Small-Town Tech, Big-City Service

Before he got an electronic health record, David Fairbank, MD, was on the brink of bankruptcy. "A month later than that, and I would have been under," the Lacey, WA, family physician says. His practice, the Clinic at Panorama City, located in a 1,200- resident retirement community, has a patient population that is 60-70% Medicare, so it was more than just an inconvenience when the clinic's third-party billing service had a software glitch that prevented Dr. Fairbank from receiving a single Medicare reimbursement from July 17 to Oct. 6, 2006.

"Our billing company went into bankruptcy and almost took me with them," Dr. Fairbank says. At the time, he relied on the billing service to verify patient eligibility. "It was a poor way of checking it," he admits. He estimates the practice lost $30,000 one year, simply because the billing service wouldn't follow up on invoices worth less than $100. On top of that, Dr. Fairbank is a member of the Physicians of Southwest Washington IPA, a prepaid insurance network, in which the IPA and its members assume all risk. "We didn't have a handle on our finances," the solo family practitioner says. It was an all-too-frequent refrain for a small, semirural practice. But not an insurmountable problem.

In the Red and Seeing Red

Thanks to electronic health records (EHRs) and even the Internet in general, small-town and rural doctors and their patients no longer have to suffer due to geographic isolation. They can deliver the same kind of care as their big-city counterparts and also thrive financially. On July 17, 2006, the same day his old billing service went on the fritz, Fairbank took up the IPA on its offer to install an EHR in his office. The IPA is an EHR and e-Prescribing test partner for Purkinje, a St. Louis-based vendor, and Fairbank's clinic in Panorama City now is a beta testing site.

At the time of the billing crisis, Fairbank had three people working at the front desk. One subsequently left, but the remaining two were able to handle the workload with the help of the new system. Dictation and transcription had been costing Fairbank $4,000 a month. The cost is now down to $200. Overhead expenses ate up 61% of revenue from January to May 2006. In the same period a year later, overhead was down to just 51%. The EHR also represents a better way to evaluate practice performance, Fairbank says. It now takes about 7-10 days instead of 20-30 to get reimbursed by most payers, including Medicare. This is key because, as the physician states, "You've to watch your cash flow." Fairbank also is fairly certain he's delivering better care to his patients with the EHR. This is not just about putting paper charts into the computer," he explains, "this is about the clinical decision support. He specificlally cites the benefits of drug interaction checks, reminders about preventive care, follow-ups with patients, and even coding, since the software handles risk adjustment for Medicare. As soon as the coding is done, the bill goes out electronically, marking a huge advance from the old method. Previously, the practice's billing service would pick up charts twice a week, "meaning bills only went out twice a week. Now, bills get sent to the proper payer as soon as his documentation is completed for each patient encounter, helping to ensure a more constant revenue stream.

Although Fairbank has proof that an EHR saved his practice, other small-town, small-practice, primary care physicians only have their gut feelings to go on. Still, Joseph Perkinson, MD, of Victoria, TX, is glad he didn't "leave anything to chance when he hung out his shingle in January 2001 without a previous patient base in the area. "I was tarting from nothing," he recalls. "I had only served that there was not much longevity in solo family practices. That troubled me." Dr. Perkinson knew that the only way he was going to make it was to operate efficiently and provide good care. Based on his experience as a resident at Baylor College of Medicine in Houston, an EHR was a necessity. "It encourages me to be honest [with patients]," he says.

Once he's done documenting an encounter, Dr. Perkinson shows the computer screen to the patient so the patient can visualize health trends, such as historical testing values. For example, he might otherwise have danced around the issue of alcoholism with a patient, but a spike in HDL cholesterol" one symptom of alcohol abuse "that both can see, forces him to confront the issue as early as possible. "I see these tools as a Herculean leap, a huge advance in the tracking of diseases," Dr. Perkinson explains. Unfortunately, patients tend to choose physicians on "superficial" bases, "especially in small-town America," according to the small-town doctor. A doctor's perceived reputation tends to carry more weight than actual performance. "They really don't care about the tools that you use," he says.

But it sure does help around the office. "We've never had charts, ever," Dr. Perkinson adds. That means he didn't have to lease extra space just to store thousands of paper records, nor did he have to hire file clerks. He started out with two staff members, and his wife provided some part-time support; now, he employs four full-time staff and one part-time employee to support his practice, significantly less than the national average of about seven full-time workers per family physician. Clearly, the EHR has enabled him to do more with less. "Because of automation, it allows non-clinical people to participate in the clinical process to a degree," Dr. Perkinson says. For example, staff at the front desk can access patient records to handle refill requests with minimal involvement by the physician.

Ahead of the Curve

The same goes for Terry L. Turke, MD, a solo family physician in Watertown, WI. He has two physician assistants, the equivalent of three full-time nurses, three front-office workers, some part-time clerical help, as well as one person who wears the hats of x-ray and laboratory technician, document scanner, and business manager. "Our entire staff is paperless," Dr. Turke says. More importantly, he believes the EHR empowers the nurses to be real caregivers, and not spend half their time chasing paper. "They like the responsibility of being part of the team and participating in the patients' care."

Dr. Turke won an award in 2006 from Dean Health Plan, topping 17 other practices in terms of following metrics related to generic drug usage and pill-splitting in diabetes care." I'm convince that as mostly our good staff and our electronic health record," he states. Before he found the right nurses, Dr. Turke did have some trouble recruiting suitable people to Watertown, about halfway between Milwaukee and Madison. The presence of an EHR means his nurses must have typing skills. When he first started with electronic records, and for many years after, many candidates lacked those skills.

The Wisconsin physician could rightly be called an early adopter, since he has had SOAPware, a product of DOCS Inc., since 1995. "I was one of the pioneering folks," he says. Even back then, various medical journals had been saying plenty about EHRs, although computerized patient records and electronic patient records were the preferred terms at the time. "It just made so much sense to me because every other business was electronic," he recalls.

In October 1994, Turke attended the annual meeting of the American Academy of Family Physicians, which had just begun to show an interest in EHRs. He remembers participating in what was dubbed a "Computer Petting Zoo," where doctors could test out the offerings of 20 or so vendors. "I decided after going there that I would go electronic," he recalls. Prior to the meeting, he hadn't even seen an EHR before. It was at that meeting that he met SOAPware developer Randall Oates, MD, himself a small-town, small-practice family physician. "I spent a lot of time at the Computer Petting Zoo," Dr. Turke says. "When I got home, I just decided to do it."

Like so many early adopters, Dr. Turke took a leap of faith with his vendor. Nowadays, with the market's gradual maturation and the 2006 advent of a certification program for EHR software, it's less of a gamble. "Whichever one you decide [on], I'm sure it will be fine," he advises. "Just pick one." After all these years, through plenty of trial and error, Dr. Turke has refined his workflow as technology has improved. Twelve years ago, he was doing all the data entry himself. "Nobody in their right mind would do it that way now," he says. Today, he has a series of preformatted templates to help document common conditions, but that also means he has to pay attention to what he's doing. "It's so easy to use the "canned template" so you don't have to read every word," Dr. Turke notes. "If you say the bowel sounds are normal, you'd better darn well have listened to the bowels."

Next Steps

According to Dr. Perkinson, "The single biggest impediment to the adoption of the digital health record is data entry." In April 2005, when he moved to a larger office, he overhauled his local-area network and started with speech recognition as an alternative to templates and free-text entry. "I have never used dictation, ever," he says. Instead, he relies on a hybrid of typing, point-and-click templating, and speech recognition, with a USB microphone attached to his computer. Perkinson is also a fan of "scribing" where by the assistant follows him and does the typing. "It keeps me from looking at the screen when I'm evaluating the patient."

Perkinson's office has wireless laptops on carts, known in hospital circles as COWs, for computers-on-wheels. "I have never liked leaving computers in the exam room," he says. "That, of course, is a personal preference. Dr. Turke has computers both in his personal offi ce and in the exam room. Nurses, PAs, and the front office staff are all connected to the clinical system. Nurses or other staff take the patient's history, then he goes in to conduct the examination, reviewing the information along with the patient. "I see patients] in the exam room, they get dressed, and then they come into my office."

Patients leave the office with a printed summary of Turke's notes, including the diagnosis, treatment plan, and list of medications. He tells older patients to carry a copy of the report with them, particularly in case of emergency. "I think if I had a dollar for every time a patient told me this was a good idea, I'm sure I would have paid for [the EHR] by now," Turke says. Actually, he is certain the EHR has paid for itself in many ways. "When I'm gone I'm virtually connected to the Internet, and I can still review the charts, " Dr. Turke says. In the past, whenever he took time off , he would bring in a locum tenens physician, then come back to a large stack of charts to review, adding to expenses and slowing him down.

Although the Internet is pretty ubiquitous across America, technology can and does have its limitations in rural areas. In 2001, Perkinson purchased a Logician EHR, a system now sold by GE Healthcare under the Centricity brand name, which was developed more for group practices than solo physicians. He chose a Millbrook practice management system, also now part of GE's Centricity line, mostly because that was what Baylor had for its outpatient billing and management.

Now, he's working on setting up a patient portal to gather clinical information and report test results over a secure connection, but residential bandwidth issues in his community are making that difficult. And the lab he uses is not yet capable of reporting results directly into the EHR. "I would like a two-way interface, but this town isn't ready for it yet," he admits.

Neil Versel is a freelance healthcare journalist.