Nonsurgical Side of Mohs Can't Be Neglected : Behind every successful surgeon is an office efficiently keeping track of records and scheduling patients.

SAN DIEGO — Organization in both record keeping and patient scheduling is essential to a successful Mohs surgery practice, Dr. Edward H. Yob said at a meeting sponsored by the American Society for Mohs Surgery.

Patient care records may include handwritten notes, dictation/transcription, and electronic medical records, although electronic records are becoming the documentation method of choice, noted Dr. Yob, a specialist in Mohs surgery and dermatologic surgery in Tulsa, Okla.

The best electronic medical records system for your office is one that is accurate, simple, and cost effective and saves you time. Ease in training is also important; a high school-educated medical assistant should be able to learn the program with minimal training, said Dr. Yob, who owns stock in Ratio Medical Software, the company that markets the Razor electronic medical records system.

Clinical records for Mohs surgery patients include the preoperative evaluation, operative consent form, operative notes, Mohs map, anesthesia record (if any), and postoperative notes.

"Not everyone has this entire set of items for each patient, but you need enough information to substantiate the indications for Mohs," Dr. Yob said.

The preoperative record establishes the patient's candidacy for Mohs, including the general state of health, any medications, or past surgical or anesthesia difficulties, he noted.

The Mohs map is an integral part of the record. "Every bit of information you could want should be on that Mohs map," Dr. Yob said. "Accuracy is the key, and the map should tell the story exactly as it is."

Document postoperative visits, even if the patient simply comes in for care and cleaning of the wound by a medical assistant. In addition, keep the referring physician in the loop. Dr. Yob always sends a simple cover letter, along with a copy of the operative notes and photos of the defect and final repair, to the referring physician.

"I want to educate the physician and let him or her know that they made the right choice in referring the patient for Mohs surgery," he said.

Clinical logs are descriptions of your practice, compared with clinical reports, which are descriptions of individual patients. Photography is a crucial time saver when it comes to keeping a clinical log. "Digital photos are accurate and easy, and there is no better way to document treatment than photography," he said.

In Dr. Yob's office, a nurse first photographs the patient's name from the chart; the succeeding photos are of that patient until the next photo of a patient's name in a chart is taken.

When staff members archive the photos, they label the computerized file with the patient's name. In some offices, the technicians set up a file for each day and download the day's files into one directory, then erase the digital card in preparation for the next day. A staff member can later sort the photos by patient.

Data storage is another important element of record keeping in a Mohs practice. "You are going to have glass slides to store, and you need an archival system," Dr. Yob said. Store all operative reports and Mohs maps and keep track of expenses.

"You are going to generate an enormous [number] of documents, photographs, and slides, and if you take some time to think it through before you start practicing Mohs surgery, you can develop a system that will be organized and not take you an enormous amount of time to process," Dr. Yob said.

He also shared tips for patient selection and scheduling.

There are two types of scheduling: integrated and exclusive, and there are advantages to both. Integrated scheduling is more efficient and more economical, but it is extremely distracting. "You could be ready to do a Mohs repair, and then you get a complicated consultation on a lupus patient," Dr. Yob said. This type of scheduling is not practical for a high-volume Mohs practice.

Exclusive scheduling means treating Mohs patients from start to finish without interruption for other types of patients. This type of scheduling is more predictable and allows more time with the patient. "I like to see patients preoperatively so I can talk to them and evaluate them. I want them to feel comfortable, and I want to take their blood pressure," Dr. Yob said. "I don't want to waste a surgical slot if the patient's blood pressure is high."

Dr. Yob's office ranks patients by three levels of complexity: quick, average, and complex. He recommends that surgeons determine how the total number of patients with varying degrees of complexity fits with what they consider their workload. "A complicated patient may be the only Mohs surgery you do in one morning," Dr. Yob said.

Regardless of scheduling type, Dr. Yob suggests starting conservatively, with small defects, and scheduling more than enough time, and not hesitating to finish a patient's procedure the next day. The volume of patients will depend on the skill and speed of the surgeon, the experience of the surgical team, and the efficiency of the office setup.

Determine how the total number of patients with varying degrees of complexity fits with the workload. DR. YOB

Building a Mohs Surgery Practice Takes Planning and Hard Work

"When you are establishing a practice, consider how and whether you are willing to commit the time and resources—and it is a considerable commitment in the beginning—to develop a Mohs practice and do it right," Dr. Yob said. "You won't make money when you start, and you must be willing to work hard and train your staff."

When starting in a Mohs surgery practice, it is best to start small, allow extra time, not treat complex cases, avoid distractions, and pay attention to details, he said.

There are several other elements to consider:

Choosing Practice Type

Group or solo? Will patients be practice generated or referred?

Scouting Geographic Area

Research the local area and learn about the population: Is there a large population of retirees and suburban moms, or a lot of college students?

Determining Community Practice Patterns

Know the size of the community and the number of dermatologists in the area. If there are other dermatologists in the area, find out how they treat skin cancer and ask about their attitudes toward Mohs surgery. Find out whether primary care physicians treat skin cancer and how they feel about Mohs surgery. "Treat the family doctors with respect," Dr. Yob said. "The more you share with them, the more they respect you."

Evaluating Your Practice

How important is Mohs to you? Is it a focal point, or is it something you do in addition to general dermatology?

Generating Referrals

Talk to ENT surgeons and plastic surgeons. "If you can convince them that you can clean out the cancer and send them a tumor-free patient, they may appreciate that," he said.

Getting the Word Out

Other ways to generate business include giving lectures to physicians and participating in CME programs at hospitals and medical meetings, as well as giving community-based talks to church or civic groups. Pamphlets and Web sites are also helpful ways for Mohs surgeons to introduce themselves to the community.

Hiring Good Help

The lab technician is "the Mohs lifeline," Dr. Yob said. You can hire a full-time staff technician or contract with one. "If you plan to do Mohs only 2 days a week, you might be able to share a technician with another surgeon who does Mohs 3 days each week," he said. The advantages of an in-house technician are convenience, availability, and consistency, as well as faster communication. However, a contract technician is often more cost effective, usually experienced, and generally has a backup on call. A contracted technician also may have helpful insights into the community and sources of patients for surgeons who are in the early stages of establishing a Mohs practice. If a nurse or another member of your staff is eager to learn, consider training them. Their personality and willingness to learn is as important as previous background, he said.

SAN DIEGO — Organization in both record keeping and patient scheduling is essential to a successful Mohs surgery practice, Dr. Edward H. Yob said at a meeting sponsored by the American Society for Mohs Surgery.

Patient care records may include handwritten notes, dictation/transcription, and electronic medical records, although electronic records are becoming the documentation method of choice, noted Dr. Yob, a specialist in Mohs surgery and dermatologic surgery in Tulsa, Okla.

The best electronic medical records system for your office is one that is accurate, simple, and cost effective and saves you time. Ease in training is also important; a high school-educated medical assistant should be able to learn the program with minimal training, said Dr. Yob, who owns stock in Ratio Medical Software, the company that markets the Razor electronic medical records system.

Clinical records for Mohs surgery patients include the preoperative evaluation, operative consent form, operative notes, Mohs map, anesthesia record (if any), and postoperative notes.

"Not everyone has this entire set of items for each patient, but you need enough information to substantiate the indications for Mohs," Dr. Yob said.

The preoperative record establishes the patient's candidacy for Mohs, including the general state of health, any medications, or past surgical or anesthesia difficulties, he noted.

The Mohs map is an integral part of the record. "Every bit of information you could want should be on that Mohs map," Dr. Yob said. "Accuracy is the key, and the map should tell the story exactly as it is."

Document postoperative visits, even if the patient simply comes in for care and cleaning of the wound by a medical assistant. In addition, keep the referring physician in the loop. Dr. Yob always sends a simple cover letter, along with a copy of the operative notes and photos of the defect and final repair, to the referring physician.

"I want to educate the physician and let him or her know that they made the right choice in referring the patient for Mohs surgery," he said.

Clinical logs are descriptions of your practice, compared with clinical reports, which are descriptions of individual patients. Photography is a crucial time saver when it comes to keeping a clinical log. "Digital photos are accurate and easy, and there is no better way to document treatment than photography," he said.

In Dr. Yob's office, a nurse first photographs the patient's name from the chart; the succeeding photos are of that patient until the next photo of a patient's name in a chart is taken.

When staff members archive the photos, they label the computerized file with the patient's name. In some offices, the technicians set up a file for each day and download the day's files into one directory, then erase the digital card in preparation for the next day. A staff member can later sort the photos by patient.

Data storage is another important element of record keeping in a Mohs practice. "You are going to have glass slides to store, and you need an archival system," Dr. Yob said. Store all operative reports and Mohs maps and keep track of expenses.

"You are going to generate an enormous [number] of documents, photographs, and slides, and if you take some time to think it through before you start practicing Mohs surgery, you can develop a system that will be organized and not take you an enormous amount of time to process," Dr. Yob said.

He also shared tips for patient selection and scheduling.

There are two types of scheduling: integrated and exclusive, and there are advantages to both. Integrated scheduling is more efficient and more economical, but it is extremely distracting. "You could be ready to do a Mohs repair, and then you get a complicated consultation on a lupus patient," Dr. Yob said. This type of scheduling is not practical for a high-volume Mohs practice.

Exclusive scheduling means treating Mohs patients from start to finish without interruption for other types of patients. This type of scheduling is more predictable and allows more time with the patient. "I like to see patients preoperatively so I can talk to them and evaluate them. I want them to feel comfortable, and I want to take their blood pressure," Dr. Yob said. "I don't want to waste a surgical slot if the patient's blood pressure is high."

Dr. Yob's office ranks patients by three levels of complexity: quick, average, and complex. He recommends that surgeons determine how the total number of patients with varying degrees of complexity fits with what they consider their workload. "A complicated patient may be the only Mohs surgery you do in one morning," Dr. Yob said.

Regardless of scheduling type, Dr. Yob suggests starting conservatively, with small defects, and scheduling more than enough time, and not hesitating to finish a patient's procedure the next day. The volume of patients will depend on the skill and speed of the surgeon, the experience of the surgical team, and the efficiency of the office setup.

Determine how the total number of patients with varying degrees of complexity fits with the workload. DR. YOB

Building a Mohs Surgery Practice Takes Planning and Hard Work

"When you are establishing a practice, consider how and whether you are willing to commit the time and resources—and it is a considerable commitment in the beginning—to develop a Mohs practice and do it right," Dr. Yob said. "You won't make money when you start, and you must be willing to work hard and train your staff."

When starting in a Mohs surgery practice, it is best to start small, allow extra time, not treat complex cases, avoid distractions, and pay attention to details, he said.

There are several other elements to consider:

Choosing Practice Type

Group or solo? Will patients be practice generated or referred?

Scouting Geographic Area

Research the local area and learn about the population: Is there a large population of retirees and suburban moms, or a lot of college students?

Determining Community Practice Patterns

Know the size of the community and the number of dermatologists in the area. If there are other dermatologists in the area, find out how they treat skin cancer and ask about their attitudes toward Mohs surgery. Find out whether primary care physicians treat skin cancer and how they feel about Mohs surgery. "Treat the family doctors with respect," Dr. Yob said. "The more you share with them, the more they respect you."

Evaluating Your Practice

How important is Mohs to you? Is it a focal point, or is it something you do in addition to general dermatology?

Generating Referrals

Talk to ENT surgeons and plastic surgeons. "If you can convince them that you can clean out the cancer and send them a tumor-free patient, they may appreciate that," he said.

Getting the Word Out

Other ways to generate business include giving lectures to physicians and participating in CME programs at hospitals and medical meetings, as well as giving community-based talks to church or civic groups. Pamphlets and Web sites are also helpful ways for Mohs surgeons to introduce themselves to the community.

Hiring Good Help

The lab technician is "the Mohs lifeline," Dr. Yob said. You can hire a full-time staff technician or contract with one. "If you plan to do Mohs only 2 days a week, you might be able to share a technician with another surgeon who does Mohs 3 days each week," he said. The advantages of an in-house technician are convenience, availability, and consistency, as well as faster communication. However, a contract technician is often more cost effective, usually experienced, and generally has a backup on call. A contracted technician also may have helpful insights into the community and sources of patients for surgeons who are in the early stages of establishing a Mohs practice. If a nurse or another member of your staff is eager to learn, consider training them. Their personality and willingness to learn is as important as previous background, he said.

SAN DIEGO — Organization in both record keeping and patient scheduling is essential to a successful Mohs surgery practice, Dr. Edward H. Yob said at a meeting sponsored by the American Society for Mohs Surgery.

Patient care records may include handwritten notes, dictation/transcription, and electronic medical records, although electronic records are becoming the documentation method of choice, noted Dr. Yob, a specialist in Mohs surgery and dermatologic surgery in Tulsa, Okla.

The best electronic medical records system for your office is one that is accurate, simple, and cost effective and saves you time. Ease in training is also important; a high school-educated medical assistant should be able to learn the program with minimal training, said Dr. Yob, who owns stock in Ratio Medical Software, the company that markets the Razor electronic medical records system.

Clinical records for Mohs surgery patients include the preoperative evaluation, operative consent form, operative notes, Mohs map, anesthesia record (if any), and postoperative notes.

"Not everyone has this entire set of items for each patient, but you need enough information to substantiate the indications for Mohs," Dr. Yob said.

The preoperative record establishes the patient's candidacy for Mohs, including the general state of health, any medications, or past surgical or anesthesia difficulties, he noted.

The Mohs map is an integral part of the record. "Every bit of information you could want should be on that Mohs map," Dr. Yob said. "Accuracy is the key, and the map should tell the story exactly as it is."

Document postoperative visits, even if the patient simply comes in for care and cleaning of the wound by a medical assistant. In addition, keep the referring physician in the loop. Dr. Yob always sends a simple cover letter, along with a copy of the operative notes and photos of the defect and final repair, to the referring physician.

"I want to educate the physician and let him or her know that they made the right choice in referring the patient for Mohs surgery," he said.

Clinical logs are descriptions of your practice, compared with clinical reports, which are descriptions of individual patients. Photography is a crucial time saver when it comes to keeping a clinical log. "Digital photos are accurate and easy, and there is no better way to document treatment than photography," he said.

In Dr. Yob's office, a nurse first photographs the patient's name from the chart; the succeeding photos are of that patient until the next photo of a patient's name in a chart is taken.

When staff members archive the photos, they label the computerized file with the patient's name. In some offices, the technicians set up a file for each day and download the day's files into one directory, then erase the digital card in preparation for the next day. A staff member can later sort the photos by patient.

Data storage is another important element of record keeping in a Mohs practice. "You are going to have glass slides to store, and you need an archival system," Dr. Yob said. Store all operative reports and Mohs maps and keep track of expenses.

"You are going to generate an enormous [number] of documents, photographs, and slides, and if you take some time to think it through before you start practicing Mohs surgery, you can develop a system that will be organized and not take you an enormous amount of time to process," Dr. Yob said.

He also shared tips for patient selection and scheduling.

There are two types of scheduling: integrated and exclusive, and there are advantages to both. Integrated scheduling is more efficient and more economical, but it is extremely distracting. "You could be ready to do a Mohs repair, and then you get a complicated consultation on a lupus patient," Dr. Yob said. This type of scheduling is not practical for a high-volume Mohs practice.

Exclusive scheduling means treating Mohs patients from start to finish without interruption for other types of patients. This type of scheduling is more predictable and allows more time with the patient. "I like to see patients preoperatively so I can talk to them and evaluate them. I want them to feel comfortable, and I want to take their blood pressure," Dr. Yob said. "I don't want to waste a surgical slot if the patient's blood pressure is high."

Dr. Yob's office ranks patients by three levels of complexity: quick, average, and complex. He recommends that surgeons determine how the total number of patients with varying degrees of complexity fits with what they consider their workload. "A complicated patient may be the only Mohs surgery you do in one morning," Dr. Yob said.

Regardless of scheduling type, Dr. Yob suggests starting conservatively, with small defects, and scheduling more than enough time, and not hesitating to finish a patient's procedure the next day. The volume of patients will depend on the skill and speed of the surgeon, the experience of the surgical team, and the efficiency of the office setup.

Determine how the total number of patients with varying degrees of complexity fits with the workload. DR. YOB

Building a Mohs Surgery Practice Takes Planning and Hard Work

"When you are establishing a practice, consider how and whether you are willing to commit the time and resources—and it is a considerable commitment in the beginning—to develop a Mohs practice and do it right," Dr. Yob said. "You won't make money when you start, and you must be willing to work hard and train your staff."

When starting in a Mohs surgery practice, it is best to start small, allow extra time, not treat complex cases, avoid distractions, and pay attention to details, he said.

There are several other elements to consider:

Choosing Practice Type

Group or solo? Will patients be practice generated or referred?

Scouting Geographic Area

Research the local area and learn about the population: Is there a large population of retirees and suburban moms, or a lot of college students?

Determining Community Practice Patterns

Know the size of the community and the number of dermatologists in the area. If there are other dermatologists in the area, find out how they treat skin cancer and ask about their attitudes toward Mohs surgery. Find out whether primary care physicians treat skin cancer and how they feel about Mohs surgery. "Treat the family doctors with respect," Dr. Yob said. "The more you share with them, the more they respect you."

Evaluating Your Practice

How important is Mohs to you? Is it a focal point, or is it something you do in addition to general dermatology?

Generating Referrals

Talk to ENT surgeons and plastic surgeons. "If you can convince them that you can clean out the cancer and send them a tumor-free patient, they may appreciate that," he said.

Getting the Word Out

Other ways to generate business include giving lectures to physicians and participating in CME programs at hospitals and medical meetings, as well as giving community-based talks to church or civic groups. Pamphlets and Web sites are also helpful ways for Mohs surgeons to introduce themselves to the community.

Hiring Good Help

The lab technician is "the Mohs lifeline," Dr. Yob said. You can hire a full-time staff technician or contract with one. "If you plan to do Mohs only 2 days a week, you might be able to share a technician with another surgeon who does Mohs 3 days each week," he said. The advantages of an in-house technician are convenience, availability, and consistency, as well as faster communication. However, a contract technician is often more cost effective, usually experienced, and generally has a backup on call. A contracted technician also may have helpful insights into the community and sources of patients for surgeons who are in the early stages of establishing a Mohs practice. If a nurse or another member of your staff is eager to learn, consider training them. Their personality and willingness to learn is as important as previous background, he said.