In 2008, Allison Blazek, M.D., made a bold career move, going from working in the emergency room at MD Anderson Cancer Center in Houston, Texas to starting a unique internal medicine solo practice just a few miles from downtown Houston, but with a small town feel nonetheless. With that career jump for Blazek came an array of new challenges that simply wouldn’t exist if she stayed at MD Anderson. She had to learn on the fly how to manage her own practice and incorporate technology to meet healthcare’s changing dynamics. At that time, one thing for Blazek became crystal clear: it was time to move off paper.
Blazek says she started out at her new solo practice with just a Sony Vaio laptop that was the “center of her life.” She says she was a hospice medical director and did house calls, so she brought her laptop with her everywhere, allowing her to work remotely all the time. But still, patients’ records were on paper charts at the time, and Blazek knew that eventually she would have start looking into electronic health record (EHR) solutions.
However, this process was far from seamless. Blazek says that every time she called a vendor, she would get the workaround in terms of never being told the product’s cost. “I would be on the phone for an hour and finally the [vendor would say] that the EHR will cost me $30,000 plus more afterwards, but at the time I wasn’t making any money so I couldn’t do that.” Blazek says she figured that she would just stay on paper for the time being considering the difference in cost. But then one day, while reading a story about the poor adoption of EHRs, she came across Practice Fusion, which offers a free web-based solution. “I thought to myself, free I can do,” Blazek says.
Even after the implementation of Practice Fusion, Blazek was essentially still working on IT alone. She says she does have a friend who is an actual IT person who helps her out from time to time, but there is nothing resembling a real IT department at her practice. “I’m constantly looking up things and asking other doctors who make these decisions in private practice what they’re doing, and then I try different stuff out. I download everything and I figure it all out myself. There’s no one else here to help me,” she says.
While this level of sole responsibility might sound scary to many doctors, Blazek actually says it’s better for her since she’s the one making the decisions. For example, she notes that MD Anderson had an “amazing medical record system” that was developed by an internal radiologist, but the organization eventually decided to switch to Epic, which Blazek says has caused problems. “They had no choice in that [EHR] switch,” she says. “Here, no one has ever forced change on me that I may or may not agree with. So I think I actually have it better now,” she attests. She adds, “I would say that it has made my practice more possible. Everything is easier. I can check messages and do refills from another country. And I don’t need to have someone in my office covering for me when I am gone because I have everything with me.”
At Blazek’s practice, there is an emphasis on treating the whole patient, thus seeing no more than 15 patients a day to allow time for comprehensive care. But how does a small practice like this make time for comprehensive care? For one thing, patients are now sending messages through the office’s portal, and Blazek says she gets several messages per day. She also notes that she has a service in which patients pay a small fee every year in exchange for access to and more time spent with her. “So that means I see less patients per day. I would say an average patient visit is about 30 minutes, but new patients might be an hour or more if they’re complicated and have seen specialists which require me gathering data,” she says. Indeed, although many healthcare organizations of all sizes seem to struggle with patients being active through technology, Blazek says that patients will tell her if something she noted in the record is inaccurate. “I believe in transparency. I believe it keeps you out of trouble,” she says, additionally noting that e-prescribing at her practice, which allows prescriptions to be ordered directly from the patients’ electronic chart, leads to fewer errors compared with a handwritten process.
Many small and solo practices have a tough time in complying with federal mandates simply due to lack of time and resources. But Blazek says that so far, she has experienced little difficulty. “Meaningful Use was actually easy for me,” she says, perhaps to the shock of some. “I attested to Meaningful Use for the first three years, and then the returns diminished so I didn’t bother to do it anymore. Also, since it’s just for Medicare patients, I figured that even if they ding me the 2 percent [penalty for not attesting] who cares, that’s nothing,” she says. Blazek continues, “The first year I got a big check and Practice Fusion made it really easy; I was able to do it all without anyone else’s assistance. I felt good about it doing it correctly, and felt that I would withstand an audit if it came my way.”
To this end, small and solo practices are also nervous about the upcoming Medicare Access and CHIP Reauthorization Act (MACRA) program that will launch its first reporting period next year in which eligible Medicare clinicians will be reporting to a Quality Payment Program. For many high-volume Medicare practices with few resources, this new program is daunting. While Blazek’s practice is not a high-volume Medicare one, she still has to decide if it’s worth taking Medicare insurance due to what will be required of her under the QPP. One plus for her is that she is part of an accountable care organization (ACO), Memorial Hermann, which Blazek calls “a big and successful one.” She adds, “That covers a lot of stuff, and one of the pathways for practices [in MACRA] is being in one of these ACOs that takes risk.”
Blazek says she is not yet panicking about MACRA, since more is still to be determined. But, she doesn’t have real interest in cutting Medicare patients because of how much they mean to her. “It depends on how much it will change things,” she says. A 2 percent [penalty] doesn’t change much for me. My patients pay me a little extra every year anyway, so it may not really matter.” She further says that it feels like every year there’s something new in healthcare policy that everyone fears. But for Blazek, it doesn’t make sense to live in fear when the future is still uncertain. “It’s sort of like skiing,” she says. “You see the mogul and you turn one way or the other, but you can’t see down the hill and you have no idea what’s coming up.”
In the end, Blazek says that, just like with everything else on her solo practice journey, it will work out. “Maybe I won’t take Medicare insurance. But I’ll still see the patients. I have a tight relationship with them and they will still want to see me even if I can’t take their insurance. I will figure it out; I’ve gotten good at that.”