Paths to practice success: two physicians' stories.

SAN DIEGO -- Physicians are finding ways to redesign their practices and improve efficiency, both with and without the use of electronic medical records.

Dr. Kevin D. Egly of Sandwich, Ill., has used his comprehensive electronic medical record (EMR) system to practice in a scaled-down office without staff. Taking a lower-tech approach, Dr. Barbara E. Magera of Charleston, S.C., uses preprinted forms to accomplish many of the functions done by an electronic system but for a fraction of the cost.

The two physicians presented their different approaches at the annual meeting of the American College of Physicians. Both practices have been studied by the ACP's Center for Practice Innovation, a 2-year project created by the ACP to help small practices improve their work flow.

For Dr. Egly, the comprehensive EMR system, which performs chart documentation and billing, is what makes it possible for him to practice the way that he does. He and his wife Angela, also an internist, each work about 20 hours a week in their small practice. Since they don't employ any other staff, they answer the phones themselves and handle their own billing.

Dr. Egly and his wife started the practice after each working in a large multi-specialty group, and they quickly realized that to be successful they would have to practice differently.

They implemented the EMR system from the start and have tried to keep overhead low. For 2007, Dr. Egly estimates that overhead for the practice will be about 36% of projected revenue, with the EMR and its network accounting for only about 2.5%.

The benefits of the low overhead are that he and his wife can see a lower volume of patients and still support the practice. They estimate that it takes about four patients a day to cover their expenses.

They can also provide generally longer patient appointments. For example, they provide 60 minutes for a physical, 40 minutes for a chronic care appointment, and 20 minutes for an short-term care visit. "It provides a good work flow for the day and breathing room every day," he said.

And the design of the practice also lends itself to better patient access, Dr. Egly said. Because he and his wife answer the phones themselves, patients can speak directly to their physician. They also provide 24/7 access to patients. After-hours calls to the office are put through to a pager, and the patient receives a call back in about 15 minutes. "By giving them the access I actually get fewer calls, but the calls I get are the important ones," he said.

To improve access, they are working on creating a patient portal that will allow patients to make online appointments, check lab results, and access their charts.

"This is a very satisfying way to practice medicine," Dr. Egly said.

For Dr. Magera, an EMR system is still too expensive, and she hasn't been able to find one with the necessary functionality for her practice. Instead, she uses preprinted forms that are aimed at streamlining the work flow in her office and reducing callbacks from pharmacists, caregivers, other physicians, and insurers.

Dr. Magera, who has been in practice for about 10 years, sees allergy and internal medicine patients at four offices. The preprinted forms she created have made it easier for the staff to code correctly, she said. "We code it right the first time. Therefore, we get very few calls back," she said.

For example, Dr. Magera uses preprinted prescription pads for each drug she prescribes with the drug name and dosage already printed. The prescriptions are compliant with state pharmacy laws and are color coded for patients with low literacy. The pads are relatively cheap but make prescribing much faster, Dr. Magera said. And she doesn't run into the handwriting problems or dosage mistakes that can plague handwritten prescriptions.

Dr. Magera and her staff also have created special forms for phone notes, allowing the staff to document any contact the patient has with office staff that does not happen during a visit.

The notes, which also cover contacts by e-mail, letter, fax, or handheld personal digital assistant, are given first to a nurse for review and then signed by the physician. The office rule is that all phone notes must be reviewed before the end of the work day, she said.

She also uses preprinted forms to request laboratory, x-ray, and CT studies.

Some of her forms help her to get paid, she said. Dr. Magera has a standard insurance verification form that asks for current demographic information on the patient and policy holder, deductibles and copays for the office visit and procedures, preexisting conditions, which facilities are covered for lab and x-ray procedures, and whether precertification is required.

Although the process was originally time consuming, the staff is now able to get some information online. Having the standardized form allows her billing staff to discuss financial responsibility with the patient before the first office visit.

So far, consistently using the form to collect information before the visit has helped increase revenues by 25%-40%, she said. And the process is popular with patients because there are no surprise bills later on, she said.

Having a paper-based office can work, Dr. Magera said, and her rule of thumb is that if she does a task more than once it qualifies for a preprinted form.

But she doesn't expect to be using paper forever. "These forms are really preparing us for when we get our EMR," she said.

BY MARY ELLEN SCHNEIDER

New York Bureau