: Is bigger always better?

Dr. Michelle Eads, a family physician in Colorado, decided seven years ago that the only way to work in a 5-star practice was to create her own. She had been working in a 60-doctor group practice, always fully booked a month or two ahead of time, and she had to rush through appointments to earn enough to meet her overhead and still make a living. She couldn’t sleep at night because she couldn’t do a good job in that situation. So today, in solo practice, she’s doing a lot more with a lot less. She and her medical assistant/front office person make liberal use of health information technology along with phone calls, e-visits, and same-day appointments to offer 24/7 access to a much smaller panel of patients. Dr. Eads says, “Patients are happy. Staff is happy. I am making less than I did in a group practice, but I am much less stressed out.” She concludes that the leap she took was well worth it.

This Essential Practice Tip was based on the Becoming a 5-Star Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Can a mid-level practitioner help your practice?

If you need extra help in your practice, hiring a non-physician provider could be the solution. First, it’s cheaper. Several surveys show that the mean hourly rate paid to nurse practitioners is about $45, and their malpractice insurance rates are significantly lower than physicians’ rates. Second, a mid-level practitioner can assume many of a busy physician’s routine tasks; studies show that physician assistants perform between 70 and 90 percent of services that their supervising physicians perform, according to the American Academy of Physician Assistants. Additionally, a non-physician hire is a good alternative if you are concerned about hiring a doctor who might become a future competitor, or if you fear that the new doctor might be difficult to fire if he or she became a partner.

This Essential Practice Tip was based on the Becoming a 5-Star Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

What it takes to be a 5-Star practice

Typically, we might describe a 5-star primary care practice as one that balances top-notch, evidence-based patient care with a smooth-running, profitable operation using the latest technology, making optimal use of teamwork, and communicating a caring attitude. But topping the list of priorities is this: a practice that has shifted from being doctor-oriented to being patient-oriented. For example, no 5-star practice rents space in a building that patients dislike just because the building is convenient for doctors. It doesn’t refuse to offer evening hours simply because that’s the way they’ve always done it. A 5-star practice pays attention to the fact that it’s hard for patients to leave their jobs during the normal workday. It calls for a revolutionary shift in attitude, but becoming a patient-oriented practice is the clear new direction in healthcare.

This Essential Practice Tip was based on the Becoming a 5-Star Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Social media: more useful than you may imagine

If you scoff at social media like Facebook and Twitter, you may be ignoring their potential in healthcare. Experts say that exceptional medical practices are now using social media to improve their care—and/or to think about ways to do so. Some practices are using Twitter to post their office delays and wait times. Last fall some practices used Facebook to announce the availability of the H1N1 vaccine. And Dr. Barbara Morris, a pediatrician in Saratoga Springs, N.Y., is part of a large multispecialty group that is experimenting with a Facebook project to address adolescent obesity. The idea is to use volunteer teenagers on Facebook to try to convince their peers to come in and talk to nutritionists and trainers associated with the practice.

This Essential Practice Tip was based on the Becoming a 5-Star Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Interactive Use of the Internet

Information retrieval was only the first step in healthcare’s use of the Internet. And now interactive use of the Internet is becoming more and more important for your patients. According to Manhattan Research, today more than 60 million adults are reading or writing health-related blogs or message boards, participating in health-related chat rooms, posting health content online, and/or using online patient support groups. According to health technology consultant Brian Klepper, as a physician you should become familiar with high-quality online resources and social networks in order to refer your patients to them or even provide a link to them on your practice Website.

This Essential Practice Tip was based on the Becoming a 5-Star Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Are you modern enough to make your patients ‘customers’?

According to Dr. Barry Silbaugh, CEO of the American College of Physician Executives, perhaps the first step in improving your customer service is to end the debate about semantics that has kept many physicians from viewing their patients as “customers.” He has attended many focus groups in which consumers say that the term ‘patient’ means that they’re not on the same footing as the doctor, reinforcing the idea of doctors acting paternalistically. “A lot of patients don’t like that,” he says. “They say they like to be considered a consumer because it puts them on a more equal footing with the physician.”

This Essential Practice Tip was based on the Becoming a 5-Star Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Health Information Technology

Identifying a single patient vs all patients with a single disease

Harnessing the power of EHRs calls for a basic change in the way you think about patient care. Doctors are used to dealing with patients as individuals, but they aren’t used to identifying all their patients by disease category. As Dr. Karim Keshavjee, CEO of a Toronto health information consulting company, points out, “Paper files are great for dealing with one patient, but they can’t help me find all the information about a particular kind of patient.” But once you have harnessed your EHR to give you that information, you can easily identify all of your patients with diabetes or heart disease, for example, so that you can track them to make sure all of them are getting appropriate care at the proper time.

This Essential Practice Tip was based on the Health Information Technology issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Delays in e-prescribing

No one disputes the advantages of e-prescribing; and within one recent year, e-prescription transmissions grew from a total of 29 million to 68 million. But a recent report shows that only 12% of office-based physicians are e-prescribing. And smaller practices are less likely to do so than larger ones. Why? Cost is one factor, especially if you buy a complete EHR system all at once, rather than a stand-alone e-prescribing system. Compatibility is another problem, as there is great variety from one system to another. But those problems will resolve once the government’s universal standards for certification come into play. Experts predict the vendor landscape will shift dramatically, and you will benefit by being able to buy pieces of EHR systems incrementally, thus less expensively, when all certified products are compatible with each other.

This Essential Practice Tip was based on the Health Information Technology issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Your technological future

The movement toward Web-based technology is in line with the trend toward patient-centered healthcare. How will technology serve your practice in the future? A new joint project of Massachusetts General Hospital and three other organizations may suggest the answer. The patient will be at the center of a collaborative-care team made up of a physician, a nurse, a life-balance coach, and a care coordinator. A typical day will start with a team huddle. Then Dr. Nicole will check her e-mail. Let’s say she has a message from Ray, who is homebound. Ray asks her about a rash that’s developing on his leg. She sees that Ray is currently online and sends him an instant message asking if they can have a video conference later in the day. This will happen at 2 p.m. when Dr. Nicole plans to be at her desk answering e-mail questions, conducting virtual visits, and doing research. Clearly, it’s a new day for healthcare.

This Essential Practice Tip was based on the Health Information Technology issue of Doctor’s Digest. Click for expanded information from the specific chapter.

How should your E.H.R. be customized?

The best EHR for your practice needs to be customized to reflect each physician’s “thought flow,” or the way you approach the typical patient encounter. Dr. Samuel Bierstock, president of a Florida-based health IT consulting company, suggests that you decide what information you need most in the exam room so that you can pick a product that won’t make you enter a half-dozen mouse clicks to reach the data you need. For example, a pediatrician who often prescribes penicillin will want that drug to appear near the top of the pop-up drug list, not down the list in alphabetical order. A common complaint is that doctors have to click too many times to get what they need. So your system should be customized to accommodate your thought flow. Dr. Bierstock observes that, 9 out of 10 times, doctors select a system by calling a colleague and buying the one the colleague likes. Instead, he says, it pays to take time to list the most common problems you see, the information you’ll need fast, and the actions you’ll need to take.

This Essential Practice Tip was based on the Health Information Technology issue of Doctor’s Digest. Click for expanded information from the specific chapter.

A simple mistake to avoid with your E.H.R.

A recent workshop conducted by Dr. Karim Keshavjee, CEO of a Toronto health information consulting company, vividly demonstrates a danger that could decimate the effectiveness of your EHR. Dr. Keshavjee asked 12 doctors how they identified patients with diabetes, and he got 6 different answers that included “DM,” “diabetes mellitus,” and “NIDDM.” Having an agreed-upon standard—in which your EHR is programmed to attach specific terms to specific diseases—can prevent many patients from falling through the cracks. “The alerts and reminders [for these patients] weren’t being identified in the system,” Dr Keshavjee says, in the absence of a unified label.

This Essential Practice Tip was based on the Health Information Technology issue of Doctor’s Digest. Click for expanded information from the specific chapter.

The ‘virtual’ visit and the E.H.R.

Vivid evidence of how e-mail and an electronic health record (EHR) can transform patient contact comes from Dr. Richard Baron, a Philadelphia internist, who finds he can now often interact with patients without seeing them face-to-face. For example, in one recent week, the following three events occurred: A patient with diabetes e-mailed a photo of skin changes on his foot; Dr. Baron diagnosed athlete’s foot and recommended an over-the-counter treatment. Another patient e-mailed him a pre-operative form that Dr. Baron completed and returned by e-mail. Still another e-mailed to report that her sister had just been diagnosed with a rare genetic disorder and asked if she should be screened for the disease. Each e-mail was automatically copied into each patient’s EHR. Clearly Dr. Baron’s experience represents the wave of the future in “virtual” patient visits.

This Essential Practice Tip was based on the Health Information Technology issue of Doctor’s Digest. Click for expanded information from the specific chapter.

The growing trend toward e-mail

Today about 4 out of 10 physicians are communicating with their patients online via e-mail, instant messaging, or secure messaging systems. That’s nearly triple the number from just six years ago. And if you have an EHR, no matter how you may feel about e-mail, you may find it hard to resist e-mail as a time-saving and efficient way to communicate with your patients. Doctors at Greenhouse Internists in Philadelphia found that e-mail can be much easier than the phone; as internist Dr. Richard Baron puts it, “On the phone, I have to document both sides of the conversation whereas with e-mail, patients document their half; and it goes directly into the [electronic] record.”

This Essential Practice Tip was based on the Health Information Technology issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Transferring data from paper to an E.H.R.

Transferring clinical information from paper charts to your new electronic record may seem like a mundane administrative chore, and many practices assign the job to an assistant. But experts say it’s important for you to be personally involved. According to Dr. Kenneth Adler, medical director of IT for a practice in Tucson, Arizona, three main things have to get into the EHR: problem lists, medication lists, and allergy lists. “The medication and allergy lists can be copied over from the paper charts by a medical assistant, but the problem list is an important piece that usually has to be done by the physician.” If you leave it up to someone else, you may regret it. At one Ohio clinic, medical assistants transferred social data—such as smoking or family history—before the patient came in. That enabled the physician to focus on more complex information, such as problem and medication lists.

This Essential Practice Tip was based on the Health Information Technology issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Five questions to ask E.H.R. vendors

When you’re choosing among EHR vendors, here are five key questions to ask, as suggested by Dr. Samuel Bierstock, president of a Florida-based health IT consulting company: 1. How many clients do they have? (If they service only 50 to 100 physicians, it may be a challenge for them to afford to maintain costly certification.) 2. What support do they provide? 3. How do they make changes or customizations? (For example, can you make changes without their help?) 4. What are their key development plans? (For example, do they expect progress in content or enhancements to the system?) 5. What are they doing to ensure security? (For example, do they comply full with HIPAA guidelines?)

This Essential Practice Tip was based on the Health Information Technology issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Should you buy an E.H.R. now or wait?

New federal incentives are prompting many practices to rush into EHRs. But for some, there are sound reasons to wait. According to Dr. David Kibbe, an expert on HIT and a senior adviser to the American Academy of Family Physicians, the government may significantly redefine EHRs, simplifying features and functions—bad news for vendors, but good news for small practices needing simpler, less costly ways to go high-tech. Dr. Kibbe advises a wait-and-see attitude if you haven’t already made the leap to an EHR. “If you’re contemplating purchasing it in the next two years and want to be assured it will meet meaningful-use criteria, then you should probably hold off until it’s clear who the certified vendors and products will be,” he advises. Because the meaningful-use rule could change substantially, “getting information now and following it could be dangerous,” he cautions. He suggests learning about the stimulus program and product certification guidelines, but delaying purchases until later this year.

This Essential Practice Tip was based on the Health Information Technology issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Considering a stand-alone e-prescribing system?

It’s hardly surprising that most physicians who have purchased e-prescription systems are using stand-alone software: 70% vs 30% who purchased e-prescription as part of an EHR package, according to Surescripts. Stand-alone systems are much cheaper than fully functioning EHRs and can be purchased either as software packages or through an e-prescription ASP, which charges monthly fees for Web-based access. Many doctors prefer to start with a stand-alone package in order to get used to the technology before springing for a full EHR. Others feel that the advantages of e-prescribing multiply when the function is embedded in a full EHR with access to patient medication and problem lists. Depending on upfront and ongoing costs, among other factors, a stand-alone system can cost from $500 to $2,500 a year, according to the AMA.

This Essential Practice Tip was based on the Health Information Technology issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Virtual visit or office visit?

It’s clear that Web visits are appropriate only for certain types of patient complaints. Family Practice Associates of Lexington, Kentucky, inform their patients that a virtual visit should be used only for non-urgent symptoms: “We use it for acute problems such as nausea, vomiting, or skin rash,” says Susan Miller, RN. And because the virtual visit is meant to treat simple problems, the practice charges only twenty dollars for each one. If the problem can’t be treated online, the patient is asked to make an office appointment. An increasing number of insurers will reimburse for Web consultations. Medicare doesn’t specifically cover them, but you can account for your time spent on e-mail when you determine the level of evaluation and management service to bill for a related face-to-face visit.

This Essential Practice Tip was based on the Health Information Technology issue of Doctor’s Digest. Click for expanded information from the specific chapter.

How to Error-Proof Your Practice

Five key ways to ensure good administration

How well does your practice function on the administrative level? According to Chris Zaenger of Z Management Group, Elgin, Ill., you should be able to answer “yes” to all of the following five questions: 1. Do you have an up-to-date manual of your practice’s policies and procedures that all your employees are familiar with and follow daily? 2. Does your practice verify each patient’s insurance coverage before the patient shows up for an appointment? 3. Does your front desk collect a co-pay from every single patient who owes one? 4. Do you update your coding materials every year, and have you and your billing staff taken coding classes in the past year? 5. Does your practice routinely obtain pre-authorization for all in-office or outside procedures and services?

This Essential Practice Tip was based on the How to Error-Proof Your Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Some Medications May Need their Own Safety Plan

Some medication errors are so common and dangerous that they may warrant a systemic solution all their own. Warfarin, for example, is a routine lifesaver for cardiac patients, but can cause dangerous bleeding and is a common cause of adverse drug events. It can be challenging to establish the right dose for a patient new to the drug, says Dr. Jeff Brady of the Agency for Healthcare Research and Quality (AHRQ). With warfarin, close communication is essential, because a patient’s diet and activities can compromise effectiveness and safety. With an AHRQ grant, an anticoagulation therapy clinic was set up in Iowa to address these needs. The clinic closely monitors more than 200 patients on warfarin to make sure their dosage is right, and educates them on adhering to instructions. The program has paid off: Today these patients are less likely than others to miss doses, require dose changes, have bleeding or clotting events, or end up in the hospital due to anticoagulant therapy.

This Essential Practice Tip was based on the How to Error-Proof Your Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

A Culture of Safety

Instead of punishing employees who report or admit mistakes, it’s far wiser to establish a culture of safety with built-in safeguards. Dr. John Hickner, chair of family medicine at the Cleveland Clinic, suggests you start by focusing on areas in which errors easily happen and where consequences could be serious, then institute simple procedures to head them off. For example, in the case of blood tests, he recommends that you make sure your practice has clear, consistent answers to these three questions: How do you know the patient had blood drawn? How do you know the result came back? How do you know the patient was notified? Sticky notes, tickler files, registries, or any other simple strategy can help you make sure that these questions get strong answers.

This Essential Practice Tip was based on the How to Error-Proof Your Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Making staff cuts—a double-edged sword

If you’ve decided that a good way to save money may be to reduce your practice’s staff, the experts would urge you to think again. According to Judy Aburmishan, a CPA with the consulting firm FGMK in Bannockburn, Ill., an adequate staff is your practice’s most powerful weapon against costly administrative errors; but many physicians regard it as the first place to cut costs. “The more practices get their reimbursement cut, the more they feel they have to save their way into a profit—so they cut staff. You can’t save your way into a profit. If you’re short-staffed, you might save $25,0000 or $35,000, but not having enough front-desk help could cost you patient volume of $100,000.” Once you’ve found reliable staff, pay them enough to keep them—and give them the resources, such as classes and up-to-date manuals, to develop the business expertise you need.

This Essential Practice Tip was based on the How to Error-Proof Your Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Saying “I’m sorry” to a Patient

No matter how careful we are, medical errors will occur. If a medical error has been made in your practice, resulting in harm to your patient, your first step is to acknowledge the event to the patient and his family, explaining what happened and then responding to their questions. According to an analysis from The Doctors Company, an effective apology includes the physician’s accepting overall responsibility—which is not an admission of fault or negligence. You should empathize with the patient and express your concern and regret. Then discuss the future consequences of the injury—for example, hospitalization or surgery. Finally, explain to your patient what is being done in your practice to make sure that the same event never happens again to another patient.

This Essential Practice Tip was based on the How to Error-Proof Your Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Avoid Errors by Having Redundant Systems

Because many primary care physicians operate relatively small practices, they may lack the kinds of redundant systems that have helped many industries reduce their error rates. Dr. Joseph W. Stubbs, president of the American College of Physicians, believes that physicians could learn a lot from such industries as manufacturing, in which an error-proofing culture, not just a lone employee or two, works to minimize what may fall through the cracks. “Maybe you told a patient to follow up an office visit by getting a chest X-ray,” Dr. Stubbs suggests, “but he didn’t; so you missed diagnosing a pulmonary nodule; and the next time you see him, he has advanced cancer.” Some practices avoid this kind of scenario by having the patient wait in the office after his appointment while a clerk calls the imaging center and schedules his procedure for him.

This Essential Practice Tip was based on the How to Error-Proof Your Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

How does your office compare as a safe practice?

Do you ever wonder where your practice stands on key measures of patient safety? The federal Agency for Healthcare Research and Quality (AHRQ) surveyed 182 practices in 2007, most of which were primary care. The practices rated themselves on whether they had good systems for preventing and discovering errors, and whether the staff communicated well—both among themselves and with patients and outsiders. While most practices scored themselves high on teamwork, more than half said the staff felt that mistakes were held against them and that it was hard to voice disagreement in the office. Almost 60% thought their offices were more disorganized than they should be, and well over half reported problems in communicating with outside parties—hospitals, pharmacies, and other doctors—during the month before the survey. What would an internal survey reveal in your practice?

This Essential Practice Tip was based on the How to Error-Proof Your Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Did the patient really understand you?

If you ask your patient whether he understands what you’ve just told him, and he nods, does that mean he understood? Not always. The hurried nature of many office visits, combined with nervousness or another “white coat” phenomenon, as well as medical literacy issues, can lead to a serious communication gap between you and your patients. Instead of a yes-or-no answer, a better strategy is to ask each patient to explain things right back to you. The National Patient Safety Foundation suggests you use the “Ask Me 3” protocol for patient communication. To avoid misunderstandings and errors, check whether each patient can answer these three questions: 1. What is my main problem? 2. What do I need to do? 3. Why is it important for me to do this?

This Essential Practice Tip was based on the How to Error-Proof Your Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

What Causes Most Medication Errors?

What causes medication errors in office practice? A Danish team did a meta-analysis of 29 studies of adverse drug events in ambulatory care, published over a 52-year period. The analysis revealed that about 20% of all adverse drug events are preventable. Almost 87% of the preventable events involved cardiovascular drugs, pain medications, and hypoglycemic agents. The most frequent error was the use of inappropriate drugs. For preventable events that required a hospital admission, the most frequent cause was inadequate monitoring. The research team concluded that quality improvement programs should target errors in prescribing and monitoring, especially for patients who use those three types of drugs.

This Essential Practice Tip was based on the How to Error-Proof Your Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

A Free Way to Start e-Prescribing

If you haven’t yet used electronic prescribing, there’s no reason to wait. Free software is available through the national ePrescribing Patient Safety Initiative (NEPSI), based on software offered commercially by Allscripts, a leading source of physician office software. Over 45,000 physicians are already using this free software. The tool lets you enter a patient’s current medications, problem list, and allergies, which it then uses to automatically check for side effects and interactions. Then you can write a prescription and send it directly to a pharmacy. The pharmacy can use the system to return a message alerting you to allergies or other potential problems noted on the patient’s pharmacy record, or to let you know when the patient needs a refill.

This Essential Practice Tip was based on the How to Error-Proof Your Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Avoiding Dangerous Abbreviations

Over a period of only ten months, physicians at Geisinger Health System in Danville, Pa., managed to cut their use of dangerous abbreviations in prescriptions by 75%—from more than 6,000 to around 1,500. How? Largely by using an electronic health records (EHR) system. A few years ago, Geisinger set out to eliminate dangerous abbreviations, a feat that would have involved painful human retraining in a paper-based system, but is much simpler with an EHR. By using the ISMP list of dangerous abbreviations, along with a few additions of its own, Geisinger developed a list of the medications commonly prescribed in its primary care offices, and its EHR includes standard instructions for using each one. Because the only function of abbreviations is to save time, using the pre-written instructions solves most of the abbreviation problem.

This Essential Practice Tip was based on the How to Error-Proof Your Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

When your colleague makes an error

An awkward circumstance for a physician is addressing a colleague’s error with the patient. Dr. Frederick Turton, a Florida internist and current chair of the ACP Board of Regents, says this situation can be especially complex if you have a longstanding tie with the colleague. “You risk your professional relationship and your ability to practice with them, and you wonder how much it’s your business to reveal their problems.” Although ethics demand that you reveal an obvious error, Dr. Turton says there’s a grey area if the colleague made a decision you wouldn’t have made—a decision that may have been based on different knowledge or a different assessment of risks and benefits. Rosamond Rhodes, PhD, director of bioethics at Mount Sinai School of Medicine, says that, if you don’t understand how the error occurred, you should make that clear to your patient. Your next step is to learn your colleague’s side of the story. Even if you take some heat for it, she says, “Do your job, and be non-judgmental.”

This Essential Practice Tip was based on the How to Error-Proof Your Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Your Practice and the Recession

Medicare Reform and Primary Care

When we consider the issues of cost and coverage, could changes in the Medicare payment system be the key to transforming our healthcare system? According to the Commonwealth Fund, a private foundation dedicated to high-performance healthcare, “Medicare could lead the way by introducing a system for the rapid testing, adoption, and spread of innovative payment methods. These should include rewarding high-performing healthcare organizations for results, not for the quantity of services.” According to its annual report, the three most promising changes to provider payment are these: providing financial rewards for top-performing providers, paying a global fee for acute hospital episodes (including 30-day follow-up care), and recognizing physician practices or health systems that serve as patient-centered medical homes.

This Essential Practice Tip was based on the Your Practice and the Recession issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Renegotiate Your Office Lease

Have you thought of renegotiating your office lease as a way to reduce overhead costs? According to Jeremy Behar, president of a Toronto consulting group, a more flexible lease might have a number of advantages for your practice. A death-and-disability clause could enable you to terminate your lease in case of a catastrophe. A properly worded assignment-and-subletting provision could enable you to bring other healthcare providers into your practice without having to ask your landlord’s permission. An effective “option to extend” might help you reduce costs by preventing your landlord from hiking up your rent at renewal time. It could also help protect tenant improvements and fixture investments by maintaining some security for your practice well into the future, avoiding an unexpected relocation that could wreck your bottom line.

This Essential Practice Tip was based on the Your Practice and the Recession issue of Doctor’s Digest. Click for expanded information from the specific chapter.

It’s Not Too Late to Participate in PQRI

The Physician Quality Reporting Initiative, or PQRI, is Medicare’s effort to link physicians’ payments to quality performance. If you haven’t already tapped into the program, in which you can earn a 2% bonus based on total allowed charges, you still can. The PQRI program is claims based. Just select the quality measures that are applicable to your patient panels and submit the designated quality data codes on claims for services paid under the Medicare physician fee schedule between January and December of this year. To be eligible for the bonus payment, you have to report on a minimum of three quality measures for at least 80% of the cases in which the measure was reportable. First review the quality measures to see which ones apply to your practice. Then review your total Medicare claims between January and December; and finally, multiply by 2% in order to estimate your potential bonus.

This Essential Practice Tip was based on the Your Practice and the Recession issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Selling Products from Your Office

One way some practices are increasing revenue is by selling products directly from their offices. Frederick Turton, chair of the American College of Physicians’ Board of Regents and a Florida internist, offers a useful test for determining whether a particular product is appropriate for you to sell. One, the product should relate directly to your type of practice. Two, it should be supported in the literature. Three, it should be medically appropriate. Four, the price should be right. Five, there should be no conflict of interest for you. And five, the evidence—or full disclosure—for the product should be readily available to patients. Dr. Turton points out that when a doctor sells a product, he is recommending it; if he can’t support its appropriateness, then he shouldn’t sell it. An example of an appropriate product, he suggests, would be crutches sold from an office in a rural area where patients could not obtain them nearby.

This Essential Practice Tip was based on the Your Practice and the Recession issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Healthcare Reform and Primary Care

As the details of the stimulus package play out, experts predict that it may be up to large-scale healthcare reform to make a real difference for primary care following the recession. According to Michael LaPenna, a practice management consultant in Grand Rapids, Michigan, “The few cents being spent on primary care [in the stimulus package] are not going to be enough to turn primary care around. One thing that is positive is that the money being put into the stimulus plan will save on healthcare costs by covering the uninsured and underinsured. This may have an indirect positive impact for physicians. Medicare will be used as a tool to shift payments from specialty to primary care, while Medicaid will be augmented by a new healthcare program format.”

This Essential Practice Tip was based on the Your Practice and the Recession issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Accepting Credit Cards: Could it Work for You?

Many physicians refuse to accept credit cards from their patients in order to avoid paying transaction fees, which are typically from 3% to 4%. But according to Kenneth Hertz, principal of the MGMA Healthcare Consulting Group in Louisville, Kentucky, credit cards may be a good way to improve your collection efforts. A survey showed that in April of this year, 33% of physician practices were not accepting credit cards. But consider the fact that the alternative to paying transaction fees may be collecting nothing at all! Accepting credit cards can improve your practice’s cash flow with more timely payments and can reduce overhead and billing-related expenses such as chasing down small co-pay amounts, mailing out paper statements, and dealing with bounced checks. Credit cards offer patients the financial flexibility to obtain the healthcare they need, when they need it—regardless of their cash situation.

This Essential Practice Tip was based on the Your Practice and the Recession issue of Doctor’s Digest. Click for expanded information from the specific chapter.

How Primary Care is Coping with Decreased Revenues

How is your practice coping with the economic recession? It may be useful to see how other primary care practitioners have changed the way they do business in order to counteract reduced revenues. According to an MGMA physician practice survey, 35% of respondents have postponed capital expenditures while 34% have cut their operating budgets. In addition, 34% have implemented a staff hiring freeze, 24% have frozen their staff salaries, 33% have improved their billing and collections process, 18% have stopped taking new Medicaid patients, 5% have stopped accepting new Medicare patients, and 13% have renegotiated or eliminated low-paying commercial payer contracts.

This Essential Practice Tip was based on the Your Practice and the Recession issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Patient Care During the Recession

Patients are sicker as a whole because of the economic recession. They are putting off preventive care, not picking up their prescriptions, alternating dosages by cutting pills in half, or even skipping a dose. A Henry J. Kaiser Foundation Report earlier this year found that 53% of Americans are cutting back on their healthcare due to costs. How can primary care address the problem? One way, according to Dr. Kevin Pho, an internist in Nashua, New Hampshire, is to make costs a part of every discussion you have with your patients about diagnostic tests and treatments, so that they can consider less expensive alternative tests or treatment plans, along with generic drugs that may be more affordable. Another way to help is to openly ask patients about their jobs and changes in their insurance coverage, and to advise them of community resources that can help them get free or reduced-cost prescriptions.

This Essential Practice Tip was based on the Your Practice and the Recession issue of Doctor’s Digest. Click for expanded information from the specific chapter.

A Few Tips on Weathering the Recession

Practice management experts offer a number of ways for primary care doctors to weather the recession. One, this is not the time to jump into a new business plan; instead, focus on low-tech, base-level services. Two, in order to reduce your overhead costs, cross-train your staff and stagger their hours to maximize what you’re already paying in overhead. Three, re-evaluate your equipment needs; this may not be the right moment to invest in costly new technology. Four, communicate very clearly with your patients about medical costs, and encourage those who are struggling to pay their bills to call your office in order to set up a payment plan.

This Essential Practice Tip was based on the Your Practice and the Recession issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Best Practices: Patient Safety

The Patient Safety Organization (PSO) and You

Today there are 66 patient safety organizations (PSOs), both public and private, in this country. Mandated by the Patient Safety and Quality Improvement Act four years ago, the PSO adds a valuable new way to analyze patient safety. The basic purpose of the PSO is to collect and analyze medical errors; and, according to Dr. Bruce Bagley, medical director for quality improvement at AAFP, “Having a central collection point for error data makes it possible to recognize patterns that might otherwise be overlooked. For example, if 50 separate physicians report the same error, but each reports only a single instance, the [cause] might not be noticed. But in the new system, even if it occurs infrequently, it begins to add up.” If the PSO analysis reveals a system-wide cause, then it recommends a system-wide solution. As Dr. Bagley points out, “That’s more valuable than punishing one individual who made an error.” Although many patient safety programs focus on hospitals and large institutions at this point, your small practice can get a head start by looking at programs designed for large facilities and adapting whatever components fit your needs.

This Essential Practice Tip was based on the Best Practices: Patient Safety issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Assessing Your Practice’s Safety

If you think you’re already doing a good job with patient safety, it may be eye opening to get another opinion—a thoroughly objective one. For example, internists who are members of the American College of Physicians can use ACPNET, a Web-based quality improvement program that helps doctors incorporate evidence into practice, teaches them how to implement quality improvement, and offers support. The ACPNet analysis can reveal things about your safety practices that may astonish you. For example, an analysis might show that your practice’s diabetic patients aren’t getting regular eye and foot exams and A1c monitoring. Dr. Amir Qaseem, senior medical associate in ACP’s clinical programs and quality-of-care department, says that a doctor’s first reaction is often denial: “The data must be wrong. This cannot be my practice data.” But once you realize the data is in fact yours and is accurate, then you’re ready to make some positive changes.

This Essential Practice Tip was based on the Best Practices: Patient Safety issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Rethinking Old Routines

Best practices for office efficiency call for doing the most with your existing team. But Catherine Tantau, president of a healthcare consulting firm in Chicago Park, California, says primary care providers typically spend about 30% of their day doing clerical tasks because the support staff is busy with other work. Nurses report that nearly one-half of their day is spent in almost purely clerical work. “If you’ve got one nurse,” Ms. Tantau says, “you’ve got four hours a day during which, frankly, someone earning far less money could be accomplishing those tasks. That nurse could be freed to support patients and providers in more clinically relevant ways.” The solution? Select one key routine and map out your current process. Ask several staff members to help with the mapping to get a full picture, and you’ll see where the bottlenecks, rework, and redundancies occur. Then, still working with your staff, find new ways to simplify the routine with fewer steps and fewer hand-offs.

This Essential Practice Tip was based on the Best Practices: Patient Safety issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Patient Safety and the Way You Communicate

You know that the way you communicate with your patients is important—but did you know it can affect their safety? A decade ago, the Institute of Medicine’s report “To Err is Human” pointed out how many deaths occurred each year due to preventable errors in American healthcare. Are things any better today? According to the Consumers Union 2009 Safe Patient Project, more than 100,000 patients still die needlessly every year in our hospitals and healthcare settings. And a major factor is communication. It’s been found that 70% of adverse events can be traced to a communications problem. Dr. Alan Rosenstein, medical director of Physician Wellness Services, reports that his organization has found that 50% of doctors “are just not good communicators” and that this relates directly to patient safety. Do you really listen to your patients? Do you make sure they understand your instructions? Do you get them to repeat your instructions to make sure? And when you write a prescription, do you make sure it’s legible enough so that a similar drug won’t be dispensed by a well-meaning pharmacist? These are just a few ways communication skills can make a huge difference in the safe care of your patients.

This Essential Practice Tip was based on the Best Practices: Patient Safety issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Safety Starts at the Front Desk

Does it surprise you that patient safety may start at the front desk of your practice? That’s what Dr. Gary Brazina, an orthopedic surgeon in Del Rey, California, believes—and he adds that this key position shouldn’t be filled with the newest hire or the lowest-paid. Dr. Brazina offers the following safety tips for your front-desk position: Use duplicate-sheet message pads so that every message automatically creates a copy of itself; pick up your messages from the front desk at least twice a day; have the receptionist document each message, including what the problem is, whether it is urgent, and whether it pertains to a medication refill; make sure your receptionist answers every call promptly and doesn’t let it get forwarded to voice mail; and file every incoming message with the patient chart.

This Essential Practice Tip was based on the Best Practices: Patient Safety issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Your Handwriting: A Breeding Ground for Error?

It is axiomatic that doctors tend to have poor handwriting; they write hastily and under pressure, and it’s little wonder that communication errors often result and that patient safety may be compromised. But the credentialing committee of St. Joseph’s Hospital in Tampa, Florida, is taking steps to solve the problem. Physicians who apply to the hospital are required to write out a paragraph so that committee members can see their handwriting. If it’s not legible, the applicant is required to take a handwriting course as part of his or her credentialing process. And having an electronic medical record can’t exempt doctors from this requirement; as Elaine Fantle Shimberg, current chairman of the hospital foundation, says, this hospital already has electronic medical records, but nurses still have to read the physicians’ handwriting.

This Essential Practice Tip was based on the Best Practices: Patient Safety issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Assessing Your Practice’s Safety

If you think you’re already doing a good job with patient safety, it may be eye opening to get another opinion–a thoroughly objective one. For example, internists who are members of the American College of Physicians can use ACPNET, a Web-based quality improvement program that helps doctors incorporate evidence into practice, teaches them how to implement quality improvement, and offers support. The ACPNet analysis can reveal things about your safety practices that may astonish you. For example, an analysis might show that your practice’s diabetic patients aren’t getting regular eye and foot exams and A1c monitoring. Dr. Amir Qaseem, senior medical associate in ACP’s clinical programs and quality-of-care department, says that a doctor’s first reaction is often denial: “The data must be wrong. This cannot be my practice data.” But once you realize the data is in fact yours and is accurate, then you’re ready to make some positive changes.

This Essential Practice Tip was based on the Best Practices: Patient Safety issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Two Steps to Medication Reconciliation

An important element in ensuring patient safety is medication reconciliation, which is a two-step process. The purpose is to keep your practice current on what medications your patients are actually taking. If you haven’t seen Mr. Smith in a year, he may have been prescribed new medications by his dentist, ophthalmologist, psychiatrist, or others–or he may have stopped taking a drug. He may have started taking over-the-counter medications that could affect his health. All these changes need to be logged into his record. The first step is for you or other staff member to make a list of his current medications. The second step is to compare, update, and reconcile that list with any other lists from a hospital, walk-in clinic, or other facility where Mr. Smith has been treated. Since a medication list is not always updated at each step as the patient moves through the healthcare system, your practice’s regular medication reconciliation is a critical necessity for patient safety.

This Essential Practice Tip was based on the Best Practices: Patient Safety issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Marketing for the Primary Care Physician

Overcoming Your Bias Against Marketing

Many primary care physicians think they don’t have to market their practice–or themselves; they consider it inappropriate for their profession. However, according to Patrick Buckley, author of Physician Entrepreneurs: Marketing Toolkit, that’s not the case. “The market is changing. All of a sudden you’re going to get up in the morning and say, ÔA third of my patients are going to Walgreens. How did this happen?’”he says. That’s why you need to treat your practice as a business even though it may take you a little while to get comfortable with the idea. Times have changed, and you need to understand that marketing is now an imperative–and the Internet is an important part of the picture. Patients have no problem with doctors going online; that’s where they look for health information anyway–so the reality is that you need to get past your bias and figure out how to make the right marketing moves that fit your style, your budget, and your goals.

This Essential Practice Tip was based on the Marketing for the Primary Care Physician issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Tips for creating your own blog

If you decide that a blog is a suitable marketing tool for your primary care practice, here are a few tips for creating one. First, focus on providing content that you know will be useful and interesting to your target audience. Second, keep it topical by tapping into what you see on the evening news, in the paper, or in your practice. Third, keep postings brief–usually just a few paragraphs. Fourth, offer tips, comment on newly published medical findings or research, and supply links to online news articles. Fourth, drive traffic to your blog by including your blog’s Web address in all your marketing materials. Fifth, make sure that any other sites that include your online ID have updated information and contain a link to your Website. Finally, it’s best not to try to outsource your blog to an employee ghostwriter; instead, you might invite all your practice’s physicians, nurse practitioners, and other staff to take a turn at it on a rotating basis.

This Essential Practice Tip was based on the Marketing for the Primary Care Physician issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Testing Your ‘Brand’ Message

Once you come up with a description of your primary care practice that is your “brand”message, you need to make sure that message matches up with what your patients feel about your practice and what they want from it. Develop several short statements that express the message–for example, “We make healthcare painless.” Then test each variant of the message with your patients, either in one-on-one conversations or in a group. Lead the discussion yourself. Ask, “What does this message mean to you?” “Does it motivate you?” “Is there anything in it that confuses you?”and “Would this motivate you to take action?” Listen carefully to their comments, then ask them to select the one message that they think works best. With this kind of patient input, and this degree of research, you should end up with a brand message that accurately and positively reflects your practice. Now you’re ready to use that message in all your marketing efforts.

This Essential Practice Tip was based on the Marketing for the Primary Care Physician issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Seven Referral Strategies that Really Work

In order to keep your name in front of the people who refer patients to your primary care practice, follow these seven useful tips: 1. Add referral sources to your patient newsletter mailing list. 2. Meet each doctor who refers patients to you, take colleagues to lunch, and network at professional meetings. 3. Demonstrate your expertise by lecturing in the hospitals of referring doctors or at large practices. 4. Make sure you’re easy to work with so that other doctors will want to do business with you. 5. Make sure that referring physicians receive copies of your notes, tests, and diagnoses. 6. Make it a two-way street by referring your own patients to the doctors who refer to you. 7. To deliver a personal thank-you to referring doctors, phone them or seek them out at a meeting.

This Essential Practice Tip was based on the Marketing for the Primary Care Physician issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Writing a “Tip Sheet”

A simple marketing tool that will promote your primary care practice and earn it some valuable publicity is to write a “tip sheet” and offer it to your local newspaper or other media. The “tip sheet” can be the topic for a press release and is an ideal way to share helpful medical information with the community—for example, “Six ways to prevent dry skin in winter.” Start by introducing yourself: “Dr. Henry Jones, an internist at the Smith Medical Center, offers the following tips for lowering your cholesterol without medication.” Then list your tips with bullets or numbers, using a “do” and “don’t” format for the list. Finally, back up your tips with statistics and quotes from authorities. And conclude with a paragraph describing your practice.

This Essential Practice Tip was based on the Marketing for the Primary Care Physician issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Your Practice Website

If you have a Website for your primary care practice, make sure it offers a visual representation of your brand “look” and personality. For example, one doctor who wanted to be perceived as informal, friendly, and relaxed put personal photographs of herself and her family on her Website. While your site can simply include the basics—physician biographies, testimonials, frequently asked questions, driving directions, specialty areas, and contact information—practices are increasingly adding information and patient forms to their Websites. Patients can print out the forms they need, fill them in, and bring them along to their next appointment. In addition to patient scheduling, you might consider adding practice policies and procedures, how to contact a doctor after hours, and even information on lifestyle choices that can improve health or prevent problems, such as diet and exercise resources. Some doctors are even adding videos and podcasts (audio recordings) to their Websites to aid patient education.

This Essential Practice Tip was based on the Marketing for the Primary Care Physician issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Consider Public Speaking

A great way to promote your practice to potential new patients is to do a little public speaking—such as addressing a local civic group like Kiwanis or Rotary. It’s a chance to educate the public about your own pet health topic. Toastmasters International suggests the following tips when you make the leap to public speaking. First, know your material. Pick a topic that interests you, and present it with humor and personality, in conversational language. Avoid medical jargon. Practice your speech out loud, and make revisions as often as necessary. Practice with a timer to make sure you won’t run over. Know your audience. Greet some of them as they arrive; it’s easier to deliver your speech to friends than to strangers. Keep in mind that your audience wants you to succeed—they’re on your side! And don’t apologize for your nervousness; chances are, nobody even noticed. The more you speak in public, the more comfortable—and the more skilled—you’ll become.

This Essential Practice Tip was based on the Marketing for the Primary Care Physician issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Your Practice and Sponsorships

A cost-effective way to reach potential new patients is for your practice to sponsor some kind of public event. But before you decide what to sponsor, consider your practice’s image. If one of your hallmarks is promoting preventive care, don’t sponsor an event that will showcase risky behavior, such as an auto race, even if the demographics are a good fit. But there are plenty of other sponsorship opportunities that may be right for you. Geriatricians might have a presence at events hosted by a local group that advocates for the elderly. A cardiologist’s staff could volunteer at a 10K run, wearing t-shirts promoting your practice. Fundraising luncheons, sporting events, cultural performances, health expos—the possibilities are limitless. Just ask yourself these questions first: Is this sponsorship a good fit with my practice and our goals? Does the sponsorship reach our target audience? Will it help my practice reach our marketing goal? Can we afford it? And, very important, what is the track record for this event? Talk to past sponsors and ask if they’d do it again—then ask why or why not.

This Essential Practice Tip was based on the Marketing for the Primary Care Physician issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Assessing Your Marketing Plan

Once you’ve put a marketing plan to work in order to promote your primary care practice, you’ll want to have some form of assessment tool to find out what’s working and what isn’t. For example, if your goal is to increase patient satisfaction, you should conduct a fresh round of research with patients a year after your program starts in order to measure the results. For most practices the challenge will be gathering the information you need, recording it appropriately, and then monitoring your progress for trends and patterns. Practices that make this a priority and pay attention to the data soon learn what they’re doing right and what needs fine-tuning. The result is an ever-evolving marketing plan that keeps your practice on its toes and delivers precisely the kind of care that your patients value most.

This Essential Practice Tip was based on the Marketing for the Primary Care Physician issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Conducting Patient Research

Once you ’re committed to marketing your primary care practice, you ’ll need to do a little patient research before you ’re ready to develop a marketing plan. Start with your patient database that gives age, marital status, hometown, and employer. These data will reveal details about the people who seek your care, details that will help you target your marketing. For example, you may discover that a high percentage work for the same company. This may lead you to host a lunch-hour workshop at that company to draw even more patients. Your research should include anonymous questionnaires or focus groups to find out what your patients do and don ’t like about your practice. Seeing things from their point of view is critical, according to Linda Pophal, CEO of Strategic Communications in Chippewa Falls, Wisconsin: “We need to understand patient perceptions and determine patient goals, then make changes within the practice according to patient needs,” she says. Nationwide, there are three patient hot buttons: the quality of service you provide, the accessibility of your team, and the degree to which patients are treated courteously. Short, specific questionnaires can give you the answers you need.

This Essential Practice Tip was based on the Marketing for the Primary Care Physician issue of Doctor’s Digest. Click for expanded information from the specific chapter.

What About a Blog?

A blog is a type of Website that lets you communicate directly with an audience by typing news, opinions, and other information into a Web-based template on a regular basis. If a blog might work for your primary care practice, you should plan to post a new message at least twice a week so that it’s always current and gives patients a reason to keep coming back. Blogs are a great way to establish your reputation as a trusted source of information on a specific healthcare topic. A well-written, frequently updated blog can build credibility in the local community and can serve as a stepping-stone to regional or national speaking, specialty leadership, or publishing opportunities. Blog content can also boost a practice Website’s ranking with search engines, helping patients find you more quickly. Maintaining your blog right on your Website can greatly enrich the site. So consider creating your own blog—a dynamic marketing tool.

This Essential Practice Tip was based on the Marketing for the Primary Care Physician issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Your Practice as a ‘Brand’

A description of your practice’s personality is called a “brand.” And defining your brand is an essential step in marketing your primary care practice. Do you want your practice to be known as warm and caring, cool and clinical, or maybe a combination of the two? David Miller, a partner in a brand-consulting firm in Seattle, recommends conducting an “experience audit” to learn what in your practice creates an impression on patients. For example, are all the parking spots closest to your entrance reserved for doctors? If so, you obviously shouldn’t try to brand yourself as a practice that puts patient needs first; otherwise, they’d get the priority parking! Assess the actual personality of your practice—relaxed? Engaging? Conservative? Nurturing? Then describe it in somewhat emotional language—not just “We provide good care” but “We treat our patients like family.” Finally, your brand needs to match up with the reality; your patients will know at once if it doesn’t. Once you have the right “brand” message, reflect that message in everything you do—stationery, logo, Website, patient forms, even staff apparel.

This Essential Practice Tip was based on the Marketing for the Primary Care Physician issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Primary Care and the Medical Home

Medical home: It Takes a Village

Certainly primary care physicians have much to gain from the medical home concept. But what about specialists, and what about hospitals? Elliot S. Fisher, MD, director of the Center for Health Policy Research in New Hampshire, says there’s no point in instituting the medical home without a “medical neighborhood” to go along with it. He points out that Medicare and other payers think of the medical home as a zero-sum game: Increased payments to primary care doctors will be offset (at the very least) by reduced payments for unnecessary ER visits, inpatient admissions, and specialty visits. As a result, the medical home may not be warmly embraced by either hospitals or specialists. If the incomes of other providers continue to depend on volume, the ability of primary care doctors to change the system singlehandedly is going to be limited.

This Essential Practice Tip was based on the Primary Care and the Medical Home issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Primary Care in Crisis

The medical home model of care is being promoted, not only as a real boon to patients and a potential cost-cutter for the entire healthcare system, but also as an essential lifeline for a beleaguered profession. Last year the American College of Physicians combined two alarming sets of statistics in a white paper: the increasing patient population, especially those over 65 with chronic illnesses, and the shrinking pool of primary care physicians. The ACP concluded that the primary care profession is on its way to oblivion without drastic action. In a recent 9-year period, the number of medical school graduates in this country who entered family medicine residencies plummeted by 50%. And just a decade ago, more than half of third-year internal medicine residents planned to practice internal medicine; recently that figure had dropped by over 50%. Making matters worse, many primary care physicians are choosing early retirement—11% in the next three years. And another 20% plan to cut back on the number of patients they see. The medical home, by transforming the way primary care is delivered, may offer fresh hope.

This Essential Practice Tip was based on the Primary Care and the Medical Home issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Payers and the Medical Home

Should you be paid for volume—or for results? According to Robert Zirkelbach, a spokesman for AHIP, “There’s widespread agreement from stakeholders across the board that the current payment structure is not providing the right incentives in our healthcare system. We need a system that rewards quality and value. There is a growing momentum to look at the payment system and see if we have the right incentives in place.” One idea is to have a comprehensive annual payment based on the size of a physician’s patient panel, risk adjusted so that those with sicker patients get paid more. The base payment would be enough to support the entire care team that is the basis of medical home care, and also the necessary computer technology. The source of this idea, Dr. Allan Goroll of Harvard Medical School, envisions that the base payment would be at least forty percent more than what most primary care practices are now making on a fee-for-service basis. The second part of his plan would be a bonus of up to twenty-five percent of the base payment for achieving quality goals, outcomes standards validated by national groups, patient satisfaction measures, and cost-and-efficiency targets. The bonus would be risk adjusted, too, so that there would be a bigger reward for improving the health of a patient who was very sick to start with.

This Essential Practice Tip was based on the Primary Care and the Medical Home issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Medicare and the Medical Home

No single agency is more influential in changing the face of medical care in this country than the Centers for Medicare and Medicaid Services, or CMS. And this is the year in which CMS is starting to test the medical home concept. Over 400 practices are being recruited in eight states, with a goal of 2,000 physicians, to revamp their practices to provide medical home services. In addition to their usual fees for Medicare services, these practices will receive extra payments ranging from forty to a hundred dollars per patient per month, depending on the level of services provided and how much care is needed. CMS estimates that participating physicians will care for an average of 250 Medicare patients each. Since the medical home concept puts some onus on patients, especially those who are chronically ill, to participate in their treatment, patients have to agree to be part of the trial. The extra payments will begin at the start of next year and continue through the year 2012.

This Essential Practice Tip was based on the Primary Care and the Medical Home issue of Doctor’s Digest. Click for expanded information from the specific chapter.

EMRs: Apples-to-Apples Uniformity

One of the most frustrating aspects of the electronic medical record, or EMR, is that sharing information from one system to another can be infuriating or even impossible. Many products out there don’t adapt to each other or to new uses. And now the medical home model will impose new needs—for example, can your practice pull up a list of your patients who share certain characteristics? If the information has been entered properly, it should be easy; otherwise, it may be impossible. The good news is that EMRs have a standard-setting body called the Certification Commission for Health Information Technology, or CCHIT, an independent, not-for-profit organization that is a leading candidate to be responsible for certifying EMRs under the provisions of the American Recovery and Reinvestment Act. An EMR that is CCHIT-certified will store data in certain standard ways so that it can be easily pulled out for reports or passed on to another system. For a list of systems that have passed CCHIT certification tests, visit cchit.org online.

This Essential Practice Tip was based on the Primary Care and the Medical Home issue of Doctor’s Digest. Click for expanded information from the specific chapter.

The Medical Home and Enhanced Work Life

Can your work life be enhanced if you shift your practice to the medical home model? Doing so can make the day less fractured and may give you, your nurses, and midlevel providers a chance to build stronger relationships with your patients. The medical home model implements computer technology effectively, uses doctors only where their training is absolutely necessary, and relies on patient education and coaching to prevent and help treat chronic illness. If it works as it should, your patient panel will shrink, making your day a lot less frantic; but since you’ll still be paid to manage each patient, your income won’t shrink and, in fact, should grow. Visits will be longer, but there will be less need for follow-up. Computer technology and the use of extenders will mean that much of what’s done will not be done by you. As Paul Keckley, PhD, executive director of the Deloitte Center for Health Solutions, puts it, “The doctor has to change strides and become a leader and a manager instead of a clinician. It’s a different business. It puts primary care physicians in exactly the role they want to be in—coordinators of care, managing a team to get a result for which they’re paid based on outcome. It rewards their skill in clinical management rather than their ability to juggle 39 patients a day.

This Essential Practice Tip was based on the Primary Care and the Medical Home issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Subsidizing Care with Auxiliary Businesses

If you’d like to shift your practice to the medical home model, but you haven’t found a way to pay all the bills, consider the example of the Romeo Medical Center in Turlock, California. Its solution was to include some auxiliary businesses that subsidize their family practice. These businesses include a sports medicine practice and a corporate wellness and occupational medicine program. The doctors–two brothers and a sister–also have ownership interest in the building where their clinic has its home. This building also houses a pharmacy, a dentist, and other tenants associated with a healthy lifestyle. The practice has found that those extra businesses enable it to balance the books, allowing it to subsidize medical home-style care for its two thousand patients with the help of eight medical assistants, a part-time dietician, and a part-time behavioralist. “Our practice is fun,”says president and co-founder Mike Romeo, MD. “We’re not frustrated, we’re not disenchanted, and we enjoy what we do.”

This Essential Practice Tip was based on the Primary Care and the Medical Home issue of Doctor’s Digest. Click for expanded information from the specific chapter.

An Easy Way to Measure “Medical Homeness”

The Center for Medical Home Improvement, or CMHI, offers a self-assessment tool that is one of the easiest ways to start your practice on its way to becoming a medical home. CMHI’s criteria encompass six areas, with four levels of “medical homeness” identified in each area. For example, consider communication and access. If your practice is only at level one, communication between the family and the primary care provider occurs as a result of the family’s inquiry. If you’re at level two, your practice is already using standardized office communication methods with the family—such as phone triage for questions or provider callback hours. If you’ve reached level three, your practice and the family are communicating at agreed-upon intervals, and both have agreed on a best time and way to contact each other. Finally, if you’re all the way up to level four, your office activities encourage individual requests; and access and communication preferences are documented in the care plan and are used by other practice staff—for example, fax, e-mail, or Web messages, and home, school, or residential care visits. For more information, go online and see medicalhomeimprovement.org.

This Essential Practice Tip was based on the Primary Care and the Medical Home issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Medical Home: Building from Scratch

When pediatrician Xavier Sevilla finished his residency in 1999, he went to work in a community health center, where his ideas of partnering with patients collided with harsh reality: “We had long waits, frustrated and angry patients, and basically a chaotic care environment,” he says. So he tried to fix it. This effort led him to join the AAP’s quality improvement steering committee and later the committee that devised the principles of the medical home model of care. This in turn inspired him to build a medical home from scratch once his center opened a satellite office. Within a year he had grown this office to 1500 patients, adding a nurse and a nurse practitioner. All along he experimented with the various elements of the medical home: open access, electronic communication, quality measurement, and comprehensive care. The practice reached the financial break-even point last summer and is now showing a profit. Dr Sevilla couldn’t be more pleased. “This is what I thought practice would be like,” he says, “when I was a medical student.”

This Essential Practice Tip was based on the Primary Care and the Medical Home issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Concierge Lite and the Medical Home

When an experimental practice model fails, you may get it right the next time if you relocate and adjust your new model based on what you’ve learned. That’s what happened to Doctors Rushika Fernandopulle and Pranav Kothari. They had taken out second mortgages and invested a million dollars in a primary care practice near Boston. That medical-home model combined the best of the small-town doctor tradition with up-to-date information technology. It offered personalized health assessments, group visits, online medical records, and lots of direct communication. They charged a monthly fee—$55, adjusted for those who couldn’t afford it—on top of what they billed insurers, a format they called “concierge lite.” In two years they had built up to about 450 patients, but insurance companies gave them negative feedback, and they called it a day in late 2006, with three key lessons. First, they moved to another state, and they are now implementing their care model in the Atlantic City area. Second, they now focus on invitation-only, chronically ill patients, who benefit most from their kind of intense personal attention. And third, they now take a firmer stand on the need to restructure the financing system to encourage desirable patient behavior.

This Essential Practice Tip was based on the Primary Care and the Medical Home issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Will the Medical Home Improve Patient Care?

At this point, only a small number of practices in this country have become medical homes, and the medical home model hasn’t yet been studied extensively; but evidence suggests that the model really works and can improve the care you give your patients. A study of the available literature published late last year in Pediatrics concluded that medical homes can lead to better health status, better timeliness of care, more family-centeredness, and improved family functioning for children with special needs. However, after combing through 33 studies, the authors concluded that none of them looked at the medical home in its entirety, and the studies used varying definitions for elements of the medical home.

This Essential Practice Tip was based on the Primary Care and the Medical Home issue of Doctor’s Digest. Click for expanded information from the specific chapter.

The Medical Home: ‘Just Another Gatekeeper concept?’

If you’re a primary care physician with a long memory, you may think a medical home sounds too much like the “gatekeeper” concept from the early days of managed care. In those days part of your front-line job as a primary care physician was to keep patients from getting expensive specialty care unless it was really critical. But the medical home is different because it is voluntary for both patient and physician. Patients will be able to bypass you and go directly to a specialist if they choose. And unlike the per-patient “capitation” payments that you received each year from HMOs, medical home reimbursement will try to confine any physician risk to factors within your control. What’s significant here is that the medical home idea came, not from payers, but from physicians themselves.

This Essential Practice Tip was based on the Primary Care and the Medical Home issue of Doctor’s Digest. Click for expanded information from the specific chapter.

What Patients Consider Important

Last year the Patient-Centered Primary Care Collaborative conducted a survey to find out from over 2,000 patients exactly which elements of healthcare they care most about. The results may intrigue you. Ranked “extremely/very important” by 67% of respondents was “the ability to have a relationship with a doctor who takes a whole-person approach to patient care (social, mental, and physical) and who provides care for all levels of health, including unexpected illness, emergency care, chronic care, and preventive care.” The next most important element, as ranked by 59% of the respondents, was “same-day appointments with the primary care physician for unexpected illness.” Third was “disclosure of cost and quality of physician services.” Fourth was “technology that enables doctors to securely share medical records and histories with other specialists.” One of the lowest-ranking elements, evaluated as “extremely/very important” by only a third of the respondents, was “appointments with primary care physician on evenings and weekends.”

This Essential Practice Tip was based on the Primary Care and the Medical Home issue of Doctor’s Digest. Click for expanded information from the specific chapter.

EMRs and the Disease Management Population

Any practice changing to the medical home model will benefit greatly from using computers to focus on and identify a specific disease management population. And the pressure’s on, since Medicare’s home demonstration project won’t even consider a practice that doesn’t have EMRs. Assessing the right information at the right time is key, says Barbara Morris, MD, chief medical officer at Community Care Physicians in Latham, New York. “It’s impossible to have a medical home without electronic support if you have a large patient population,” she says. “An overloaded primary care physician taking care of the urgencies of the day doesn’t have a good, reliable way to know what types of patients he or she has, and which ones have specific issues in common that constitute a disease management population.” One practice uses Allscripts to collect basic data in patients’ records; it then “mines” that information to analyze the patient population and track performance. The right EMR system can easily do both, because physicians enter as much data as possible by simply filling out boxes or clicking buttons rather than typing or dictating notes. As a result, the system can quickly find the data it needs to build a database and produce reports.

This Essential Practice Tip was based on the Primary Care and the Medical Home issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Step Back and Assess Your Routine

Converting your practice to a medical home model can reveal room for improvements that are extremely easy to make. Just stepping back to assess your usual ways of doing things can be a revelation. Diane Cardwell, a TransforMED practice enhancement facilitator, begins her work with practices by doing an assessment in areas like work coordination and outside communication. When one practice she worked with started tracking its phone calls, the staff realized that messages sometimes went in a complete circle: from call center to nurse to doctor, then back to nurse, back to call center, then to the patient, and back again! When the staff created some standard protocols to deal with common problems that resulted in that kind of phone runaround, they managed to reduce their volume of phone calls by ten percent, saving time and reducing frustration for both staff and patients.

This Essential Practice Tip was based on the Primary Care and the Medical Home issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Computers and the Small Practice

Computers may not be outside your patients’ reach. Even physicians in small practices are discovering that they can offer their patients the benefits of sophisticated computer access. Dr. Joseph Mambu, a family practice physician in Lower Gwynedd, Pa., has been experimenting recently with a Web portal that lets patients review their own records, make appointments, and communicate with him and his staff. Because his reimbursement structure doesn’t allow time for him to swap e-mails with 3,000 patients, he is currently charging each patient $6.50 a month for the portal. Five or six dozen of his patients are willing to pay the fee so far, and he says it’s working great for them.

This Essential Practice Tip was based on the Primary Care and the Medical Home issue of Doctor’s Digest. Click for expanded information from the specific chapter.

The Medical Home: A New Kind of Patient Care

The medical home is a new way to deliver patient care that is gaining momentum. It’s built on the idea of patient-centered care, which will allow physicians to focus on patients instead of patient volume. What is very different about the medical home concept is that you can often deliver patient care without an office visit. Patient care can occur by phone, e-mail, or text message. It might also take place in a group education session or even on a house call. The most startling part is that sometimes you, the doctor, won’t even have to be there! Most routine care—including immunizations, sore throats, and school physicals—will be shifted to nurses, medical assistants, or case managers. As a result, you will be able to focus your time, energy, and clinical insight on complex situations that make the most of your training. As one happy Florida pediatrician, Xavier Sevilla, put it, after building a medical home from scratch, “This is what I thought practice would be like when I was a medical student.”

This Essential Practice Tip was based on the Primary Care and the Medical Home issue of Doctor’s Digest. Click for expanded information from the specific chapter.

EMRs and the Medical Home

An EMR is essential to the medical home concept. But don’t feel bad if your practice has waited until now to invest your money, time, and effort to convert to an EMR system; that decision may actually prove to be to your advantage. Most EMR systems were originally designed to help with coding and billing rather than managing patients, according to Dr. Terry McGeeney, president and CEO of TransforMED. And while vendors are now learning how to tack medical home-friendly capabilities onto their existing products, some experts say they haven’t yet embraced the needs of the medical home as they need to do. A medical home’s EMR will need to generate reports so that outside parties can measure how the practice is doing, especially as pay-for-performance enters the reimbursement picture. In order to assess how a practice is performing, quality reports have to become a part of the regular workflow, and not just an added component. The larger EMR vendors know what they need to do for the medical home, and they’re working on it.

This Essential Practice Tip was based on the Primary Care and the Medical Home issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Accurate Billing and Coding

Avoiding Billing Problems

According to experts, staffing properly may be the most important way to avoid billing problems. Billing and coding accuracy need to be considered at the time you hire your staff and assign their functions. Debbie Sword, a certified coding and billing specialist, says a practice should consider having one person take care of both the billing and posting of funds. “Don’t let someone who has nothing to do with accounts receivable post the payments,” she says, “because they won’t recognize [when something has gone wrong].” Ms. Sword feels that billing shouldn’t be done by multitasking front-desk staff, even if it’s cheaper for doctors to organize staff that way. “I’m a big advocate that the billing should be in back,” she says, “away from the front desk. Those doing it at the front desk are also checking in patients and doing data entry. It’s too confusing.” Some revenue problems start because the coding and billing departments are separate, says Deborah Grider, a consultant and president of the National Advisory Board of the American Academy of Professional Coders. “We’re turning out coders who don’t have a clue what an Explanation of Benefits looks like,” she says, or what a Medicare denial looks like, or how to go through the appeal process. And if coding and billing staff do have to be separate, they at least need a good working knowledge of each other’s jobs. There needs to be good communication among doctor, coder, and biller to make sure the practice gets the money that its doctors have earned.

This Essential Practice Tip was based on the Accurate Billing and Coding issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Tiered Physicians

Some practice administrators are now using coding to track productivity among individual physicians by employing a relative value unit for each CPC code. Nancy Enos, an independent consultant who has worked with the Medical Group Management Association’s Healthcare Consulting Group, believes that since coding is linked to a doctor’s productivity, it can be a fair way to compensate that doctor. Payers may use coding to put doctors into “tiers,” or levels, depending on their analysis of the doctor’s efficiency and quality of care. Dr. Gerald J. Russo, chief medical officer of Bloodhound Technologies, a claims-editing provider, reports that in New York State during early 2008, some managed care companies began dividing physicians into “quality” and “non-quality” networks. The insurance companies set their own parameters and place a doctor in their quality network if he or she meets certain criteria. Patients who choose a physician in the quality network get a reduction in their co-pay. Since many patients are likely to choose doctors who require a lower co-pay, this practice has real ramifications for physician reimbursement.

This Essential Practice Tip was based on the Accurate Billing and Coding issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Coding and Physician Report Cards

Coding data reaches far beyond reimbursement; today it can also be used to generate physician “report cards” and to analyze quality-of-care issues. While physician report cards are generally an inpatient phenomenon, they sometimes extend to the outpatient setting as well. Donna D. Wilson, a senior director at Compliance Concepts, a company that helps healthcare organizations comply with federal coding regulations, offers as an example an analysis that examines total joint replacements in a hospital setting. This analysis can identify the best-performing physicians in regard to length of stay, readmission rate, resource consumption, complication rate, morbidity, and mortality. After drilling down the statistics by physician, the hospital will be able to compare trends and patterns for all physicians in a given department. Dr. A’s patients might have a 3-day average length of stay, while Dr. B’s patients stay 6 days. Neither has a difference in complication rate or mortality. Consultation with Dr. B reveals a key difference: Dr. B. usually orders additional tests that could be performed after discharge, in an outpatient setting. This kind of analysis can lead to a change in practice habits that reduces the use of healthcare resources and can actually improve quality of care.

This Essential Practice Tip was based on the Accurate Billing and Coding issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Doctor’s Role in Coding

Most doctors view coding as a necessary evil. According to Patricia Hubbard, CPC, a medical practice manager in New York State, most would rather take care of their patients and work on what they were trained to do. But once they realize that proper coding can affect not only reimbursement, but also quality ratings, they sit up and take notice. Even if you don’t do procedural coding, you should be familiar with CPT descriptions and guidelines for the procedure codes that pertain to your specialty. According to Dr. Gerald Russo, chief medical officer at Bloodhound Technologies, a claims editing company in North Carolina, doctors at the very minimum should do their own code assignment for the evaluation and management service. “In the best functioning office,” he says, “the doctor assigns the code on a routing slip.” Then the coding and billing specialist checks it to see if there are any questions about over-assigning or under-assigning, and the specialist gets back to the doctor with any concerns. To make it easier, your office should print commonly used codes for your specialty on the superbill. You can then simply check off items on the charge sheet so that it’s ready for billing. Although only 50 percent of physicians use superbills, they can be invaluable in making coding more convenient and more accurate.

This Essential Practice Tip was based on the Accurate Billing and Coding issue of Doctor’s Digest. Click for expanded information from the specific chapter.

More Accurate Coding

How can doctors ensure that they are coding as accurately as possible? Donna D. Wilson, a senior director at Compliance Concepts, a company that helps healthcare organizations comply with federal coding regulations, recommends that the coding staff at the physician practice set up roundtables to discuss coding issues. When the hospital coding staff and the physician’s staff combine their efforts by conducting their own self-audits, they can cut down on denials from external auditors. Ms. Wilson points out that Medicare Administrator Contractors, or MACs, routinely compare Part A (hospital) and Part B (outpatient) billing to make sure they match. One way to be proactive in protecting your own hospital’s ranking is to respond quickly when queries arise from the documentation specialist or hospital coder. In some places, doctors who habitually fail to respond to such queries find themselves facing a peer review committee. The query process is actually a very useful way for doctors to learn how to improve documentation in order to reflect the actual intensity of the services they provide.

This Essential Practice Tip was based on the Accurate Billing and Coding issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Pay-for-Performance Data

The concept of pay-for-performance is relatively new and is currently applied mostly in the hospital setting, according to Dr. Garry L. Huff, associate director of DRG Review, a national consulting firm. But that may be changing. For a number of years, hospitals voluntarily submitted data on patient treatment; then that data became mandatory, and today hospitals can’t get full payment unless they submit their statistics. Dr. Huff points out that, even though statistics may be reported for the hospital as a whole, rather than by individual physician, if that hospital’s overall scores are not good, they reflect poorly on the individual physicians as well. And keep in mind that these statistics appear on public Websites. According to Dr. Huff, the history of hospital reporting is now repeating itself in the doctor’s office: reporting is still in the voluntary phase at this point. In certain areas, pay-for-performance is already affecting the individual physician. More than half of all health plans now use pay-for-performance, and these plans include 81 percent of all patients enrolled in HMO programs.

This Essential Practice Tip was based on the Accurate Billing and Coding issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Physician Profiling by Insurance Carriers

Physician profiling based on coding data is not confined to hospitals. Some of the larger insurance carriers are now doing their own physician profiling—and the problem is, they aren’t consistent in how they do it. According to Dr. Thomas Felger, a board member of the American Academy of Family Practitioners, “One of the dilemmas we face is that, if there are eight carriers doing it, there are eight systems or criteria that they’re using. And if you don’t know what quirks a company has, you can’t necessarily meet their expectations.” What makes matters even worse is that, according to Managed Care Magazine, the average number of insurance contracts per physician is thirteen. This makes it difficult to keep track of each carrier’s profiling methods, let alone its coding and billing issues. According to Dr. Felger, the impact of physician coding by insurance carriers is at this stage unclear. “If you’re going to rate,” he says, “and pay more or less, based on that [rating], you need to do it correctly. The results have been mixed.” There is an effort to standardize and nationalize the process of physician profiling, but that may be a long way off.

This Essential Practice Tip was based on the Accurate Billing and Coding issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Renewing and Evaluating Managed Care Contracts

When your practice is negotiating or renewing a managed care contract, you can save hassles and money by asking the payer certain questions. For example, will the payer quickly and accurately verify the patient’s enrollment in the plan? You should also carefully check the payment schedule for your most commonly billed procedures to make sure payment will cover costs. And once the contract is in hand, you should develop your own payer report card to make sure payers are upholding their part of the contract, says Deborah W. Keegan, PhD, president of Medical Practice Dimensions. To develop the report card, your practice should track the following: net collections, percent of claims outstanding at 90 days, average number of days until you get initial payment, and actual payment versus contracted payment. Dr. Keegan also suggests keeping a log of administrative costs for each payer. This might include the “contact failure rate,” which looks at how many times your office tried to contact the payer but got a busy signal, for example. Another consideration is whether the payer offers electronic fund transfers. Dr. Keegan says that if a payer is costly to do business with in terms of denials and administrative hassles, your practice may decide either to negotiate for higher payments or not to renew the contract.

This Essential Practice Tip was based on the Accurate Billing and Coding issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Switching to Electronic Records

Is your practice still sending out paper claims to payers? If so, you should really switch to electronic submission, according to Patricia Hubbard, CPC, a New York State medical practice manager. “It’s very affordable,” she says. “The turnaround time is much faster than paper claims, and the clearinghouse confirms that your claims were received by the payer. Paper claims go off in the mail, and you don’t know what happens to them.” She adds that clearinghouses processing electronic claims provide excellent reports. Other advantages of filing electronically include a reduction in manual administrative functions, identification and resolution of potential claim issues before you submit the claim, online claims receipt and tracking, and faster turnaround and payment. A solo practitioner spends about $70,000 a year for manual insurance administration, compared with a cost of only $18,000 for electronic submission, according to a 2003 report from Milliman Technology and Operations Solutions. Cost savings can derive from decreased telephone time for actions like verifying eligibility, preauthorizing care, checking claims status, and filing claims. The report estimated that a clean electronic claim costs $12.90 while a similar paper claim can cost as much as $6.63.

This Essential Practice Tip was based on the Accurate Billing and Coding issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Variations in Coding Practices

We know that coding is now being widely used to analyze trends in healthcare and to assess physician performance. But the problem with relying on coding data is that, while all physicians may be using similar codes, all of them aren’t coding in quite the same way. A small-scale study in 2006 checked the coding in five ophthalmology case presentations among three physicians. Even though all three were using a computerized coding system in conjunction with an electronic medical record, they chose the same codes only 44 to 53 percent of the time. The authors of the study suggested that physician training, technological improvements, and refinement of terminology will help increase reliability. According to Donna D. Wilson, a senior director at Compliance Concepts, a company that helps healthcare organizations comply with federal coding regulations, doctors usually welcome feedback about their coding and documentation. And improvement starts when they become involved in the process. Ms. Wilson offers as an example the physician whose operating room time ran 20 minutes longer than his peers for the same procedure. After discussion, that doctor came to realize that the clock began ticking as soon as he entered the OR. Instead of being “Mr. Friendly” and chatting while setting up his iPod, he now does those things before he enters the OR—and his data has improved as a result.

This Essential Practice Tip was based on the Accurate Billing and Coding issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Why Accurate Codes Matter

When doctors think about coding, the first word they associate with it is likely to be “reimbursement.” Obviously, the codes you choose dictate how much the payer will give you for services provided. But today codes are used for a lot more than reimbursement, and if you’re not highly accurate in your choice of codes, it could actually hurt your public reputation. Gary L. Huff, MD, associate director of DRG Review, a national consulting firm that provides coding quality assessments, says that the three biggest issues in coding are, first, payment, then compliance—that is, making sure you’re neither overpaid nor underpaid—and third, performance quality, which is being monitored by payers. Coding data is used to compare physicians and healthcare institutions on both quality of care and patient outcomes. Your codes become part of the hospital record and are used to measure performance. For example, 30-day mortality rates are reported for public information for specific diagnoses and surgeries. If you’re a physician associated with a hospital that has an excessive 30-day mortality rate relative to risk, people aren’t going to want to use you, Dr. Huff points out. Like it or not, there are more and more Websites that profile doctors on the care they’re delivering. And your coding could make a big difference.

This Essential Practice Tip was based on the Accurate Billing and Coding issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Why Documentation Matters in Coding

Documentation is the basis for coding. But doctors don’t always include enough documentation to support their codes. Nancy Enos, FACMPE, a consultant and coding instructor in Rhode Island, says that you should make sure your medical record meets two requirements: One, is it complete? And two, does it prove the treatment was necessary? Another coding expert, Marie Felger, CPC, based in Indiana, notes that what doctors have the most trouble documenting is history of present illness. “If patients have a multitude of problems,” says Ms. Felger, “they’ll likely need the highest level of service and [the doctor] should code for that. If doctors haven’t documented the history of present illness well enough, it’s going to limit [patients] to a lower level of service.” For example, she says, suppose you cite abdominal pain as the chief complaint. That one element is not enough to justify a higher level. Instead, you need to say something like “Lower abdominal pain, moderate severity, going on for two days, and it’s constant.” Those would be enough elements to get you to that higher level. If you carefully document your extra time and work, the coder can account for them in the claim and ethically ask for more money. Otherwise, if your coder doesn’t have the information, you wind up not being paid for your actual services.

This Essential Practice Tip was based on the Accurate Billing and Coding issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Time Management

Exam Room Signal Systems

One of the best ways to increase your productivity may be as simple as installing an inexpensive flag system outside your exam rooms. Rob Scroggins, a consultant with Cincinnati-based Clayton L. Scroggins Associates, says an exam room flag or light system in the hallway can significantly improve patient flow. “Staff should never be standing around waiting for doctors to come out of exam rooms,” he says, “to be told what needs to be done next.” Nor should doctors spend time looking for staff members to give instructions. It’s a useful visual signal to flag your exam room to indicate that a patient is ready to be prepped for a procedure, or that the room is ready to clean. Installing a light system can be expensive, but color-coded flag systems are easy to install and can cost as little as $50 per room. On the other hand, a Texas doctor who averages 40 office visits a day, all between 8 am and 4 pm, attributes his ability to see so many patients to the practice’s light-buzzer system. Each time he leaves the exam room, he pushes a button that sounds a buzzer at the nurse’s station. He says it’s this “beep-beep” that keeps his practice moving.

This Essential Practice Tip was based on the Time Management issue of Doctor’s Digest. Click for expanded information from the specific chapter.

How to Say No

Physicians have a hard time saying no. But learning to say no effectively may be the only way you can achieve a balance between your life and your work. Nationally recognized speaker Pam Vaccaro of St. Louis, Missouri, says that saying no is really about being honest. If your answer is an unequivocal no, then just say it—firmly and politely. Ms. Vaccaro suggests these words: “Thank you for thinking of me, but no.” No explanation necessary—end of sentence! If you need time to consider a request, say that. For example, she suggests, “I’d like to think about that and get back to you.” But don’t use this tactic simply to get rid of someone; use it only if you really want to decide between yes and no. The most respectful way to use this technique, she says, is to let the other person know exactly what to expect: “I’ll get back to you by Friday,” for example. Another technique is negotiation. If you’re asked to volunteer for something you love but don’t have time for, say yes—with conditions. Maybe you agree to participate only during the planning stage and let others take over for executing the plan. Or maybe you know you’ll be best working behind the scenes. Say yes, but clarify exactly what you are willing to do based on your skills, interests, and availability.

This Essential Practice Tip was based on the Time Management issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Managing E-mail

Some doctors consider e-mail an efficient way to communicate; others see it as time-consuming task that isn’t reimbursable and may open them up to liability. Productivity expert David Allen says that you really have two choices: accept e-mail as part of your life and deal with it effectively or get rid of it altogether. If e-mail is going to remain a part of your life—and most likely it is—then learn how to deal with it efficiently. One way is to clean up your e-mail at the end of each day, limiting the time you spend to between 30 and 60 minutes. Keep your backlog as close to zero as possible. If you’re not dealing with it, then the backlog will increase. Use the 2-minute rule: if you can handle an e-mail in 2 minutes, deal with it immediately. Don’t open and reopen it for days—as Mr. Allen says, “Don’t keep on not deciding.” And learn to type fast. According to Mr. Allen, “The keyboard is the most important tool for the rest of your life.” How can you reduce e-mail? One, unsubscribe to anything you don’t routinely read. Two, ask your friends to resist “forwards,” no matter how clever they may seem. Three, install a foolproof spam filter, or else train your assistant to screen and handle e-mail that doesn’t need your personal attention.

This Essential Practice Tip was based on the Time Management issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Screening New Staff

Busy doctors, especially those in solo or small practices, too often hire new staff members based on gut feeling alone. Intuition may be helpful, but a little science can’t hurt. One systematic way to screen new staff is to ask them practice-specific questions during the interview process, according to Rob Scroggins, a consultant with Cincinnati-based Clayton L. Scroggins Associates. Ask how they would handle a situation when the waiting room is full, and the exams rooms are full, and the doctor is running 30 minutes behind. Ask what they’d do if they were at the front desk and four patients were lined up waiting to check in. And how would they prioritize the situation if their co-worker has been out ill all week, it’s Friday morning, you’re backlogged with work, and the work area is a mess? What would they do if a patient demanded to be worked into the schedule for a non-urgent matter? Such real-life situations can teach you a lot about the candidate’s instincts, coping skills, and intelligence.

This Essential Practice Tip was based on the Time Management issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Timing Your Rest

Knowing a little about the body’s circadian rhythms can be helpful to physicians in planning rest. Psychiatrist and sleep medicine specialist Matthew Edlund, of Sarasota, Florida, says that most people are at their best during the mid-to-late morning hours and then again in the early evening. That’s when we should schedule those activities, such as seeing patients, that require the most attention. But the period from early to mid-afternoon is a down time for most of us. We’re pretty bad at multitasking, he says, especially in mid-afternoon, when we tend to make more mistakes. Schedule paperwork and other tasks that don’t require a lot of creativity in the mid-afternoon when energy is likely to flag. During this period, Dr. Edlund says, it is important for physicians to take time to rest. Thirty to sixty seconds of deep breathing can help. Taking three minutes to re-set yourself by walking outside or preparing a cup of tea can also be refreshing in the middle of a chaotic day. “Physicians should spell themselves,” Dr. Edlund says, “especially when things get really crazy.” He recommends taking short naps in the middle of the workday whenever possible. Even five to ten minutes can make a difference. (TM, pp. 21-22)

This Essential Practice Tip was based on the Time Management issue of Doctor’s Digest. Click for expanded information from the complete issue.

The No-Show Patient

If you have a reliable patient population and don’t suffer from an unusually high number of no-shows, then a standard ten-, fifteen-, or twenty-minute schedule may work fine for you. But if you have a patient population that often misses appointments or arrives late, what effect should this have on the way you schedule your patients? Practice management expert Elizabeth Woodcock may have the answer for you. Ms. Woodcock says that if you can comfortably see six patients each hour, and experience a ten-to-twenty-five-percent no-show rate, you should schedule eight patients for the hour instead. “Schedule four at the top of the hour,” she says, “then two more at fifteen minutes after the hour, and two more at half past the hour.” With this system you will always have patients to see, and it’s unlikely that any patient will have to wait too long. At the top of each hour, if all goes as planned, you can start the process over with eight more scheduled patients. According to Ms. Woodcock, many doctors get too focused on the micro level of scheduling. You probably don’t need more than two basic types of appointments—short and long. Forcing your staff to gather a lot of information from patients in an effort to schedule perfectly, she says, is usually a waste of time. (TM, p. 11)

This Essential Practice Tip was based on the Time Management issue of Doctor’s Digest. Click for expanded information from the complete issue.

Staff’s Role When You Fall Behind

When you fall behind schedule in seeing your patients, make sure your front office staff has been empowered to deal with the situation on their end. Your staff can alert patients of the situation upon arrival; and if necessary, they can reschedule those on a tight schedule who can’t wait to be seen. This approach is respectful of patients and may lighten your load temporarily to enable you to catch up. Patients who choose to reschedule should be given the very next available appointment that is convenient for them. In the Shreveport, Louisiana, dermatology office of practice administrator Rhonda Holloway, the practice has one employee who is responsible for rooming patients for all the doctors. This same person oversees who is lagging behind. If a patient waits more than 45 minutes, the office policy is to check the patient’s record to see whether he or she has previously seen another doctor in the office. If so, the patient is given the option to change doctors for that day’s visit or continue to wait. According to Ms. Holloway, forty-five minutes is the magic number; usually by then, the patient has complained to the front desk. “Most doctors try to be so accommodating,” she says, “that they don’t realize when they’ve fallen behind.” But with the staff sharing the responsibility for getting back on the appointment schedule, the situation becomes easier for everyone involved.

This Essential Practice Tip was based on the Time Management issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Scheduling Patients

Experts in practice management often say that a doctor’s most precious asset is time. And the strategic way you schedule your patients can make the difference between efficient and wasteful use of time. As Elizabeth Woodcock, an author and practice management expert, puts it, “The number-one goal is for the doctor to stay busy. There is no CPT code for the doctor’s waiting.” Dr. Helen Kollus, an internist in Cleveland, Ohio, feels fortunate that she was trained during her residency to use a sophisticated electronic medical record system that she still uses in her practice today. She makes it a habit to study her appointment numbers and work flow regularly, then she makes scheduling adjustments to maximize efficiency and best meet her patients’ needs. She has kept data for every year she’s been in practice, and she can use that information to plan her time accordingly. “I can look back month to month,” she says, “or at seasons. Is June different from December? Was two years ago the same as this year? Do I see more patients in the afternoons or mornings?” She says you have to have this kind of solid information to know how your schedule is really working. (TM, p. 10)

This Essential Practice Tip was based on the Time Management issue of Doctor’s Digest. Click for expanded information from the complete issue.

Rest

It’s axiomatic that most doctors don’t get enough rest. Psychiatrist and sleep medicine specialist Matthew Edlund of Sarasota, Florida, says that, as a society, we’re getting an average of ninety minutes less sleep per night than we did forty years ago. “We’ve managed to eviscerate rest,” he says. Many physicians get by on six or seven hours of sleep each night, and some even wear that habit as a badge of honor. Burt Dr. Edlund says we may be giving up more than shut-eye with a late-to-bed-early-to-rise schedule. Dr. Edlund offers a few important reminders for developing good sleep hygiene. One, give yourself enough time to rest. Rearrange your schedule, if needed, and cut back on activities so that you can routinely get as much sleep each night as you would when you’re on vacation. Two, create a good environment for sleep. Invest in a great mattress set, and sleep in a cool, comfortable, relaxing room. Three, become a creature of habit. Get up and go to bed as close to the same time as possible each evening and morning, even on weekends. Four, avoid stimulants. Coffee and other caffeinated drinks keep most people awake. Five, move your body. Exercising in late afternoon or early evening may help you sleep better at night. Six, hide the clock—especially if you have trouble falling asleep.

This Essential Practice Tip was based on the Time Management issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Falling Behind Schedule

No matter how hard you try, some days you’re bound to get way behind in seeing your patients. How much does it matter to them that they have to wait past their appointment time? A 2007 study of more than five thousand patients showed that the amount of time your patient spends with you is more likely to impact his or her satisfaction level than the waiting time. The study found that patients are willing to wait longer without becoming dissatisfied if they feel that, once they are actually with their doctor, they aren’t rushed through the appointment. However, as you might guess, a long wait time followed by a brief visit with the doctor results in reduced satisfaction. According to the study, five extra minutes with a patient can make a meaningful difference. Patient satisfaction expert Dr. Steven Feldman says, “If you keep patients waiting a long time, they may feel that you don’t respect or care about them. Sometimes we do have to keep them waiting; but when we do, we need to make sure they understand why and, more important, not try to make up for lost time by rushing through appointments. Patients need to feel that their health concerns are being heard and addressed.” Pam Vaccaro, nationally recognized speaker and owner of Designs On Time in St. Louis, Missouri, advises physicians who fall behind schedule to step into the reception area and announce to waiting patients, “I’m running behind. I’m sorry. I’ll be with you just as soon as possible.” Patients will be impressed with your attentiveness and perhaps less likely to give up and leave without being seen. (TM, pp. 14-15)

This Essential Practice Tip was based on the Time Management issue of Doctor’s Digest. Click for expanded information from the complete issue.

Ethics in Medicine

Thinking as an Ethical Decision Tool

One way to resolve an ethical issue before it becomes a conflict is to stop and think about your own thinking. According to Dr. Ronald Epstein, a professor of psychiatry in Rochester, “When you feel yourself in a situation where your antennae are saying, ÔThere’s something going on here that I need to deal with that I don’t understand,’ train yourself to stop, take a breath, and step back from the situation to reassess how you’re thinking,” he says. This gives you a different perspective so that you can then say to your patient, “Listen, I need to stop and think about this for a moment.” According to Dr. Epstein, most patients will say, “Of course you do.” One of the best ways to cultivate what Dr. Epstein calls “mindful practice” and to identify ethical issues before they pose conflicts is to engage in reflective self-questioning and identify personal values that might compromise your judgment or affect your behavior. Ask yourself such questions, he suggests, as these: Is there an ethical issue embedded in this situation? How might my prior experiences affect my actions? What am I assuming about this patient that may not be true? What interfered with my ability to observe, be attentive, or be respectful with this patient? Have I ignored any relevant data? And finally, what would a trusted peer say about this situation?

This Essential Practice Tip was based on the Ethics in Medicine issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Getting Help with Ethical Problems

Often it’s not the life-or-death ethical issues that physicians wrestle with; it’s the grey-area conflicts that don’t fit neatly into a traditional, rule-based approach. Written codes may not be very helpful in such a case. As ethicist Dr. Faith Fitzgerald says, “In ethics, written codes don’t work all that well unless you believe them before you read them. I don’t want to codify ethics because there will be situations where it is not easy—where you will be facing right versus right.” When asked how often he faces ethical conflicts, Dr. Richard Neubauer, an Anchorage internist and former chair of the ethics committee of the American College of Physicians, says, “After 30 years in practice, I can honestly say that I can’t think of a day that ethical issues don’t come up.” But where do you turn for help? Hospitals often have ethics committees or consultants; but for the solo-practice physician, such help may not be available. Dr. Fitzgerald recommends that you seek out an ethicist or a physician who manifests ethical conduct. Although books and articles may be too time consuming and theoretical for day-to-day issues, she also suggests that physicians steep themselves in ethical topics and gain a working knowledge of current thinking on such topics as confidentiality, informed consent, patients’ rights, and end-of-life care, at a minimum.

This Essential Practice Tip was based on the Ethics in Medicine issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Ethical Responsibility

Internist Frederick Turton, MD, former chair of the American College of Physicians ethics committee, recently reviewed classical and modern versions of the Hippocratic oath to see how they hold up today. In some ways he was surprised at how well the original oath covered the important issues; but he points out that even the modern version has inherent discrepancies with today’s practice environment. “So much of physicians’ behavior,” he says, “is generated by fear of malpractice, and litigation is a cloud that follows us wherever we go. And it’s dealt with by over-ordering, over-testing, and over-treating, often just to cover the doctor,” Dr. Turton adds. He feels this may violate the ethics principle of non-malfeasance. If physicians order tests primarily for their own protection, that counters the ethics principle of patient-centeredness, he adds. While granting that these issues are complicated, he says it all gets down to patient autonomy and the need for truth and transparency. The oath reminds us, he says, of physicians’ collective responsibility to take care of everyone, including the uninsured, in an equitable manner that supports human dignity. That duty is challenged when a patient loses his insurance, and when health plans dictate how a doctor must interact with patients regarding co-payments and billing. “If your patient becomes uninsured and can’t afford you,” Dr. Turton says, “you have to make some very basic decisions, and there’s the question of whose responsibility it is to care for the uninsured.” Some feel that physicians have had to assume a disproportionate burden for caring for the uninsured, in essence letting the government off the hook for what is really a societal issue. Clearly there are no easy answers.

This Essential Practice Tip was based on the Ethics in Medicine issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Ethical Challenges

What can physicians use as an ethical guideline in everyday practice? While the Hippocratic oath may be a helpful starting point, it doesn’t address some issues that modern physicians wrestle with. In fact, a study conducted by ethicist Dr. Robert Orr revealed some interesting findings about the oath. For example, 98 percent of medical schools were using some form of the oath. But of the various versions in use, fewer than half included a vow that physicians be accountable for their actions. And only 14 percent included a prohibition against euthanasia. Many physicians may find the original oath’s maxims out of sync with their day-to-day lives. Dr. Faith Fitzgerald, assistant dean of humanities and bioethics at the University of California, is a renowned educator and ethicist. She has found that the oath gets her through a lot of terrible situations, and she regards it as a promise that must be kept. Beyond the oath, her view is this: The moral and ethical terrain that physicians find themselves in today is daunting and tricky, but you can find your way through challenging situations if you place the patient’s interest first and always above your own. “It really means conducting [yourself] in such a way as to keep the patient’s trust,” she says, “because maintaining that trust cuts right to the heart of things—and it takes care of a lot of other issues along the way.”

This Essential Practice Tip was based on the Ethics in Medicine issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Confidentiality and Ethics

Medical ethicists agree: Physicians should strive to keep the patient’s interests foremost and should seek counsel when a legal obligation is at odds with that interest. But ethicist Dr. Faith Fitzgerald warns, “We should never turn to lawyers to ask them what’s right—only what’s legal. The law is not the same thing as ethics, and it’s important for physicians to remember that law varies from time to time and place to place. Sometimes laws can be wrong or unethical.” In recent years HIPAA laws, enacted to protect patient privacy, have caused a number of ethical conflicts. One involves quality improvement projects, or QI. Dr. Frank Davidoff, a Boston endocrinologist and former editor of Annals of Internal Medicine, says that privacy issues are really affecting physicians since most of what’s being done in QI requires taking information from patient charts. Although HIPAA offers research waivers, he says, “HIPAA is a tricky business, and physicians involved in improvement projects need to be aware that there’s an ethical dimension and a legal dimension.” Use of the Internet poses another threat to patient privacy. A recent study of blogs written by physicians and nurses found that nearly 60 percent contained enough information for readers to identify the authors even though most had used fake names. Worse, about 42 percent included descriptions of interactions with individual patients, and nearly a fifth included enough information for patients to identify their doctors or themselves. Physician organizations offer these basic guidelines in privacy issues: Don’t release patient health information without written consent unless disclosure is necessary to protect others. To the extent possible, limit discussion of patients and their care to the patient visit unless prior permission was granted. Know the laws governing adolescent patients’ rights to confidentiality and treatment consent.

This Essential Practice Tip was based on the Ethics in Medicine issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Raise Your Scores: Improving Quality

A New Model of Care

Would you like a glimpse into the future of quality measurement? You might be interested in how an integrated delivery system in Utah experimented with a new model of care. Their pediatricians were frustrated in trying to treat children who kept coming in over and over with somatic complaints that their doctors believed were caused by underlying depression. Health plans would pay for treating their physical symptoms but not for depression, which falls under the mental health category. One doctor took a step back and argued that if these children were properly diagnosed and treated for depression, their total cost of care would actually drop. He figured that even if they increased the costs for psychiatric treatment, the lower medical costs would more than offset that increase.

So they put his theory to the test with a new model of care. Front-line staff at one clinic were trained to identify possible cases of depression with a short questionnaire. Patients they identified were treated by a primary care physician with patient education and medication. If that didn’t work, the children went for counseling with an on-site psychologist. This was potentially a big expense for the clinic if reimbursement didn’t cover it. If the counseling didn’t work, the children got two sessions a week with an off-site psychiatrist. Their progress was measured by whether the children functioned better in daily life.

The clinic found that while detection costs increased by twenty-five percent, the patients were being treated more effectively. And although the cost for treating depression went up, the average total cost of care did in fact go down due to the drop in unnecessary medical treatments. They are now rolling out this same care model to all their primary care providers, and they are confident that insurers will pay for it.

This Essential Practice Tip was based on the Raise Your Scores issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Pitfalls

The goal of the quality measurement movement is to improve healthcare, and it seems clear that meaningful quality measurement is going to be able to achieve that goal. However, many physicians who are experienced in this area point out the importance of being realistic about the pitfalls of quality measurement.

One of the most significant pitfalls at the outset is simply agreeing on the measures themselves. Should a physician be measured on the basis of what he or she does for the patient, or on whether that intervention turns out to be effective? Most quality measurement efforts start with “process” measures. For example, did the diabetic patient get the appropriate examinations, tests, and medications? The next step in the process is to measure “intermediate” outcomes, such as whether the patient’s hemoglobin A-1-C level falls below nine or eight or seven. Unfortunately, at this point, few quality measurement initiatives have been around long enough to measure ultimate outcomes, such as—in the case of diabetic patients—a drop in amputations or blindness, or additional years of living without impairment. Once we get there, knowing the ultimate payoff is going to be a critical step in the whole process.

Another pitfall is figuring out how to attribute medical care. When you’re measuring quality, it’s all too easy to assume that the healthcare system is tidier than it actually is. A patient with a chronic illness typically has to see several different healthcare specialists, and while the primary care physician may write the order, he or she has very little control over what happens next. If you send a patient off with a referral to get an eye exam, how can you be certain that he actually gets it? Have you delivered high-quality care even if your patient doesn’t follow through? How could you possibly have done anything more? As one cardiologist points out, the chronically ill patient who is most vulnerable and most challenging is the one who is noncompliant. Clearly, the quality measurement system has to be careful not to punish physicians for the inevitable shortcomings of some of their patients.

This Essential Practice Tip was based on the Raise Your Scores issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Quality Measurement

Have you “Googled” yourself lately? If not, you may be in for a surprise. With so many physician-rating Websites on the Internet, chances are pretty good that a patient of yours has already written something about you and posted it on the Web. And certainly payers—including the government—are busily collecting data to help them evaluate the quality of care at your practice.

The quality-measurement movement marks a new era in practice management. Some would say that it’s arrived none too soon. The United States spends more than twice as much on healthcare per capita as most other developed countries. If we were twice as healthy, we could say we’re getting at least equal value for our money; but apparently we’re not. Our average life expectancy remains in the bottom third of OECD countries, which is a consortium of thirty industrialized nations. In a study comparing U.S. healthcare with that of five other countries, we ranked last in overall quality of care, defined as effective, safe, coordinated, and patient-centered; and we ranked last in a number of sub-areas, including safety, coordination of care, access, and efficiency.

The absence of universal health coverage and unequal care between the insured and the uninsured may explain some of this, but they’re not the whole story. The U.S. also lags behind in adopting information technology in healthcare, and we lack comprehensive national policies to promote overall healthcare improvement.

Clearly change is in the air. Rising healthcare costs invite closer scrutiny of quality and value from the government, from traditional payers, even from consumers themselves. As doctors become aware of how traditional quality measurement can apply to what they do, they themselves are looking for ways to measure outcomes and do a better job. As one industry spokesman put it, “No one likes report cards, but the starting point is to show doctors that they have room for improvement.” The good news: doctors only want to provide the best care possible; and if quality measurement means better patient care, you can count on doctors to lend their support.

This Essential Practice Tip was based on the Raise Your Scores issue of Doctor’s Digest. Click for expanded information from the specific chapter.

EHR Strategies

If your practice is thinking about installing an electronic health record system, or EHR, there are a few important things you need to think about. One is this: make sure that whatever system you get will be able to swap data with other providers you work with regularly. For example, check with the hospitals you’re affiliated with, and look for a system that can offer you seamless integration with theirs. It would be a real advantage if your EHR vendor already has partnerships with other healthcare facilities in your area. And ask your vendor whether your data can be extracted for quality measurement projects—not just the ones you want to do internally, but external projects as well.

Once you’ve settled on a system, experts recommend that you follow certain guidelines when you enter data, to make sure that the data can be extracted easily later on. For example, be sure to enter the data in the exact form that you will want to pull out later for quality measurement. For example, you don’t want to enter blood pressure as a single value if someday you’ll have a measurement project that will need to see blood pressure as two separate values.

Next, avoid scanning. Enter as much data as possible in machine-readable form, rather than as scanned images from a piece of paper. Your computer won’t be able to query scanned images, so the data they contain will be no more useful to you for quality measurement than a paper chart would be.

Next, keep free text to a minimum. When the computer has to search your narratives for particular phrases, it’s a lot more difficult than searching for specific fields and then recording the values from those fields. Make maximum use of check boxes, pull-down menus, and other strategies that limit the number of possibilities for a given piece of data.

Finally, when you enter data in the computer from a paper chart, be sure to include all data points that you want to track for quality. This way, you can avoid having the system send you an alert to remind you to schedule a test that your patient has already had.

This Essential Practice Tip was based on the Raise Your Scores issue of Doctor’s Digest. Click for instant issue access.

Never Events

As we all know, the quality measurement movement has become an enormously popular one in healthcare in the past few years. One interesting corollary of this movement is a cost-containment measure by Medicare that may actually be improving healthcare for a lot of people. That is Medicare’s decision last year to refuse to pay for certain things that should never happen during medical care in the first place.

Other insurers have followed rapidly in Medicare’s footsteps, so that hospitals are now likely to be on the hook for any costs associated with bedsores, two kinds of infections associated with catheters, air embolism, mediastinitis after coronary bypass surgery, blood infusions of the wrong type, objects left inside surgical patients, and falls that occur while patients are hospitalized.

According to a survey taken last year by the Leapfrog Group, an employer coalition, more than six hundred hospitals—or fifty-two percent of those that responded to the survey—have now agreed not to bill for these things, acknowledging that, like car mechanics, they shouldn’t get paid for making matters worse.

This summer Medicare went even further with this plan, expanding the list of “never” events to include surgical-site infections that occur after certain elective procedures, some cases of poor control of blood sugar, and deep-vein thrombosis or pulmonary embolism following knee or hip replacement.

And that’s not all. More “never events” are under consideration, with a lively debate going on as to whether all of them are a hundred-percent preventable. Those under consideration include Legionnaire’s disease, lung collapse resulting from medical treatment, delirium, ventilator-associated pneumonia, staph infection in the bloodstream, and disease associated with Clostridium difficile infection. Even if all of these don’t get added to the list, this is just one more sign of changing times—when payers are looking for value for their money and believe they know what value looks like—or doesn’t look like. So far, this non-payment-for-nonperformance trend hasn’t hit outpatient care, where life-threatening mistakes are less likely and costs are less obvious--but change is in the wind.

This Essential Practice Tip was based on the Raise Your Scores issue of Doctor’s Digest. Click for expanded information from the specific chapter.

TQM and Healthcare

The quality measurement movement is now engulfing healthcare in the United States. One concept influencing this movement is “total quality management,” or TQM. TQM holds that the best way to improve quality is by examining not just individual processes, but an entire system, and then continually adjusting and refining procedures. Another TQM precept is that high quality actually costs less because it reduces waste and increases productivity. TQM began as a manufacturing philosophy during World War Two. After the war, the Japanese used it to transform their manufacturing industry—particularly automotives—from a synonym for mediocrity into an international role model for excellence. Since then, many people started to wonder whether TQM might be applied to healthcare.

Until recently, healthcare providers had little incentive to curb the resources used per patient. Physicians decided what was best for the patient, and they made their decisions with little outside scrutiny. That pattern changed as healthcare costs mounted and employers turned to managed care. Payers began having a bigger role in deciding how health services were used. Then in 1983, when Medicare adopted the prospective payment system, suddenly the emphasis shifted to what resources were likely to be used, rather than what was actually used. Despite these cost-control efforts, healthcare costs kept growing much faster than the inflation rate.

That’s the setting in which TQM has come to be examined vis-à-vis healthcare. One precept of TQM is that variation is the enemy of quality. Healthcare economists have long decried the level of variation in U.S. healthcare. Physicians’ techniques are a blend of what they learned in med school, their experience, and what they get from medical journals or CME courses. Obviously, this cluster is never the same for any two doctors; therefore, practice patterns vary greatly. One economist analyzed Medicare expenditures over the last two years of a beneficiary’s life and found that patients in New Jersey were running up bills twice as high as those in Utah—with no discernible difference in outcomes or quality of care. Can TQM precepts improve medical care—or do they threaten to reduce it to an assembly line of undifferentiated procedures? There are many opinions on the subject, and the debate goes on.

This Essential Practice Tip was based on the Raise Your Scores issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Technology for Patient and Practice

Adherence

Getting patients to adhere to your therapeutic recommendations is a problem that never seems to go away. Do you ever wish you could be right there in the room when patients either take—or fail to take—their pills? Well, there’s a new “smart pillbox” technology out there that can actually offer you the next best thing.

This device connects to drug databases by way of the Internet. It gives the patient both on-screen and audible reminders to take their medication, and it even warns them about potentially harmful interactions. The “smart pillbox” has dispensing compartments for up to five different drugs. It will record when a pill is removed from the compartment, then it will report that information back to you, a nurse, or the patient’s caregiver.

This type of automatic, active remote monitoring can be considered an outgrowth of more passive technologies like the medication-tracking and reminder systems that are on several consumer Websites. All of those systems, however, require some sort of human intervention—such as entering data or printing a dosing schedule—otherwise, they won’t work.

So what about the “smart pillbox” technology—does it really work? According to the manufacturer, adherence can improve rather dramatically. For example, average adherence to HIV drug regimens is less than seventy percent, and as many as a third of HIV-positive patients in this country miss at least one dose over any given three-day period. But the smart pillbox changed all that in a test among seventy-six HIV patients. Their adherence climbed all the way up to eighty-nine-point-five percent. That’s a twenty-percent leap in overall adherence!

The smart pillbox is just one of many examples of the way computer technology is changing and improving patient care in this country. Is your practice ready for the change?

This Essential Practice Tip was based on the Technology for Patient and Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Home Health Monitoring

What’s new in medical technology? Home health monitoring. Imagine a chronically ill patient who manages to stay right at home and avoid trips to the emergency room by sending his vitals data to the hospital over a phone line each and every day. Home health monitoring is one of the most intriguing new ideas in medical technology, and although the monitoring devices are not yet in widespread use, that may be changing very soon.

A number of physician groups are already working to help this kind of technology proliferate. Experts are predicting phenomenal growth. Forrester Research predicts that this technology will become a thirty-four-billion-dollar industry in the next seven years. In fact, hey believe that home monitoring devices will be in the hands of sixty percent of all patients discharged after long hospitalizations, and in the hands of forty percent of all chronically ill patients, by the year 2015.

One obstacle standing in the way of home monitoring technology is the fact that major insurance companies are not yet willing to pay for it. A medical center in Iowa has decided not to wait. They’ve installed telehealth monitors in the homes of certain patients who have diabetes, congestive heart failure, chronic lung disease, and/or renal failure. The hospital rents the monitors for eighty-one dollars a month, which is a lot less than the purchase price, which would be thirty-eight hundred dollars apiece.

Each day, a patient with the monitor takes his or her own vitals, including weight, temperature, oxygen saturation, blood pressure, and heart rate. If they’re diabetic, they can check their blood glucose level as well. Text or voice prompts walk the patient through each step, and the machine automatically sends readings by way of a phone line or wireless pager to computers located at the hospital. The patient’s own physician sets parameters for each data point, and someone from the hospital will call if the levels are abnormal or if the patient forgets to take regular measurements.

The goal is to help these patients avoid rehospitalization. If they get readmitted within a month, the hospital loses money; but if they can stay out of the hospital, the patients, of course, are the true winners. And although it’s footing the bill at this point, the hospital believes that it may actually end up saving money in the long run by cutting down on “frequent flier” trips to the hospital emergency room. Would home health monitoring work for your patients?

This Essential Practice Tip was based on the Technology for Patient and Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Telemedicine

Technology designed to improve patient care is a lot more diverse than you might imagine. Electronic health records and other technology centered in the physician’s office may get the most attention, but many other advances—such as remote monitoring devices, cellphones, and PDA applications, are also improving patient care.

Telemedicine is a technological way to deliver advanced medicine to patients in rural areas or anyone who can’t get to the doctor’s office. In February of this year, what may have been the first cochlear implant ever performed on the Internet took place between a doctor in New York and a patient in Africa. And that’s just one example of what’s happening out there. One expert estimates that telemedicine could save over four billion dollars a year if emergency departments, physician offices, nursing homes, and correctional facilities nationwide had enough telecommunications technology with a hybrid of live video and stored data. That figure doesn’t include inpatient telemedicine, teleradiology, home monitoring, or CME, all of which are popular applications for telemedicine technology.

One obstacle to telemedicine may be our present third-party reimbursement system, which mainly rewards face-to-face encounters. Fortunately, reimbursement is less of an issue in a relatively closed system like the Veterans Health Administration, or VHA, where telemedicine has become the primary means of care coordination and disease management. The VHA has a three-pronged telemedicine effort. One links patients with specialists at VA hospitals, primarily for mental health, rehabilitation, endocrinology, and telesurgical services. The second treats and monitors veterans with diabetes, chronic heart failure, pulmonary disease, post-traumatic stress disorder, depression, and spinal-cord injuries. The third consists of data and images saved for later retrieval, and it is used for teleretinal imaging, teledermatology, telepathology, and wound care. Clearly telemedicine is not just the wave of the future—its time is now.

This Essential Practice Tip was based on the Technology for Patient and Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

A Case History

If your small practice is considering converting your patient records from paper to electronic, you may be interested in the experience of a three-physician practice in Austin, Texas. Exactly two years ago, this practice bit the bullet and replaced its early-1990s practice management system with an updated electronic one.

As a result, an independent consultant who helped the doctors implement the new system says that they are charging forty percent more Level Four and Five visits, simply because they now have better documentation to support their billing. Overall, they have increased their services by well over a hundred thousand dollars—a significant amount for a three-physician practice.

By automating a number of processes, they are also saving two thousand dollars a month in document storage costs and a thousand dollars a month in paper and printing expenses.

Each doctor carries a portable, wireless tablet computer with him into the exam room. With that computer he reviews the patient’s record, charts the encounter, enters orders, and sends electronic charge slips to the clerical staff. About ninety-five percent of the time, this documentation is done before the patient leaves the office.

Have there been any downsides? Yes. One doctor says it now takes him longer to write good notes—but he and his colleagues are no longer misplacing super bills in paper charts, which had been a major cause of lost revenue before they made the switch to an EMR.

Another doctor, who is sixty-seven, says that he doesn’t like having to break eye contact with his patient when he works on his tablet PC. But he concedes that it’s probably more of a problem for the doctor, especially one his age, than for the patient. One of his colleagues says it just takes time for patients to get used to doctors’ carrying a computer into the exam room, but they seem to have adjusted. Most of the reaction from their patients has been positive.

This Essential Practice Tip was based on the Technology for Patient and Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Certification

If you’re thinking about adding an electronic records system to your practice, you’ll want to be sure that the system you buy will be interoperable with other clinical systems that you interact with. At first you may be bewildered by the wide range of options in the marketplace. But now that certification is beginning to take effect, some of the work has already been done for you, and now you won’t have to look at two hundred different products before you can make up your mind which one to buy.

The most prominent effort toward certification of ambulatory electronic health records is being made through a federally sanctioned, private, not-for-profit organization called the Certification Commission for Healthcare Information Technology, known as CCHIT. Since certification began in 2006, more than a hundred ambulatory products have been certified as meeting basic standards for interoperability. This is said to represent at least half the vendors and three-quarters of the total EHR marketplace. As the chairman of CCHIT put it, “We’re trying to just create a level playing field with some good, clear information.”

That information can be very valuable when you’re trying to find what you need in an electronic system. But it’s important to understand exactly what certification means and does not mean. Certification can get you past the first stage of the process by indicating which products have been inspected against CCHIT criteria, but it can’t tell you which product will fit your practice best, because with over a hundred products already certified, you still need to do some selecting. The good news is that, with certification narrowing the field somewhat, you can now move straight into deciding which company you want to work with, then into searching for a product that fits your workflow and has the special features you need that may go behind the baseline requirements.

Some pay-for-performance programs may require participating physicians to use certified software. And in the future, certified software may be become a requirement for participating in Medicare or state Medicaid programs, as well as for quality reporting. If you wish to take advantage of the Stark and Medicare anti-kickback safe harbor in order to receive assistance from a hospital, look for the CCHIT seal of approval. As written, the safe harbor requires that your software be certified as interoperable by a recognized testing body—and CCHIT is the only such organization that HHS has recognized so far.

This Essential Practice Tip was based on the Technology for Patient and Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

EHR Cost

Installing an electronic health records, or EHR, system is an expensive proposition for any practice. If you’re wondering exactly what kind of cost this entails, here’s the experience of one small practice in Plano, Texas. It cost about a hundred thousand dollars, plus twenty thousand dollars in lost revenue, to install an EHR and companion practice management software for this three-physician group.

That cost is in line with a 2004 estimate by the Medical Group Management Association that the median initial cost of an integrated EHR/practice management system in a group practice would be thirty-two thousand dollars per physician.

Let’s break that cost down. Software is likely to make up about thirty-six percent of the total. Infrastructure, including hardware plus network structure, will account for another thirty percent, and support services will account for the remaining thirty-four percent.

Of course, your actual price tag will vary widely based on such factors as the specific technology features you want, and the complexity of the installation, right down to physician acceptance of the technology and workflow redesign. The return on your investment will also depend on these dynamics.

By itself, an EHR system has limited positive effect on the practice’s cash flow. As one expert points out, it’s still going to be the practice management system that brings money in the door. But today EHR vendors are joining forces with practice management software vendors to form either a single database for both, or a seamless interface between the two.

It took about eighteen months for the three-physician practice in Plano, Texas, to recoup its investment. The group has now expanded from three to eight doctors. And today the practice estimates that each of the eight doctors in the group brings in between sixty thousand and eighty thousand dollars more per year, just because of the technology. Clearly, from a cost perspective, those doctors did something right.

This Essential Practice Tip was based on the Technology for Patient and Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Small Practice Survival Guide

Malpractice Insurance

Today nearly all states require physicians to buy malpractice liability insurance, which you can get either individually or through a group practice. Premium costs vary widely based on your degree of risk and your geographic location.

Because the malpractice industry has taken a beating in recent years, many states have adopted a variety of tort reforms. The most common of these reforms are caps that limit the amount of non-economic damages that can be awarded in a malpractice case. By 2006, these reforms had already reduced the average malpractice award by twenty to thirty percent. Another welcome change is that more and more hospitals are providing malpractice insurance to their affiliated physicians, which means a cost savings for everyone.

There are two types of malpractice insurance: occurrence coverage and claims-made coverage. In some states, occurrence policies are more common; in other states, claims-made policies dominate. The major difference is the date known as the coverage trigger. For occurrence policies, the coverage trigger is the date the incident took place. For claims-made policies, the coverage trigger is the date that the claim gets filed. An occurrence policy may be your better choice in the long run, even though it may cost more during the first five years. A claims-made policy allows you to grow your practice with less overhead; however, some claims-made policies require you to buy tail coverage, to cover claims that may be filed after your policy is no longer in effect. Tail coverage can cost up to two hundred fifty percent of your annual premium. With an occurrence policy, you don’t need this extra tail coverage because it’s already built in.

Consultants advise working with a malpractice company that takes a risk-management approach. Such a company will review how your practice functions, including patient interaction with technicians, nurses, and other non-physicians who have patient contact. Risk management firms will evaluate your practice and recommend which type of malpractice insurance you should buy.

This Essential Practice Tip was based on the Small Practice Survival Guide issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Benchmarking

Do you ever wonder how your practice measures up to similar practices? If you do, you might look into a comparison process known as benchmarking. You can benchmark your practice by comparing specific indicators of your performance against industry-wide norms or, if you prefer, against your own internal norms. For example, if you want to know if your overhead expenses are higher or lower than national norms, you can look at benchmark statistics from other practices nationwide that fall within your specialty and are similar in size.

Benchmarking is helpful, not only because it lets you know how your practice is doing in comparison with others, but also because it gives you an incentive to set some goals and monitor performance. One very useful way to benchmark is to see how the members of your practice compare with each other according to various key indicators. For example, you might compare physicians according to their patient volume, compensation formulas, patient satisfaction scores, or other indicators. Once you’ve made the comparisons, you can use the highest-performing physician to figure out what he or she is doing differently that the other doctors can gain from.

Once you’ve benchmarked physician performance, you may decide to go a step further by polling your patients to get some satisfaction data, and maybe asking your staff for some input to see if you’re really running a happy ship.

Benchmarking opens your practice to new methods and ideas, because it prompts you to identify problem areas and focus on what’s working and what isn’t. You may even decide to visit a couple of successful practices with your office manager to get a hands-on feel for their methodology.

Whatever you choose to measure, benchmarking is a way to stay current and make sure your practice is delivering the best healthcare possible while achieving its goals, both financially and otherwise.

This Essential Practice Tip was based on the Small Practice Survival Guide issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Transition

There comes a time in every physician’s career when he starts thinking about selling the practice and retiring. Transition planning is a very important step—but it doesn’t work the way it used to. The old-school philosophy was to grow the practice, then merge with another practice, then hire a younger doctor for a few years before you retire, and finally let him buy you out of the practice and take over for you. The buy-in price, which was typically four hundred thousand dollars for a small practice, was used to fund the older doctor’s retirement.

But things work differently today. For one thing, the typical doctor entering the work force is likely to start out working at a hospital or other large practice setting that doesn’t give him or her an up-close look at how to run a practice. When he or she later joins a small practice, it becomes the senior doctor’s job to train the younger one in how to run it successfully. During this time, the older physician takes the new profits generated by the younger one in order to fund his own retirement. In return, he gives the young hire an equity interest in the practice for little or no cost. This gives the young physician an incentive to learn the business and stick with the practice, earning ownership through “sweat equity.” This is known as the equity ownership concept. Instead of making a cash investment in the practice, the younger doctor’s buy-in is the years of work that he or she has already put into the company before becoming an equity partner.

Those who haven’t planned ahead for an equity ownership arrangement may be in for a surprise, according to financial experts. Many doctors have an inflated view of what their practice may be worth. That’s why it’s recommended that you have a practice evaluation done in order to find out its true value. Once you’ve settled on a firm date for your retirement, the three most important questions facing you are these: how much money you’ll need in retirement, how you can put together that amount before you retire, and whether you will work part-time, full-time, or not at all while your practice is in transition.

This Essential Practice Tip was based on the Small Practice Survival Guide issue of Doctor’s Digest. Click for expanded information from the specific chapter.

CPOE

If your small practice is considering how you can best spend your limited technology dollars, one option that’s likely to come up is CPOE, or computerized physician order entry. This is a software application that can help you in a lot of ways. It can order diagnostic, lab, and radiology tests. It can order new medications or refills. It can arrange referrals. It can even provide clinical decision support from a range of diagnostic and treatment-related sources.

After your system is installed and you undergo a learning curve, your CPOE can lead to quicker and better patient care—for example, quicker turnaround times for medications and tests. It can make it easier to keep track of orders for tests and prescriptions, since there are no paper forms to misplace. And illegible handwriting problems become a thing of the past.

CPOE can work in conjunction with electronic records to reduce medical errors. For example, when you write a prescription, it will check automatically to make sure your patient isn’t allergic to the drug or the dosage isn’t too high. The Center for Information Technology Leadership has predicted that nationwide adoption of CPOE would eliminate nearly two-point-one million adverse drug events each year.

Sounds too good to be true? Well, maybe. Certainly there have been problems. Twenty-two situations have been identified in which CPOE actually increased the probability of medication errors. There were two categories. One was information errors caused by fragmented data and various hospitals’ information systems. The other was interface problems between humans and computers, cases where the computer’s requirements were different from the way clinical work is actually done. Another problem is that using CPOE may actually take you more time than ordering on paper.

So what’s the bottom line? Some are enthusiastic; others are skeptical. Certainly it pays to ask a lot of questions and check out the experience of your colleagues before you make your decision.

This Essential Practice Tip was based on the Small Practice Survival Guide issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Disability Insurance

If you’re operating a small practice, is your disability insurance adequate for your needs? Although it’s not as popular as life insurance, disability insurance may actually be even more important. In fact, according to one insurance expert, disability coverage is the cornerstone of personal financial planning for physicians. And you should have as much disability coverage as you can afford and can qualify for. The typical amount is sixty to seventy percent of your annual salary.

If you’re like many physicians, you may have taken out a disability policy when you first started out in practice, but over the years you haven’t really thought about updating it. If your policy is ten years old, and you haven’t updated it yet, you may be eligible for as much as five to eight thousand dollars a month of added coverage—and, for a number of reasons, you should get that coverage as fast as you can.

If you’re in a solo practice, what would happen if you became temporarily disabled? Everything would come to a halt. But insurance experts have noticed that most physicians’ spending habits and standard of living remain the same even when they become temporarily disabled—which is just one good reason to buy as much disability insurance as you can get.

An insurance company can’t cancel an individual disability policy for any reason, as long as the premium is paid. But paying the premium is no guarantee that you have enough coverage. You can update your policy by purchasing cost-of-living adjustments, usually around three percent a year. You can also vary your coverage above or below the typical sixty percent of annual salary. For example, if you have a typical group policy that provides sixty percent coverage, an individual physician or staff member may choose to buy an additional fifteen or twenty percent.

The best disability policies include what is called an “own occupation” clause. Suppose, for example, you’re a surgeon; if you became disabled, your insurance company might argue that even though you’re unable to practice surgery, you can still teach it to residents; therefore, they may not consider you disabled. The “own occupation” clause would protect you in that situation.

This Essential Practice Tip was based on the Small Practice Survival Guide issue of Doctor’s Digest. Click for expanded information from the specific chapter.

The Budget

Is your small practice currently operating without a budget? If so, practice management experts would urge you to consider how vulnerable the practice may be to a wide variety of problems, such as embezzlement, over- or under-staffing, supply waste, inappropriate purchasing, inadequate savings for improvements, and higher-than-necessary income taxes.

If that list alarms you, you may be ready to start developing a budget. The first step, logically enough, is to become familiar with your practice’s recurring expenses—what they are and how much is spent—in each area. Then you, along with your office manager, can base your ongoing budget on that knowledge.

Once the budget is in place, it would be a good idea for the office manager to keep everyone on staff notified through quarterly budget reports so that you’re aware of where you stand on expenses. Each quarter, there should also be a variance analysis, which enables you and your staff to see exactly where your expenses may have gone off target. Did you add a new physician to the practice? Was it a period of high staff turnover? Did you install a computer system during the quarter? Any of these events could, of course, explain higher-than-expected expenses.

The experts caution, however, that you shouldn’t think of your budget as a static document. The budget is a tool to keep your practice on track, and it should evolve as your needs evolve. By regularly updating as you check actual expenses against the budget, you will be able to control expenses and pinpoint the ones that exceed your budget. The variance analysis should be done once every quarter because that’s the way problems can be identified and dealt with quickly. Another staff member, a CPA, or a physician should occasionally check the work of the person who prepares the variance analysis, in order to protect the practice against the possibility of embezzlement. And, by the way, there is some effective practice-management software available that could be a tremendous asset in this area.

This Essential Practice Tip was based on the Small Practice Survival Guide issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Reducing Practice Risk

E-mail

Some physicians like e-mail; others refuse to use it in their practice. Patients, however, are pretty clear about it. A Wall Street Journal poll found that if given the choice, more than fifty percent would choose a medical office that allows them electronic access to their records and other communication, over a practice that didn’t offer these services.

In the survey, three out of four said they wanted e-mail reminders about appointments, the ability to make appointments online, and the option to e-mail their physician. Interestingly, according to another survey, only twenty percent of clinicians work in a place where patients and clinicians can e-mail each other.

Many doctors feel that getting e-mail directly from patients is a better way to hear about their concerns than getting phone messages or playing phone tag. With e-mail, the patient sends the information in his own words, rather than having a receptionist take a message, and the e-mail message can be returned at the doctor’s convenience.

On the other hand, physicians need to be aware that, like phone messages and lab reports, e-mail messages become an official part of the medical record and can be used during a lawsuit. If you put something in e-mail, that message is discoverable in a court of law. So you need to watch your words carefully.

Doctors are often advised by risk specialists to put copies of both received and sent e-mails right into the medical chart. Either use copy-and-paste in an electronic medical record, or print the message out for the paper chart.

If physicians in your office aren’t consistent about adding e-mails to the record, this very inconsistency can cause continuity-of-care issues, further exposing your practice to risk and your patient to working with a doctor who has incomplete information.

Another issue is how often you read your e-mail. If you do give out an e-mail address to your patients, it’s important to caution them that you may not get back to them as quickly as they might like. Otherwise, a patient may e-mail you with an urgent question that you may be unaware of for a dangerously long time—again imposing a risk for the patient and a risk for the practice.

This Essential Practice Tip was based on the Reducing Practice Risk issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Prescription Errors

The number of prescriptions written in this country increased seventy-one percent between 1994 and 2005. In view of the sheer number of those prescriptions, it’s hardly surprising that one of the most common causes of medical error is the prescription process.

Data shows that errors can occur at any step in that process, from prescribing to administration. Prescribing alone accounts for twenty percent of the errors. Clearly, the responsibility begins with the prescribing physician. Ask yourself whether you’re guilty of any of these bad habits. Do you ever hand a prescription to your patient without asking him to repeat back to you what the medication is, at what dose and frequency he’s going to take it, and why he needs it? Do you hastily scribble down the order, legibly or not, using abbreviations that experts have been warning us not to use for over ten years now? And is your own signature legible enough so that a pharmacist will be able to contact you if there’s a question?

One solution to prescribing errors is the Computerized Physician Order Entry system, or CPOE. These systems are gaining popularity in hospitals and medical practices, and although they can’t prevent all errors, they offer many advantages. Legibility alone is a great help: it’s easier for a pharmacist to read typed information than someone’s handwriting. Another advantage is that these systems can be programmed to require more information than a paper script; for example, diagnosis may be a mandatory entry. And they can alert you to drug allergies or potential drug-drug interactions.

But no computer can prevent a doctor from ordering a sound-alike drug from the menu. Sound-alike drugs alone cause about twenty-five percent of all medication errors. And if you’re not fully familiar with the system you’re using, you may inadvertently increase a dose rather than canceling a previous order in favor of a new one.

The point is that, with or without computerized prescribing, the physician’s own caution is the key to avoiding a chain of events in the prescription process that could result in a disastrous medication error. Extra caution up front can save lives at the other end.

This Essential Practice Tip was based on the Reducing Practice Risk issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Telephone Risk

Do you put your practice at risk every time you talk to your patients on the phone? Some physicians may need to be reminded that phone messages are a part of the official medical record, and the documentation—or lack of documentation—of a simple phone call could become a decisive factor in a malpractice suit. Ironically, you may not get paid for answering your patients’ calls; yet you are exposed to malpractice risk whenever the phone rings. The exposure comes from the fact that you’re providing a free service, and you’re held accountable for any advice that you offer during the call.

That’s one reason risk management experts advise that you should make a full record of every telephone call with a patient, and you and your staff should treat each phone message like a lab report. That is, it shouldn’t be filed away in the record until the doctor has initialed it. It’s important to document everything you discuss during the call, since patients may be so worried about their condition that they don’t hear or remember everything you say.

If you take a call while you’re traveling, have paper or a message pad handy in order to write down the information discussed, soon after the call. That call needs to be documented just as a call to the office would be, noting the complaint, the time, the date, the advice you gave, and any other discussions or recommendations.

What about phone coverage by non-physicians at night or on weekends? In those cases, your responsibility as physician in charge is to set forth criteria for how various situations should be handled. Specify under what circumstances patients should be told to go to the emergency room, what is considered life threatening, and what situations need a physician’s judgment. Your nurse shouldn’t give medical advice over the phone, and his or her response should be no more than “call your doctor” or “go to the ER”—otherwise, you’re establishing a duty to act. Knowing when not to give advice is very important.

Experts say that you should document phone calls, not for legal reasons, but for the patient’s own good; however, having that documentation will be much better than not having it, if things should wind up in a court of law.

This Essential Practice Tip was based on the Reducing Practice Risk issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Who Gets Sued?

Do all doctors get sued? Some physicians who are at high risk for malpractice suits try to rationalize their situation by saying that every doctor in their field is going to get sued at one time or another. But is this really true?

Actually, the facts prove otherwise. An expert in practice risk says that risk managers have always known that every physician group can be sorted into three buckets. The first bucket is that large group in every specialty, including high-risk ones, who never get sued. The second bucket, which is equally large, gets randomly hit with lawsuits. This group is responsible for about fifty percent of all the money spent on malpractice awards and settlements.

Then there is the third group, whom he labels the high-fliers. The high-fliers are a tiny group: only one-and-a-half to eight percent of the physicians in each discipline. But despite their small numbers, the high-fliers account for a full twenty-five to forty percent of all malpractice claims. Various studies confirm this data. For one, a retrospective study of data from 1990 to 2005 found that a mere five percent of physicians accounted for almost a third of all the money paid out in claims.

Another study, an annual review, showed that a third of physicians in its data bank had been responsible for fifty-seven percent of all malpractice payments on record.

When you look beyond the tiny group that draws the most fire, you discover that not all malpractice claims are about medical errors. A seminal study in the New England Journal of Medicine found that only two percent of patients with valid malpractice issues actually sue, but for every one of those who file with a valid claim, there are three to five others who don’t have valid claims but sue anyway. Malpractice risk in this country, one expert explains, is mostly about bad outcomes and something other than poor technical care. He believes that a significant portion of the claims is related to the failure of high-risk professionals to establish a good partnership with their patients and other members of their team. Improving communication skills is an important way to reduce malpractice claims; doctors who communicate well with their patients get sued less often.

This Essential Practice Tip was based on the Reducing Practice Risk issue of Doctor’s Digest. Click for expanded information from the specific chapter.

EMRs and Risk Control

One of the best risk management tools for a medical practice is the electronic medical record, or EMR, system. Only ten to twenty-five percent of physicians are actually using these systems, and they are likely to cost somewhere between three thousand and a hundred forty thousand dollars or more, but they do offer risk protection as well as efficiency. Forty-five percent of surveyed physicians felt that their EMR systems made them safer from malpractice cases, and twenty percent reported that their malpractice insurance carrier gave them a discount for having an EMR system.

But just having a system is not enough. Last year a survey found that ambulatory care physicians using paper records provided equal care to those using EMRs. The authors concluded that as implemented in most offices, EMRs did not result in better care. The reason is that most physicians with EMRs don’t use them to their full advantage. And when you do take advantage of your system’s capabilities, be alert to its strengths and its vulnerabilities.

From a risk perspective, the strengths are obvious. EMRs are more legible and more clearly organized than paper charts, and the system can alert you and your staff to possible problems or missed care. The EMR system can flag an overdue immunization, prostate exam, or mammogram. It can keep its screen flashing until the right person reviews and signs off on an incoming lab report. It can send prescriptions electronically, sharply reducing errors. And because the EMR is likely to have more complete information than handwritten notes, it can reduce claims and lawsuits.

But there are vulnerabilities. For example, if someone fails to log off after making a change, that record is no longer confidential, and that’s a HIPAA violation. Worse yet, anyone could alter that record, and if you’re the one who logged on, the system would show that you’re the one who made the change. That’s one reason experts warn physicians never to share their passwords, not even with trusted nurses or secretaries; the password is like your own signature. Make sure that you and your staff use your EMR system with controls that reduce risk for your practice.

This Essential Practice Tip was based on the Reducing Practice Risk issue of Doctor’s Digest. Click for instant issue access.

HIPAA and Privacy

How well does your staff protect the privacy of your patients’ records? Could you or your colleagues be at risk due to inadequate protection of health data? Today every medical practice needs to be thoroughly familiar with the privacy rules commonly known as HIPAA. This acronym, as most medical practitioners are well aware, comes from the Health Insurance Portability and Accountability Act, which became public law in 1996. This act for the first time established nationwide standards for protecting the privacy of patient health records. But it does more than provide for privacy; it was also designed to see that medical data can flow easily and effectively to the people who have a legitimate need for it, in order to protect individual and community health.

How well do you comply with HIPAA rules? Here’s a little quiz for you. Let’s suppose a patient ask you for a copy of her medical record. Should you give it to her? In most cases, a patient can legally obtain a copy of his or her record. Exceptions include psychotherapy notes or a case in which legal proceedings have already begun. First the patient should sign a record request form; after that, your office can make a copy for her, and is allowed to charge a reasonable fee for the copying.

But those records do belong to your office, and the patient should never be given the originals to take home. Even viewing the records in an unsupervised area can create a problem. If a document is missing, added, or changed while outside your office’s control, that could affect your case in a claim action. There are a few exceptions as to when a patient can receive copies of the records. If there are any questions about it, your staff should get advice from an attorney or your insurance company’s risk management department before copying and releasing the records.

Here’s another one for you. If a patient asks you to leave a message with test results on her answering machine, can you do it without violating HIPAA rules? Yes, you can leave a detailed message on her answering machine if she gives permission. But if she hasn’t asked you to do it, it’s safer to leave a message asking her to call your office for the information.

This Essential Practice Tip was based on the Reducing Practice Risk issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Consumer-driven Healthcare

How Will CDHC Impact Healthcare?

Are your patients turning into consumers? For a lot of people, the word “patient” implies subservience, while the word “consumer” acknowledges the important role that people can play in choosing their own healthcare. Since physicians think of themselves as healers rather than salespeople, this shift in terminology may represent a pretty revolutionary change in the way patients and physicians interact.

In fact, consumer-driven healthcare, known as CDHC, is a new trend in health insurance that is making a lot of physicians uneasy. Patients are taking a greater role in choosing their own healthcare services and even their own treatment. The tradeoff is that they are also paying more of their medical bills. CDHC insurance plans offer patients lower monthly premiums and the option of setting up a tax-free health savings account in exchange for higher out-of-pocket expenses. The idea is to apply “consumerism” to healthcare, encouraging patients to act on their own to seek out high-quality, cost-effective medical care.

The trend is growing fast. CDHC-plan enrollment totaled four-and-a-half million Americans a year ago, and that was a forty-three-percent increase over the previous year. But this trend raises some big questions: how does redefining “patients” as “consumers” affect the physician-patient relationship? What changes do physicians need to make in their practices in order to accommodate CDHC? And exactly how will this trend affect the business and practice of medicine?

Proponents and critics agree that CDHC is leading to some profound changes. But they differ on whether these changes are for the better or the worse. For example, those who watch patients struggling to pay their CDHC-plan deductibles may wonder whether patients are actually saving any money. While they definitely save on insurance premiums, whether they save overall is dependent on a wide range of factors often beyond their control, such as their unique biologic heritage and their need for the more extensive—and expensive—forms of medical care.

One theory behind CDHC is that when patients are paying for their own medical care, they will be more likely to avoid unnecessary tests and procedures that drive up the cost of healthcare. They may think twice before seeing a doctor for a common cold. But some are concerned that they may also avoid seeking care when it’s medically necessary. And should it be up to the patient to decide whether he has a bad cold that doesn’t need a doctor’s attention, or early pneumonia that definitely calls for professional care?

What are the facts? Well, the facts themselves are confusing. Data compiled by the RAND Corporation support both sides of the controversy. CDHC participants were more likely than those in traditional insurance plans to forego needed care and more likely to delay getting care due to costs. However, in other studies, CDHC enrollees were more likely to obtain preventive exams and to comply with treatments recommended by their doctors. Statistics from both CIGNA and Blue Cross/Blue Shield indicate that CDHC-plan participants are not more likely to put off care. The only safe conclusion at this point seems to be “Sometimes they do, sometimes they don’t.” Late last year, Medscape conducted a poll with over fifteen hundred respondents in the medical community. Interestingly, eighty-one percent of the respondents in the poll believed that patients would be less likely to seek medical care when they themselves were footing the bill.

Another concern is that CDHC may turn out to be a bad deal for low-income patients. One expert has expressed his fear that the negative effect of CDHC will fall mostly on the medically indigent: the working poor with incomes near the poverty level, who are ineligible for Medicaid or Medicare. These people will face big deductibles and costs under CDHC, and they are the least able to contribute to health savings accounts. Surveys have shown that two-thirds of people in CDHC plans with annual household incomes under fifty thousand dollars spent five percent or more of their total income on out-of-pocket medical expenses and premiums. Two in five spent ten percent or more. Obviously, those who are financially secure have more insulation against this kind of expense.

Still another unanswered question is how qualified the average patient may be to choose his own healthcare. While CDHC encourages patients to comparison-shop for healthcare, it’s a big question whether patients have access to the kind of information they need to make informed choices. Will price-shopping be the main criterion for many patients? And will physicians have to alter their practice in order to accommodate price-shopping among their patients? And is price really the best way for them to choose healthcare in the first place?

Certainly CDHC is playing a major role in redefining the business and practice of healthcare in America today. Whether patients and/or physicians will ultimately benefit or lose from this trend remains to be seen.

This Essential Practice Tip was based on the Consumer-driven Healthcare issue of Doctor’s Digest. Click for expanded information from the specific chapter.

The Health Insurance Dilemma

If there’s one thing everyone agrees on, it’s the fact that our healthcare system in this country badly needs fixing. Patients, physicians, healthcare institutions, and even the federal government have voiced complaints. According to one study, the United States spends more than twice as much per capita on healthcare as five other developed countries; yet, compared with those same five countries—Australia, Canada, Germany, New Zealand, and the United Kingdom—we ranked last or near-last on various measures of quality, access, efficiency, and health outcomes.

Exactly how much are we spending on healthcare in this country? Over two trillion dollars a year! And that figure is expected to more than double in the next decade. Despite what we’re spending, Census Bureau statistics tell us that sixteen percent of our population is uninsured, and that number, too, is growing steadily. Many more people have some insurance but are underinsured, and they may discover too late that their insurance company pays less than they expected—or even nothing at all for certain treatments or tests. A Consumer Reports survey showed that nearly half of adults below the age of 65, including those with medical insurance, feel unprepared to deal with a costly medical emergency. Another survey showed that Americans are more worried about being able to pay for healthcare than about losing their jobs!

The American health insurance system faces the vexing challenge of supporting high-quality medical care while trying to control rising costs. In recent years, physicians have had to cope with an alphabet soup of insurance innovations, from HMOs and PPOs to DRGs and RBVUs. And now there’s still another ingredient in the mix: CDHC, or consumer-driven healthcare plans, which offer lower premiums in exchange for higher out-of-pocket expenses. Will CDHC help us control healthcare costs by offering more affordable coverage and giving patients incentives to lower their health risks and costs? And exactly how is this plan likely to affect the practice of medicine?

Certainly the concept of CDHC is an intriguing one. Unlike other health insurance models, CDHC puts the patient himself in the driver’s seat. The patient will decide when he needs medical care and what medical services he is willing to use his own money to obtain. In essence, the assumption behind CDHC is that patients themselves, acting as independent consumers, can hold down healthcare costs. Presumably, the patient will be motivated to make economical choices and to demand high-quality care when he himself is footing the bill.

If the patient is going to pay a larger share of his medical costs, it would be helpful for him to have some money set aside in advance for that purpose. A key component of a CDHC plan is the health savings account, or HSA. This is a personal savings account that allows consumers to pay for qualified medical expenses with pre-tax dollars—that is, without paying income tax on what they spend. An HSA has to be used along with an eligible high-deductible health insurance plan. An individual can deposit up to twenty-nine hundred dollars in such an account for his own health costs, or up to fifty-eight hundred dollars for family coverage. People over age fifty-five can deposit somewhat higher amounts. And all that money is deposited tax free. If all of it is not spent within a given calendar year, the rest can stay in the account for the next year without incurring a tax penalty.

Some physicians are concerned that their patients may not have enough information to enable them to make informed choices when they shop around for healthcare. Others worry that price-shopping will become the most important consideration in making those choices. On the other hand, some have suggested that patients will demand the maximum benefit for their healthcare dollar, insisting on quality care. If they reject inferior services and think twice about unnecessary office visits or tests, they may ultimately improve the overall quality of healthcare.

As a relatively new entry into the health insurance marketplace, the jury is still out on whether CDHC plans and health savings accounts can really make a dent in the staggering cost of healthcare in this country. What is clear is that this new variation on the health insurance theme is already having a pronounced effect on the business and practice of medicine.

This Essential Practice Tip was based on the Consumer-driven Healthcare issue of Doctor’s Digest. Click for instant issue access.

Information Systems

In the era of consumer-driven healthcare, or CDHC, patients are making unprecedented new demands on medical practices. They are asking for more detailed cost and quality data. Many of them also want online access to their medical records and e-mail contact with their healthcare providers. Many practices are discovering that the only way to meet such demands is to adopt new electronic information systems.

This can be a costly proposition, especially for small practices. But electronic systems definitely save time for physicians and for financial staff members by improving patient flow, clinical tracking, and the payment process.

No matter how you may feel about it, the pressure to go electronic is clearly growing. The 2006 Institute on Medicine report on preventing medication errors recommended greater use of the Internet for two reasons: to improve doctor-patient communications and to help patients get quality information about prescribed medications. The report also encouraged physicians to use electronic prescriptions. It recommended that, by this year, they should all have plans in place to implement electronic prescribing. The report further suggested that by 2010, all prescribers should be writing electronic prescriptions—and all pharmacies should be able to receive them.

Last year, America’s Health Insurance Plans (AHIP) added its voice to the growing chorus and issued similar recommendations to improve medical quality and safety. AHIP urged health providers to use electronic health records to give consumers real-time access to their personal health records.

Despite all these recommendations, recent studies show that only about twenty percent of physicians’ offices have installed the electronic record systems that are needed for electronic prescribing and for patient access to personal records.

Those who have already opted for electronic records systems have seen even more benefits than these in streamlining their practices. The paperless systems hold patient charts, prescription records, and other important information, but they can also be configured to give patients access to their records, and to schedule appointments, renew prescriptions, and even have secure e-mail contact with the physician and office staff. The systems can be programmed to send automatic reminders to patients who are due for preventive care. And by contracting with consultants or IT companies, many practices even have their systems modified to interface directly with payers.

This Essential Practice Tip was based on the Consumer-driven Healthcare issue of Doctor’s Digest. Click for instant issue access.

The Patient as Decision-Maker

With the advent of consumer-driven healthcare, or CDHC, your patients may now find themselves in the unique position of making a lot more of their own medical decisions than in the past. The questions then arise: how prepared are patients to assume this responsibility? And how can they get the information they need to help them choose healthcare?

One thing patients definitely want to know more about is medical cost. A survey showed that 84 percent of consumers wanted healthcare prices to be published; 70 percent said that, if they did have cost information, they’d shop around for the best prices. But they find cost information pretty hard to come by. Of those who were using CDHC insurance plans, fewer than 16 percent said they had access to information about cost and the quality of their healthcare providers and hospitals. That is not surprising, since physicians themselves often don’t have that information, either, which makes it hard to help patients who ask about ways to control their costs.

However, cost is only part of the patients’ decision-making process. They also want to know that their healthcare professionals are providing quality care. That turns out to be even more difficult to measure than cost. The Government Accounting Office reviewed the decision-support tools from five CDHC insurance providers and found that there was only very limited cost-and-quality information available about specific physicians and hospitals. Most of the companies provided average rates for physicians and hospitals but did not provide specific rates for individual physicians and individual hospitals. Some claim that antitrust laws and health-plan contracts limit the insurance companies’ ability to provide that kind of information.

Part of the problem in providing quality ratings is that there is a wide range of opinions about how quality should be rated. In fact, there is a lack of consensus across the insurance industry over what constitutes ideal quality measures and what methods should be used to obtain data. Some rating methods emphasize process, and others emphasize outcomes. For example, those that emphasize process may look at whether a particular physician follows the accepted standard of care, such as monitoring A1c levels for patients with diabetes. Those that emphasize outcomes are more likely to focus on whether that doctor’s patients have been able to avoid complications from diabetes. Some have argued that looking at this kind of outcome data is likely to penalize physicians who are willing to take on the really tough cases, since the overall outcomes from tough cases are likely to be less favorable.

A growing number of healthcare organizations are now measuring patient satisfaction. But research suggests that patient satisfaction alone is not an accurate gauge of a physician’s true quality of care. One study looked at patient satisfaction ratings and determined whether the doctors being rated had met quality-of-care standards for 22 medical conditions. The study found that patient satisfaction did not correlate well with how doctors had met quality-of-care standards. Instead, patients tended to rate their doctors on the basis of their communication skills.

The American Medical Association has taken a firm stand on the issue. AMA is committed to the goal of empowering patients to become more informed purchasers of healthcare. But it is concerned that a lack of oversight has led insurance companies to come up with unfair evaluations of individual physicians. It points out that these evaluations can be skewed in a number of ways: by the use of economic criteria, by insufficient sampling of patient cases, by questionable quality measures, and by poor adjustments for risk. The resulting distortions in the ratings can mislead patients and erode their trust in their physicians.

A possible solution would be a nationwide standard for evaluating physicians. Andrew Cuomo, Attorney General of the state of New York, initiated a probe into how insurance companies measure and disclose physician ratings. As a result of that probe, he was able to gain agreement from some major insurance companies to help guard against inaccurate, biased, or unfair information about physicians. These companies agreed to use nationally accepted standards when rating physicians, and to hire an independent group to monitor the rating systems. These changes will affect physician-ranking systems all over the country and may result in a national standard for rating physicians.

But as some observers have noted, the more things have changed, the more they remain the same. No matter what kind of information patients may be able to access in choosing healthcare, what they seem to want most is still the same thing: a meaningful engagement with their own physician.

This Essential Practice Tip was based on the Consumer-driven Healthcare issue of Doctor’s Digest. Click for instant issue access.

Decision Counseling

What’s the prognosis for consumer-driven healthcare, or CDHC? It may be too early to know whether CDHC is the wave of the future or just another failed insurance experiment. Critics point out that enrollment in CDHC plans has not increased much in the past couple of years. And people using these plans appear to be less satisfied than people with more comprehensive health insurance. They are also less likely to recommend their insurance plans to their friends.

In fact, fewer than half are happy with their insurance plans, but the good news is that eighty-one percent are happy with their doctors. This suggests an opportunity through CDHC to build a stronger doctor-patient relationship. In CDHC, the patient’s preferences and choices play a central role in treatment decisions. Therefore, strong decision counseling on your part may be the key to making this concept work for both of you.

Because they are footing the bill themselves, patients in CDHC plans are going to come to you with a lot more questions. And you will at last be free to counsel these patients without regard to what third-party payers might have to say about eligibility. There won’t be an insurance company saying that the patient can’t have this or that procedure because the policy won’t cover it. Or they can’t have this particular medication because it’s not on the formulary. Until now, some believe there have been too many decision-makers getting between the patient and the physician. With CDHC, instead of healthcare plans saying yes or no, the decision is the patient’s. And good decision counseling from you can help ensure that you get to deliver what you were trained to deliver: quality healthcare.

Through detailed and effective decision counseling, you’re helping your patients understand the potential risks, benefits, and uncertainties of their various clinical options. Once you’ve pointed these out, you can help your patients select the treatment option that best accommodates their personal preferences and values.

Conventional counseling apparently wasn’t working very well. One study showed that sixty percent of seriously ill Medicare patients preferred comfort care over aggressive interventions—but only forty-one percent felt that their actual care reflected this preference. Good decision counseling on your part can make unwanted and costly interventions a lot less common.

This Essential Practice Tip was based on the Consumer-driven Healthcare issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Personal & Professional Growth

Money and Other Motivators

Recently, Doctor’s Digest interviewed a healthcare consultant who spends a lot of his time helping residents and young physicians make decisions about their careers. Some of the things he has observed may surprise you. For example, while finance is definitely on physicians’ minds, and influences some decisions that they make, he has concluded that money is not the primary driver for most physicians.

What is the top motivator? The work itself—the specialty, the cases, and the patients.

And what is the second most important motivator? In his experience, it is the culture of medicine—basically, a healthy work environment.

The third motivator is location. Physicians have a strong sense of place and seek an individual lifestyle that works for them.

Finally, compensation comes in fourth. One consultant likes to open his conversations with physician clients by asking them to express exactly what motivates them: are they doing it for money or to help people or to find a cure? They need to be perfectly clear about this question before they can do any planning around money itself.

Regardless of their top priorities and motivators, obviously money is a significant consideration. Bills have to be paid. One consultant recommends that physicians take time out to analyze how much money they actually need. Instead of working as hard as they can, to make as much money as they possibly can, he recommends that they sit down and figure out how much money they will really need, both while they are working and after retirement. At this point they can factor in vacation time, time with their families, hobbies, whatever else matters to them, instead of sacrificing those goals that drew them into medicine in the first place. After they make this decision, and know what their actual financial needs are, physicians tend to relax and become happier with their working lives.

This Essential Practice Tip was based on the Personal & Professional Growth issue of Doctor’s Digest. Click for instant issue access.

Avoiding Burnout

A lot has been written about physician burnout—how to recognize the signs and symptoms and how to get back on track. But the best course is to avoid burnout in the first place. The challenge is to find a workable balance between your work and your life so that burnout can never happen. Here are five tips from the experts, as reported in the current issue of Doctor’s Digest, entitled “Personal and Professional Growth.”

Number one, be clear about what you really want. For example, if you were told early in your career that you would need to do research and publish in order to succeed, decide whether research and publication really interest you. If they don’t, set them aside and focus instead on direct patient care as your real calling. For some physicians, success means being an owner or partner in a group practice. For others, success means working part time or changing jobs several times over the course of their career. Decide what it is you really want—and go for it.

Number two, try teaching or mentoring. Many physicians who teach—whether to medical students or to residents—find that teaching helps them enjoy their careers more than ever. Teaching offers a wonderful chance to give back to the profession. It can also help you keep up with changes in the profession. As one expert points out, most medical schools and residency programs are begging for volunteers.

Number three, get out of the office. Physicians who get out of town occasionally to attend meetings and network with their peers claim that they come home refreshed, invigorated, and eager to put what they’ve learned into practice.

Number four, stay positive. Don’t allow yourself to be surrounded with people who have negative attitudes. One way to be positive is to focus on treating your patients the way you would want your own family treated, rather than focusing on meeting job quotas. One doctor reports that he stays positive by saving thank-you notes from his patients; on a really down day, he gets those notes out and reads them to remind himself of the real value of his professional efforts.

Number five, volunteer. Although physicians never seem to have enough free time, a professional study showed that about two-thirds of all surveyed physicians had participated in at least one public role at some point in the past three years. The possibilities are endless: coaching a kids’ soccer team, volunteering at church or temple, running for school board, helping out at a charity event. Any of these volunteer roles could offer a great way to find a successful balance between your work and your life.

This Essential Practice Tip was based on the Personal & Professional Growth issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Continuing Medical Education

Almost every state in the country requires physicians to complete a certain number of hours of continuing medical education, or CME, in order to maintain their medical license. But CME is important for another reason, too: it offers you a chance to stay clinically current, challenged, and invigorated. The current issue of Doctor’s Digest, entitled “Personal and Professional Growth,” offers the following information about how to make CME a convenient and helpful addition to your professional life.

First—a word about what makes good CME. According to the Accreditation Council for Continuing Medical Education, better known as the ACCME, there are three basic quality criteria. One, CME should contribute to patient safety and practice improvement. It should directly impact the quality of patient care. Two, it should be based on valid content. Obviously, it should not promote treatment or recommendations that pose risks or dangers that outweigh benefits, or those that are known to be ineffective. Third, it should be independent of commercial interest. It should not in any way be influenced by a pharmaceutical company, a medical device manufacturer, or any other commercial interest.

Today, going online is one of the most convenient ways to acquire CME credits—and this approach is getting more and more popular. One expert observes that there are currently over three hundred Websites offering more than twenty-six thousand CME Category-one hours for physicians! Just ten years ago, there were only thirteen.

Online CME offerings are fairly heavily weighted toward primary care; however, specialty and sub-specialty courses are also available. And you may be surprised by the versatility of the course offerings. In addition to strictly clinical learning, some sites offer courses in medical ethics, practice management, legal issues, and risk management.

CME doesn’t have to cost you anything. Most online providers offer free CME hours. Others may charge a modest registration fee ranging from five dollars to twenty-five dollars per credit hour.

The ACCME maintains strict standards for separating medical education from commercial sponsorship. For example, pharmaceutical and medical device companies cannot place accredited educational activities directly on their corporate Websites. And CME sites cannot reference commercial sponsorship on the pages that physicians visit to acquire their hours.

Teaching methods vary widely from site to site. You may find text with or without graphics, slide shows, audio, video, interactive case-based lessons, Q-and-A, and even learning games. Podcasts are becoming increasingly available. As one expert put it, the more varied sensory input you have to stimulate your brain, the more likely you are to learn. Whether you choose online CME or the kind you can access at a specialty meeting or clinical conference, CME is an increasingly interesting way not only to keep current, but to enhance your patient care.

This Essential Practice Tip was based on the Personal & Professional Growth issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Working Part-Time

Although physicians in some specialties tend to work more hours than others, the average physician clocks significantly more than the standard five eight-hour days. Physicians in anesthesiology, obstetrics and gynecology, general surgery, and urology report averages above 60 hours per week. Dermatology, emergency medicine, and pathology doctors clock in on the low end, but still hover around 46 hours per week.

There are no definitive statistics on the subject, but many physicians choose to work part-time at some point during their careers. In addition to caring for young children, there are a variety of other motivations for physicians to work part-time. Easing into retirement, pursuing additional education, and making time for entrepreneurial ventures top the list. Along with the obvious benefit of working a less-than-100-percent schedule—more time for other pursuits—there are also some challenges. Earning less money is one, and there are a variety of logistical issues. More subtle challenges also come into play, including the reaction of colleagues when a physician makes the decision to work less. Physicians who want more time for themselves or their children may have to (a) ignore judgments about what a physician “should” do, and (b) quiet their own nagging doubts.

Once a physician makes the decision to scale back to part-time, the question becomes how to do it. Physicians may have to get creative to come up with their own plan. Some physicians may be able to cut down while continuing in their current practices.

For those with a full patient load, reducing hours or days at the office may need to be done gradually so as not to overburden colleagues. For solo physicians or those in a small group, a good first step might be to close the practice to new patients or, with proper notice, to stop participating in some insurance plans.

Job-sharing is one alternative—and not an uncommon one for husband-wife physician teams and physicians who have young children. If more than one physician in an office are considering a switch to part-time, it may be possible to work out sharing and cross-coverage arrangements with other doctors.

When looking for new opportunities, it pays to look beyond what the employment ad in the back of the journal says. An organization or community experiencing a shortage of physicians may be more open to negotiating a part-time position—even when their first preference might be to have a full-time employee.

For those interested in segueing from full-time to part-time within the same organization, it pays to make yourself indispensable on the job so that when you eventually request cutting back to part-time, the group or employer will make it happen rather than lose a valuable player.

But, before you take the plunge, make sure your financial house is in order. A financial planner or accountant can help with this.

This Essential Practice Tip was based on the Personal & Professional Growth issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Resistance to Innovative Technology

Technology is so pervasive in medicine today that it’s even changed what physicians carry around in their pockets. Not so long ago, lab coats were stuffed with note cards and reference books; today’s residents are more likely to be carrying cellphones, PDAs, and iPods. In fact, most of today’s young physicians grew up at a keyboard, and for them technology is just another tool in their arsenal.

Still, some are reluctant to jump on the technology bandwagon. They’re so busy practicing medicine that they haven’t looked at how technology could enhance their practice—for example, by converting to electronic medical records, or EMRs. But as EMR systems become more efficient, less expensive, and more widely used, experts predict that it will be rare to find an office using paper charts five years from now.

One reason for this resistance is the fact that technology standards are changing every day. Physicians worry that the system they invest in today will be obsolete tomorrow, forcing them to start all over. The answer to this dilemma may not be comforting: in fact, technology will change, and they will have to update again and maybe again after that. This may lead some physicians to join larger organizations, where there are more resources for dealing with the cost of these changes.

Beyond EMRs, there is an emerging cluster of technologies that may revolutionize patient care, resulting in a very different model of the doctor-patient relationship. This cluster will include e-mail, voice response technology, and remote patient monitoring that, in combination, may result in a way to connect with and manage patients without an office visit.

Physicians perform many functions that don’t require an office visit—for example, renewing prescriptions, checking vital signs, and looking for adverse drug reactions. These things can be done remotely, monitored by information technology, and backstopped by the physician’s office staff. This clears the way for office visits that are really needed—visits that can be longer and more intensive, resulting in greater satisfaction for the patient as well as the physician.

This Essential Practice Tip was based on the Personal & Professional Growth issue of Doctor’s Digest. Click for instant issue access.

Health Policy Review

The Uninsured

Universal health insurance coverage is a popular if controversial issue among aspiring Presidential candidates. And because of the enormity of the problem, this issue is not going away any time soon. The trend over the past few decades has been a slow, steady decline in the number of people covered by private health insurance.

Specifically, the number of uninsured has climbed steadily every year since 2000. The Census Bureau’s estimate of the number of uninsured Americans during the year 2006 is 47 million people. That number is well over 15 percent of the total population. Even worse, that number had climbed by over two million people just since the previous year.

In a nation that spends twice as much per capita on health care as any other country in the world, few would argue that an uninsured 15 percent is an acceptable number. The Census Bureau calculated how many people went without insurance for the entire year, but some experts maintain that a more telling gauge would be to look at how many people went without health insurance at any single point during the year. Calculating it that way would push the number a lot higher—possibly as high as 70 million people.

Despite the erosion in both public and private insurance coverage, some physicians are still making an effort to provide health care to the uninsured. A recent study shows that almost half of uninsured patients know a doctor in their community—or are seeing one—who offers discounts or lower prices for patients who pay cash. Most of these physicians were either in an office-based setting or working at a community health center. With help from the federal government, community health centers are serving around 15 million patients a year, and the number of these centers is growing constantly. But sadly, many communities have no such safety net. In Minnesota, 18 percent of the uninsured have no primary care provider, while in Texas, a full 60 percent are in that situation. How can the problem be solved? History awaits the answer.

This Essential Practice Tip was based on the Health Policy Review issue of Doctor’s Digest. Click for expanded information from the specific chapter.

The Health Court

When a patient and a doctor wind up in a court of law over a medical liability problem, the frustrations on both sides can be overwhelming. One of the worst is the long delay that often results from backed-up court dockets. But help is on the way. The health court system offers an intriguing new solution to many of the problems that plague almost everyone dealing with a medical liability issue.

A key element of the health court system is that both patient and doctor must agree to pursue any injury complaint through the health court from the start. Here is one way this might work. A company that provides medical liability insurance may choose to use health courts. The company will require Dr. Jackson to process all injury claims through the health court system. That means Dr. Jackson’s patients would also have to agree to use this system. If a patient refuses, Dr. Jackson would simply refer that patient to another doctor.

But what happens if the decision of the health court is not satisfactory to a patient? First he would be able to appeal his case to an administrative panel. If he is still not satisfied, he could appeal to the tort system. But because he has already agreed from the start to use the health court for any claims, he cannot bypass that system in favor of the tort system. First the health court decision—then the appeal to an administrative panel—and finally a court of law.

Interestingly, other countries that have adopted the health court system have found that the number of appeals is quite low. One reason may be that health courts in those countries tend to be rather generous in their awards to patients, so there is no motivation to appeal.

Many physicians will ask, “How do we know the people who come to the health court system have meritorious claims?” One expert’s response is that the health court system will be well positioned to dispose of non-meritorious claims fairly quickly—certainly far more quickly than the current system does.

This Essential Practice Tip was based on the Health Policy Review issue of Doctor’s Digest. Click for instant issue access.

The Entrepreneurial Practice

Today nearly all physicians would agree that there’s more to practicing medicine than simply practicing medicine. The decisions you make day after day, month after month, may determine how the practice works for you—or against you. One trend that is growing among primary care as well as specialty physicians is making the practice more entrepreneurial. With reimbursements dropping lower and lower, physicians are looking for ways to increase income without necessarily seeing more patients each day.

As one specialist says, you don’t have to do a lot of things to gain more control of your practice as a business; you just need to start thinking more like a businessperson. Where are you losing time? What is inefficient? Where could new technology help you?

One of many options you might consider is to create new revenue streams for your practice. Some physicians are adding cosmetic procedures—within the scope of their specialty, of course—or skin care products or supervised weight loss programs. Others are expanding their staff in order to offer massage therapy, acupuncture, nutritional consultation, and life coaching services. If you do consider such options, it is important to put patient needs first and to proceed tastefully and ethically at each step. It’s also a good idea to do a little market research among your patients to find out just what new services they might like to have—or not have.

Another option is to reduce your reliance on third-party payers in order to make your practice less complex, reduce overhead, and regain control of how you deliver care. One Maryland practice eliminated all insurance plans except Medicare, accommodating patients as they aged into that category. The practice collects fees at time of service and gives patients a printed form to submit to their insurance companies for reimbursement. As a result, this practice is able to operate more efficiently with fewer staff members.

The point is not which alternative you choose; it’s to take a step back and give your practice a cold, hard look as a businessperson. How can you make your practice more entrepreneurial and at the same time more responsive to your patients’ needs?

This Essential Practice Tip was based on the Health Policy Review issue of Doctor’s Digest. Click for instant issue access.

Pay-for-Performance

Is “pay-for-performance” an idea whose time has come? If that question were posed to ten physicians, you’d be likely to get ten different reactions. Early attempts at pay-for-performance have fostered distrust between many physicians and payers.

Part of the problem is that “pay-for-performance” is such a popular term that it has come to mean different things to different people. Basically, these programs offer some means of comparing the services of medical providers with those of their peers, in order to promote high-quality, appropriate medical care. But early attempts to rate physicians’ performance have either failed to consider the variation in patient mix from one practice to another, or else contained technical mistakes without a built-in mechanism for correcting those mistakes. As a result, some physicians may have been unfairly terminated by health plans due to such glitches. A fair and accurate process for reconsideration after a bad report is one recommendation.

Obviously, there are many hurdles in the path of any pay-for-performance proposal. Experts say that physicians are very hungry for information about how they perform relative to their peers. But any comparison program is likely to be doomed from the start if it does not seek the collaboration and support of physicians themselves.

Physician groups such as the American Medical Association generally support performance-rating programs as long as they are voluntary and are primarily designed to improve the quality and safety of healthcare. Programs whose only goal is to save money for health insurers are unlikely to be tolerated.

A number of pilot programs conducted by Anthem over the past couple of years have shown that claims data alone aren’t enough to assess quality of care. Clinical information is needed to complete the picture, and that clinical information is very hard to come by—because providing it is likely to be just one more administrative hassle for overworked physicians. Whatever the future may be for pay-for-performance, it is clear that physician input at every stage of the process will be important for success.

This Essential Practice Tip was based on the Health Policy Review issue of Doctor’s Digest. Click for expanded information from the specific chapter.

New Breed of Patients

Young physicians today are very different from their predecessors. They have new priorities and values, and working twenty-four-seven is not likely to be at the top of their lists. They seem determined to set boundaries and to design their careers to fit their specific life priorities—in order to achieve a longer and happier career path.

But physicians aren’t the only ones changing. Today’s patients have very different attitudes from yesterday’s patient, who simply yielded to his all-knowing physician and did exactly what he was told. Gen-X and Gen-Y patients are far less compliant. As one of them put it, “We are picky, pushy, and much more information conscious than the generation before us. We are not brand loyal.”

This new breed of patients is opening doors to new practice models—such as concierge practices, mobile practices that make house calls, and high-tech surgery centers that take the hassle out of hospitalization. But they’re also placing new stresses on physicians, especially when combined with a new degree of transparency in medicine.

Publication of patient satisfaction data is just the first of many examples of this new transparency. Government and business associations are demanding that certain data be up on the Web. Access to actual prices for healthcare services is likely to be next. There is a shift from publishing prices for services as retrospective averages to making prices available in “real time.” And this new way of pricing will very likely change how patients choose their healthcare.

Another shift will occur as consumers start looking at outcome statistics instead of process statistics. That is, rather than checking the percentage of patients who receive perioperative antibiotics for a given procedure, they will focus on the percentage of patients who actually get postop infections. Measuring a physician’s outcomes and making that information available to the public are logical next steps in the transparency process. How will it all end? Some predict that within ten years, everyone in the country may be covered for healthcare, the care itself will be of higher quality, and it will cost half as much. But only large structural changes can achieve these lofty goals.

This Essential Practice Tip was based on the Health Policy Review issue of Doctor’s Digest. Click for instant issue access.

Medicare and the SGR

As the presidential primaries heat up, surveys show that the top domestic concern of voters—and therefore of candidates—is health care. Lawmakers worry that healthcare spending could reach 20 percent of the U.S. gross domestic product by the year 2015. That high price tag, in combination with a rising national debt, has led to increased resistance to raising spending on federal health programs.

The government estimates that Medicare spending alone will reach $524 billion by the year 2011. That number makes Medicare a hot topic in Congress. Clearly, one of the most controversial aspects of Medicare is the Sustained Growth Rate formula, commonly known as the SGR.

This formula determines whether the Centers for Medicare and Medicaid Services raises or lowers its payments to physicians each year. The initial idea behind the SGR was to link spending increases to growth in the economy, plus a couple of extra percentage points to allow for inflation. But by the time the legislation passed, the inflation adjuster had been deleted. And now, due to a quirk in the formula, the SGR dictates increasingly large cuts in the future, a situation that has caused Congress to step in each year to set physician rates.

An AMA survey reports that 60 percent of physicians expect to limit the number of new Medicare patients they see, if the ten percent reimbursement cut Ðas expected under the SGR—is not averted. The AMA and AARP are supporting the same legislation designed to address the matter. Many physicians are hoping to avoid even a one-year reduction in pay rates. Lawmakers are being asked to raise Medicare rates a mere 1.7 percent for next year, with a promise to begin work on a permanent remedy in 2008.

This Essential Practice Tip was based on the Health Policy Review issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Medical Liability

How can a patient be compensated when something goes wrong—without destroying the physician who made the mistake? In the year 2000, medical liability insurance premiums began to skyrocket. And ever since then, the topic of medical liability reform has inspired prolonged and heated debate. Certainly the high cost of liability insurance is only one of many complex issues. Some argue that the present tort system fosters an environment of fear that leads many young doctors to avoid high-risk specialties and to think twice about setting up a practice in a rural area or in a state without tort reforms. Another issue is whether doctors are feeling pressure to order expensive and unnecessary tests and procedures simply to reduce the risk of being found liable later on.

The physician community has been pushing for action on the medical liability front for the past 30 years. Various states have experimented with a number of plans, including placing a cap on damage claims and imposing a statute of limitations, with mixed success. The AMA and other physician groups advocate placing a limit on non-economic damages such as pain and suffering. In California, for example, there is a cap of two hundred fifty thousand dollars for non-economic damages. But the impact of such caps is not entirely clear. Some say that a low cap can be harmful to severely injured patients. And although some argue that caps will reduce the cost of health care, others point out that there is no evidence of reduced costs in those states that have imposed caps. Moreover, a study has shown that caps have had no effect on the price that individuals paid for health insurance.

Recently there has been discussion of ways to compensate injured patients without trying to place blame on providers. Some state legislatures have introduced bills to establish demonstration projects, such as health courts, that would be alternatives to the tort system. There is growing support for federal legislation to help states finance such measures. Many believe that health courts offer a promising—if partial—solution to the overall problem.

This Essential Practice Tip was based on the Health Policy Review issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Funding Research

One of the most critical issues facing the field of medicine today is the funding of medical research. The landscape has changed dramatically in recent years, and hardly anyone would argue that those changes have been for the better. For example, in 1980, federal funding paid for more than two-thirds of the medical research in this country. Today it pays for less than half.

In particular, consider the National Institutes of Health. With twenty-eight billion dollars in funding from the federal government, the NIH supports the bulk of basic science in the United States—as opposed to clinical research, which is funded primarily by private industry. Although there are six thousand scientists directly employed by NIH, only a small proportion of its funding actually goes to support research within the Institutes. Most of the research budget is used to fund grants to medical schools, teaching hospitals, universities, and other research centers.

The NIH budget doubled between 1998 and 2003. During that period, new laboratories were built, new faculty were hired, and there was an explosion of new ideas. But that budget expansion came to an abrupt halt a few years ago, not even keeping pace with inflation. Last year, the NIH budget actually ended up being less than it was in 2005, making 2006 the first time in almost four decades that federal funding for medical research dropped in real dollar value.

Many researchers are finding it more and more difficult to predict whether high-priority projects will get funded and whether ongoing grants will get renewed. Just a few years back, the National Cancer Institute funded the top twenty percent of research grant applications. Two years ago, that percentage fell to sixteen percent. Last year it fell even further to eleven percent.

Some experts fear that without funding, research institutions will eventually be forced to cut back on staff and facilities. This in turn could erode our country’s hard-won research capabilities and may slow down the development of important new therapies.

This Essential Practice Tip was based on the Health Policy Review issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Emergency Planning

Computerized Reminders

Getting medical practices up and running quickly after fire, flood, or other disaster is not just good business sense, it’s good patient care. What’s the key to a quick recovery?

Being prepared. That means more than just knowing which exit to take to leave the building or whom to call if you notice something suspicious. It’s essential to set up the infrastructure—including staffing, communications, information management and income flow—so that your practice can be ready to serve your patients when they most need you.

Let’s start with telephone communications, the life’s blood of most medical practices. The emergence of alternatives to the classic corded land line has introduced new solutions—and new problems. Cellphones have probably saved thousands of lives, but in some cases like a power outage, they aren’t reliable. Only with a plain old land phone (not a cordless phone or high-tech phone with all the bells and whistles) can one make calls during a power outage.

Then, there’s medical records. Paper records are much more vulnerable than electronic ones. If you haven’t switched to a electronic medical record, make sure your staff—or an outside firm—copies or scans all records and stores them off-site in a secure location. If you have an electronic medical record, make frequent backups and store copies offsite. You should also conduct frequent “restore” tests, to make sure the data is being stored correctly for easy use in case of need.

Another essential piece of the equation is income flow. That will take a combination of investment, insurance, and other financial planning tools.

This Essential Practice Tip was based on the Emergency Planning issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Bioterrorism

Before September 11, 2001, one would have considered the idea of bioterrorism an exotic footnote in the medical school curriculum. Now, doctors must consider “zebras” as well as “horses” when diagnosing patients. The first case of avian flu or other highly pathogenic form of influenza in the United States could show up in almost any doctor’s office in the country. Do you and your staff know what to look for?

Since all the category A bioterrorism agents—such as anthrax, plague, and smallpox—as well as the new strains of flu cause initial symptoms that resemble the ordinary flu, proper diagnostic recognition can be a huge challenge. Physicians need to be on the lookout for unusual clusters of certain disease patterns or flu-like symptoms out of season, experts say.

Here are some red flags to look for:
Exaggerated symptoms compared with ordinary flu: Whereas typical seasonal flu causes shortness of breath only in rare cases, avian flu is often associated with this symptom.

Clusters of patients outside the normal profile: If a physician starts seeing clusters of patients who don’t fit the normal age—for example, young adults in their 30s with severe flu symptoms—that’s a red flag.

Re-emerging pathogens: Physicians should be on the lookout for re-emerging pathogens like whooping cough, multi- and extreme drug-resistant TB, and variant forms of pathogens that are increasing in virulence and deadliness.

While most symptoms probably will end up being due to common illnesses, an alert physician should always consider other factors (travel, occupation, population exposures, and others) before dismissing an uncommon or unexpected symptom as a mere anomaly.

This Essential Practice Tip was based on the Emergency Planning issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Emergency Plans

Without the threat of a snowstorm or hurricane, or a Code Orange security advisory, it may only be human to ignore disaster plans. However, while emergency planning takes time, energy, and money, it proves invaluable when a disaster actually strikes. While some businesses may have the luxury of a few days to get back in operation, patients count on their physicians to be there when they need them.

How well is your practice prepared for an emergency? Do you have an emergency plan? What would you do if your telephone system went down? How would you access patient records if you are unable to get into your office? Do your patients know how to get refills on their prescriptions in case of emergency?

If you answer “I don’t know” to any of these questions, you’re not prepared— and you’re also not alone. Although healthcare organizations are more likely to have an emergency plan than some other businesses, experts say that most practices are unprepared for a serious disaster, such as a hurricane, fire, flood, or even a winter storm.

Having an emergency operations plan will increase your staff’s confidence during an emergency and knowing you have a plan will also help assure your patients. An easy way for a doctor to start making an emergency operations plan is to think about the threats that are specific to the area. Is your area earthquake prone? Is your town susceptible to wildfires? Are you in a hurricane zone or do you have frequent, severe winter storms?

Most community hospitals have some sort of preparedness plan for disasters, including pandemic flu, bioterrorism, or mass casualty incident. Physicians should know where they fit in to these plans. By joining with other practices, you might be able to come up with a more flexible and efficient backup plan than just acting on your own.

Although you hope you’ll never need to use your practice’s emergency plan, your patients and your staff will benefit from the increased training and preparation.

This Essential Practice Tip was based on the Emergency Planning issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Financial Planning for Emergencies

In an emergency situation, physicians and their medical practices are often on the front lines of the disaster response. That means their emergency preparations need to include financial planning that gets practices up and running fast and takes into account the risk of physical injury. But many physicians have not done this big picture planning.

A study published in Financial Planning magazine noted that less than 10 percent of affluent individuals have ever gone through a formal comprehensive financial planning process. Are you financially prepared for an emergency?

Cash reserves are the most essential piece of the puzzle. All the insurance in the world won’t help if it’s late in coming. Make sure you have some cash at the ready.

The next piece is business interruption coverage to cover the loss of profits plus those expenses that continue following a loss. Make sure your policy covers the contents of the office as well—medical equipment is expensive and easily damaged. To cover yourself against flood damage, you’ll need to purchase separate flood insurance.

Physicians also need disability insurance. Although most policies will not give you at most 60 percent of your monthly salary, that amount can make a huge difference in the case of a long-term disability. You may also want to purchase Business Overhead Disability Insurance to cover lost business income if a doctor in your practice becomes disabled.

Make sure your life insurance coverage has kept up with your current income and responsibilities. Life insurance rates have gone down in recent years, and physicians who haven’t reviewed their policies within the past five or six years should do so immediately.

Disaster recovery coverage can help get you back in business faster after an emergency. The recovery firm supplies the knowledge and the connections to get replacement equipment there fast, so you can focus on serving your patients effectively.

This Essential Practice Tip was based on the Emergency Planning issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Fire Protection

There are so many things to think about in the daily operation of a medical practice that it’s all too easy to overlook one of the most basic safety needs: fire protection. The best starting point for good fire protection is to have a written plan that outlines your staff’s responsibilities both in preventing fires and in dealing with a fire—including procedures for evacuating the building and relocating everyone to an area of refuge. This plan should be fully understood by everyone on your staff and updated regularly. Here are some points to cover in your practice’s plan:

Because fires in medical facilities are often related to equipment, it’s important to make sure that all your equipment is in good condition and that your office staff is keeping up with the preventive maintenance that’s recommended by the manufacturer.

If you store oxygen, has your staff been trained in how to handle it properly in case your office has to be evacuated? And does everyone on your staff know who is in charge of shutting valves? All employees should be instructed and updated on their various duties in a fire emergency, and fire drills should be conducted every quarter.

And what about those alcohol-based hand-rub dispensers? They should never be installed near a source of ignition. Unless you have a sprinkler system, don’t install them over carpeted areas, either.

Another thing to think about is the exits. Your facility should have at least two exits, and each one should be marked by an approved sign, one that is visible from any direction.

And what about emergency lighting? It should be provided and maintained in every medical facility.

Do you have fire extinguishers located throughout your building? And does everyone on your staff know how to operate them? They also should be taught that, in case of a fire, they need to sound the alarm or call the fire department and evacuate the building before they try to use an extinguisher to put out the flames.

This Essential Practice Tip was based on the Emergency Planning issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Preparing Practices for Emergencies

Should physicians talk about emergency preparedness with their patients? Stories of patients who lost their medical records or couldn’t get prescriptions filled after Katrina hit New Orleans remind us that disasters—both natural and manmade—affect patient health. Physicians have an important opportunity to talk to patients about the medical reasons for emergency preparedness—especially for those who are undergoing active treatment or taking medications regularly. But how do you do this without taking time away from the primary reason for the office visit?

While including a crash course in “Disaster Preparedness” in an office visit may be counter-productive, there are some simple ways to educate your patients about the importance of emergency preparedness. At the very least, physicians should let patients under current treatment know how to fill a prescription or how to continue therapy in case an emergency closes the practice for several days. For general preparedness information, physicians can refer patients to the Federal government’s preparedness Website, www.ready.gov, and have a stack of preparedness brochures available from the Centers for Disease Control. Physicians should also remind patients of the importance of a family communication plan, because one of the greatest challenges in disasters is finding loved ones.

In an emergency situation, staff may have to deal with a surge of phone calls and walk-in patients with questions. Take time to prepare staff for answering these questions effectively. The most likely questions will be specific to their care or the practice’s policies, but for others, it can be useful to have some key websites bookmarked. These include the websites for the Centers for Disease Control, the National Institutes of Health, and MedlinePlus. Specialty websites often have preparedness information tailored specifically for that patient population. For example, the American Academy of Pediatrics has information on its website to help families respond to an emergency.

This Essential Practice Tip was based on the Emergency Planning issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Staff Response to Emergencies

In the case of a pandemic, experts predict that up to 30 to 40 percent of the workforce will be sick or taking care of sick family members at any one time. How will your office respond to this type of emergency? Do you know on whom you can rely? While a physician doesn’t want to alarm staff by having daily pandemic briefings, waiting until the Centers for Disease Control or the federal government declares a pandemic will be too late to make the necessary preparations.

Knowing your staff members’ particular fears and responsibilities in the event of disaster is key to preparedness. A recent study at Columbia University revealed that healthcare workers are more willing to respond to an environmental disaster or mass-casualty event than to a small pox epidemic or a SARS outbreak. Emergency planning can actually increase staff willingness to respond because it can increase confidence in the practice’s ability to keep workers safe.

Experts recommend involving employees in the development of your plan so that you can get an idea of whom you can count on to work during an emergency and which staff members will have other pressing concerns. It’s a good idea to have a tabletop talk-through of staff members’ own family emergency plans. This gives staff a chance to address any fears they may have about their own safety during an emergency and to gain some familiarity with the level of preparedness of the office.

Talking about staff and physician protection is an important part of the “willingness” dialogue, experts say. Physicians should have all staff fitted with N95 respirator facemasks so that they are protected from contagious diseases. Another way to help protect staff from new contagions is to ensure that everyone is up to date with vaccinations. A pneumococcal vaccine protects against the bacterial infection which, superimposed on influenza, raises the risk of complications. The CDC also recommends flu vaccines for all healthcare workers.

This Essential Practice Tip was based on the Emergency Planning issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Taking a Closer Look

Remember the game “What’s wrong with this picture?” You look at a picture that at first glance looks just fine. Then, when you examine it more closely, you realize that the electric drill is not plugged in and the horse in the background is wearing boots.

The same thing can happen at the hospital or medical practice. Actions that seem perfectly normal may actually constitute a serious infraction of infection control procedures. Can you identify the problem in the following situations?

You’re late to meet a colleague at the local coffee shop for some lunch. You head out of your office without taking time to take off your lab coat.
What’s wrong? Your clothing is a vector for disease. If you’ve treated a person with MRSA (methicillin-resistant staphylococcus aureus) or a patient colonized with MRSA, 65 percent of the time, your clothing will be contaminated. Take the time to change your clothes before leaving work or even heading to the cafeteria for lunch. Wear a clear plastic or disposable paper gown over your lab coat while seeing patients. When heading home at the end of the day, change your clothes completely, even your shoes, which can track bacteria all the way to your carpet at home.

To amuse two young brothers who are being examined at the same time, you check their heartbeats one after the other.
What’s wrong? While it’s great to engage your patients and to make an examination fun, you should clean stethoscopes between patients.

For emotional support, your sick patient brings a friend in to keep him company in the hospital. You allow them to walk around the hallways to kill time.
What’s wrong? Sick patients should not walk around the hospital, and visitors should wear protective gear. During the SARS outbreak in Toronto, relatives came to visit a SARS patient, then took the elevator to the cafeteria. In the process, they spread the disease to other people.

How’d you do on our quiz? How did your staff do?

This Essential Practice Tip was based on the Emergency Planning issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Your Family Emergency Plan

When you’re called to respond in an emergency—whether it’s a flu clinic or a mass casualty incident—you’ll be able to focus on your patients better if you know your loved ones are safe. The key to that is having a Family Emergency Plan.

Nobody likes thinking about disasters, but it’s important to take the time as a family to consider what you’ll do in case of an emergency in your home, town, or workplace. Your plan should mesh with the emergency plans of the schools, businesses, or other facilities family members frequent. It’s also a good idea to work with neighbors and friends. Here are some questions to consider:

Where will you meet if something unexpected happens and we can’t communicate? Choose a place in the neighborhood where family members can meet if it’s not feasible to go home. You should select a backup location as well, in case the first is unavailable.

Which out-of-state friend can act as an emergency contact if communication services don’t work locally? Even when cellphones and land lines don’t work locally, you may be able to make long distance calls. Choose someone out-of-town who can act as a relay point among your family members.

Do you have enough supplies on hand to get us through an extended power outage? In addition to working flashlights and extra batteries, it’s smart to have a hand-cranked radio. Although a 14-day supply of food is considered ideal, it may be more practical to stock up with three days worth of water, canned goods, and other non-perishable foods.

Are the items you need in case of evacuation at the ready? Experts recommend having a “go bag”—packed with copies of vital documents, cash, cellphone, first aid kid, toiletries, list of prescription medications, and family contact information—ready to go at all times. Physicians will need a separate go bag in case they must report to work while the rest of the family evacuates the area.

This Essential Practice Tip was based on the Emergency Planning issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Your Home

Physicians deal with emergency situations every day at work. But, what about at home? How prepared are you and your family for an emergency? And have you done what you can to protect your home from danger and make it a safe haven during an emergency?

A home emergency plan isn’t complete without an open and honest evaluation of the major and minor threats inside and outside your home. Although thorough insurance coverage is critical too, it’s much better to prevent damage than to recover from it.

Take a look around your property: Are there dead or dying trees near the house that could fall in heavy winds and damage the house? Is there paper clutter in an area of the home that increases the risk of fire? Do you have a carbon monoxide detector? Is there an area where family members will be protected from broken glass and other damage from a severe storm or explosion?

Stock up for an emergency: Do you have flashlights, battery-powered or crank radio, charged cell phone, and extra batteries at the ready? Do you have food and water to feed your family for at least 3 days? If a family member depends on medication, do you have plenty on hand to carry you through an emergency?

Protect your paperwork: People often overlook the importance of document protection. A fire or flood can destroy important documents, including licenses, diplomas, identification cards, and other vital documents. Taking the time now to scan these papers and back them up to a CD can save you hours of headaches in the event of an emergency. It’s a good idea to send a copy of the CD to a friend or relative in another area as an additional safeguard.

Know how to turn it off: In an emergency, you might need to turn off your water, electricity, gas, and security system. It’s better for you and your family members to learn how to do this now, rather than trying to figure it out in the midst of a crisis.

This Essential Practice Tip was based on the Emergency Planning issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Optimize Your Practice

Coverting to an EMR

The most important information in any medical practice is the patient record. That information has to be readily accessible to whoever needs it; but the patient’s privacy must be protected. How do you manage the dual need for access and protection? More and more practices are deciding that the best solution may be the Electronic Medical Record, commonly known as the EMR.

EMRs are the wave of the future, and it’s getting harder and harder to avoid converting. Many practices are put off by the high price tag for going electronic, especially smaller practices that can’t spread the cost over a large patient base.

If you’re considering converting to EMRs, a few advance steps will help ensure your success. First, explore the true cost of setting up a system. Prices for basic systems range from about fifteen hundred dollars to hundreds of thousands for fully integrated, multiple-practitioner systems. Next, consider timing; after the training period, it takes most practices about three months for the staff to go live with a new system.

A final step: take your office manager with you and visit a practice that already has a system like the one you’re considering. Even if you have to fly across the country, it’s time and money well spent. Be sure to see how well the system is working, not just for the doctors, but for the office staff as well.

If you do convert to EMRs, the rewards will be worth it. The American Academy of Family Physicians found the biggest return-on-investment was chart access. Scanning older charts into new systems eliminates misfiling problems and gives immediate access.

This Essential Practice Tip was based on the Optimize Your Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Documenting Practice Services

How many times has this happened to you? You’re on overnight call, and the phone rings at 2 a.m. You talk a patient through an urgent matter, collecting information to determine if he needs to proceed to an emergency room or call the office for an appointment in the morning. After half an hour on the phone, you collapse back into bed, confident that the problem can be handled in the office during regular hours. The next morning, the patient calls the front desk and says he feels fine now and doesn’t have time to come in for an appointment. With no record of the half-hour phone conversation, the details of the conversation are lost and your time goes unreimbursed.

If notes from a telephone or other on-the-go consultation aren’t recorded, important elements of patient history may be lost. That documentation can make a huge difference in ensuring quality patient care—and avoiding medical errors. In addition, one of the largest areas of revenue loss for medical practices is services that remain uncaptured.

The solution can be as simple as having a portable mechanism for physicians to record charges for billing. And the result will be more complete patient records, as well as the potential for increased revenue.

By carrying a simple medical memo pad, physicians can easily record patient services rendered on the telephone, on call, even by email—anywhere the patient record may not be easily accessible. Your notes ensure proper documentation in the patient’s chart of a new medication, change in dosage of existing meds, and new instructions.

Even if the care provided is not billable, a checklist pad to document telephone care can result in a more complete and useful record. For example, if the patient had decided to come in for an appointment and had seen another practitioner, the details of the phone call would be in the chart. That saves time and allows the doctor to focus on the patient. To top it off, the patient is impressed with the efficiency of your practice.

This Essential Practice Tip was based on the Optimize Your Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Efficient Insurance Claims

If your practice is like most others, your cash flow comes primarily from payors such as Medicare, Medicaid, and private insurance companies, with a smaller percentage coming from patient co-pays and other miscellaneous revenue sources.

How fast this cash flows into your practice is largely determined by how efficiently your staff files claims. Establishing a method that grants quick reimbursement from insurance companies will help ensure the healthiest bottom line possible.

First, are you filing claims electronically or on paper? Today most insurance claims are electronic, which has helped speed up reimbursements. According to a recent survey, more than 75 percent of claims were filed electronically in 2005, up from 44 percent in 2002. This survey, based on data from nearly 25 million claims, found that almost all of those claims were processed within 30 days of receipt by the payor. And electronic claims were processed faster than paper claims. Almost 70 percent of properly submitted electronic claims were processed within 7 days, while only 29% of paper claims were processed that rapidly.

Although this fast turnaround is good news, the survey also found that there was a big gap between the time the physician saw the patient and the time the claim was submitted. Almost a third of the claims were submitted more than 30 days after the date of patient service. Even worse, 15 percent were submitted more than 60 days afterward. Clearly, prompt submission of claims is an excellent way to improve cash flow.

Also, is your office submitting “clean” claims—that is, claims for which no additional information or corrections are required? The survey found that 98 percent of claims are clean. But a claim that has an improper code or an incorrect birth date will take, on the average, nine additional days to process.

This Essential Practice Tip was based on the Optimize Your Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Managing Practice Finances

One of the first decisions a physician needs to make when going into practice is how to handle the money side of things. As your practice grows, you may have to re-visit the decision.

A common mistake that small, growing practices make is to assign the office manager the responsibility for bookkeeping functions. Putting the bookkeeping function on the plate of an overworked office manager can be a recipe for disaster, since that person will not have the time to devote proper attention to this critical function.

Billing and collections are often good tasks to outsource. Your practice management or electronic medical records software vendor may have a billing and collections service at a reasonable fee. Compare the costs of the service to hiring another staff member.

Whether you outsource or take these functions in house, you’ll need a good accountant. To find the names of qualified accountants or accounting firms, start with your state medical association. You can also ask colleagues for referrals to good firms.

It’s important to select a firm that has experience with medical practices similar to yours. If you have a small practice, it’s not necessarily the best use of funds to hire an expensive firm that primarily deals with large healthcare facilities. You’ll get more for your money with a firm that understands and caters to smaller practices. While some firms may be bound by confidentiality agreements not to disclose their client list, most successful firms are able to get permission from at least a few of their clients to act as references. Be sure to call and ask questions about what the office manager or physician likes about the firm and the level and value of service provided.

Monitoring cash flow, profit, and expenses is essential for understanding the health of your practice. Your accountant should be able to advise you on how to be most successful in these areas, as well as to offer sound business advice to help you run your practice better.

This Essential Practice Tip was based on the Optimize Your Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Promoting Your Practice

Managing schedules to reduce wait times and keep patients flowing efficiently through the office is a good way to keep patients happy and keep them coming back to your office. But how do you attract new patients to your practice in the first place?

Ways to help get the word out about your practice include advertising in local media, creating direct-mail campaigns, generating publicity, participating in community groups, and affiliating with appropriate causes. What’s most important is to target the promotional opportunities as carefully as you can to reach the audience most likely to need the services that you provide.

Newsletters can be an effective choice, whether they are distributed in print format or by e-mail. The key is to be more informational than promotional. By including articles and information that inform the reader, with your practice’s information clearly printed on the newsletter, you put yourself in a position of authority. If the information is useful patients are likely to pass it along to friends, relatives, or colleagues who might be interested in the content. It’s a good idea to send copies of the newsletter to other physicians and practices that might be in a position to refer patients to you. These newsletters can serve as a resource to colleagues if they contain content that helps inform patients about a particular procedure or treatment.

A well designed newsletter or other promotional material should contain well-balanced and reported articles that help the patient better understand a procedure, illness, or other medical issue. If there’s a drawback to a procedure, it’s better to address it upfront rather than sugar-coating it. Patients appreciate have the full picture when deciding whether to proceed with a particular treatment.

Before and after photos are a good idea to promote practices that offer weight-loss surgery or plastic surgery. Better yet, happy patients may be willing to let you tell their stories. Hearing real people’s success stories give prospective patients confidence in your services.

This Essential Practice Tip was based on the Optimize Your Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

The Practice Identity

Running a medical practice is one thing; running a medical practice that functions like a finely tuned instrument is something else entirely. Optimizing the efficiency and profitability of your practice is essential to its ability to grow, its long-term prospects, and its focus on patient care. Practice management pundits urge physicians to remember that you can’t entirely separate the business of medicine from the practice of medicine.

So what’s the first step in optimizing your practice? Experts say that understanding your practice identity is essential for setting long-term goals success.

As in other service-related businesses, a practice’s identity is linked to the identity of its customers. Physicians sometimes bristle at the idea of customers, rather than patients. But, the term customer encompasses more than patients. For example, referring physicians are customers for many practices. If a practice participates with certain insurance or managed care companies, those payers may be considered customers as well. Practices also need to look at their specific patient population. Different practices will have different sets of customers. Whom does your practice serve? Families? Older women? Low-income singles?

Each group of customers has different needs: balancing them all can be tricky. How the practice intends to meet— and perhaps exceed—its customers’ needs determines the practice’s identity.

Of course, if there is more than one partner physician in the office, determining the practice identity and the customer-service philosophy needs to be a team effort. Everyone needs to be on board, not only with the practice positioning, but with other facets of running a business. Even if one partner has controlling interest, keeping partners and staff on the same page concerning how the practice is operating and growing can mean the difference between harmony and acrimony.

This Essential Practice Tip was based on the Optimize Your Practice issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Evidence-based Medicine

Computerized Reminders

There is probably no profession on earth that requires more things to remember than medicine. Do you sometimes wish you had a reliable memory jogger to make sure you don’t forget something important? Physicians in the Veterans Administration are depending more and more on computerized clinical reminders. These reminders are expected to gain widespread use throughout the medical community now that electronic medical records are becoming more widely accepted.

Clinical reminders can save you time and improve patient care. Let’s say you have a patient who is diabetic. The system requires that such a patient get his hemoglobin A1c checked at least twice a year. If the A1c level is not within acceptable limits, the computer will expect some change in the patient’s treatment to be documented; and each time the patient comes into the clinic, the computer will check to see whether his A1c is within target values. If it’s not, the computer sends a clinical reminder to the physician to take some action to improve this patient’s care.

The computer is even more insistent in the case of colon cancer screening. For every patient who enters the clinic, the computer checks to see when the patient was last screened for colon cancer. If it has been too long, a clinical reminder prompts the physician either to order an approved screening test or to tell the system that a test was conducted outside the VA, in which case the test results need to be entered. The clinical reminder can’t be ignored; you can’t go on until you have dealt with that particular reminder!

In some cases, the VA system sends out “flags” to the physician when there are abnormal test results that may indicate a serious problem. The computer may even suggest therapeutic options.

As Evidence-based Medicine becomes more widely embraced in the medical community, these clinical reminders may help you to use the best available evidence in order to make the best choices for your patients’ care.

This Essential Practice Tip was based on the Evidence-based Medicine issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Cost of Care

Many believe that evidence-based medicine holds great promise for improving patient care and raising standards of care by ensuring that treatment decisions are based on the best available medical evidence. But how does evidence-based medicine affect the cost of care? While we don’t have a definitive answer on that, experts have put forth some ideas:

Guidelines will save time—and money. According to a study published in the American Journal of Public Health in 2003, performing all the recommended preventive care for an average patient population would take a family physician 7.4 hours each day—leaving little time to address acute complaints. With active evidence-based guidelines built into electronic medical record packages, physicians can zero in on the tests and procedures that are most important for that particular patient’s diagnoses.

Differences in interpretation of evidence may lead to reimbursement problems. A physician who bases a patient’s treatment on his or her own past experience or even a clinical study that he or she has read may have trouble getting reimbursement if the payer contends that the evidence is not relevant or strong enough. There is already a provision in Medicare Part D that puts the burden on the physician and the patient to prove that a drug that’s not on the formulary is actually medically necessary.

Evidence may lead to new ways to bill and even increased coverage for certain services. As more and more patients have multiple chronic conditions, studies show that it is more effective to center care around the patients’ overall condition, not the complaint with which they present. The “Chronic Care Model” takes a team approach, with nurses, medical assistants, nutritionists, and other healthcare professionals addressing different parts of the patients overall health. While this model has proved very effective in clinical studies, it does not fit with current reimbursement structures. In this case, the evidence is convincing insurers to pay for services they previously denied.

This Essential Practice Tip was based on the Evidence-based Medicine issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Data Selection

Do you sometimes get frustrated when you can’t find a study that addresses your specific medical questions? Randomized, controlled trials are often referred to as the “gold standard” of medical evidence. While RCTs are the best way to learn which prevention, diagnosis, and treatment strategies works best, that doesn’t mean that RCTs are the only source of useful data for making evidence-based medical decisions.

Actually, most of the medical literature does not consist of randomized trials. Retrospective and case series studies are much more common. The point to remember is that various kinds of evidence are useful to answering various kinds of questions.

For example, if you’re wondering how long patients tend to survive with a particular disease, that’s a prognosis question. A randomized trial will not hold the answer. A better way to find the information is to explore the outcomes of other patients who had that disease by looking back at your last 100 patients’ experiences—or, better yet, looking a published study of 25,000 patients who had that disease.

When looking for evidence on which to base medical decisions, physicians need to look use the right resources, too. For example, the Cochrane Library contains analyzed results from RCTs. For efficacy of different interventions, experts say it’s as good as it gets. But, for data on a wider range of medical questions, physicians might be better off choosing diagnosis support tool, such as UptoDate, which contains peer-reviewed, fully referenced reviews.

Whichever resource or data type physicians choose to help answer a clinical question, it’s important to analyze and weigh the information to make sure it applies to your patient’s specific situation. That’s what evidence-based medicine is all about: using the best available evidence to make the best choices for patient care.

This Essential Practice Tip was based on the Evidence-based Medicine issue of Doctor’s Digest. Click for expanded information from the specific chapter.

Keeping Up to Date

The results from an estimated 82 randomized controlled trials are published every day. How do you keep up with this staggering amount of new medical knowledge?

Evidence-based medicine offers some useful answers to this classic dilemma. While physicians have always used evidence in diagnosis and treatment decisions, the formal concept has led to new resources for physicians. For one thing, there are now medical journals that have been created specifically to review newly published evidence, evaluate it, and make conclusions about it. Consulting these journals can result in an enormous savings in time and intellectual energy.

Online databases, such as PDQ for Cancer from the National Cancer Institute and The Cochrane Database of Systematic Reviews, and the American College of Physicians’ Journal Club, can be consulted via the Internet to give you a formal assessment of the strength of new medical evidence. You can search by your question or by key words or topics, such as “rising PSA count.” The database can tell you to whom the new evidence applies, how strong the evidence is, and what the potential benefits and harms may be. Some even rate the strength of the recommendation. In ten to twenty minutes, you can read through all the results of a given search.

The next step, of course, is for you to apply your own knowledge and skill in deciding how to use the evidence. How closely does the literature match your patient’s situation? Do results gathered from a study of healthy 60-year-olds apply to your 80-year old patient? Evidence-based medicine resources don’t give you the answers, but they can ensure your decision is based on up-to-date medical knowledge.

This Essential Practice Tip was based on the Evidence-based Medicine issue of Doctor’s Digest. Click for expanded information from the specific chapter.