Re: Cholesterol and Diabetes Clinic -- Progress report at the end of 5.5 mon

[Guest guest]

Don- Fascinating description of your practice, it is absolutely helpful to see how a 21st century thoughtful patient centered chronic care micropractice got set up. I am really wowed.I am interested to see what the revenue is for a typical diabetic patient in the 25 minute visit with urine, cholesterol, etc..sums up to be in your area. It will probably provoke a mild episode of syncope for me. As regards the appointment quest accounts, you could go through eliminate all but one account and then email the patient with the pw and username and tell them to use that account from then on. Then you could do the Clemenssen thing and lock down new users so that only you could add them.I love how you get the patients to come in and get their own vitals. Maybe I will set up an Omron and scale in the outer anteroom so that patients can do that before I see them. Great idea.One thing that I would love to hear about in future is how the howsyourhealth numbers stack out with this kind of care- I bet they will be fabulous. Thanks for putting in the time to give us this great description- I would love to hear more as time progresses. LynnTo: From: DonS@...Date: Sat, 5 Jan 2008 02:45:44 -0800Subject: Cholesterol and Diabetes Clinic -- Progress report at the end of 5.5 months

A couple people have asked about the Diabetes and Lipid Clinic,

and I have been at it a little more than 5 months now, so I can post a bit

about the experience.

First of all, I already had a well-established

practice. I opened my doors as a solo FP in 1983.

I grew the practice to 6 providers, built a building, and finally sold the

practice to a hospital system in 2003, when I got tired of running on the gerbil

wheel. I stayed on as the Clinic Medical Director until I resigned and

left to open the Diabetes and Lipid Clinic in late July of 2007.

I had started out doing a full range of Family Practice, but

stopped doing OB after a few years, due to the malpractice costs at the time

and the fact that the office was 40 minutes from the hospital. After my first

10 years, I got fewer and fewer pediatrics because a large pediatrics group

moved in next door, and I was pretty busy anyway. I was interested in

chronic care, and my other associates needed to build their practices, so

patients with acute illnesses usually were seen by one of my other associates,

the PAs, or the NPs. By 2003, most of my patients were 50 years and

older, and most of my visits were for problems with diabetes and lipids. I

had turned inpatient care over to the hospitalists by the mid-1990s, and

I had stopped doing surgical assists on my patients by about 2000.

After I sold the practice in 2003, being an employee, rather

than the owner of the practice, gave me the time to reassess things, and I

became more interested in the chronic care model, computer registries, and

diabetes and lipid care. I participated in the Washington State Diabetes

Collaborative, and became a NCQA recognized diabetes physician. I decided

to become certified as a lipidologist. I also decided that I did not want

to be scheduled with patients more than about 20 hours a week. My wife,

Eva, a NP and PA who had worked with me in the practice since the

beginning (originally as the RN), had retired from practice around the end of

2004, and I missed having her around.

The kids had moved out of the house, which had a full daylight

basement that had been a Mother-in-Law apartment in years past, and our previously

semi-rural community had just incorporated into a city, which did not have

enough office space, so was very friendly to home businesses. Most

important, my wife loved to remodel and redecorate, and was willing to hang

sheetrock, paint, lay tile, and pour concrete, with the help of a friend

of ours who was a handyman. It was not a big leap to think about working

out of the basement of the house, with very low overhead, and just focusing on

providing quality care to my patients with diabetes and lipid problems.

At the AAFP meeting in 2006 in Washington DC (the first

one I had ever attended because of being “too busy” for 20+ years),

I first heard Gordon ’s name, learned about the listserv, and

decided it was time to make the switch. Eva started remodeling, and I

gave a 6-month notice to the hospital system January 1, 2007. The

contract with the hospital system did not have a non-compete agreement, and my

home was only a couple of miles from the original office, so making the switch

was not a problem for most of my patients.

The hospital sent out a letter to all of the patients in March

telling them that I was leaving to pursue a specialty practice, but was

mum about the details. I told my patients during their visits what

I would be doing, and about a month before I left, sent out an email to

1100 patients giving them the full details, with instructions to request a

release of records from the clinic if they wanted to follow me. By the

time I left, there were 700 record requests. The month I left, the clinic

was switching to the Epic EMR, and all of the existing patient records were on

Practice Partner, which I had installed a couple of years before the hospital

bought me out. They agreed to let me take the EMR files (purged of all

the patients who had not signed a release), and I helped them convert the data

to Epic for the remaining patients, and allowed them to use my server on loan

for 6 months through the conversion.

Although my employment was over on June 30, I stayed on as a

locum at their request for 3 more weeks, because they had not hired anyone to

replace me, and they were very short-handed, with staff out in Epic training

sessions in June and July.

We purchased our medical equipment from medical surplus stores

and e-bay, and my brother donated a couple of beautiful desks. Exam room

furniture was from Craig’s list. Eva sewed the curtains, did the

remodeling, and poured a sidewalk from our widened driveway to the entry door. She

also landscaped our entry and an incredible job on the garden. One of my

patients with a bull-dozing business widened my driveway, for additional

parking. Our neighbors were incredibly supportive.

By the time we opened I had contracts with our local Blue Shield

and Blue Cross, as well as with United Health Care and First Choice, the largest

PPO in the area. I didn’t get a contract or any payments from

Medicare, Secure Horizons, or Pacificare until last week (literally 8 – 9

months after we started the application process). I saw the patients,

anyway. Last week, I got my first checks for Secure Horizons and

Pacificare patients I had seen in July.

Getting the billing running was more of a challenge than I had

expected. I had obtained the full integrated version of Practice Partner,

with all of the bells and whistles, but misunderstood how to do the

installation/upgrade of my old data, and managed not to get the billing module

properly integrated with the patient data. Unfortunately, the medical

records part of the upgrade worked like a charm, and the problems with the

billing were not obvious until I had been in business for a month.

Fortunately, Practice Partner Tech Support was great, and were able to

get everything up and running correctly, once they figured out how I had

screwed up the installation, without losing any of the clinical data I had

entered prior to the discovery of the problem. But, I had been

seeing patients about two months before we were able to send out the first

bills to the insurance companies.

Our set-up has parking for three patient cars, a level entry to

the basement, which opens into the waiting room, which used to be a family

room. There are built-in bookshelves and a fireplace. We have

a short hallway that goes past the bathroom to the one exam room. Off

of the hallway is another hallway that leads to our garage and stairs, and

there is a built-in counter and cabinets to hold our centrifuge, microscope, and

an Autoclave. We have an old refrigerator in that hall to store the

supplies that need to be cold, but we don’t stock anything that

needs rigid temperature controls, like some immunizations.

The entrance to the exam room is on a corner of the

room. On the wall to the right of the entry door is a sink with a

wide enough counter to hold two Cholestech LDX machines and printers (so

I can do a lipid battery and AST/ALT at the same time) , a Bayer 2000+ for HgbA1cs,

a Bayer Clinitec Status for Microal/Creatinine, and an INRatio for patients I

decide to do INRs on at the time of service. Under the counter is a mini

refrigerator for lab supplies and immunizations, as well as drawers for storage

of surgery supplies. Next to the counter is a full height 2’

x 3’ closet for exam supplies and storage of things I use clinically.

As one enters, the wall on the left has a patient chair, and

next to it is a large roll top desk rescued from my grandfather’s

basement and refinished by my brother 20 years ago. On the desk, I have

two flat-screen computer monitors hooked in to an old Dell 650 Precision

Workstation, which is basically a small dual Xeon server that I purchased on e-bay

for less than $300.00. On the other side of the desk is a Laserjet

printer supplied by LabCorp for printing lab requisitions. During the

remodel, I pulled cable for gigabit Ethernet, so we don’t need to worry

about wireless security, though I have unencrypted wireless Ethernet available

for patient convenience. My real servers reside in my shop, where I

tinker with computers and other things.

In the corner opposite the door to the room is an old, but very

functional power table that cost $400.00 from a local medical surplus supplier.

Eva sewed a curtain that hangs from a track on the ceiling to separate the exam

table from the desk area, so patients can change with some privacy while I work

at the desk. On the wall between the exam table and the desk is a

steel-topped mobile serving table that we got on sale at Home Depot which has

an easy-to-clean top and lots of storage for my EKG and spirometer, tongue

blades, bandages, and so on. It gives me lots of space to work when

I am drawing blood, or doing minor surgeries. I got a slick used

Hyfrecator as a gift from one of my ex-associates that hangs on the wall behind

the curtain, and a nifty HP fiberoptic spotlight off of e-bay.

Everything I need to see patients is within easy reach in the exam room.

Eva has volunteered to greet the patients, scan their insurance

cards, drivers licenses, credit cards, and gets them to sign a HIPPA form and a

release that allows us to bill the credit cards for copays and balances after

the insurance companies adjudicate the bills. We now have about 500 patients

fully registered, so within a few months, that part of her job will largely

disappear. She also teaches them how to check their own blood pressure on

the machine on her desk and to get their own weight, explaining that she might

not be there the next time they come in. She reminds the diabetics to get

a urine sample and to bring it into the exam room when they are seen.

I built a website and linked it to AppointmentQuest and

HowsYourHealth. The patients (most of whom had been selected because I

had their email) make their own appointments except for the few who just don’t

have computer access or can’t figure it out. Our office phone is

through Vonage, and we have a fax line with them, too, which goes to a computer

that is a fax server. I have both a DSL internet line, and a Cable

internet connection (which I use for the Vonage IP Phones and as backup in case

the DSL goes down), and we have battery backups on all the computers as well as

a home generator system.

The first couple of months, we rarely answered the phone,

letting it roll over to a message that tells the patients to make their own

appointments on the website, to leave a message, or to call me on my cell phone

in an emergency. We were really amazed that my schedule filled up

very quickly without having anyone answer the phone. The patient

satisfaction with the scheduling has been very high. The biggest problem

we have had with AppointmentQuest has been that I neglected to put a reminder

on the website that they need to log in with their username and password before

they schedule an appointment, and so many patients have ended up creating

multiple accounts without knowing it, which makes it difficult for them to

reschedule or cancel their appointments on line. Now, Eva answers

the phone most of the time, which saves me a great deal of time. However,

she still asks the patients to schedule their own appointments on line, unless

they are unable.

My typical diabetes or lipid visit is listed as 25 minutes, with

5 minutes of dead space after the appointment. The patients enter the

exam room with their urine cup (if diabetic) and vitals, and sit down on the

chair. I dip the urine for Microal/Creat and put the strip in the

Clinitec Status. I then poke a finger and load the cassette into the

2000+ for HgbA1c, which takes 6 minutes to run. I then fill the

Cholestech pipettes, and then load the cartridges for the ALT/AST and Lipid

Battery/Glucose into the two Cholestech machines. These take 5 minutes to

run, so the Urine, Lipids, Glucose, and A1c all are done about 7 minutes

after the patient enters the exam room. While I am drawing the blood and

waiting for the results, I am interviewing the patient, and entering the information

into Practice Partner.

My diabetes template automatically brings in the previous

history of their diabetes, as of the last visit, as well as recent pertinent

lab values, health maintenance items that are due, self-maintenance goals from

the last visit (like how many days a week they were going to try to exercise),

what their previous concerns and worries were, most recent diet, exercise,

alcohol and smoking habits, and even pertinent abnormal physical findings from

the last visit. It is very easy to bring these values all up to date

while I am waiting for today’s labs. I then enter the new lab

data into the note, discuss it with them, and do an exam, which is heart, lungs,

neck, and feet, including vibration sense. This takes about 15 minutes in

all, so I have about 10 extra minutes for teaching, counseling, setting goals

for the next period, and dealing with their other problems.

The 25 minutes is about right for diabetic follow-up, but it is

more time than I usually need for just lipids and/or hypertension follow-up

alone. This gives me a little flexibility if I need to work someone in

for an acute problem. Patients can schedule urgent care visits for 10

minutes, office surgery for 30 minutes, multiple or complex problems for 40

minutes, and complete physical exams or vasectomies for 50 minutes.

AppointmentQuest always adds 5 minutes slack time after every appointment.

My schedule is as follows:

Monday: 8:00

– 11:00 and then 12:00 – 3:00

Tuesday: 3:00

– 8:00

Wednesday: 8:00 – 12:00

Thursday: 8:00

– 12:00

I might see anywhere from 6 – 12 patients on a given day,

depending on who gets scheduled for what. On a given day,

AppointmentQuest will tell me I have between 75 – 120 future appointments

booked. Patients usually can schedule a 50 minute exam within 10 days,

and a 10-minute exam within 3 days. Of course, because of the light hours

I work, I can almost always add people in at the end of the day, or before my

day starts on Tuesdays. Today, which is Friday, my “day off,”

I saw a diabetic with pneumonia at 9:00 in the morning because he called and

said he was sick, and I did a house call on a 99 year-old woman with pneumonia

who did not want to go to the hospital in the afternoon. Her husband

called me at 11:00, and I saw her after I had my car emission tested

after lunch.

My billing is done by creating an electronic encounter form in

Practice Partner at the end of the visit. I did hire a billing service,

which logs in to my system over the internet, enters the patient’s insurance

data from their scanned cards into the billing part of the system, submits the

bills (now electronically), and runs statements twice a month to a text file on

the server. Eva then goes through the statements and bills the

credit cards for the patient responsibility. She has been posting, too,

but this takes time and we will have the billing people do this soon. We

would have the billing people do the credit card billing, but they do not have

the capability to do that, and I am not sure the patients would trust us with

their credit cards if they knew someone else had access to them.

I don’t think it would be fair to post my financial data

at this point, since we have only been working for 5.5 months, have only been

able to submit bills to about 2/3 of our patients’ insurances for 3.5

months, and just submitted the last 1/3 of our patients’ bills in the

last week, but it is pretty clear that I will net as least as much as I did in

the hospital system scheduled at 28 - 30 hours a week with patients, and

I also have the capability of earning additional money doing computer and EMR

consulting, which was not an option when I was an employee. I am

actually putting in quite a bit more total hours now than I did as an employee,

but lots of it is low-stress setting up accounts in the EMR, resizing patient’s

photos, answering faxes, building computers, and so on. Once I have all

800 of my current patient list set up with accounts and have all of their

paperwork scanned, it will free up about 10 hours a week that I can use doing

EMR consulting. I will also have the freedom to drop poorly-paying

insurance companies, and even to do a limited number of consults, which I

am avoiding until I pass my lipid boards in May.

Sometime in the next few months, I will be able to post the

financial specifics, especially related to the in-house labs I do. Having

Eva as an unpaid, “volunteer” worker obviously makes a tremendous

difference in the overhead, but we are getting to the point where she doesn’t

have to be in the office all of the time. Also, not having to borrow any

money to start up, not having to pay any more rent than our routine

house payment, and having a pre-established patient panel makes a huge

difference, too.

I apologize for the length of this post, but I have trouble

being succinct, and for some reason felt a need to do a brain dump about the

practice today.

Happy New Year to all.

T. , MD

Sammamish Diabetes and Lipid Clinic, PLLC

A medical home for patients with cardiovascular risk.

From:

[mailto: ] On Behalf Of Egly

Sent: Thursday, January 03, 2008 7:55 AM

To:

Subject: Re: INR Machine

:

Also, interested in how you established your cholesterol and

diabetic clinic.

Watch “Cause Effect,” a show about real people making a real difference. Learn more

[Guest guest]

Don -I remember meeting you at the 2006 AAFP conference and have read your posts since then with interest. This is a great description of your practice and process. Don- Fascinating description of your practice, it is absolutely helpful to see how a 21st century thoughtful patient centered chronic care micropractice got set up.  I am really wowed.I am interested to see what the revenue is for a typical diabetic patient in the 25 minute visit with urine, cholesterol, etc..sums up to be in your area.  It will probably provoke a mild episode of syncope for me. As regards the appointment quest accounts, you could go through eliminate all but one account and then email the patient with the pw and username and tell them to use that account from then on.  Then you could do the Clemenssen thing and lock down new users so that only you could add them.I love how you get the patients to come in and get their own vitals.  Maybe I will set up an Omron and scale in the outer anteroom so that patients can do that before I see them.  Great idea.One thing that I would love to hear about in future is how the howsyourhealth numbers stack out with this kind of care-  I bet they will be fabulous.  Thanks for putting in the time to  give us this great description-  I would love to hear more as time progresses.  LynnTo: From: DonSpinelakemedDate: Sat, 5 Jan 2008 02:45:44 -0800Subject: Cholesterol and Diabetes Clinic -- Progress report at the end of 5.5 monthsA couple people have asked about the Diabetes and Lipid Clinic, and I have been at it a little more than 5 months now, so I can post a bit about the experience.  First of all, I already had a well-established practice.   I  opened my doors as a solo FP in 1983.   I grew the practice to 6 providers, built a building, and finally sold the practice to a hospital system in 2003, when I got tired of running on the gerbil wheel.  I stayed on as the Clinic Medical Director until I resigned and left to open the Diabetes and Lipid Clinic in late July of 2007. I had started out doing a full range of Family Practice, but stopped doing OB after a few years, due to the malpractice costs at the time and the fact that the office was 40 minutes from the hospital. After my first 10 years, I got fewer and fewer pediatrics because a large pediatrics group moved in next door, and I was pretty busy anyway.  I was interested in chronic care, and my other associates needed to build their practices, so patients with acute illnesses usually were seen by one of my other associates, the PAs, or the NPs.  By 2003, most of my patients were 50 years and older, and most of my visits were for problems with diabetes and lipids.  I had turned  inpatient care over to the hospitalists by the mid-1990s, and I had  stopped doing surgical assists on my patients by about 2000. After I sold the practice in 2003, being an employee, rather than the owner of the practice, gave me the time to reassess things, and I became more interested in the chronic care model, computer registries, and diabetes and lipid care.  I participated in the Washington State Diabetes Collaborative, and became a NCQA recognized diabetes physician.  I decided to become certified as a lipidologist.  I also decided that I did not want to be scheduled with patients more than about 20 hours a week.  My wife, Eva,  a NP and PA who had worked with me in the practice since the beginning (originally as the RN), had retired from practice around the end of 2004, and I missed having her around.  The kids had moved out of the house, which had a full daylight basement that had been a Mother-in-Law apartment in years past, and our previously semi-rural community had just incorporated into a city, which did not have enough office space, so was very friendly to home businesses.    Most important, my wife loved to remodel and redecorate, and was willing to hang sheetrock, paint, lay tile,  and pour concrete, with the help of a friend of ours who was a handyman.  It was not a big leap to think about working out of the basement of the house, with very low overhead, and just focusing on providing quality care to my patients with diabetes and lipid problems.  At the AAFP meeting  in 2006 in Washington DC (the first one I had ever attended because of being “too busy” for 20+ years), I first heard Gordon ’s name, learned about the listserv, and decided it was time to make the switch.  Eva started remodeling, and I gave a 6-month notice to the hospital system January 1, 2007.  The contract with the hospital system did not have a non-compete agreement, and my home was only a couple of miles from the original office, so making the switch was not a problem for most of my patients.  The hospital sent out a letter to all of the patients in March telling them that I was leaving  to pursue a specialty practice, but was mum about the details.   I told my patients during their visits what I would be doing, and about a month before I left, sent out an email  to 1100 patients giving them the full details, with instructions to request a release of records from the clinic if they wanted to follow me.  By the time I left, there were 700 record requests.  The month I left, the clinic was switching to the Epic EMR, and all of the existing patient records were on Practice Partner, which I had installed a couple of years before the hospital bought me out.  They agreed to let me take the EMR files (purged of all the patients who had not signed a release), and I helped them convert the data to Epic for the remaining patients, and allowed them to use my server on loan for 6 months through the conversion. Although my employment was over on June 30, I stayed on as a locum at their request for 3 more weeks, because they had not hired anyone to replace me, and they were very short-handed, with staff out in Epic training sessions in June and July. We purchased our medical equipment from medical surplus stores and e-bay, and my brother donated a couple of beautiful desks.  Exam room furniture was from Craig’s list.  Eva sewed the curtains, did the remodeling, and poured a sidewalk from our widened driveway to the entry door.  She also landscaped our entry and an incredible job on the garden.  One of my patients with a bull-dozing business widened my driveway, for additional parking. Our neighbors were incredibly supportive.  By the time we opened I had contracts with our local Blue Shield and Blue Cross, as well as with United Health Care and First Choice, the largest PPO in the area.  I didn’t get a contract or any payments from Medicare, Secure Horizons, or Pacificare until last week (literally 8 – 9 months after we started the application process).  I saw the patients, anyway.  Last week, I got my first checks for Secure Horizons and Pacificare patients I had seen in July. Getting the billing running was more of a challenge than I had expected.  I had obtained the full integrated version of Practice Partner, with all of the bells and whistles, but misunderstood how to do the installation/upgrade of my old data, and managed not to get the billing module properly integrated with the patient data.  Unfortunately, the medical records part of the upgrade worked like a charm, and the problems with the billing were not obvious until I had been in business for a month.   Fortunately, Practice Partner Tech Support was great, and were able to  get everything up and running correctly, once they figured out how I had screwed up the installation, without losing any of the clinical data I had entered prior to the discovery of the problem.   But, I had been seeing patients about two months before we were able to send out the first bills to the insurance companies. Our set-up has parking for three patient cars, a level entry to the basement, which opens into the waiting room, which used to be a family room.  There are built-in bookshelves and a fireplace.   We have a short hallway that goes past the bathroom to the one exam room.   Off of the hallway is another hallway that leads to our garage and stairs, and there is a built-in counter and cabinets to hold our centrifuge, microscope, and an Autoclave.   We have an old refrigerator in that hall to store the supplies that need to  be cold, but we don’t stock anything that needs rigid  temperature controls, like some immunizations. The entrance to the exam room is on a corner  of the room.  On the wall to the right of the entry door is a  sink with a wide enough counter to hold  two Cholestech LDX machines and printers (so I can do a lipid battery and AST/ALT at the same time) , a Bayer 2000+ for HgbA1cs, a Bayer Clinitec Status for Microal/Creatinine, and an INRatio for patients I decide to do INRs on at the time of service.  Under the counter is a mini refrigerator for lab supplies and immunizations, as well as drawers for storage of surgery supplies.   Next to the counter is a full height 2’ x 3’ closet for exam supplies and storage of things I use clinically.     As one enters, the wall on the left has a patient chair, and next to it is  a large roll top desk rescued from my grandfather’s basement and refinished by my brother 20 years ago.  On the desk, I have two flat-screen computer monitors hooked in to an old Dell 650 Precision Workstation, which is basically a small dual Xeon server that I purchased on e-bay for less than $300.00.  On the other side of the desk is a Laserjet printer supplied by LabCorp for printing lab requisitions.  During the remodel, I pulled cable for gigabit Ethernet, so we don’t need to worry about wireless security, though I have unencrypted wireless Ethernet available for patient convenience.  My real servers reside in my shop, where  I tinker with computers and other things. In the corner opposite the door to the room is an old, but very functional power table that cost $400.00 from a local medical surplus supplier.  Eva sewed a curtain that hangs from a track on the ceiling to separate the exam table from the desk area, so patients can change with some privacy while I work at the desk.   On the wall between the exam table and the desk is a steel-topped mobile serving table that we got on sale at Home Depot which has an easy-to-clean top and lots of storage for my EKG and spirometer, tongue blades, bandages, and so on.  It gives me lots of space to work when  I am drawing blood, or doing minor surgeries.   I got a slick used Hyfrecator as a gift from one of my ex-associates that hangs on the wall behind the curtain, and a nifty HP fiberoptic  spotlight off of e-bay.  Everything I need to see patients is within easy reach in the exam room. Eva has volunteered to greet the patients, scan their insurance cards, drivers licenses, credit cards, and gets them to sign a HIPPA form and a release that allows us to bill the credit cards for copays and balances after the insurance companies adjudicate the bills. We now have about 500 patients fully registered, so within a few months, that part of her job will largely disappear.  She also teaches them how to check their own blood pressure on the machine on her desk and to get their own weight, explaining that she might not be there the next time they come in.  She reminds the diabetics to get a urine sample and to bring it into the exam room when they are seen. I built a website and linked it to AppointmentQuest and HowsYourHealth.  The patients (most of whom had been selected because I had their email) make their own appointments except for the few who just don’t have computer access or can’t figure it out.  Our office phone is through Vonage, and we have a fax line with them, too, which goes to a computer that is a fax server.   I have both a DSL internet line, and a Cable internet connection (which I use for the Vonage IP Phones and as backup in case the DSL goes down), and we have battery backups on all the computers as well as a home generator system. The first couple of months, we rarely answered the phone, letting it roll over to a message that tells the patients to make their own appointments on the website, to leave a message, or to call me on my cell phone in an emergency.   We were really amazed that my schedule filled up very quickly without having anyone answer the phone.  The patient satisfaction with the scheduling has been very high.  The biggest problem we have had with AppointmentQuest has been that I neglected to put a reminder on the website that they need to log in with their username and password  before  they schedule an appointment, and so many patients have ended up creating multiple accounts without knowing it, which makes it difficult for them to reschedule or cancel their appointments on line.   Now, Eva answers the phone most of the time, which saves me a great deal of time.  However, she still asks the patients to schedule their own appointments on line, unless they are unable. My typical diabetes or lipid visit is listed as 25 minutes, with 5 minutes of dead space after the appointment.  The patients enter the exam room with their urine cup (if diabetic) and vitals, and sit down on the chair.  I dip the urine for Microal/Creat and put the strip in the Clinitec Status.  I then poke a finger and load the cassette into the 2000+ for HgbA1c, which takes 6 minutes to run.  I then fill the Cholestech pipettes, and then load the cartridges for the ALT/AST and Lipid Battery/Glucose into the two Cholestech machines.  These take 5 minutes to run, so the Urine, Lipids, Glucose, and A1c  all are done about 7 minutes after the patient enters the exam room. While I am drawing the blood and waiting for the results, I am interviewing the patient, and entering the information into Practice Partner. My diabetes template automatically brings in the previous history of their diabetes, as of the last visit, as well as recent pertinent lab values, health maintenance items that are due, self-maintenance goals from the last visit (like how many days a week they were going to try to exercise), what their previous concerns and worries were, most recent diet, exercise, alcohol and smoking habits, and even pertinent abnormal physical findings from the last visit.  It is very easy to bring these values all up to date while I am waiting for today’s labs.   I then enter the new lab data into the note, discuss it with them, and do an exam, which is heart, lungs, neck, and feet, including vibration sense.  This takes about 15 minutes in all, so I have about 10 extra minutes for teaching, counseling, setting goals for the next period, and dealing with their other problems. The 25 minutes is about right for diabetic follow-up, but it is more time than I usually need for just lipids and/or hypertension follow-up alone.  This gives me a little flexibility if I need to work someone in for an acute problem.  Patients can schedule urgent care visits for 10 minutes, office surgery for 30 minutes, multiple or complex problems for 40 minutes, and complete physical exams or vasectomies for 50 minutes.  AppointmentQuest always adds 5 minutes slack time after every appointment. My schedule is as follows:Monday:              8:00 – 11:00  and then 12:00 – 3:00Tuesday:              3:00 – 8:00Wednesday:      8:00 – 12:00Thursday:            8:00 – 12:00 I might see anywhere from 6 – 12 patients on a given day, depending on who gets scheduled for what.  On a given day, AppointmentQuest will tell me I have between 75 – 120 future appointments booked.  Patients usually can schedule a 50 minute exam within 10 days, and a 10-minute exam within 3 days.  Of course, because of the light hours I work, I can almost always add people in at the end of the day, or before my day starts on Tuesdays.  Today, which is Friday, my “day off,” I saw a diabetic with pneumonia at 9:00 in the morning because he called and said he was sick, and I did a house call on a 99 year-old woman with pneumonia who did not want to go to the hospital in the afternoon.  Her husband called me at 11:00,  and I saw her after I had my car emission tested after lunch.  My billing is done by creating an electronic encounter form in Practice Partner at the end of the visit.  I did hire a billing service, which logs in to my system over the internet, enters the patient’s insurance data from their scanned cards into the billing part of the system, submits the bills (now electronically), and runs statements twice a month to a text file on the server.   Eva then goes through the statements and bills the credit cards for the patient responsibility.  She has been posting, too, but this takes time and we will have the billing people do this soon.   We would have the billing people do the credit card billing, but they do not have the capability to do that, and I am not sure the patients would trust us with their credit cards if they knew someone else had access to them. I don’t think it would be fair to post my financial data at this point, since we have only been working for 5.5 months, have only been able to submit bills to about 2/3 of our patients’ insurances for 3.5 months, and just submitted the last 1/3 of our patients’ bills in the last week, but it is pretty clear that I will net as least as much as I did in the hospital system scheduled  at 28 - 30 hours a week with patients, and I also have the capability of earning additional money doing computer and EMR consulting, which was not an option when I was an employee.   I am actually putting in quite a bit more total hours now than I did as an employee, but lots of it is low-stress setting up accounts in the EMR, resizing patient’s photos, answering faxes, building computers, and so on.  Once I have all 800 of my current patient list set up with accounts and have all of their paperwork scanned, it will free up about 10 hours a week that I can use doing EMR consulting.  I will also have the freedom to drop poorly-paying insurance companies, and  even to do a limited number of consults, which I am avoiding until I pass my lipid boards in May.  Sometime in the next few months, I will be able to post the financial specifics, especially related to the in-house labs I do.  Having Eva as an unpaid, “volunteer” worker obviously makes a tremendous difference in the overhead, but we are getting to the point where she doesn’t have to be in the office all of the time.  Also, not having to borrow any money to start up,  not having to pay any more rent than  our routine house payment, and having a pre-established patient panel makes a huge difference, too. I apologize for the length of this post, but I have trouble being succinct, and for some reason felt a need to do a brain dump about the practice today. Happy New Year to all.   T. , MDSammamish Diabetes and Lipid Clinic, PLLCA medical home for patients with cardiovascular risk.           From:  [mailto: ] On Behalf Of  EglySent: Thursday, January 03, 2008 7:55 AMTo:  Subject: Re: INR Machine :  Also, interested in how you established your cholesterol and diabetic clinic.   Watch “Cause Effect,” a show about real people making a real difference. Learn more