Technology for Small Medical Offices

How Not to Sell Software

Further to my rant in the previous post regarding the difficulty in getting pricing and full information about medical office software without a sales visit, check out this excellent article by Alex Payne, How Not to Sell Software in 2012.

 

Patient Scheduler Requirements

Probably the most work on my part went into choosing a patient scheduling solution.

Remember, we're not using electronic health records; most EHR systems include a scheduler or have one available as a module to their system. If we were using an EHR, the efficiencies gained by using its scheduler would have been definitely worth checking out.

There are no shortage of solutions in the appointment scheduling space, but it still took quite the search to find one that would fit well with my wife's practice. Here are some of the things I was looking for.

Integrated Patient Database

I've seen too many clinics operate with patient information either in paper charts or an electronic record of some sort, and appointment bookings done in Microsoft Outlook. This makes all the middle managers in these organizations who live in Outlook happy, but sucks for clinicians. You want to be able to do things like book an appointment for someone, or look up their info from the calendar, without a lot of manually copying information back and forth.

Available On-Site and Off-Site (Securely)

The reality of a very small medical office is that there isn't always someone in the office 12 hours a day. However, plans change, which can necessitate changes to the schedule. Therefore, having access to it from off-site, and being able to change appointments or look up patient phone numbers to get in touch with them last minute is extremely useful.

Similarly, on-site it was important to be able to look up patient information or view and change appointments both from the doctor's office and the reception area computers. 

Right off the bat this helped steer me towards a hosted, Software-as-a-Service (SaaS) type service, as opposed to one where we'd install software on one of the office computers.

Security was of course important. While clinical information isn't being stored in this system, a lot of patient identifying information is, and that has to stay private.

Configurable and Easy-to-Use

This was a big one, as you can imagine. A system that was painful to use or took a long time to do things would be a constant irritant in even a small practice.

Configurability was important, as most of the scheduling solutions out there are very general purpose (good for anything from medical practices, to courses, to spas, to personal trainers and more). Some of the things we wanted included:

• being able to set open/closed hours in calendar, flexible appointment times and lengths, and mark exceptions
• schedule both patient appointments and other non-patient reserved times
• track an appointment history for each patient (including no-shows)
• have the terminology reflect the type of practice (e.g. 'patient' vs. 'customer')
• record a full range of information on each patient (referring doc, health number, addresses, multiple contact numbers and privacy preferences, etc.)
• track and differentiate between current (active), past and pending patients
• basic reporting, including daily appointment sheets and active patient roster
• day/week view on calendar, and quick access to phone numbers and common operations (e.g. confirm an appointment)

Affordable and Easy to Purchase

These were secondary things, and certainly would have been sacrificed if the above issues weren't met.

But, in my mind, there is no good reason that she should be shelling out hundreds of dollars a month (plus training, setup consulting, etc.) for a "medical office" appointment scheduling system unless it works a hell of a lot better and saves a lot more time than the more general scheduling tools that typically cost between $10 and $50 a month.

Plus, good luck trying to even find pricing and basic information on most systems that doesn't involve a sales guy coming out to present their "solve-all-problems practice solution". I know doctors can easily afford the considerably higher prices associated with this direct sales model, and many are willing to pay just to not have to think about it. But really, does this need to be the way it is always done?

Okay, just needed to get that off my chest.

Non-Requirements

There were a few things we didn't need.

First was the ability to have patients book their own appointments, e.g. over the web. Fantastic for a lot of businesses, usually not so good for specialist physicians. This is a big area of focus of course for most of the SaaS scheduling systems out there, but we just didn't need it.

Mobile integration was another area that we didn't really need, though it would probably fall under the "well if it was there and really easy then okay" category. While my wife does use an iPhone, she's not permanently glued to it. YMMV.

And the Winner is...

Like I said, I looked at a lot of systems. Next time I'll tell you what we actually went with, and some of the tradeoffs involved.

 

Computer Gear

Given the choice to go with paper charts, there weren't a ton of constraints when it came to the type of computing gear that the office would need.

Given I would be the one maintaining it and/or getting called when something wasn't working right, it was a pretty easy choice to go with a Mac setup.

For the reception area, we got a base 21.5" iMac, and for my wife the doc we got a 13" MacBook Pro. The various networking gear was chosen mostly because it would work well with the RingCentral phone system. We did set up a protected wireless network, which the MacBook uses, and also her iPhone.

We're also using Apple's address book application to keep track of contact info for various doctors and other people she works with (though not patients; we'll take more about that another time). That gets synced between the iMac and the MacBook (via a gmail account used just for that purpose).

Reports, etc. are kept on the iMac, which is shared over the network to the MacBook. In addition, we picked up another hard drive we stuck on the iMac for Time Machine backups. We take offsite backups, stored at our home, just via a flash drive. The front office got a Canon laser multifunction printer (double-sided), and we also got a cheap color inkjet MFP we put in the doctor's office.

Software-wise, we're just using normal things like Apple Mail and Safari. For reports etc. I decided to install NeoOffice (an OpenOffice derivative) rather than Microsoft Office, mostly because I can never find what I need in the user interface in the newest Mac version. No problems with that choice.

I also set up a screen sharing application (join.me) on the iMac, so that if the receptionist runs into trouble, we can just use that to troubleshoot the problem rather than me needing to come in. After the first little bit (the person we hired hadn't worked on a Mac before), we haven't needed to use that much.

Here's a peek at most of the gear we got, taken when I was configuring everything at home before we moved her into the office. This is in my home office, so some of the stuff is my own equipment. Needless to say, after tripping over boxes and cords for a week or two, I was glad to have her stuff taken over to her office!

And just a brief aside... I was at my dentist's yesterday. They've already got a lot of technology there and are pretty advanced compared to other dentists I'd gone to. But, they were in the process of taking the last steps to being completely paper-free when it came to patient records. What chaos! Everything took longer, not only due to learning curve, but just that some steps were more convoluted than they would be by hand. I had to jokingly ask the staff if there was going to be time to clean my teeth at this appointment!

Needless to say, I hope my wife doesn't suddenly have a change of mind and want to go that route with her practice!

 

 

Paper Files. There, I Said It.

Paper charts for patients or an Electronic Health Record (EHR)? For my wife, a psychiatrist, this was a no-brainer.

In her practice, the bulk of her sessions are longer appointments, where she does a combination of medication management and psychotherapy (yes, psychiatrists in Canada, who don't need to deal with HMO's, can actually bill for doing psychotherapy). Her notes on the initial consultation (e.g. patient history) can also be pretty wide-ranging, and cover a lot of ground very quickly.

So why paper? Two main reasons. First, much faster "data entry". Second, it's a lot easier to develop and maintain a therapeutic relationship if you're sitting and talking to someone and subtly writing notes as compared to talking to them over a desk banging on a computer. In the former situation your attention can be on the patient, while in the latter it is all too often on the computer, especially making sure that all the right things go in the right fields.

Now my family doctor uses an EHR, and so our appointments consist of him typing away on his laptop while we discuss things. He's a very good doctor, and I appreciate why he uses those tools, and think most of the time they are a help.  But particularly if there were topics that were more emotional, I think it would get in the way.  

As an aside, despite me being a techie, a lot of my grad school work was in Human-Computer Interaction (nowadays usually called 'User Experience'), so I have some biases against any tools that get in the way of the task at hand. Plus, paper is a pretty versatile tool.  Google 'affordances of paper' sometime.

From researching various EHR options, I think for her particular situation, going the full electronic route would be a complete disaster, in that any inefficiencies in sorting through paper files would be dwarfed by the training and productivity hits associated with fitting her work into the software's more rigid system and interactions.  I'm sure I'll have much more to say on EHR software another time.

 

Internet, Phone and Fax

Despite this being 2012, communication in most Canadian doctor's offices still revolves around phone and fax. 

Having said that, it doesn't mean you have to go to the phone company, get them to activate a few phone lines, plug a fax machine into one, and some phones into the others. And especially when you start looking at various telephony features useful for businesses, this can start getting both painful and expensive.

In the olden days, that would mean plugging your own office phone system into those phone company provided lines. Nowadays, you can run things over the internet using "voice over internet protocol" (VOIP) technology, and run a "virtual" phone system (where you don't have any equipment beyond the phones themselves), outsourcing the whole management of the phone system and its features. 

Look ma, no phone system!

There are lots of companies that provide these services. We picked RingCentral, and in particular their "RingCentral Office" cloud-based phone system as they call it. We bought three Polycom IP phones up front (plus a ATA, which I'll come back to), plus some network gear, and then for $132 (CAD, incl taxes) per month, we've got effectively six different phone numbers (two of which are publicized, the rest are internal and let us ring particular extensions directly), multiple incoming lines per phone number, plus all the minutes we need, a wonderfully configurable phone system with all the business telephony features we'd ever need, etc.

With this kind of system, rather than plugging a telephone cable from the phone into the wall, we connect each phone to a network router via an Ethernet cable.

This does of course need an internet connection to run, so tack on another $60 for business internet service from the cable company, which we of course can use for other things too. 

One of the nice things about a cloud phone service is you can get at everything remotely. There are web interfaces, desktop interfaces and smart phone interfaces to get at the system, configure it, and pick up voice mails. We also have things set up so that all voice mails are sent to the office email address as attachments. So the email inbox is also the voice mail inbox. Again, all completely configurable. So we've set things up too so that even though there are different phone numbers, all of the voice mails get dumped into the same voice mail box.

Send this telegram... err, fax...

The evil faxes are also handled the same way, automatically coming in as emails with the fax contents being a PDF attachment. So they can be printed if necessary, but not necessarily printed. It's also easy of course just to forward them around to another email address.

Outgoing faxes can be sent through a email to fax service provided by RingCentral. Essentially we just need to create a regular email, attach the pages of our document to send as PDF's, and send the email to a special email address that contains the fax number of the recipient. Way easier than printing things out and sending them through the fax machine.

But speaking of which, we can still send faxes from paper without scanning them into the computer and emailing them. The main office printer is a multifunction printer (MFP) which includes fax capabilities. Of course, these are analog using a regular phone line, which wouldn't jive well with the digital phone system. A special box called an Analog Telephone Adapter (ATA) lets you connect your analog device to the system. So then we can use the MFP to send faxes the old fashioned way.

As an aside, we use RingCentral's 'Mobile' product for our home number, and have done so for a long time. We'd set it up when we were first starting to plan our move from Ontario to Alberta. We got an Edmonton number and just had it ring whereever we happened to be at the time, which changed quite a bit as we jumped between a couple of short-term locales before we bought our current house here.

Other Internet setup

The phone system requires a wired network, though at least the phones have a little hub in them so that you can run the long Ethernet cable from each phone to the main hub, and then just plug each computer into the phone. We've also got a (protected) wireless network running, which is used for the doctor's laptop, as well as for our mobile devices (e.g. iPhone).

Email was set up using an existing service (via IMAP) that we were already using on our own domain name, with one "public" email address that everyone gets, and some private email addresses which are used mostly to route things internally.

Any downsides of settings things up this way?

Admittedly, the quality of VOIP phones can be a bit less than regular phone lines on occasion, but with a decent internet connection and decent network configuration, this can be greatly minimized. If you've never set up a network before you'll need to worry about things like purchasing hubs and/or switches, along with lots of network cables. RingCentral has good recommendations on their websites and instructions how to set things up, but its still not for the faint of heart.

Actually configuring the system (setting up phone lines, etc.) which is all done through the web interface can also be a bit complex, but the staff at RingCentral set up an appointment with you to figure out your needs and help you get all this working. We didn't use this because we were already familiar with the basic RingCentral service from using it at home.

And of course, the learning curve to use any business phone system is higher than it probably needs to be, but the Polycom phones we bought from RingCentral have nice large displays and lots of dedicated feature buttons that make this easier. I think it will be a while (if ever) before I install the desktop based "Call Controller" application for them to use.

Oh, and the one thing that still pisses me off about RingCentral's service is that they don't support Busy Lamp Field (BLF) which would show on the receptionist's phone that the doctor is currently on the phone with someone else.

Phew!

Anyway, enough about that, but I'd be happy to provide more details on any specific piece.

 

 

 

Basic Needs

Let's get some of the basics out of the way first.  

In her office, there is her and her admin assistant. The clinic has a large waiting room and two private offices, one used mostly as a break room and one used as a combination personal doctor's office and interview room.

Before choosing technology, we first need to figure out what sorts of activities needed to be supported. Here is a sample:

• receive and make phone calls, handle voice mails, etc. (booking appts, communicating with other doctors, etc.)
• receive and send faxes (this is worth a rant on its own, but the fact is, particularly for private medical offices, around here almost all communication is still done by faxes)
• email and web access (you think doctors don't look everything up on Google?)
• some way of scheduling and managing patient appointments
• some way of creating, updating and otherwise managing patient health records
• dictating and transcription of reports
• access to lab results and selected other reports; in Alberta, all lab results get posted to Netcare, the provincially run electronic health record (EHR) system, which contains only a subset of information on patients
• billing the government for medical services
• general business needs (e.g. accounts payables, bookkeeping, etc.)

Psychiatry is pretty light on specialized equipment; after all, the only "procedure" they can bill for is electroconvulsive therapy (ECT), which due to the anesthesia requirements is not done in your typical outpatient setting. But some standard tools like a basic blood pressure cuff and scale are handy to have.

Next post I'll cover some of the basic communication choices (internet, phone, fax) before getting into one of the big decision points: paper or electronic charts.

 

Pity the Poor Doctor

Pity the poor doctor. Not likely you say, but when it comes to technology, I'd like to convince you otherwise.

I'm a tech guy (software developer) and run a business doing that. My wife is a doctor (psychiatrist). I've known her since before she got into med school, so I can say with some confidence that the practical aspects of business and technology were not part of her med school or residency training. 

She finished her residency in 2004, and until recently she was working at various hospitals.  About six months ago, she opened up a new private practice here in St. Albert (a bedroom community of Edmonton, Alberta, Canada).

Other than getting to pick out furniture (no couch, but several comfy chairs), I'm pretty sure that she would have loved to be able to just snap her fingers and have everything else magically taken care of. Things like finding an office, lease negotiations, insurance, hiring an admin assistant, registering the new clinic with the provincial health bureaucracy, change of addresses, office supplies, stationary. Oh yeah, and technology.

I offered to help her get things set up (this gave me the leverage to ensure she got a good coffee machine). While I'll spare you the details about assembling furniture and hauling garbage, I do want to say a fair bit about the technology that is available, what we picked (and why). Hence, this blog.

Off the top of my head, some of the things worth discussing are phone systems, faxes (what century is this?), scheduling, dictation, patient records, contact management, billing, social media, privacy, computers, peripherals, and networking. Among other things.

The reason I want to talk about it is because most of this stuff is a real mess, an expensive and more importantly, time-consuming, mess. My wife is like most doctors we know who just want to be able to take care of their patients, and the last thing they want is crap like technology (or bureaucracy, or politics, or...) slowing them down when they're trying to do that.

So if some of what I have to say helps save some doctors some time, frustration, or poor choices, that's fantastic (especially for their patients). If I can learn a bit more about what else is out there, and perhaps how to make it a bit better, or fill in some of the gaps, that would be great for me too.