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Wired for Success: Practices Prosper by Going Paperless

MDNG Primary Care, September 2007, Volume 9, Issue 9

Walk into the practice of family physician John Wilson, MD, in Daly City, CA, and you'll notice something unusual: It's a tiny space. Wilson uses just half of a 1,000-square-foot office for his solo..

Walk into the practice of family physician John Wilson, MD, in Daly City, CA, and you’ll notice something unusual: It’s a tiny space. Wilson uses just half of a 1,000-square-foot office for his solo practice, which includes one nurse practitioner/physician assistant, one medical assistant, and no office manager, in part because he’s a member of the Brown & Toland IPA, but mostly because electronic health records and other information technology have pumped up efficiency.

“The EHR keeps me very efficient,” Wilson says. “I can manage a lot of things with it,” including clinical notes, problem sheets, prescriptions, and schedules for a patient base of more than 2,000. Thanks to the EHR, Wilson makes a living despite practicing only half the time. “It allowed me to feel comfortable taking that extra time off ,” Wilson says. He can log in from home to read results or check secure, electronic messages from other clinicians in his practice or within the IPA. He permits e-mail communication with patients who have signed a waiver indicating that they are aware that standard e-mail is not secure. “It helps me do my documentation,” Wilson says.

With the EHR, Wilson doesn’t need a big file room. “I go to the trouble of printing my progress notes and putting them in the chart because I like to have something to refer to when I’m in with a patient,” Wilson says. “Otherwise, I don’t really need a paper chart.” Wilson also loves that chart pulls are a thing of the past.

When Wilson opened his practice in 2002, he had a Millbrook electronic scheduling and billing system (GE has since acquired Millbrook). He migrated to Allscripts software for practice management, and, at the beginning of 2007, farmed out billing services to Brown & Toland, further reducing his workload. A MedPlexus EHR was installed in 2004. At the time, Wilson took his old paper charts and scanned them to reduce the amount of paper in the office. “The quality of my progress notes is way better,” he says. He also has become “compulsive” about keeping medication lists up to date. “I never really did interaction checking before [the EHR] unless the patient had a long list of meds.”

Wilson’s experience is characteristic of wired physicians, who have wholeheartedly embraced IT as a means toward delivering better care for less money. Another commonality among high-tech doctors is that they keep sane working hours. “Our office is a ghost town at 5:15,” says James R. Morrow, MD, of North Fulton Family Medicine, a practice with 10 physicians and 10 PAs at four suburban Atlanta locations. The practice won the 2004 Davies Award for primary care, a prestigious honor from the Healthcare Information and Management Systems Society (HIMSS), and Morrow himself was named 2006 HIMSS Physician IT Leader of the Year.

Rise and Shine

Sure, they do start early, with PAs in the office at 7:15am to handle walk-in patients—the physicians generally arrive an hour later—but nobody rushes. The average provider sees 28 to 32 patients a day. And by midday, physicians usually don’t have to choke down a sandwich while filling out clinical notes. “It’s a nice, leisurely lunch,” Morrow reports. “With each of the patients, all the documentation is complete [by the time they leave].”

Charge-capture technology at the point of care sends bills directly to the practice management system, and that has helped boost revenue. “The coding thing is very good,” Morrow says. Indeed, he reports that the practice has the documentation to support an average code of 99214 for established patients. “Now it’s so much easier to document the work we do.”

The extra room reclaimed by virtue of not having to store paper charts has enabled North Fulton Family Medicine to add ancillary services, including bone-density screening. The practice also recently got computerized x-ray equipment, eliminating film, and there is no more scrambling between locations to find images. It was an expensive proposition, but Morrow believes it will pay for itself in short order. Most of the documentation at North Fulton Family Medicine is template-based, and Morrow has no problem with that. “It’s no different than dictating, ‘50-year-old female, physical,’ then having a transcriptionist type the dictation,” he says. In fact, the practice financed the entire EHR project by eliminating transcription expenses.

Templating vs. free-text entry vs. speech recognition is a point of contention in any EHR-purchasing decision. Although Wilson also no longer has to pay for transcription services, he is a fan of speech recognition. Wilson uses version 9 of Dragon Naturally Speaking, an EHR system which he believes is many times more accurate than previous editions. “The mistakes it does make are so incredibly obvious that there’s no question in my mind what I meant to say,” Wilson says. When he’s not in the office, Wilson can electronically send his dictated notes to Brown & Toland’s Web portal and access the Dragon software via the same portal.

Change is Good

Morrow has his reasons for embracing templating rather than speech recognition. “Now it’s old hat. It’s no different for me than driving a car,” he says. Plus, he still has problems with even the most advanced speech systems. “With my Southern drawl, [speech recognition] still can’t get it,” Morrow jokes. North Fulton Family Medicine has used HealthMatics EHR, now

owned by Allscripts, since December 1998. Morrow could not see himself ever going back to paper.

Sure, plenty of paper still comes in from insurance companies,laboratories, specialists, and hospitals. Although otherwise-paperless primary care practices have different ways of dealing with it, scanning is a popular option. “It takes a couple of extra steps to open a [scanned] document,” says Wilson, “but finding it is a lot more efficient.” That is not to say scanning is the solution to everyone’s paper problems.

Well-known workflow-redesign proponent Allen Wenner, MD, is no fan. “We hate it. It’s time-consuming, it’s error-prone, it’s non-digital, and it’s hard to find in the system,” says Wenner, a family practitioner who also is vice president of clinical applications design for Primetime Software, Columbia, SC, producer of a tool called Instant Medical History, which automates the process of capturing and maintaining patient-reported data. Wenner has become a popular speaker at physician IT meetings because he’s streamlined his whole practice with the help of technology and some plain, old common sense. His new practice, Twelve Mile Creek Family Medicine, in Lexington, SC, has just two physicians and two family nurse practitioners—and zero clerical employees. Back-office functions are being automated or


“This is really the edge,” Wenner says. “We’re just going to collect the co-pay. The doctor will enter the charges.” Just like Morrow in Georgia, “We code it based on how sick they are, and the documentation just falls into place,” explains Wenner.

After the diagnosis and treatment, “the doc walks to the printer, gets the prescription, referral letter, and a copy of the visit note,” Wenner says. The patient keeps the copy. “It might be radical, but it’s efficient,” he explains. “They never remember what I tell them in the exam room, anyway.”

To Wenner, that makes much more sense than the traditional method, in which the patient gets home from the doctor, can’t recall what happened, then calls the office the next day and asks the nurse to pull a chart. If the notes aren’t back from transcription, the nurse has to interrupt the doctor. “Now, the nurse asks, ‘Did you read the paper we gave you?’” Wenner says.

Wenner’s practice now is moving to an integrated Cerner outpatient system. Best known for its hospital systems, Cerner now offers an application service provider (ASP) version of its ambulatory EMR for small offices. “Distance is irrelevant with the Internet,” he says. Wenner still does not care much for traditional scheduling software, however, since it tends to encourage “wave scheduling,” and, yes, long waits.

“We have a waiting room. We just try not to have anybody in it,” says Wenner. “If we operate efficiently, the waiting room should be empty.” Because the practice takes patient history electronically in advance of the office visit, Wenner can know ahead of time which patients are sickest and thus need extra time, and plan his day accordingly, even before he leaves for work in the morning. Physicians ordinarily have to adjust on the fl y to provide sick patients with the time they need, a process that does not exactly lend itself to advance planning. “If you’re up to your head in alligators, you’re not worried about water quality,” Wenner quips.

Wenner also believes that patients have not yet grasped the notion that they should be doing more things at home to prepare for a doctor visit—particularly filling out history online—but that they will come around as physicians see the light. “A more efficiently run office is a cheaper office,” he says.

Out With the Old

Wenner bases efficiency on the automation of three steps: the history-taking process; eligibility checking and, if possible, advance collection of co-payments; and recording of vital signs. The new Cerner system will let medical devices populate the EHR. “Instead of creating data, I am editing data,” Wenner says. Wenner can order lab work electronically, but he’s going to be changing hospitals soon because the current one cannot send results electronically. Instead, it takes up to three weeks to get results by standard mail. “Three weeks is too long,” if the value is abnormal, Wenner says. “It’s unsafe, and it’s not good patient care.”

Morrow would be likely to agree. Right on his practice’s homepage is a button that says, “Get Your Lab Results Here.” Another highly efficient practice, Family Medical Specialists of Texas, in the Dallas suburb of Plano, sends out most test results via secure e-mail, with the exception of severe abnormalities and other complex results, which are communicated by phone.

Doctors there will no longer mail out test results. For more than two years, Family Medical Specialists has had a patient portal for secure messaging and appointment requests, and any clinical information sent that way goes right into the patient’s electronic chart. “It levels out your workfl ow. It doesn’t tie you up,” says one of the founding partners, Christopher Crow, MD. As of August, Family Medical Specialists combined four practices into an eight-physician practice. Others wanted to join the original three doctors in part because of the EHR, a GE Centricity product that the six-year-old practice has had for the last four years.

Prior to the merger, the practice had seven staff members supporting three physicians, about half that of the national average for staff per full-time primary care physician. Crow estimates that the EHR and related technologies—including a secure communication system from Portland, OR-based Kryptiq—has produced $60,000—70,000 per doctor in annual efficiency gains and additional revenue. “And everyone goes home at 5 o’clock,” Crow adds.

The asynchronous nature of electronic messaging means that the doctors can answer non-emergency questions whenever they get a break—or even after hours—instead of having to drop everything to take a phone call. “There’s kind of a catharsis there, that the patient is heard,” says Crow. Crow estimates that about 10% of his patients schedule appointments online. “They pick the day, they pick the hour and give us a second choice, and we send them a confirmation,” he says. “The encounter is the same.”

Meanwhile, transaction costs have dropped precipitously since patients got the option of scheduling, viewing test results, and requesting medication refills online. Revenue has had a slight uptick, thanks to a $50 annual fee for patients who wish to ask their doctors health-related questions via the Web. The Kryptiq technology also enables provider-to-provider communication, both formal and informal. Other practices in the area saw how easy the system was and decided to get their own EHRs, according to Crow. “We’ve increased the adoption in our area,” he confidently states.

Morrow wishes more practices would get the hint. “Hurry up!” he advises those who have yet to ditch their paper charts. “Every day you don’t do it, you’re not practicing medicine as well as you could. Every day you wait, it’s going to end up costing you more to do it.”

Neil Versel is a freelance healthcare journalist and proprietor of Neil Versel’s Healthcare IT Blog.