Making Practices Perfect
Tuesday, August 26, 2008
The waiting room of Ramona Seidel's family medicine practice is empty, and she works hard to keep it that way.
After several years in a traditional suburban group practice that blended pediatrics and family medicine, Seidel quit to start her own micro-practice in Annapolis: a low-overhead, high-tech office that gives her more control over how she treats patients and more time to spend with them. She's happier. Her patients are happier. And she's pretty convinced they are healthier having a physician who knows them well.
"It's more friendly; it's personal. She's very good about giving answers. It feels comfortable talking to her," said Ronald Porciello, 41, a contractor with a family history of high blood pressure who has been Seidel's patient for seven or eight years. He liked her at her old practice. He likes her better now.
Patient-centered care, chronic disease management, self-care and medical homes are all buzzwords in health policy circles these days, in the midst of the national dialogue about quality and systemic reform. But countless doctors, generalists and specialists alike, are moving ahead on their own, reinventing their clinical practices and finding more-effective and more-fulfilling ways of practicing medicine.
"I knew there had to be answers, ways of improving and changing," said Anna Maria Izquierdo-Porrera, who until recently was the medical director for two Spanish Catholic Center clinics serving poor immigrants in Adams Morgan and Langley Park.
Frustrated by the long waits and other barriers to quality care that her patients were facing in the crowded clinics, Izquierdo-Porrera began plowing through quality improvement data looking for solutions. Eventually she raised the money to enroll in a program, sponsored by the Institute for Healthcare Improvement, where she learned how to apply business techniques to a busy, stretched clinic. The initial results were impressive.
The clinics introduced computerized medical records that help track patients with chronic disease. Waiting times were reduced, although not quite as much as Izquierdo-Porrera would like. Patients get appointments fast, often the same day, and a single clinic visit may include follow-up tests, consults and referrals to specialists, including several who volunteer at the clinics. This efficiency is crucial to low-wage workers who might have difficulty missing work for health appointments and might delay getting the treatment needed for chronic conditions such as diabetes and high blood pressure.
"If a rich person wouldn't be caught dead there, neither should a poor person," Izquierdo-Porrera said. She recently left the clinics to try to develop a program that will bring similar changes to clinics and practices in other low-income and under-served populations.
"The way the average office practice still works, it's almost indistinguishable from the early 1900s, minus the computer screen," said Donald Berwick, president of IHI. "We're practicing horse-and-buggy medicine in the space age." Getting rid of waits, using e-mail and telephone consults, improving efficiency for doctor, nurse and patient frees up time for delivering care.
"The same things that frustrate patients frustrate the doctor. The dropped balls, the long waits, the missed communication, the poor communication," said Berwick, noting that he can order a pizza over the Internet but has to visit a doctor to get a prescription.
The micro-practice is only one of several models IHI and other quality-improvement groups use, but it's the one that Seidel thrives in. A mother, she works two-thirds of the time that her Bay Crossing Family Medicine office is open; two other working-mom doctors split the rest of the schedule. Instead of an army of nurses and clerks, they have one part-time office manager. Seidel is building Bay Crossing slowly, striving to balance the supply of her time and the demands of her patients in a way that keeps her waiting room empty.
When patients arrive, there's no checking in at a front desk, no filling out repetitive forms, no sitting around waiting. They tap an old-fashioned bell, and Seidel comes out to greet them. The magazines in the waiting room aren't dog-eared; no one is here long enough to read them. If a book on the shelf -- they're mostly about parenting, nutrition and health -- catches a patient's eye, he can sign it out: That's the only part of the practice still using a paper filing system.
Part of the allure is control. "When I want to change something, I just do it," Seidel says. But she is also convinced that she has more time to do preventive medicine, control chronic diseases, help patients quit smoking, watch their weight.
Porciello knows the consequences of not managing his blood pressure. His grandmother died after suffering from hypertension at 56. Yet he slacked off recently about monitoring his pressure, and he has been skipping some morning doses of his medication. In a traditional practice, Seidel said, she'd probably gently chide him to do better. Here, they took the time to talk out the problem and brainstorm a solution.
His work schedule had been more erratic than usual; he was sometimes rushing to get out of the house by 5 or 5:30 a.m. That meant he bypassed the kitchen, where he kept his meds. Moving the pills next to his toothbrush might solve the problem.
"Even when I'm in a hurry, I'm always going to brush my teeth," said Porciello, who gets e-mail reminders from Seidel when he's due to come in, after Seidel herself gets an alert on her laptop from the electronic medical record system. For patients who aren't so comfortable with e-mail, she'll send a note or call.
When patients have questions, they can call or e-mail her 24-7. Occasionally -- for instance, when making sure an elderly patient is tolerating a drug without side effects -- Seidel uses a computer link to the patient's home that allows her to check the person's status, although she'll bring the patient in if she thinks a face-to-face visit is in order.
She lives five minutes from the office and comes in when necessary at nights or on the weekend. Once she coordinated the Saturday sports and carpool schedule of her own three kids with the schedule of a mom who was worried about one of her own children. They rendezvoused at her office between soccer and lacrosse, just long enough for Seidel to check that the child had an ordinary sore throat and had not caught strep.
That doesn't happen often. Since she's taking care of patients' needs as they arise during the day, she doesn't get a flood of off-hour calls. By being available, she can not only reassure patients, she can often keep them out of the ER at night -- or tell them, yes, those chest pains are alarming, and you should dial 911 immediately.
Seidel earns less than in a traditional practice, partly by choice. Gordon Moore, who helped develop micro-practices in Rochester, N.Y., before his recent move to Seattle, said that's not true of all micro-practices, although he has identified "dead zones" where the model won't work because of high local costs and low insurance payments.
Seidel takes Medicare and she is a network provider in a few health plans (including one for Medicaid), but many patients see her "out of network," paying upfront and getting reimbursed by their insurer. Despite that bell in the waiting room, it is not a "concierge" practice. There are no annual fees, and she's affordable for middle-class patients. She takes new patients, but carefully, not wanting to throw her micro-practice off balance.
"It's a little more money," said Anne Agnoni, who had brought in 18-month-old Santino, the youngest of her four sons, for a checkup. "But she spent 30 or 45 minutes each with my older sons, and that was just the camp physical. I have to pay a $100 diagnostic fee just for my mechanic to look at my car, never mind repair it. With Ramona -- I mean, Dr. Seidel -- she's compassionate, and my kids and I feel comfortable. She treats you like you're one of her own."
Joanne Kenen, a health policy writer at the New America Foundation, edits thehttp:/