RE: Cholesterol and Diabetes Clinic -- Progress report at the end of 5.5 months

[Guest guest]

That's a very informative post .

Now, I am not being silly, but, if I were to run a

diabetes/lipid/cardiovascular clinic, and I had the room, I would

place a treadmill or similar in the waiting room so that approved

patients could exercise while waiting for their appointment !

--

Graham Chiu

http://www.synapsedirect.com

Synapse-EMR - innovative electronic medical records system

[Guest guest]

I actually do have a treadmill in our guest bedroom, which is

right next to the exam room, but my patients generally don’t have to wait for

the appointments, and the fact that I only have three parking spaces means I

have to run on time, so it would never be used.

The real issue, is how I can motivate myself to get on that

treadmill?

don

From:

[mailto: ] On Behalf Of Graham Chiu

Sent: Saturday, January 05, 2008 12:12 PM

To:

Subject: Re: Cholesterol and Diabetes Clinic --

Progress report at the end of 5.5 months

That's a very informative post .

Now, I am not being silly, but, if I were to run a

diabetes/lipid/cardiovascular clinic, and I had the room, I would

place a treadmill or similar in the waiting room so that approved

patients could exercise while waiting for their appointment !

--

Graham Chiu

http://www.synapsedirect.com

Synapse-EMR - innovative electronic medical records system

[Guest guest]

Ahh, sometimes you have to lead by example

I can't expect my patients to diet and exercise to help manage their

dylipidemias ec if I don't do this myself.

>

> I actually do have a treadmill in our guest bedroom, which is right next to

> the exam room, but my patients generally don't have to wait for the

> appointments, and the fact that I only have three parking spaces means I

> have to run on time, so it would never be used.

>

>

>

> The real issue, is how I can motivate myself to get on that treadmill?

>

>

>

> don

--

Graham Chiu

http://www.synapsedirect.com

Synapse-EMR - innovative electronic medical records system

[Guest guest]

Another listserver mailed me this privately, but said I could quote

it as long as I left off his name and location:

,

I

enjoyed reading your post on the list serve about your practice. I was

very impressed. We started about 15 months ago and my wife also helps me

as an unpaid volunteer. We have rented a small 600 space but can leave

the lease with a 6 month advance in about 18 months. We have been

thinking about an office in our basement. I have had about 600

established patients follow me also and agree that really helped with start

up. I was interested in how the home practice was working-how is it

fitting into your home life/do patients stop by off hours and how does that

work/how have they reacted to a basement office/any problems with having

patients know where you live?

The home practice is much nicer for my home life. Our house

actually has two driveways, and the upper driveway leads to the main home

entrance. We have a sign there that says “Private Residence”,

so we actually haven’t ever had a patient come to the front door since we

opened. The first driveway, which is closest to the street, has two signs,

one that says “Patient Parking,” and the other that says “Entrance,”

with an arrow to the sidewalk that goes directly to the office door. The office

door has a window with my logo and the practice name stenciled on it, there

is a small sign on the door that says that if the door is locked, they should

ring the bell. We have had a few older patients come by outside of scheduled

hours in the beginning, because they were doing a “dry run” to see

if they could find the place. Since I have no signs visible from the

Parkway that identifies it as a medical office and this is a totally

residential area, they have to come into the driveway, and sometimes walk up to

the door to be sure this is the right place. I have had one or two

patients who have trouble with boundaries show up unscheduled outside of normal

hours, and I have gently “balled them out,” letting them know

that they can always call me on my cell phone and ask to be seen, but that I

have the right to the privacy of my home outside of regular hours. They

have not done it again. When someone really is sick, and needs to

be seen, it is much easier to walk downstairs, see them, and send them on their

way than it was in the past when I had to drive 22 minutes to the office,

unlock it, wait for them to arrive, then shut everything down and drive home

again. I can see an urgent patient after hours in 10 minutes of my time

now, as opposed to a minimum of an hour out of my day in the past.

This is a daylight basement, with picture windows with an incredible

view of Lake Sammamish. Sometimes the patients can watch the real-estate

magnate who lives on the point about 200 yards South land his helicopter and

park it in his garage. Also, we frequently have deer in the yard, eating the

flowers and apples. This is a thrill for many patients. The

waiting room has overstuffed leather furniture, as well as a couple of sturdy

chairs that are easy to get out of, and is decorated with medical antiques.

All of my patients have said the office was much nicer than my previous office.

Finally, since I have practiced and lived in the community for

25 years, a large number of my patients knew where I lived anyway. It has

never been a secret. These are mostly people I have known for a long

time.

Also we have a lab company supply a lab tech that sends the lab to them.

She is paid by them, cannot help us of course with Stark, and we have enjoyed

having her. Having said that, I order a fair number of HGBA1C,

Lipid/hepatic, Basic panels, as well as other routine primary care labs that

may require send out. My coumadin is sent out and all of my labs come

back in about 24 hours (they are shipped up the road at night for 3 hours-a

competing system was willing to allow the lab tech if we sent them the

labs). I do have about 5 (seems like more) coumadin folk-could have

more-the cardiologist would be glad for us to take at least 5 more if I asked

them. What was your experience with the lab aspect, ie financially and

time wise would you do it if you could have a " free " phleb to draw

the labs in our current arrangement. I could probably have her still work

and do some of the same labs and still have it profitable for the lab company.

If you have any pictures of your office, would love to see how you set it

up.

I typically draw a venous sample from my patients about once a

year, for creatinine, TSH, potassium, PSA, and so on. On some, I order a

VAP or Berkley once or twice a year. One of the reasons I went into

Family Practice is that I like to do things with my hands, so I don’t

mind a bit drawing my own blood.

I try to make it as efficient as possible. If I am doing a

physical exam that will have an EKG and venous draw, I have the patient sit on

the table to do the head and neck and lung exam, then lie them back for the

heart and abdomen exam, then hook up the EKG while they are still lying down,

then draw the blood, then put the women’s feet in the stirrups for the

GYN exam or have the men stand up and cough and bend over. Since

everything is close at hand, doing an EKG adds about 3 – 4 minutes to the

exam, and drawing blood adds 2 – 3 minutes (on a good day). I am

talking with the patients while I do this, so the extra 5 – 7 minutes

counts as additional time counseling the patients and is appreciated by the

patients.

Given the $3.00 I usually get for doing a venous draw, and the

extra time the patient would have to be in the office, taking up a parking

space, as well as the extra space I would have to dedicate for a “free”

phlebotomist, I honestly don’t think I could afford one. When I was

running on the Gerbil Wheel 15 years ago, keeping 4 – 5 exam rooms full

on a busy day, a phlebotomist and a medical assistant was necessary. I have

chosen to leave that part of my life behind me.

I will have to postpone the financial discussion of the labs for

a couple of more months, until I have data on all the payers that is accurate,

however, I would not recommend drawing blood from a patient who is not being

seen for an appointment at the same time. Without an appointment for a visit, I

ask the patients to go to the lab instead.

One of these days, I will get around to posting some pictures of

the office. . . .

dts

[Guest guest]

What about security?

Is there a possibility of drug users coming to your house at night

looking for drugs?

I had the unfortunate experience some years ago when some drug users

came to my house one night, broke the windows to my cars, and then

entered the downstairs thru another window. The interior pressure

change woke us up ( my bedroom door flew open ), but they were gone

before I realized what had happend.

The police said they had broken into every known doctor's house in our

suburb .. and they were eventually caught. After that I went

ex-directory removing my phone and address from the telephone

directory, and installed a burglar alarm.

>

> The home practice is much nicer for my home life. Our house actually has two

> driveways, and the upper driveway leads to the main home entrance. We have

> a sign there that says " Private Residence " , so we actually haven't ever had

--

Graham Chiu

http://www.synapsedirect.com

Synapse-EMR - innovative electronic medical records system

[Guest guest]

I haven’t kept any drugs anyone would steal in the office

since my first break-in 20 years ago.   However, that didn’t prevent the

next several break-ins, which have been about one  every 4 years in my original

office.    All the last thieves  got out with from the break-in 3 years ago

were a few Viagra samples. (The police put out an alert for “hardened

criminals” . . . )  I don’t really have any samples except for

diabetes and lipid medications now.    I think that there are more break-ins

for identity theft than there are for drugs any more, since I don’t know any

doctors who keep narcotics or scheduled drugs in the office. 

Regarding the identity theft issue, all of my  hard drives are

encrypted, and I have a strict password policy. My wife doesn’t even know

the passwords.  My backup media is all encrypted, too.   Getting the data out

of my system would be a lot more work than it is worth for anyone. 

I do have a burglar alarm.  In the basement, I have a huge and

very secure safe (it took 4 people and a special safe-moving  jack to get it

into the house and no one is going to get it out without the same equipment.)  Not

that I have much that needs to be in the safe, which was a gift from a friend 

who worked at a Financial Services company that shut down.  In terms of

personal security, we have a secure lock on the door at the bottom of the

stairs that go to the office.  None of my computers are new, and they are all

heavy.  They wouldn’t be worth much to someone wanting to sell them for

drug money.

Finally, I have great neighbors who are supportive of me and who

notice when cars are by the house after hours.  Although my house is

comfortable, it is not the most attractive one in the neighborhood.   There are

many other houses nearby that would be an easier and much more lucrative target

for thieves. 

I am sure I will be burglarized again at some point, and I will

hate it, but it is not likely to put me out of business.  And, the burglars are

not going to get much, because there isn’t much here worth stealing.

dts

From:

[mailto: ] On Behalf Of Graham Chiu

Sent: Saturday, January 05, 2008 11:04 PM

To:

Subject: Re: Cholesterol and Diabetes Clinic --

Progress report at the end of 5.5 months

What about security?

Is there a possibility of drug users coming to your house at night

looking for drugs?

I had the unfortunate experience some years ago when some drug users

came to my house one night, broke the windows to my cars, and then

entered the downstairs thru another window. The interior pressure

change woke us up ( my bedroom door flew open ), but they were gone

before I realized what had happend.

The police said they had broken into every known doctor's house in our

suburb .. and they were eventually caught. After that I went

ex-directory removing my phone and address from the telephone

directory, and installed a burglar alarm.

>

> The home practice is much nicer for my home life. Our house actually has

two

> driveways, and the upper driveway leads to the main home entrance. We have

> a sign there that says " Private Residence " , so we actually

haven't ever had

--

Graham Chiu

http://www.synapsedirect.com

Synapse-EMR - innovative electronic medical records system

[Guest guest]

,

This does mean you are getting a lot of nonfasting lipids?

Or do your patients fast until later in the day for you?

EKG takes me a lot longer unfortunately. Has to do with my

not having Windows Server 2003 and not being able to use my integrated EKG over

Terminal Services.

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

[Guest guest]

Put signs out:

No money, no narcotics kept in office.

Prominently.

Matt in Western PA

RE: Cholesterol and Diabetes Clinic -- Progress report at the end of 5.5 months

I haven’t kept any drugs anyone would steal in the office since my first break-in 20 years ago. However, that didn’t prevent the next several break-ins, which have been about one every 4 years in my original office. All the last thieves got out with from the break-in 3 years ago were a few Viagra samples. (The police put out an alert for “hardened criminals” . . . ) I don’t really have any samples except for diabetes and lipid medications now. I think that there are more break-ins for identity theft than there are for drugs any more, since I don’t know any doctors who keep narcotics or scheduled drugs in the office.

Regarding the identity theft issue, all of my hard drives are encrypted, and I have a strict password policy. My wife doesn’t even know the passwords. My backup media is all encrypted, too. Getting the data out of my system would be a lot more work than it is worth for anyone.

I do have a burglar alarm. In the basement, I have a huge and very secure safe (it took 4 people and a special safe-moving jack to get it into the house and no one is going to get it out without the same equipment.) Not that I have much that needs to be in the safe, which was a gift from a friend who worked at a Financial Services company that shut down. In terms of personal security, we have a secure lock on the door at the bottom of the stairs that go to the office. None of my computers are new, and they are all heavy. They wouldn’t be worth much to someone wanting to sell them for drug money.

Finally, I have great neighbors who are supportive of me and who notice when cars are by the house after hours. Although my house is comfortable, it is not the most attractive one in the neighborhood. There are many other houses nearby that would be an easier and much more lucrative target for thieves.

I am sure I will be burglarized again at some point, and I will hate it, but it is not likely to put me out of business. And, the burglars are not going to get much, because there isn’t much here worth stealing.

dts

From: [mailto: ] On Behalf Of Graham ChiuSent: Saturday, January 05, 2008 11:04 PMTo: Subject: Re: Cholesterol and Diabetes Clinic -- Progress report at the end of 5.5 months

What about security?Is there a possibility of drug users coming to your house at nightlooking for drugs?I had the unfortunate experience some years ago when some drug userscame to my house one night, broke the windows to my cars, and thenentered the downstairs thru another window. The interior pressurechange woke us up ( my bedroom door flew open ), but they were gonebefore I realized what had happend.The police said they had broken into every known doctor's house in oursuburb .. and they were eventually caught. After that I wentex-directory removing my phone and address from the telephonedirectory, and installed a burglar alarm.On Jan 6, 2008 6:43 PM, T. , MD <DonSpinelakemed> wrote:>> The home practice is much nicer for my home life. Our house actually has two> driveways, and the upper driveway leads to the main home entrance. We have> a sign there that says "Private Residence", so we actually haven't ever had-- Graham Chiuhttp://www.synapsedirect.comSynapse-EMR - innovative electronic medical records system

[Guest guest]

Do EKG and scan in?

M

RE: Cholesterol and Diabetes Clinic -- Progress report at the end of 5.5 months

,

This does mean you are getting a lot of nonfasting lipids? Or do your patients fast until later in the day for you?

EKG takes me a lot longer unfortunately. Has to do with my not having Windows Server 2003 and not being able to use my integrated EKG over Terminal Services.

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

[Guest guest]

Matt,

EKG electronic, no paper produced.

Kathy

From:

[mailto: ] On Behalf Of Dr Levin

Sent: Sunday, January 06, 2008 9:23 AM

To:

Subject: Re: Cholesterol and Diabetes Clinic --

Progress report at the end of 5.5 months

Do

EKG and scan in?

M

-----

Original Message -----

From: Kathy Saradarian

To:

Sent: Sunday, January 06,

2008 9:08 AM

Subject: RE:

Cholesterol and Diabetes Clinic -- Progress report at

the end of 5.5 months

,

This does mean you are getting a lot of

nonfasting lipids? Or do your patients fast until later in the day for

you?

EKG takes me a lot longer

unfortunately. Has to do with my not having Windows Server 2003 and not

being able to use my integrated EKG over Terminal Services.

Kathy

Saradarian, MD

Branchville,

NJ

www.qualityfamilypractice.com

Solo 4/03,

Practicing since 9/90

Practice

Partner 5/03

Low staffing

[Guest guest]

RE electronic EKG

If cannot integrate it, then print it out, and scan it back.

Not elegant, but will be accessable and usable?

Matt

RE: Cholesterol and Diabetes Clinic -- Progress report at the end of 5.5 months

,

This does mean you are getting a lot of nonfasting lipids? Or do your patients fast until later in the day for you?

EKG takes me a lot longer unfortunately. Has to do with my not having Windows Server 2003 and not being able to use my integrated EKG over Terminal Services.

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

[Guest guest]

I do lipids fasting or not. I have a high-risk group. If

they have very high non-fasting triglycerides, that is a problem I want to know

about, and to do something about. If their non-fasting

triglycerides are low, then I can trust the LDL. Actually, I pay more

attention to the Non-HDL Cholesterol than the LDL anyway. When

I really want to be exact, I do a Berkley, VAP, or NMR. But, for quarterly

follow-up, random lipids are better than none at all.

I actually don’t use the integrated EKG. I have an

EKG I got on ebay for a few hundred bucks that used to be marked by HP and

which has its own interface I run on my workstation, and later on I convert it

to a PDF and upload it to the patient’s chart. All-in-all, I

probably spend as much time doing EKGs as you, just less time in the room with

the patient.

dts

From:

[mailto: ] On Behalf Of Kathy

Saradarian

Sent: Sunday, January 06, 2008 6:08 AM

To:

Subject: RE: Cholesterol and Diabetes Clinic --

Progress report at the end of 5.5 months

,

This does mean you are getting a lot of

nonfasting lipids? Or do your patients fast until later in the day for

you?

EKG takes me a lot longer

unfortunately. Has to do with my not having Windows Server 2003 and not

being able to use my integrated EKG over Terminal Services.

Kathy

Saradarian, MD

Branchville,

NJ

www.qualityfamilypractice.com

Solo 4/03,

Practicing since 9/90

Practice

Partner 5/03

Low staffing

[Guest guest]

Would you share your expertise with us on the Berkeley, VAP or NMR proprietary tests?Are there good data to support their use?And with what criteria vs following old-fashioned fasting lipids?(or non-fasting trigs, as you mentioned).I do lipids fasting or not. I have a high-risk group.  If they have very high non-fasting triglycerides, that is a problem I want to know about, and to do something about.   If their non-fasting triglycerides are low, then I can trust the LDL.  Actually, I pay more attention to the Non-HDL Cholesterol  than the LDL anyway.    When I really want to be exact, I do a Berkley, VAP, or NMR.   But, for quarterly follow-up, random lipids are better than none at all.    I actually don’t use the integrated EKG.  I have an EKG I got on ebay for a few hundred bucks that used to be marked by HP and which has its own interface I run on my workstation, and later on I convert it to a PDF and upload it to the patient’s chart.   All-in-all, I probably spend as much time doing EKGs as you, just less time in the room with the patient. dts From:  [mailto: ] On Behalf Of Kathy SaradarianSent: Sunday, January 06, 2008 6:08 AMTo:  Subject: RE: Cholesterol and Diabetes Clinic -- Progress report at the end of 5.5 months ,This does mean you are getting a lot of nonfasting lipids?  Or do your patients fast until later in the day for you? EKG takes me a lot longer unfortunately.  Has to do with my not having Windows Server 2003 and not being able to use my integrated EKG over Terminal Services.  Kathy Saradarian, MDBranchville, NJwww.qualityfamilypractice.comSolo 4/03, Practicing since 9/90Practice Partner 5/03Low staffing 

[Guest guest]

Matt,

We are having a communication problem.  If I print it out, I am

printing it from the medical record so there would be no reason to print it and

scan it back in.  I am not sure why you suggested that.  It is perfectly accessible

and usable in the electronic format.  It just takes a little longer and a few

more steps to get one with my current set up.  But it is not such a big issue

that I will spend the money on a new server or even new operating system for

the server; I will spend the extra 5 minutes with the lengthier process.

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

From:

[mailto: ] On Behalf Of Dr Levin

Sent: Sunday, January 06, 2008 10:54 AM

To:

Subject: Re: Cholesterol and Diabetes Clinic --

Progress report at the end of 5.5 months

RE

electronic EKG

If

cannot integrate it, then print it out, and scan it back.

Not

elegant, but will be accessable and usable?

Matt

-----

Original Message -----

From: Kathy Saradarian

To:

Sent: Sunday, January 06,

2008 10:40 AM

Subject: RE:

Cholesterol and Diabetes Clinic -- Progress report at

the end of 5.5 months

Matt,

EKG electronic, no paper produced.

Kathy

From:

[mailto: ] On Behalf Of Dr Levin

Sent: Sunday, January 06, 2008 9:23 AM

To:

Subject: Re: Cholesterol and Diabetes Clinic --

Progress report at the end of 5.5 months

Do EKG and scan in?

M

RE:

Cholesterol and Diabetes Clinic -- Progress report at

the end of 5.5 months

,

This does mean you are getting a lot of

nonfasting lipids? Or do your patients fast until later in the day for

you?

EKG takes me a lot longer

unfortunately. Has to do with my not having Windows Server 2003 and not

being able to use my integrated EKG over Terminal Services.

Kathy

Saradarian, MD

Branchville,

NJ

www.qualityfamilypractice.com

Solo 4/03,

Practicing since 9/90

Practice

Partner 5/03

Low staffing

[Guest guest]

RE communication.

Thought you were having difficulty finding the file in your system and appending it to the file, in that case, making it an outside file to import in I thought would help.

Glad it's working for you.

For me, I'd find the extra step of making the EKG integrate directly into my system not worth it, but with a more fully integrated system, glad it works for you.

Was mainly using it as an illustration for others who would be working so hard to find a fully integrateable EKG machine that as long as you can capture the file electronically, OR scan in a paper copy, that you can incorporate the EKG into a virtual or EMR system.

Regards,

Matt

RE: Cholesterol and Diabetes Clinic -- Progress report at the end of 5.5 months

,

This does mean you are getting a lot of nonfasting lipids? Or do your patients fast until later in the day for you?

EKG takes me a lot longer unfortunately. Has to do with my not having Windows Server 2003 and not being able to use my integrated EKG over Terminal Services.

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

[Guest guest]

I think you can get a lot of information from old-fashioned

fasting lipids. They are what I follow the most.

I have spent too much time posting the last few days, so I will

have to defer discussing advanced lipid testing right now. I am in the

middle of studying this stuff for boards, and so my answers will be much more

cogent in a few months.

dts

From:

[mailto: ] On Behalf Of Guinn

Sent: Sunday, January 06, 2008 12:22 PM

To:

Subject: Re: Cholesterol and Diabetes Clinic --

Progress report at the end of 5.5 months

Would you share your expertise with us on the Berkeley, VAP or NMR

proprietary tests?

Are there good data to support their use?

And with what criteria vs following old-fashioned fasting

lipids?

(or non-fasting trigs, as you mentioned).

I do lipids fasting or not. I have a

high-risk group. If they have very high non-fasting triglycerides, that

is a problem I want to know about, and to do something about. If

their non-fasting triglycerides are low, then I can trust the LDL.

Actually, I pay more attention to the Non-HDL Cholesterol than the LDL

anyway. When I really want to be exact, I do a Berkley, VAP,

or NMR. But, for quarterly follow-up, random lipids are better than

none at all.

I actually don’t use the

integrated EKG. I have an EKG I got on ebay for a few hundred bucks that

used to be marked by HP and which has its own interface I run on my

workstation, and later on I convert it to a PDF and upload it to the patient’s

chart. All-in-all, I probably spend as much time doing EKGs as you,

just less time in the room with the patient.

dts

From: [mailto: ] On Behalf Of Kathy Saradarian

Sent: Sunday, January 06,

2008 6:08 AM

To:

Subject: RE:

Cholesterol and Diabetes Clinic -- Progress report at

the end of 5.5 months

,

This does mean you are getting a lot of

nonfasting lipids? Or do your patients fast until later in the day for

you?

EKG takes me a lot longer

unfortunately. Has to do with my not having Windows Server 2003 and not

being able to use my integrated EKG over Terminal Services.

Kathy

Saradarian, MD

Branchville,

NJ

www.qualityfamilypractice.com

Solo 4/03,

Practicing since 9/90

Practice

Partner 5/03

Low staffing