Oftentimes, electronic health records (EHRs) are blamed for physician burnout and dissatisfaction, especially for smaller physician practices. Indeed, in Rogers Ark., when Dan Weeden, M.D., and Joel Fankhauser, M.D., opened Direct Care Clinic of Northwest Arkansas, the doctors had a challenge ahead of them to select the right EHR.
At Direct Care, Drs. Weeden and Fankhauser employ a direct primary care (DPC) model, one which serves as an alternative to fee-for-service insurance billing, typically by charging patients a monthly, quarterly, or annual fee that covers all or most primary care services (at Direct Care Clinic of Northwest Arkansas, the physicians charge a monthly of about $40 to $50 per patient). But, the two practitioners weren’t in a position to purchase a costly system, such as Epic. In a recent interview with Healthcare Informatics, Weeden reflects on his EHR journey and the nuances that go along with implementing technology for a DPC model.
Tell me about your technology journey as a direct primary care small practice?
It started when both my partner and I worked for a big hospital system, Sisters of Mercy (St. Louis, Mo.), and they used Epic, so that was our first encounter with an EHR. We converted over after going out on our own, so we used that up until January 2015. We first tried to use an EHR that was free, Kareo, and by free I mean that we pay for the accounting aspect of it. But we didn’t use that aspect of it, so it was free for us. It didn’t work well for us so in about a month we swapped over to an EHR put out by Atlas.md, which was a small group of guys from Wichita, Kansas, who in a way, have pioneered direct primary care.
When they first launched they hired someone to begin writing software specifically for direct primary care. In some ways it was okay, but it was different in that it was designed for family medicine doctors, and my partner and I are in internal medicine pediatrics. So it didn’t have robust pediatric charting, and when that was eventually put in, it didn’t work very well. It was also designed for using on a mobile device and most EHRs don’t work well on mobile devices since there is too much information.So we began a free trial with Amazing Charts’ InLight EHR (Boston, Mass.). I saw an ad for it while searching online; it was an EHR specifically for direct primary care. I contacted them, and we went live with it in May 2015. It’s been building, so it’s not complete yet. The pediatric part will be updated this summer, and we’re waiting and working on that with them.
Dan Weeden, M.D.
Was a larger EHR system ever an option for your practice?
A system like an Epic was never really feasible for us. The problem we had with Epic, and we used it in conjunction with a big hospital system, so I don’t know if this is the case with all Epic versions, was that the system has so many “stop signs,” meaning you can’t navigate any further until you follow a direction. You couldn’t close a chart or sign a chart, as there all different stop signs you encountered.
Also, we don’t bill based on coding, and we don’t file insurance, so we don’t need all of that coding [that Epic had]. For us, you just code the visit code you charge for. We don’t have levels of visits or corresponding diagnoses. An Epic-type system is based on that—you order a lab test and the system will tell you that Medicare will pay for it. We don’t deal with that.
You hear a lot about EHRs causing burnout for small practices. Have you experienced this at all?
I like the system we have now. If you have more than one physician in a practice and you both have to access an EHR, what options do you have, unless you go back to paper charts? We can access InLight from home, and I like the way it is organized, as it’s problem-focused. You think about hypertension, coronary disease, diabetes—that’s the way physicians think. So I can look and I can see every visit in which I addressed diabetes, and it will have a synopsis with the date and what I did. That would take three pages of charting [manually].
If you asked me this question when I was on Epic, I would say that it creates ridiculous notes that don’t help the doctor at all. I’m not a great typer, but my notes are short—all I put in is what the diagnosis was, what the findings were, and what I need to know next time I look at the chart, or when my partner looks at it. It might only be three lines, but that’s what a chart should be for. To me it’s refreshing, because I can close a chart without stop signs. A medical record wasn’t designed to be a coding and medical legal document, but instead something that has what you need to know next time you see that patient.
Can you explain how your EHR experience as a DPC model might differ from someone in a PCP model?
We live in a mobile, fluid environment, and with our practice, we are direct primary care so we are paid a monthly fee. I don’t have to bring a patient into my office to charge him or her. I am caring for the patient via phone and email too, so being able to very easily access the medical record, document what I did, and to put a message or email directly into the chart can be very valuable.
We feel strongly that the primary care part is not the expensive part of medicine. I am the first doctor you see, I am not a specialist, and so what I do is predictable and routine. You shouldn’t go to a primary care office and get a $3,000 charge. When you insure something that doesn’t cost that much, it makes it cost more. So the way we are set up, we charge a flat monthly fee, and you put it right into the EHR with an auto-monthly draft with the patient’s bank information.
We went from having four employees per doctor [at Sisters of Mercy] to one nurse for two doctors. That’s a huge difference. We went from taking care of 2,300 patients apiece to a total of 1,000 now. We started at 300 patients, and will go up to 1,400 when we are full, but that’s for two of us, so 700 patients each. We are much more accessible—we can see patients the same day, we can talk on the phone, and we can make an appointment to talk on the phone. They are paying for our time, they are not paying for us to bring them in. Fifteen percent of our practice has no insurance, but you will get fined if you don’t have it so we tell them to get it. But look at what they pay us compared to paying insurance, which they cannot afford.
What are the challenges for you, as a DPC model, using technology?
Every system has its quirks, but it’s nothing major. We are dealing with a system that has been written for direct primary care, so they are trying to put the membership fees into the record. In Epic, there was nothing about prices or fees, so this is really different for us. Most practices are set up to gather data on every visit for reimbursement purposes, so every time a patient comes through the door he or she is assigned to a provider and any charges generated go to that provider. But our practice is very different, as we do it by membership. This patient is my person, and I get paid for his or her monthly fee even if my partner sees him when I am on call. We don’t send out bills, we know exactly how much we will make each month. It’s a very simple approach. But we haven’t gotten all of that down in this EHR model yet. It’s hard to say this is how much I generated versus what my partner generated, and we are still working on that.