Home Forums Discussions General Discussion End of practice/retirement issues

I don't find a thread on this issue but wanted to see if anyone had thoughts. While I don't plan to retire for eight years yet, I'm trying to see how records from AC can be made available to patients after close of business.
In my area, what I have seen in practices using paper charts, is they will bequeath their paper charts to a records management company, and patients who wanted copies of their records pay a fee to this company to get copies made and mailed.
When I asked Support how the entire record, not just a CCR or CCD, could be generated, I did not receive a satisfactory answer. They said I could keep working in retirement to print off these records (um, not happening), or I could use a batch utility to generate the CCR or CCD, but these are just so grossly inadequate.
My suggestion is that Amazing Charts develop a batch utility that can convert every office note, addendum, imported item, etc. in the system to PDF files grouped by patient name or identifier. These could then be downloaded to a hard drive or burned to DVDs, and handed over to a records management company as above. Any thoughts?

I gave my patients 3 months notice of intent to close my practice and instructed them to come in and sign a records transfer sheet. We then burned their entire AC chart to CD and had the patient come pick it up, recording that records were released to the patient. It has been nearly a year since the closure and I have probably had only 5-6 requests for records from patients that procrastinated in getting their charts from me as I recommended. Those I have burned myself as the server now resides in my home.
There were several issues however:
1. When you ask to print the entire AC record, it seems like it is done in a disorganized fashion. I had to print everything to the Paperport desktop and then bundle them in a sensible fashion. You would think it would make sense for the Imported Items to print in the categories you had arranged them, e.g. labs, imaging, consults, etc.....they did not.
2. Secondly, many of the facilities to which the CDs were being taken were incapable of reading the CDs even though everything was in a PDF format. I thought at the time that was outrageous but, believe it or not, some of my old patients have followed me to my new practice and this large entity cannot transfer their records from the CD into their EMR. I have had to then print their records for them and send them down to "document management" where they are then rescanned into Epic.
3. All in all though, this was an easy, cost-effective way to give patients their records.

Thanks for your thoughts. I remember being told at the last User Conference I attended that the imported items are all saved in .pdf format, and can be directly accessed on a per-patient basis by going into the AC directory and finding the patient's folder (I think they said they are sorted by the patient's AC record number), and there can be directly copied or printed like files in any Windows directory; BUT the office encounters, etc. would all have to be hand printed one-at-a-time, then scanned, etc., as you wound up having to do. (Plus, your generated .pdfs proved unreadable, which is a worry).
It seems to me, with all of us facing retirement at some point, that AC would find it wise to write a utility that would do this at a push of a button for either an individual record, or as a batch command, which could be based on some selectable criteria like 'active records with visit within last 3 yrs' or something.
Perhaps they'll consider it. I appreciate your response.

Yes, we for sure need a one button "export everything, including imported items, to a .pdf" file. We frequently get requests for "entire chart" for transfers, insurance purposes, legal purposes. It doesn't have to be pretty, just complete. It takes too much time to do this manually.

Easy enough to do. If the market can determine a value, I can make the magic happen.

Anyone have experience with a records management company that could at least manage the exported electronic records in our absence?

The way I provide the entire chart to patients relocating or leaving practice:
1-Go to summary sheet. Click formal health records. Flag all boxes EXCEPT imported items. Click preview and then click Export Report rather than PRINT. Now I change report formate to PDF from the drop down menu and name file Medical Records and save it to a CD or in my case to the pt's subfolder under a Transferred pts main folder. Now you have all your records except imported items.
2- Go to main AC folder and click on Imported Items folder and find the chart number and drag the folder to my CD or to the pt's subfolder and you are done.
3- You now have a CD will all records or a folder with the pt's entire records which you can drag to a CD or a thumb drive, etc.
4- I always include a CCD copy of the records.
4- I keep a folder with all records transferred in case of a repeated request.

fircha, I don't follow.

On the summary page, I do not see anything related to a formal health record.
On past encounters, there is the option to print the entire chart, then with/without imported items as you suggest, but no option to export as PDF. I can only do this by selecting CutePDF as the default printer, but this is really terribly clumsy, and taking 10 minutes or so per patient. Can you explain further?

Right click on patient name, then Print Formal Health Record.

Thanks Boondoc.
This way you save yourself a few clicks.

Great tips. Boondoc's tip and separate import of imported items really speed things up.

Do you include the messages?

I do except when request is for disability or life insurance, etc.

Another way to do it. About 1-2 years before retiring, go to nearest hospital and tell them you want to join them in one of their hospital owned clinics. They don't buy practices anymore but they will come in and take over and they will handle your charts. You work 1 year then retire and now they have to deal with the records.

That sounds like a great plan TVO7: and also get them to pick up your insurance tail if they join instead of paying for the practice.

By above methods, growth charts are not printing for us Pediatricians. Anyone figure out any other way besides printing them separately?

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.

David,

Thanks for sharing. You are a good man. We will miss you (on AC). Please follow in Leslie's footsteps and keep posting. It's funny, because the MMA just recommended a boot on how to close a practice. I did have some recommendations on your records. At least as a Internal Medicine doctor, you only have to keep them so many years. With peds, it's like three years after their 18th birthday. That could be 21 years.

True, Bert. But after a bit they have only legal value. They will be on an old laptop in the closet, and will awaken only for subpoenas.

David,

Thank you for a most interesting and inspiring post. I am going to print your last paragraph and reread on days when the irritating stuff surfaces.

I feel like we are losing a good friend and mentor. I would also like to add my thanks for what I have learned from you. I do hope you will stay in touch. And, should you ever make it to the east coast, please come and visit your friends in Baltimore.

The problem is this it is increasingly rare to find a doctor who follows those tenets with the demand of corporate medicine for keeping on schedule, and lack of control of the staff and working on EMRs that do not encourage communicating with the patients. While many doctors are good and caring people, often they are in situations where this does not come across.

I once worked in an office where I would be asked several times a week "do you practice anywhere else?." When I left, the majority of patients left with me.

I'm glad it worked out for you. I wish you well on your new endeavour.

Thank you David. I have learned a lot from you, and at 71, am beginning to feel there may be retirement in my future (up to this year, I had imagined myself immortal). Thank you for your insights and helpful guide to avoiding turbulence on the glide path.

Obviously, the corporate world has taken over in a big way, and I believe their model is unsustainable in the long run. In the short run, however, I guess we have to turn to them for a "transition model." When I started practice, one bought or bought into someone else's -- now you can't give away a practice, and you are saddled with all those things you so articulately enumerated.

We have had people in our town suddenly cease practice -- leaving many patients high and dry for a variety of reasons, the most difficult of them being their need for controlled substances. Some of those people find homes (we occasionally feel sorry for them and take them on, knowing full well there will be trouble when it is our turn to quit) -- some of them never do land anywhere but on the street or in an alcoholic stupor because no one will care for them.

American medicine has so quickly devolved -- who would have guessed this 10 years ago.

well after 29 years of practicing medicine, I am retiring after Dec 21, 2020 at age 56. It was for many reasons. For one thing I just don't have the energy I once had to manage a small business / solo practice. My own health is not what it once was. I do want to spend some quality years in retirement traveling, visiting family and pursuing some interests outside of medicine.

Many thanks to all of you on this board for your technical help and emotional support over the years. I adopted Amazing Charts in the early 2000s. I enjoyed meeting many of you at the Amazing Charts conferences. I made two or three in Providence and one in Orlando.

I did enlist the help of JamesNT at dataintegrationsolutions.net for his help in creating a pdf for each patients medical record that can easily be burned to a CD. I HIGHLY recommend this. His services are quite reasonable and much much less than it would take staff (or me, when the staff gives up) to create a disc with all the amazing charts notes, messages, labs, imported items. I can now burn a disc and label it in under 3 minutes.

Best of luck to all of you.

The pandemic has forced almost everyone to confront their mortality.

Physicians work hard. It doesn't seem hard frequently because we love what we do and we are motivated to help people. Most of us here appear to be self sacrificing but at the end of the day, one has to consider your own well being and life for the future.

As my grey hair increases, I get more questions from parents of patients about when I am going to retire. My standard line has been "when I win the lottery." Now the consideration has become real for I realize as much as I love medicine I love myself and my family more. Still haven't come to a conclusion, but the thought process is there.

Now if only I can get that winning lottery ticket (I only play when it's over 200 mil or so, probably even worse odds)

Damn as I read it was hoping the see you won the lottery, LOL.
I get the question of retirement frequently even though my 'baby' face masks my 69 years and my standard reply is 'not yet in the vocabulary'.
Compounding the need to still bump up the retirement account is the 'sense of duty' as I am one of the few primary care docs left standing in the area after the big city medical center just closed the other practice in town and doesn't look like they are planning to reopen it.
Abandoned/desperate 'new' patient phone calls leads to saying yes and adding another straw to the camels back, did my share of strenuous labor before medical school so think the back will hold up.
Just have to give up the idea of getting the golf handicap down to single digits.
That being said we have all sacrificed more of our and our family's time then most professions do and none of us should feel guilt with walking away whenever the time is right.
Just win the lottery dammit!

@Wendell


Speak for yourself. I'm 47 and deadlifting 500lbs on a twice broken left tibia (complex fracture above ankle and crushed plateau) from two separate motorcycle accidents. I plan on surviving a while longer.

JamesNT

Or apparently, in rare cases, their immortality!

Keep on truckin', James.

James, you are not allowed to go anywhere. We need your technical expertise :-)

Hi Ken,

Congratulations and enjoy your last 2 weeks in practice! Let us know how it feels after you see your last patient.

I am 64, and I agree with most of the thoughts listed above. I am tired, and things are getting harder.

I do not think I would financially be able to retire at this point, I absolutely agree with the responsibility to patients, but there is another issue as well.

Generally, as physicians, we eat, drink, and breathe medicine. For most of our lives, we have put an immense amount of time and energy into this field. No longer seeing patients will be an enormous change.

I have been keeping track of a few older physicians who retire. It seems like over half get back into medicine one way or another, working for someone else, doing some shifts in a doc in a box, or so forth.

Best story involves an internist, who was Peruvian. Nice guy, excellent physician, kept going until his early 70s. He retired.

6 months later he was back to working, just about full time, at a Community Health Center. He did this for about 4 years, then decided it was time to really retire. To help to ensure that he never got back into medicine, he moved to California.

Last I heard he was working part time out there.

Again, congrats!

Gene

One more note on older physicians. Our area has an older physician, I believe he is an internist, who must be getting up in years. He still practices full-time.

Wondering how old he is, I searched for his profile. He graduated from University of Maryland School of Medicine in 1958.

I feel young!

Gene

Okay one more. This is supposed to be true, although I do not have first hand knowledge.

I believe it involved a female pediatrician, I believe in Georgia, who had just celebrated her 98th birthday. She was still practicing, full time, with a busy schedule.

She wondered if she was getting too old. She called a friend of hers, I believe a male internist, who was also in his 90s. Her question was "When is a time to retire?"

His answer: "When the patients stop coming."

Gene

Hello James NT ,

I read that you have a program for converting AC records to 'easy to burn' PDF files for patient records , when a physician is due to retire
Can you tell me if this service is still available and how much it costs ?
I may need it in the next few months
thanks in advance
Bala

Hi Bala,

In case JamesNT isn't monitoring every post on this forum, here's JamesNT's site with phone:

https://www.dataintegrationsolutions.net/

Cheers,

Carl Fogel

It's very weird to read my retirement posts from 7+ years ago. I don't know if our approach would work now... a lot has changed in American medicine.... but it worked for us then, and allowed a graceful exit into limited resource care which has rounded out our professional lives. I hope you all can be as fortunate.

David Grauman MD
Saipan

@Carlfogel: Thank you. Dr. Bala did reach out to me.

JamesNT

Hi James,

Glad to hear that you two are in touch--hope things work out.

Cheers,

Carl Fogel