In August of this year I opened a private ocular oncology and retina practice in Miami, after spending more than 2 decades in an academic setting at Bascom Palmer Eye Institute. Murray Ocular Oncology & Retina is a state-of-the-art, 6000-square-foot facility in Coral Gables, FL, just a short distance from the University of Miami main campus.
The transition from academic practice to private practice was exciting, exhilarating, and challenging, and the result has been rewarding in every way imaginable. During the experience, however, when I was planning the move, I looked for published material that could help me with the transition, and I found little information of relevance. It occurred to me that it might be valuable to put down on paper some of what I learned in the process of starting this practice, to focus on some of the challenges and insights, and share this information with others who may find themselves in a similar situation.
Almost everyone who chooses the subspecialty of ophthalmology as a profession comes out of training into an established practice of some type—either an academic setting or a large retina or comprehensive ophthalmology practice. It is very rare for someone to open a high-volume retina, solo practice, especially coming out of academics. Further, starting a private ocular oncology practice from scratch is almost unheard of.
The questions facing the adventurous soul who chooses to launch such a practice are numerous: How much capital will be needed, and where will it come from? Should the practice start small and grow, or come out of the gate at full speed? What technologies are necessary? What about electronic health records (EHR) and practice management software? What about staffing? Hopefully this article, in describing some of the decision-making I went through in starting this new practice, will provide some guidance for others undertaking such a move in the future.
I came to the Bascom Palmer Eye Institute of the University of Miami Leonard M. Miller School of Medicine 21 years ago, when founder Edward W.D. Norton, MD, was still chairman. Bascom Palmer is a freestanding facility, but it also serves as the ophthalmology department of the University of Miami. It has been the top-ranked ophthalmic institution in the country for most of the past decade.
During my tenure at Bascom Palmer, I was actively involved in the fellowship training program and the residency selection process. My main interest is ocular oncology, and I was director of the ocular oncology service, primary director of the ocular imaging department, and director of the echography section. I was also active in surgery, and I have always had a strong interest in new technology for the OR and for imaging.
About 5 years ago I got my MBA with a health management focus, and at that time I became interested in the operational management of a clinical practice. How do you focus on providing excellence when you are expected to see a large volume of patients and see them quickly? How do you allocate resources from the technical staff, the imaging staff? How do you establish the layout of your practice and other parameters to enhance efficiency? These were topics that began to occupy my thinking.
Around this same time, changes occurred in leadership in the university and the institute, and along with those I began feeling the pressures of dwindling reimbursement and increasing volume that everyone in health care in general and retina practice in particular has felt in recent years. It started to become clear to me that providing care in the manner I was used to was going to become more difficult in the academic setting, and my choice was either to change my vision of how I wanted to practice, or to change my situation.
It was a difficult decision, but certain factors made it easier. I envisioned that a private practice would allow me to continue my focus on excellence in patient care and care management and the application of new imaging technologies and surgical tools for my patients with sight-threatening and life-threatening oncology issues. On the downside, going into private practice would distance me to a degree from the educational role, the residency and fellowship programs that I had been involved with at the university, and from my ocular oncology laboratory on the university campus. Those were the biggest tradeoffs associated with leaving academia.
Once I decided to make the move, things happened very quickly, in a matter of months. As I write this, Murray Oncology & Retina has been open for about 4 months, and I made the decision only about 7 months ago. In that time, I had to line up capital, acquire space, have the space remodeled to suit my needs, recruit staff, establish new surgery locations, make arrangements with payers, and obtain all the necessary technologies including EHR and practice management software (which had to be able to integrate with each other), and deal with numerous other issues.
Lining up capital. This was one of the areas in which my MBA was a big help. In the current economic climate, it is a difficult time to look for a bank or individuals willing to invest in someone starting a private practice— especially someone with no experience in private practice. When it came time to meet with the financial team that would finance the practice, it was a tremendous benefit for me to be able to put a business plan together, model the financials based on different levels of growth, and speak the language of the money people.
Acquiring space. In a perfect world, with enough time and capital, it would have been ideal to build a new facility from the ground up. With the short time frame I was facing, that was not an option, so I had to find a space that would allow me to do everything I needed and eventually expand. I thought that, with the economy as it is, there would be ample medical space available, but I found that there was virtually no medical office space available in the upscale areas of Miami. Ultimately, I found space that had been owned by a plastic surgery group, with 2 ORs and multiple rooms that would accommodate the practice I envisioned.
Remodeling. It took about 2.5 months to do the remodeling construction, which was very tight. If I have had sleepless nights in the process of launching this private practice, most of them came during the construction phase, hoping that everything could be completed on time to meet the date we had committed to seeing our first patients, which to me was a very firm date. The layout now includes 3 clinician rooms where I see patients, 3 technician rooms, 2 rooms for multifunctional imaging platforms that perform fluorescein and indocyanine green angiography and spectral-domain optical coherence tomography (SD-OCT), and 2 echography rooms, as well as front reception area and back billing office.
Recruiting staff. I am the only physician at this new practice—a significant contrast with my former academic setting. I have a director of optometry who coordinates all OD activity and a nursing director with an MBA. I was able to bring over key staff from Bascom Palmer as part of my separation agreement. The current staff are all experts in their own areas of care delivery, and that made the transition a lot easier for me.
Finding new operating environments. One of the most important steps I had to undertake was to establish new relationships with the hospitals and ambulatory surgery centers where I am now performing surgery. Although the new facility contains 2 existing ORs, I am not yet comfortable operating in these ORs, particularly with the complex pediatric and oncologic procedures I do. I believe that we will undertake office-based surgery for some simpler surgeries in the future, but for the time being I needed new places to operate. Before looking into the matter, I thought that I could have walked into any OR. But the equipment and educational needs for the OR teams for these innovative surgeries were more involved than I expected. In some of these environments, I have had to adapt more than the staff had to. Also, the re-credentialing process, moving my operating credentials from the university to the other facilities as a private provider, was agonizing.
Arranging for payment. The front office and back office teams have been essential in arranging participation with multiple payers to accommodate my patients, establishing reimbursement levels, and setting up the billing system. This is all managed using the EHR and practice management software we adopted from day 1. There was no EHR system at Bascom Palmer; although the Epic system was in use university-wide, the ophthalmology module, Kaleidoscope, was never put in place. Therefore, we went from paper to electronic in 1 day, thanks to a well-prepared and highly competent staff.
Acquiring technology. In the past 21 years I have had the opportunity to build strong relationships with many people in the ophthalmic industry, and those relationships paid off in this move. My established contacts at imaging and equipment companies stepped up for me in a big way, helping to move technology in quickly and to make sure we had appropriate training so the staff could use the new gear at the level we wanted, right from the start. As mentioned above, the diagnostic technology includes advanced echography for following my oncology patients and a combined platform for fluorescein/ indocyanine green angiography and SD-OCT.
And everything else. At Bascom Palmer, in addition to my primary role seeing oncology patients, I also had a high volume intravitreal injection practice. For the new practice I had to arrange for compounding of the bevacizumab (Avastin, Genentech) that I use and figure out an efficient layout for the injection rooms. I was lucky to have a good exit strategy arranged with the university, so that all of my patients would be notified that I was leaving the university, with information about how I could be contacted in my new setting. That was a critical aspect of moving a 2-decade practice from one institution to another.
UP TO SPEED
The practice opened on schedule, the first week of August. On the first day we saw 35 patients, and within 3 weeks we were up to full speed. At Bascom Palmer I was seeing 85 patients a day, 2 days per week, including typically injecting about 45 patients. Virtually all of those patients had requirements for fundus photography with fluorescein imaging or SD-OCT, and the oncology patients required echographic imaging. Now I have structured my day so that I see 65 patients a day, 3 days a week, rotating through 3 exam rooms. I have 3 technicians who each see 22 patients a day for workup, each with his or her own room. Imaging is performed on the majority of patients because, again, they are here either for tumor evaluation or evaluation for IV injection. The 2 multifunctional imaging rooms and 2 echography rooms each have separate staff. On days when we do injections, we use 2 rooms staffed by a nursing team to complete about 35 to 40 injections.
The EHR system is networked into all exam and treatment rooms, and a server-based network integrates all of the imaging so that we can view all of the imaging (OCT, angiography, and ultrasound) on a separate screen. When I come into the room to see the patient, the EHR and the imaging are displayed. This is a tremendous opportunity to educate patients, and it also expedites the patient care. At 3 months now into the clinical practice, as patients return for follow-up, these visits are clearly enhanced by being able to see and compare the EHR and imaging from their previous visit.
Although I am no longer at the university every day, I do grand rounds there about every other week, and I still have my laboratory there, so I am back on campus about once a week, maintaining my academic teaching and research interest. Even though I have transitioned to private practice, I think it is important to continue to maintain a relationship and give back to the institution.
One aspect of the new environment that is very important to me is the change in the patient experience. In my last few months at the university, the cycle time for some patients, from check-in until they departed, was more than 7 hours. In the first week of our clinic, the average cycle time was 92 minutes. And patients have commented that they now have more time with me. To be able to reduce patients' time commitment from 7 hours to 1.5 hours, while simultaneously being able to increase the time I spend with them, has been a real game-changer. This is especially true for some of the oncology patients who come from great distances for their evaluations and treatments, but also for the patients who return every 4 or 8 weeks for injections.
It is important to realize that none of this would be possible without a phenomenal staff. All of these professionals are as committed to this new practice as I am, and it shows. I am thrilled to come to work each day—just as I was 21 years ago when I first came to Bascom Palmer— and I can sense that the staff are just as happy to be here as I am. This is not Dr. Murray's practice, it is our practice.
It has been wonderful for me to realize once again that I love practicing ophthalmology. And it has been a humbling experience to realize the loyalty of the patients who followed me here, and of the physicians who have continued to refer patients to me in this new setting. I recognize that this whole experience could have gone very badly, but it has been exactly the opposite. I have been lucky to work with the right people, to have great referring ophthalmologists, and to have patients who continue to travel out of their way to have their care provided here.
Timothy G. Murray, MD, MBA, FACS, is the founder of Murray Ocular Oncology and Retina in Miami, FL. He can be reached at +1 305 487 7470; fax: +1 786 567 4380; or firstname.lastname@example.org.