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   RE: Work flow advice
 From: Michael Safran
 To: Member Forum
 Posted: 10-09-2017 22:41
 Message: Tracy

Thank you for sharing your practice information.   12-14 patients daily after just 3 months is huge number.   You should be able to earn good income with proper billing and overhead control.

With that volume so soon, after hours lacerations, etc., 24 /7 on call, no urgent care or hospital in region, I would be very concerned about potential burnout.   IMO, you will need an associate or colleagues to share call very soon.

Here are a couple of work flow issues, but I fear coverage and lifestyle and time off issues will be much more important in the long run.  Hopefully others who are working in a rural community will chime in.

I see why you need to draw blood.    Training an MA or your RN would make sense.   Is there a retired nurse or phlebotomist in community who you could hire to run a blood draw clinic twice a week for an hour?  Preferably when you are not there,  except in beginning to help train and assure competence.

Most important things I ever did:
Have labs available before the visit.
Have patients bring in list of all meds, pharmacy, and number of refills (or bring in bottles)
Have MA prepare perscriptions for signature or click.
Always give enough refills until the next planned visit.
Nominal charge for calling in refills between visits.
Do my own INRs.
Learn the billing dos and donts
Most visits are 99214
Bill for AWV or preventative visit once a year (usually along with a 99214-25)
I offer telephone management (charged to patient) but much less of issue now that can finally collect for CCM.

Sure, have patient take their own weight.  (That will save 15 seconds).  Having patient take their own BP is an option.  Although I am starting to update social history, and noting 90% of the physical exam while I am rooming patient and doing the VS.

Also, cannot minimize value of "laying on of the hands".  If machine can do everything, will patients minimize your value?

It takes 1-2 years to learn billing, work flows, know your patients, etc.   As a new doctor in town, you have lots of new patients, enter all their meds, new problems, record height, social issues, patients changing doctors, insurance issues etc., etc.

It will get better if you can hold on.   I have been doing this for many years so very few surprises.   I schedule each visit for 1/2 hour (and occasional squeeze in of easy acute).  12 to 14 visits per day.   One employee,   Start at 830 or 9 and leave by 430 to 530.  Average $40,000 income per number of days per week in office.

Not rich, but enough and happy.  My situation is very different from yours.   I am in 8 person call group.  4 of us are independent  and 4 are in a larger group.   2 urgent care facilities in area and hospital and ER.

Hopefully others in rural areas will chime in with suggestions.

Michael S. MD
Original Message:
Sent: 10-08-2017 14:58
From: Tracy Baum
Subject: Work flow advice

A few other details about the workflow....

1) Mountain Sage Clinic is located in a frontier area of Wyoming, 80 miles for the nearest hospital/ urgent care. We try to fill the gap providing family practice with after hour availability. (It's currently hunting season and I see alot of lacerations after hours this time of year.) There is a CHC across town that is actively trying to put me out of business. (that's a long story for another day.)

2. Lab work is provided for these reasons. No real options for people. I know this is a drain on my time and hope to resolve this, just unsure how at this point. I do have the usual CLIA-waived tests in house.

3. The patient load is approxamately 2-3 pts per hour. 45% of my pts are Medicare. We have been actively working on marketing to younger families, but I do a lot of Internal Medicine right now. I find this has it's pros and cons. The schedule is not full at this time, and hope to iron out some of the workflow glitches before attempting to increase the numbers. Avg pt/ day is between 12 and 16. 

4. It seems that constant interuruptions is a BIG issue. Our receptionist is new - just 3 weeks into training and has a lot of questions at this time. 

5 Currently using eClinical Works EHR and RCM and have to spend 2-3 hours a week fixing codes. (Don't even want to think about the time I have to spend updating information for MIPS! I really can't afford the penalties as since I am an NP, I already am subjected to a 15% decrease in reimbursement.) Considering switching to hiring a coder/ biller - would appreciate input on this issue. 

6. Due to no pharmacy w/in 80 miles, I also have a dispensary for abx, etc. I am the one counting the pills. I plan to use some pre-packs to help with the time drain for this area. 

7. The RN (5-6 hrs/ wk) is used for for the CCM and calling with lab results,refills at this time. Not a lot of rooming pts, VS etc. My goal is to have this be cost neutral or even help increase revenue with this program. We are just 3 mos into this and are still identifying pts and enrolling. 

8. I have started shifting more clerical tasks to the receptionist - she is eager to take on additional tasks. Ex. DOT paperwork and data input. 

9. A typical pt visit goes like this: I get the pt from the waiting room and we then sit and discuss HPI./ ROS. At this point I plug in a template that I have developed for the most freq complaints - URI, UTI HTN etc.  I then review meds, ask about any new hx. I then take VS and do the exam. Recently, I have started to stay in the room and order labs, meds, imaging right there. This allows me to tell the pt that is is completed (some pharmacies tell them - 'we didn't receive the order!) and prevents me forgetting to do this. Maybe spending a few more moments to just finish the note would help my sense of "oh crap, there's someone waiting in the waiting room" .

10. The business manager is my husband and he is now moved out from the front desk (bless his heart for hanging in there as receptionist for as long as he did!) He also handles the IT stuff. The bookkeeper is 5 hrs a week. 

What opportunities for smoothing out this work flow do you see? Do you use any 'blocked time' to do the lab reviews etc? I currently do this during the day or at the end of the day. I am open to all suggestions.


Original Message------


I stopped drawing blood years ago.    Two main reasons:

Much more efficient for our office flow to have patients go to the two national labs in the community within 2 miles of my office.

More importantly - Patients have learned to do blood work prior to their visits and I have results available for discussion.   I think patients appreciate it also.   Much more efficient, less follow up phone calls, email discussions, etc.   I give them lab slip, if needed, for next visit visit when current visit is done.   It works very smoothly.

If they need acute labs to complete assessment during a visit, they just go down the street.

Of course, we do send out cultures, paps, etc.

Only labs done in office are those I get results myself - U/A, micro, Strep, INR, very rare glucose.

Michael S. MD

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