I have laid out many of the issues that primary care practices are facing in the last three blogs.
I would like to share how my private practice, Birmingham Internal Medicine Associates a/k/a BIMA (www.bimapc.com), has taken it upon ourselves to try to figure out how to do a better job and be transformational.
At the end of the blog I added comments about wheelchair accessibility in London and Paris….I hope you enjoy.
We adopted the electronic medical record (EMR) before it was even required by the government over 10 years ago. This was our first major transformational change. Unfortunately,the partner we went with ended up not being capable of providing the services we needed. We then made the difficult choice a year and a half ago to switch to a different system. This was costly and painful, but so far it seems like a good decision.
Some of the other innovative things we’ve done in our practice is aggressively push a patient portal long before it was in style. We now have over 70% of our patients using our patient portal to get their test results and schedule appointments. This has significantly cut down on our number of incoming and outgoing phone calls. We still get more than we can handle on some days. However, as more people become comfortable with the portal that will continue to be less of an issue. The goal is the older patients who don’t like technology or understand it will still be able to use the phone and will have an easier time doing so because more people will be using the portal. The portal eliminates the middle man and the delay and potential for medical errors that comes with that.
We implemented a registration tablet replacing the clipboard. On this tablet people can fill out their history electronically, make changes easily just by editing previous information, and pay their co-payments. No need for paper or pens at our check in. We have also started online check-in where you can check in the day before.
Online Appointments have begun. This is a scheduling process but ultimately by year end you will be able to book a visit at our office like you now book a plane ticket.
We started a case management and quality department. We hired two nurses to oversee this. They also follow up on all of our hospitalized patients and get them appointments within seven days of being discharged. The data we have on this follow-up indicates significantly decreased number of our patients readmitted to the hospital within 30 days of being discharged. Colonoscopy rates, mammography rates, and immunization rates have all gone up.
We started a daily walk in clinic every morning from 7:30 AM till 9 AM where people can just show up without calling. This has been very popular as people know they can just wake up and if they feel bad simply come to our office. Usually everyone is gone by 9:45 at the latest. This has significantly cut down on urgent care and emergency room visits. It has also resulted in a decrease in the middle of the night calls (waking the doctors up) for which we are grateful and allows us to better treat our patients in clinic having rested without interruption.
Two years ago we started a virtual office visit program. Our patients that have been seen within a year can go online and be treated for certain simple problems without an office visit. There is a small fee for this but the convenience is outstanding. We will significantly upgrade this later this year.
We are moving towards guaranteeing same-day appointments for all patients (by having practitioners available even if it’s not their physician it is a physician or nurse practitioner that works along side their physician; better than just “any” local urgent or walk-in clinic that has no access to their physicians charts).
Everything we have been trying to do is to provide improved convenience for patients, increase quality, and lower overall cost.
To make all this happen we have moved towards team-based care using our medical staff as well as our nurse practitioners.
When we have come across high cost providers for testing we have switched our patients to lower cost providers as we are aware many patients have high deductibles and increased out-of-pocket expenses.
As I had laid out my last post Primary care physicians need to be the captain of the ship and we need to direct our patients to the best quality care at the best price that is most convenient for the patient.
Keeping in mind that we are dealing with a system that has not really changed in 100+ years. We have definitely run into some issues. The technology does not always work as advertised. Wi-Fi can go down, servers can go down, and some patients just don’t like change.
The overwhelming response to the changes we have made has been very positive. We have had some patients leave our practice because they have not been happy with it. Interestingly the vast majority return asking for forgiveness after sampling other practices.
We have attracted tens of thousands of new patients and are adding one to two new physicians a year.
In closing, I want to reflect on a few thoughts from our recent European trip. We took our handicapped daughter who is in a wheelchair for her 18th birthday to London and Paris.
We found London to be very handicapped accessible. Every black cab had a wheelchair ramp.The Tube not so easy (subway). Many of the stations were not handicapped accessible for a wheelchair. While there we witnessed a big debate going on about whether the government should continue to pay for medications. Currently they pay for a lot of over-the-counter medicines. They also play for food for people with gluten sensitivity (gluten free diets). They are getting ready to end those benefits. Just like in our country they are facing growing health care costs with an aging population.
Paris was much more difficult handicapped wise although the people were very accommodating. The taxis do not have ramps. The subway system does not have very many stations at all that our handicap accessible. We did not try the public buses, but apparently they are fairly accessible. The museums are all free if you were handicapped and quite accessible.
John W Farley, M.D.