On the Obama and National Healthcare

After Obamas stunning victory Tuesday, I got an email from an old friend asking if we were concerned about the ramifications of socialized national healthcare on our business. I was asked how we would prepare. I was asked if I was happy about the election results. My friend Larry put it best in his response to the recent voting experience...I didn't see "none of the above" on the ballot. Amen brother, and ditto.

So in response to my other friends inquiry...how will we prepare?

I get it, believe me, but I have seen the worst in the business, and yes: healthcare is a business. I want to tell you a story that I think illustrates what I'm talking about here. A few months ago, we were pursuing a contract with a 42 bed rehab facility (physical, not substance). The facility was across the street from a major hospital, and seen many of the long term care patients after they were discharged from the neighboring acute care facility.

Patients that have been sedentary for an extended period of time can develop blood clots in their lower extremities, a potentially deadly condition called DVT (deep vein thrombosis). This condition is easily detected by MRI with contrast, but MRI is expensive and insurance companies won't pay for it simply to rule out a certain condition. DVT is also easily diagnosed with vascular ultrasound, a portable and much less expensive modality. Still, insurance won't cover the DVT ultrasound because in such cases it would be considered a screening, and therefore unnecessary.

Lets compound the problem...The rehab center is scared to death of DVT. If they admit a patient that has all of the classic warning signs of potential DVT...swelling, edema, sedentary for an extended period, trauma or surgery in the lower extremities... then they are assuming a huge liability. What if the clot breaks loose when they put the patient into physical therapy? The patient could die. Would the family sue the insurance company? The hospital? No, of course not...they sue the rehab center. So since the rehab center is not chartered to do diagnostic imaging, they would simply admit the patients, never take them off the gurney, then turn right around and send them back to the hospital for an ultrasound...on the rehab center's dime of course, because an ounce of prevention is worth a pound of cure, right?

This whole ordeal is like a six hour process for the patient. Oh, and how do they get them back to the hospital for the ultrasound? Ambulance of course. $400 dollars each way. So, here we come...we show up on our white horses offering to bring the ultrasound to the rehab center for a flat fee, everybody wins, right?

When talking to the administrator of the rehab center I discovered perhaps the most disturbing bit of insight that I had heard in years. While we were trying to negotiate a time frame that we could arrive and see his patients, he informs me quite casually that they never admit patients from the hospital across the street before 2pm. This presented a small challenge for me since I only had two morning slots available. If he wanted afternoons, I would have to rearrange a tech or go hire someone. Not a big issue, but big enough for me to pry a little deeper.

"So, why do you only admit in the afternoon?" I asked. "Simple", he says with a perplexed, "I can't believe I have to explain this" sort of look on his face... "The first shift nursing staff at the hospital across the street get off at three in the afternoon. If they release a patient before two, they have to prep the room for a new patient, set IV's, capture the new patients vitals, etc. You know, do some actual work. If they release their patients after 2pm, the second shift has to admit the new patients."

So there you have it. Now you know. Now you know why you have to wait forever. It is sad really, but very, very true. Fixing that is to fix our collective morality, and althouh Obama's good, I've seen no water-walking from the guy yet.

Fax Router

OK, so here was the problem...SWI Diagnostics is a mobile company, a small and limited staff mobile company at that. As a result, we rely heavily on technology to help us keep our heads above water. Our work flow for final reports simply wasn't working. The studies themselves were transmited securely enough through a VPN tunnel using a DICOM compliant PACS system, but the technologist's worksheet had to be faxed to the reading physician separately. The radiologist would dictate the study and send the dictation file to the transcriptionist, who would then send the final back to the radiologist for his digital signature. Only then would the final report be sent back to us, at which time we would route it via fax back to the originating physician. It was a nightmare, especially when you're on the road doing studies, as far away from the fax machine as you can get. I needed to be able to route incoming faxes to an email account as a PDF attachment, and there are plenty of Internet fax services out there that will do that for you for a price. eFax is around sixteen bucks a month plus something like seventy cents a sheet. With any volume that solution would quickly add up to more than we were willing to spend. The Fax Services Manager available in Microsoft Server 2003 and SBS will also route faxes via SMTP gateways, but that also seemed like a bit of an extreme since I was running XP pro on every machine in my network. Mixed clients don't work well for Microsoft. So, whats the answer here? Write our own fax router of course. Which is exactly what I set out to do over the weekend. The windows fax console embedded in XP SP2 seemed to send and receive faxes just fine, and it placed the converted tiff file in a directory of my choosing with just a few out of the box configurations. My solution was to develop a windows service using visual studio that would essentially invoke a filesystemwatcher component on the incoming fax directory that I set up during the fax console initial configuration. Whenever a new file arrived in the folder, I would capture the file name and pass it as a parameter to a simple smtp function I wrote to route the file as an email attachment to any address I specified. I used the System.Net.Mail namespace to accomplish this. Also, I used the GMail smtp server since I don't run the mail protocol on my machines. It works great. Our techs are now able to receive faxed orders on their mobile devices, regardless of where they are. I am working on a module to evaluate the fax header information in order to develop routing rules so that I can use the application to automatically send a carbon copy fax to the referring physician as soon as we receive the incoming fax of the final report. This is a huge step forward for our operation, and I'd be happy to post the source code for anyone who might be interested in the router. It is fully configurable and uses a modest xml file to store its connection parameters.

Free Advice! Free Advice!

If you’re considering self employment let me be the first to say - go for it man. It can be the most rewarding thing you will ever do. It could also be the biggest pain in your ass you’ll ever experience, and I mean the large inmate, prison rape kind of pain in the ass. I've been doing this for some time, and believe me; I've made my share of mistakes. I've also stumbled across a good decision here and there. So, since I'm in a generous sort of mood, I've decided to compile some choice nuggets for those of you who have either recently started a business or are considering taking the proverbial leap of faith. Consider this free advice, wisdom from lessons learned if you will.

First, if you're a small business owner, you already know (or should already know) that one of your greatest challenges is the challenge of providing value to your customer at all times. Now, that value can either be real or perceived. You can over analyze that statement all you want, but the fact is that in the end, you want people to feel like they are getting their moneys worth, or at least that they leave feeling as if they were treated better than they would have been treated had they gone to see your competitor. I use the word "feel" for a reason, because honestly, you could care less how their experience would have been across the street. You just want them to think it’s always a better experience at your place. That doesn't mean you get an open license to publicly blast your competition in front of potential customers. In fact, that angle more often than not backfires, and it makes you look like an asshat. Between true value and perceived value, perceived value is the most ubiquitous. Wanna know why Americans are so damn fat? Because Outback and Applebee’s and TGI Fridays and Bennegan’s and O'Charlies have all figured out that by serving you big ass portions, portions that you cant possibly eat in one sitting, they are creating a very lucrative perceived value. You, the fat ass customer, end up thinking that you're getting more for your money. More than let’s say, if you had gone to Olive Garden. Hey, here’s a thought... maybe that endless salad bowl isn't such a bad idea after all. Anyway, the point is that the perception of value is often more powerful than value itself. Why? Because it doesn't cost Chili's squat to heap on an extra pound of mashed potatoes, even if it ends up in the trash. They will gain so much more when you leave feeling fat and happy. You'll gain a few things too, by the way.

Second, as a rule, don’t ever misrepresent yourself, your experience, your service, or anything about your business. In short, cut the bullshit. People hate bullshit. I mean, you would think that one is common sense, but then again maybe collective wisdom isn't really as common as it should be. So it’s not surprising that we're a victim of shit slinging more often than we should be. If you're the a owner of a small business hocking goods or services to the general public, and it's just you, I mean...just you as in no other employees or help, do us all a favor and refrain from using misleading statements such as "we" offer the best blah, blah, blah or "our team of qualified professionals". If you're a sole proprietor-- and the only one on the job, just say so. There’s no shame in being an owner operator. People often make that mistake because they think it's always better to portray some sort of image that their company is larger or more established than it really is. Don't do it! It's disingenuous and retarded. Imagine meeting your soul mate online. (I know it's a goofy analogy, but humor me here...) Imagine meeting someone, I mean really meeting "the one". You guys hit it off right away and start chatting it up every day for months. You tell each other everything. You have really fallen for each other. Then one day she tells you that she's really into you and wants to meet in person. Problem is, those were Jude Law's abs in that shirtless photo you sent her of yourself back on day two. Nice job asshat. Now what?? It's the same thing with your business. What happens when your "extensive resources" can't deliver because YOU'RE SICK??? What happens when your "eager staff" has to pick up YOU'RE KIDS??

Lastly, don't give your shit away. TIME IS MONEY, if you've spent time on it, charge for it! I have a friend who's a high-end trim carpenter. I'm talking about a real old school craftsman. The kind of stuff where the crown and baseboards fit so tight that no caulk is needed. He also builds custom wood shutters, those Spanish Cedar Bermuda beauties you often find on historically correct eighteenth century houses on Tradd Street. He told me once that some competitors confronted him at a jobsite on the peninsula and angrily asked him how he got away with charging so much. He told them that value is not the same as price. Value is what someone is willing to pay for something, if that something happens to be perceived to be of a higher value, it will command a higher price. Over the years he had created the perception of being the very best. Are their others just as good? Sure there are... but this is the guy that built those custom mahogany bookshelves over on their buddies Edisto Island Estate. He has created a perception of value every bit as lucrative as that pound of mashed potatoes they heap on your big ass extra value meal.

New site is up...

As many of you know, we have been transforming our business from an elective 3D ultrasound service into a full diagnostic Mobile IDTF. The process has been slow but deliberate, and we have made great progress both in refining our service value, as well as in getting the word out. We have some very good physicians on board and we are pleased with the transformation to date. I had set initial goals to bring on additional accounts, as well as to branch out into the sub-specialty area of musculoskeletal ultrasound. MSK, as it is known, is an incredible asset to orthopedic surgeons in the real-time evaluation of procedural efficacy. Think of rotator cuff range of motion evaluations after surgery, in stunning 3D clarity. By combining MSK, Vascular, and general ultrasound services along with Per Diem technical coverage and accreditation support services, the doors are wide open for growth. We also changed our corporate image and have adopted a new more professional look and feel. Our website has also been transformed by this new and improved attitude. Take a look at it here. I'll have to give the credit there to my friend and long time colleague, Larry Collete. Larry and family will be making the move to South Korea soon, and we'll miss him while he's away on his far east adventure. Thanks Again Zonka.

Networking DICOM enabled devices

Over the last few weeks I have been working with our Radiologists' IT guy, Randy, to optimize the virtual private network (VPN) between our PACS servers. The initial configuration has been working in a pull mode, but now we finally have a true point to point secure network. Sean, a colleague of mine from SPAWAR helped design the network. He has a ton of experience designing network security systems for both ship and shore based applications. Another SPAWAR guy we know, a true old school network engineer, has been developing teleradiology solutions for Navy Medicine since the technology emerged. Actually, Navy Medicine is one of my largest sponsors, so I also have a great deal of experience with the nuances and overarching regulatory requirements for medical networks. Just as it is for a small branch medical clinic in the military, if a small civilian family practice wanted to get into telemedicine or teleradiology, there would be very few options out there without going through the big box vendors like GE or Phillips. We find that in the defense environment, even though the medical activities rely heavily on technology, they do not have the resources required to implement information assurance and security effectively. After all, Information Technology isn't their core competency; medicine is. That's where commands like SPAWAR come in. We have the experience and know-how to integrate common off the shelf products to create a layered network protection strategy. We can help the medical commands insure HIPAA compliance. We figured the same holds true for private practice in the civilian world, even for small rural hospitals. We have been kicking around the idea of doing some consulting work through SWI diagnostics, my wife’s LLC. Her customer base is heavily rural, and initial conversations with some of these folks have generated a very positive reception. Although we may initially have to drive to Georgetown to reboot a print server for fifty bucks, we will eventually open the door to an array of future support functions, including helping rural practices go digital and securely connecting them to the outside world. Second opinions from university hospital specialist are only a click away.

Operation Ultrasound

Holly and I watched a moving piece on public television a few weeks ago that documented the lives of military families. The program examined how these families cope with the stress of separation and the ubiquitous fear of the unknown. It left us feeling indebted and obligated to the people who risk their lives to preserve an esoteric right for the rest of us to live ours the way we choose. We wanted to give something back, and as valuable as a care pack full of chocolate is in Kabul, we wanted to offer something that could genuinely help some of these young families to stay connected. Starting May 1st we are launching "Operation Ultrasound", a FREE service to pregnant wives of deployed US servicemen. Participants will get a CD with a digital image file of their baby that they can email to their husband oversees. Recent studies have shown that the bonding experience provided by a 3D ultrasound can help mothers improve their diets and exercise more frequently, but for military fathers, the chance to actually see the baby and create a pre-birth bond is instrumental in drawing the whole family closer together, and it can provide an important bridge connecting dad back home. Holly figured she would do something she knows, and she knows ultrasound. If you guy's know of a local military family that could use this service, feel free to pass them our way. You can see the official press release here, and there is more information about it on our website. Help us get the word out, we tentatively set this to run through June, but if the response is there and it's not overwhelming for us, we're open to extending it as long as we need to.

Ignorance is bliss

Every once in a while those uncertain actions we take on a hunch are validated by a successful outcome. As small business owners, my wife and I make a lot of decisions from the gut. You have to. Market analysis is about 95% common sense and about 5% hunch. Several years ago when my wife started her elective ultrasound center, we did a full scale market analysis. We researched the total available market utilizing US Census data for our regional population and combined it with data pulled from South Carolina's Department of Health and Environmental Control on birth rates in our area. We divided the total available market into income level categories and analyzed the resulting cross sections. Through statistical inference we were able to quantify our projected target market. The numbers didn't lie. We knew going in that we would have to reach an abnormally high percentage of the target market in order to generate enough cash flow to remain solvent, but since there was no competition in the area, we decided to go ahead and take a leap of faith. Months into the ordeal and very near throwing in the proverbial towel, we realized that Dionysus had slain Apollo and the ensuing exuberance outweighed the rational. We ended up making significant changes to our business model out of necessity, but we emerged stronger and wiser in the end. We still offer elective 3D ultrasound, after all, being able to offer this incredible experience to women in the Lowcountry was the impetus for the business in the first place, and that hasn't changed. We spent a tremendous amount of time and energy to convert from an elective, self pay approach to a physician ordered reimbursable approach. It has already proven to be the best decision we have made to date. Last week while I was doing some research on the Internet I noticed that the owner of a well established elective 3D ultrasound center in the midlands had placed her business on the market for sale, effectively validating our hunch that an abnormally high percentage of the market is required to support these endeavors. I won't claim to know the underling reasons behind that sale, but based on her publicly disclosed financials, I'd say it was because it barely pays the rent. Been there done that. Like I said, market analysis isn't rocket science, it's common sense. Unlike other service oriented businesses, the market for elective ultrasound is finite, meaning, you can't manufacture clients --without an army of irresponsible gigolos. To be in the market for a novel 3D ultrasound, you have to be a female, be between eighteen and twenty-six weeks pregnant, and have at least some degree of disposable income. If that's not a finite market I don't know what is. A few months ago while our business was already undergoing its transformation, we received a phone call from a potential competitor who stated that they intended to open an elective 3D ultrasound center in our market. To be fair, they were returning a anonymous call we had placed to inquire about their pricing structure and service offerings. They just wanted us to know that they thought there was enough business out there for everyone, and wanted us to think of them as a partner as opposed to a competitor. Holly and I both got a good chuckle out of that...but under the circumstances, perhaps a belly laugh would have been more appropriate.

Moving up, Moving out

I realize that this blog was originally conceived to chronicle the restoration of a charming downtown Summerville cottage, but restoring a 100+ year old home is only one of my many duties. I have a large hat collection. Monday to Friday I wear a business systems analyst fedora for a defense contractor supporting the Space and Naval Warfare Systems Center over on the old Naval Weapons Station. In the evenings I don the IT guy derby for my wife’s diagnostic imaging center. I keep the VPN firewall up and running and make sure that the radiology and DICOM files are being processed and archived as planned. Maintaining the PACS system should be a full time job, but I squeeze it into a few hours in the evenings. On weekends and most holidays, I put the hardhat on and work on the house.

As I described in a previous post, we purchased the property primarily as a mixed use residential-professional office arrangement. We intended to convert a large detached two car garage into a home base for our mobile diagnostic ultrasound service, and that is precisely what we did. I completely renovated that outbuilding, wired it, installed a bathroom, installed central heat and air, and built out the area as office space, but as our business grew, we grew out of the building and ended up moving our offices into our residence and redesigning the converted garage to function as an outpatient exam room for vascular and prenatal ultrasound.

The CMS (Medicare) test deposit was entered into our bank account on Thursday, so it would appear that our enrollment package is nearly complete. We will be able to accept insurance any day now. Our promotional material has arrived and we will begin a comprehensive marketing campaign within the next two weeks. What that means is that our business is growing. We will soon need even more space. After many hours of contentious deliberation, Holly and I decided that we would inevitably have to convert the entire residence into an outpatient imaging center. With some work, the building would make an ideal medical practice. After all, a local attorney operated out of the space for many years. So, essentially the front two bedrooms will be converted into exam rooms, and the parlor will be converted into a waiting room. The living room will house a horseshoe administrative area, and the back bedroom will be an executive office. The kitchen, of course will become the employee break room. The converted office outside will become a vascular lab.

In order to make this space work as a state of the art imaging center, we have to take on several large projects including building a wheelchair ramp off of the front porch. We also have to remove the gorgeous claw foot tubs and replace them with urinals and ADA compliant fixtures. We have to build the horseshoe administrative area, run the appropriate communication lines, and put sinks in all of the exam room spaces. Most of the doors will have to be widened and replaced with industrial solid core flush units. We would have to replace all of the carpeting, and install vinyl composite tile in the exam rooms. We also would need to replace the windows and cover them with attractive Bermuda shutters on the exterior to limit the sunlight infiltration and create the appropriate ultrasound conditions. Of course, I will probably hire a general contractor to tackle these projects. All in all, the layout couldn't be better, and the great part is that in the end we can deed the property over to the LLC and instantly increase the asset side of the balance sheet.

A couple of weeks ago I noticed that our facility was chastised as “make-shift” on another merchant’s blog. I don’t know what this persons motivation was or even if they have ever been inside our facility. I doubt that they know the reasons behind our conscious and socially responsible decision to utilize a mixed use zone. I doubt that they know that most of the homes on our street, with the exception of one, are currently in use as professional offices. In fact, I doubt that this person knows much of anything. I have lived in Summerville my entire life with the exception of a few years while I was away in college. I was born in the old hospital, now the county services building off of Main Street. When I was in high school the US Census count said there were less than six thousand residence in Summerville. There are nearly fifty thousand now, with over half of them arriving in the last decade alone. With all these new residents comes new services, new shopping centers, and new strip malls. If there is one thing I despise more than anything else, It's seeing new strip malls detracting from our truly remarkable landscape. Don’t get me wrong, as a small business owner; I’m clearly not against growth. I just think it’s a shame to build new strip malls when so many existing ones are so anemically vacant.

In order to maintain the integrity of the town center, people need to live where they work. Otherwise you don’t have heterogeneous sustainable growth, you have sprawl. No one wants sprawl. Anyway, a note to the uninformed: Our decision to live and work from our home was not based on financial reasons, or any other reason that you might dream up for that matter, rather it was based on a humble attempt to revitalize a part of our beloved community; a community that is being threatened by the very irresponsible development you operate your own business from. Get a life. Get informed before you feel the need to comment on something you obviously know nothing about.

Thoughts on Ultrasound

With South Carolinas' proposed ultrasound bill making headlines nationally, I thought I’d chime in on the business of ultrasounds in general...while the subject was still at arms reach. I feel uniquely qualified to comment on ultrasound since my better half operates an independent diagnostic testing facility, or IDTF, specializing specifically in the modality. Her facility offers both full diagnostics as well as 3D/4D limited diagnostic/elective ultrasounds.

Elective keepsake ultrasound facilities started appearing around the country in the late 1990’s, when ultrasound technology made the leap from grainy single-slice two dimensional renderings to volumetric three dimensional images that generated incredibly life-like images of babies in utero. We’ve all seen the commercials. These keepsake ultrasound places use the new 3D and 4D technology to provide expecting parents an exciting preview of their baby with detailed graphic image quality and motion.

My wife is an ARDMS registered sonographer and registered vascular technologist(RVT). She chaired the Diagnostic Medical Sonography program at our local community college, first as its clinical coordinator and then as the Program Director. She started the 3D-4D elective center three years ago. I wont hesitate to say that perhaps we viewed the world with rose colored glasses back then. The endeavor nearly broke us. The whole starting a business thing was exhaustingly hard work, and needless to say, although it has been what one would consider successful, it did not go as well as we had imagined it would in the sense that it failed to produce that elusive sense of fulfillment often associated with an entrepreneurial spirit. If you're a professional in the medical community in the Holy City you know that the community itself is holier than thou...both tight-knit and conservative by nature. So, for every minute of positive publicity she managed to generate, it was equally matched with two minutes of the negative variety. She only saw a handful of clients her first month despite aggressive advertising and a costly professional marketing campaign. She had essentially been black-listed by the establishment.

She started this business out of sheer passion and a love for the profession, and by stripping away the bureaucracy that has become ubiquitous in our health care delivery system, she could allow women access to the latest applications and technology while still maintaining a small, patient-focused atmosphere. After all, these services wouldn’t be available if there wasn’t a demand for them, and 3D ultrasound is truly a patient driven service. 2D ultrasound on the other hand, when operated by qualified sonographers is quite sufficient for obtaining clinical indications. Interestingly enough, very few CPT codes exist for 3D procedures, which means that reimbursements are the same for 2D as they are for its more desirable 3D cousin (desirable from the parent’s perspective that is).

So, for the short term at least, these entertainment businesses will thrive, and as well they should…because there is a demand, right? Not so fast. After three agonizing years in the elective ultrasound business, all the while kicking and scratching to preserve what was left of her professional image while fighting for every client, the handwriting was quietly etched on the wall. It is only a matter of time before the elective ultrasound industry is regulated completely out of business, but before that is allowed to happen, technology will catch up with it and drive the final nails into its coffin. I used this analogy with my son: "Why would you pre-order an x-box for $600 when you have a perfectly good play-station? You don't need the x-box, you simply want the x-box...and if you're patient, you can buy it next year for $350." The same holds true for these new ultrasound machines. Right now, Doctors don't need them, but as the technology advances, the new machines will become more affordable and rapidly replace the older units currently found in every OB-GYN office, thereby eliminating the demand for boutique ultrasounds altogether. In fact, there is convincing evidence that this trend has already began to manifest itself in the Lowcountry, and if you need further proof that self-refer is a tough row to hoe, take a look at what happened to Prevecare east of the Cooper a few years back.
My wife’s own company just purchased a brand new 3D ultrasound machine that is more portable, more powerful, and cost about half of what her first unit did…Now don’t get me wrong, it was still outrageously expensive, but my point is that they are now well within the reach of most private practices. Seeing that the handwriting was indeed on the proverbial wall, she felt it was time to start transitioning out of the elective ultrasound business and into the mainstream medical market. We needed to enroll in Medicare as a certified provider, begin accepting insurance, hire a physician, and contract with a radiology service to interpret the studies. She’ll still provide 3D ultrasound, it just means that we’ll be marketing to the doctors for referrals as opposed to marketing to the general public, but it also means an ADA approved facility, wider doors, wheelchair accessible ramps; grab rails, sinks in every exam room, the whole nine yards. More overhead? Absolutely. More regulatory oversight? Absolutely. Brighter future? Undoubtedly. One thing we will miss though is the 100% reimbursement we enjoy with the self refer work…a traditional provider only collects on about sixty percent of what is billed. Now I understand why they bitch so much.

So for all the moms-to-be out there seeking those keepsake ultrasounds...Do it the right way. Do it the safe way. Let your doctor know you want to have your diagnostic exam performed in a relaxing, patient focused environment, where the 3D pictures are complementary. He'll get a full report from our board certified in-state radiologist, we'll bill your insurance, and you can invite your family to share the experience. You'll leave with reassurance instead of a kitchen magnet and a false sense of security. We’ll keep you posted on the transformation.