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On a Solo Ride to PCMH

July 19, 2012
by Gabriel Perna
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How one solo practitioner M.D. defied the odds

This article highlights the third-place winner in our 2012 Healthcare Informatics/AMDIS (the Association of Medical Directors of Information Systems) IT Innovation Advocate Award. The award winners were announced at HCI’s annual Executive Summit earlier this year in May. For more, check out a listing of the other winners as well as an interview with our first place winner, the health informatics team at the St. Paul, Minn.-based HealthEast Care System, led by HealthEast CMIO Brian Patty, M.D..

The road Edward Rippel, M.D., internist at the Hamden, Conn.-based Quinnipiac Internal Medicine P.C., took to becoming the first solo practitioner in the state of Connecticut to be recognized by the National Committee for Quality Assurance (NCQA) as a patient-centered medical home (PCMH), stretches back to the first year he was on his own.  As he tells it, in 1999, when he started his solo practice after the group practice he was in had been dissolved, he made it an obligation to keep track of what people were due for based on preventive care guidelines.

“[My team did it] Just as good measure,” Dr. Rippel says. “And if people needed to be referred throughout the healthcare system and had it coordinated, we just sort of did that. We tried to track it as best we could, obviously without computers. When we did obtain results for any chronic diseases of preventive care, we communicated back to the patient with a treatment. That sort of seemed to be the right thing to do.”

At the time, Rippel says, EHRs weren’t quite ready for primetime. They weren’t polished and most were expensive, he says. That all changed in the middle of last decade when prices became competitive, and products become more refined. While listening to a speech at a conference on EHRs and pay-for-performance, he recognized the efficiency the system could provide him in capturing and querying important preventive-measure data more quickly. At this point, the symbolic light bulb went off in his head.

Getting PCMH Status

In 2006, Rippel invested in an EHR application, from eClinicalWorks (Westborough, Mass.), and from the start captured discrete data in the EMR app using structured data and a bidirectional interface with a laboratory. He says, initially he took 6-12 months of paper chart data, and put the discrete data into the system. “That gave me a running start of data,” he says. “After a year or so of having new data and old data, I learned how to use the patient registry.”

By the end of the decade, Rippel had read about and applied to NCQA’s diabetes recognition program (DRP). After receiving recognition under DRP, he applied to NCQA’s heart stroke program and once again received recognition. This led to him looking at NCQA’S PCMH recognition. He says he heard of PCMH, but didn’t know exactly what it was.  After some research, he discovered as with the diabetes and heart stroke programs, he was doing everything that made a practice PCMH applicable.

“In 2010, I decided to go for it and it was quite a project,” Rippel says. “Not from the standpoint of re-engineering workflow, because to be honest, most of the workflow we were already doing. The question was, ‘Can we provide that information to NCQA in a format they request?’ That was one of the bigger challenges.”

With the help of Qualidigm, Connecticut’s American Health Quality Association (AHQA) appointed quality improvement organization (QIO), Rippel’s practice was able to achieve recognition as a level 3 PCMH. “Historically, it had been said that it can’t be done in solo practice, but as it turns out, there are a few of us who have been able to do it,” he says.

Edward Rippel, M.D.

Success Owed to the EHR

To put it simply, last year was a great year for Rippel, something he humbly acknowledges. Along with achieving PCMH status from NCQA, he received additional accolades and recognition from NCQA, New Haven Magazine, the Connecticut Center of Primary Care, and former national administrator for the Centers of Medicare and Medicaid (CMS), Donald Berwick, M.D. Getting to PCMH, and receiving these accolades, would not have come about if he didn’t make the investment in the EHR, he says.

The things that allowed him to achieve PCMH are built into the EHR. For instance, it captures demographics such as race, ethnicity, etc. Using the patient registry, he says, the data can be “sliced and diced” anyway you’d like.  “I don’t know the patient-centered medical home improved my practice, more likely using the EHR significantly improved my practice,” Rippel says.

Before Rippel fine-tuned his systems to achieve PCMH, he used the EHR’s registry to improve diabetic goal levels of control. When he started, the first query showed that about 39-40% of his Diabetic patients had achieved goal levels of control.  Using the EHR’s patient registry actionable capabilities, that number went up to 50 percent one year later, and was at 70 percent two-and-a-half years later.

“The EHR allows us to pay better attention to the data we have. Using regular registry queries, I can tell which of our patients are overdue for a service related to chronic disease management and preventive care…and it becomes actionable right then and there,” Rippel says. “It’s not just using the EHR as a data repository. It’s using it as a data repository with actionable events.”

Rippel, like many others in his field, is still figuring out why some patients use the secure, online access to their EHR, and some do not. He says those who use his portal, love it. It allows him to get back to them in a timely fashion, much quicker than the phone that requires simultaneous availability. Also, if he doesn’t have all the data on something, he can further research it and provide a reference for the patient.

A Patient-Centered Neighborhood

In two short years, Rippel made back his entire investment in EHR training, software, and hardware – a number he puts at approximately $50 thousand. “I wish all my investments had an ROI like this,” he says bluntly.

The majority of the compensation, Rippel notes, didn’t come from government incentives, but rather through the costs saved from no longer having to outsource billing because it was integrated in the EHR and through pay-for-performance from commercial payers. “These insurers are saying data is power, and they are willing to pay for it,” he says.

All this is to say that Rippel says the investment is worth it, even for smaller or solo practitioners like him, who have less to spend than a major hospital system or integrated provider. “An investment and improvement of primary care now is extremely modest compared to the benefits on the back end that the patients and the healthcare system will gain from and enjoy be able to enjoy from the perspective of health and the perspective of cost,” he says. 

As for Rippel himself, he recognizes that his own road in the overall transformation of healthcare is “only a third of the way along.” However, he is skeptical about a pure pay-for-performance model for solo practitioners, saying the lack of resources do not justify the additional costs.

As a result, he is working with a group of colleagues to start a multispecialty group in his community that will be physician owned and operated. His goal is to implement a single, community-wide EHR solution that brings as many primary care providers, and engages sub-specialists, within a reasonable timeframe, to be involved with elements of a patient-centered neighborhood.

“The essence of the multispecialty group is that everyone who participates shares a fundamental belief that it’s in a patients; best interest and the interest of the healthcare system for physicians to coordinate their healthcare, while controlling costs and improving quality,” Rippel says.

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