Single Doc Seeks

By eileen lockwooD Unique Opportunities July/August 2008

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.

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.”

Going it alone 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.

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.

Technology rules

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.

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