American College of Physicians: Internal Medicine — Doctors for Adults ®

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How one group gives new meaning to 'virtual' access

Replacing many follow-up visits with e-mail and phone calls has made physicians—and patients—much happier

From the April ACP Observer, copyright 2003 by the American College of Physicians.

By Phyllis Maguire

Rushed office visits and falling reimbursements have many physicians frustrated over how to improve patient care. But one Oregon group has found a solution: Give patients better access to physicians via phone calls and e-mail, and charge them up front for it.

By relying on phone calls and computers to reach patients, GreenField Health System has successfully eliminated more than 50% of all follow-up visits, said Charles M. Kilo, ACP Member, the group's chief executive officer. Just as impressively, the five-physician practice in Portland, Ore., has been able to survive financially without the income that follow-up care typically brings.

Dr. Kilo has long been interested in changing office-based practice models. Before founding GreenField, he served as vice president of Boston's Institute for Healthcare Improvement, leading an initiative to redesign medical practice. He became convinced that while follow-up care is essential, many face-to-face office visits—particularly follow-up appointments—are unnecessary.

"Many patients can be managed through other means," he explained. "We wanted to move the practice model away from visit-based care to one where physicians and patients have relatively free and ongoing communication."

Following up with patients

A key component of GreenField's practice model is its electronic medical record (EMR) software, which reminds physicians to call or e-mail patients after office visits and ask about new medications or ongoing symptoms.

"We take the initiative to follow up with patients, instead of telling them to call us if they have questions or problems," Dr. Kilo said. "Patients appreciate not having to come back in a week to communicate face to face."

The group's physicians, nurses and medical assistants also rely on phone and e-mail to manage patients with chronic illnesses. They urge patients with hypertension, for instance, to buy a blood pressure cuff and send in readings from home.

To successfully incorporate virtual patient management into office-based care, GreenField needed a very fluid approach. "The key to efficiency is to remove as many barriers as possible from your work processes," Dr. Kilo said.

Instead of dedicating a specific time to phone care, for example, he talks to patients when they call—unless he's with other patients. Every time an assistant has to take a message or he has to retrieve voicemail, he said, "it adds work." If he isn't available when patients call, he gets back to them as soon as possible, instead of waiting until the end of the day.

GreenField also produces a monthly electronic newsletter, which its physicians use to weigh in on controversial topics like new developments in hormone replacement therapy.

Keys to success

How is such a practice possible—and profitable? Dr. Kilo pointed again to the group's EMR software, which allows physicians to access patient records within seconds.

"We're completely electronic, so components like e-mail are seamless without additional administrative costs," he said. While many physicians talk to patients on the phone or via e-mail, GreenField's doctors have instant desktop access to patient information. They don't have to waste time—or money—pulling patient charts or rifling through folders.

The practice also offsets revenue lost from eliminated office visits by charging patients a $350 annual fee. (Individual family members each pay 10% less.)

Most GreenField patients have private insurance, which covers the cost of office visits, and pay standard co-pays in addition to their annual fee. Because GreenField's physicians have opted out of Medicare, senior patients pay out of pocket and receive no Medicare reimbursement. (They do, however, get a 20% discount if they pay for services at the time of their visit, instead of waiting to receive a bill.)

According to the contract patients sign when they join, the annual fee entitles them to 10 extensive phone and 15 e-mail consults a year. Dr. Kilo said, however, that physicians never enforce those limits, which were developed to prevent abuse of the system. And, he stressed, virtual access is available only to established patients after an initial visit with a physician and a thorough review of their medical records.

Typically, patients use their phone and e-mail access most extensively when they first join. Dr. Kilo recalled a patient suffering from anxiety and depression who has sent him 14 e-mails since signing on with the practice six months ago. Many of the messages concerned her drug therapy, but some gave Dr. Kilo an opportunity for "gentle coaching," helping establish a much closer relationship with her than rushed office visits would allow.

The patient also lives more than an hour away, Dr. Kilo said, and joined the practice because it offered an alternative to office visits.

A supportive patient base

While the group charges an annual fee, Dr. Kilo said there are many differences between GreenField's practice model and so-called "boutique" practices. For one, GreenField's $350 yearly fee is a far cry from the several thousand dollars boutique practices typically charge. And unlike most boutique groups, GreenField doesn't offer open or virtual access around the clock.

Also, GreenField's patients know they're supporting the group's EMR system and its safety and data mining features. They also know they're offsetting care costs for some patients who can't afford the yearly fees: GreenField now absorbs the costs of caring for 300 Medicaid patients and intends to dedicate 10% of its services to either Medicaid patients or free care.

While he wouldn't say how many patients now participate in the practice, Dr. Kilo noted that the group recently had to hire a new physician to accommodate its expanding patient base.

In part, he said, the practice is thriving because of its geographical location. Located in the "Silicon Forest," an affluent part of Portland where Intel Corp. is the biggest employer, GreenField caters to a technology-savvy patient population.

Many practices around the country may not enjoy that level of patient support for technological innovation, he admitted. And many patients don't understand that they need to spend more for comprehensive health care.

"Most people still think health care is free and an entitlement," Dr. Kilo said. "Many patients lack real knowledge about how health insurance functions-and they don't know that very few of their health care dollars actually go to their physician."

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