The Great Practice Makeover: Just Like Starting Over

When he launched his solo family practice in 1995, Roy Gondo knew that to stay afloat he’d have to have to work long, hard hours and look for ways to save money. It’s hardly surprising, then, that he enlisted help from his wife, Angela, to handle much of the practice’s administrative functions as well as play a role in marketing and building a patient base.

Nearly nine years later, Angela Gondo is still (unhappily) the practice’s de facto office manager, and both Gondos are up to their elbows in backlogged patient charts and billing. Angela has begun to wonder whether it wouldn’t be better if her husband took a full-time position in another clinic. An office where he’d have a steady salary would be nice. And regular vacation time. “We used to go to Hawaii,” she says wistfully, but the Gondos haven’t been able to take a break from their practice in Yakima, Wash., in five years.

As for Dr. Gondo, he isn’t ready to give up on his practice just yet, but he does worry. “I enjoy solo practice, but I don’t know how long I can do this without it being taken away,” he says, citing the increasing burdens of regulation, pay-for-performance, and the like. A series of disastrous staffing decisions - one of which resulted in a draining legal battle over unemployment benefits - compounds the questionable long-term viability of this practice.

The Gondos needed help. Fast.

When Physicians Practice brought The Great Practice Makeover to Gondo’s aid, we found burnout looming. In addition to putting in packed days at his own clinic, Gondo serves as medical director for a prison and chief medical consultant in a psychiatric hospital. Angela Gondo routinely works until at least midnight six or seven days a week. Rhea Peralta, a medical assistant who worked in the practice from 2000 to 2003, suspects Angela sometimes spends the night there.

Both Gondos feel completely responsible for every detail of the practice’s operations. That’s understandable. It is, after all, their business. Still, Dr. Gondo is going to have to be willing to cede some control to avoid total burnout.

With a good referral base in the area and their modified open-access schedule filling up daily, it’s time for the Gondos to take a step back from the minutiae of everyday business operations. Some significant tasks have languished far too long while Gondo’s attention has been scattered over a myriad of concerns.

Charts, Charts, and More Charts

They’re piled on nearly every available surface throughout the back rooms of the practice. Yet Gondo’s office is well stocked with computers, printers, and all of the other technical accoutrements of a modern, digitized practice. In fact, Gondo has a fully functioning EMR. Yet he is drowning in paper.

The solo doc installed his EMR six years ago but didn’t fully begin the process of implementing it into his workflow until last year. That’s like buying a car and leaving it in the garage while you procrastinate learning how to drive. This five-year lag provides an insight into the practice’s overall ineffectual implementation and planning processes - and how easily Gondo’s focus is diverted by other concerns. Gondo says he’s happy with his Amazing Charts EMR, and he praises the openness and accessibility of company founder Jon Bertman.

So why are nearly 200 charts (almost one-tenth of the practice’s patient panel) occupying cardboard boxes that line the hallways and lie stacked on multiple desks? Because Gondo sees roughly 20 patients a day, but then completes only three charts. That backlog has quickly become a huge problem for the practice in terms of work flow, space, and billing.

The chart backlog also creates redundancies. When a specialist to whom Gondo has made a referral calls the practice with findings, staff members often have to search through the stacks for the patient’s chart. Occasionally a patient arrives for a follow-up appointment before the note from his or her initial visit has been completed.

We discussed Gondo’s chart backlog with Bertman; if anyone could explain why the practice isn’t taking full advantage of its EMR, we figured the EMR vendor’s founder could. Bertman told us that a learning curve and subsequent backlog and catch-up period at the beginning stages of an EMR’s implementation are to be expected. But it’s clear that at the bottom of Gondo’s sea of charts is his inability to complete a note during - or even relatively close to - a patient encounter. “It’s painful sometimes,” Bertman says, but the key to getting a handle on those records will be having the discipline to complete as much of each patient note as possible (ideally all of it) immediately after each visit or while the patient is still physically in the exam room. Patients may have to wait a little longer for their appointments, but it’s in the name of better service and documentation.

Gondo is a competent typist, so Bertman sees no reason he shouldn’t be completing encounter notes on the spot. Part of the problem is the physician’s own perfectionism.

When a patient arrives, Brenda Pearcey, the practice’s current medical assistant, pulls up that patient’s record on the exam room’s desktop screen. She overwrites the previous history and plan, checking on any needed lab work and making notes to give Gondo details on the reason for the visit.

So far, so good.

When Gondo comes in, he too sits at the computer and enters information into the EMR. At the end of the visit, he sends prescriptions to the printer at the front desk. So what’s left to be done that can’t be accomplished in the few minutes that Pearcey is rooming the next patient?

His Own Worst Enemy

When pressed for an answer, Gondo says he’s fine-tuning templates for retrieved information, replacing abbreviations, and fixing spelling errors. Bertman is blunt: “He may be being too anal retentive about his notes,” he says. Spelling accurately and avoiding abbreviations are obviously crucial when writing prescriptions, but Bertman’s own experience suggests that with “less documenting and more quick assessment, I can write a note I’m proud of.”

And what about those templates? If you have to scroll through your computer screen to view all the templates on your list, chances are you have too many. Bertman advises keeping templates broad enough to allow for quick modification during a visit. Don’t use gender-specific pronouns, and try to make each template generic so it can be used for a number of conditions. And avoid redundancies. For example, rather than typing out, “discussed sore throat and need to call me if symptoms don’t go as planned” - written in a template for sore throats - simply type “discussed the diagnosis … ”

Taped to the door of Gondo’s private office is an upward-trending graph that tracks how many patient records are awaiting completion. Rather than wasting time charting exactly how far behind he is, Gondo needs to get down to business. A glance at those cardboard boxes in the hallway ought to be a detailed enough reminder of the work that needs to be done.

“If I have any spare time, I work on the charts at home,” says Gondo. How much progress he makes there is debatable. With two young children - ages 2 and 4 - extra minutes are no doubt extremely difficult to come by. Weekends and holidays hold the promise of more time, but that time tends to be eaten up as other domestic tasks arise.

Angela Gondo thinks her husband should simply take two or three weeks off from his work at the prison and psychiatric hospital. They’ve even discussed bringing in a locum tenens physician once a week or so to allow Gondo more time to work on completing his notes.

But both of these fixes would be temporary at best - like paying off your credit cards with a home equity loan and then falling right back into debt - unless Gondo is able to bring himself to complete his patient notes during actual patient visits.

If it proves impossible for Gondo to complete notes during or immediately after a patient visit, he can always use the “fourth exam room” concept to catch up after every few appointments. Using this model, after each third patient encounter, Gondo would “schedule” an appointment with his charts, giving himself 15 minutes or so to finish up charting the patients he just saw, and then move on to the next patient visit. Or Gondo could do his paperwork at the end of the day, remembering that any chart left unfinished at that point will cost him, and once again he’ll fall back to spending his time organizing his workload rather than doing it.

How does Gondo fare in charting patients he sees at the prison and psychiatric hospital? Brilliantly, according to his wife; she says he finishes those charts almost immediately - because his employers require it. It’s as if he feels more of a responsibility to these other care settings than to his own practice.

Although Gondo originally took on these additional jobs because, as he says, “You gotta hustle to make it in solo practice,” it’s no longer clear that such moonlighting makes financial sense. Focusing more on his own practice and seeing more patients there may be a better bet.

Technologically Impaired

Under-using his EMR isn’t the only tech issue bogging down Gondo’s practice. But as in other areas, this physician’s approach toward enlisting help is piecemeal. At least two consultants and a series of technology experts of varying stripes have spent time in the practice over the past few years. One advocated more robust billing by integrating the office’s practice management and billing systems. Sound advice - and Gondo knows it - but he hasn’t acted on it.

Instead, he’s been trying to get his e-fax system up and running for the past six months.

And then there’s a printer/fax/ scanner in the office that’s not yet fully operational; implementing a scanning process for incoming documents has also been occupying Gondo’s thoughts.

“I would like to find a system in which we could go totally paperless and start archiving everything,” he says, mentioning that other practices in the area are also confounded by how to “really eliminate a need for paper charts.” It’s not at all clear, however, that going completely paperless is feasible for Gondo - or even advisable.

Most physicians we know who are happy with their EMRs don’t scan every piece of paper that comes through the door or sits in old chart folders. Bertman, for one, scans only the key items he wants to be able to flip through. Digitizing only consult notes is a much more sane approach than trying to capture every EKG and phone message within one’s EMR.

Even though he’s unable to make the most of the technology he already has, Gondo talks about improving electronic communications with his patients. He’s applied for a Qualis Health grant to make more tech upgrades, and he mentions the possibility of allowing his patients to schedule their own appointments online. As if all that weren’t enough, Gondo holds up a digital camera he’s been trying to use to enter patient photos into his EMR. He hasn’t been able to establish a process for doing that, either.

Quite understandably, Gondo says he can’t keep up with current technology, and he feels as if he’s drowning in it. This physician clearly thinks he should adopt every new gadget on the tech market, even if he has no idea how it might actually benefit his practice. As with the charts, Gondo’s attention appears completely fractured. No wonder he can’t find the time to finish a note.

In spite of all the gizmos lying around Gondo’s office, some tech-enabled fundamentals are sorely lacking. The practice is a month behind on its billing and an alarming three months behind on posting. Part of the problem is that Gondo trusts no one other than Angela to handle the practice’s financial data. With daily office management falling to her as well, she simply has too much on her plate to keep up.

Add to that the fact that Gondo uses a 10-year-old version of Medisoft to generate his billing. That leaves Angela lacking some very basic capabilities that would make her life much easier. For example, with the tools she has, she is unable to bill Medicaid or secondary claims electronically, and electronic remittance and denial tracking is next to impossible with her outdated system.

Ken Kark, vice president of sales for Per-Se Technologies, which owns Medisoft, assures us that the newest version of the product allows e-billing to virtually every payer, and it includes features like integrated eligibility verification. He also promises that the data Gondo’s practice has captured in the old Medisoft version he still uses will translate to a new one. Even if a hardware upgrade is required - the office’s computers are three to four years old - the relatively small investment in upgrading his billing software would be more than worthwhile in terms of the potentially dramatic increase in speeding the practice’s billing and collections. Gondo should jump on this relatively easy method to eliminate at least some of the paper he has floating around.

Additional basic tech issues need to be addressed before Gondo can launch more complex technology. The practice is still working on its ability to allow for debit card payments from patients. The Gondos know they need this capability, but as with other processes, it hasn’t yet materialized. Simple upgrades like this one can directly increase the practice’s cashflow, and thus should be given priority status.

In a perfect world, Gondo himself wouldn’t be personally responsible for implementing these types of upgrades. As the physician and owner, he certainly needs to know what’s going on, but because the details of smaller projects are draining his attention, he should delegate them to a staff member. However, the practice retains only two staff members in addition to Angela - a medical assistant and a receptionist, both of whom are new to the office. (More later on Gondo’s staffing difficulties.)

All Things to All People

Gondo is very much a family doctor, happy to be practicing within a close-knit community. But there’s an inherent tension between that small-town-doctor style he prefers and the demanding reality of 21st-century medical practice. Pearcey cites as a major work flow obstacle the fact that Gondo tries to address patients’ every concern each time they come into the office, often dealing with “a grocery list of problems,” regardless of the ostensible reason for the visit.

As we discuss this issue, Angela points out the chart of a patient whose recent unscheduled procedures won’t be reimbursed because the practice characteristically failed to obtain the necessary authorizations beforehand. She reminds Pearcey to try to help the doctor remember not to perform unscheduled procedures.

An elderly man then enters the office, complaining of a head injury. His visit takes nearly an hour, not because of Gondo’s concerns about the patient’s injury, but because the man wants to discuss his medication list, his gout, and so on. The patient’s lengthy medication list includes a couple of drugs prescribed by another physician that Gondo can’t readily identify. He leaves the exam room to embark on a search for information on the drug among his many stacks of papers and books piled on each available surface. (Why he did this is a mystery, as every exam room computer has Internet access.)

Later, with another patient, Gondo leaves an exam room to search for a medication sample. Rummaging through drawers is not a good use of his time. Instead, he should communicate to Pearcey what he needs, letting her pick up tasks that fall within her scope of work to allow him to focus on tasks that fall within his. It’s great that Gondo has set up one of his exam rooms to more easily allow for procedures, but that doesn’t mean he should be performing them as soon as patients bring up any minor issue. Why? For one, Medicare pays for only one procedure per day per diagnosis. Wanting to help every patient on the spot is laudable, but not always realistic. And overloading each appointment isn’t helping that charting backlog, either.

“There’s no problem with the patient care here,” Angela Gondo says. “How to get the system working is the main thing.” But “the system” can’t be separated from good patient care. The practice’s all-things-to-all-people manner of care delivery hinders the implementation of any sort of system - and that, in turn, does inevitably have some impact on patient care. It’s time for Gondo to start thinking of the business of medicine as entwined with the practice of medicine - rather than perceiving business-imposed constraints on health care delivery as an insurmountable barrier.

Scheduling a follow-up appointment to discuss a patient’s hypertension if he’s currently in your office for a work-related injury doesn’t constitute poor care. But lumping such a complaint in with the documentation for the injury, as Angela Gondo tells me her husband has done, isn’t good for the practice’s reimbursement or the patient. She feels the practice needs to find a way to respectfully let patients know they’ll have to come back to address concerns beyond those they came in for. “We’ll need to schedule you another appointment to allow us to give that issue the full attention it deserves” ought to be a phrase Gondo teaches his staff to use.

Sometimes, of course, it does make more sense to address all of a patient’s issues in one sitting, provided Gondo documents everything. If he spends more than 50 percent of a visit consulting with a patient, he can bill by time - that is, at a higher E&M level. Rather than billing a Level 2 code twice on two different days, he can bill for a more complex Level 4 or Level 5 visit.

Staffing Headaches

In the beginning, it was one line on Gondo’s Practice Makeover application that led Physicians Practice to his doorstep: “All my staff walked out on me five weeks ago.” A scenario like this is the stuff nightmares are made of for many small business owners. Even considering the charting chaos, both Gondos say staffing is their biggest stressor.

A mass exodus might have everything to do with the employees, not the employer, as Gondo says is true in this case. (Litigation is ongoing.) The practice has had trouble retaining staff in the past, however, so it’s difficult for us to sort out this specific situation. In any case, it’s always wise to hold exit interviews with departing staff members to examine their reasons for leaving. (These can be useful even in cases in which an employee has been dismissed.)

A word on the spouse as office manager, about which we atPhysicians Practice hear a lot: Although this works amazingly well for some families as a permanent arrangement, it’s usually best employed only as a stopgap. When a spouse fills the top management role, the vested interest that person has in the practice can lead to undue interference with other staff members’ activities. The physician is busy taking care of patients - or should be - but the spouse must deal daily with employees who might not perform revenue-enhancing tasks the way the spouse would. It can be difficult for staff to take concerns to the spouse, too, leading to the physician’s over-involvement in human resource matters.

The Gondos are at a turning point - the practice has become busy enough for them to evaluate where their family business is headed, and under whose stewardship. In fact, Angela says she’d like to step away from the practice within a year. For now, Gondo seems to have conflicting feelings when it comes to his wife’s presence. Angela has no clearly defined role in the practice’s day-to-day operations; she doesn’t even have a firm job title. Although Angela refers to herself as the office manager, Gondo says she is the “acting business manager” and has apparently told previous employees that she is not the manager. Although a consultant has helped the practice revamp its policies and procedures manual, the practice’s list of job descriptions doesn’t include one for an office manager (or business manager).

“I do too much in the office,” Angela says. “I have a habit of covering every area because I was doing it at the beginning.” Peralta, the practice’s former medical assistant, notes that the office had become an extremely stressful, chaotic environment by the time she left three years ago. Angela knows this, and she wrings her hands as we talk about the practice’s various operational hiccups.

The Gondos say their previous staff - those in the round after Peralta left - often used divide-and-conquer methods. As Angela puts it, “They ganged up against us.” The physician, though, doesn’t seem to recognize that he’s enabling this behavior by not supporting Angela. While Angela remains in the practice, Gondo needs to back her up 100 percent, which may mean spending more time after hours strategizing as a team.

Angela, who offers insight after insight into the practice’s operations during our conversations, may be better suited to a strategic planning role. She points out that her husband needs to help the staff to function as a team, saying he “is the captain, and he needs to set the direction.” She repeats this plea for focused leadership several times during our conversations. But this ship’s captain is occupied with serving the passengers cocktails - worrying about details like punctuation, office supplies, and the mail - rather than steering the ship.

Staff-wise, things are looking up now, but Gondo will have to radically change his habits if he hopes to hang on to his two new employees. Nina Ocampo, the practice’s friendly receptionist, had been at the office for only a month at the time of our visit and already was a patient favorite. And the fact that she’s bilingual is invaluable in the practice’s culturally diverse region.

Pearcey, who has more than 20 years of experience as a medical assistant, is helping Gondo get the exam rooms in better order, improving follow-up tracking of patients through a calendar program, and implementing process improvements wherever she can. She’s been with the practice for three months, and Gondo plans to eventually give her more management responsibilities.

He may have been forced to do so in the past, but when Gondo opens the mail today - a favorite pastime, according to Angela - it’s a source of frustration for the staff. They know that while he’s reading the mail, other tasks remain undone.

Laurie Hyland Robertson is a managing editor for Med-IQ, the parent company of Physicians Practice. She has been in the medical publishing field for nearly 10 years, working editorially on both clinical and management topics. She can be reached at lrobertson@med-iq.com.

This article originally appeared in the October 2006 issue of Physicians Practice.