Through his Hamden internal medicine practice, Dr. Edward Rippel has become something of a pioneer. He takes his notes in a tablet computer and closely monitors patients with chronic conditions. Those who are overdue for a test get a reminder, part of an effort to more carefully manage patients’ health.
Rippel isn’t the first doctor to use electronic medical records or to practice as a patient-centered medical home, an increasingly popular concept in health care.
But unlike most of those who do, Rippel is a solo practitioner. And whether more physicians can be like him is a key question for the future of health care in Connecticut.
The way primary care is delivered is changing, from a system based on paper charts and payment schemes that reward doctors for performing more procedures to one that involves computerized records and paying doctors for coordinating care and keeping patients healthy. The federal government is leading a massive push for electronic medical records, while Connecticut has plans to encourage health care providers to become medical homes for Medicaid patients.
Both are costly, time-consuming changes that experts say are far easier for large medical groups than small, independent practices. In Connecticut, where eight of every 10 doctors work in a practice of four or fewer physicians, experts caution that the medical groups that have made significant changes are not representative of the state’s health care providers.
Of the 91 providers recognized as patient-centered medical homes by the National Committee for Quality Assurance, or NCQA, most work at community health centers or in hospital-owned practices.
And then there’s Rippel.
This year, he became the first solo practitioner in Connecticut to receive the highest-level medical home recognition from NCQA. He said he spent about $50,000 getting and implementing electronic medical records, but recouped the money in just over two years through increased efficiency, pay-for-performance programs, and changing the way his office works.
“I think it’s actually something of a myth that you can only do this if you’re a big practice,” said Ellen Andrews, executive director of the Connecticut Health Policy Project, which recently produced a report on “early adopters” of medical homes.
Nationally, practices of one or two doctors make up 37 percent of the 2,314 medical practices recognized as medical homes by NCQA. Another 44 percent have three to seven doctors.
“It’s hard to envision a small practice having the resources to do that. But people are doing it,” said Dr. Robert McLean, a New Haven internist and rheumatologist and governor of the American College of Physicians’ Connecticut chapter.
And in spite of the challenges, some say small practices could have an advantage when making major changes.
“In some ways, it’s easier for a small practice,” Andrews said, “because you really only have to convince one guy at the top.”
A solo doctor’s experience
Rippel speaks of having a vision of primary care–comprehensive care that includes managing chronic diseases and preventive medicine. He saw electronic medical records as a way to help him realize the vision. Later, he sought recognition as a medical home after determining that the standards reflected the way he practiced.
Year earlier, Rippel had tried to actively track patients, without computers. He made charts by hand for each patient’s file to track screenings, vaccines and other preventive care. Another chart tracked measurements for patients with chronic diseases.
But the paper spreadsheets had limitations. They were time-consuming, and while they could help in monitoring individual patients, they didn’t help at the practice level. If Rippel wanted to know which patients were overdue for screenings, he or his staff would still have to look chart by chart. At the time, he didn’t think electronic medical records were financially feasible.
Then, in 2005, Rippel heard about pay-for-performance programs that pay doctors for meeting certain care standards. He found he was already doing much of what they measured. But documenting it without computerized records would be a “paperwork conundrum.”
So he decided to invest in electronic medical records. He bought computers, printers, servers, scanners and software; had a network set up; got an information technology team to help; and had his staff trained on the system. The billing database was used to create files for each patient, but without medical history. Rippel entered that information, as searchable data, not just scanned images, over seven months of nights and weekends.
Rippel had outsourced his billing, but the electronic system allowed it to be done in house, by his staff, who no longer had to spend time tracking down paper charts. Not having to store charts on-site left him with 120 square feet of office space that became his billing office.
The new system also allowed Rippel to get a better sense of how well his patients’ conditions were being managed. One of the first he looked at was diabetes.
“I thought I was doing a pretty good job, much like every other doctor thinks that they’re doing,” he said. “You work hard, you go home at the end of the day, you’re really tired, you think that you’re really doing the best you can for your patients.”
“And it turns out that my percentage of success in getting patients to goal for diabetes was about the same as other primary care doctors in the United States,” he said. “And I said, ‘But that’s not good enough.'”
So Rippel set up his records system to do a regular query to determine which patients’ diabetes were not being optimally managed, and had them come for appointments.
He began doing the same for cardiovascular disease and other conditions and received recognition from two NCQA programs for diabetes and heart-stroke care. Applying for patient-centered medical home status required more documentation, but only modest workflow changes in patient care, Rippel said.
In the first two years of using electronic records, the percentage of Rippel’s patients whose diabetes were under control rose from around 40 percent to 70 percent. Seventy percent of his patients receive appropriate colorectal screening, he said, compared to a national average around 50 percent.
The computer didn’t make him smarter or a better doctor, Rippel said. “It made me much better able to handle huge amounts of data quickly.”
Still, it can be a challenge for doctors to make the changes.
“The motivation to achieve all these things, at the same time that you’re still seeing patients all day long and taking care of sick people and addressing all of the economic concerns that any health care practice faces today, can sometimes be emotionally overwhelming,” Rippel said.
Will there be others?
Among doctors, there’s “huge interest” in medical homes, said Matthew Katz, executive vice president of the Connecticut State Medical Society.
“It’s the practical application that is scary to a vast majority of practices in Connecticut because of the resources required and education required” for both the physician and the office staff, he said.
The medical society, its practice association and Qualidigm, a health care consulting and research company, have been working with more than 100 doctors in small practices to help them through the process of becoming a NCQA-recognized medical home, using of a grant from the Physicians Foundation.
“The hardest part we’re finding for these small physician practices is just the time,” Katz said.
Becoming a medical home requires re-engineering most practices, changing everything from patient scheduling–so sick patients can get appointments quickly–to, for the higher levels of recognition, using electronic data to improve the quality of patient care.
“I have not met a physician yet in Connecticut, primary care or otherwise, that doesn’t see the medical home as a laudable goal or as something that could potentially improve access to quality patient care,” Katz said. “But many of them see it as a financial burden to their practice that no one is paying for.”
As part of an overhaul of the Medicaid system in Connecticut, state officials want every Medicaid patient to have access to a medical home within a few years. So what could the state do to get more doctors to adopt the model?
Dr. Thomas Meehan, chief medical officer of Qualidigm, which helped Rippel and other doctors applying for medical home recognition, said technical support would help practices make the changes, as would financial incentives from government and private insurers that could help defray the costs of purchasing technology.
Many other doctors agree, saying added payment would make jumping through the hoops more appealing.
“It’s always money,” McLean said.
Rippel said making the types of changes he made is not for everyone. But, he added, “I think that once you’re on the other side, you’ll be glad you did.”