MAY 2009 � VOLUME 58, NO. 5

group practice journalP U B L I C A T I O N O F T H E A M E R I C A N M E D I C A L G R O U P A S S O C I A T I O N®

Going Electronic with an Eye on QualityBY JEFFRY MICHAEL DUKE, CPA

Reprinted from

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the pressure on physician groups to acquire electronic health records

is increasing. In a few years, the Centers for Medicare & Medicaid Services (CMS) may even require EHRs as a condition of Medicare participation. Physicians remain cautious of fully electronic systems, partly because they fear that their use will create burdensome workfl ows that can slow the delivery of care. As one senior physician in my group said, “If it takes longer to do on the computer than it does by hand, I will not adopt it.”

Our practice, the Medical & Surgical Clinic of Irving, has put together an electronic solution that has helped prepare our physicians

for a complete EHR, while improv-ing patient care and signifi cantly enhancing our fi nancial position.

Th e Medical & Surgical Clinic of Irving, which was founded in 1953, is located between Dallas and Fort Worth, Texas. With 26 physicians, it is one of the largest physician-owned multispecialty practices in the area. Among our 17 primary care physi-cians are family physicians, general internists, and pediatricians. Our other specialties include allergy and rheumatology, cardiology, gastroen-terology, ophthalmology, otolaryn-gology, radiology, and surgery.

In January 2004, when we were developing plans for our current building, we decided we did not

want to take our paper charts with us. So we took our fi rst step into the digital realm by acquiring a document management system from Allscripts. Our medical records staff created an electronic record of all of our charts within the system before we relocated. Today, we digitize all incoming reports and correspon-dence by scanning them and moving the images to the appropriate electronic folders. We do the same with the paper encounter forms that our physicians use for documenta-tion. Th is enables our physicians to securely connect to and retrieve patient information quickly.

The Medical & Surgical Clinic

of Irving, has put together an

electronic solution that has,

helped prepare our physicians

for a complete EHR.

Document ManagementOur technological solution has

required minimal change in our physicians’ workfl ow. Our doctors ask patients the same questions and document care in the same way that they have done all along. Some handwrite on their forms; others dictate; and a few use voice recogni-tion software.

Th is approach has a few other advantages. First, the document management program is interfaced with our internal lab system, so lab results are electronically fi led within the patient record. Second, the solu-

Going Electronic with an Eye on Quality BY JEFFRY MICHAEL DUKE, CPA

tion allows us to create forms and use them in internal messaging. For example, when a patient call comes in or a lab result becomes available, an electronic message (similar to an e-mail) is created and sent to a physician’s or nurse’s inbox with an alert that further action is required. Th ird, the system has an electronic prescribing component that all of our doctors are now using. In its latest iteration, the e-prescriber allows them to create medication lists, view formularies and drug interactions, and send prescriptions online to area pharmacies.

Th e document management system has made our operation more effi cient by eliminating the need to pull, fi le, and store paper charts. Our physicians also like being able to access patient data remotely. Th ey can fi nish their daily work at home, instead of having to stay late in the offi ce to complete charts and review labs. Especially for younger physi-cians who want a more balanced lifestyle, this is a real plus.

Population HealthWhen we reviewed our

operations a couple of years ago, we realized there was still something very important missing. We wanted to better manage our population’s health, but it was hard to improve preventive and chronic disease care systematically because many patients were noncompliant and didn’t schedule appointments when they were supposed to. Nurses made tickler fi les, and doctors tried to identify the patients whom they were concerned about—but it was a tedious, manual process. Letters and phone calls to patients were time-consuming and expensive.

In addition, we were concerned about our no-show rate, which was reducing our practice revenue. After researching several options, we found a physician-driven health improvement solution from Phytel Inc. that provided automated messaging to patients about needed appointments.

Registry-Based MessagingTh e appointment reminders

reduced our no-show rate sig-nifi cantly, increasing our volume by several hundred thousand dollars over the past three years. But what really got our physicians excited was that the messages could be coupled with an electronic disease registry, evidence-based guidelines, and a customizable protocol engine to remind patients when to come in for recommended care.

The clinical intelligence be-

hind the solution consists of

evidence-based health man-

agement protocols.

Registries, which can be used with or without electronic health records, manage a directory of all of your patients with a particular condition, along with the services that have been provided for them and their compliance rates. Registries can also store lab data and other information to show how well a patient is doing compared to the recommended limits. For example, you might target recent HbA1c values for diabetic patients and blood pressure readings for patients with hypertension.

Th e clinical intelligence behind the solution consists of evidence-based health management protocols derived from such organizations as the National Quality Forum, the U.S. Preventive Services Task Force, and the National Committee on Quality Assurance. Using the fl exible protocol engine, our physician leadership could easily customize the protocols individually for various preventive and chronic-care services. However, we decided to customize them by specialty. Within primary care, for example, we have elected disease management and annual visit recalls. Pediatricians also have well-child and immunization recalls. Our scheduling system also includes a recall feature, and sometimes nurses

still enter reminders to contact spe-cifi c patients. Th e solution integrates those recalls with the ones automati-cally generated by the registry.

For security reasons, the automat-ed messaging does not tell patients why they’re being contacted. Instead, it reaches patients on behalf of our organization saying that the patient’s doctor would like that person to schedule a follow-up appointment. If the patient doesn’t respond within two weeks, he or she receives another call. Most patients appreciate the reminders and feel that their physi-cian is providing a valuable service to monitor and improve their overall health.

Financial ResultsWe launched the patient outreach

solution in April 2006—a month after the appointment confi rmation system and just 60 days after signing the contract. Almost immediately, our phones began ringing. In fact, so many noncompliant patients called for appointments that we had to limit the number of reminders for each physician and the days on which they went out so that our schedulers wouldn’t be overwhelmed.

Th at was a good problem to have, as it turned out. In the fi rst year we used the system, the number of appointments for physicians who were with us during 2005 and 2006 increased between 6 and 11 percent, depending on the physician. Overall receipts also grew by a million dollars. And that level of revenue has not only been maintained, but has continued to grow.

For example, the number of annual visits, including those patients in need of preventive and chronic care services, for family physicians jumped from 48,400 in 2005 to 52,400 in 2006. For pedia-tricians, the number of encounters increased from 41,000 in 2005 to 46,000 in 2006. In 2008, even as the recession was beginning to take hold, the number increased to 49,500.

We have a busy practice, but our physicians had no problem absorbing

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GROUP PRACTICE JOURNAL 39

the extra volume. Th ey are the kind of professionals who will always see another patient if they can help better manage chronic care condi-tions and deliver preventive services that improve the quality of care and health outcomes within our commu-nity. Meanwhile, we’ve been growing as established physicians in the area have joined our group. Two more physicians are coming on board as I write this.

Quality ImprovementOur improvement in fi nancial

results is related to an increase in patient compliance. Patients who would have formerly come in for follow-up visits on a hit-or-miss basis or not at all are now coming in like clockwork.

Before we adopted the registry and messaging system, physicians would notice that some patients whom they saw were falling out of compliance with their treatment plans. And, when patients didn’t visit, our doctors would worry. Now our physicians have the technology they need to stay on top of their patients’ health needs, and they’re getting the patients in without requiring the staff to do a lot of time-consuming, tedious tasks. Our nurses can be more productive because they’re not spending time calling patients and mailing letters. Moreover, there’s no extra work for the physicians, nor do they have to change how they work.

Today, our doctors have no doubt that the solution has resulted in better care. Some of the patients with whom they struggled in the past—such as those with diabetes, asthma, and thy-roid problems—are being more pro-actively managed. Patients may not be as compliant as physicians would like them to be, but they’re being seen more frequently. Th at allows a physi-cian, for example, to make sure he or she is telling diabetic patients face to face about the importance of blood sugar monitoring. Our physicians are much more comfortable about the health status of their patients than they have ever been before.

What we have done is to motivate patients to get in touch with their doctors and stay on track with their care plans. At the same time, we’ve created the conditions that make it easier for physicians to optimize their time with patients and provide all of the services that they need.

Our doctors have no doubt

that the solution has resulted

in better care.

We are also very well positioned to qualify for P4P rewards when private payers and Medicare begin off ering P4P programs in our area. We are already submitting data to CMS’ Physicians Quality Reporting Initiative (PQRI), and it would be easy to use our registry to provide much of the data for other P4P programs. Our outreach solution will also help us qualify for NCQA’s Patient Centered Medical Home (PCMH).

One Stage in a JourneyWe know that we still have a

way to go on our journey into the electronic world of the future. To begin with, although our physicians are now in closer touch with patients between appointments, more could be done to strengthen that relation-ship and to monitor patients with chronic conditions.

Our practice leaders also believe that a complete EHR will be a necessity in the future, and we’re doing everything we can to prepare for that. Getting physicians used to accessing patient data on a computer and prescribing electronically are essential steps toward that goal. So is the use of an electronic registry with automated messaging and preven-tive and chronic care management. Th e fi nancial benefi ts have been outstanding, and the physicians have greater peace of mind because they know they’re doing more to improve the health of their patients. From there, it’s only a short step to persuade them to expand our current technologies so they can do even more for their patients.

I’m glad that we did not try to go completely electronic all at once. Physicians are not anti-technology. But if you’re going to ask them to change how they practice medicine, you better give them a pretty darn good reason, and you ought to do it in stages. In addition, our decision to implement a health improvement solution during this transitional period put us in the best possible spot as healthcare payers start to reward quality.

Jeff ry Michael Duke, CPA, is execu-

tive director of the Medical & Surgical

Clinic of Irving in Irving, Texas.

Reprinted with permission of The American Medical Group Association®

©Group Practice Journal May 2009

40 GROUP PRACTICE JOURNAL M A Y 2 0 0 9