Intro
Hey, I'm Dr. Ariana De Mers. I'm an Orthopedic Sports Medicine Surgeon, and I have successfully integrated orthobiologics into my busy practice so that I can provide a continuum of care and treat patients who are in the gap. The gap is this gray area in orthopedics where standard conservative treatments have not been effective, but surgery may not be warranted. And we usually tell our patients, come back when it's worse. What? These are your patients coming to you for help. Orthobiologics is that solution that can fill the gap and help you treat your patients who are in your office looking to you for help. Orthobiologics can also be an excellent treatment for frustrating problems without good surgical outcomes. This podcast will help you create the orthobiologics business that will make you love your job again. We will focus on the value of orthobiologics, patient selection, how to talk to your patients about money, office setup, and other logistics. If this is something you've always wanted but don't know where to start, join me in "The Business of Orthobiologics" podcast.
Dr. Ariana
Hi, welcome to our "Scheduling Module". Here's what we're going to be covering today. Scheduling software, consults, procedures, blood draw, pain management, injection timing with biologic optimization, and follow-up. So let's talk a little bit about scheduling software. You guys think about what your needs are. You do need a scheduler. Sometimes an EMR or a Customer Relations Manager, or a CRM will be helpful. When we talk about a scheduler versus an EMR, we use an appointment scheduler if you're going bare bones. It's usually paired with a GDrive or Google Workspace to house your health records securely. Please note, a G Suite is not specifically designed to be an EMR system and may not meet all the requirements for medical practice but it can be super helpful and very low-cost and a HIPAA-compliant option. Obviously, we're all familiar with your electronic medical record as a system for keeping track of your patient records, history, test results, treatment plans. It's obviously HIPAA-compliant, make sure it is. And it should be easy to use for all your staff members. And really, you need to be using this if you're transitioning to a full cash practice. If you're adding this to your existing practice or clinic, make sure you can identify a separate location for your cash practice option. If you're really interested in doing a lot of the marketing and customer outreach, a CRM is a software application that helps your business manage the interactions with your customers and potential customers. A CRM system can help your business streamline your sales, your marketing, and your customer service efforts by providing a centralized place where all of the customer information and history can be stored. This can be paired with a GDrive to house your medical record as well. So just to make sure you understand, the CRM can manage customer information, track customer interactions, as well as purchases, automate sales, and marketing processes. You have your drip marketing options through email or other outlets. It can provide analytics and reporting for who is your best customers and where you're finding your customers. So we're going to talk a little bit about your office scheduling considerations. So I'm going to recommend a block schedule to allow time and flow with a little bit of wiggle room if things go along or people have more questions. I currently am doing 30 or 60-minute consultations. It's super helpful if you pre-educate your patient before they come into the office. So they come in with some knowledge on what you're offering, what orthobiologics are, that we do non-surgical management, and maybe there's limited downtime or a more natural approach, non-narcotic treatment of pain, etc. We want to also recommend to get clear on who this is for, how it works, maybe the evidence supporting the use of orthobiologics, how it is the way to achieve their goals and dreams. So we do this by pre-framing. We pre-frame with written materials or phone calls. But I think an ideal way that would be helpful is to send them a video so that they get to know you before they even come in. And it can go something like, "Welcome to our practice. This is what we do here. We take care of the whole patient to address all of their concerns. We are looking forward to helping you. And this is how to prepare for your visit". And then we schedule procedure days around consultation days separately. We batch this to keep the efficiency in the flow. And then we serve all of the same types of people to elevate their experience. I don't want to be mixing my wound care follow-ups and trauma follow-ups with patients who are considering injection-based therapy and lifestyle modifications. We also schedule in some wiggle room to try to stay on time. That's one of my huge pet peeves is that I want this to feel like a very relaxed experience where it's not rushed and they may be the star of the show, the only person in the room. Additionally, we need to make sure that we intersperse these blood draws during procedures. So an example of a schedule that I have is that my nurse and I kind of go back and forth. So I'll do an 8:00 AM consult and she'll be doing an 8:00 AM blood draw and PRP processing. I do a 9:00 AM procedure. She's going to be doing another blood draw and processing for the next patient. At 10:00, I'll be doing the nerve block and she'll be doing phone calls, check-ins, data collection. Then I'll be doing the procedure from 10:15 to 11:00 o'clock. I'll do an MRI follow-up or consultation. She'll be doing the blood draw. We'll go ahead and do another consultation at 11:30, and then we'll have lunch. I know this is shocking, but we need to stay hydrated and nourished. And then at 12:45, she'll do a blood draw. 1:00 PM, I'll do a nerve block. She'll process the PRP at 1:00 PM. I'll be doing the procedure from 1:00 to 2:00. She'll do a 1:30 blood draw and patient education. At 2:00 o'clock, I'll do another procedure, and she'll continue to make phone calls for checking in on our patients, patient education, pre-framing, medication checks, are our patients doing well. And then I'll finish up with consultations at the end of the day, as well as check-ins with my patients. And she'll confirm all patients that are going to be coming to our clinic for the next day or two. Another option would be a more batched schedule where we do more procedures, less consultations. But we do need to do a pretty clear nerve block procedure, a phone consultation, a nerve block procedure, lunch, procedure, procedure, procedure, consult. And this gives people time to-- people meaning my nurse, to draw blood, process PRP, make phone calls to our patients, do check-ins, data collection, and then basically blood draw, process PRP, blood draw, process PRP, medication checks, confirmations. So that's a more batched schedule. And that just takes me doing the procedures and her doing the blood drawing and PRP processing. And that gets pretty efficient. There are benefits and drawbacks to both. So let's talk a little bit about blood draws. So obviously, this is platelet rich plasma. We're going to be needing to do blood draws. So the way I have done it is that I don't need to be present for the blood to be drawn. So my nurse is drawing blood during the procedures or at a time when they're not needing me. So maybe I'm taking my daughter to school while they're doing their first blood drop. We've been really clear on the process and making sure that our patients are super comfortable. And we're going to be drawing quite a bit of blood. And so we make sure they're hydrated the night before. We routinely draw 120 ccs of blood, 60 cc minimum, up to, depending on what we're doing, if we're doing multiple joints, 180 ccs. We always do this in a seated or semi-reclined position. You use a pillow under the arm and then place the arm kind of off to the side using gravity as well. Make sure and be prepared for the vasovagal response. People get woozy, so either a chair or bed that can lay all the way back. Have water, juice, and snacks available. And then have a plan for difficult draws. In my clinic, my plan is an ultrasound-guided blood draw by me. It is a scheduled sabotage. However, we cannot move forward without blood to create the PRP. So it's more effective to have it than not have it. And so that is our solution. Maybe a vein finder, maybe a second phlebotomist, or a nurse who can draw blood or try the different options. I've had one time where we absolutely could not draw. I tried multiple times. My nurse tried multiple times. Turns out he was dehydrated, did not hydrate, and drank three Monsters that morning before he came in. And we just had to reschedule and really push hydration. And it was no problem. I was shocked because it was a young guy with really-- my thought was really good veins, but that did not seem to be the case. So be ready for that as well. I would like to talk a little bit about pain management. So nerve blocks and radial anesthesia, for me has been a game-changer. Please, please, please, if there's any way that you can get trained with either your anesthesia colleagues or training courses, ultrasound training courses, this has been a game-changer for both me and my patients. Depending on your training and comfort, it takes about 15 extra minutes. Please don't forget to charge for this. This is an additional service. What I've ended up doing is I have actually bundled it into the cost of the procedure, so we assume everybody's going to get some sort of nerve block or radial anesthetic. This allows me to do the procedure in a significant comfort for the patient, and it allows me to not be worried if I'm hurting my patients or, you know, oh gosh, how's this going? And then it obviously elevates the experience for your patient and they have a word of mouth referrals like, oh my gosh, it was nearly painless. So this has been a game-changer for me, for sure. Make sure that you have time to let the block set up. Otherwise, it's all for naught. What I have ended up doing is after our blood draw, we send in narcotic medications for the patient to go pick up in time for-- ahead of the procedure so that they have the narcotic medications that I use for 24 to 48 hours if I'm doing aggressive treatments, and that seems to be effective and efficient. So injection schedule timing. When can we do this? If a patient comes in for a consultation, can we do an injection that day? We really try to separate those and have them come back. Now, if they're from out of town, we do plan for both the consultation as well as the-- assuming that they're a candidate and planning for the injection at the same time. Ideally, for me, I would prefer to have those separate, partly because I want to make sure they're biologically optimized, that they're not on any anti-inflammatories, that we can optimize the medications that they're on or discontinue some medications, make sure they're having optimized nutrition, hydration, hemoglobin A1C. That all takes you know, one to three months. And we want to discontinue the NSAIDs three to four weeks before the procedure, and a minimum of two weeks afterwards. We want to know if they're on daily anti-inflammatories or inhaled steroids. We can also recommend or work on prehabilitation, doing some physical therapy to optimize their situation, muscle imbalances, that kind of thing, four to six weeks before scheduling the injection. This also gives you room in your schedule to plan ahead. When we talk about medication management, there may be a need for washout time. If you're on anti-coagulants, just like any other procedure, we need to make sure that it's safe from a medical standpoint. But also if we're doing injections, especially spine-based injections, epidural hematomas are a disaster and we don't need that. If we're doing just intra-articular injections, I will go ahead and be more lenient on the use of anti-coagulants. But if we're using soft tissue, bruising and swelling and bleeding in the joint is not ideal and really should be considered. There may be a washout time for cannabis, giving it a suppressant like Methotrexate or those kinds of things. There's some discussion about the anti-hypertensives and whether some of those anti-hypertensives for stem cell type procedures should be discontinued or transitioned away from the calcium channel blockers. And this is not standard of care, but really a consideration for what's happening in our patients so that they're biologically optimized. So medications to discontinue, non-steroidal anti-inflammatories, aspirin, Ibuprofen, naproxen, and others which can interfere with your platelet function and increase your risk of bleeding. That's a one-week minimum before PRP. Your anti-coagulants like Warfarin, Heparin, and Enoxaparin, all of the non-reversible blood thinners can increase your risk of bleeding and may diminish your platelet function and de-granulation. So making your treatments less biologically active. I use standard surgical and epidermal recommendations, which is usually seven to ten days. When we talk about herbal supplements, these are things that can thin the blood such as ginkgo biloba, garlic, ginger, and others which can affect your platelet function but also increase the risk of bleeding. And I use a standard surgical and epidermal recommendation usually 7 to 10 days. Let's talk a little bit about your follow-up. The devil is in the details and our patients really, really appreciate the follow-up and keeping in touch and making sure that everything is going right. And if things are not going right, or maybe they just need some reassurance that we are keeping in contact. So post-injection day one, we give a phone call or a text checking in with my nursing staff. In week one, we do a physician check-in. These are pretty quick and we batch these. And we just want to make sure that if they need a pain medication refill or reassurance, and you don't have to do a physician call, you can do your clinic call, nurse call, and check-in. I have an in-person visit at week six to eight. We do an evaluation, rehab evaluation, do we need additional treatments, get testimonials, and do our data collection for our research studies. In month four, we want to do functional and pain data collection. Month six, final evaluation, obtain testimonials, referrals, and data collection. So this is a new schedule paradigm. I'm really going to recommend block scheduling. And this creates happy patients, happy doctors. They get leisure and attention, and we have a happy life. As Roosevelt said, "Believe you can, and you're already halfway there". Thanks for listening and we will see you in the next episode, and we'll talk next time about equipment and other options that we can do. Have a great day.
Outro
This has been "The Business of Orthobiologics" podcast. Thank you so much for joining us today. If you want to know more, please join us on the website, "PRP-Now.com", and click on the FREE Masterclass. Also, don't forget to "SUBSCRIBE" to this podcast to get more guidance on integrating PRP in your busy practice. Bye for now.
