Private Practice EMR?

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So I'm anticipating starting a low key private practice as moonlighting during fourth year as a bridge into post-residency. Overall I'm thinking way ahead of time, but investigating a low-cost (or free) EMR system for psychiatry, that would include flexibility for psychotherapy, and templates for other notes.

Any suggestions?

The APA does offer assistance in making a private practice. I don't know what that extent is & exactly what types of things they do with the help.

IMHO private practice is quite a jump straight out of residency if its your own private practice. Reason why is because there still are things to learn after residency. Simply the act of practicing without an overseeing attending is an experientally different. My first 2 months I found myself 2nd guesing myself on things I knew darned well what to do in residency. Practicing in any new environment even if you know what you're doing is stressful for a few weeks because you're still getting used to the new settings.

If its your own private practice-you're on your own. If you work in a bigger institution such as a hospital, you have colleagues & doctors in higher positions where you can always ask for counsel, advice and a 2nd opinion with little problem.

Of course private practice cases in general are of lesser intensity too. You're not going to get a dangerous to self or others person in outpatient, and if you do-you make them go to the hospital.

Originally Posted by nitemagi

So I'm anticipating starting a low key private practice as moonlighting during fourth year as a bridge into post-residency. Overall I'm thinking way ahead of time, but investigating a low-cost (or free) EMR system for psychiatry, that would include flexibility for psychotherapy, and templates for other notes.

Any suggestions?

I've created EMR systems for companies in the past, but I'm all about open source. I work on a collaboration project to make a free system available to all. You can go to hear and download our free system and see if you like it.

It takes some skill to setup and get going, but like it said, it's completely free.

Good luck!

EDIT: I guess we won't finish the psych-specific modules until later, sorry! Still you should have a look at that program if you have time

I've been considering the same (private practice 4th year.) How do you go about doing this though? Do you just get permission to moonlight from the residency program?

Is private practice while still a resident even legal? Even so, I think you will find that buying your own malpractice insurance is prohibitive. And unless you plan to be cash only, you will also find that insurers will not credential you having not completed a residency program and being at least board eligible.

Yes this is legal. One needs only have their medical license. Insurance won't likely take you, but that's why you do cash only. Liability insurance isn't a requisite to practice medicine. Its smart, but not necessary. Let it be known to patients up front that you are still a resident, don't have insurance, and will be charging a reduced fee as a result. I suspect you would need approval from your program to moonlight. You'll want to set up your own LLC. Also, crunch the numbers and make sure you'll have enough patients and income to make it worthwhile to pay the taxes since you'll most likely be in a new tax bracket.

One of the downsides, as I've contemplated this myself, is in setting up an LLC you'll need to list an address for your company. Since you only own a home and it will likely be listed as your business address is it will be fair game in any malpractice suits...

A psychiatry resident has more training then any masters level therapist. If some one is truly concerned about not having colleagues in solo practice one now has Sermo to seek out colleague input.

One thing I would be interested to know about is recruiting patients for such a practice. I have a suspicion that you can't refer patients you see on University time to your own clinic. I have a feeling it is the same as trying to profit from an idea you think of while a university employee.

On a related topic: can a PA work under you during residency?

I don't know for sure, but in theory I don't see a problem with it except the real logistics of running your own side practice under duty hour restrictions, paying them, and trying to market such a weird set up. However, on the positive side I doubt it would be lower quality than what the nursing boards are permiting. You'll have to meet the same requirements as any other supervising physician. Have a state medical license. Here is a source to check for required years of residency to be licensed. Most require just one for a US grad. http://www.fsmb.org/usmle_eliinitial.html

I personally wouldn't do this though.

Originally Posted by Sneezing

A psychiatry resident has more training then any masters level therapist.

...in therapy?

In my former program, the residents did two years of therapy with a minimum of 5 hours per week, which mean't having at least 6-7 therapy patients at any one time, many had 10 or more, and had 3-4 hours of supervision per week on those therapy hours, with specialists in CBT, Psychodynamic, Supportive, Couples and Family, and Prolonged Exposure for PTSD, Exposure and Response Prevention for OCD, and Clinical Hypnosis (in some variation).

I'd be curious if a master's level therapist has that level of training, both that varied and with that much individualized supervision for two full years solidly.

Originally Posted by worriedwell

In my former program, the residents did two years of therapy with a minimum of 5 hours per week, which mean't having at least 6-7 therapy patients at any one time, many had 10 or more, and had 3-4 hours of supervision per week on those therapy hours, with specialists in CBT, Psychodynamic, Supportive, Couples and Family, and Prolonged Exposure for PTSD, Exposure and Response Prevention for OCD, and Clinical Hypnosis (in some variation).

I'd be curious if a master's level therapist has that level of training, both that varied and with that much individualized supervision for two full years solidly.

That sounds like a great experience. It seems that your training is atypical of a psychiatry residency, but I'm glad to hear they are out there. My comment was directed more towards the traditional psychiatry programs that don't have nearly the available training and supervision in regard to therapy that you listed above.

To answer your question about the MS level of training, I am sure it varies by programs. I have seen some very well trained and supervised MS level therapists....and many who were there to book the hours and not learn much.

Originally Posted by Therapist4Chnge

That sounds like a great experience. It seems that your training is atypical of a psychiatry residency, but I'm glad to hear they are out there. My comment was directed more towards the traditional psychiatry programs that don't have nearly the available training and supervision in regard to therapy that you listed above.

To answer your question about the MS level of training, I am sure it varies by programs. I have seen some very well trained and supervised MS level therapists....and many who were there to book the hours and not learn much.

We were taught therapy from day 1. We also taught it to all the medical students that rotated there. There are different skills sets and levels of therapy and a psychiatrist who completed residency at my program is an expert in psychotherapy. As much as any PhD or PsyD. This is true at many residencies. It is true that some psychiatrists don't learn therapy in great detail but neither do some therapists.

That being said, this isn't a thread about therapy...

So. I would also be interested in learning about some EMR options, free or relatively low cost as I want to start a 1-2 day private practice.

If you are a solo practice and don't have any other physicians or clinicians who need to adequately document it is their name on the chart I would just use something simple.

Use a dragon speak program and do your own dictation. Formulate your own macros (templates that allow you to jump to key areas, i.e. mood, speech, appearance...). Have your own stored routine phrases, and know your fast keys for them. This I know can all be done in microsoft word. Use internet based faxes. On the off chance you have loose documents scan them. Use .pdf as your work horse for the medical record. I believe you can also do electronic signatures and document locking with .pdf too (not required, but seems to be the cool thing to do these days medico-legaly). I don't know if you can use dragon speak in .pdf like I have seen done in microsoft word (I am betting you can).

At the end of the day, you have one large .pdf file that is the medical record for the patient.

Psychiatry doesn't really have any special charting needs like a GI or PM&R doc that would warrant a special EMR.

The old adage applies... KISS

Keeping it simple is one thing but that is TOO simple.

I NEED labs, medications, prescriptions

I would LIKE ECGs, imaging, orders and expandability.

I am also a sleep physician but thats another whole can of worms.

Hello.
The thread is a bit old, but as it fits perfectly my problematic...
I am working for a software company specialized in clinical information management.
We are creating digital forms for physicians, and we are now looking for some psychiatrists to help us to build a series of charts for this specialty.
So I am looking for psychiatrists interested in collaborating with us on this.
As we would offer the resulting product to our potential collaborators, it may resolve the kind of problems mentioned in this thread.
If you are interested, PM me.
Thank you.

Stay away from EMR if you are doing solo private practice and not billing Medicare. Use paper note templates with checklists. This way, you can complete your notes (including evaluations) while talking to the patient and you don't have to spend the extra minutes at the end of the session translating written notes into an EMR. You can spend extra time after seeing the patient typing out Assessment/Plan/Risk Assessment/Informed Consent. Typing while talking to patients is not a good way to build an alliance.

Originally Posted by strangeglove

Stay away from EMR if you are doing solo private practice and not billing Medicare. Use paper note templates with checklists. This way, you can complete your notes (including evaluations) while talking to the patient and you don't have to spend the extra minutes at the end of the session translating written notes into an EMR. You can spend extra time after seeing the patient typing out Assessment/Plan/Risk Assessment/Informed Consent. Typing while talking to patients is not a good way to build an alliance.

I have been using a small lightweight Netbook on my lap over the last year and my perception is that it has been non-obstructive to communication and rapport.
Though this option might only work well if you're a fast typist without the need to constantly look down at the keyboard.

I was looking into giving Practice Fusion a try since it's free. Last I heard, Nightmagi was using it in his private practice. Ideally, I wish they would release an EMR for iPad with a customizable template and checklist option that can be seamlessly uploaded to a secure server for remote access. I've looked into several iPad EMRs such as drCrono but it just seems like a huge ripoff.

Originally Posted by F0nzie

I have been using a small lightweight Netbook on my lap over the last year and my perception is that it has been non-obstructive to communication and rapport.
.

ummm.....and you know this exactly how? many pts undoubtedly find such a setup disturbing, and some may even be even more offended by your attempt to minimize what you are doing with a netbook.

Im not telling you how to see pts....you can obviously do anything you want. I just think your naive if you think some pts arent bothered by the fact that you are typing/entering into a netbook while they talk.

Originally Posted by vistaril

ummm.....and you know this exactly how? many pts undoubtedly find such a setup disturbing, and some may even be even more offended by your attempt to minimize what you are doing with a netbook.

Im not telling you how to see pts....you can obviously do anything you want. I just think your naive if you think some pts arent bothered by the fact that you are typing/entering into a netbook while they talk.

Ya know, vis, in the recovery community they call this "working someone else's program".

Not telling you how to interact with others online...you can obviously do anything you want...

Originally Posted by vistaril

ummm.....and you know this exactly how? many pts undoubtedly find such a setup disturbing, and some may even be even more offended by your attempt to minimize what you are doing with a netbook.

Im not telling you how to see pts....you can obviously do anything you want. I just think your naive if you think some pts arent bothered by the fact that you are typing/entering into a netbook while they talk.

The irony in that is they keep coming back and working with me. Also, several of my psychotherapy patients have been paying out of pocket once their insurance ran out.

Originally Posted by OldPsychDoc

Ya know, vis, in the recovery community they call this "working someone else's program".

Not telling you how to interact with others online...you can obviously do anything you want...

well in your recovery community opiate addicts who take controlled opiates every day are in "recovery" as well, so.........

regarding the original post though, it's impossible for him to know whether pts are bothered by it or not. Most arent going to tell him if they are. And many will keep coming back even if they are somewhat bothered by it. It just seemed more like a case where he wants to use the computer while he sees pts(which I dont disagree with....to each their own) and he's trying to justify it. It doesnt need justifying.

Originally Posted by vistaril

ummm.....and you know this exactly how? many pts undoubtedly find such a setup disturbing, and some may even be even more offended by your attempt to minimize what you are doing with a netbook.

He even said, "my perception"....which is far from trying to be authoritative by saying something like "undoubtedly".

Originally Posted by vistaril

Im not telling you how to see pts....you can obviously do anything you want. I just think your naive if you think some pts arent bothered by the fact that you are typing/entering into a netbook while they talk.

Strangelove: Use paper note templates with checklists. >> that would be exactly the aim of a digital form, the only difference would be to use a digital template instead of a paper-based one.

Originally Posted by F0nzie

Ideally, I wish they would release an EMR for iPad with a customizable template and checklist option that can be seamlessly uploaded to a secure server for remote access.

Hello.
That's quite exactly what our product does. As I don't want to spam the forum, I can only advise you to PM, this way I can explain it better. But I think it might interest you.

Yes this is legal. One needs only have their medical license. Insurance won't likely take you, but that's why you do cash only. Liability insurance isn't a requisite to practice medicine. Its smart, but not necessary.

I wouldn't say so. It depends on your local state laws and what your program will allow. Several states will not allow one to practice without malpractice insurance. Programs must allow you to moonlight and you must report it to the program. If you were sued and didn't have malpractice insurance plus the program found out and you didn't report it to them you could very well face punishment there from the program.

If I were a PD, and this is my own opinion, I would be strongly hesitant to allow any resident to moonlight in private practice. Reasons being that PP forces a commitment upon the resident and that could come into conflict with their residency. To give you a counter-example, in my area, residents that moonlight at the VA, once their shift is over, it's over. They don't ever have to go back to the VA. In PP, you leave, your patient could call you up at any moment. You have a commitment, as their doctor, to continue their treatment, so even during the month of your grand rounds, when you're working your tail off, you still may be forced to do the PP hours because patients may have faced some type of emergent situation where they need to see their doctor.

The other problem is if the resident was sued, if the plaintiff had a savvy lawyer, they could try to extend the lawsuit to the program even if the program didn't do anything wrong other than to allow the resident to moonlight in private practice. If that resident didn't have insurance, that'd also force my hand to not allow them to moonlight.

If the resident moonlit and didn't tell me (as they are required to do so), I'd seriously consider kicking that resident out. That'd be a serious violation of contract that could've put the program at risk not just in terms of a lawsuit but also with following GME guidelines. If that resident was practicing without insurance and that was a legal requirement, I'd seriously consider reporting them to the authorities.

I'm an EMR and HIT consultant, and hopefully med student next year. If you are going to start a small group use practice fusion with kareo for billing. I have implemented it seamlessly in 5 clinics, and it is really easy to chart in the room. You can use a tablet fairly easily (imho better than a netbook.) We use a program that actually allows us to run our desktop remotely (log me in) so the desktop actually does all of the work. We run 3 paperless clinics that all met meaningful use with this setup. Patients think nothing of you charting electronically, in fact many are happy to hear that their charts can't get lost, are easy for them to read, and sync to their PHR etc. The best part is you can generate a bill right from your chart note. After my MCAT July 06, I'd be happy to walk anyone through set up as a volunteer.

Two big caveats, you NEED to be behind a firewall and if you use wireless it must be WPA, non-broadcasted ssid, that only connects to designated IPs.



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I suspect that when you type in front of patients, they think you are doing it because you have to. If you write in front of them, they think you are doing it because you are interested enough to write down things they say. Who knows? Personally, I find it quite disconcerting when my doctor types while listening to me. We live in an era where typing in another person's presence usually means you are ignoring them.

Originally Posted by strangeglove

I suspect that when you type in front of patients, they think you are doing it because you have to. If you write in front of them, they think you are doing it because you are interested enough to write down things they say. Who knows? Personally, I find it quite disconcerting when my doctor types while listening to me. We live in an era where typing in another person's presence usually means you are ignoring them.

It helps if you tell them at their initial appointment, "Just so you know, we have electronic records here, and I may, at times, type during our conversations."

Then see if they have a problem with it.

Originally Posted by strangeglove

I suspect that when you type in front of patients, they think you are doing it because you have to. If you write in front of them, they think you are doing it because you are interested enough to write down things they say. Who knows? Personally, I find it quite disconcerting when my doctor types while listening to me. We live in an era where typing in another person's presence usually means you are ignoring them.

I was interviewing a cranky middle-aged male borderline one day, and both the resident and med student in the room with me were both typing away (I suspect on other patients' notes--who knows, they might have been chatting on a date line or something...), when the guy looks at them and blurts out, "What are you? The f------ stenographers!??"

I do attempt to discourage that behavior. (By the trainees, I mean, not the patient. )

Originally Posted by digitlnoize

It helps if you tell them at their initial appointment, "Just so you know, we have electronic records here, and I may, at times, type during our conversations."

Then see if they have a problem with it.

I'm sure they will be completely honest with you about how they feel about this after one meeting. "Actually, doctor, your typing will most likely make me feel uncomfortable."