Books give not wisdom where was none before, / But where some is, there reading makes it more.

- Sir John Harrington (1615)

A colleague once asked me, “Where do you [and your practice] keep getting new ideas from?,” and my response was, “From reading.” But not reading medical journals or ‘throw-away’ publications (although the latter often do have some great ideas). From reading as varied topics in different industries as possible: business, marketing, technology, science, even fiction. And I have subscriptions to magazines and newsletters in these areas as well.

Our practice administrator usually knows when I have devoured a couple of management or marketing books over a weekend because I will barrage him on a Monday with a bunch of new ideas, some that we can either try out or at least bounce off the other partners if they’re too drastic. Not everything pans out – my partners may be quick to point out – but sometimes we score a hit. As conservative as most medical practices tend to be, they would do well to think outside the box.

Actually, even better is how Harry Beckwith, a Fortune 200 consultant, puts it:

Grow a Bigger Box

And the best way to grow your box bigger is to keep adding ideas to it. So, pick up a book on advertising or a magazine on fly-fishing, or watch the MythBusters program on television, and stuff some fresh new ideas in your box, then put them to work in your business – and make your business grow.

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Now that medical practices are joining the rest of the computerized world, they are having to deal such issues as office network security policies. As in most companies with a computer network, the weakest link is usually an employee who either inadvertently, or wittingly, commits one of these mistakes:

1. Trusting outsiders too much – security experts have a name for this: social engineering, where people are manipulated into divulging sensitive information such as passwords or security protocols. This is actually the most common way that thieves hack into computer systems. Employees may share passwords with each other to try to save time or cover their tracks – or out of sheer ignorance. That makes it difficult for a practice to know who is who in an EMR system. This can violate the integrity of the medical record which is critical in cases of having to defend a malpractice suit.
2. Leaving an unattended computer or terminal unlocked – besides potentially violating HIPAA policy, leaving a terminal unlocked can allow access to sensitive information by either employees who are not authorized to do so or, worse yet, non-employees. The practice would then be left to handle damage control when information gets into the wrong hands. HIPAA violations can carry hefty fines.
3. Not changing a password periodically – there should be a password policy in place and employees should adhere to it. To be on the safe side, passwords should be set so that they automatically expire, at least monthly, and they should be complex, including numbers and symbols and different-case letters, for example. This makes them less likely to be figured out by intruders.
4. Keeping passwords or sensitive information on sticky notes – although something like this should also be part of the practice’s password policy, I mention it here by itself because it happens so much.
5. Downloading inappropriate or unauthorized software – some inadvertently-downloaded ‘malware’ programs can wreak havoc on an office network, while other “harmless” file-sharing programs can open up your network to outside intrusion. This can result in everything from damage to your hardware to HIPAA violations if patient information is breached.
6. Inappropriate use of practice equipment – this would include such things as viewing pornography, which could also make the practice liable for a sexual harassment lawsuit, or using practice email for personal uses. There is software that can allow you to monitor employees’ internet use.

A physician once asked me if it was possible not to even have internet access in his office. While it is possible, it is difficult for a medical practice not to have internet access at all because so much information travels across some sort of internet connection. It is better to have a good written internet policy and have proper oversight.

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Medical practices that are planning to get an electronic medical records (EMR) system in the near future will also need to consider whether they will be keeping their existing practice management software (EPM). Many factors come into play and we will discuss the pros and cons another time. For the purposes of our discussion, let’s assume you decided to upgrade to a new EPM that comes integrated with the new EMR system.

What do you do with all of the existing patient insurance and demographic data?

Keep it or throw it all away?

First, a little background. It is the year 1998 and businesses around the world are beginning to panic about the impending specter of the Y2K (year 2000) crisis. You remember – all computers will stop working because nobody thought to put the year in four digits instead of ‘19’ followed by two digits. (more…)

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No military commander likes the idea of getting to within sight of a goal only to see defeat snatched from the jaws of victory due to the mutineering of key personnel. If that sounds a bit melodramatic, well, folks in the medical world generally tend to respond best to military idioms, so it helps to make the point.

There are few projects of comparable magnitude to the purchase and implementation of an EMR system for a medical practice. And there is nothing more certain to scuttle (another military term) an EMR project than a physician, owner, or administrator who is not supportive of the endeavor. Obviously, this person has more of a detrimental effect if he is one of the partners and has some control over the purse-strings. He will typically take on one of several personae:

- The Denier - this person will make the claim that EMR is decades away, like some contraption seen in a Star Trek episode. He will usually wait until after the practice has purchased either the EMR software or hardware or both before voicing serious objections to the whole idea of pursuing a paperless office. Even in the face of legislation and mandates from both Republican and Democratic administrations, the Denier will paint the entire EMR project as folly. Apart from this, the Denier does not actively obstruct the implementation process.

- The Passive Aggressor – this person is not quite so vocal in his opposition as the Denier. He will usually abstain when it comes to votes of major significance related to the EMR budget – or he might ask to go on the record as voting ‘no’, knowing that there are enough votes to carry the motion. When it comes time for the rubber to meet the road, the administrative or IT staff have their hands full trying to pin this person down for certification on the EMR system or signing off on templates and commonly weeks of time are unnecessarily wasted.

- The Silent Saboteur - this person has begrudgingly gone along with the EMR process and has seemed to ‘be on the team.’ However, soon there are reports from the staff that they are receiving mixed signals from the doctor regarding everything from second-guessing the decision to switch to EMR in the first place to the possible effects that EMR may have on people’s jobs – not so great for staff morale. Some skillful sleuthing will usually pinpoint this insidious villain who should be outed before his peers.

- The Invisible Spectre – this person could also be called the Passive Pacifist. He usually will go along with the majority but may be swayed by the vocal minority. He often will not show up to mandatory meetings or trainings and, like the Passive Aggressor, makes the job more difficult for the staff.

The unlucky practice that has more than one of these nay-sayers has a good chance of not seeing their EMR implementation come to fruition. While I describe these tongue-in-cheek to some degree, it illustrates how one person in a position of power can demoralize the entire practice – and make things that much more difficult for the administrative team, who has had to get the troops motivated in the first place. Don’t underestimate the effect that the one bad apple can have on everyone else – and your EMR project.

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A consultant once asked me “What is the purpose of your business?”

Have you ever asked yourself this question? Pause a second before you actually answer.

My response to her question was, “Keeping customers satisfied.” And I think that this would apply to you as well – regardless of your specialty.

A colleague of mine didn’t particularly like my answer. “Customers? Don’t you mean ‘patients’?”

Now, perhaps if you are in an academic environment where all of your patients are by referral only, your schedule is always full, and your bedside manner has no bearing on your practice…perhaps then your patients are merely patients.

But, for the rest of us, patients are more than just patients. They are also customers. And like the customers of any other type of business – retail, restaurant, service, etc. – they can take their business elsewhere, if they’re not satisfied with your business.

Patients have a certain expectation when they go to see a doctor, but it is their experience with that doctor which determines whether or not they will continue as a patient. Ira Blumenthal , an expert on personal branding, describes this in a formula

PROMISE + EXPERIENCE = RELATIONSHIP

Have you thought about what your patients experience when they come to your practice?

Shag carpet and wood paneling from the 1970s? A rude, inattentive front desk person? Extremely long waits before seeing the doctor? By the way, these are what John Pinto, a practice management consultant, refers to as ‘coffee stains.’ They make a patient have second thoughts about their choice of medical practice.

It is something you must be ever vigilant about. One of our partners pointed out that we had a sign with the name of a doctor who left our practice more than six months ago. He also discovered that one of the waiting rooms didn’t have any current magazines – apparently the subscription service stopped doing an automatic renewal without informing us and nobody caught the mistake.

Business experts say that, in the future, the customer experience is what will separate the winners from the losers. So, take a good look at what a person would experience visiting your practice from the perspective of a patient, especially a new patient. Is there any way this can be improved? You’ll be pleasantly surprised by how your practice can benefit from this exercise.

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Book Review by Jose Gaudier, MD

Of all the great ideas of science, Evolution has been scrutinized more than any other. There is overwhelming evidence to support it, and lack of any scientific data against  evolution. Despite this, however, fundamentalist religious groups, guided more by misconceptions rather than their faith, promote limitations on the teaching of this the most important idea on biological sciences.

Finally we have  a book that any Christian can read, and the author helps them to understand that Evolution ranks highest among the most clever ideas that God ever had. Author Karl Giberson, a Christian with a fundamentalist background, dissects and explains all the important data on Evolution while sharply rebuking questions raised by the creationist/Intelligent design movement in a definitive way.

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Every time the administration changes in Washington, physicians wonder what impact it will have on their professional lives. One of the more closely-watched issues is tort reform.

An article written by the AMA takes a look at a pilot project run jointly by a county Medical Society and Bar Association in Pennsylvania. This was created in large part because of skyrocketing liability costs in that state and at the request of Governor Ed Rendell. The project relies on a two-step mediation process that aims to reduce legal costs, improve quality of care, and help involved parties to learn from the experience. Other places such as Chicago’s Rush University Medical Center have similar programs in place.

Here in Florida, considered by some to be the “Wild West” when it comes to medical malpractice, many insurance carriers have bailed on their clients and have pulled out of the state. In addition to that, physicians have become tired of the constant stress of practicing defensive medicine and feeling like every new patient is a potential lawsuit plaintiff.

One thing that our practice started doing over three years ago is requiring a binding arbitration (BA) agreement on every patient prior to an elective procedure. One of the requirements of this process is that a practice’s liability carrier must support binding arbitration – and in our case, FPIC does. In fact, their legal counsel worked closely with our physicians to help develop the process as we were one of the first practices in Florida to take this path.

This forum is inadequate to cover all of the ins and outs of the binding arbitration process – how it works, how it is implemented, what about emergent cases, etc. But out of thousands of cases we perform each year, we have had perhaps a handful of patients who have refused to sign our agreement. They were then given a list of ophthalmologists in the area that they could be referred to.

Interestingly enough, we also use it for cosmetic surgery such as LASIK and have performed surgery on many attorneys after signing the binding arbitration. I asked them what they thought about the BA agreement and they usually reply that, if a case goes to arbitration, patients usually get larger awards.

They then ask me why we do it. I guess what most non-physicians don’t understand is that we don’t have a problem with an injured patient recovering damages – that is what malpractice insurance is for. What we find distasteful is the whole circus of the malpractice court cases with their lottery prizes and overly compensated plaintiff attorneys. In addition, for states like ours which have some sort of “three strikes’ provision, pretty soon you could end up with a lot of neurosurgeons and OB-Gyns at risk of losing their licenses.

Physicians interested in alternatives to medical malpractice jury trials should speak with their liability insurance company as well as their legal counsel and local medical society.

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