“It's such a revolutionary idea to be sharing a chart,” says Daniel Mingle, M.D. Though perhaps an unlikely revolutionary, Mingle's ambulatory EMR program at MaineGeneral — “One Patient One Chart” — has seen success rarely found across the country.
A family practice physician for 23 years, Mingle is driven by a profound commitment to provide the best care possible. “If we can't do good patient care, it's not worth getting up in the morning.” He believes so strongly that sharing information ultimately helps provide that care that he has managed to surmount the many obstacles, both cultural and technical, of sharing a single chart among practices in the community.
Mingle is head of the technology department at MaineGeneral Medical Center, a 578-bed hospital network based in Augusta, Maine. Since he began the project, Mingle has managed to sign on more than 100 physicians in 22 practices. That means primary, specialty and ancillary care, and school-based health programs all sharing problem lists, medication lists, quality measures and reporting. The EMR provides clinicians with automated decision support and alerts them to FDA medication recalls, drug interactions and overdue follow-up appointments.
The program also allows for anytime, anywhere access to an EMR across the community. Far from its infancy, the program counts more than 68,500 patients in the system.
Mingle's enthusiasm and deep commitment to patient care overcame obstacles when he began the project in 2003, though with generosity he credits early success to his CIO, Kash Basavappa, senior vice president and CIO, and Barbara Crowley, M.D., executive vice president on the clinical side.
Mingle left his practice in rural Maine in 1998 to join the family practice residency program at MaineGeneral. Though he says it was serendipity that brought him together with leadership that shared his vision, it's clear that his unrelenting enthusiasm was an integral part in helping make that vision a reality.
MaineGeneral's three part system includes aggregate reporting to the Maine Health Management Coalition and a weekly report to each physician practice detailing how it performed against key measures. Mingle says that, for him, the third part is the most exciting: a disease management component that shows alerts indicating best treatment practices.
Doctor resistance to the new quality reports was prevalent when Mingle started. He says the first reports electronically delivered to the physician offices were mainly ignored. But his perseverance prevailed. He says in the early days, doctors had one reaction to sharing a patient's chart — “It's a great idea but it will never work.”
Soon, he says, one practice indicated it was using the reports. Then one more, then another. Now, he says, if for any reason the reporting system fails, doctors all over the system call him to say, ‘How can I provide the proper care without my reports?’
Faced with Mingle's enthusiasm, physicians have a hard time saying no to his recruitment efforts. “I see the barriers,” he says, “but the fact that I can speak to the patient needs and experience from the front lines makes a tremendous difference when I try to turn the no into a yes.”
Getting doctors to put aside their individual needs and agree to embrace the new paradigm of care isn't easy. “The simple answer is we don't take no for an answer,” he says. Mingle counters every no with a standard response: What will it take? “You have to get at the root cause of the reluctance,” he says.
The relaxation of the Stark laws in 2006/2007 came at the right time for Mingle's EMR project. MaineGeneral purchases the licenses for the EMR (it uses Chicago-based Allscripts) and gives them away, subsidizing up to 85 percent of software costs for doctors in private practice. He says his relationship with Allscripts has been a true partnership, with the vendor constantly making improvements to the product based on Mingle's users input.
When Mingle already had two years of the project under his belt, MaineGeneral received a $1.5 million grant from the Agency for Healthcare Research and Quality (Rockville, Md.) to implement an EHR in 115 Maine physician offices serving 140,000 patients. He says the money was nice, but he was already in for the long haul of building the EMR community.
He also has a refreshing view of grants: “If something is important to an organization, you can't count on a grant to do it,” he says. “It can't determine the direction.” Though a grant lasts three years, this project will benefit his grandchildren, Mingle adds.
To stay in touch with the doctors in the community, Mingle keeps traveling to neighboring health systems in Maine to speak with front-line caregivers. Mingle loves living in Maine. “Maine is a nice place to do this,” he says. “It's a small state and I see the people doing this stuff several times a week. I know everybody.”
Mingle has never lost his sense of wonder at the value of the EMR project. He says he looks at all the effort he puts into reporting, then imagines if each practice had to do the same amount of effort. “I can do it once for all 90 doctors.”
Just like a good parent who knows when it's time to let go, Mingle says the time will come when he has to relinquish control of the project. And he's making sure his doctors have a good foundation for “life without Mingle.”
“The next part of our project is not about IT, it's about people,” he says. His strategy is to reorient the project out of the IT realm and into the hands of the physicians. “It's been in IT long enough,” he says. “We believe the home for this project is going to be our PHO (a Physician Hospital Organiation is an entity formed and owned by one or more hospitals and physician groups in order to obtain payer contracts and to further mutual interests.) And again, Mingle is not taking no for an answer. “I'm not going to be asking whether they want to participate, but how they want to participate. They're going to start running the project.”