Home Forums Discussions General Discussion Closing up shop

My wife, a Family Physician, and I, her Office Manager, are closing our practice after 20 years (the usual reasons; ever-increasing prior auths, referral and procedural roadblocks imposed by insurance companies necessitate hiring another employee, and we can't afford that). She will work for a corporate entity for a couple of years (she has to learn Allscripts initially, and then the organization is supposed to transition to Epic next autumn) and then plans to retire. Fortunately, she'll still be in the same town, so many of her patients will follow her to the new practice.

I have been taking care of my aging father-in-law and my mother, so my retirement from office management frees up more of my time.

I'd like to thank the people who have maintained this board, and thanks to the many who have helped us over the years (we've used A. C. since the beta for version 1).
We wish everyone the best of luck in the future!

Kurt

Best of Luck to you and the wife. Feel free to pop in on the forum here and there to say hello.

JamesNT

It is very sad to me to see the ranks of independent physicians depleting. Sue and I closed the office at the end of 2022, and we are struggling with forwarding records and tying up loose ends for people who are having trouble finding a new "PCP".

So far, we are very happy with the ability to print or send records from Amazing Charts in a reasonable format and with the ability to control what we send, tailored to each forwarded chart. It's a little labor intensive, but the result is a meaningful, hopefully useful record and not the overwhelming data dumps we have received from some practices.

Amazing charts may be unique among EMRs in allowing us to continue using the program (for record storage) after we stop paying the annual maintenance fee. I am trusting my server to hold up for another 7-10 years to meet the requirement for record storage. I have some computers around the place that are still perfectly useable after >15 years, so hopefully that is a realistic expectation. Amazing Charts Guardian Angel has assured me that if the server fails, they will help me reconstruct a new one from backups -- they claim they are intending to stay in business for the indefinite future, and hopefully that is realistic as well.

A colleague was quoted an estimate of $20,000+ for physical records maintenance for 10 years (he has only paper records, no EMR). That would be really painful.

What Guardian Angel wouldn't tell me was whether I could make a backup image of the server and run that as a virtual machine in a new server box without having to get registration codes for a new server from AC. There has been a lot of talk on this board of "virtualization" but I have never actually tried it. Just using a 2016 Microsoft Server Essentials which so far has done the job.

We've got AC v8.3, so the full pt data is just an archive that can be installed on any Windows PC running AC. We can no longer install AC on any computer, as the AC installer uses components that are no longer available, but fortunately I had the foresight to do a full installation in a virtual machine many years ago. We'll keep the records for the 10 years that is required, and I won't worry about anything beyond that.

Tomastoria,

If given a copy of your database and imported items, I can convert all that data to one PDF per patient for a modest fee. That way should your server fail (which is a real possibility in 7 - 10 years), you'll still have the PDF files to hand out. In fact, you may forget about your server by then because handing out PDF files is easier than logging on to a server and printing paper copies.

I'll DM you the details.

James

Tomastoria (and others)...
Please at least consider James' proposal. Coming to grips with a long-term plan for record management post-retirement is a bit of a minefield. And an expensive one, at that.
James is helping a colleague with a surprisingly inexpensive solution.

To JBS and James (and anyone interested in medical records custodianship -- which I confess never entered my mind prior to the decision to retire):

James hasn't described exactly what he is doing in "converting all the data to a PDF file" -- at least I haven't seen it if there was such a post.

If that means that everything in each chart is converted to one giant PDF file, then I can't see how it will be very useful to the next doctor's office. I have received a few "records transfers" like that over the years, and it turns out to be so tedious to sort through all the extraneous stuff to get at what we really need that we usually give up. Presumably, that would be necessary if you were defending a legal case or a Medicare audit, but most doctors offices I can imagine would only want a subset of all the information in each chart..

AC makes it pretty easy for a clerk to print the "clinical summary" and a selection of visit notes, consult notes, lab and imaging reports, etc. to a file which can be saved on a USB stick for faxed, and so far, no receiving physician has complained about our records transfers. We are assuming that most of the records transfers will occur in the first 2-3 months after closing the office, and we are planning to have such a clerk on staff for about that long. After that, I guess I become the clerk -- but I have long since realized that we seem to have gone to medical school to become not "physicians", but clerk-typists, data entry clerks and "PCP's"

Faxing is very old technology of course and at fax speeds it would take a very long time and probably jam up the receiving fax with some of our charts that could easily run to a couple of hundred pages if printed directly to paper. A large PDF file could of course be sent by email -- but it isn't "secure" and not everyone has secure messaging, so the default is fax.

I will likely contact James at some time after the mad scramble of closing the clinic is over.

thank you all for your interest and your posts.

The conversion creates one PDF per patient. That PDF is named as such: lastname firstname - PatientID - Birthdate.pdf

Example: Summerlin James - 1006 - 12291970.pdf

This enables using Windows File Explorer to search for one file out of thousands. The files are in two parts. Part 1 is a report I made that contains all the database data. Demographics, insurance information, allergy list, problem list, SOAP notes, ROS, Assessment, Family History, and so on is all there. If you typed it in, it should be there. The second half is the imported items. All of them are converted to PDF if not already in that format and added to the report PDF. Yes, one patient's PDF can be hundreds of pages long depending on the patient and how many years you saw that patient.

Tomastoria is right, some doctors won't need all that stuff. Yes, they will spend several minutes looking for one thing. That is the one weakness of this approach. There is no way for me to know what doctor is going to want what as I am not clairvoyant. So, I have no choice but to extract everything. Secondly, we have to account for lawyer requests; therefore, we should extract everything.

For those of you who want to retire and maintain your own server for the next 7 - 10 years, that is certainly your choice. However, do note that I've already been on the phone with the crying 73 year old woman getting angry letters/phone calls from patients/doctors/lawyers demanding information that she doesn't know how to provide because her husband (the doctor) died 6 months earlier and she had no idea what to do. I've already been on the phone with the 76-year-old doctor who had retired 4 years earlier who needed me to fix his 9-year-old server that was really an old Windows 7 workstation that suddenly decided to give up the ghost and there were, again, patients/doctors/lawyers calling for information and he didn't know what to do (the server was unrecoverable and there were no backups).

These are NOT fun conversations to have.

I've already done my part. I've developed an easy and highly cost effective and fully automated conversion. Most of you will pay less than $1,000 and that includes FedEx shipping of the USB drive to and from me. For those of you retiring, the BEST thing you can do is call Andrew at www.desertriversolutions.com and have him take full custodial ownership of your data after I convert it so you can retire in peace and not have to deal with this stuff. The second-best thing you can do is have me convert your data to a format (PDF) that is easy to maintain and doesn't require you to run Amazing Charts and be at the whims of their support when you stopped being a paying customer years ago should something go wrong. And you can easily copy the data to another device when the one it's on starts showing signs of wear and tear.

For those of you who want to continue to run your server for the next 7-10 years after you retire which could have you maintaining said server into your 80s with the hope that your server will just sit in your house and be happy for a decade AND that you won't die in the interim leaving your spouse totally screwed AND that you won't develop dementia or otherwise become mentally unable to keep things going AND should something go wrong with the server that someone will be there to save your butt assuming it can be saved........ go with God.

JamesNT

James,

I have always admired your direct, practical and plain spoken advice.

I do still miss the old days of AC where we gathered in person and had these conversations, I learned so much.

Thank you very much.

I've always despised IT people that use highfalutin words to confuse people and talk over their heads. I've always preferred the direct approach.

JamesNT

Thanks James for a non-hifalutin, direct, clear explanation of your method.
It is what I surmised, and is clearly the most logical, cost-effective, and safe way of storing all those records for the required 7-10 years.
How do you recommend storage of the charts? My whole database and ImportedItems will fit on a 64G flash drive, but will that be readable in 7-10 years?
Would an SSD be better for storage? Or even a standard hard drive? What can just sit on a shelf and not lose data?
What has the best chance of long term survival?
The Googlable gurus are not totally clear or convincing about long term storage.

James,
The portion of each pdf that is notes/encounters is presumably chronological.

How about the pdf's. Do you have any idea in what order the pdf's are recorded? By category? By date? Randomly based on some generated label?

@Tomastoria,

For those who are retired I typically recommend storing the files on your TRUSTED computer. When I say trusted, I mean this computer is used for things such as checking bank account balances, QuickBooks, shopping on Amazon, and so forth. In other words, it is used by you for trusted activities involving trusted applications and websites. This computer is NOT used for playing video games, keeping the grand kids occupied, surfing porn, going to the pirate bay and downloading illegal movies and music, and installing random things you find on the Internet.

This TRUSTED computer will also have a backup to a USB drive using Windows Backup or Veeam or other well known and well supported backup program.

AND YOU WILL KEEP IT ALL UPDATED.

Now you see why keeping the files yourself well into retirement is the SECOND best choice. You still have to do the whole computer-backup-maintenance thing when all you really want to do is drink mimosas on the beach and chase your wife around the house. And this may mean having two computers: One for the business side and one for the wife and grandkids to goof off on. And we haven't talked about offsite backup at all.

The reason I don't recommend using just a USB drive is because USB drives can be dropped, damaged, lost, and over time become less and less reliable with data storage - even SSD drives.

Just because you are retired doesn't mean the steps for proper data storage, security, and backup goes away when you insist on maintaining your own data. You are still bound by HIPAA and you are still responsible to your patients. Period.

Sounds like a wonderful retirement plan.

That's why I say the best plan is to contact Andrew at www.desertriversolutions.com and let him deal with all that crap while you spend your retirement years travelling the world and posting pictures of historical monuments on Facebook so the rest of us can live vicariously through you.

As much as I love technology. As much as I love what I do. I promise you when I'm 78 my biggest concern will be making certain I'm on the correct side of the bathroom door at certain times of the day and NOT having to deal with all this computer/HIPAA crap.

JamesNT

@JBS

All data, including imported items, are placed in chronological order by either date of service or date of entry (imported items would be date of entry).

JamesNT

I hate to say it and maybe I will get demolished for this, but I can actually claim I have looked at records which were transferred to me maybe 25 times and then only to find one specific thing.

I have NEVER heard from any office that my records were insufficient, and I have sent many insufficient records. The transfer of records whether on an organized PDF or the back of a box of Raisin Bran makes most offices happy.

Regading Bert's first comment:

The difference between what Bert is doing and what the thread indicates is Bert is still in business. If Bert does not send the info the doctor is looking for, the doctor can always contact Bert and ask for clarification or a resend or something. In the case of this thread, and as the title of this thread indicates, the business is closing. Amazing Charts is being turned off. Permanently. Therefore, the export MUST endeavor to cover every aspect of the data, even if that means some duplication (e.g. the retiring doctor typed some allergy stuff into the SOAP notes and into the Allergy List). There is no chance of asking for further records. What you see is what you get.

That being said, I do agree with Bert's second comment. Some doctors are happy just to get a response.

JamesNT

First, a "meta" comment.... this board was most busy and valuable in the early days when people were picking an EMR and learning how to use and live with AC. It continued to serve a purpose, but with some decreased activity and urgency in recent years. Now the board and this group demonstrates its value once again, as some of us approach the end of our careers. Even if you are not "there" yet, it is helpful to think about how you will deal with records post-retirement or after moving on to some other job or EMR.

To summarize some of the above comments... we need to preserve medical records for a variety of reasons. After we are done with them, others use them in a variety of ways. After retirement (and I will use that word as a shorthand for "not using AC to see patients anymore", in all its forms), we want to satisfy the needs of our patients and their new doctors. We also have legal responsibilities that we must meet. We want to do all of that with a modicum of effort, time and expense.

We need to have a complete record on each patient for legal purposes for a given number of years. That number I believe varies state to state, but is usually 7-10 years. There is no room for discussion on this point, though there might be room for some discussion as to what constitutes the "full" record. For our purposes, in general, the record consists of the two main parts of AC, the notes/encounters and imported items. If a lawyer asks for the patient's record, I think you must be able to provide all of that.

We also want to be able to provide a record to assist in follow-up care of the patient. There is much more individual variation here. Sometimes the new doc just wants the latest note. Maybe most recent bloodwork and EKG. Maybe, as Bert says, they don't look at any of it. Others may want more, like the CBC's from the last decade, or the last colonoscopy report from 8 years ago.
Then there is variation based on the retiring doc. Some may be willing to spend the time to curate each individual chart, or create a summary. That may be a great service to his patients who are moving on. It is certainly time-consuming and may provide more than the receiving doc will use. Others just send the entire record, which may or may not even be examined.

This also may vary based on timing. In the first months after you retire, you will get lots of requests and may be willing to make the commitment to sending something useful. Three to five years later, the situation changes.


In my view, we need a complete record for legal purposes, and we need the ability to store and send the records in a form that will be useful to the referring doc and a minimal burden to the retiree (or his/her staff or survivors).
James' approach serves all functions well. Legally you are covered. The doc who sees the patient and wants little or nothing from the record gets it all, and can easily file and store the pdf.
If they want the most recent note and labs, it is easy to find each of them. Notes are printed chronologically, and as James describes it, so are the imported items). So the most recent note is presumably at the top of the pdf. If you need a recent CBC, no need to scroll through hundreds of pages ... it will be at (or near) the front of the imported items since it is recent. If you want an old chest x ray or colonoscopy, you can search the pdf for those terms, and find them easily.

From our side.... it does not get much easier than this. You are storing a batch of pdfs that you can put on a couple hard drives in various places, or stored in the cloud. No need to worry about a computer going bad or a program going out of date or a company out of business. You can't lose the files, can easily store them, never lose them, and can easily transmit them on a hard drive/cd/thumb drive/fax or via encrypted email.


Lots of ways to do this, but this is what makes the most sense to me.

Thanks for all the input -- it is very interesting to see how different people think about medical records.
I have a few comments yet:
1. At least in our area patients come and go and come back into our practice as insurance changes and doctors move away. The records shuffle is a constant feature of "PCP" life. It is often impossible to obtain records from doctors who have moved on-- and no one seems to be very interested in trying to track them down and hold them to their supposed responsibility. So much for concern for patients.
2. The only people who want "complete" records are lawyers looking for something to catch you on, insurance and Medicare auditors looking for potentially censurable "upcoding", and Medicare Advantage clerks dredging through the records for potentially "upcodable" diagnoses that didn't make it to the problem list so they can pad their "complexity" portfolio. There are of course the occasional hypochondriac or obsessive-compulsive patients who want every scrap of data, useful or not.
3. The idea of a crystalized data blob (e.g. a collection of PDF files) is attractive, but only as useful as the initial cataloging -- assigning file names, dates, and so on correctly. I assume that James' method of making his giant catalog file by date means "by date within already assigned categories". That in other words, the CBC won't be filed in date order with MRI records. Even sticking with ImportedItems assigned categories (lab, consult, radiology, etc) is not totally foolproof. Despite much training and coaxing, new staff members who are assigned to file the incoming faxes don't always get it right and a lot of items get misfiled. Also, lab and X-ray reports that come in as PDF files from institutions where we don't have an interface are often not filed or even titled accurately. Finding lab and X-ray reports from outside hospitals can be a challenge.
4. It's sort of like trying to find the Epic of Gilgamesh in a pile of Sumerian clay tablets, most of which are records of commercial transactions.
5. All that being said, I think I will ask James to convert my records to PDF in a couple of months -- when I am tired of answering the phone and transferring the records myself after all the staff has left.

Tom,
Spot on.
This is why I have been filing, dating and labelling all my incoming reports myself for many years now.
I also sometimes note the substantial delay in receiving reports, or having to request them.
Obviously stupid and a poor use of my time, but I sleep better.
Unfortunately, as you alluded to, I don't think anybody cares.
But at least it will hopefully help me if I have to stand in front of a judge or jury.
I wish you a happy retirement, and look forward to one myself (age 61).
Best,
Ton Zwaan

Thanks Ton for the validation and the well-wishes. I am already beginning to feel better about retiring, and its only been a month!
The office building is being repurposed to an apartment and studio for a physical therapist/yoga therapist, so probably something useful will remain

Sad to see you go! I think when I close up shop I will hire someone to replace me, and continue to own the company. Don't forget you can charge for records legally, and make some money from all the insurance companies, lawyers, and others wanting them.

Chris--
I couldn't give away my practice, let alone sell it, and I couldn't come close to matching the salary the hospital clinics currently pay-- but then the new doctors only stay a little while and leave. I'm not entirely sure what is going on, but independent family practice is a dinosaur.
Maybe it's different in Alaska?

I think that like most of us who got records from other doctors, I found it was pretty useless. Best case, the other doctor kept complete, CONCISE and comprehensible notes, but didn't think like I do. That was the best case. It went downhill from there. So, I think reality is that getting records for the most part simply fulfills a requirement.

When we did close our practice, we tried to give every one an "exit exam" where I summarized all active problems in a succinct manner. Thus when the next doctor read them they did not have 100 pages of inane drivel to delve through.

As to how to store them, that is an issue. We kept someone on part time staff for 6 months to copy t the PDF's to disk when patient's asked. Then the hospital was gracious enough to accept the files on the rest.

Good luck. Retirement ain't for sissies!!

Well, about one month in, my wife is gradually getting used to using Allscripts. But it is obviously not designed for typists, as much of it is point and click. The layout of AC was a lot less complicated, but the most difficult thing now are the dozen or so logins and passwords and 2-factor authentications. It seems every function outside of the EMR uses a different application, and mostly through a web browser interface. Very cumbersome! The powers that be did not want to import any data into their EMR, so there is a LOT of catch-up data entry for existing patients. A nuisance, and very time consuming.

I'm getting the picture that there is nothing unique about my situation -- and given the fact that if we live long enough, we will get too old to keep practicing medicine! I previously thought that being a doctor, I could escape that fate -- but guess what? NOT.

The next best thing is to age gracefully and quit in time --dying in one's boots sounds idyllic -- but it isn't fair to the patients if you do it on purpose. (like that morbid joke about my grandfather dying peacefully while the other people in the car were screaming). These days no one wants to step into an existing practice, so at some point there has to be an arbitrary decision to close the practice.

Here's where Amazing Charts shines: we own the data, and the program will continue working even if we don't pay any more to AC when the office closes. 12 years of records will back up on a thumb drive and can be accessed even if the server fails -- so maintaining custody of records is relatively easy compared with maintaing custody of all the paper charts. (we so far have paid over$1500 to shred the last 7 years of paper records -- one of the practice partners refused to deal with EHR, so we had duplicate paper records) and probably are looking at another $500 or so before we are done.) I don't think that very many other EHR's out there have that flexibility of dealing with historical records.

You finally close up shop. You have AC and you can make copies of records to give out to patients. You do all of the other little things.

What will I do with that copier that I don't need anymore? Throw it away? Give it to a friend?

Keep in mind that most copiers made in the past few years have hard drives to make it work faster and store all your print and copy jobs. Tons of HIPAA data are on those hard drives. Giving it away is like giving much of your data to someone else.

You have to make sure you remove the drives, wipe them clean, then have a professional hard drive destruction company destroy it and give you a certificate to same.

Just a thought that some people don't know.

Seems like a splitting maul would make short work of a hard drive and recovery would be essentially impossible (except in a movie)

What you said about time consuming is right on. I've changed EHR's a couple of times, neither time was conducive to importing data, which is a good thing. The data corruption that is waiting to happen is worse than starting from scratch. We now budget one hour for any patient not yet seen in the new system. I try to get a lot done ahead of time, if they are on the schedule, but there are a lot of "walk ins" that have to be done on the fly. Plus, I have to be very careful; it is too easy to make a mistake. It is awful.

@Tomastoria,

Might I recommend either a Sig Sauer or Kimber .45 ACP. Both are excellent craftsmanship and would provide good entertainment when deallocating patient data from a computer hard disk.

JamesNT

@James,

Would a Sig Sauer 9mm be good enough? I already have two of those. Since I have two, would you suggest just emptying both magazines at the same time Eastwood style?

@David,

What EMR are you using currently. I agree that I would just start fresh.

@Bert,

All of my guns are Kimber and Sig. You can't go wrong either way. Unfortunately, I did lose my guns in a boating accident a few weekends ago, so I'm trying to decide if I want t restock or not.

JamesNT

Motorcycle accident? Boating accident? One that results in the loss of multiple guns?

Maybe sticking to IT is safest? Just a thought....

@JBS

I can assure you sticking with just IT seems to be the direction I am pushed in.

JamesNT