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Opening Solo Practice, Internal Med, Cash Only – EMR choices

Home Practice Management Opening Solo Practice, Internal Med, Cash Only – EMR choices

  • Avatar jblankenshipnc 
    Participant
    Status: Spouse
    Posts: 5
    Joined: 05/06/2019

    Hello WCI family.  My wife will be opening a solo practice this year, and I’m the “tech” guy (and spouse).  I plan to setup the website, emr, back office, and all things tech.  Our plan is to be a direct pay office (no insurance initially), and initially plan to be open 3 days per week, 10-15 patients per day.  The focus will be on nutrition and lifestyle medicine (obesity, diabetes, sports performance, etc…)

    Some of our criteria for software:

    – Cloud based – this serves multiple purposes, 1. No software/hardware to maintain;   2. Access from home or office

    – Prefer 1 application to “do it all” if that is possible – EMR, cash billing/payment, appointment scheduler, and office management

    – Minimal Cost – not sure what is a reasonable expectation here, but Practice Fusion was very appealing at $0/month; However, even at $100/month it seems reasonable if it can replace a front desk person for scheduling and appointing reminders

    – e-Prescribe

    – Lab Integrations

    – Charting

    – Appointment scheduling, patient ability to select their own, reminders, etc…

    – Office Management

    Those are a few that I’m aware.  I’m sure some of you will be able to provide some guidance on other features that may be or may not be important.  Since price will probably drive our decision, here are a few that I’ve looked at:

    Kareo & Atlas – $300+/month – expensive

    Praxis – $250/month

    DrChrono – $200/month

    OpenEMR & OpenMRS – $200/month I have no interest in downloading, installing, maintaining our own webserver, and it appears any 3rd party hosting provider is $200+/month

    I have not ruled out the above even though they are $$$ that the choices below.  If they will eventually save money due to their usability, integrations, and efficient, then the extra $$ will be worth it.  However, if I use Practice Fusion as the standard at $100/month, then do the above provide value for $200+ more per month?

    Others that I come across and curious if anyone has any experience or recommendations :

    Practice Fusion – $100/month – Seems many are looking for alternatives since it moved to $100/month from free – but is it still the best deal?

    Office Ally – $30/month

    CharmEHR – $/per encounter – based on her volume, I “think” this one should be $100/month or less

    Therapy Notes – $50/month – geared for Mental Health, so I’m unclear if it would be a good fit, but seems to get good reviews, and price is right

    Simple Practice – $50/month – another mental health solution – so, again, I’m unclear if it would be a good fit

    Solismed – $50-$80 month – free EMR, but provides a paid HOSTING solution – $80 if you use your own domain name

     

    I’m looking for advice from the community on your experiences or evaluations of any of these applications, recommendations of other applications I did not list, and advice on my process for finding a good fit.

    #212626 Reply
    Liked by fiomi
    ENT Doc ENT Doc 
    Participant
    Status: Physician
    Posts: 3454
    Joined: 01/14/2017

    What kind of evaluation has been done to assess the viability of this business model?  If everything checks out then more power to you.  But with increasing deductibles/premiums there’s less flexibility in people’s budgets to pay money to someone they don’t need to – particularly for soft items like nutrition.  Just my opinion.  At least with someone accepting insurance they can work towards meeting their deductible.  With your model they get no additional benefit.  Do you really think you’ll be able to cover expenses with 10-15 patients a day, 3 days a week, with the pricing power you’re going to have as an add-on service?

    As for EMRs, have you considered just paper charting?  If you don’t accept insurance, particularly Medicare, you aren’t subject to coding standards and aren’t coerced into EMR adoption via payment reductions.

    #212638 Reply
    Avatar Dont_know_mind 
    Participant
    Status: Physician
    Posts: 909
    Joined: 11/21/2017

    I use paper, excel spreadsheet for my diary and billing. EFT machine. If just you and wife, you can do payroll on an excel spreadsheet too. But I am in psychiatry. Not sure about IM.

    #212644 Reply
    IntensiveCareBear IntensiveCareBear 
    Participant
    Status: Physician
    Posts: 235
    Joined: 12/22/2018

    Agree with above, I’d use templated MS Word +/- Dragon (can look pretty decent with the right headers, footers, borders) and some scanners. That is the”paper” charts nowadays… I don’t think handwritten is actually an option anymore, lol. Dragon can be good as an option, but it isn’t really even needed unless you have very slow typers or very verbose charters. Good and fast scanners for labs/tests/ID/receipts/etc are a huge key, though (whether you do EMR or not)… don’t go cheap on those.

    EMR is a huge purchase with recurring liability (at rates unknown to you). It’s not essential to any practice, least of all cash practice. Cash practice doesn’t get any bonus for having EMR and doesn’t have to get insurance audits; those are the reasons people are scared into EMR. You are really only charting for memory of what you did, doc-to-doc communication, and potential med malpractic reasoning (aka the way it should be).

    Billing cash pts is very straightforward in cash practic: collect it up front… or expect to never see 90% of what you don’t! Do everything you can to make it easy and mandatory for patients to pay while at the office; staff training is key. Collection calls could be outsourced if you’re uncomfortable with it and can find a place charging minimal, but again, most patients who didnt pay at appointment never will. You will probably find that is isn’t even worth the time and postage stamp mailing invoices 🙂

    You can save the word files and scans and etc on an access drive so she can work from home or access info in a pinch, but you don’t want to get in the habit of doing much of that anyways for QOL reasons. No reason you can’t get charts done at the office each day. GL

    "Hmm, that sounds risky." - motto of the middle class

    #212682 Reply
    Avatar jblankenshipnc 
    Participant
    Status: Spouse
    Posts: 5
    Joined: 05/06/2019

    ENT Doc – well, you certainly bring up a great point.  EMR software will not matter if you cannot make any money:)  She has worked in a 900bed hospital, on call every other weekend, and private practice for 2 years with call every 3rd weekend, etc, etc, etc..    The plan is to be a DPC, subscription model, with overhead at a minimum. Currently she works for a small salary 1 day a week, sees about 15 patients at a free health clinic, and was studying for Obesity Med Cert.  Obesity Medicine, Diabetes, will certainly be top of the list, but she is open to most anything in the internal medicine space.  However, catering to the obesity epidemic will be her “specialty.”

    Paper/excel charting is fine.  However, Office ally would do everything for $30/month.  That seems like a much better option that me putting and maintain excel sheets.

    #212684 Reply
    Avatar Radonlake 
    Participant
    Status: Physician
    Posts: 34
    Joined: 01/24/2019

    I think you/she needs input from DPC colleagues in regards to EMR. All these EHR/EMRs are geared towards billing insurance and compliance. I know several offices here in town use several of the ones you listed but I have yet to meet the one who likes theirs. All I hear is they are clunky, you spend lots of time clicking boxes and checking items to cover this screening, that compliance measure – which is exactly what you don’t want to do if you are DPC since you don’t have to do that acrobatics for insurers/CMS’s sake. We are a minimal overhead radiology practice so I cannot help with EHR – but we also found less is more in regards to “office management” software and do ours on Excel and paper. We tried some but it took the same time fiddling to make it work and to check it that is has done what it is supposed to do, than just do it. I would probably rather spend on bookkeeping and marketing – and keep administration to a minimum 😉

    #212726 Reply
    Avatar jblankenshipnc 
    Participant
    Status: Spouse
    Posts: 5
    Joined: 05/06/2019

    Radonlake – great advice.  One of our family motto’s is “less is more.”  I had not considered the fact that using an EMR and/or practice management software may actually create additional time/overhead.  I’m pretty handy with Excel, and have already created several spreadsheets for a Chiropracter friend.  Yes, I think marketing and bookkeeping would be money well spent.  thanks for the advice.

    #212739 Reply
    Avatar Dont_know_mind 
    Participant
    Status: Physician
    Posts: 909
    Joined: 11/21/2017

    ENT Doc – well, you certainly bring up a great point.  EMR software will not matter if you cannot make any money:)  She has worked in a 900bed hospital, on call every other weekend, and private practice for 2 years with call every 3rd weekend, etc, etc, etc..    The plan is to be a DPC, subscription model, with overhead at a minimum. Currently she works for a small salary 1 day a week, sees about 15 patients at a free health clinic, and was studying for Obesity Med Cert.  Obesity Medicine, Diabetes, will certainly be top of the list, but she is open to most anything in the internal medicine space.  However, catering to the obesity epidemic will be her “specialty.”

    Paper/excel charting is fine.  However, Office ally would do everything for $30/month.  That seems like a much better option that me putting and maintain excel sheets.

    Click to expand…

    What happens when your phone line or internet are not working?

    #212865 Reply
    Avatar Kamban 
    Participant
    Status: Physician
    Posts: 2421
    Joined: 08/01/2016

    10 patients three times a week doing just boutique cash pay patients will not be viable if you need things like EMR and billing software, which are both superfluous and also cost a lot to purchase and maintain.

    For those patients paper charts with MS Word noted on templates and Quicken Home and Business may all that be needed and affordable at that level of income.

     

    #212875 Reply
    Avatar Radonlake 
    Participant
    Status: Physician
    Posts: 34
    Joined: 01/24/2019

    EMR is a huge purchase with recurring liability (at rates unknown to you). It’s not essential to any practice, least of all cash practice. Cash practice doesn’t get any bonus for having EMR and doesn’t have to get insurance audits; those are the reasons people are scared into EMR. You are really only charting for memory of what you did, doc-to-doc communication, and potential med malpractic reasoning (aka the way it should be).

     

    Click to expand…

    IntensiveCareBear brought up a very important point – EMR is a liability. From the moment you start one, you are hooked. Changing EMR/billing software is about as painful as changing billing offices or accountants. They pretty much hold your charts hostage because it costs effort, time and money to transfer them – and they make that as difficult as possible. I would be very careful with committing to any before you have been in business for a bit and know what and how she will continue to practice. The practice has to come first including building up a patient base, fancy software, scheduling etc should come later in my opinion. Even the fanciest scheduling software, reminder calls, texts etc does not make the patients show up unless they want to. If you don’t get insurance payments and don’t come up with an overly complicated fee list, billing software is not really needed imho. Will you do payroll of any sort?

    #212909 Reply
    Lordosis Lordosis 
    Participant
    Status: Physician
    Posts: 1654
    Joined: 02/11/2019

    I agree if you are not taking insurance then you do not need an EMR.

    Be careful with this venture.  A classmate of mine tried to go this route and abandoned when she was not doing very much good.  Her main draw was the worried well and that was not what she wanted.  Those that were living an unhealthy lifestyle either did not come or when they did were looking for someone to give them diet pills.  Enough was enough and she is back to adjusting DM and HTN meds like the rest of us.  YMMV

    “Never let your sense of morals prevent you from doing what is right.”

    #212914 Reply
    Liked by Kamban
    Avatar Slav4ikMD 
    Participant
    Status: Physician
    Posts: 215
    Joined: 01/09/2016

    In my direct pay practice (psychiatry) I use Practice Fusion for e-prescribing (required in my state and frankly is convenient) and paper charts for notes (I do a typed detailed intake and for follow ups have a printed template note which then becomes handwritten – this works for me but YMMV).

    #213998 Reply
    Liked by StateOfMyHead
    Avatar StateOfMyHead 
    Participant
    Status: Advanced Practice Provider
    Posts: 112
    Joined: 01/01/2019

    In my direct pay practice (psychiatry) I use Practice Fusion for e-prescribing (required in my state and frankly is convenient) and paper charts for notes (I do a typed detailed intake and for follow ups have a printed template note which then becomes handwritten – this works for me but YMMV).

    Click to expand…

    Thank you for sharing this. I wondered if a EMR was required to do e-prescribing. Paper notes seem like a reasonable and more portable option for out of network psychiatrists.

    #215362 Reply

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