Small-Town Tech, Big-City Service

Published: Tuesday, Feb 12, 2008
Before he got an electronic health record, David Fairbank, MD, was on the brink of bankruptcy. "A month later than that, and I would have been under," the Lacey, WA, family physician says. His practice, the Clinic at Panorama City, located in a 1,200- resident retirement community, has a patient population that is 60-70% Medicare, so it was more than just an inconvenience when the clinic's third-party billing service had a software glitch that prevented Dr. Fairbank from receiving a single Medicare reimbursement from July 17 to Oct. 6, 2006.

"Our billing company went into bankruptcy and almost took me with them," Dr. Fairbank says. At the time, he relied on the billing service to verify patient eligibility. "It was a poor way of checking it," he admits. He estimates the practice lost $30,000 one year, simply because the billing service wouldn't follow up on invoices worth less than $100. On top of that, Dr. Fairbank is a member of the Physicians of Southwest Washington IPA, a prepaid insurance network, in which the IPA and its members assume all risk. "We didn't have a handle on our finances," the solo family practitioner says. It was an all-too-frequent refrain for a small, semirural practice. But not an insurmountable problem.

In the Red and Seeing Red

Thanks to electronic health records (EHRs) and even the Internet in general, small-town and rural doctors and their patients no longer have to suffer due to geographic isolation. They can deliver the same kind of care as their big-city counterparts and also thrive financially. On July 17, 2006, the same day his old billing service went on the fritz, Fairbank took up the IPA on its offer to install an EHR in his office. The IPA is an EHR and e-Prescribing test partner for Purkinje, a St. Louis-based vendor, and Fairbank's clinic in Panorama City now is a beta testing site.

At the time of the billing crisis, Fairbank had three people working at the front desk. One subsequently left, but the remaining two were able to handle the workload with the help of the new system. Dictation and transcription had been costing Fairbank $4,000 a month. The cost is now down to $200. Overhead expenses ate up 61% of revenue from January to May 2006. In the same period a year later, overhead was down to just 51%. The EHR also represents a better way to evaluate practice performance, Fairbank says. It now takes about 7-10 days instead of 20-30 to get reimbursed by most payers, including Medicare. This is key because, as the physician states, "You've to watch your cash flow." Fairbank also is fairly certain he's delivering better care to his patients with the EHR. This is not just about putting paper charts into the computer," he explains, "this is about the clinical decision support. He specificlally cites the benefits of drug interaction checks, reminders about preventive care, follow-ups with patients, and even coding, since the software handles risk adjustment for Medicare. As soon as the coding is done, the bill goes out electronically, marking a huge advance from the old method. Previously, the practice's billing service would pick up charts twice a week, "meaning bills only went out twice a week. Now, bills get sent to the proper payer as soon as his documentation is completed for each patient encounter, helping to ensure a more constant revenue stream.

Although Fairbank has proof that an EHR saved his practice, other small-town, small-practice, primary care physicians only have their gut feelings to go on. Still, Joseph Perkinson, MD, of Victoria, TX, is glad he didn't "leave anything to chance when he hung out his shingle in January 2001 without a previous patient base in the area. "I was tarting from nothing," he recalls. "I had only served that there was not much longevity in solo family practices. That troubled me." Dr. Perkinson knew that the only way he was going to make it was to operate efficiently and provide good care. Based on his experience as a resident at Baylor College of Medicine in Houston, an EHR was a necessity. "It encourages me to be honest [with patients]," he says.

Once he's done documenting an encounter, Dr. Perkinson shows the computer screen to the patient so the patient can visualize health trends, such as historical testing values. For example, he might otherwise have danced around the issue of alcoholism with a patient, but a spike in HDL cholesterol" one symptom of alcohol abuse "that both can see, forces him to confront the issue as early as possible. "I see these tools as a Herculean leap, a huge advance in the tracking of diseases," Dr. Perkinson explains. Unfortunately, patients tend to choose physicians on "superficial" bases, "especially in small-town America," according to the small-town doctor. A doctor's perceived reputation tends to carry more weight than actual performance. "They really don't care about the tools that you use," he says.

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