The old days: You walked with your mother to a pleasant clapboard house where, in a sunny side room, your friendly family doctor would make you say “ah,” diagnose a respiratory infection and send you on your way with a timely prescription. Or worse, wave a frightening needle in your face and then stick it in your arm.
Solo practitioners: The wave of the future?
The new days, as described by a growing number of 21st-century physicians: Patients make same-day appointments on the internet, type in health information online, and drive to a small office building where they know that friendly Dr. Jones will see them immediately. During the exam, which includes a couple of clicks on the physician’s laptop and to bring up the patient’s electronic medical record (EMR, or EHR for electronic health record), Dr. Jones may spend a good half hour with the patient, perhaps typing a prescription order on the computer, zipping it off to the patient’s pharmacy. After the visit, he enters new information—online—into the health record, prepares his bill, and zips that off to the appropriate medical insurer.
Exhibit A: Scott Clemensen, MD, who can’t resist a little preening. “By the end of the day, I’ve completed all documentation, my billing has been sent electronically to the clearing house, all of my correspondence is done, and all my patients have been followed up with on the daily work,” he says. In today’s technological terms, “The inbox is empty at the end of the day.”
Micro practices: A new trend?
One day in 2005, Clemensen, who now practices family medicine in the New York Finger Lakes community of Canandaigua, spent an afternoon in the office of his colleague, friend, and then chief of the University of Rochester medical school residency program, L. Gordon Moore, MD. Moore had started his own “micro practice” in 2001 and has since organized Ideal Medical Practices (www.IMPCenter.org), a support/information program for physicians who want to shed ties with large group practices. Says Clemensen, “It took about two hours (at Moore’s office) to decide [to go electronic and open his own micro practice.]. I’m thrilled. It’s the best decision I ever made.”
Though the terms are used somewhat interchangeably, “solo” practitioner applies to a single-physician practice, but there may be a fair-sized support staff of nurses or medical assistants, scheduler or receptionist, etc. A micro practice can—but typically doesn’t—include more than one physician—but refers to a doctor who uses technology to slash support staff, cutting overhead. Regardless of the terminology, the trend is catching on. From Peterborough, New Hampshire, to Petaluma, California, more physicians are “liberating” themselves from group practices, according to a map on the IMP web site. Many of the IMP “members” listed there also report full practices, some even with waiting lists. that includes both Moore and Clemensen, both of whom are making healthy profits.
The reason: They are not weighed down by overhead that eats into the coffers of many group practices. It’s common for them and other micro practitioners to have only one assistant and often none at all. They can juggle practices and paperwork so that, as Moore says, “we achieve key attributes of practice that lead to good patient outcomes. and we can accomplish it in a practice that gives us incredible autonomy in how we do it, and allows us to practice in a way that gets us back to our profession with less of the business and industry injecting itself into health care.”
Many physicians like Moore and Clemensen have figuratively thrown paper out of their lives in favor of EMRs, billing software and other systems to replace the once-cumbersome paper record.
There’s another, more humanistic, reason for the switches. Now 47 years old, Moore, who named his Rochester, New York, practice Ideal Health Network, recalls his “breaking point” in a group practice. He and his colleagues had come under pressure to increase profits by seeing more and more patients per day, sometimes as many as 30 and usually for only 15 minutes each. Many patients had to wait weeks to get appointments. Simple prescription refill orders had become complicated bureaucratic exercises. Guaranteed salaries were changed to shares of the revenue, a chancier pay system. All of the office conversations seemed to involve money.
Hitting the solo path
To offer better patient care—and keep his sanity—he decided it was time to hit the solo path. In early 2001, he borrowed $15,000 and started searching for cheap office space. For $400 a month he rented a minuscule 150 square feet—one room. He bought a new exam table, an electronic thermometer, and some used furniture for $1,100. With computer charting software and barebone expenses for phone, electricity, insurance, and other necessities, his recurring costs totaled $1,600 a month. He hired no staff. Slow at first, business began to pick up, enhanced by patients referred from his former group practice. At the end of nine months, his projected annual net income was about $156,000.
Today, he refers to his office setup as “a Norman Rockwell practice with a 21st-century information technology backbone.” He has become a zealous promoter of micro practice, which may include some hired staff, and genuine go-it-alone solo practice. Moore himself has cut his actual practice to half-time. The other half is devoted to teaching and IMP.
As part of its support system for current and potential solo practitioners, IMP had its first conference last summer, which was attended by 36 people. At publication time, more than 150 were expected for this year’s event in June.
How technology impacts the solo practitioner trend
At the American Academy of Family Physicians (AAFP) in Leawood, Kansas, Steven Waldren, MD, reports that from a sampling of 4,000 AAFP members, half indicated they have either adopted an EHR or are in the process of doing so. Waldren is the director of the AAFP’s Center for Health and Information Technology. “In terms of percentages, [family physicians] have definitely been leading the charge in the technology adopted in their practices,” he says. That could be partly because reliable software for specialties is still harder to find, although usage by the total medical community stands at about 24 percent, according to Waldren.
Some cautions are in order, however. Going from Point A (group practice and paper records) to Point B (solo, with total automation) can be painful, possibly expensive, and even disastrous, without proper planning and execution. Step 1: “You really have to go through an extensive business assessment. This requires some discipline, thought, and analysis,” says Noah Lockwood, who manages the delivery of automated systems for a large consulting firm on the East Coast. Step 2: “Find software that meets your needs, and weigh the cure (benefits) against the pain (cost). Is this an Advil kind of pain or a morphine kind of pain, and what do I have to do to remedy it?” Step 3: “Determine what are the true long-term costs, both in your time and in maintenance.” Step 4: “Determine what it’s going to take to make the change and what steps have to be taken, such as installing and configuring the software and contracting with a provider or providers to get it up and working,” Lockwood says
If a variety of software is chosen, it’s important to make sure it will all interface. “You have to build the bridge for all the pieces to talk to each other,” Lockwood says. “All data must be in a protected network that complies with HIPAA as the information is transmitted to other sites, such as hospitals, specialists, and insurers. You need to be aware of the security implications and the potential liability for unauthorized access to the data,” he says.
Moore agrees. “Technology is like the Wild West now. There’s a lot of stuff out there. Some is real junk, some is outrageously overpriced, and a bunch of the parts don’t work and integrate with other parts, which makes it maddenly complex,” he says. However, an increasing amount of advice for newcomers has also surfaced.
Although many a loner dismisses “ready-made” systems from large vendors as too expensive and inflexible, there are some advantages to buying an all-in-one package. Jim LaSalle, DO, and his two family practitioner partners, with offices in two Missouri locations, chose an all-in-one package, PowerWorks®, produced by the Kansas-based Cerner Corporation and is pleased with his choice, both from a business perspective and a medical one. Ease of use was key to his decision, he says.
“We could be the most automated practice in the area if we so chose,” LaSalle says. He has since installed a lab interface component. The menu of add-on options is another point to consider in evaluating different systems.
For LaSalle and his partners, automation was less a means of reducing staff than a way of using existing employees to bring in additional revenue. For example, a former full-time filing person can now spend 75 percent of her time concentrating on collections. The easy record keeping can track minute details. “Now you can begin to actually understand at the end of a month that you only gave 50 flu shots when you have the potential to give 200,” La salle says, “or maybe you evaluated 50 of your patients for lipid abnormalities when there were 1,000 that you could have the potential to do.”
One of the most crucial parts of any office automation, LaSalle says, is the quality of billing software. When submitting bills to third-party payers, “make sure all the t’s are crossed and the i’s are dotted. There’s no room for a wrong dot or a wrong space or a lack of patient ID number.” He cringes at the memory of waiting almost for months on as much as $150,000 in claims. “We were looking at borrowing money to stay afloat.” He recommends a dry run for the implementation of sending insurance forms. “The system should be perfect before (a physician) ever tries to get involved with third-party payers,” he says.
In Lockwood’s experience one of the most daunting tasks in the switch from paper to electronic records is entering data from old charts. “You should explore alternatives to doing it yourself,” he says. “Hiring an assistant might be cheaper in the long run when you consider the cost of time that could be spent with patients.” Remember, too, that you probably want to transfer only the most critical elements of a patient’s chart, not every lab, progress note, or benign ER visit.
For do-it-yourselfers, Waldren at the AAFP suggests a step-by-step approach. “You can’t expect to come in Monday morning and say, ‘We’re going to use the EMR on all patients for everything, and we scanned all our records over the weekend or paid somebody to do that.’ It’s better to go slow and steady and get used to the system.”
Waldren says, “For the first two weeks or months start with a nice, basic EMR application, such as entering meds and e-prescriptions for all patients. Or, pick a special population, such as diabetics, and work that into the electronic document. Then well-woman exams, then student exams, then male physicals, and so on. The first couple of steps are baby steps, but very quickly you are up and running, and the next thing you can add quite quickly.”
That’s contrary to the advise of many experts, who favor a “head-first dive” into EMR. Everyone going through the same processes at the same time allows for group learning, support, maximum use of on-site system support, and doesn’t permit any techno-phobic stragglers.
While totally committed to an EMR, Christopher Flores, MD, in Rancho Mirage, California, has sidestepped one headache. “We are completely out-of-network to all insurance and Medicare. Patients pay fees with cash, credit card, check, or debit card and can submit claims for lab work and other subsidiary services. This eliminates the need for billing software.”
Flores also opted for a consultant, on retainer, to assemble his electronic setup. “It’s one of the best things we’ve done,” according to his wife, Marciela Fernandez, who works with him. “When you look at what you pay out for other things, such as supplies, we don’t pay him an exorbitant fee. (Without him) it could cost thousands and thousands of dollars to recover lost data,” she says.
Flores is pleased with his decision to go solo. After 18 years in “different types of environments, usually as an employee physician, I found I couldn’t do what I do what I was trained to do. I couldn’t provide the type of service, and quality that was the reason I went into medicine in the first place. I figured the only way I could do it was to do it myself,” Flores says. “Maricela, an attorney, wanted to try something different, so we’re working together, just the two of us.”
He says that, because of low overhead, “two people still can handle 600 to 700 patients, meet their needs, and be timely and personal. I only have to see eight patients a day to be successful, whereas most doctors’ offices have to see at least three times as many, and the phones are ringing off the hook [with patients who want to join his practice].” In October 2005, Flores found a space of 1,000 square feet that includes an office with a relaxing desert view which he uses to interview patients and can double as a second exam room.
His initial $20,000 outlay included one scanner (he now has two), fax, printer, copier, two desktops, and a laptop. He selected SOAPWARE EMR, “mainly because it was one of the lower-cost programs with a good reputation.” Also part of the package: a server, used for computer and data storage, and four hard drives with 80 gigabytes which constantly back themselves up. “They call it a redundant array,” Flores says. The server has a metal tape backup, because Flores and Fernandez are “very, very aware that if you lose your medical records, you really are in hot water.” Once a week Fernandez removes a tape, backs it up, and takes it off-site for secure storage.
Flores also customized his EMR, which is a universal option, with key phrases that he uses repeatedly, saving him hours of data entry. With a few keystrokes, he can generate whole paragraphs. “For instance,” he says, “if I write ‘ALERT,’ and hit a base key, it fills in the rest: ‘Patient alert and oriented, aware, can answer all my questions, doesn’t look depressed, etc.’ It saves an endless amount of valuable time.”
Two desktops are now networked into his server. Flores uses a wireless laptop in his exam room, where he can type prescriptions and referrals and send them to Fernandez, who faxes them from her computer. More recently, they purchased headsets. One patient, a 70-year-old woman who asked Flores for a donation to support her participation in a charity run, was amazed at the magic of it all. Talking into his headset, Flores told Fernandez to cut a check. By the time the patient left, both her bill and a check were waiting.
While some physicians have tried and given up on solo practices because of low profitability or for other reasons, many physicians report full practices with waiting lists. The AAFP’s Waldren says, “It’s not an easy decision to go ahead and bite the bullet. It takes time, energy, effort, and commitment to make it successful, but I think most physicians will see significant rewards
if they stick to it.” END
Eileen Lockwood is a freelance writer based in St. Joseph, Missouri.
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