Having just gone through this, I'd like to offer a number of observations. Some will prove to be unique to our practice, some general, some predictable, and some totally surprising. This may get sort of long. it has been an astonishingly complex process.
There were several broad problem areas that were immediately obvious:
1) What to do about patients? Some need continuous ongoing care, and there are a limited number of physicians in town with open practices, and pretty much only one internist... certainly not 5,000 patients worth.
1a) What to do about creating a coherent transfer record for those patients needing active care? We have all by now received notes on a new patient generated by one of our wonderful electronic records systems, hundreds of pages worth, with no medically useful information. I do not exclude (and here is my final dig at AC) records from AC using templates. I have come to not even look at them any more. They are worthless. My patients need better... some kind of capsule summary, the kind of thing we used to keep on a 3X5 card in our pocket in residency to hand off to the next person on call as we were stumbling home. So, what we have been doing for the last two months is offering an "Exit exam"... a brief exam to summarize active problems in the HPI, and to make sure the patient has enough medication to last until they can get reestablished.
2) What to do about getting records to patients, both now and in the future. I plan to be on the other side of the world. No one is taking over my practice, nor it is being folded into another.
3) What to do about staff? These are people who have worked hard for me for years. Anyone who thinks an employer can just give out a pink slip and go home to a cocktail party has a heart of flint. These people have devoted a big part of their lives to me, and some have aged to the point that finding new jobs may be difficult. I have responsibility towards them.
4) What to do about office equipment and supplies? I can't take a bunch of syringes and needles to the dump. The value of a 30 year old exam table is minimal.
So, here is what happened. For all the hostility I feel towards the hospital (administered now by a large healthcare corporation) and its large captive clinic, they stepped forward to assume a huge load. The clinic made sure there were openings in their family medicine department for our patients. To be sure, our patients all liked being seen by us because they thought that an internist was better for them, but we all know that a well trained Family Medicine doc can do 99.9% of what we do. It took some selling, but by and large our patients accepted this transition. There were a modest number that the FP people did not want, due to multiple or complex problems or use of unfamiliar medications (antimetabolites and the "-ab" drugs, like infliximab seem to top the list), so our one remaining internist with openings was courted, bribed, wheedled, etc. to step in for these. We of course had to be selective whom we sent. Some patients were insistent I make a referral, despite having only very basic problems. My colleague and I worked out a code for the referral letters... those I really needed him to see, and those I was referring under duress. Needless to say, NOBODY wanted patients taking chronic controlled substances, of which we, like everyone else, have a few we have carefully vetted and monitored throughout the years. The pain clinic only wants to do procedures. At the moment, this issue remains unresolved.
They also offered to become our records custodian. They had done this before for another practice, by doing so in some convoluted manner that did not mean "The Clinic" had the records, but some sort of other legal entity acting only as records custodian and so avoiding HIPAA pitfalls. This got pretty convoluted. I became amazed and frankly sympathetic to the people locally trying to make this happen, as I watched all the ways a big corporation can strap heavy weights to itself and jump into the deep end of a swimming pool. I did have some smug satisfaction however to watch this since at our initial meeting their CEO and IT head both rather arrogantly brushed off any suggestions I had with "We do this sort of thing all the time, there's nothing too it." At one point their suggestion was to print out PDF files of all 5,000 plus records one at a time. I pointed out to them just how useless that would be, and that if we copied say the Imported Items folder the records were totally unusable without AC t0 unscramble them. I suggested just making them a user on our AC system, and giving then a standalone computer to sit in the corner and export things on demand. They seemed, however, incapable of grasping that I did not want them to have to buy anything; it was a gift to make their and our patients lives better. Altruism is a totally alien thought to Big Healthcare. So, as it stands, what will probably happen is they or we hire a temp employee to periodically come burn records to disk. I think most of the patients have theirs already.
The staff issue is mostly resolved. A couple of staff members decided to take a year or more off, and think about work later. Most of the rest have already found employment which has agreed to let them delay their start a few weeks. One staff member has not. It is a concern, and weighs somewhat heavily on me, as she is older and probably our most vulnerable employee. I am doing all I can on her behalf. Our billing person will work from home on an hourly basis until it is clear what remains of the AR is not worth paying her to collect, and all refunds have been processed. I'm going to keep UpDox going until this is done for faxes and credit card processing, but turn off the portal.
We found a nurse practitioner who is setting up an office in a neighboring town, and needed office equipment on a shoestring budget. Consequently, she is not fussy that much of the equipment is dated. We pretty much gave it to her for the hauling away. I wasn't kidding when I posted a while back "free to a good home". I feel our equipment has served us well, and should be set free to do good wherever it can, unencumbered by the taint of haggling over price.
But, probably the most wonderful part was unexpected. I mentioned our offering "exit exams" to those who felt they needed it. By in large these are medically unnecessary... the next provider could really look at our last comprehensive exam, which we do yearly and in which we summarize all current problems, and get what they need.... but a lot of patients felt they needed this. For the most part, they did not need it for any medical reason... they needed it to come say "goodbye" and thank us for what we have done. It has been an amazing, moving experience, like being alive at your own wake. People bring us presents. We cry together (and I am not a terribly sentimental guy). We hug. They send us cards... lots and lots of cards... telling us how much we meant to them.
I am convinced that it is not because we were such amazing physicians. We are good doctors, we try to do good and cost effective medicine, we treat our patients with care and respect.... but no more so than any other good physician. I think they were honoring us as a symbol of what we all do, that we care for those that are vulnerable, that we earn their trust, that we do our best for them. So, for that reason, I want to share that thanks with all of you. In the midst of all the bullshit of Meaningful use, and whether NewCropScreens is working, or anything else that irritates your day, try to remember that what you do is terribly important. And appreciated.
