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    Starting a practice
    5-6 months out: Office design and supplies

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    Now's the time to consider how your office will be laid out and what furnishings and equipment you'll need.

    Congratulations. As a physician launching a private practice, you have an opportunity most people don't enjoy—the ability to shape your work environment. And that's what you'll do when you design and outfit your office. The carpet you walk on, the chair you sit in, the computer you type at—they're your call.

    Some of the decisions you'll make will be innocuous, such as where to buy tongue depressors. But others will have a major impact on patient care, practice productivity, and your prosperity for years to come. How will you lay out exam rooms to prevent wasted motion? What computer system will reduce medical errors or maximize collections?

    Besides creating an office that works for you rather than against you, you want the most bang for your buck. After all, doctors starting new practices are stretched thin financially. We've interviewed experts to help you make good decisions that are affordable, too.

    Two basic choices in rental space

    There are two kinds of medical office space on the rental market, and each one presents you with slightly different choices. If you're leasing in a brand-new medical office building, you're probably getting a shell that you must then "build out" with walls, plumbing, etc. This scenario gives you the most freedom to design your workplace, but it's also the most expensive—anywhere from $60 to $90 per square foot, depending on location, says Richard Haines, Jr., an architect in suburban Atlanta. If you're a veteran doctor who's starting over in your hometown after a stint with a hospital system, and you expect to be busy from Day One, you may have enough financial resources—or bank credit—to go this route.

    Landlords generally provide new tenants with an allowance for building out, calculated by the square foot, but it's not a freebie since it's rolled into the rent. Also, the allowance may only be enough for a bare-bones design, so be prepared to kick in extra money, says practice management consultant Keith Borglum in Santa Rosa, CA. "Since you may practice medicine there for 30 years, it's a good investment."

    In a build-out scenario, you'll need to hire an architect, who will ensure that the design meshes structurally with the rest of the building. Look for someone who specializes in physician offices, preferably someone who's worked in your medical field and will be able to give you a design that maximizes your efficiency.

    An architect usually will give his drawings to the landlord, who will either use them as is or have his own architect adapt them. Either way, the landlord will give the final plans to a contractor who's finishing other offices in the building.

    Given the varying availability and high cost of new medical office buildings, it's more likely that you'll lease space that's already built out. Here, you may opt to remodel—construct a new receptionist station, lay down new carpet, perhaps create an extra exam room. You'll have fewer design choices because you can't gut the space, but the bill will be considerably lower. Again, the landlord probably will give you a remodeling allowance, which may not cover all your costs.

    If you're just remodeling, says Borglum, you may be able to rely on an interior designer instead of an architect, since the work is less structural. And you'll probably be able to choose your own contractor, who may provide design services.

    There are situations, though, when even remodeling, never mind superefficiency, has to go on the back burner. "If you're fresh out of residency, or an old pro transplanted to a new community, you may see only 10 patients a day at first," says Haines, president of Medical Design International. "Efficiency won't be a big issue for you. I'd recommend looking for cheap space you wouldn't have to change much, and living with the imperfections. You'll have enough cash flow problems as it is. You can move when the practice gets rolling."

    Minimize steps maximize comfort

    Whether you build out or remodel, keep in mind the tenets of good medical office design and achieve as many as your pocketbook will allow.

    One tenet, says architect Richard Haines, is that people don't get work done while they're walking. Hence, minimize the number of steps that you and your employees must take. Cluster the exam rooms, for example, so you can move quickly from one to another. Include a recessed workstation in the middle of that cluster, says Haines, so that you can study charts and make phone calls between patients. If you can save 15 or 20 seconds between patient encounters, you can free up enough time to see an extra patient each day.

    Streamlined floor plans move patients logically from waiting room to nurse's station to exam room without backtracking or hallway congestion, says Haines. "When you and the patient exit the exam room, he should turn one way toward the cashier station while you turn in the opposite direction."

    Experts say a primary care doctor needs at least three exam rooms for top productivity. "Remember, you're not the only one using the rooms," says consultant Keith Borglum. "Medical assistants need to work up patients before you get to them."

    Unfortunately, many old offices have only one or two exam rooms. If you're renting such quarters, consider converting the physician's private office into an exam room or carving one out of the waiting room. "The more exam rooms you have," notes Borglum, "the less space you need in the waiting room."

    To determine how big your waiting room should be, take the number of patients you expect to see during your busiest hour and multiply that number by 2.5 to account for tag-along relatives and friends. Then subtract the number of exam rooms. That's how many chairs you'll need. Next, multiply the number of chairs by 20 square feet. Accordingly, a solo practice that peaks at six patients per hour should plan on a 240-square-foot waiting room with 12 chairs.

    Creating a comfortable, practical waiting room is a science unto itself. Patients should see the receptionist counter as soon as they come in, so they don't feel lost. In turn, the receptionist should be able to see all of your patients no matter where they're seated, so nobody is forgotten. Make sure pathways are wide enough and the receptionist counter low enough for people in wheelchairs.

    A good waiting room avoids institutional coldness and makes patients feel at home. Arrange chairs in cozy pods rather than lining them up along the walls. You can avoid glare by putting diffusers over fluorescent lamps or using incandescent table lamps. The time-honored aquarium helps everyone relax, provided it's kept clean.

    Since patients tend to judge you by the quality of your waiting room, it pays to make a good first impression. Furnishings should convey affluence, but not opulence. You can accomplish a lot with strategically spent dollars, says Borglum.

    "If the door and doorjamb are dinged up, you should replace them," says Borglum. "Likewise, install a marble countertop at the receptionist station. Small touches don't cost that much, but they make patients think positively about you, even if the rest of the office is plain."

    Where to go for furnishings and supplies

    Turning an empty office into a functioning one requires a shopping spree. Before you start loading your cart, though, do your homework. Ask colleagues where they buy ECG paper and syringes. Find out whether your national or state medical society recommends vendors and if members receive discounts. AMA members, for example, get discounts of 20-36 percent on office supplies from a company called Penny Wise Office Products. Members of the Texas Medical Association can buy their paper clips and ink pens from Histacount for 15 percent less. You might save money by purchasing through a local hospital or an IPA. Consultants can steer you to good deals, too. Increasingly, supply companies have Web sites, so take advantage of shopping online.

    Furniture. If you've got the budget, consider using an interior designer to help you select and purchase chairs, tables, and other waiting room furniture, which he'll coordinate with the entire room. But designers charge huge markups. You'll need to negotiate hard, says architect Richard Haines. "Limit the price to wholesale plus 25 percent."

    Other good sources for furnishing your new digs include medical supply vendors and used and refurbished office furniture stores in big cities. Wherever you shop, don't skimp on what patients sit on. "You want sturdy chairs with arm rests that let older or infirm patients push themselves up, and a couple armless chairs for obese patients," says Keith Borglum. "New chairs like this can easily cost $200 to $300."

    These same companies sell furniture that you and your staff need. Discount office-supply stores are also worth a look. "Be a good boss and provide comfortable seating for staff," says practice management consultant Gray Tuttle Jr. in Lansing, MI.

    Clinical equipment and supplies. Don't know where to start? You'll find a supply checklist containing many items needed in primary care practices in the Clip and Copy article in this issue. Consultants and vendors usually have similar lists.

    In the quest for bargains you may want to purchase a few big-ticket items, such as an ultrasound machine, individually. But when it comes to most supplies, including so-called consumables like exam table paper, it's more practical to buy en masse from a single source. Give your list to two or three vendors and ask for bids. We list several leading medical supply companies (see box).

    Office supplies. If you'll rely on paper charts, you must buy them from medical supply houses or specialty companies such as Bibbero Systems ( www.bibbero.com ) or Colwell Systems ( www.colwellsystems.com ). For ordinary stuff like copy paper, consider retailers such as Office Depot ( www.officedepot.com ), where you can shop online and enjoy free next business-day shipping for orders of $50 or more.

    Purchasing should be handled by only one employee; often it's the office manager. If several staffers get into the act, you risk duplicate orders. Plus, an employee who's given full responsibility for purchasing is more apt to learn where to get good products at the best prices. Get bids on consumables at least once a year to keep vendors hungry for your business.


    Our July 23 installment will discuss what to do three to four months before opening your practice. Topics will include determining staff size and makeup, salary and benefits, developing job descriptions, advertising for help, and how to interview and make hiring decisions. Previous articles in this series are available here.


    Checklist for starting a practice


    5 to 6 months before opening

    Check off as completed
    Hire an architect or designer for your new office.
    Lay out office to ensure comfort and ease of workflow.
    Seek bids for remodeling, if need be, and hire a contractor.
    Determine your needs for furnishings, clinical equipment, and supplies.
    Shop for furnishings, equipment, and supplies.
    Determine your need for information technology.
    Choose IT vendors and negotiate a deal.
    Make a plan for IT installation and training.


    Look, Ma—no paper: Information technology for your new practice

    If cost were the prime factor, you'd automatically opt for a pencil and a piece of paper rather than a wireless tablet computer. However, you can't afford not to build your practice on the latest in IT. Patients, hospitals, and payers increasingly want to communicate with you online. Quality-of-care advocates want you to prescribe electronically. And wouldn't you like to eliminate those time-wasting searches for lost paper charts?

    The high price of computer hardware and software, of course, is a speed bump on the road to the paperless office. Accordingly, if you're starting your own practice and money is a problem, Sarah Wiskerchen with KarenZupko & Associates in Chicago says you may be a candidate for an outside billing company. You'd be using the billing company's practice management software instead of buying it yourself. And some companies provide computer terminals for scheduling patients and reviewing billing records. Your practice might only have to buy several desktops for bookkeeping, word-processing, Web surfing, and e-mail.

    However, it may not make sense to outsource billing if you also want an electronic medical record. Practice management and EMR systems should exchange information, and increasingly, they're sold together as integrated products, sometimes sharing a single database. "It's rare to find a billing service that's using practice management software with a strong EMR connected to it," says computer consultant Rosemarie Nelson in Syracuse, NY.

    And the launch of a new practice is a perfect time to set up an EMR. "It's more painful to convert to one after you've been using paper records," says Laura Jantos, an IT expert with ECG Management Consultants in Seattle. "You have to break old habits."

    A combination practice management/EMR system isn't cheap. When you add up software, hardware, implementation, training, maintenance, and updates, the cost can easily be $30,000 to $40,000 over five years for a soloist. However, by leasing everything, you can get your fingers on a mouse for a monthly payment of $500 to $800. Web-based software from a so-called application service provider might nudge down the cost, since you wouldn't need to buy a server.

    What you should know about healthcare IT

    The foundation of your IT system is software, which dictates what hardware you need. If you buy hardware first, you may discover your software won't run on it very well, if at all.

    Practice management software comes with the same basic features no matter who makes it. They allow practices to register and schedule patients, generate bills, post payments (including capitated ones), produce critical reports such as aged accounts receivable by payer, and transmit electronic claims; the best ones post electronic remittances and capture real-time information from payers about patient eligibility.

    Compared with practice management systems, EMRs are all over the map. The EMR label can get slapped on something as primitive as paper charts that have been scanned and archived as PDF files. Full-fledged EMRs, however, are more powerful, allowing you to chart a visit, prescribe, view lab results, and communicate electronically with staffers. Truly integrated systems let you generate diagnostic and procedure codes and then send charges to the practice management side.

    Well-designed EMR systems are flexible: They give you several options for data entry, such as voice recognition, typing, stylus, and even handwriting. And they're easy to customize, letting you add your own questions to a template for, say, examining diabetics.

    How to shop for the right system

    When you understand what healthcare IT systems can do and what features are important to you, start checking out vendors. Attend trade shows, ask your colleagues what they're using, try online demos, and see if your medical society offers recommendations. The American Academy of Family Physicians, for example, has partnered with four companies that sell both EMR and practice management systems and two others that sell only EMR systems. They've agreed to give hefty discounts to AAFP members.

    Evaluate potential vendors as carefully as you would a partner. "The first thing to determine is if they're financially stable," says Laura Jantos. "You'd like a company that's been around a while and is making money."

    Narrow down your list with other questions. Does the vendor market to small practices, or is its software designed for big groups? Was the EMR software written with your specialty in mind? Can the practice management software generate HIPAA-compliant claims? Will it let you tweak the claims to suit specific payers? If the vendor works through a "value-added reseller" in your area, what's the VAR's reputation?

    Once you've come up with a handful of prospects, send them a "request for proposal" listing the features you want. Your shopping list should include hardware, experts say. Buying hardware through the vendor helps ensure compatibility and simplifies troubleshooting. Pare your list to two or three candidates and schedule a demonstration of their software.

    Ask for references and visit one or two users to see the product in action. Remember, though, that vendors sometimes compensate references with price discounts or extra service, rendering them biased, says Susan Jones, a healthcare IT expert in Lebanon, IN. "Seek out uncompensated references," says Jones, co-author of How to Select and Implement the Right Computer Solution for your Practice (available for $67.50 at www.medicalbusinesspublishing.com ).

    Find a winner? Negotiate your price, paying careful attention not only to the initial cost of software and future updates, hardware, plus implementation and training, but also annual support fees, which may balloon over time if you're not careful. "Some companies include updates in the support contract, others don't," says Jones. Also pin down who's responsible for installing hardware—you, the vendor, or a VAR.

    Once you've signed a contract, establish a timeline for installation and training that will work comfortably with your scheduled opening date. Also plan for training beyond the initial startup so that you and your staff can master advanced features of the system that would be too much to absorb at the onset.

    We've touched on the basics of practice IT here; to read more on the subject, visit the Technology section of our Web site.


    Clinical supply vendors

    Here are some major players in the business of outfitting physician offices.


    Henry Schein

    McKesson Medical-Surgical

    MedMatrix (used equipment)

    Physician Sales & Service


    Further reading from Medical Economics

    "Make your office layout serve your needs," June 19, 2000

    "Spot the safety hazards in this office—and yours," May 7, 2001

    "Order supplies online? You bet!" March 8, 2002

    "Practice management systems: Here's what to look for," Feb. 7, 2003. Special Technology Section

    "Add services without big debt," April 11, 2003

    "The key to a HIPAA-safe computer system," April 11, 2003

    "EMRs: What you need to know," May 9, 2003. Special Technology Section

    "Practice Pointers: Create a first-rate first impression," Nov. 7, 2003

    "Computer Consult: Don't buy home computers for the office," Jan. 9, 2004


    Robert Lowes. Starting a practice: 5-6 months out--Office design and supplies. Medical Economics Jun. 18, 2004;81:39.
    Robert Lowes
    Bob has reported on the medical profession since 1988, covering everything from HMOs to end-of-life controversies. He now specializes in ...

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