Home Forums Discussions Problems DEEP THOUGHHTS by Walter Handy

Hi everyone. I am a doc's husband and her IT guy, an exIBMer and an adjunct prof, and WE need help bad. My doctor burned out for quite sometimes, who is not? She is a perfectionist, and since moving to Amazing Charts from papers and starting her solo clinic 3 years back,many day she stays up till 4,5 AM and up again at 7:30. Our doctor friends telling jokes that doctor breed doesn't need much sleep... Something must be definitely wrong here, and we needs all our wonderful friends in the forum, as Amazing Charts users, to give us suggestions or willing to be our visiting doc and Amazing scholar for couple hours, we are in Dallas/FWorth metroplex. Only about 15-25 patients a day, 15-30 minutes a patient. Lots of chart templates, lots of copy and paste, she starts to develop hand/arm pain by too many mouse clicks. I told her to get an assistant, but she is afraid no help can do what she can, as a family doctor. Most the time she doesnt finish chart after seeing a patient but doing it later. Then charts accumulated end of day, after 2,3 days then loosing sleep.... Million thxs in advance

Hi FhcWalter,

Hi and welcome to AC and the board. I can't help with the mouse clicks other than using DNS, which tons of people on here use.

But, the best advice I can give you is:

ALWAYS finish the chart in the room. Finish it with the patient in the room, the scripts ePrescribed or printed, the letter printed and the chart saved. You, of course, won't have a letter most times.

Not to brag, but in seven years, I would say I didn't finish a chart while in the room maybe 25 times. It is easy to get used to. If your MA does all of the subjective on the left and the vital signs, all you have to do is fill in the exam, assessment and plan.

Do you go by Walter? Can you go to your profile and add a signature with your name? It's easier than calling you FhcWalter.

BTW if finishing all the charts in the room seems daunting, just pick 9 out of the 15 that you will definitely finish in the room.

Suggest Dragon Dictate Medical version 10.1. Costly but could eliminate 90% of mousing.

John,

Can Tom Hamilton help with that in vendor forum? I don't know.

Thanks Bert, you are one of our most wonderful, and kind friends in our forum. I am kind of surprise to see how you can handle your everyday plus inform plus helping others... I am waiting to see more life saving suggestions then I copied all into one long email and send it to my doc. It is tough to convince my doc to change her way of doing things. . Are you one of our gifted ones? a former X guy in hidden? Walter

Walter,

Thanks for the kind words. I do it by staying as late as she. As she learns to use templates and allow her MA (is she uses one) to do the subjective (she can always add to the HPI), she will soon get through a note very quickly.

And, I think John deserves a lot of credit on the DNS, as it would be very helpful. Of course, some people feel comfortable dictating in front of a patient and others don't. Not that you couldn't after the fact.

Ryanjo, I already suggested her to use Dragon and bought her a non medical to try out couple years back.But she is 'slow' to think how to say but quick with her fingers, and time to learn the software. She hate new things! Probably after 20 years in practice, she 120% burned out and ready to crash any minutes.... So DNS is out of questions. Bert suggested to finish chart after each patient, but when too many patients waiting she gets kind of 'freaked out', too many frustrated patients, insulted paper works, now a day also the reasons, and wants to move to the next one... a loving, dedicated female doctor? you bet! Medical is wrong field for her in modern time? might be! Do you know about the hot Angry Bird game payable on your Chrome browser apps... you too can do the shooting

If you have an MA who you can actually trust to take the subjective, that can really help with time. But if they can't do that properly, it can make it worse.

Templates are your friend.

For a while, you may have to reduce the number of patients just to let her get some relaxation and a few good nights sleep. Or you may have to pick one day during the week when you close at 1PM (or you're not open) assuming you are not already doing this. She can catch up on charts at a relaxed pace, or just watch TV and shop. But she MUST get some down time. If you are not exaggerating about the crash, cancel all patients for this Friday and take another long weekend.

Get patient's pharmacies and while she is in the room she can quickly send the RX the pharmacy.

Make up a policy statement and provide to each patient. In this statement, clearly state that for all Rx Renewals they must come in, you will not autorenew from a pharmacy telephone call, and will not call in renewals on weekends. Tell them to be sure to give adequet time to come in for an appointment for the renewals. We did that a couple of years ago (at my insistance after seeing some other doctor's policy statements) and our weekend calls for Rx renewals dropped by some huge percentage. We don't get them anymore now. Well, maybe once a month.

I agree on the above strategies for a start. One important point is that the coding is being done correctly so she can be possibly better paid while seeing few patients. Most doctors don't use 99214 enough. The AAFP has a great score card on their website to quickly see if you note is meeting that criteria. Most do level 4 work but code it down for fear that it 'isn't enough'.
Next, reduce the number of patients per day. Maybe 16 would be plenty. Then, start getting every note done in the room with a longer visit. Remember, adequate 'time' with a patient will qualify a level 4. She should be able to go home soon after the last patient leaves. When speed on the charting increased, then number of patients can increase. A pile of charts at the end of the day is enough to burn anyone out. An MA who can do the subjective would help, but also an MA may be able to 'transcribe' the whole note in the room. The doctor could even verbally dictate the exam in the room for typing: i.e. chest clear, heart regular, no murmurs. Just some ideas I have seen done before.

Personally, I really dislike templates for anything other than a starting point the physical exam and ROS, but I am in the minority. On the other hand, Dragon Naturally Speaking medical version 10 is so good that it needs almost no proofreading. I see 10-12 patients a day, no appointment less than 15 minutes (usually 30), never try to finish a chart in the room, and am always done and out the door by 5:00. My priority is to be eager to come to work, not dreading it. It is sometimes hard to control the monster we created, but reducing the load a bit may well help. That gives time to work on a chart in between patients. Consider scheduling 4 15-20 minute breaks in the day, and make them inviolate so nothing invades those slots.

There are different ways to skin this cat. I have trained myself away from perfectionism and over to regarding the note as a working document that needs to be useful to me. It needs to be my servant, not vice-versa.

Wow, you guys are amazing, so quick to the rescue. Thanks Bert, Ryanjo, Wayne, Boondoc... I have already sent the link to her, probably when she has time to night she'd read it. I did not exaggerative at all Wayne, that serious. As we are not getting younger, to the point, a former workloads might become too much. Solo practice now aday is no longer that as it used to be, have you read the NYtimes article couple weeks back, about an old doc likes to give away his practice, Wayne? You are dead on Boondoc, she details level 4, 10 steps! 16 patients a day is only makes expenses...so she wants to see more...catch 22.. a trusty, intelligent enough MA is not easy to find, but only to transcribe might be a good suggestion, but then we need to get more MA, as one needs to be constantly with doc. We already had two MAs on busy days like Mon, Tue, Fr... all practical ideas are very welcomed... do you know that female doctors are 'wasting' more time than male

Walter:

I can fix the arm pain from mutliple clicks, etc...(i do sports med). . .

I would also recommend doing the notes right away. I don't always get to them but I do them all before I leave for the day. Maybe she is overdocumenting (yes there is such a thing) ,but she shouldn't be falling so far behind and taking that long with that many patients.

Also does she have a staff member fill in some of the notes? so for new patients all the ROS, PHx, Social Hx, etc. . .that always helps too. I only ever need to work on the HPI and the PE and the plaan...templates makes things a lot shorter and I agree about dragon, though i have it i don't use it often! i need to work on my dragon templates!

On the coding side to insure you get max revenue...

Don't forget code 99051.

I use this for any appointment at or after 5 pm. All insurance wont pay, but Aetna does, and I noticed a payment on a BCBS one yesterday.

99051 is an add-on code for "regularly scheduled, after-hours appointments." That is, if you have regularly scheduled late or weekend appointmetns, you charge this for those appointments.

There is another code for "non-regularly scheduled, after-hours appts." like when you stop at say, 5pm, but someone calls saying they are just so sick and you agree to wait and see them at 5:45.

oh, another thing.

Handouts are your friend.

If you find situations where she says the same thing over and over, you need a handout. Then she can give a BRIEF explanation to a patient, give them the handout, and have them schedule another appt. if they have additonal questions. So much time can be spent attempting to explain things when the patient "has the claws in and won't let go." It might seem callous, but she has other patients to see.

A frequent example is someone whose screenings came back positive to herpes simplex. They come in, and want to spend 30 minutes trying to figure out who gave it to them, etc. You have a couple of brief statements for this (well, up to 4 minutes), and a handout containing excruciating detail. Our standard handout on this is about 3 pages. Plus an article we wrote posted on our website. We also have a 30 page version, but we won't inflict that on anyone unless they want to ask really detailed questions. Haven't needed it in a couple of years now.

We have cholesterol handouts, an IBS diet, and there is this company called Vivacare that can post handouts to your website. One of our new-onset diabetes patients really liked the one we gave him on DM2.

I have been getting handouts from the AAFP at Family Doctor.org. Does anyone else have some good handout sources online?

I agree with all of the above...pick and choose what helps. Wayne's handout idea, and the creation of templates are areas that YOU (or someone else in the office) can help her with. Go back through her old charts and find repeated paragraphs (elements of the physical, assessments and plans for sinusitis, allergies, bronchitis....whatever she sees repeatedly). Use her own text to create templates. The process is pretty quick but if she is overwhelmed by a full waiting room and a backlog of charts, it may get done. Do it for her, and next time she makes a few clicks instead of dozens.

And one other off the wall idea. It sounds like she values her role as a clinician, diagnosing and treating patients "old-style". The problem is with the documentation. Have you heard of a medical scribe? These people accompany the doc in the office and exam room and create the note (at least the H and P; maybe more) as the patient and doc talk. She could interact with the patient and forget the documentation. The scribe takes it down. Now this does take some degree of proficiency with language and writing....and I don't want to insult any scribes...but there are nearly zero jobs for recent college grads out there (let alone smart high school students). Maybe consider hiring one at a pretty low rate of pay, perhaps even just for the summer to give your doc a breather and develop some of the strategies suggested by others above.

All of the above are great ideas. In addition, your Doc needs some serious help with time management. I have been solo practice Int Med - Self Employed, for 22 years. There is no way that she should be awake at 3 -5 AM doing her charts. I use Dragon, Templates, Macros, and free type, and like Bert, I am finished with the chart when I exit the room. Perfectionistic tendencies is just a nice way of saying that you're (or your Doc) is somewhat neurotic. I'd suggest a good vacation and re-kindling some passions(diversions) outside of medicine. This could be almost anything. Music, painting, gardening, long walks or an exercise program. The list goes on. Check out the music under the stars at Levitt Pavilion/Summer concert series. This Doctor needs a break away from medicine (time off, not resignation). Good luck. If she has the opportunity to attend a user's conference the socal support networking is great. I made the first one, but not the last two. Good luck.

Thanks Ketan, Jon, Chris, Wayne, Bert, Dave and more come to the rescue. I need all your heavy duty hits to push my doc to think away from her preferred 'old style'. But myself like Dave's idea the most . Are docs in Alaska any difference? 10 patients a day? 5 o'clock and getting out off the office and go fishing, heavenly...
Jon you are right about documentation overload, but that is something I can not help her much because I am a senior now, absent minded, sometimes mind not clearly focused. I did think about someone to scribe but she is old school and said family practice too complicated, too many different assessments...not a high class derm or GI doc to have a low pay side kick around(not offensive any derm doc and not you Jon ...her question was that any family doc out having an assistant like Jon's suggestion? Any doc out there having an assistant in the room, or doing most of subjective chart items to give more advice on this? I read this from many of you before in the forum but like to retouch the subject as a comprehensive survival help in one topic.

What did she do before? Did she use paper? Here is what I envision when I see her in a room.

I see an MA triage the patient and write vitals on a sheet of paper that may have the chief complaint on it. I then see her enter the room and begin talking to the patient, taking a history and finally an exam ALL without even having the chart open. I am JUST guessing. After a twenty minute history and exam, it would be time to chart it, but there is now an empty chart with nothing in it. Am I wrong?

Instead, my MA would see the patient in the triage area. The chart would have already been sent to her from the receptionist. She triages the patient, enters all vital signs and takes a very thorough and good history. The chart is then forwarded to the room in my inbox.

So, from there, your doctor would walk in the room and have a little idea of what the CC was from the Superbill on the clipboard. She would walk over, say hi, then unlock the computer and pull the patient's chart from her inbox. So, at that point, we are talking 30 seconds. She briefly reads the HPI, then hits the return key and begins to interview the patient based on what she has read and fills in the spaces. That takes two to five minutes. The ROS has been filled in by the MA, and you check them briefly. You always have enough to count for a 99214 if you need it. The PMH and PSH are pretty much the same. I generally, open the script writer and go over the medications. With ROS check and medications check we are at four to seven minutes.

Now, you do your exam. As one doctor taught me, you can do an awful exam in three minutes and a great exam in five. Something tells me she does the great one. Now we are at nine to twelve minutes.

You finally sit down to actually finish your note. You use a template to enter the exam findings and tweak it a bit to add another finding. Less than a minute.

You must choose a diagnosis/assessment and possibly why you came to that conclusion. You then document a plan and possibly print out the plan or some information sheets. This process should take about four to five minutes. So, we are at 14 to 19 minutes.

You close the note, then sit and chat with the patient for 30 seconds and answer questions. This will likely be a 20 minute appointment. So, since she has 15 minute appointments, they average out with one being a five minute or less conjunctivitis and another being a 35 minute Type II diabetic.

I understand everyone who charts later. I understand that she doesn't want the full waiting room. Not sure the layout of your office, but how about trying one day where she doesn't SEE the waiting room and just works right along finishing every chart she can. Take it to the extreme and after you or her MA tells her that she has seen the last patient, she should just walk out the day, eat at a nice restuarant, grab a bottle of red wine and curl up by the television. Then you know it can be done. Worse thing that could happen is she gets an hour behind, her patients who love her stay and wait, and maybe one patient leaves and goes to the ED where they wait four hours more.

The reason she is up so late doing the notes is that it takes longer to do a note that you are struggling to remember a visit hours after an appt as well as while sleep-deprived. Type the pt's info while they are speaking to you. Practice your typing skills until you are up to speed. Then do the exam, hit the templates while the pt is throwing those last questions out. I usually get slowed down by searching for dx codes and coding the visit so I may leave that part until later. This will go much faster than typing nothing at the time of the visit. I tried using the nurses as scribes but I could not perfect that skill and it sometimes inhibited the patient's ability to disclose sensitive information.

I agree completely, well obviosly. But, to head off the "What about patients who don't like it when you don't pay full attention to them while you are typing, well they can go to a psychologist and sit face to face.

The government healthcare and insurance debacle has led us to see 25 to 30 patients a day, which means we need to chart and type while we are seeing the patient, except for those who don't.

You are right on the money, Tom, Bert. I think she needs to reconsider her time management, full attention to finish the chart before going for the next patient. She'd been working for others before and could see 40 patients a day, doing paper charts of course, in and out in 5-10 minutes.

So

Time management including multiple breaks
Charts completion strictly enforced end of day
Effective coding to extract max pay from time spend
RX refill strictly enforced
Handouts to minimize time spent explaining
Assistants in the exam room

I am sorry but I forgot another issue equally important,

Practice management, this requires a full time attention and many multi page docs need doctors to do the previews and signs like lots of home health paper work requests,
reminders from insurances asking why patients not taking this or that,
claim denials because of patients in and out of system and slip thru the system (we use outside billing/accounting) needs doc to review, vaccinations inventory (one friend let his trusty assistant to do all the orders and she made mistakes, huge invoices...

I went to some seminars and heard that many practices loosing lots of money because of employees' action, so to control risks, my doctors like to keep this under her control also.

She made jokes saying that family docs like dumpsters

She does assign some of this to her office manager but still ....

How our docs in the forum in the solo practices to see full time patient loads and doing practice management at the same time and to be able to get out after seeing last patients and enjoy nice meals? Very trustworthy office managers? Doing at nights (assume all charts done in the office)?

More suggestions please

In this healthcare climate, you HAVE to delegate. Unless she is paying her office manager minimum wage, which of course, she is not, then she needs to trust her with a lot more of these things including coming up with ways to be efficient.

Haha our Catherine, solodocmom, your username saying it all, you have been there and done that... a female doc also to my doc rescue. Research saying that female docs are caring more, spending time more and also having more stresses.... now more practice management advice please. I've been frustrated myself and kept telling my students and friends that family and medicine practice many times not right matches.

Clearly defined roles based on actual strengths and weaknesses ala she is the doc but you went to all the PM meetings and learned medical and contract laws from the consultants so you are the leader there and you both have to share a be cool with the other looking over your shoulder making sure your part jives with the other person's part. I have a right to look at any chart or note to make sure she is not coding weird, leaving money in the exam room or running afoul of rules and laws... She has a right to question my understanding of such things and her medical judgement although she may use me to bounce things off of me because it is fun and needed to knock things around, clearly she is the doc with all the training and her medical judgement unless clearly sick with a 105 degree flu is final.

Trust including when challenging or discussing things that it is always for your best interests be it to be safe, make more safe money or in the practice and patients best interests... Comfort and respect, mixed with some hugs and love.... Trust me we have been business partners in two different industries and the trust and ability to laugh and love it off, to compromise and care is super key...

Now Yes women do care more, spend more time, and they actually get and are used sometimes in many practices as the Dumping Ground for the long messed up needy tissue box visits. So the women don't hit productivity seeing only one or two really tough level 4's in an hour while the men get to rock out 4 to 6 level 3's and 4's in that same hour.... Guess who wins in the hourly rate and who catches hell even as the co-workers keeping using the women as the garbage dump for those difficult emotional psychological cases...

Also many times women chart differently and with more detail with less just get it done kind of who gives a rat's behind that the guy's do.... I might also suggest from experience to consider something like this burnout or something else interfering with "Focus" and the ability to get things done. You mentioned burn out I believe so this could be a residual problem leftover from that... Focus is so key and if lost it can mess with a good doc with all this busy work to do like plague. My wife is a fall behind charter too, so I so totally get it....

Paul

Walter,
I want to let you in on another totally different practice managment and office practices style that my wife and I are attempting to go this other direction as best as possible for the sanity of the provider as well as the health of any and every patient in the practice. This is what we presently refer to as the IMP style of practice, standing for Ideal Medical Practice... It is our belief system that the present dysfunctional non-system is unsustainable and makes most normal primary care office not viable. Under the present model of actual Price Controls the only solution to this present model is to add more patients and chew out more work in the same amount of time.

As we all know this destroys the doc, burns them out, ruins the quality of the care provided, and destroys the doctor patient relationship. We have a proven theory that there are many "Dead Zones" across the country where the present model is a road to ruin and a negative cash flow model as well... So here is a link to the IMP's main web page and I would strongly suggest that any and all good primaries of good conscience join the organization and try to review and learn from the basic model as originally started and designed by the likes of our great friend and mentor Dr. Gordon Moore and his friends at Dartmouth who researched and granted the beginings of our growing movement.

We IMP's think outside the box Big Time and rule one is to gain back some breathing room for the doctor so that they can literally Heal Theyself.... It is a really intelligent and logical way of viewing things and taking a stand with other great thinkers of wonderful caring nature, but it means opening your eyes and really accepting that the Emperor has no clothes. Or better yet use the Matrix model of the awakening of the average good solo primary... Morphious does not offer any tinted glasses answers with wine and roses only to help him see the truth.... Take one pill and you will learn the answers to your questions and will never again be able to go to sleep again, or take the other pill and when you awaken you will remember none of this and you will be once again be lost in your false world and cage built for you by your abusive oppressors who have enslaved you... You may hate what you learn here and wish that you made the other choice but once you choose to be awakened you can never go back...

http://impcenter.org/

This year our Annual get together which is a great set of workshops on how to work extra on the cheap to regain breathing room and not running the Hamster Wheel of seeing more and more patients only to have to support more staff and other expenses just to be able to keep seeing the newer higher level of visits and patients per day. We have proven that the increase the speed of the hamster wheel is a no win option as there is loss of productivity and most docs are burnt out after only the 10th patient of the day. So the next 25 to 30 patients are up the river without a paddle... This year "camp" as we call it is going to be in the DC area and we are probably going to have a day of lobbying on capital hill on the Monday after camp ends for those who are interested... Damn am I interested....

Honestly, no matter how decent and well intended no matter how basically ethical, NO doctor can really properly Manage and improve the care and get top quality relationships established and better high quality outcomes while attempting to barely treat the problem infront of them, jumping thru the hoops and barriers errected to care of the present system with a panel of 2000 to 3000 patients and seeing 35 to 40 patient visits per day... Honestly, I remember when my wife first entered med school we were starting to complain about the insanity of seeing 20 or more patients per day which the average IMP would see as too many even....

Trust me when I tell you that perhaps the most loving and caring act you can perform for your wife and your marriage is to join IMP and starting learning what you can, and freeing her from her present bondage from her Corporate and Gov't Price Controlling Masters... She will love and apperciate it for you and you and your family will get their wife and mother, family member back... A priceless reward for an obviously caring, supportive and concerned husband such as yourself....

So Mr. Anderson, do you want the Red Pill or the Blue one??? Have a great night and be well,

Paul

It is difficult combining being a mom with any job. This job is more difficult because of the extra time demands of being on-call 24/7. Using AC for the past year has not only made my staff happy, it has made my family happy. My husband thanks me for not bringing charts home.

I think the key was that I forced the entire office to use the electronic way exclusively. This forced us all to develop better computer skills. I was taught to type in grade school and to not look at the keyboard. I refreshed this old skill and can look at the pt while typing. Now, the pt does not feel separated by the computer. Now their exact words can be typed in as they speak and I do not have to recreate this encounter hours after it is over. You must force yourself to develop new habits for this to work.

If I cannot review all of my imports at work, I sit with my family during tv time and work on my sign-offs. The family feels my presence and I get my scut work done. My VPN connection is invaluable. It enables me to start the next day with a clear in-box.

The patients are very positive about the EMR. They receive the benefits of eprescribing, patient portal, better access to our office and ease of communication. UPDOX is a must for this to occur!

If your wife would like to speak with me about any of the above, please notify me. BTW (by the way)- when was her last vacation? That might be the start of putting her on course again.

BTW, some great points here from a women in the trenches. On the same idea Cathy (is that OK or are you a strick Catherine?) here speaks of her VPN, which might be OK for you guys because you say you have lots of computer experience (which is always a plus for any doctor in our situation so your help is great in this regard) but another just as secure method is the us something like Log Me In which the Free version has been just great for us for almost 3 years or more now. It is 256 encripted and unlike a VPN that sends real data back and forth, this kind of method is more remote fly so it only transmits screen shot kind of data so even if someone was to grab a hold for a few moments all they get is a couple of encripted screen shots, which to me is about as safe as we can do in this day and age I think...

Ask Bert, it took awhile for Nancy and I to convert and trust Log Me In, but today we couldn't be happier with it. It gets the remote work done and even allows me to run a virus check from home and one or two other basics too....

Paul

At least a year!

I took in a retired DO from our local medical group who said he would retire instead of learning their EMR, and he did. However, he still wants to practice since he is 'young' and bored. After trying many other things, including dragon through digital dictation, we settled on having a scribe for him (actually two who share other office duties). They print the last encounter and whatever other paper work for him such as labs and reports prior to the visit. The scribes do the intake, vitals, CC, HPI, updates allergies, med list, demographics, etc. Then he comes in and chats a little, while the scribe expands on the HPI and perhaps ROS. If he moves onto other things (such as OMT), the scribe may leave the room. Whatever the scribe misses, he would fill her in when she re-enters. Most of the the time the scribe would be there for PE and he would verbalize findings. Finally, the scribe writes down his agreed-to plan and puts in the eRx. Since the scribe is there in the room, they can also answer and clarify with the patient afterward. A lot of his patients have been with him through 5 offices and 40 years, and do not mind the scribe at all.

Wayne, how much do you get for a 99051, and what is your time criteria? I routinely see patients until 8pm.

Healing, caring docs still out there full force... starting next week we are going to implement most of your suggestions.

My late night statement of thanks to our JackChoi, Paul, Catherine, Tom, Jon, Ketan, David, Chris, Wayne, John, Bert ... at the time being, counting in reverse,and hopefully more coming. Our docs, and doc companions are more than amazing.

Katherine, you might be better than many of our docs in your ability to do multitasking. My doc can touch type fast but she can't concentrate on more than one thing at a time and easily getting distracted. Either talk/listen or type but not at same time. To complete her charting we might need to put in multiple, non disturbing time slots so any unfinished charts could be done at that time, also this required highly disciplined time management on her part.

Paul, IMP sounds terrific but to break away from this 'lowly doc mold' of current ins/audit/gov attitude requires great adventurous mindset and that is something tough for my 'traditional, conforming) doc. We can do it but have to be either financially strong or risk taking attitude ( that was myself, younger shell )
Solo doc doesn't have much voice at all and can't create a unified force to stand up, so he lives by the rules. That is my view of the modern medicine solo practice, eventually all solo docs will become obsolete, might be not in the next twenty years. I am both an insider and an outsider.

JackChoi, Jon, your ideas to be implemented last if all else failed as scribes might be taking time to adapt. Most agree upon that charts need to be done at end of day, taking home is the no no. But Jack mentioned he routinely worked till 8 seeing patients so where is the time for pm? or life? More inputs please?

We had a bad snow days couple mos back then everything shuts down for 3 days, considered non-pay vacation, but then admin stuffs piled up, and more overtime needed to catch up, same thing when she tooks CME out of towns, more stresses after those off time, not talking thousands loss income. 3 year solo docs would not that financially able yet, at least 5 years or more now a day... When was your breaking point Tom?

BTW, she has been using remote logon for the past 3 years, that might be one of the problem cause as things not done at the office can be taking home...

No disrespect, but too bad he couldn't just learn to type. The retiring doc I took on has warmed up to AC quickly and is doing great after 36 years of paper.

I had gotten into the habit of finishing my notes at my desk after the visit. Thanks to some of your suggestions, I tried the discipline of getting them all done in the room today with the patient. It was SO nice to be actually done after the last patient left! I really appreciate you all and your ideas!

My criteria is for the appointment to be regularly scheduled at 5pm or later. If it was scheduled for 4:30 and we are late, that doesn't count. This is a code to compensate you for having regularly scheduled hours during times considered "outside normal business hours."

There are about 5 of these 9905x codes for slightly different situations, for instance there is one for seeing patients after hours when you don't have regular hours at that time. And there is one basically for walk=ins, that is they walk in and are seen on your full schedule, disrupting your flow of seeing patients.

For 99051 we got about $25 I think when we get paid for it.

It is interesting you mention her problem with multi-tasking. I found that initially when I switched from writing to typing, it was almost as if I did not have that "pathway" in my brain. I could take the dictation but I could not simultaneously process what the pt had just said to form a plan. I was more comfortable w/ listening/writing/thinking as I had done before. I literally had to learn a new skill and force open a new process. (Luckily, our schedule was slow at that time and I could do it. We switched over in the summer which is our slowest time.) I would compare this to learning a foreign language. It is better accomplished if you force yourself to use it as much as possible.

Whenever I find myself saying that a new process is "too hard", I remind myself that I succeeded at medical school. I can do this! Failure is not an option.

Last summer, the NJAFP sponsored a speaker who had us work on chain of command. He spoke on the Toyota company principle. That company succeeds by getting the employees to think up ways to simplify processes. For example: How many steps are there to receive a lab result, notify the pt and file the result. By engaging my entire team, I am able to simplify steps and improve efficiency.

Example: Refill requests are routed through the pharmacies so that I can receive them electronically and respond accordingly. Result: dramatic reduction in phone calls.

Example: Updox portal is used for receipts, results, and instructions.
Result: Patients not standing around office waiting for printed papers to be given. (You know they come up with more questions while they are standing there.)
Plan for future: put all my forms on Updox for easier access. They just updated the ability of putting forms on public access so that the patient does not have to sign in.

Problem: Many things that I type are repetitive.
Result: I took the time to make templates specific to MY needs. The AC provided ones were just a rough frame. This one effort saved hours of time.

Problem: Labslip processing slowed down pt departure.
Answer: One employee actually loves going on-line and ordering through Quest and Labcorp, so she is labslip central. She then sends the labslip confirmation to the pt portal.

Problem: Filling out forms delayed appt.
Answer: (You know what I am going to say...) Forms are sent through Updox and pt brings them at time of appt. This works wonderfully for new patients! We are also using it for the Medicare Physicals, even if we have to send them to the pt's child.

Bottom line, if you are not satisfied, make a change!

Catherine, you don't draw blood in the office and send it down? You make them go to the patient service center?

In NJ there is no way to be reimbursed for drawing labs. Not even a co-pay. It is illegal. My private insurances pay less than Medicare. Amerihealth rates have not changed in 10 years. I am solo and cannot afford to pay someone to be drawing labs. My patients are used to the lab routine. If they complain about the lab, I direct them to complain to their insurance company.

Well, they don't reimburse much in NYC. about 2-5 bucks. We only do it because of competition--so many other offices do. There is also the compliance issue here, since they so often never make it to the lab when we do send them.

No reimbursement - No draw.

Wayne, thanks for 9905x codes. I guess I have been leaving money on the table. I will try 99051 on the payors.

Walter, my schedule matches my wife's. She gets up much later than me, and comes in the office to work as manager/director M W F by mid afternoon. When I work late, so does she. When she does her wife things on T Th, I come home about 6pm. On some days when I don't have other meetings, I come home some times and brings her coffee and spend quality when she wakes up. We work on home projects (which never end) together during 'off' times. I assume at your age (and mine) you do not have any full time children, they just visit every now and then.