Dr. Sumir Sahgal moved into private practice in 1999, leaving the hospital setting for good. For some reason, he felt he could do more, contribute more positively to the community, as a care provider if he was running his own practice.
Since then he’s built a thriving medical practice, Essen Medical Associates, that has 25 healthcare providers who provide services in 20 medical facilities including nursing homes, hospitals and in one of five multi-specialty offices (with more coming online) owned by the practice.
Based in the greater New York City metro area, Sahgal’s practice, a certified medial home, serves more than 15,000 active patients per year. But true to his calling in that he wanted to do even more to provide care to patients, in 2005 he started down a new path that, at the time, most of the people he spoke with said he was making a costly mistake.
Of the population he’s served, there were several dozen (80 patients, in fact) that were home bound. Other than the random hospital visit, they received no care. That is until Sahgal opened EssenMED House Call Service.
EssenMED House Call Service primarily provides care for elderly home-bound patients in the Bronx, Manhattan, Brooklyn, Queens and Westchester. It is currently one of the largest private medical house call programs in New York.
“We opened a house call practice in the Bronx and everyone thought we were crazy,” Sahgal said. “We serve some pretty tough neighborhoods.”
After six months, the practice’s leaders evaluated the program. It made no financial sense to continue the service, he said, but there was an inherent value in the service his practice provided, and that’s all that mattered. The house call service fit his patients’ needs and they were receptive, and word of the program spread.
First slowly and then much more quickly. In seven years, the number of patients has doubled each year. There are now 1,800 being cared for by Essen’s nine caregivers.
“Through word of mouth, patients kept calling,” he said, “and eventually we had enough volume that it created efficiency in the program. Patients gravitate to where they can get the best care.”
The investments the practice made in electronic and mobile technologies also helped. Without his EHR, he currently uses eClinicalWorks, and being able to access patient data through iPad, the house calling practice is almost no different than the office-based practice.
“Healthcare technology helps create efficiency, and since we’ve moved to eClinicalWorks, our coordination of care has gotten much better,” he said.
All of the information needed to care for patients is on hand through mobile technology. In many ways, his staff is just as efficient in the homes of the patients as they are in the practice setting.
Much of the business’ success can be tied directly to the current technology in place.
All of the information is available wirelessly through the practice’s server including labs and documentation. “It’s like truly transferring the office to the home,” he said. “We can prescribe directly from the patient’s house.
The technology has helped him grow his practice and open communication lines with colleagues and share information, as would be expected, making for a much easier documentation process, especially for staff members in the field.
“The technology has helped us improve care and increase patient engagement. With improved patient engagement, patients have better access to their health information, access their medications and communicate with us, which helps us improve care,” he said.
As devices and capabilities continue to improve, Sahgal is confident that the same can be said for patient care, which he’s extremely passionate about. He’s in the business of practicing health to help people have better or more comfortable lives.
His approach is also saving money for the overall system. The more home care is available to patients, the less likely they are to seek care in the hospital. Likewise, the more comfortable patients are as they manage their conditions or approach the end of their lives.
The patient’s response to the technology has been overwhelmingly positive, he said, especially when he’s able to provide video consultations with patients through his iPad and perform remote triages and blood pressure checks from miles away. The services provided by Essen save patients from unnecessary hospital visits and many thousands of dollars in the process.
At this point, one of the next things that can be done to improve care is for interoperable systems to be fully engaged and useable by caregivers despite the vendor in which they employ. But, for now, the technology is in place to allow for the patient to be the central figure in this play, not the technology.
Serving patients in their space and in their areas of comfort is not a common business model and is much easier now than it has been in the past. Dr. Sahgal says his work is his calling, something he does because he loves providing care.
It’s not always easier either: “You are in the field, there are environmental factors to deal with; we have our war stories. But we’re able to provide TLC in the patient’s home, where they are most comfortable,” he said.
Dr. Anne Brooks in 2012 at the site of several Habitat for Humanity homes.
The American Osteopathic Foundation recently named Dr. Anne Brooks the 2012 physician of the year, for several reasons in which I have described here.
In a nutshell, she’s compassionate, caring and loving of all her patients, and as a nun, it probably helps that she relies on a little help from above.
But, even with her country doctor ways in which she still makes house calls, helps teach her patients to read and write, and building community centers and Habitat for Humanity homes with her own hands, she’s connected technologically – using an electronic health record in her practice – and is informed of many of the latest issues affecting healthcare and healthcare policy.
As a practicing physician, she also serves in the hospital setting, and she drives care for patients while in people’s homes, caring for them in their own environments. As such, she is considered a partner by those lives she’s touched, and she’s seen a great deal of change at the practice level.
The following are a few of her observations from 20 years of practice.
How has patient care changed since you became a physician in 1983?
There are mid-level providers on the scene who are not always appreciated by the patients, who seem to think they need a doctor or by their physician colleagues who often look down on them because it’s a less intense training.
There are RNs who get a doctorate in nursing, but what we need is bedside nurses who care physically and emotionally for and about patients.What I see happening is often the best nurses end up being paper pushers because of new and complicated regulations and disease tracking and length of stay requirements.
Are the patients getting more involved in their care or do they just not care?
I think we need a health blitz in our school curricula so that kids and parents/caregivers all know how to care for an illness or accidents and how to eat healthfully, and the manufacturers of all the fat food would make and sell something much more nourishing so that diabetes and obesity would not cause so much ill health and lower the mortality rate. Change has got to start in the home, but in our case, many parents didn’t go to school so what they don’t know and what they need to know and do are two different things.
Behavior needs to change, too. For example, too many patients have no teeth and eat soft starchy foods which only puts on weight; kids get soft drinks in their baby bottles way early on. So we teach and teach and review and teach some more and a few people get fired up because they learn they have power — which is a big deal at our office — to empower each patient is our major goal. And when we see people actually making lifestyle changes it is incredibly rewarding.
Why did you decide to implement an EHR?
Because of the benefits of speed in communication, ability to quickly access past clinical info and dealing with the handwriting deciphering issue (fewer mistakes related to bad handwriting) the desire not to have to lug a pile of charts home to finish them; urging from forward-looking trusted colleagues; the availability of a grant; articles in medical journals that piqued my curiosity; and the ability to invite salespeople in to speak to the administrative team and then the staff, and pepper them with questions.
Are you more efficient because of an EHR or has there been little or no change?
Technically, I’d probably have to get someone to actually do a time study, but I feel more efficient, which removes some levels of stress for me.
When your career is over, what one thing will you want to carry on in your absence?
Patient-centered care given generously without regard to ability to pay meaning that every patient will get the best care.
I also want our patients to be welcomed with concern, care and compassion, and I want the caregivers to educate and empower patients so they can assume responsibility for their own healthcare, change their lifestyles, and learn how to pass on the education and empowerment to their families and friends.
And, I want caregivers to follow the M*A*S*H* model:
As we move toward an environment in which technology is more widely accepted, there’s little doubt tools that organizations like hospitals and health systems (individuals, too, for that matter) use to build their brands, educate their communities and engage patients are paying dividends.
At least for the organizations taking steps to utilize the tools.
According to a new survey by CSC (Computer Sciences Corporation) conducted in July and August, of 36 hospitals, the use of social media in the space is growing, and having some positive effects on the communities each serves.
In the survey, hospitals reported using social media to enhance their brands, create awareness and manage their reputations, as well as “to promote wellness and healthy behaviors through the dissemination of generic information for a general audience.”
CSC found that for organizations, direct engagement with individual patients remains uncommon and only one hospital reported that it uses social media in care coordination or care management, unlike some individual caregivers who actually use the tools to engage patient populations with generic care instruction or knowledge transfer.
Healthcare organizations, like all of us using social media, want to attract a large audience to our message and products. However, using social media for improved patient outcomes were not a popular objective according to the survey as less than 25 percent of organizations listing it as a primary objective.
Only a couple hospitals survey said they did not use social media at all, citing fear of liability or malpractice concerns, and concerns that users would post negative comments about the organization while some organizations do not get involved in social media because they do not feel they have the internal expertise needed to drive the program.
Now the real heavy lifting begins.
According to CSC, “The next step for hospitals and health systems will be to use social media more strategically. The risk and cost of doing so is relatively small, yet the upside includes potentially substantial performance improvements and the realization of sizable competitive advantages.”
Beyond building brands and managing messages, healthcare organizations may wish to think about more their products, long-term goals like driving patient engagement and improving healthcare outcomes.
To take action and begin moving a social media and engagement program forward, CSC recommends the following, and I quote:
Develop an overarching strategy of how to make social media work for you. Begin with easy areas, such as marketing and communications, proceed to patient education and announcements, and then look for ways to leverage social media to improve care and generate other benefits. Look for ways to connect patients to providers, or providers to each other.
Get involved in social media now at whatever level you feel comfortable with and/or have the resources to manage (do not take a wait-and-see attitude or it will be too late and your patients will find someone else to interact with). It is often possible to recruit savvy users internally who are excited about the technology
Pre-empt possible negative experiences by communicating openly about social media with employees and with patients. Develop a social media policy that outlines appropriate use for staff, and post a disclaimer on your site informing patients that information provided is not meant to serve as medical advice. Social media is a force for good; concerns about the use of social media are often overstated. Individuals are more likely to share positive health-related experiences via social media than negative experiences.
We’re here now, we’re ready and the tools are available to serve the greater good. It’s time to engage, damn the consequences.
Farzad Mostashari, national health IT coordinator, says more progress has been made in health IT in the last 20 months than during the last 20 years. It’s a statement he made during the first day of National Health IT Week in September.
Increased adoption of electronic health records and the push toward meaningful use have been the catalysts for this movement, most of which has been driven by the financial incentives associated with meaningful use.
The ultimate goal of meaningful use, and the subsequent adoption of the healthcare technology, is data collection. A subset is patient engagement.
To a lot of different people, patient engagement means a lot of different things. For some, it’s about patients having access to their information, and for others it has nothing to do with “giving” patients information, but more about making them the center of care, Mostashari said recently.
Health and its information are owned by its community, he said, and the community must have access to its information. Policies and practices need to be set in place to unleash and unlock the activities of the community.
One effort to encourage this is “Blue Button.”
“Blue Button is national symbol for the concept of ‘give me my data,’” he said during his address at National Health IT Week in September 2012.
But the effort is transcending patients. It’s being brought to the vendor community, and their commitment is being requested. Mostashari has challenged vendors to make it easy for consumers, by as early 2013, to view, download and transmit to another party their health information through Blue Button. Engaging the vendor community is exactly the kind of effort the market needs since they have a seat at the table.
So far, several vendors have committed to meeting the deadline for the challenge, which is by the HIMSS Annual Conference in early March 2013. The current list of vendors to accept the challenge (those deserving some recognition) include:
Alere Wellogic
AllScripts
AthenaHealth
AZZLY
Cerner
eClinicalWorks
Greenway Medical Technologies
Intellicure
NextGen
SOAPware
Engaging the vendor community in this effort, for an early push toward view, download and transmit, is the right thing to do and it’s encouraging to to see Mostashari putting ONC’s muscle behind this effort.
Vendors are the folks playing a huge part in the overall effort for a transformed healthcare system and they plan to gain the most because of it. As such, it’s good to see them encouraged to take greater ownership of this process and play a larger role in encouraging the patient engagement process.
Too big to fail comes to mind when I think of Allscripts. That’s the way the company was painted when it made news on June 9, 2010, after announcing it had bought Eclipsys.
Needless to say, the last two years have not produced the expected milk and honey for the vendor, which currently occupies the largest footprint in the ambulatory EHR market. Poor quarterly reports, board member infighting and firings and a pile of implementation troubles stemming from far too many systems currently running have made for a mess of a time.
What’s ironic about everything that’s going on with the company now is that at the time it was announced, the Allscripts deal with Eclipsys was game changing for those of us in the vendor space. No one will admit it publicly (other than me, here), but when this merger was announced in 2010, there were many executives at competitive companies wondering just how long their respective business ventures would still be around because of the move.
At the time, I worked for what was then considered the third or fourth largest EHR/PM in the space and the Allscripts news sent wave of shock and perhaps a bit of panic through my office. We braced for the worst and hoped for the best, and started to develop strategies akin to what might have been implemented at the Alamo.
It was hard not to feel the pressure. A great EHR army was coming and we stood in its path to greatness.
“The combination of Allscripts and Eclipsys will create a clear leader in healthcare information technology, with the most comprehensive solution offering for healthcare organizations of every size and setting.
“By combining the leading physician-office and post-acute care solutions from Allscripts with Eclipsys’s leading enterprise solutions for hospitals and health systems, the combined company will offer a single platform of clinical, financial, connectivity and information solutions. The combined company’s client base will include over 180,000 U.S. physicians, 1,500 hospitals, and nearly 10,000 nursing homes, hospices, home care and other post-acute organizations. The combined company will be positioned to connect physicians, other care providers and patients wherever care is provided-in the hospital, in small or large physician practices, in extended care facilities, or in a patient’s home – resulting in the unique ability to deliver a single patient record and a seamless patient experience.”
Even at our best, this new entity was a behemoth far larger than even our marketing folks and their clever wit could help us position our way out of. So we held our breath, and, I bet like a lot of vendors, we waited …
It’s easy to cast stones when you know where they should be thrown based on the luxury of hindsight, but I said from the beginning of all this – to the president of our company and to her executive support team including the then SVP of marketing – that the one weakness of Allscripts was that it was being positioned as too big to fail.
But before long, the fear started to subside and we slowly began to realize we were receiving more than our fair share of scraps; in fact, we were actually at the banquet table along with the likes of others who, like us, previously must have wondered how much of a future we’d actually have left. In the end, we were still closing deals. All vendors kept signing deals. Finally, the fear abated and the “promise” of what was to come never came.
Certainly, Allscripts hasn’t failed in wanting to go private, it just needs to find a private place to go for awhile where it can sort out its problems, do away with some of its product overabundance and cut the proverbial fat without having to continually find ways to report positive balance sheets.
Even if it proves too big to fail, there’s nothing stopping it from stumbling backward from time to time.
Dr. Brooks, in Tutwiler, returning from a house call early in her career.
I’ve known Dr. Anne Brooks for nearly three years and I consider her a friend. She’s always receptive, available and willing to lend an ear, and offers insight I can only hope to have one day.
Plus, her stories are chronicle-like and filled with wit, humor and poignancy. And she’s got a tomb’s worth of them she could tell, and probably should. But, perhaps she doesn’t have the time. She’s too busy caring for the folks of her adopted hometown of Tutwiler, Mississippi.
Dr. Brooks is a nun. She’s taken a vow of poverty. In Tutwiler, she’s needed it. The people here are part of the one of the poorest in the United States. Patients pay for their care, if they can, with vegetables or other goods. Some times they drop a few bucks on the counter, but it’s a guarantee that by the end of the year, the clinic – Tutwiler Clinic – is going to be significantly short of operating funds.
More than 75 percent of its operating funds come from donations by individuals and grants. Those who wish can contribute through a PayPal donate button on the clinic’s site.
The Tutwiler Clinic is a nonprofit founded in 1983 by Dr. Brooks, D.O. and three other Sisters of the Holy Names. Its purpose is to provide wholistic healthcare in Tallahatchie County, located in the middle of the Mississippi Delta. According to its site, the median household income in the county is $18,800, while the US poverty level for a family of four is set at $20,650.
Two-thirds of the clinic’s new patients have no Medicare or Medicaid or other health coverage assistance. To say Brooks has operated the clinic as a personal mission for the last 20 years is no understatement.
The clinic is her calling; Tutwiler is her home.
She became a physician at age 40, following a career in education. However, for 17 years prior, from the time she became a nun, she was confined to a wheelchair because of what had been diagnosed as severe rheumatoid arthritis. She eventually met a physician in Clearwater, Florida, who asked to treat her and through osteopathic methods and acupuncture, eventually she was out of the chair and walking again.
The same doctor to help treat her was the same physician who encouraged her to join him in the medical ranks. She acquiesced and eventually began to study.
When she graduated, she wandered around the south through Mississippi, Louisiana and Florida seeking a clinic to serve. Next, she wrote several letters to towns that were in medically deprived areas offering her services. Tutwiler was only community to respond.
The town gave her a few funds to refurbish the clinic that had been shuttered since the early 1960s and she opened it in August 1983. By January she was seeing more than 700 patients a month. The clinic had a segregated waiting area when she arrived, but she immediately changed tat.
She serves as medical director and chief administrator at the Tutwiler Clinic, serving about 8,500 patients a year. She also is Chief of the Department of Medicine at the Northwest Mississippi Regional Medical Center in Clarksdale, where she has also is on the board of trustees and has served as Chief of Staff.
She is one of three doctors in the county, and currently mentors two medical students. She admits that she is desperate for another doctor at the clinic, which has a staff of 30.
She prays every day for anew doctor to join their staff, but to date (she’s been searching nonstop for months) she’s received little interest.
Sister Anne Brooks recently with a young patient at the Tutwiler Clinic.
Brooks is a country doctor in so many ways, like you’d imagine from the 19th century: she makes house calls, and has seen the greatest level of poverty and unhealthful living. Her heart seems to explode with passion for those she cares for and the folks she cares for often suffer from sever chronic conditions, such obesity and diabetes, because of lack of quality nutrition because of their poverty.
She prays a lot for them. When she’s not praying, the 74-year-old who works 12 hour days, most days a week. She believes in wholistic care — taking care of the whole person and enabling a person to care for themselves.
When not providing care, she and her staff run a Habitat for Humanity program that has built 37 homes, and she also started a second-hand clothing store and a community center, with a gym and library and helps residents learn everything from life skills like cooking, to earning a GED, to staying fit with Zumba. To fund the community center, they sell locally made quilts.
Even though she lives in a world seemingly lost, if not a little forgotten, she’s dedicated the Tutwiler Clinic to employing the most current tools to ensure her patients receive the best care possible.
As such, she utilizes an electronic health record.
In her 20 years as a physician, “Care has changed in many, many ways,” she said recently.
There are new forms of care, new understandings of how various body systems that medicine can affect, and, most notable to her, are genome studies and the potential for tailoring medicine to a specific patient.
“You know, every direction you turn, especially in your area of expertise, there are new and exciting ideas about integrating medical records seamlessly into patient care,” she said, “or should it be the other way around?”
Perhaps it makes no matter. Machine at her side or not, she still knows how to provide the best care she knows how to provide, and the people she cares for are blessed to have her at home in her community. In many cases, they owe her their lives; at the very least she should be given some thanks.
Perhaps that’s why the American Osteopathic Foundation recently named her the 2012 physician of the year.
Any mention of money and people’s ears seem to perk. Work, for the money, on the other hand, seems to stifle a person’s desire to embark on the profitable journey.
“Money here.”
“What’s that, you say? Money? Where?”
“Well, I’m glad you asked. By taking the following simple steps, by performing the following tasks, you might be able to save your practice time and money.”
“Tasks? ‘Might?’”
“Right.”
“How much?”
Shoulder shrug…
“See ya.”
The above over dramatization is courtesy of yours truly. Stellar dialogue, wouldn’t you say? Among my many talents. I’m actually a playwright. No, really. Published and everything.
Anyway, getting to the point, it seems that not matter where we turn, in this new healthcare environment where there seem to be opportunities for ‘49ers where ever you turn, someone is trying to tell you how to produce more profitability or efficiency for your practice.
Despite the zingers, there really are a few good pieces of advice out there that do seem to make sense, but, yes, you’ll need to put in a little time and work.
Here’s one example, courtesy of Carol Stryker and Physicians Practice magazine. According to Stryker, 30 percent of any activity is wasted. Thus, as she so eloquently writes, “The more useless labor you can eliminate, the bigger the increase in productivity and the fewer mistakes. A careful review of some or all of the processes in a medical office can generally be expected to yield productivity gains of at least 30 percent in the areas addressed.”
So, to eliminate wasted work and improve efficiency, which improves profitability, establish a process and iron out the wrinkles. The following six steps will help, she says.
1. Choose a process to streamline. One that is causing problems will most likely be easy to identify and will probably already will be taking your attention.
2. Answer this question, Stryker says: “What should the process accomplish and why is that important?” She encourages practice leaders to clearly identity the purpose and value of the process and write it down. “This is the yardstick for future evaluations. This is the only aspect of the project that the physician(s) cannot delegate or outsource,” she said.
3. Write down the steps to follow, in order. Once all the steps are documented, walk them through them to be certain you have not left anything out. Add what you left out and walk through again. Repeat until all steps have been captured.
4. For each step, ask the group: “What does this have to do with the goal?” If nothing, eliminate it. If not much, eliminate it or combine it with another step.
“Is another step performing the same function?” If so, which one produces the best outcome? Eliminate the less effective step.
“Is there a better way?” Do you have a tool, not available when the process was first developed, that gets the job done more effectively and/or efficiently?
“Could a step be added that would have a positive impact on a subsequent step?”
5. For the amended process, ask: “Are any additional steps necessary? If something will be printed now that was not printed before, what will be done with the paper?
“Are the steps in the most logical order?” Examine alternative sequencing as a possible improvement to the process.
“Is the process intuitive?” Will it be easy for the person doing the work to remember or to engage?
“Are any steps error-prone?” What can be done to eliminate error? If it can’t be done away with, what can be done to validate the step was done properly?
Repeat from Step 5 until satisfied with the proposed process.
6. Once the improved process is implemented, choose another process and repeat the analysis. Continue until satisfied with the way the office works.
According to Stryker, “The only difficulty is finding the time and discipline to perform an analysis of a process and implement improvements. Each successful project frees up resources and makes it easier to address another process. Morale improves because office operations are improving. Stress decreases because there is actually time to do what needs to be done. Staff turnover goes down and profits go up.”
And hopefully, once all of the steps in the process have been completed, you’ll find yourself with more time, a more efficient practice and you’ll identify ways to free up a little extra cash.
For some, it’s frightening time to be in healthcare.
Given the continual changes related to reform and reimbursements, compounded by the fact that independent practices are being gobbled up by hospital systems and independent practitioners are becoming employees, but a new study commissioned by The Physicians Foundation say that roughly 60 percent of physicians would quit the profession or retire today if given the opportunity.
This is no new trend. And as noted in HealthLeaders Media report, that’s what makes this latest piece of data so much more shocking.
What’s also somewhat shocking about the Physicians Foundation study, which featured more than 13,000 physicians, is that the results clearly reflect this sentiment – that physicians are frustrated with the overwhelming pressure facing them – and that they would rather get out than picture themselves as professional caregivers for the long haul.
Certainly, this is not insignificant. These are not your typical professionals working a job, taking an hour lunch and then heading home to the family. It’s not like they’re working in one field one week and they decide to try a new job at a different company the next week. These are highly educated professionals who have dedicated their lives to a cause and a belief that they could make a difference by helping people “get better.” Simply put, they’ve made a lifelong decision to practice medicine that the majority could sooner walk away from.
Apparently, physicians just don’t feel they are being heard. They feel their opinions don’t matter so the only way they may have to make themselves heard is to pack up and hit the road.
Because of the pressure they face from regulation, reduced reimbursements and providing greater quality at a lesser cost, many feel alienated, and some are beginning to do something about it.
For starters, they’re reducing or eliminating the number of Medicare and Medicaid patients they’re seeing. Some are leaving private practice (some by choice, others not) and becoming employees where they’ll have fewer managerial worries than if they were to stay put in their practices. After all, employees are hired to do a job; managers are required to solve most of a business’ problems. Employed physicians are employed because, for the most part, they got tired of trying to solve the world’s problems.
But, according to the study, becoming an employee is not viewed as a positive move. Especially for what has traditionally been a fiercely independent population.
What’s most troubling about this study is that most physicians just want out. They want to turn in their white coats and head for the sunset. They want to come to Florida, where the sun always shines, hit the beach and play with sand between their toes. (I made that last part up.)
Here’s the heart of it, and I quote the HealthLeaders story: “We found that 60 percent said they would retire today if given the opportunity. What was worrisome is that this is up from 45 percent in 2008,” Walker Ray, MD, vice president of the nonprofit foundation. “We also know from the survey that we disaggregated it into certain categories, 47 percent of physicians under 40 said they would retire today if given the opportunity.”
Almost half of physicians under age 40 would board the windows and find another way to pay their student loans.
Half!
In some cases, there are certainly doctors among this population that just got into practice. These are the physicians who are supposed to be changing the way, setting the new normal for the industry; unabashedly accepting that this is the new world order of things and the hells bells, we’re in it to win it.
If this is indeed the truth, that so many young physicians are wondering why they spent so much time in school and spending so much money on their educations just so they could become employees of the “state,” the future doesn’t see that much different than the present and we have bigger problems that we’re anticipating.
