Physician manpower seminars. Part III: Modem systems in a medical office CARLIE ORESKOVICH Maybe the interest in computers re- office accounting system and whether equipment appropriate would cost sults from hints of what they can it's viable and economic. Is it a threat $10000 to $12000: for 4 to 8 do - their potential for increasing or can it really aid the practice? Is people around $20 000; and 10 and office efficiency, cutting costs, their the cost justified? How do you pick above would be $35 000 and more. The cost of operating the new use as diagnostic tools. Maybe it is the right one and how can the staff just the practitioner's innate fascina- and patients be adequately prepared equipment has been somewhat retion with gadgets. But whatever the to use the computer? And can it cut duced because the new computers source of the interest, computers, in labour costs, help improve cash flow are so easy to use. Any of the office the year since MD Management first and streamline the office practice so staff can be trained to use the equipment. The older language FORTRAN began to cover them in physician- it can generate a higher income? The computer can fill five basic has been superseded by natural lanoriented business symposia, have guage systems, such as BASIC, which earned their own spot on the agenda functions: is very close to English - interactive and today generate as much interest * Appointment scheduling, so and conversational. "As a result, you, as any other part of the curriculum. Indeed, one radiology specialist that no patient is ever kept waiting a member of your family or your at the Toronto sessions complained long and there is a smooth flow of present receptionist will be able to use the computer," says Bannerman. that not enough time was spent on patients through the office. accounting, and billing * Patient And when you become more familiar computer systems. None the less, MD provide to bill patients immediately, that language you can change with Management devoted 2 hours of the 3-day course to computer use, with a running account and - sometime or write your own programs to meet Ronald Bannerman (vice president, in the future perhaps - allow a the precise needs of your practice. MD Management Ltd.) providing the direct hookup to a government cen- Who knows, you could even make additional income by selling the probackground, Dr. Jan F. Brandejs tral computer. and of medical profiles * Storage grams you develop. ecoand systems statistics, (director, With stories of government comnomic research unit) the scientific records. * Patient education. puter information leaks, there is perspective and "whiz kid" Subhash * Continuing medical education. more concern about confidentiality. Sarkar the computer program. Symposium speakers suggested that Briefly surveying the history of com to main objections The three personal and shared in-house comcomputers, Bannerman noted that it puters are more secure than a filing was the diminutive microprocessor puter use, cryptically known and dethe system, as computers can be locked chip that made it possible to cram scribed by MD Management as and by key or coded to prevent unauthortogether thousands of electronic com- three Cs, are cost, complexity confidentiality. use. "The greatest danger to ized ponents onto a cm' of silicon that rebeen drastically Costs have is in a centralized sysconfidentiality electronic heralded the "new" age of computerization. Over the last 25 duced. For example an IBM com- tem where all information is kept years the computational power has puter 370 model 168 cost $5 million in one large data bank." In the symposium's information become so miniaturized that what until March 1977 when IBM cut its it Last fall to $3.5 million. price it is suggested that the probbooklet years would have weighed 30 t 25 ago now need weigh only 1 g. Today dropped to $1.8 million. This is cer- lem of acceptance by staff and papractically everyone can have his tainly not the type of computer at tients "is precisely the reason for own "brain". It's already used in which most doctors would be look- looking into and beginning to use grocery checkout counters, banking, ing, but the micro variety, with computers now. Starting with schedcommunications and the billing pro- enough capability to do appointment uling and accounting operations will cedures of large organizations. And scheduling and accounting, is now allow you, your staff and your pait's due to come into the home as available for around $5000 and costs tients to grow with the computer as well, regulating temperatures, keep- can get as low as $500. That's only new functions and capabilities are ing tab on supplies, waking us in the hardware - just one aspect of added. Instead of suddenly finding one day that you should have started the morning, playing games and the costs. Although these equipment costs computerizing 10 years before and taking 'phone messages. Although computer use is fairly are being reduced by 25 % a year, that you have to catch up all at once, limited now, Dr. Brandejs predicts the software, programming, computer you can get used to computer operthat by 1980 there will be some 5 language preparation and personnel ations now." One of the problems for computermillion microcomputers in North costs are continuing to increase, with doctors is that the computer minded The a up by 6% year. alone salaries America. "It's developing at a fanmost appropriate to mediprograms practifor the solo microcomputer tastic rate." Bannerman says the main ques- tioner can basically run anywhere cal operations are still under develtions for doctors about use of the from $1000 to $5000. For a 2- to opment. However the CMA has a computer are how it can fit into the 3-person operation, the type of program that should be available in CMA JOURNAL/SEPTEMBER 9, 1978/VOL 119 521
NEI%T! (4
TLAGYS¶UATIN¶. CREAM 4/
effective topical treatment for vaginitis due to both major vaginal pathogens about 6 months. Subhash Sarkar says the association has been developing the program for 2 years at a cost of $60 000 to $70 000. He says this program will initially be sold for about $3000 a shot (in some cases a greater cost than the hardware), but it's expected the cost will quickly fall to $500 with increased sales, and some officials expect the price will never be any more than $500. MD Management suggests that doctors look for a system that enables information to be entered only once, that eliminates the need for most of the present paperwork and storage and that allows the practitioner to select the output needed. It should be modular to enable the practice to increase its computer capability as the need arises. The system chosen should be one that provides a substantial saving to the practitioner's business. "It should be viewed as a capital investment and analysed carefully on a cost-benefit basis. "The public relations aspects of computerization should not be overlooked either. The personnel operating the system should be happy with
Pouienc it and the inquisitive patients should be made to appreciate the benefits of a computerized practice." Looking dimly into the future, MD Management predicts that future care will involve a greater personal involvement on the part of the patient. "With an increase in prospective medicine and preventive medicine the physician will come, more and more, to be seen as a consultant to the patient in planning his or her own health care." Computers can help by making more information available to the patient. MD Management also sees the use of computers by doctors as an additional safeguard against government control. "By acquiring personal computers now, physicians will be contributing toward safeguarding the confidentiality of their patients. If the information is not kept in the hands of physicians it will be in centralized memories." Toronto doctor Michael Cord, 32, in his 6th year of general practice, believes in the inevitability of the computer. He says that it is necessary to get a computer, even in a solo practice as he has at present.
522 CMA JOURNAL/SEPTEMBER 9, 1978/VOL 119
Dr. Cord has been following the development of computers for some time. He finds that initially the program operators' jargon is difficult to penetrate, but it is necessary to get a grip on those technical aspects so you have a better idea of what you're buying. Dr. Jerry Green, nutritional specialist practising in a suburb north of Toronto, was stimulated by the computer work. In solo practice, he is considering getting some equipment in the next year or two to ease the load. He feels, though, that there is a great deal of work involved in setting up a system. He would have liked more information in the symposium on pricing of equipment and was worried about the problems with breakdowns and what happens to patient medical information, appointments and so on when the equipment fails. Others, such as Dr. Mark Sager, weren't as familiar with computer use. In his 5th year as a Toronto GP, he hadn't really thought about using computers until he walked into the conference room, but he quickly saw that getting patient information
on the computer would be a mindboggling task, one that would take one heck of a lot of time. And the operators agreed. As a billing, appointment or patient management system it is extremely useful but "I can't see any other way it can be used," says Dr. Sager. "I can't see how to get all my patients' file data on the computer. I have charts that are 5 years old that would be useless on a computer." In reply Dr. Brandejs points to a CMAJ series (CMAJ 113: 693, 903, 1006, 1101, 1975) which notes that the computerization of medical records "is one of the most controversial aspects of health information systems", and the core of the problem is coding - getting information onto the computer in a readable form. Once it is there there are intriguing possibilities for comparisons and correlations. Until computers come along, however, office systems can be upgraded, operated more efficiently. The aim is to develop an accounting system that minimizes the amount of paper work and maximizes the return.
For those in government plans, Michael Landry, vice president, marketing, of MD Management, suggests that copysets be used where available, or at least two cards, one for claims and one for accounts receivable. And doctors should set up a numerical ordering of bills to make it easier to check on accounts, rather than relying on the alphabetical printout. Unfortunately, some provinces are not geared up to provide the hard copy printouts on this basis. Some doctors in the session mentioned that they have tried such a system without much success; the government's computer is not equipped to deal with this approach; readouts come back alphabetically and this involves even more time checking the accounts. The problem, says Landry, supported by Greg Korneluk, health care consultant formerly with MD Management (and now with the American Medical Association) was that they have not given the system enough time since it takes about 3 months to work out. For those directly billing, Landry recommends the pegboard (one write) system where one writing ac-
complishes about four functions. This is the best for those with 20 to 25 billings a day. And if the practice is going to operate like an efficient business, it is wise to set up a practice budget at the beginning of the year to set priorities and control costs and know just how business is changing over the year. Dr. Mohan S. Virick, 34, in general practice in Sydney, Nova Scotia, told of his own system for recording information in the files. It involves dictating precise notes and having a secretary type out the information on a roll of perforated pieces of paper, which are detached and glued into the file. He says he decided on this approach because he just couldn't read his own writing, a problem not unknown to the profession. The MD Management program stresses that the first and most important step for any physician who is opting out is to communicate with his patients, telling them why he is opting out and how this will affect them. He should ensure that patients know just how much each service is
FLAGYSTATIN® CREAM metronidazole/nystati n
Elegant Effective
Immediate relief without staining... ordiscomfort1 Highly effective against both Candida albicans and trichomonas1'2
Economical
Inexpensive treatment gives rapid results without secondary overgrowth of either pathogen2
INDICATIONS: Mixed vaginal infection due to Trichomonas vaginalis and Candida albicans. CONTRAINDICATIONS: Hypersensitivity to one of the components. Combined treatment with oral Flagyl should be avoided in caaes of active neurological disorders or a history of blood dyscrasia, hypothyroidism or hypoadrenalism unless in the opinion of the physician the benefits outweigh the possible hazard to the patient. WARNINGS: Nystatin possesses little or no antibacterial activity while metronidazole is selective against certain anaerobic bacteria; therefore, Flagystatin may not be effective in bacterial vaginal infections. Flagystatin should not be prescribed unless there is direct evidence of trichomonal infestation. PRECAUTIONS: Where there is evidence of trichomonaf infestation in the sexual partner, he should be treated concomitantly with oral Flagyl to avoid reinfestation. It is possible that adverse effects normally associated with oral administration of metronidazole may occur following the vaginal administration of Flagystatin. When administering oral Flagyl (see Flagyl Product Monograph) the following precautions must be borne in mind:
Patients should be warned against consuming alcohol, because of a possible disulfiram-like reaction. Although no persistent hematologic abnormalities have.een observed in clinical studies, total and differential leukocyte counts should be made before and after treatment especially if a second course of oral Flagyl therapy is needed. Metronidazole passes the placental barrier. Although it has been given to pregnant women without apparent complication, it is advisable that oral use be avoided in pregnant patients and the drug be withheld during the first trimester of pregnancy. Oral treatment should be discontinued if ataxia or any other symptom of ONS involvement occurs. ADVERSE REACTIONS: They are infrequent and minor: vaginal burning and granular sensation. Bitter taste, nausea and vomiting, already known to occur with Flagyl, were mainly seen when oral Flagyl was administered concomitantly with Flagystatin local treatment. In the course of clinical trials with Flagystatin, reactions, not necessarily related to the product, were observed: spots on the skin around the knees, welts all over the body, aching and swelling of wrists and ankles, pruritis, headache, coated tongue and fatigue. OVERDOSAGE: There is no specific antidote.
Treatmentshouldbesymptomaticaftergastric.**/ lavage. DOSAGE AND ADMINISTRATION: One vaginal * insert or one applicatorful of Flagystatin cream daily, inserted deep into the vagina, tor 10 consecutive days. It atter 10 days ot treatment a cure .-.-.--has not been achieved a second 10-day course 01 treatment should be given, It Trichomonas vaginalis has not been completely eliminated, oral Flagyl 250 mg b.i.d. should be administered br 10 days. SUPPLY: Vaginal inserts containing 500 mg metronidazole and 100,000 U. nystatin, boxes of 10 with applicator. Vaginal Cream delivering 500 mg metronidazole and 100,000 U. nystatin per applicatortul, tubes 01 55 g with applicator. 1. Audet Lapointe, P.: Union Med. Can., iDS, August 1976 2. Otticial product monograph
/
Full Information upon request
-Pouleno ,.
8580 Esplanade, Montreal
CMA JOURNAL/SEPTEMBER 9, 1978/VOL 119 523
going to cost. For office visits, Lan- tors have nothing and want nothing have to waste time setting it up in dry suggests that after examining the to do with billings. Landry, possibly alphabetical order," he said. "We patient, the doctor should write the courting paranoia, advises doctors al- always think the alphabetical orderservices rendered on a charge slip ways to assume that they can be ing system is the best way to organto be handed to the medical assistant. stolen from. By understanding and ize things but we know numbers. This way the patient knows the fee keeping in touch with the accounting Once you have the number, retrieval before leaving the office. Non-office procedure they can monitor their is much faster. We know exactly visits should be discussed before the operations. "Be consistently incon- where things should be. It's difficult procedure. "Never fail to mention sistent," says Landry. "Let the med- organizing names. What do you do that the fee assumes normal time and ical assistant know that there's a with McDonalds, for example, in Cape Breton?" Most physicians who that the cost could be higher should chance you might be checking." problems occur." use the numerical system use an alphabetical card index to store oftenHigh collections depend on a high Filing systems ratio of payments on the spot and used bits of administrative informaproper follow-up procedures. With A prime element of any efficient tion about each patient. Once com80% of the patients there will be medical operation is a filing system puters are introduced in offices, the little problem collecting fees, as most that allows for good recording and cross indexing will be accessible on a collections are made at the office. prompt recall of information. As video terminal by merely typing the With the 20% who ignore bills there well, inactive files should be easily name into the computer. This will should be an organized system for removed. A colour-coded lateral probably give numerical filing the getting payment, based on direct tele- filing system will go a long way in edge. phone contact. The AMA offers a achieving these goals. Landry pointed At a suggestion that doctors could taped instruction with collecting tips out the pros and cons of alphabetic have lateral files constructed more for medical aides, which recognizes and numerical colour-coded systems. cheaply than buying metal case ones, the fact that they are not full-time The disadvantage of numerical sys- 43-year-old Dr. Bruce Stewart, a bill collectors and need to have their tems is the need for cross-references. Toronto neurologist, warned that time free for other things. One participant sighed: "Just an- confidentiality could be violated. He Surprisingly enough fraud and other bit of information"; another believes someone used information theft are problems for doctors. It added: "It would be nice if it works." from his files to make obscene 'phone seems it is very easy to steal from Landry defended the numerical ap- calls to patients using his name. He'd a medical practice, since most doc. proach. "It's better because you don't like to see all files locked securely.
Part IV: Patient management The MD Management symposium on patient management could well have been entitled Selling the Doctor. And despite the dissident who said he already had enough patients and didn't want to attract more, those present agreed that patient relations are being more recognized as important. Patients are becoming more critical of doctors and the medical profession in general. Physicians who opt out of medicare are going to have to explain why and show how patients are going to benefit. Be spectacular This is a new state of affairs for medicare, according to Michael Landry, vice president, marketing, of MD Management. "You have to use your imagination. Why not be spectacular? Offer the patients something that's really different," he urged. "Whether you like it or not, you are judged largely on the basis of
how good you appear to be as a doctor and not on your professional ability," stated the program notes. "It's simple - people react to interest, concern, empathy, understanding etc... Showing that you care (or don't care) for your patients can be expressed in many ways - providing a pleasant reception area, recognizing that the patient's time is also valuable, giving your patient undivided attention." Landry told the symposium it's not the time spent with a patient that is seen as important but "how much you concentrate on the patient during that time." Style and content are the critical factors. A 1973 study commissioned by the OMA under retired industrialist Edward A. Pickering lent support to this view. Pickering found that human relations were most important to patients. "Mere competence is perhaps taken for granted and is not enough. Quality of service, of re-
524 CMA JOURNAL/SEPTEMBER 9, 1978/VOL 119
sponsiveness, is of overriding importance." Medically it is probably fair to say that better doctor-patient relations will lead to better care. From a business point of view, to attract new patients and to keep old ones it is, ironically, more important to appear competent and caring than it is to be competent and caring. "It is a business fact of life." Patients are people In a survey taken by Physician's Management, the 10 most frequent complaints emerged as: the feeling that doctors are more interested in disease than health; doctors fail to keep appointment times; office staff give patients little respect; doctors act like God; doctors and staff give patients no privacy; fees are not explained on statements; doctors abuse investigative techniques; there are inadequate waiting room facilities; of-
NEI%T! (4
TLAGYS¶UATIN¶. CREAM 4/
effective topical treatment for vaginitis due to both major vaginal pathogens about 6 months. Subhash Sarkar says the association has been developing the program for 2 years at a cost of $60 000 to $70 000. He says this program will initially be sold for about $3000 a shot (in some cases a greater cost than the hardware), but it's expected the cost will quickly fall to $500 with increased sales, and some officials expect the price will never be any more than $500. MD Management suggests that doctors look for a system that enables information to be entered only once, that eliminates the need for most of the present paperwork and storage and that allows the practitioner to select the output needed. It should be modular to enable the practice to increase its computer capability as the need arises. The system chosen should be one that provides a substantial saving to the practitioner's business. "It should be viewed as a capital investment and analysed carefully on a cost-benefit basis. "The public relations aspects of computerization should not be overlooked either. The personnel operating the system should be happy with
Pouienc it and the inquisitive patients should be made to appreciate the benefits of a computerized practice." Looking dimly into the future, MD Management predicts that future care will involve a greater personal involvement on the part of the patient. "With an increase in prospective medicine and preventive medicine the physician will come, more and more, to be seen as a consultant to the patient in planning his or her own health care." Computers can help by making more information available to the patient. MD Management also sees the use of computers by doctors as an additional safeguard against government control. "By acquiring personal computers now, physicians will be contributing toward safeguarding the confidentiality of their patients. If the information is not kept in the hands of physicians it will be in centralized memories." Toronto doctor Michael Cord, 32, in his 6th year of general practice, believes in the inevitability of the computer. He says that it is necessary to get a computer, even in a solo practice as he has at present.
522 CMA JOURNAL/SEPTEMBER 9, 1978/VOL 119
Dr. Cord has been following the development of computers for some time. He finds that initially the program operators' jargon is difficult to penetrate, but it is necessary to get a grip on those technical aspects so you have a better idea of what you're buying. Dr. Jerry Green, nutritional specialist practising in a suburb north of Toronto, was stimulated by the computer work. In solo practice, he is considering getting some equipment in the next year or two to ease the load. He feels, though, that there is a great deal of work involved in setting up a system. He would have liked more information in the symposium on pricing of equipment and was worried about the problems with breakdowns and what happens to patient medical information, appointments and so on when the equipment fails. Others, such as Dr. Mark Sager, weren't as familiar with computer use. In his 5th year as a Toronto GP, he hadn't really thought about using computers until he walked into the conference room, but he quickly saw that getting patient information
on the computer would be a mindboggling task, one that would take one heck of a lot of time. And the operators agreed. As a billing, appointment or patient management system it is extremely useful but "I can't see any other way it can be used," says Dr. Sager. "I can't see how to get all my patients' file data on the computer. I have charts that are 5 years old that would be useless on a computer." In reply Dr. Brandejs points to a CMAJ series (CMAJ 113: 693, 903, 1006, 1101, 1975) which notes that the computerization of medical records "is one of the most controversial aspects of health information systems", and the core of the problem is coding - getting information onto the computer in a readable form. Once it is there there are intriguing possibilities for comparisons and correlations. Until computers come along, however, office systems can be upgraded, operated more efficiently. The aim is to develop an accounting system that minimizes the amount of paper work and maximizes the return.
For those in government plans, Michael Landry, vice president, marketing, of MD Management, suggests that copysets be used where available, or at least two cards, one for claims and one for accounts receivable. And doctors should set up a numerical ordering of bills to make it easier to check on accounts, rather than relying on the alphabetical printout. Unfortunately, some provinces are not geared up to provide the hard copy printouts on this basis. Some doctors in the session mentioned that they have tried such a system without much success; the government's computer is not equipped to deal with this approach; readouts come back alphabetically and this involves even more time checking the accounts. The problem, says Landry, supported by Greg Korneluk, health care consultant formerly with MD Management (and now with the American Medical Association) was that they have not given the system enough time since it takes about 3 months to work out. For those directly billing, Landry recommends the pegboard (one write) system where one writing ac-
complishes about four functions. This is the best for those with 20 to 25 billings a day. And if the practice is going to operate like an efficient business, it is wise to set up a practice budget at the beginning of the year to set priorities and control costs and know just how business is changing over the year. Dr. Mohan S. Virick, 34, in general practice in Sydney, Nova Scotia, told of his own system for recording information in the files. It involves dictating precise notes and having a secretary type out the information on a roll of perforated pieces of paper, which are detached and glued into the file. He says he decided on this approach because he just couldn't read his own writing, a problem not unknown to the profession. The MD Management program stresses that the first and most important step for any physician who is opting out is to communicate with his patients, telling them why he is opting out and how this will affect them. He should ensure that patients know just how much each service is
FLAGYSTATIN® CREAM metronidazole/nystati n
Elegant Effective
Immediate relief without staining... ordiscomfort1 Highly effective against both Candida albicans and trichomonas1'2
Economical
Inexpensive treatment gives rapid results without secondary overgrowth of either pathogen2
INDICATIONS: Mixed vaginal infection due to Trichomonas vaginalis and Candida albicans. CONTRAINDICATIONS: Hypersensitivity to one of the components. Combined treatment with oral Flagyl should be avoided in caaes of active neurological disorders or a history of blood dyscrasia, hypothyroidism or hypoadrenalism unless in the opinion of the physician the benefits outweigh the possible hazard to the patient. WARNINGS: Nystatin possesses little or no antibacterial activity while metronidazole is selective against certain anaerobic bacteria; therefore, Flagystatin may not be effective in bacterial vaginal infections. Flagystatin should not be prescribed unless there is direct evidence of trichomonal infestation. PRECAUTIONS: Where there is evidence of trichomonaf infestation in the sexual partner, he should be treated concomitantly with oral Flagyl to avoid reinfestation. It is possible that adverse effects normally associated with oral administration of metronidazole may occur following the vaginal administration of Flagystatin. When administering oral Flagyl (see Flagyl Product Monograph) the following precautions must be borne in mind:
Patients should be warned against consuming alcohol, because of a possible disulfiram-like reaction. Although no persistent hematologic abnormalities have.een observed in clinical studies, total and differential leukocyte counts should be made before and after treatment especially if a second course of oral Flagyl therapy is needed. Metronidazole passes the placental barrier. Although it has been given to pregnant women without apparent complication, it is advisable that oral use be avoided in pregnant patients and the drug be withheld during the first trimester of pregnancy. Oral treatment should be discontinued if ataxia or any other symptom of ONS involvement occurs. ADVERSE REACTIONS: They are infrequent and minor: vaginal burning and granular sensation. Bitter taste, nausea and vomiting, already known to occur with Flagyl, were mainly seen when oral Flagyl was administered concomitantly with Flagystatin local treatment. In the course of clinical trials with Flagystatin, reactions, not necessarily related to the product, were observed: spots on the skin around the knees, welts all over the body, aching and swelling of wrists and ankles, pruritis, headache, coated tongue and fatigue. OVERDOSAGE: There is no specific antidote.
Treatmentshouldbesymptomaticaftergastric.**/ lavage. DOSAGE AND ADMINISTRATION: One vaginal * insert or one applicatorful of Flagystatin cream daily, inserted deep into the vagina, tor 10 consecutive days. It atter 10 days ot treatment a cure .-.-.--has not been achieved a second 10-day course 01 treatment should be given, It Trichomonas vaginalis has not been completely eliminated, oral Flagyl 250 mg b.i.d. should be administered br 10 days. SUPPLY: Vaginal inserts containing 500 mg metronidazole and 100,000 U. nystatin, boxes of 10 with applicator. Vaginal Cream delivering 500 mg metronidazole and 100,000 U. nystatin per applicatortul, tubes 01 55 g with applicator. 1. Audet Lapointe, P.: Union Med. Can., iDS, August 1976 2. Otticial product monograph
/
Full Information upon request
-Pouleno ,.
8580 Esplanade, Montreal
CMA JOURNAL/SEPTEMBER 9, 1978/VOL 119 523
going to cost. For office visits, Lan- tors have nothing and want nothing have to waste time setting it up in dry suggests that after examining the to do with billings. Landry, possibly alphabetical order," he said. "We patient, the doctor should write the courting paranoia, advises doctors al- always think the alphabetical orderservices rendered on a charge slip ways to assume that they can be ing system is the best way to organto be handed to the medical assistant. stolen from. By understanding and ize things but we know numbers. This way the patient knows the fee keeping in touch with the accounting Once you have the number, retrieval before leaving the office. Non-office procedure they can monitor their is much faster. We know exactly visits should be discussed before the operations. "Be consistently incon- where things should be. It's difficult procedure. "Never fail to mention sistent," says Landry. "Let the med- organizing names. What do you do that the fee assumes normal time and ical assistant know that there's a with McDonalds, for example, in Cape Breton?" Most physicians who that the cost could be higher should chance you might be checking." problems occur." use the numerical system use an alphabetical card index to store oftenHigh collections depend on a high Filing systems ratio of payments on the spot and used bits of administrative informaproper follow-up procedures. With A prime element of any efficient tion about each patient. Once com80% of the patients there will be medical operation is a filing system puters are introduced in offices, the little problem collecting fees, as most that allows for good recording and cross indexing will be accessible on a collections are made at the office. prompt recall of information. As video terminal by merely typing the With the 20% who ignore bills there well, inactive files should be easily name into the computer. This will should be an organized system for removed. A colour-coded lateral probably give numerical filing the getting payment, based on direct tele- filing system will go a long way in edge. phone contact. The AMA offers a achieving these goals. Landry pointed At a suggestion that doctors could taped instruction with collecting tips out the pros and cons of alphabetic have lateral files constructed more for medical aides, which recognizes and numerical colour-coded systems. cheaply than buying metal case ones, the fact that they are not full-time The disadvantage of numerical sys- 43-year-old Dr. Bruce Stewart, a bill collectors and need to have their tems is the need for cross-references. Toronto neurologist, warned that time free for other things. One participant sighed: "Just an- confidentiality could be violated. He Surprisingly enough fraud and other bit of information"; another believes someone used information theft are problems for doctors. It added: "It would be nice if it works." from his files to make obscene 'phone seems it is very easy to steal from Landry defended the numerical ap- calls to patients using his name. He'd a medical practice, since most doc. proach. "It's better because you don't like to see all files locked securely.
Part IV: Patient management The MD Management symposium on patient management could well have been entitled Selling the Doctor. And despite the dissident who said he already had enough patients and didn't want to attract more, those present agreed that patient relations are being more recognized as important. Patients are becoming more critical of doctors and the medical profession in general. Physicians who opt out of medicare are going to have to explain why and show how patients are going to benefit. Be spectacular This is a new state of affairs for medicare, according to Michael Landry, vice president, marketing, of MD Management. "You have to use your imagination. Why not be spectacular? Offer the patients something that's really different," he urged. "Whether you like it or not, you are judged largely on the basis of
how good you appear to be as a doctor and not on your professional ability," stated the program notes. "It's simple - people react to interest, concern, empathy, understanding etc... Showing that you care (or don't care) for your patients can be expressed in many ways - providing a pleasant reception area, recognizing that the patient's time is also valuable, giving your patient undivided attention." Landry told the symposium it's not the time spent with a patient that is seen as important but "how much you concentrate on the patient during that time." Style and content are the critical factors. A 1973 study commissioned by the OMA under retired industrialist Edward A. Pickering lent support to this view. Pickering found that human relations were most important to patients. "Mere competence is perhaps taken for granted and is not enough. Quality of service, of re-
524 CMA JOURNAL/SEPTEMBER 9, 1978/VOL 119
sponsiveness, is of overriding importance." Medically it is probably fair to say that better doctor-patient relations will lead to better care. From a business point of view, to attract new patients and to keep old ones it is, ironically, more important to appear competent and caring than it is to be competent and caring. "It is a business fact of life." Patients are people In a survey taken by Physician's Management, the 10 most frequent complaints emerged as: the feeling that doctors are more interested in disease than health; doctors fail to keep appointment times; office staff give patients little respect; doctors act like God; doctors and staff give patients no privacy; fees are not explained on statements; doctors abuse investigative techniques; there are inadequate waiting room facilities; of-
