Jennifer Silverman

SAN FRANCISCO — There is a cost-effective way to go paperless and make a profit for your group practice, Jeffrey P. Friedman, M.D., said at the annual meeting of the American College of Physicians.

Dr. Friedman, an internist and founding partner of Murray Hill Medical Group in New York, increased office appointments—and saved $238,000 annually in staff pay and benefits—by installing an electronic medical record (EMR) system and integrating the new technology on a gradual basis, cutting down on staff and phone time.

Patient registrations grew rapidly (currently at 18,000), and salaries for the group's internists and subspecialists in 2004 were two to three times the national average, Dr. Friedman said.

Murray Hill started out in 1992 with just a few partners and associates, one exam room per physician, and no ancillary help, using a local, small electronic billing package.

Over the years, the practice filled its space, adding more subspecialty partners, associates, and equipment, and in 1998 acquired an EMR system. The practice added online bill paying this year.

The practice now has 35 doctors, an office lab, and a technician who oversees the fully automated practice. “Our employee/doctor ratio is very low,” he said.

Installing an EMR system does cost money, “but a major thing physicians need to understand is that you have to spend money to make money,” Dr. Friedman said.

In his experience, “those bucks are not out of control” if invested in the right kind of system.

When considering software vendors, it's important to visit practice sites that are already using installed systems.

He suggested that physicians look at big vendors that are likely to be in business at least 10 to 20 years down the road.

“This is a big investment, because whatever one you buy you're going to live with for a long time,” he noted.

The problem with medical records is that if you decide to dump one, “you can't convert the data from one system to another.”

In conducting research with vendors, Dr. Friedman got a general idea of what it would cost to install an EMR system, “including the whistles and bells.”

The per-doctor cost was $30,000–$50,000, including training.

“A lot of people spend that much on a car every few years,” he observed.

Training should ideally take place during the slow season, from the end of June through early September in order to interfere as little as possible with patient care.

Murray Hill physicians went through 3 months of formal training during such a period. The practice hired college and medical students to preload diagnoses, medicines, and vaccines into the new EMR system.

Physicians won't be able to get everything into the record, “but you'll find that over the years the important stuff's there,” Dr. Friedman said.

Conversion to an EMR system should take place gradually, he cautioned. A staff of two physicians, for example, should take turns going online. “You should have cross coverage so physicians are not out seeing patients while they learn how to use the system,” he advised.

It's crucial to practice with the software before going live with the system. Within 1 to 2 weeks, Murray Hill's physicians had learned the system and regained their usual level of efficiency. Many become even more efficient after going online, he noted.

In addition to handling appointment scheduling (see box), the system helps automate prescription refills. “The patient does it, the doctor signs it. When it's electronic, it's done,” Dr. Friedman said. With a few clicks and a printout, a physician can quickly take care of a Medicare patient on 12 different prescriptions that need to be shipped to several locations.

Physicians using an EMR can check drug interactions when looking at their patients' prescriptions.

In addition, instituting a system of online preventive notices can remind physicians of what needs to be done for each patient. “And any work you do provides income,” he said.

An EMR also can point out errors in coding. “A lot of times we find out that the doctor has been undercoding. It's not fair to give back to carriers and the government. That's a lot of lost income,” Dr. Friedman said.

“It continues to amaze me that 90% of physicians are not” paperless, he said. People traveling on planes “would never put up with a pilot navigating by the stars.”

Online Appointment Scheduling 24/7

Patients favor online systems that provide a 24/7 service for appointments. “By integrating with the Internet you get patients to do things for themselves without staff,” Dr. Friedman said.

His practice, Murray Hill Medical Group, developed its own software so that patients could sign in online, make their own appointments, refills, or referrals, or pick a physician or location. Dr. Friedman is now marketing the software for use by physicians who use compatible electronic medical record systems.

Patients get a tracking number plus three e-mail reminders about their visits. For annual exams, the e-mail will remind them not to eat or drink for 8 hours prior to the visit.

The patient who has forgotten the time of a Monday appointment can look up the visit online Sunday instead of becoming a “no show,” he said.

The practice estimates that 35%–45% of all of its appointments are made online, and the no-show rate with Internet appointments is less than 1%. Murray Hill Medical Group has open-access scheduling, so most appointments are scheduled within 24 hours.

“We always add on more hours. Patients can always get in because that's how we make a living. We're not going to make them wait 3 weeks,” he said. The electronic system makes it easy to fill up slots when patients drop out of appointments.

Physicians have long struggled with patients having online access to their practice, Dr. Friedman said. “They have a problem with letting patients see their open schedule slots.” In addition, “they think patients are too dumb, they'll abuse the system, [or] they don't know what they're doing.”

But patients are smarter than you think, he said. Of Murray Hill's patients, 95% have Internet access, and other data point to widespread access to online services.

A 2003 Harris Interactive poll found that 80% of all patients use the Internet to search for information.

SAN FRANCISCO — There is a cost-effective way to go paperless and make a profit for your group practice, Jeffrey P. Friedman, M.D., said at the annual meeting of the American College of Physicians.

Dr. Friedman, an internist and founding partner of Murray Hill Medical Group in New York, increased office appointments—and saved $238,000 annually in staff pay and benefits—by installing an electronic medical record (EMR) system and integrating the new technology on a gradual basis, cutting down on staff and phone time.

Patient registrations grew rapidly (currently at 18,000), and salaries for the group's internists and subspecialists in 2004 were two to three times the national average, Dr. Friedman said.

Murray Hill started out in 1992 with just a few partners and associates, one exam room per physician, and no ancillary help, using a local, small electronic billing package.

Over the years, the practice filled its space, adding more subspecialty partners, associates, and equipment, and in 1998 acquired an EMR system. The practice added online bill paying this year.

The practice now has 35 doctors, an office lab, and a technician who oversees the fully automated practice. “Our employee/doctor ratio is very low,” he said.

Installing an EMR system does cost money, “but a major thing physicians need to understand is that you have to spend money to make money,” Dr. Friedman said.

In his experience, “those bucks are not out of control” if invested in the right kind of system.

When considering software vendors, it's important to visit practice sites that are already using installed systems.

He suggested that physicians look at big vendors that are likely to be in business at least 10 to 20 years down the road.

“This is a big investment, because whatever one you buy you're going to live with for a long time,” he noted.

The problem with medical records is that if you decide to dump one, “you can't convert the data from one system to another.”

In conducting research with vendors, Dr. Friedman got a general idea of what it would cost to install an EMR system, “including the whistles and bells.”

The per-doctor cost was $30,000–$50,000, including training.

“A lot of people spend that much on a car every few years,” he observed.

Training should ideally take place during the slow season, from the end of June through early September in order to interfere as little as possible with patient care.

Murray Hill physicians went through 3 months of formal training during such a period. The practice hired college and medical students to preload diagnoses, medicines, and vaccines into the new EMR system.

Physicians won't be able to get everything into the record, “but you'll find that over the years the important stuff's there,” Dr. Friedman said.

Conversion to an EMR system should take place gradually, he cautioned. A staff of two physicians, for example, should take turns going online. “You should have cross coverage so physicians are not out seeing patients while they learn how to use the system,” he advised.

It's crucial to practice with the software before going live with the system. Within 1 to 2 weeks, Murray Hill's physicians had learned the system and regained their usual level of efficiency. Many become even more efficient after going online, he noted.

In addition to handling appointment scheduling (see box), the system helps automate prescription refills. “The patient does it, the doctor signs it. When it's electronic, it's done,” Dr. Friedman said. With a few clicks and a printout, a physician can quickly take care of a Medicare patient on 12 different prescriptions that need to be shipped to several locations.

Physicians using an EMR can check drug interactions when looking at their patients' prescriptions.

In addition, instituting a system of online preventive notices can remind physicians of what needs to be done for each patient. “And any work you do provides income,” he said.

An EMR also can point out errors in coding. “A lot of times we find out that the doctor has been undercoding. It's not fair to give back to carriers and the government. That's a lot of lost income,” Dr. Friedman said.

“It continues to amaze me that 90% of physicians are not” paperless, he said. People traveling on planes “would never put up with a pilot navigating by the stars.”

Online Appointment Scheduling 24/7

Patients favor online systems that provide a 24/7 service for appointments. “By integrating with the Internet you get patients to do things for themselves without staff,” Dr. Friedman said.

His practice, Murray Hill Medical Group, developed its own software so that patients could sign in online, make their own appointments, refills, or referrals, or pick a physician or location. Dr. Friedman is now marketing the software for use by physicians who use compatible electronic medical record systems.

Patients get a tracking number plus three e-mail reminders about their visits. For annual exams, the e-mail will remind them not to eat or drink for 8 hours prior to the visit.

The patient who has forgotten the time of a Monday appointment can look up the visit online Sunday instead of becoming a “no show,” he said.

The practice estimates that 35%–45% of all of its appointments are made online, and the no-show rate with Internet appointments is less than 1%. Murray Hill Medical Group has open-access scheduling, so most appointments are scheduled within 24 hours.

“We always add on more hours. Patients can always get in because that's how we make a living. We're not going to make them wait 3 weeks,” he said. The electronic system makes it easy to fill up slots when patients drop out of appointments.

Physicians have long struggled with patients having online access to their practice, Dr. Friedman said. “They have a problem with letting patients see their open schedule slots.” In addition, “they think patients are too dumb, they'll abuse the system, [or] they don't know what they're doing.”

But patients are smarter than you think, he said. Of Murray Hill's patients, 95% have Internet access, and other data point to widespread access to online services.

A 2003 Harris Interactive poll found that 80% of all patients use the Internet to search for information.

SAN FRANCISCO — There is a cost-effective way to go paperless and make a profit for your group practice, Jeffrey P. Friedman, M.D., said at the annual meeting of the American College of Physicians.

Dr. Friedman, an internist and founding partner of Murray Hill Medical Group in New York, increased office appointments—and saved $238,000 annually in staff pay and benefits—by installing an electronic medical record (EMR) system and integrating the new technology on a gradual basis, cutting down on staff and phone time.

Patient registrations grew rapidly (currently at 18,000), and salaries for the group's internists and subspecialists in 2004 were two to three times the national average, Dr. Friedman said.

Murray Hill started out in 1992 with just a few partners and associates, one exam room per physician, and no ancillary help, using a local, small electronic billing package.

Over the years, the practice filled its space, adding more subspecialty partners, associates, and equipment, and in 1998 acquired an EMR system. The practice added online bill paying this year.

The practice now has 35 doctors, an office lab, and a technician who oversees the fully automated practice. “Our employee/doctor ratio is very low,” he said.

Installing an EMR system does cost money, “but a major thing physicians need to understand is that you have to spend money to make money,” Dr. Friedman said.

In his experience, “those bucks are not out of control” if invested in the right kind of system.

When considering software vendors, it's important to visit practice sites that are already using installed systems.

He suggested that physicians look at big vendors that are likely to be in business at least 10 to 20 years down the road.

“This is a big investment, because whatever one you buy you're going to live with for a long time,” he noted.

The problem with medical records is that if you decide to dump one, “you can't convert the data from one system to another.”

In conducting research with vendors, Dr. Friedman got a general idea of what it would cost to install an EMR system, “including the whistles and bells.”

The per-doctor cost was $30,000–$50,000, including training.

“A lot of people spend that much on a car every few years,” he observed.

Training should ideally take place during the slow season, from the end of June through early September in order to interfere as little as possible with patient care.

Murray Hill physicians went through 3 months of formal training during such a period. The practice hired college and medical students to preload diagnoses, medicines, and vaccines into the new EMR system.

Physicians won't be able to get everything into the record, “but you'll find that over the years the important stuff's there,” Dr. Friedman said.

Conversion to an EMR system should take place gradually, he cautioned. A staff of two physicians, for example, should take turns going online. “You should have cross coverage so physicians are not out seeing patients while they learn how to use the system,” he advised.

It's crucial to practice with the software before going live with the system. Within 1 to 2 weeks, Murray Hill's physicians had learned the system and regained their usual level of efficiency. Many become even more efficient after going online, he noted.

In addition to handling appointment scheduling (see box), the system helps automate prescription refills. “The patient does it, the doctor signs it. When it's electronic, it's done,” Dr. Friedman said. With a few clicks and a printout, a physician can quickly take care of a Medicare patient on 12 different prescriptions that need to be shipped to several locations.

Physicians using an EMR can check drug interactions when looking at their patients' prescriptions.

In addition, instituting a system of online preventive notices can remind physicians of what needs to be done for each patient. “And any work you do provides income,” he said.

An EMR also can point out errors in coding. “A lot of times we find out that the doctor has been undercoding. It's not fair to give back to carriers and the government. That's a lot of lost income,” Dr. Friedman said.

“It continues to amaze me that 90% of physicians are not” paperless, he said. People traveling on planes “would never put up with a pilot navigating by the stars.”

Online Appointment Scheduling 24/7

Patients favor online systems that provide a 24/7 service for appointments. “By integrating with the Internet you get patients to do things for themselves without staff,” Dr. Friedman said.

His practice, Murray Hill Medical Group, developed its own software so that patients could sign in online, make their own appointments, refills, or referrals, or pick a physician or location. Dr. Friedman is now marketing the software for use by physicians who use compatible electronic medical record systems.

Patients get a tracking number plus three e-mail reminders about their visits. For annual exams, the e-mail will remind them not to eat or drink for 8 hours prior to the visit.

The patient who has forgotten the time of a Monday appointment can look up the visit online Sunday instead of becoming a “no show,” he said.

The practice estimates that 35%–45% of all of its appointments are made online, and the no-show rate with Internet appointments is less than 1%. Murray Hill Medical Group has open-access scheduling, so most appointments are scheduled within 24 hours.

“We always add on more hours. Patients can always get in because that's how we make a living. We're not going to make them wait 3 weeks,” he said. The electronic system makes it easy to fill up slots when patients drop out of appointments.

Physicians have long struggled with patients having online access to their practice, Dr. Friedman said. “They have a problem with letting patients see their open schedule slots.” In addition, “they think patients are too dumb, they'll abuse the system, [or] they don't know what they're doing.”

But patients are smarter than you think, he said. Of Murray Hill's patients, 95% have Internet access, and other data point to widespread access to online services.

A 2003 Harris Interactive poll found that 80% of all patients use the Internet to search for information.

The internal medicine community is concerned about the number of subspecialists in internal medicine who are choosing to recertify in their specific fields rather than in core internal medicine.

Data from the ABIM show that 87% of subspecialists are keeping their subspecialty certificate, but only 71% have renewed their certification in general or core internal medicine. Many of those in the latter group may be renewing in both core internal medicine and in their subspecialty, ABIM spokesman Leslie Goode said in an interview.

Interest in the general internal medicine certificate tends to vary by subspecialty, noted William E. Golden, M.D., an American College of Physicians regent, and professor of medicine and public health at the University of Arkansas, Little Rock, said in an interview. For example, “60% of nephrologists recertify in core medicine, but the vast majority of cardiologists don't, if they recertify in cardiology,” he said.

Subspecialists may be shying away from core internal medicine because they don't find it relevant or think they won't be able to pass the general recertification exam without intensive work. Technically, these subspecialists are internists and should be recertifying in the core discipline, said Dr. Golden, a member of the Liaison Committee on Recertification, which was formed several years ago to advise the board about new pathways for recertification.

“Most members of the committee believe that good physicians are better diagnosticians if they understand key issues beyond their area of interest,” he said. The committee and ABIM “are actively trying to look at how recertification in core internal medicine reflects information that all internists should know, or is relevant to a subspecialty internist.”

Most internists, no matter what their discipline, choose to recertify. Since 1990, the year that the ABIM began issuing 10-year certificates, nearly 80% of general internists with a time-limited certificate have recertified in core internal medicine.

The new “maintenance of certification” program that the ABIM plans to roll out in January 2006 may further test the staying power of general internal medicine, which has been hit hard by declining match rates. The ABIM reports that 20% of physicians who certified in internal medicine after 1990 no longer practice in the field, Ms. Goode said.

Early estimates are encouraging: Nearly two-thirds of ABIM diplomates with 10-year certificates have enrolled in the new program. In April, the board announced more flexible options for maintenance of certification, hoping to encourage internists without time-limited certificates to participate.

The steps required for maintenance of certification “are useful and important,” but the process runs the risk of exacerbating the hassle factor, said Robert Hopkins, M.D., associate director of the medicine/pediatrics residency program at the University of Arkansas, Little Rock.

“Several of my colleagues in private practice—general internists and subspecialists—are concerned that the number of steps required for maintenance of certification [will] pose a major barrier to carrying out day-to-day patient care,” Dr. Hopkins said. The ABIM faces challenges in getting the message out to private practices about the value of recertification, he said.

Still, Dr. Golden expressed confidence. “In the past, people have been anxious and uncertain about what it would mean,” he said, but they have become more comfortable as the process has become clearer.

Dr. Golden said that in his recent presentations at American College of Physicians regional meetings, he never gets a “single question or complaint” when he explains the maintenance of certification program. “It sounds complicated, but when you look at it, it's pretty straightforward.”

As part of its revision of the certification process, the ABIM plans to make it simpler to renew certificates in internal medicine and the subspecialties of internal medicine. Also, more options will be available to meet the ABIM's new standard for practice performance, which entails practice improvement modules.

This Month's Talk Back Question

Should subspecialists be required to recertify in core internal medicine, and not just in their own subspecialty?

The internal medicine community is concerned about the number of subspecialists in internal medicine who are choosing to recertify in their specific fields rather than in core internal medicine.

Data from the ABIM show that 87% of subspecialists are keeping their subspecialty certificate, but only 71% have renewed their certification in general or core internal medicine. Many of those in the latter group may be renewing in both core internal medicine and in their subspecialty, ABIM spokesman Leslie Goode said in an interview.

Interest in the general internal medicine certificate tends to vary by subspecialty, noted William E. Golden, M.D., an American College of Physicians regent, and professor of medicine and public health at the University of Arkansas, Little Rock, said in an interview. For example, “60% of nephrologists recertify in core medicine, but the vast majority of cardiologists don't, if they recertify in cardiology,” he said.

Subspecialists may be shying away from core internal medicine because they don't find it relevant or think they won't be able to pass the general recertification exam without intensive work. Technically, these subspecialists are internists and should be recertifying in the core discipline, said Dr. Golden, a member of the Liaison Committee on Recertification, which was formed several years ago to advise the board about new pathways for recertification.

“Most members of the committee believe that good physicians are better diagnosticians if they understand key issues beyond their area of interest,” he said. The committee and ABIM “are actively trying to look at how recertification in core internal medicine reflects information that all internists should know, or is relevant to a subspecialty internist.”

Most internists, no matter what their discipline, choose to recertify. Since 1990, the year that the ABIM began issuing 10-year certificates, nearly 80% of general internists with a time-limited certificate have recertified in core internal medicine.

The new “maintenance of certification” program that the ABIM plans to roll out in January 2006 may further test the staying power of general internal medicine, which has been hit hard by declining match rates. The ABIM reports that 20% of physicians who certified in internal medicine after 1990 no longer practice in the field, Ms. Goode said.

Early estimates are encouraging: Nearly two-thirds of ABIM diplomates with 10-year certificates have enrolled in the new program. In April, the board announced more flexible options for maintenance of certification, hoping to encourage internists without time-limited certificates to participate.

The steps required for maintenance of certification “are useful and important,” but the process runs the risk of exacerbating the hassle factor, said Robert Hopkins, M.D., associate director of the medicine/pediatrics residency program at the University of Arkansas, Little Rock.

“Several of my colleagues in private practice—general internists and subspecialists—are concerned that the number of steps required for maintenance of certification [will] pose a major barrier to carrying out day-to-day patient care,” Dr. Hopkins said. The ABIM faces challenges in getting the message out to private practices about the value of recertification, he said.

Still, Dr. Golden expressed confidence. “In the past, people have been anxious and uncertain about what it would mean,” he said, but they have become more comfortable as the process has become clearer.

Dr. Golden said that in his recent presentations at American College of Physicians regional meetings, he never gets a “single question or complaint” when he explains the maintenance of certification program. “It sounds complicated, but when you look at it, it's pretty straightforward.”

As part of its revision of the certification process, the ABIM plans to make it simpler to renew certificates in internal medicine and the subspecialties of internal medicine. Also, more options will be available to meet the ABIM's new standard for practice performance, which entails practice improvement modules.

This Month's Talk Back Question

Should subspecialists be required to recertify in core internal medicine, and not just in their own subspecialty?

The internal medicine community is concerned about the number of subspecialists in internal medicine who are choosing to recertify in their specific fields rather than in core internal medicine.

Data from the ABIM show that 87% of subspecialists are keeping their subspecialty certificate, but only 71% have renewed their certification in general or core internal medicine. Many of those in the latter group may be renewing in both core internal medicine and in their subspecialty, ABIM spokesman Leslie Goode said in an interview.

Interest in the general internal medicine certificate tends to vary by subspecialty, noted William E. Golden, M.D., an American College of Physicians regent, and professor of medicine and public health at the University of Arkansas, Little Rock, said in an interview. For example, “60% of nephrologists recertify in core medicine, but the vast majority of cardiologists don't, if they recertify in cardiology,” he said.

Subspecialists may be shying away from core internal medicine because they don't find it relevant or think they won't be able to pass the general recertification exam without intensive work. Technically, these subspecialists are internists and should be recertifying in the core discipline, said Dr. Golden, a member of the Liaison Committee on Recertification, which was formed several years ago to advise the board about new pathways for recertification.

“Most members of the committee believe that good physicians are better diagnosticians if they understand key issues beyond their area of interest,” he said. The committee and ABIM “are actively trying to look at how recertification in core internal medicine reflects information that all internists should know, or is relevant to a subspecialty internist.”

Most internists, no matter what their discipline, choose to recertify. Since 1990, the year that the ABIM began issuing 10-year certificates, nearly 80% of general internists with a time-limited certificate have recertified in core internal medicine.

The new “maintenance of certification” program that the ABIM plans to roll out in January 2006 may further test the staying power of general internal medicine, which has been hit hard by declining match rates. The ABIM reports that 20% of physicians who certified in internal medicine after 1990 no longer practice in the field, Ms. Goode said.

Early estimates are encouraging: Nearly two-thirds of ABIM diplomates with 10-year certificates have enrolled in the new program. In April, the board announced more flexible options for maintenance of certification, hoping to encourage internists without time-limited certificates to participate.

The steps required for maintenance of certification “are useful and important,” but the process runs the risk of exacerbating the hassle factor, said Robert Hopkins, M.D., associate director of the medicine/pediatrics residency program at the University of Arkansas, Little Rock.

“Several of my colleagues in private practice—general internists and subspecialists—are concerned that the number of steps required for maintenance of certification [will] pose a major barrier to carrying out day-to-day patient care,” Dr. Hopkins said. The ABIM faces challenges in getting the message out to private practices about the value of recertification, he said.

Still, Dr. Golden expressed confidence. “In the past, people have been anxious and uncertain about what it would mean,” he said, but they have become more comfortable as the process has become clearer.

Dr. Golden said that in his recent presentations at American College of Physicians regional meetings, he never gets a “single question or complaint” when he explains the maintenance of certification program. “It sounds complicated, but when you look at it, it's pretty straightforward.”

As part of its revision of the certification process, the ABIM plans to make it simpler to renew certificates in internal medicine and the subspecialties of internal medicine. Also, more options will be available to meet the ABIM's new standard for practice performance, which entails practice improvement modules.

This Month's Talk Back Question

Should subspecialists be required to recertify in core internal medicine, and not just in their own subspecialty?

DALLAS — Physicians in retainer practices are reporting better quality of care and fewer hassles, but the new approach is not without its flaws, according to a survey presented at a national conference on concierge medicine.

The retainer practices see fewer minorities and fewer patients with chronic illnesses than do regular practices, said Matthew Wynia, M.D., an internist and director of the American Medical Association's Institute for Ethics, who presented the findings. In addition, “the number of Medicaid patients in retainer practices is much smaller—6% vs. 15% in traditional practice,” Dr. Wynia said.

The AMA mailed out surveys to 144 physicians from retainer practices—also known as concierge or boutique medicine practices—and received 83 responses. As a control group, researchers mailed surveys to 463 primary care physicians in nonretainer practices from the AMA's master list, and received 231 responses. Data were collected between December 2003 and February 2004.

“We wanted to find out who was entering into these types of practices, what types of patients were they seeing, and what types of services were being offered,” Dr. Wynia said at the conference, sponsored by the Society for Innovative Medical Practice Design.

Weighing in on some of the potential benefits of concierge care, 50% of the retainer physicians said they thought they were offering more diagnostic and therapeutic services than traditional practices. In terms of more revenue, 70% of retainer physicians said they were doing better in this type of practice than they had in traditional practice. Fifty percent of the retainer physicians said working fewer hours was one of the benefits of being a retainer physician.

Not surprisingly, physicians in the nonretainer practices did not see as many benefits to concierge care. While 90% of the retainer physicians believed the type of care they provide was better quality care, only 50% of the traditional physicians thought that was true. Eighty percent of the retainer physicians thought that concierge care would result in fewer administrative hassles, yet only half of the nonretainer physicians felt the same way.

When queried about the potential risks of a retainer practice, respondents from both groups expressed concern that society and their peers would disapprove of their decision to start a retainer practice.

You risk having people “look down their noses at you,” Dr. Wynia said. In a surprising statistic, “5% of people in retainer practices thought they should be discouraged” from pursuing this approach.

Indeed, several participants at the meeting told this newspaper that their employer or practice partners did not know that they were attending a conference on concierge care.

More than half of retainer physicians and 80% of nonretainer physicians thought that concierge care created a risk of a more tiered system of access to health care.

Loss of patient diversity and insurance contracts and legal challenges were other concerns cited by the survey respondents.

Despite these potential risks, the vast majority of respondents thought that these practices should be allowed to exist. “Only 25%–30% of nonretainer physicians thought they should be discouraged or illegal,” Dr. Wynia said.

Conversion to retainer practices takes time, he said. Retainer physicians surveyed said most of their patients—about 88%—didn't follow them to the new practice. In addition, most retainer practices have some patients who do not pay the retainer fee (a mean of about 17%).

Once these factors are taken into account, transitioning from an average nonretainer practice of 2,300 patients to a retainer practice would involve transferring 2,025 patients to someone else and adding 560 new patients, he said. In addition, physicians on average would continue to see 140 patients who didn't pay a retainer.

When queried about the transition to a retainer practice, 63% of retainer physicians said they gave their patients more than 90 days notice before making the transition, Dr. Wynia said.

In other survey findings:

▸ Retainer-physicians panels averaged 835 patients vs. 2,300 patients for nonretainer practices.

▸ Retainer physicians saw an average of 11 patients per day; nonretainer physicians saw an average of 22 patients.

▸ Retainer physicians provide slightly more charity care than do their peers in traditional practice. Charity care for retainer physicians averaged 9.14 hours per month vs. 7.48 hours per month for nonretainer practices.

▸ Most retainer practices are located in metropolitan areas and on both coasts. Most started in 2001 or later and most physicians transitioned to retainer practice from another practice model rather than straight from residency.

▸ House calls, same-day appointments, 24-hour access pagers, and coordinated hospital care were services provided.

DALLAS — Physicians in retainer practices are reporting better quality of care and fewer hassles, but the new approach is not without its flaws, according to a survey presented at a national conference on concierge medicine.

The retainer practices see fewer minorities and fewer patients with chronic illnesses than do regular practices, said Matthew Wynia, M.D., an internist and director of the American Medical Association's Institute for Ethics, who presented the findings. In addition, “the number of Medicaid patients in retainer practices is much smaller—6% vs. 15% in traditional practice,” Dr. Wynia said.

The AMA mailed out surveys to 144 physicians from retainer practices—also known as concierge or boutique medicine practices—and received 83 responses. As a control group, researchers mailed surveys to 463 primary care physicians in nonretainer practices from the AMA's master list, and received 231 responses. Data were collected between December 2003 and February 2004.

“We wanted to find out who was entering into these types of practices, what types of patients were they seeing, and what types of services were being offered,” Dr. Wynia said at the conference, sponsored by the Society for Innovative Medical Practice Design.

Weighing in on some of the potential benefits of concierge care, 50% of the retainer physicians said they thought they were offering more diagnostic and therapeutic services than traditional practices. In terms of more revenue, 70% of retainer physicians said they were doing better in this type of practice than they had in traditional practice. Fifty percent of the retainer physicians said working fewer hours was one of the benefits of being a retainer physician.

Not surprisingly, physicians in the nonretainer practices did not see as many benefits to concierge care. While 90% of the retainer physicians believed the type of care they provide was better quality care, only 50% of the traditional physicians thought that was true. Eighty percent of the retainer physicians thought that concierge care would result in fewer administrative hassles, yet only half of the nonretainer physicians felt the same way.

When queried about the potential risks of a retainer practice, respondents from both groups expressed concern that society and their peers would disapprove of their decision to start a retainer practice.

You risk having people “look down their noses at you,” Dr. Wynia said. In a surprising statistic, “5% of people in retainer practices thought they should be discouraged” from pursuing this approach.

Indeed, several participants at the meeting told this newspaper that their employer or practice partners did not know that they were attending a conference on concierge care.

More than half of retainer physicians and 80% of nonretainer physicians thought that concierge care created a risk of a more tiered system of access to health care.

Loss of patient diversity and insurance contracts and legal challenges were other concerns cited by the survey respondents.

Despite these potential risks, the vast majority of respondents thought that these practices should be allowed to exist. “Only 25%–30% of nonretainer physicians thought they should be discouraged or illegal,” Dr. Wynia said.

Conversion to retainer practices takes time, he said. Retainer physicians surveyed said most of their patients—about 88%—didn't follow them to the new practice. In addition, most retainer practices have some patients who do not pay the retainer fee (a mean of about 17%).

Once these factors are taken into account, transitioning from an average nonretainer practice of 2,300 patients to a retainer practice would involve transferring 2,025 patients to someone else and adding 560 new patients, he said. In addition, physicians on average would continue to see 140 patients who didn't pay a retainer.

When queried about the transition to a retainer practice, 63% of retainer physicians said they gave their patients more than 90 days notice before making the transition, Dr. Wynia said.

In other survey findings:

▸ Retainer-physicians panels averaged 835 patients vs. 2,300 patients for nonretainer practices.

▸ Retainer physicians saw an average of 11 patients per day; nonretainer physicians saw an average of 22 patients.

▸ Retainer physicians provide slightly more charity care than do their peers in traditional practice. Charity care for retainer physicians averaged 9.14 hours per month vs. 7.48 hours per month for nonretainer practices.

▸ Most retainer practices are located in metropolitan areas and on both coasts. Most started in 2001 or later and most physicians transitioned to retainer practice from another practice model rather than straight from residency.

▸ House calls, same-day appointments, 24-hour access pagers, and coordinated hospital care were services provided.

DALLAS — Physicians in retainer practices are reporting better quality of care and fewer hassles, but the new approach is not without its flaws, according to a survey presented at a national conference on concierge medicine.

The retainer practices see fewer minorities and fewer patients with chronic illnesses than do regular practices, said Matthew Wynia, M.D., an internist and director of the American Medical Association's Institute for Ethics, who presented the findings. In addition, “the number of Medicaid patients in retainer practices is much smaller—6% vs. 15% in traditional practice,” Dr. Wynia said.

The AMA mailed out surveys to 144 physicians from retainer practices—also known as concierge or boutique medicine practices—and received 83 responses. As a control group, researchers mailed surveys to 463 primary care physicians in nonretainer practices from the AMA's master list, and received 231 responses. Data were collected between December 2003 and February 2004.

“We wanted to find out who was entering into these types of practices, what types of patients were they seeing, and what types of services were being offered,” Dr. Wynia said at the conference, sponsored by the Society for Innovative Medical Practice Design.

Weighing in on some of the potential benefits of concierge care, 50% of the retainer physicians said they thought they were offering more diagnostic and therapeutic services than traditional practices. In terms of more revenue, 70% of retainer physicians said they were doing better in this type of practice than they had in traditional practice. Fifty percent of the retainer physicians said working fewer hours was one of the benefits of being a retainer physician.

Not surprisingly, physicians in the nonretainer practices did not see as many benefits to concierge care. While 90% of the retainer physicians believed the type of care they provide was better quality care, only 50% of the traditional physicians thought that was true. Eighty percent of the retainer physicians thought that concierge care would result in fewer administrative hassles, yet only half of the nonretainer physicians felt the same way.

When queried about the potential risks of a retainer practice, respondents from both groups expressed concern that society and their peers would disapprove of their decision to start a retainer practice.

You risk having people “look down their noses at you,” Dr. Wynia said. In a surprising statistic, “5% of people in retainer practices thought they should be discouraged” from pursuing this approach.

Indeed, several participants at the meeting told this newspaper that their employer or practice partners did not know that they were attending a conference on concierge care.

More than half of retainer physicians and 80% of nonretainer physicians thought that concierge care created a risk of a more tiered system of access to health care.

Loss of patient diversity and insurance contracts and legal challenges were other concerns cited by the survey respondents.

Despite these potential risks, the vast majority of respondents thought that these practices should be allowed to exist. “Only 25%–30% of nonretainer physicians thought they should be discouraged or illegal,” Dr. Wynia said.

Conversion to retainer practices takes time, he said. Retainer physicians surveyed said most of their patients—about 88%—didn't follow them to the new practice. In addition, most retainer practices have some patients who do not pay the retainer fee (a mean of about 17%).

Once these factors are taken into account, transitioning from an average nonretainer practice of 2,300 patients to a retainer practice would involve transferring 2,025 patients to someone else and adding 560 new patients, he said. In addition, physicians on average would continue to see 140 patients who didn't pay a retainer.

When queried about the transition to a retainer practice, 63% of retainer physicians said they gave their patients more than 90 days notice before making the transition, Dr. Wynia said.

In other survey findings:

▸ Retainer-physicians panels averaged 835 patients vs. 2,300 patients for nonretainer practices.

▸ Retainer physicians saw an average of 11 patients per day; nonretainer physicians saw an average of 22 patients.

▸ Retainer physicians provide slightly more charity care than do their peers in traditional practice. Charity care for retainer physicians averaged 9.14 hours per month vs. 7.48 hours per month for nonretainer practices.

▸ Most retainer practices are located in metropolitan areas and on both coasts. Most started in 2001 or later and most physicians transitioned to retainer practice from another practice model rather than straight from residency.

▸ House calls, same-day appointments, 24-hour access pagers, and coordinated hospital care were services provided.

SAN FRANCISCO — There is a cost-effective way to go paperless and make a profit for your group practice, Jeffrey P. Friedman, M.D., said at the annual meeting of the American College of Physicians.

Dr. Friedman, an internist and founding partner of Murray Hill Medical Group in New York, increased office appointments—and saved $238,000 annually in staff pay and benefits—by installing an electronic medical record (EMR) system and integrating the new technology on a gradual basis, cutting down on staff and phone time.

Patient registrations grew rapidly (currently at 18,000), and salaries for the group's internists and subspecialists in 2004 were two to three times the national average, Dr. Friedman said.

Murray Hill started out in 1992 with just a few partners and associates, one exam room per physician, and no ancillary help, using a local, small electronic billing package. Over the years, the practice filled its space, adding more subspecialty partners, associates, and equipment, and in 1998 acquired an EMR system. The practice added online bill paying this year.

The practice now has 35 doctors, an office lab, and a technician who oversees the fully automated practice. “Our employee/doctor ratio is very low,” he said.

Installing an EMR system does cost money, “but a major thing physicians need to understand is that you have to spend money to make money,” Dr. Friedman said. In his experience, “those bucks are not out of control” if invested in the right kind of system.

When considering software vendors, it's important to visit practice sites that are already using installed systems. He suggested that physicians look at big vendors that are likely to be in business at least 10 to 20 years down the road. “This is a big investment, because whatever one you buy you're going to live with for a long time,” he noted. The problem with medical records is that if you decide to dump one, “you can't convert the data from one system to another.”

In conducting research with vendors, Dr. Friedman got a general idea of what it would cost to install an EMR system, “including the whistles and bells.” The per-doctor cost was $30,000–$50,000, including training.

“A lot of people spend that much on a car every few years,” he observed.

Training should ideally take place during the slow season, from the end of June through early September. Murray Hill physicians went through 3 months of formal training during such a period. The practice hired college and medical students to preload diagnoses, medicines, and vaccines into the new EMR system. Physicians won't be able to get everything into the record, “but you'll find that over the years the important stuff's there,” Dr. Friedman said.

Conversion to an EMR system should take place gradually, he cautioned. A staff of two physicians, for example, should take turns going online. “You should have cross coverage so physicians are not out seeing patients while they learn how to use the system,” he advised.

It's crucial to practice with the software before going live with the system. Within 1 to 2 weeks, Murray Hill's physicians had learned the system and regained their usual level of efficiency. Many become even more efficient after going online, he noted.

In addition to handling appointment scheduling (see box), the system helps automate prescription refills. “The patient does it, the doctor signs it. When it's electronic, it's done,” Dr. Friedman said. With a few clicks and a printout, a physician can quickly take care of a Medicare patient on 12 different prescriptions that need to be shipped to several locations.

Physicians using an EMR can check drug interactions when looking at their patients' prescriptions. In addition, online preventive notices can remind physicians of what needs to be done for each patient. “And any work you do provides income,” he said.

An EMR also can point out errors in coding. “A lot of times we find out that the doctor has been undercoding. It's not fair to give back to carriers and the government. That's a lot of lost income,” Dr. Friedman said.

“It continues to amaze me that 90% of physicians are not” paperless, he said. People traveling on planes “would never put up with a pilot navigating by the stars.”

Going Online for Scheduling

Patients favor online systems that provide a 24/7 service for appointments. “By integrating with the Internet you get patients to do things for themselves without staff,” Dr. Friedman said.

His practice, Murray Hill Medical Group, developed its own software so that patients could sign in online, make their own appointments, refills, or referrals, or pick a physician or location. Dr. Friedman is now marketing the software for use by physicians who use compatible electronic medical record systems.

Patients get a tracking number plus three e-mail reminders about their visits. For annual exams, the e-mail will remind them not to eat or drink for 8 hours prior to the visit.

If it's a Sunday night, a patient who has forgotten the time of a Monday appointment can look up the visit online instead of becoming a “no show,” he said. The practice estimates that 35%–45% of all of its appointments are made online, and the no-show rate with Internet appointments is less than 1%.

Murray Hill Medical Group has open-access scheduling, so most appointments are scheduled within 24 hours. “We always add on more hours. Patients can always get in because that's how we make a living. We're not going to make them wait 3 weeks,” he said. The electronic system makes it easy to fill up slots when patients drop out of appointments.

Physicians have long struggled with patients having online access to their practice, he said. “They have a problem with letting patients see their open schedule slots.”

SAN FRANCISCO — There is a cost-effective way to go paperless and make a profit for your group practice, Jeffrey P. Friedman, M.D., said at the annual meeting of the American College of Physicians.

Dr. Friedman, an internist and founding partner of Murray Hill Medical Group in New York, increased office appointments—and saved $238,000 annually in staff pay and benefits—by installing an electronic medical record (EMR) system and integrating the new technology on a gradual basis, cutting down on staff and phone time.

Patient registrations grew rapidly (currently at 18,000), and salaries for the group's internists and subspecialists in 2004 were two to three times the national average, Dr. Friedman said.

Murray Hill started out in 1992 with just a few partners and associates, one exam room per physician, and no ancillary help, using a local, small electronic billing package. Over the years, the practice filled its space, adding more subspecialty partners, associates, and equipment, and in 1998 acquired an EMR system. The practice added online bill paying this year.

The practice now has 35 doctors, an office lab, and a technician who oversees the fully automated practice. “Our employee/doctor ratio is very low,” he said.

Installing an EMR system does cost money, “but a major thing physicians need to understand is that you have to spend money to make money,” Dr. Friedman said. In his experience, “those bucks are not out of control” if invested in the right kind of system.

When considering software vendors, it's important to visit practice sites that are already using installed systems. He suggested that physicians look at big vendors that are likely to be in business at least 10 to 20 years down the road. “This is a big investment, because whatever one you buy you're going to live with for a long time,” he noted. The problem with medical records is that if you decide to dump one, “you can't convert the data from one system to another.”

In conducting research with vendors, Dr. Friedman got a general idea of what it would cost to install an EMR system, “including the whistles and bells.” The per-doctor cost was $30,000–$50,000, including training.

“A lot of people spend that much on a car every few years,” he observed.

Training should ideally take place during the slow season, from the end of June through early September. Murray Hill physicians went through 3 months of formal training during such a period. The practice hired college and medical students to preload diagnoses, medicines, and vaccines into the new EMR system. Physicians won't be able to get everything into the record, “but you'll find that over the years the important stuff's there,” Dr. Friedman said.

Conversion to an EMR system should take place gradually, he cautioned. A staff of two physicians, for example, should take turns going online. “You should have cross coverage so physicians are not out seeing patients while they learn how to use the system,” he advised.

It's crucial to practice with the software before going live with the system. Within 1 to 2 weeks, Murray Hill's physicians had learned the system and regained their usual level of efficiency. Many become even more efficient after going online, he noted.

In addition to handling appointment scheduling (see box), the system helps automate prescription refills. “The patient does it, the doctor signs it. When it's electronic, it's done,” Dr. Friedman said. With a few clicks and a printout, a physician can quickly take care of a Medicare patient on 12 different prescriptions that need to be shipped to several locations.

Physicians using an EMR can check drug interactions when looking at their patients' prescriptions. In addition, online preventive notices can remind physicians of what needs to be done for each patient. “And any work you do provides income,” he said.

An EMR also can point out errors in coding. “A lot of times we find out that the doctor has been undercoding. It's not fair to give back to carriers and the government. That's a lot of lost income,” Dr. Friedman said.

“It continues to amaze me that 90% of physicians are not” paperless, he said. People traveling on planes “would never put up with a pilot navigating by the stars.”

Going Online for Scheduling

Patients favor online systems that provide a 24/7 service for appointments. “By integrating with the Internet you get patients to do things for themselves without staff,” Dr. Friedman said.

His practice, Murray Hill Medical Group, developed its own software so that patients could sign in online, make their own appointments, refills, or referrals, or pick a physician or location. Dr. Friedman is now marketing the software for use by physicians who use compatible electronic medical record systems.

Patients get a tracking number plus three e-mail reminders about their visits. For annual exams, the e-mail will remind them not to eat or drink for 8 hours prior to the visit.

If it's a Sunday night, a patient who has forgotten the time of a Monday appointment can look up the visit online instead of becoming a “no show,” he said. The practice estimates that 35%–45% of all of its appointments are made online, and the no-show rate with Internet appointments is less than 1%.

Murray Hill Medical Group has open-access scheduling, so most appointments are scheduled within 24 hours. “We always add on more hours. Patients can always get in because that's how we make a living. We're not going to make them wait 3 weeks,” he said. The electronic system makes it easy to fill up slots when patients drop out of appointments.

Physicians have long struggled with patients having online access to their practice, he said. “They have a problem with letting patients see their open schedule slots.”

SAN FRANCISCO — There is a cost-effective way to go paperless and make a profit for your group practice, Jeffrey P. Friedman, M.D., said at the annual meeting of the American College of Physicians.

Dr. Friedman, an internist and founding partner of Murray Hill Medical Group in New York, increased office appointments—and saved $238,000 annually in staff pay and benefits—by installing an electronic medical record (EMR) system and integrating the new technology on a gradual basis, cutting down on staff and phone time.

Patient registrations grew rapidly (currently at 18,000), and salaries for the group's internists and subspecialists in 2004 were two to three times the national average, Dr. Friedman said.

Murray Hill started out in 1992 with just a few partners and associates, one exam room per physician, and no ancillary help, using a local, small electronic billing package. Over the years, the practice filled its space, adding more subspecialty partners, associates, and equipment, and in 1998 acquired an EMR system. The practice added online bill paying this year.

The practice now has 35 doctors, an office lab, and a technician who oversees the fully automated practice. “Our employee/doctor ratio is very low,” he said.

Installing an EMR system does cost money, “but a major thing physicians need to understand is that you have to spend money to make money,” Dr. Friedman said. In his experience, “those bucks are not out of control” if invested in the right kind of system.

When considering software vendors, it's important to visit practice sites that are already using installed systems. He suggested that physicians look at big vendors that are likely to be in business at least 10 to 20 years down the road. “This is a big investment, because whatever one you buy you're going to live with for a long time,” he noted. The problem with medical records is that if you decide to dump one, “you can't convert the data from one system to another.”

In conducting research with vendors, Dr. Friedman got a general idea of what it would cost to install an EMR system, “including the whistles and bells.” The per-doctor cost was $30,000–$50,000, including training.

“A lot of people spend that much on a car every few years,” he observed.

Training should ideally take place during the slow season, from the end of June through early September. Murray Hill physicians went through 3 months of formal training during such a period. The practice hired college and medical students to preload diagnoses, medicines, and vaccines into the new EMR system. Physicians won't be able to get everything into the record, “but you'll find that over the years the important stuff's there,” Dr. Friedman said.

Conversion to an EMR system should take place gradually, he cautioned. A staff of two physicians, for example, should take turns going online. “You should have cross coverage so physicians are not out seeing patients while they learn how to use the system,” he advised.

It's crucial to practice with the software before going live with the system. Within 1 to 2 weeks, Murray Hill's physicians had learned the system and regained their usual level of efficiency. Many become even more efficient after going online, he noted.

In addition to handling appointment scheduling (see box), the system helps automate prescription refills. “The patient does it, the doctor signs it. When it's electronic, it's done,” Dr. Friedman said. With a few clicks and a printout, a physician can quickly take care of a Medicare patient on 12 different prescriptions that need to be shipped to several locations.

Physicians using an EMR can check drug interactions when looking at their patients' prescriptions. In addition, online preventive notices can remind physicians of what needs to be done for each patient. “And any work you do provides income,” he said.

An EMR also can point out errors in coding. “A lot of times we find out that the doctor has been undercoding. It's not fair to give back to carriers and the government. That's a lot of lost income,” Dr. Friedman said.

“It continues to amaze me that 90% of physicians are not” paperless, he said. People traveling on planes “would never put up with a pilot navigating by the stars.”

Going Online for Scheduling

Patients favor online systems that provide a 24/7 service for appointments. “By integrating with the Internet you get patients to do things for themselves without staff,” Dr. Friedman said.

His practice, Murray Hill Medical Group, developed its own software so that patients could sign in online, make their own appointments, refills, or referrals, or pick a physician or location. Dr. Friedman is now marketing the software for use by physicians who use compatible electronic medical record systems.

Patients get a tracking number plus three e-mail reminders about their visits. For annual exams, the e-mail will remind them not to eat or drink for 8 hours prior to the visit.

If it's a Sunday night, a patient who has forgotten the time of a Monday appointment can look up the visit online instead of becoming a “no show,” he said. The practice estimates that 35%–45% of all of its appointments are made online, and the no-show rate with Internet appointments is less than 1%.

Murray Hill Medical Group has open-access scheduling, so most appointments are scheduled within 24 hours. “We always add on more hours. Patients can always get in because that's how we make a living. We're not going to make them wait 3 weeks,” he said. The electronic system makes it easy to fill up slots when patients drop out of appointments.

Physicians have long struggled with patients having online access to their practice, he said. “They have a problem with letting patients see their open schedule slots.”

SAN FRANCISCO — Pay for performance “is a great idea in theory,” but so far it has failed to work effectively in the private sector, Eric B. Larson, M.D., said during the annual meeting of the American College of Physicians.

“Word on the street is it's a disaster,” mostly because insurance companies have their own sets of performance measures, he said. That leaves physicians with the task of juggling compliance with multiple requirements in their state or community, Dr. Larson, immediate past chairman of the ACP's board of regents, said at a press briefing on policy developments.

A newly formed “ambulatory care quality alliance” between the ACP, the American Academy of Family Physicians, America's Health Insurance Plans, and the Agency for Healthcare Research and Quality “will help rationalize the performance measures movement,” Dr. Larson said.

John Tooker, M.D., ACP executive vice president, said that the goal of the alliance will be to get the Centers for Medicare and Medicaid Services, health plans, and other stakeholders “on the same page with one set of measures” that will work effectively without overburdening physicians.

The college wants to ensure that “such measures do not punish physicians, but rather provide clear incentives for improvement,” ACP President Andy Hedberg, M.D., said at the briefing.

Dr. Larson noted that conflicting performance measures are especially burdensome for small practices dealing with multiple insurance companies that use different performance measures.

The situation becomes especially complicated if a patient is covered by more than one plan and the physician has to send in performance measures to qualify for payment for each of the plans. “This is causing people to spend inordinate amounts of time doing things that are best done electronically,” he said. And, as many speakers noted during the meeting, the vast majority of physicians are not yet using electronic medical records.

As a result, physicians in various insurance markets around the country are begging health plans to leave them alone, Dr. Larson said.

Other physicians at the meeting expressed misgivings about pay for performance, including Daniel Levy, M.D., who said that performance measures tend to penalize physicians who take care of the poorest and sickest patients.

The practices with the best statistics on performance measurement tend to be practices with “the youngest, the whitest, the wealthiest patients,” said Dr. Levy, who attended a session on performance measurement. Meanwhile, “doctors who treat sick people are getting kicked in the teeth. You cannot get good performance measures on people who make less than $25,000 a year” and have a myriad of health problems, he remarked.

Pay for performance is a “double whammy” to physicians already dealing with a “terrible” reimbursement system, Dr. Levy added.

Pay for performance is just one application of performance measures, which also are intended to help physicians track their own progress in improving quality of care and provide publicly reported data that patients can use when choosing physicians.

The federal government has launched several pilots to test performance measures. In one, a 3-year demonstration project of small and medium practices in four states, primary care physicians are getting incentives for adopting information technology systems and for their results on clinical quality measures.

In another 3-year project, 10 large physician group practices are getting additional payments from CMS if they improve outcomes for Medicare beneficiaries.

The ACP and other medical organizations also are working with contractors on a third Medicare project that is using financial incentives and technology support to improve care for patients with diabetes or heart failure.

SAN FRANCISCO — Pay for performance “is a great idea in theory,” but so far it has failed to work effectively in the private sector, Eric B. Larson, M.D., said during the annual meeting of the American College of Physicians.

“Word on the street is it's a disaster,” mostly because insurance companies have their own sets of performance measures, he said. That leaves physicians with the task of juggling compliance with multiple requirements in their state or community, Dr. Larson, immediate past chairman of the ACP's board of regents, said at a press briefing on policy developments.

A newly formed “ambulatory care quality alliance” between the ACP, the American Academy of Family Physicians, America's Health Insurance Plans, and the Agency for Healthcare Research and Quality “will help rationalize the performance measures movement,” Dr. Larson said.

John Tooker, M.D., ACP executive vice president, said that the goal of the alliance will be to get the Centers for Medicare and Medicaid Services, health plans, and other stakeholders “on the same page with one set of measures” that will work effectively without overburdening physicians.

The college wants to ensure that “such measures do not punish physicians, but rather provide clear incentives for improvement,” ACP President Andy Hedberg, M.D., said at the briefing.

Dr. Larson noted that conflicting performance measures are especially burdensome for small practices dealing with multiple insurance companies that use different performance measures.

The situation becomes especially complicated if a patient is covered by more than one plan and the physician has to send in performance measures to qualify for payment for each of the plans. “This is causing people to spend inordinate amounts of time doing things that are best done electronically,” he said. And, as many speakers noted during the meeting, the vast majority of physicians are not yet using electronic medical records.

As a result, physicians in various insurance markets around the country are begging health plans to leave them alone, Dr. Larson said.

Other physicians at the meeting expressed misgivings about pay for performance, including Daniel Levy, M.D., who said that performance measures tend to penalize physicians who take care of the poorest and sickest patients.

The practices with the best statistics on performance measurement tend to be practices with “the youngest, the whitest, the wealthiest patients,” said Dr. Levy, who attended a session on performance measurement. Meanwhile, “doctors who treat sick people are getting kicked in the teeth. You cannot get good performance measures on people who make less than $25,000 a year” and have a myriad of health problems, he remarked.

Pay for performance is a “double whammy” to physicians already dealing with a “terrible” reimbursement system, Dr. Levy added.

Pay for performance is just one application of performance measures, which also are intended to help physicians track their own progress in improving quality of care and provide publicly reported data that patients can use when choosing physicians.

The federal government has launched several pilots to test performance measures. In one, a 3-year demonstration project of small and medium practices in four states, primary care physicians are getting incentives for adopting information technology systems and for their results on clinical quality measures.

In another 3-year project, 10 large physician group practices are getting additional payments from CMS if they improve outcomes for Medicare beneficiaries.

The ACP and other medical organizations also are working with contractors on a third Medicare project that is using financial incentives and technology support to improve care for patients with diabetes or heart failure.

SAN FRANCISCO — Pay for performance “is a great idea in theory,” but so far it has failed to work effectively in the private sector, Eric B. Larson, M.D., said during the annual meeting of the American College of Physicians.

“Word on the street is it's a disaster,” mostly because insurance companies have their own sets of performance measures, he said. That leaves physicians with the task of juggling compliance with multiple requirements in their state or community, Dr. Larson, immediate past chairman of the ACP's board of regents, said at a press briefing on policy developments.

A newly formed “ambulatory care quality alliance” between the ACP, the American Academy of Family Physicians, America's Health Insurance Plans, and the Agency for Healthcare Research and Quality “will help rationalize the performance measures movement,” Dr. Larson said.

John Tooker, M.D., ACP executive vice president, said that the goal of the alliance will be to get the Centers for Medicare and Medicaid Services, health plans, and other stakeholders “on the same page with one set of measures” that will work effectively without overburdening physicians.

The college wants to ensure that “such measures do not punish physicians, but rather provide clear incentives for improvement,” ACP President Andy Hedberg, M.D., said at the briefing.

Dr. Larson noted that conflicting performance measures are especially burdensome for small practices dealing with multiple insurance companies that use different performance measures.

The situation becomes especially complicated if a patient is covered by more than one plan and the physician has to send in performance measures to qualify for payment for each of the plans. “This is causing people to spend inordinate amounts of time doing things that are best done electronically,” he said. And, as many speakers noted during the meeting, the vast majority of physicians are not yet using electronic medical records.

As a result, physicians in various insurance markets around the country are begging health plans to leave them alone, Dr. Larson said.

Other physicians at the meeting expressed misgivings about pay for performance, including Daniel Levy, M.D., who said that performance measures tend to penalize physicians who take care of the poorest and sickest patients.

The practices with the best statistics on performance measurement tend to be practices with “the youngest, the whitest, the wealthiest patients,” said Dr. Levy, who attended a session on performance measurement. Meanwhile, “doctors who treat sick people are getting kicked in the teeth. You cannot get good performance measures on people who make less than $25,000 a year” and have a myriad of health problems, he remarked.

Pay for performance is a “double whammy” to physicians already dealing with a “terrible” reimbursement system, Dr. Levy added.

Pay for performance is just one application of performance measures, which also are intended to help physicians track their own progress in improving quality of care and provide publicly reported data that patients can use when choosing physicians.

The federal government has launched several pilots to test performance measures. In one, a 3-year demonstration project of small and medium practices in four states, primary care physicians are getting incentives for adopting information technology systems and for their results on clinical quality measures.

In another 3-year project, 10 large physician group practices are getting additional payments from CMS if they improve outcomes for Medicare beneficiaries.

The ACP and other medical organizations also are working with contractors on a third Medicare project that is using financial incentives and technology support to improve care for patients with diabetes or heart failure.

The internal medicine community is concerned about the number of subspecialists in internal medicine who are choosing to recertify in their specific fields rather than in core internal medicine.

Data from the American Board of Internal Medicine (ABIM) show that 87% of subspecialists are keeping their subspecialty certificate, but only 71% have renewed their certification in general or core internal medicine. Many of those in the latter group may be renewing in both core internal medicine and in their subspecialty, ABIM spokesman Leslie Goode said in an interview.

Interest in the general internal medicine certificate tends to vary by subspecialty, noted William E. Golden, M.D., an American College of Physicians regent, and professor of medicine and public health at the University of Arkansas, Little Rock, in an interview. For example, “60% of nephrologists recertify in core medicine, but the vast majority of cardiologists don't, if they recertify in cardiology,” he said. The latest ABIM figures show that only 21% of cardiologists are renewing their core internal medicine certificate.

Subspecialists may be shying away from core internal medicine because they don't find it relevant, or because they're concerned they won't be able to pass the general recertification exam without intensive work. Technically, these subspecialists are internists and should be recertifying in the core discipline, said Dr. Golden, a member of the Liaison Committee on Recertification, a panel that was formed several years ago to advise the board new pathways for recertification.

“Most members of the committee believe that good physicians are better diagnosticians if they understand key issues beyond their area of interest,” he said. The committee and ABIM “are actively trying to look at how recertification in core internal medicine reflects information that all internists should know, or is relevant to a subspecialty internist.”

Most internists, no matter what their discipline, choose to recertify. Since 1990, the year that the ABIM began issuing 10-year certificates, nearly 80% of general internists with a time-limited certificate have recertified in core internal medicine.

The new “maintenance of certification” program that the ABIM plans to roll out in January 2006 may further test the staying power of general internal medicine, which has been hit hard by declining match rates. The ABIM reports that 20% of physicians who certified in internal medicine after 1990 are no longer practicing in the field, Ms. Goode said.

Early estimates are encouraging: Nearly two-thirds of ABIM diplomates with 10-year certificates have enrolled in the new program. In April, the board announced more flexible options for maintenance of certification, hoping to encourage internists without time-limited certificates to participate.

The steps required for maintenance of certification “are useful and important,” but the process runs the risk of exacerbating the hassle factor, said Robert Hopkins, M.D., associate director of the medicine/pediatrics residency program at the University of Arkansas, Little Rock.

“Several of my colleagues in private practice—general internists and subspecialists—are concerned that the number of steps required for maintenance of certification [will] pose a major barrier to carrying out day-to-day patient care,” Dr. Hopkins said. The ABIM faces challenges in getting the message out to private practices about the value of recertification, he said.

Still, Dr. Golden expressed confidence in the new system. “In the past people have been anxious and uncertain about what it would mean,” he said, but they have become more comfortable as the process has become clearer.

As part of its revision of the certification process, the ABIM plans to make it simpler to renew certificates in internal medicine and the subspecialties of internal medicine.

Diplomates will be able to use their own data or data they receive from a valid outside source—such as a group practice or insurer—toward credit for self-evaluation of practice performance. Credit will be available for participating in a quality improvement program, such as through a hospital or medical group, that meets ABIM standards. The program will retain its basic requirements, such as holding a clean license and passing a secure exam of medical knowledge.

Some insurance companies may require maintenance of certification, and it may be a prerequisite for physician privileges at hospitals, Dr. Golden said. Also, “licensure boards are increasingly looking for mechanisms to verify that physicians maintain competency, and there's been some talk that recertification would serve as a proxy for documentation for relicensure.”

The internal medicine community is concerned about the number of subspecialists in internal medicine who are choosing to recertify in their specific fields rather than in core internal medicine.

Data from the American Board of Internal Medicine (ABIM) show that 87% of subspecialists are keeping their subspecialty certificate, but only 71% have renewed their certification in general or core internal medicine. Many of those in the latter group may be renewing in both core internal medicine and in their subspecialty, ABIM spokesman Leslie Goode said in an interview.

Interest in the general internal medicine certificate tends to vary by subspecialty, noted William E. Golden, M.D., an American College of Physicians regent, and professor of medicine and public health at the University of Arkansas, Little Rock, in an interview. For example, “60% of nephrologists recertify in core medicine, but the vast majority of cardiologists don't, if they recertify in cardiology,” he said. The latest ABIM figures show that only 21% of cardiologists are renewing their core internal medicine certificate.

Subspecialists may be shying away from core internal medicine because they don't find it relevant, or because they're concerned they won't be able to pass the general recertification exam without intensive work. Technically, these subspecialists are internists and should be recertifying in the core discipline, said Dr. Golden, a member of the Liaison Committee on Recertification, a panel that was formed several years ago to advise the board new pathways for recertification.

“Most members of the committee believe that good physicians are better diagnosticians if they understand key issues beyond their area of interest,” he said. The committee and ABIM “are actively trying to look at how recertification in core internal medicine reflects information that all internists should know, or is relevant to a subspecialty internist.”

Most internists, no matter what their discipline, choose to recertify. Since 1990, the year that the ABIM began issuing 10-year certificates, nearly 80% of general internists with a time-limited certificate have recertified in core internal medicine.

The new “maintenance of certification” program that the ABIM plans to roll out in January 2006 may further test the staying power of general internal medicine, which has been hit hard by declining match rates. The ABIM reports that 20% of physicians who certified in internal medicine after 1990 are no longer practicing in the field, Ms. Goode said.

Early estimates are encouraging: Nearly two-thirds of ABIM diplomates with 10-year certificates have enrolled in the new program. In April, the board announced more flexible options for maintenance of certification, hoping to encourage internists without time-limited certificates to participate.

The steps required for maintenance of certification “are useful and important,” but the process runs the risk of exacerbating the hassle factor, said Robert Hopkins, M.D., associate director of the medicine/pediatrics residency program at the University of Arkansas, Little Rock.

“Several of my colleagues in private practice—general internists and subspecialists—are concerned that the number of steps required for maintenance of certification [will] pose a major barrier to carrying out day-to-day patient care,” Dr. Hopkins said. The ABIM faces challenges in getting the message out to private practices about the value of recertification, he said.

Still, Dr. Golden expressed confidence in the new system. “In the past people have been anxious and uncertain about what it would mean,” he said, but they have become more comfortable as the process has become clearer.

As part of its revision of the certification process, the ABIM plans to make it simpler to renew certificates in internal medicine and the subspecialties of internal medicine.

Diplomates will be able to use their own data or data they receive from a valid outside source—such as a group practice or insurer—toward credit for self-evaluation of practice performance. Credit will be available for participating in a quality improvement program, such as through a hospital or medical group, that meets ABIM standards. The program will retain its basic requirements, such as holding a clean license and passing a secure exam of medical knowledge.

Some insurance companies may require maintenance of certification, and it may be a prerequisite for physician privileges at hospitals, Dr. Golden said. Also, “licensure boards are increasingly looking for mechanisms to verify that physicians maintain competency, and there's been some talk that recertification would serve as a proxy for documentation for relicensure.”

The internal medicine community is concerned about the number of subspecialists in internal medicine who are choosing to recertify in their specific fields rather than in core internal medicine.

Data from the American Board of Internal Medicine (ABIM) show that 87% of subspecialists are keeping their subspecialty certificate, but only 71% have renewed their certification in general or core internal medicine. Many of those in the latter group may be renewing in both core internal medicine and in their subspecialty, ABIM spokesman Leslie Goode said in an interview.

Interest in the general internal medicine certificate tends to vary by subspecialty, noted William E. Golden, M.D., an American College of Physicians regent, and professor of medicine and public health at the University of Arkansas, Little Rock, in an interview. For example, “60% of nephrologists recertify in core medicine, but the vast majority of cardiologists don't, if they recertify in cardiology,” he said. The latest ABIM figures show that only 21% of cardiologists are renewing their core internal medicine certificate.

Subspecialists may be shying away from core internal medicine because they don't find it relevant, or because they're concerned they won't be able to pass the general recertification exam without intensive work. Technically, these subspecialists are internists and should be recertifying in the core discipline, said Dr. Golden, a member of the Liaison Committee on Recertification, a panel that was formed several years ago to advise the board new pathways for recertification.

“Most members of the committee believe that good physicians are better diagnosticians if they understand key issues beyond their area of interest,” he said. The committee and ABIM “are actively trying to look at how recertification in core internal medicine reflects information that all internists should know, or is relevant to a subspecialty internist.”

Most internists, no matter what their discipline, choose to recertify. Since 1990, the year that the ABIM began issuing 10-year certificates, nearly 80% of general internists with a time-limited certificate have recertified in core internal medicine.

The new “maintenance of certification” program that the ABIM plans to roll out in January 2006 may further test the staying power of general internal medicine, which has been hit hard by declining match rates. The ABIM reports that 20% of physicians who certified in internal medicine after 1990 are no longer practicing in the field, Ms. Goode said.

Early estimates are encouraging: Nearly two-thirds of ABIM diplomates with 10-year certificates have enrolled in the new program. In April, the board announced more flexible options for maintenance of certification, hoping to encourage internists without time-limited certificates to participate.

The steps required for maintenance of certification “are useful and important,” but the process runs the risk of exacerbating the hassle factor, said Robert Hopkins, M.D., associate director of the medicine/pediatrics residency program at the University of Arkansas, Little Rock.

“Several of my colleagues in private practice—general internists and subspecialists—are concerned that the number of steps required for maintenance of certification [will] pose a major barrier to carrying out day-to-day patient care,” Dr. Hopkins said. The ABIM faces challenges in getting the message out to private practices about the value of recertification, he said.

Still, Dr. Golden expressed confidence in the new system. “In the past people have been anxious and uncertain about what it would mean,” he said, but they have become more comfortable as the process has become clearer.

As part of its revision of the certification process, the ABIM plans to make it simpler to renew certificates in internal medicine and the subspecialties of internal medicine.

Diplomates will be able to use their own data or data they receive from a valid outside source—such as a group practice or insurer—toward credit for self-evaluation of practice performance. Credit will be available for participating in a quality improvement program, such as through a hospital or medical group, that meets ABIM standards. The program will retain its basic requirements, such as holding a clean license and passing a secure exam of medical knowledge.

Some insurance companies may require maintenance of certification, and it may be a prerequisite for physician privileges at hospitals, Dr. Golden said. Also, “licensure boards are increasingly looking for mechanisms to verify that physicians maintain competency, and there's been some talk that recertification would serve as a proxy for documentation for relicensure.”

WASHINGTON — On-call emergency care dominated the agenda at the first meeting of the Department of Health and Human Services technical advisory group on the Emergency Medical Treatment and Labor Act.

EMTALA, enacted in 1986 to ensure public access to emergency services regardless of ability to pay, requires hospitals to maintain a list of physicians who are on call to the emergency department. Hospitals have the discretion to maintain these lists in a way that “best meets the needs” of the hospital's patients.

The Medicare Modernization Act of 2003 required HHS to establish a technical advisory group to review EMTALA regulation.

While the obligation to provide the on-call list falls on the hospital, physicians assume new liability and other obligations once they agree to take on-call responsibilities, Charlotte Yeh, M.D., an emergency physician and advisory group member, said in an interview.

Hospitals cannot force physicians to be on call, although individual hospital policies may require on-call services as a condition for having privileges, she said. “Factor in issues such as reimbursement, and the physician is asking himself: Why should I do this? And that's how physicians get into the EMTALA debate.”

Hospital groups who testified before the advisory group said their emergency care was suffering due to physicians' unwillingness to provide on-call services.

“It has become increasingly difficult for hospitals to manage their on-call rosters in a manner that best meets the needs of their patients because of their trouble filling on-call slots,” said Jeff Micklos, vice president and general counsel for the Federation of American Hospitals.

“Also, there no longer is any certainty that an on-call physician will report for duty when called,” he said. Physicians say that economic, medical practice, and lifestyle considerations affect their desire and ability to provide on-call coverage. As a result, they'll either refuse to be on call, or want to be paid ever-increasing fees, “which adds to EMTALA's practical effect as an unfunded mandate for hospitals,” Mr. Micklos said.

Physician-owned specialty hospitals, already a volatile issue, have exacerbated the on-call issue, said Mary Beth Savary Taylor, who spoke on behalf of the American Hospital Association. “Physicians who own limited-service hospitals often refuse to participate in emergency on-call duty at community hospitals, leaving them struggling to maintain [emergency department] specialty coverage.”

Hospitals are at a disadvantage, as they can be terminated from Medicare and Medicaid for any kind of noncompliance under EMTALA, whereas physicians are terminated only in cases where the violation is “gross, flagrant, and repeated,” Ms. Taylor said. To provide hospitals with some type of due process, the Centers for Medicare and Medicaid Services should revise its regulations to establish an administrator-level appeals process—before a CMS regional office issues a finding of noncompliance and public notice of termination, she said.

Leslie Norwalk, CMS deputy administrator, said that the agency could issue guidelines to hospitals on how they could protect themselves from lawsuits. “We'd like to help so courts will not punish [hospitals] for doing the right thing.”

Mr. Micklos asserted that the statute's obligations should apply equally to hospitals and physicians, noting that a hospital “can only can be as good as the physicians on its medical staff.”

EMTALA states that on-call coverage is a joint decision between hospital administrators and physicians who provide on-call coverage, said Jason W. Nascone, M.D., who testified on behalf of the American Association of Orthopaedic Surgeons and the Orthopaedic Trauma Association.

“But it is unrealistic to expect physicians to work together with hospitals in developing and implementing on-call plans if physicians aren't included as equal partners with more authority, oversight, and control in the development and implementation of these plans,” he said.

Interpretive guidelines developed to clarify hospitals' EMTALA responsibilities should be amended to further encourage true partnership arrangements between hospitals and physicians, Dr. Nascone said.

Physician groups urged CMS to adopt an affirmative rule prohibiting hospitals from requiring physicians to provide 24-7 emergency call coverage.

“We support the rule that physicians are not required to be on call at all times, but we fear that this provision doesn't go far enough to protect on-call physicians from nevertheless being required by hospitals to provide continuous emergency on-call coverage,” Alex B. Valadka, M.D., who spoke on behalf of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, testified.

Physicians also had concerns about a provision requiring response time to be stated in “minutes.” The advisory group should recommend modifications that such response times could be stated in a range of minutes, Dr. Valadka said. “Exceptions should be explicitly permitted in situations when the on-call physician cannot respond within the stated time frame because of circumstances beyond his or her control.”

The advisory group will be advising HHS and the administrator of the CMS on issues related to EMTALA. It includes hospital, physician, and patient representatives, in addition to CMS and state officials and one representative from a Quality Improvement Organization.

No recommendations were issued at the meeting. The advisory group decided to form a subcommittee that would address the large volume of concerns about on-call issues.

WASHINGTON — On-call emergency care dominated the agenda at the first meeting of the Department of Health and Human Services technical advisory group on the Emergency Medical Treatment and Labor Act.

EMTALA, enacted in 1986 to ensure public access to emergency services regardless of ability to pay, requires hospitals to maintain a list of physicians who are on call to the emergency department. Hospitals have the discretion to maintain these lists in a way that “best meets the needs” of the hospital's patients.

The Medicare Modernization Act of 2003 required HHS to establish a technical advisory group to review EMTALA regulation.

While the obligation to provide the on-call list falls on the hospital, physicians assume new liability and other obligations once they agree to take on-call responsibilities, Charlotte Yeh, M.D., an emergency physician and advisory group member, said in an interview.

Hospitals cannot force physicians to be on call, although individual hospital policies may require on-call services as a condition for having privileges, she said. “Factor in issues such as reimbursement, and the physician is asking himself: Why should I do this? And that's how physicians get into the EMTALA debate.”

Hospital groups who testified before the advisory group said their emergency care was suffering due to physicians' unwillingness to provide on-call services.

“It has become increasingly difficult for hospitals to manage their on-call rosters in a manner that best meets the needs of their patients because of their trouble filling on-call slots,” said Jeff Micklos, vice president and general counsel for the Federation of American Hospitals.

“Also, there no longer is any certainty that an on-call physician will report for duty when called,” he said. Physicians say that economic, medical practice, and lifestyle considerations affect their desire and ability to provide on-call coverage. As a result, they'll either refuse to be on call, or want to be paid ever-increasing fees, “which adds to EMTALA's practical effect as an unfunded mandate for hospitals,” Mr. Micklos said.

Physician-owned specialty hospitals, already a volatile issue, have exacerbated the on-call issue, said Mary Beth Savary Taylor, who spoke on behalf of the American Hospital Association. “Physicians who own limited-service hospitals often refuse to participate in emergency on-call duty at community hospitals, leaving them struggling to maintain [emergency department] specialty coverage.”

Hospitals are at a disadvantage, as they can be terminated from Medicare and Medicaid for any kind of noncompliance under EMTALA, whereas physicians are terminated only in cases where the violation is “gross, flagrant, and repeated,” Ms. Taylor said. To provide hospitals with some type of due process, the Centers for Medicare and Medicaid Services should revise its regulations to establish an administrator-level appeals process—before a CMS regional office issues a finding of noncompliance and public notice of termination, she said.

Leslie Norwalk, CMS deputy administrator, said that the agency could issue guidelines to hospitals on how they could protect themselves from lawsuits. “We'd like to help so courts will not punish [hospitals] for doing the right thing.”

Mr. Micklos asserted that the statute's obligations should apply equally to hospitals and physicians, noting that a hospital “can only can be as good as the physicians on its medical staff.”

EMTALA states that on-call coverage is a joint decision between hospital administrators and physicians who provide on-call coverage, said Jason W. Nascone, M.D., who testified on behalf of the American Association of Orthopaedic Surgeons and the Orthopaedic Trauma Association.

“But it is unrealistic to expect physicians to work together with hospitals in developing and implementing on-call plans if physicians aren't included as equal partners with more authority, oversight, and control in the development and implementation of these plans,” he said.

Interpretive guidelines developed to clarify hospitals' EMTALA responsibilities should be amended to further encourage true partnership arrangements between hospitals and physicians, Dr. Nascone said.

Physician groups urged CMS to adopt an affirmative rule prohibiting hospitals from requiring physicians to provide 24-7 emergency call coverage.

“We support the rule that physicians are not required to be on call at all times, but we fear that this provision doesn't go far enough to protect on-call physicians from nevertheless being required by hospitals to provide continuous emergency on-call coverage,” Alex B. Valadka, M.D., who spoke on behalf of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, testified.

Physicians also had concerns about a provision requiring response time to be stated in “minutes.” The advisory group should recommend modifications that such response times could be stated in a range of minutes, Dr. Valadka said. “Exceptions should be explicitly permitted in situations when the on-call physician cannot respond within the stated time frame because of circumstances beyond his or her control.”

The advisory group will be advising HHS and the administrator of the CMS on issues related to EMTALA. It includes hospital, physician, and patient representatives, in addition to CMS and state officials and one representative from a Quality Improvement Organization.

No recommendations were issued at the meeting. The advisory group decided to form a subcommittee that would address the large volume of concerns about on-call issues.

WASHINGTON — On-call emergency care dominated the agenda at the first meeting of the Department of Health and Human Services technical advisory group on the Emergency Medical Treatment and Labor Act.

EMTALA, enacted in 1986 to ensure public access to emergency services regardless of ability to pay, requires hospitals to maintain a list of physicians who are on call to the emergency department. Hospitals have the discretion to maintain these lists in a way that “best meets the needs” of the hospital's patients.

The Medicare Modernization Act of 2003 required HHS to establish a technical advisory group to review EMTALA regulation.

While the obligation to provide the on-call list falls on the hospital, physicians assume new liability and other obligations once they agree to take on-call responsibilities, Charlotte Yeh, M.D., an emergency physician and advisory group member, said in an interview.

Hospitals cannot force physicians to be on call, although individual hospital policies may require on-call services as a condition for having privileges, she said. “Factor in issues such as reimbursement, and the physician is asking himself: Why should I do this? And that's how physicians get into the EMTALA debate.”

Hospital groups who testified before the advisory group said their emergency care was suffering due to physicians' unwillingness to provide on-call services.

“It has become increasingly difficult for hospitals to manage their on-call rosters in a manner that best meets the needs of their patients because of their trouble filling on-call slots,” said Jeff Micklos, vice president and general counsel for the Federation of American Hospitals.

“Also, there no longer is any certainty that an on-call physician will report for duty when called,” he said. Physicians say that economic, medical practice, and lifestyle considerations affect their desire and ability to provide on-call coverage. As a result, they'll either refuse to be on call, or want to be paid ever-increasing fees, “which adds to EMTALA's practical effect as an unfunded mandate for hospitals,” Mr. Micklos said.

Physician-owned specialty hospitals, already a volatile issue, have exacerbated the on-call issue, said Mary Beth Savary Taylor, who spoke on behalf of the American Hospital Association. “Physicians who own limited-service hospitals often refuse to participate in emergency on-call duty at community hospitals, leaving them struggling to maintain [emergency department] specialty coverage.”

Hospitals are at a disadvantage, as they can be terminated from Medicare and Medicaid for any kind of noncompliance under EMTALA, whereas physicians are terminated only in cases where the violation is “gross, flagrant, and repeated,” Ms. Taylor said. To provide hospitals with some type of due process, the Centers for Medicare and Medicaid Services should revise its regulations to establish an administrator-level appeals process—before a CMS regional office issues a finding of noncompliance and public notice of termination, she said.

Leslie Norwalk, CMS deputy administrator, said that the agency could issue guidelines to hospitals on how they could protect themselves from lawsuits. “We'd like to help so courts will not punish [hospitals] for doing the right thing.”

Mr. Micklos asserted that the statute's obligations should apply equally to hospitals and physicians, noting that a hospital “can only can be as good as the physicians on its medical staff.”

EMTALA states that on-call coverage is a joint decision between hospital administrators and physicians who provide on-call coverage, said Jason W. Nascone, M.D., who testified on behalf of the American Association of Orthopaedic Surgeons and the Orthopaedic Trauma Association.

“But it is unrealistic to expect physicians to work together with hospitals in developing and implementing on-call plans if physicians aren't included as equal partners with more authority, oversight, and control in the development and implementation of these plans,” he said.

Interpretive guidelines developed to clarify hospitals' EMTALA responsibilities should be amended to further encourage true partnership arrangements between hospitals and physicians, Dr. Nascone said.

Physician groups urged CMS to adopt an affirmative rule prohibiting hospitals from requiring physicians to provide 24-7 emergency call coverage.

“We support the rule that physicians are not required to be on call at all times, but we fear that this provision doesn't go far enough to protect on-call physicians from nevertheless being required by hospitals to provide continuous emergency on-call coverage,” Alex B. Valadka, M.D., who spoke on behalf of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, testified.

Physicians also had concerns about a provision requiring response time to be stated in “minutes.” The advisory group should recommend modifications that such response times could be stated in a range of minutes, Dr. Valadka said. “Exceptions should be explicitly permitted in situations when the on-call physician cannot respond within the stated time frame because of circumstances beyond his or her control.”

The advisory group will be advising HHS and the administrator of the CMS on issues related to EMTALA. It includes hospital, physician, and patient representatives, in addition to CMS and state officials and one representative from a Quality Improvement Organization.

No recommendations were issued at the meeting. The advisory group decided to form a subcommittee that would address the large volume of concerns about on-call issues.

Risks of Losing Insurance

For parents, losing employer-based health insurance means their children could be uninsured for long periods of time, the American Academy of Pediatrics reports. Among an estimated 3 million children whose parents lose employer-based insurance annually, 75% subsequently become uninsured, and almost a million remain uninsured for a year or longer. Theoretically, families have options when this happens, such as COBRA, individually purchased private insurance, or enrollment in Medicaid or the State Children's Health Insurance Program (SCHIP). “But the reality is that COBRA and private coverage are mostly unaffordable to low- and moderate-income families,” and parents may not know about Medicaid and SCHIP or face enrollment barriers, such as cumbersome applications and waiting periods, according to the AAP. Among those children who become uninsured, only 1 in 8 will enroll in public programs, whereas 1 in 30 will obtain nonemployer-based private coverage. The results were based on more than 18,000 records of children obtained from Medical Expenditure Panel Survey data, from 1996 to 2001.

Data on Children's Hospitals

Hospitalizations at children's hospitals account for only one-third of pediatric inpatients. Examining data from the 2000 Healthcare Cost and Utilization Project Kids' Inpatient Database, Richard Wasserman, M.D., and a team of researchers found that almost 65% of hospitalizations for children ages 1–17 years were to nonchildren's hospitals. More than 5% of these hospitalizations were for a mental health condition. When compared to discharges in children's hospitals, significantly more discharges in nonchildren's hospitals were for 15- to 17-year-old females, patients from low-income zip codes, and uninsured patients.

“While our results do not assess quality of care, we hypothesize that nonchildren's hospitals may be underresourced in pediatric expertise while providing an excess of care for the poor and for mental health conditions,” said Dr. Wasserman, a professor of pediatrics at the University of Vermont.

Foster Care, Fewer Meds

Children in foster homes often lack medications for chronic conditions, Heather Forkey, M.D., and her colleagues at the University of Massachusetts report. By looking at health care data on 75 foster children, they found that more than 80% went into foster care needing prescription medication for a chronic illness, but did not have access to the required medication. For example, 79% didn't have asthma medications, and 90% did not have eczema medications, even though the medications were prescribed. “The numbers we came up with, albeit from a small sample, were dramatic,” said Dr. Forkey at the annual meeting of the Pediatric Academic Societies. “In particular, foster children may not receive needed medications even after placement in a new foster home because medication history is often difficult for foster parents and primary care physicians to obtain.”

Vaccine Underinsurance

Just because you have insurance doesn't mean you're covered for immunizations, a survey of 995 Americans conducted by researchers at the University of Michigan at Ann Arbor, indicated. As many as 5 million privately insured children and 36 million privately insured adults are not covered for immunizations, a factor that may contribute to low immunization rates. “Over the past few years, newly approved vaccines have been increasingly expensive, so insurance plans have been less likely to cover them,” said lead author Matthew Davis. “This means that new vaccines of the future may be available to many people only if they can pay out of pocket.”

Depression and Marijuana Use

The evidence for a link between marijuana use and depression is getting stronger, according to the White House Office of National Drug Control Policy. The office's National Survey on Drug Use and Health shows that, among persons aged 18 years or older, those who first used marijuana before age 12 years were twice as likely to have serious mental illness in the past year as those who first used marijuana at age 18 or older. “There certainly are people who self-medicate, but the danger we're talking about is the growing evidence that use itself may be triggering and may be worsening the onset of mental health problems,” ONDCP director John P. Walters said at a Washington press conference. “Now, would some of those people have mental health problems anyway? That's entirely possible. But it's also entirely possible that some of these people may not subsequently show these mental health problems, and the evidence suggests that the use of marijuana may trigger the onset of problems that would not otherwise be there.”

Risks of Losing Insurance

For parents, losing employer-based health insurance means their children could be uninsured for long periods of time, the American Academy of Pediatrics reports. Among an estimated 3 million children whose parents lose employer-based insurance annually, 75% subsequently become uninsured, and almost a million remain uninsured for a year or longer. Theoretically, families have options when this happens, such as COBRA, individually purchased private insurance, or enrollment in Medicaid or the State Children's Health Insurance Program (SCHIP). “But the reality is that COBRA and private coverage are mostly unaffordable to low- and moderate-income families,” and parents may not know about Medicaid and SCHIP or face enrollment barriers, such as cumbersome applications and waiting periods, according to the AAP. Among those children who become uninsured, only 1 in 8 will enroll in public programs, whereas 1 in 30 will obtain nonemployer-based private coverage. The results were based on more than 18,000 records of children obtained from Medical Expenditure Panel Survey data, from 1996 to 2001.

Data on Children's Hospitals

Hospitalizations at children's hospitals account for only one-third of pediatric inpatients. Examining data from the 2000 Healthcare Cost and Utilization Project Kids' Inpatient Database, Richard Wasserman, M.D., and a team of researchers found that almost 65% of hospitalizations for children ages 1–17 years were to nonchildren's hospitals. More than 5% of these hospitalizations were for a mental health condition. When compared to discharges in children's hospitals, significantly more discharges in nonchildren's hospitals were for 15- to 17-year-old females, patients from low-income zip codes, and uninsured patients.

“While our results do not assess quality of care, we hypothesize that nonchildren's hospitals may be underresourced in pediatric expertise while providing an excess of care for the poor and for mental health conditions,” said Dr. Wasserman, a professor of pediatrics at the University of Vermont.

Foster Care, Fewer Meds

Children in foster homes often lack medications for chronic conditions, Heather Forkey, M.D., and her colleagues at the University of Massachusetts report. By looking at health care data on 75 foster children, they found that more than 80% went into foster care needing prescription medication for a chronic illness, but did not have access to the required medication. For example, 79% didn't have asthma medications, and 90% did not have eczema medications, even though the medications were prescribed. “The numbers we came up with, albeit from a small sample, were dramatic,” said Dr. Forkey at the annual meeting of the Pediatric Academic Societies. “In particular, foster children may not receive needed medications even after placement in a new foster home because medication history is often difficult for foster parents and primary care physicians to obtain.”

Vaccine Underinsurance

Just because you have insurance doesn't mean you're covered for immunizations, a survey of 995 Americans conducted by researchers at the University of Michigan at Ann Arbor, indicated. As many as 5 million privately insured children and 36 million privately insured adults are not covered for immunizations, a factor that may contribute to low immunization rates. “Over the past few years, newly approved vaccines have been increasingly expensive, so insurance plans have been less likely to cover them,” said lead author Matthew Davis. “This means that new vaccines of the future may be available to many people only if they can pay out of pocket.”

Depression and Marijuana Use

The evidence for a link between marijuana use and depression is getting stronger, according to the White House Office of National Drug Control Policy. The office's National Survey on Drug Use and Health shows that, among persons aged 18 years or older, those who first used marijuana before age 12 years were twice as likely to have serious mental illness in the past year as those who first used marijuana at age 18 or older. “There certainly are people who self-medicate, but the danger we're talking about is the growing evidence that use itself may be triggering and may be worsening the onset of mental health problems,” ONDCP director John P. Walters said at a Washington press conference. “Now, would some of those people have mental health problems anyway? That's entirely possible. But it's also entirely possible that some of these people may not subsequently show these mental health problems, and the evidence suggests that the use of marijuana may trigger the onset of problems that would not otherwise be there.”

Risks of Losing Insurance

For parents, losing employer-based health insurance means their children could be uninsured for long periods of time, the American Academy of Pediatrics reports. Among an estimated 3 million children whose parents lose employer-based insurance annually, 75% subsequently become uninsured, and almost a million remain uninsured for a year or longer. Theoretically, families have options when this happens, such as COBRA, individually purchased private insurance, or enrollment in Medicaid or the State Children's Health Insurance Program (SCHIP). “But the reality is that COBRA and private coverage are mostly unaffordable to low- and moderate-income families,” and parents may not know about Medicaid and SCHIP or face enrollment barriers, such as cumbersome applications and waiting periods, according to the AAP. Among those children who become uninsured, only 1 in 8 will enroll in public programs, whereas 1 in 30 will obtain nonemployer-based private coverage. The results were based on more than 18,000 records of children obtained from Medical Expenditure Panel Survey data, from 1996 to 2001.

Data on Children's Hospitals

Hospitalizations at children's hospitals account for only one-third of pediatric inpatients. Examining data from the 2000 Healthcare Cost and Utilization Project Kids' Inpatient Database, Richard Wasserman, M.D., and a team of researchers found that almost 65% of hospitalizations for children ages 1–17 years were to nonchildren's hospitals. More than 5% of these hospitalizations were for a mental health condition. When compared to discharges in children's hospitals, significantly more discharges in nonchildren's hospitals were for 15- to 17-year-old females, patients from low-income zip codes, and uninsured patients.

“While our results do not assess quality of care, we hypothesize that nonchildren's hospitals may be underresourced in pediatric expertise while providing an excess of care for the poor and for mental health conditions,” said Dr. Wasserman, a professor of pediatrics at the University of Vermont.

Foster Care, Fewer Meds

Children in foster homes often lack medications for chronic conditions, Heather Forkey, M.D., and her colleagues at the University of Massachusetts report. By looking at health care data on 75 foster children, they found that more than 80% went into foster care needing prescription medication for a chronic illness, but did not have access to the required medication. For example, 79% didn't have asthma medications, and 90% did not have eczema medications, even though the medications were prescribed. “The numbers we came up with, albeit from a small sample, were dramatic,” said Dr. Forkey at the annual meeting of the Pediatric Academic Societies. “In particular, foster children may not receive needed medications even after placement in a new foster home because medication history is often difficult for foster parents and primary care physicians to obtain.”

Vaccine Underinsurance

Just because you have insurance doesn't mean you're covered for immunizations, a survey of 995 Americans conducted by researchers at the University of Michigan at Ann Arbor, indicated. As many as 5 million privately insured children and 36 million privately insured adults are not covered for immunizations, a factor that may contribute to low immunization rates. “Over the past few years, newly approved vaccines have been increasingly expensive, so insurance plans have been less likely to cover them,” said lead author Matthew Davis. “This means that new vaccines of the future may be available to many people only if they can pay out of pocket.”

Depression and Marijuana Use

The evidence for a link between marijuana use and depression is getting stronger, according to the White House Office of National Drug Control Policy. The office's National Survey on Drug Use and Health shows that, among persons aged 18 years or older, those who first used marijuana before age 12 years were twice as likely to have serious mental illness in the past year as those who first used marijuana at age 18 or older. “There certainly are people who self-medicate, but the danger we're talking about is the growing evidence that use itself may be triggering and may be worsening the onset of mental health problems,” ONDCP director John P. Walters said at a Washington press conference. “Now, would some of those people have mental health problems anyway? That's entirely possible. But it's also entirely possible that some of these people may not subsequently show these mental health problems, and the evidence suggests that the use of marijuana may trigger the onset of problems that would not otherwise be there.”

SAN FRANCISCO — There is a cost-effective way to go paperless and make a profit for your group medical practice, Jeffrey P. Friedman, M.D., said at the annual meeting of the American College of Physicians.

Dr. Friedman, an internist and founding partner of Murray Hill Medical Group in New York, increased office appointments—and saved $238,000 annually in staff pay and benefits—by installing an electronic medical record (EMR) system and integrating the new technology on a gradual basis, cutting down on staff and phone time.

Patient registrations grew rapidly (currently at 18,000), and salaries for the group's physicians in 2004 were two to three times as high as the national average, Dr. Friedman said.

Murray Hill Medical Group started out in 1992 with just a few partners and associates, one exam room for each physician, and no ancillary help. The practice utilized a local, small electronic billing package. Over the years, the Murray Hill filled its space, adding more partners, associates, and equipment, and in 1998 acquired an EMR system. The practice added online bill paying this year.

The practice now has 35 doctors, an office lab, and a technician who oversees the fully automated practice. “Our employee/doctor ratio is very low,” Dr. Friedman said.

Installing an EMR system does cost money, “but a major thing physicians need to understand is that you have to spend money to make money,” Dr. Friedman said. In his experience, “those bucks are not out of control” if invested in the right kind of system.

When considering software vendors, it's important to visit practice sites that are using installed systems. He suggested that physicians look at big vendors that are likely to be in business at least 10 to 20 years down the road. “This is a big investment, because whatever one you buy you're going to live with for a long time,” he noted. The problem with medical records is that if you decide to dump one, “you can't convert the data from one system to another.”

In conducting research with vendors, Dr. Friedman got a general idea of what it would cost to install an EMR system, “including the whistles and bells.” The per-doctor cost was $30,000–$50,000, including training.

“A lot of people spend that much on a car every few years,” he observed.

Training should ideally take place during the slow season, from the end of June through early September.

Murray Hill physicians went through 3 months of formal training during such a period.

The practice hired university and medical students to preload diagnoses, medicines, and vaccines into the new EMR system.

Physicians won't be able to get everything into the record, “but you'll find that over the years the important stuff's there,” Dr. Friedman said.

Conversion to an EMR system should take place gradually, he cautioned. A staff of two physicians, for example, should take turns going online.

“You should have cross coverage so physicians are not out seeing patients while they learn how to use system,” he advised.

Dr. Friedman added that it's crucial to practice with the software before going live with the system. Within 1 to 2 weeks, Murray Hill's physicians had learned the system and regained their usual level of efficiency. Many become even more efficient after going online, Dr. Friedman noted.

In addition to handling appointment scheduling (see box), the system helps automate prescription refills.

“The patient does it, the doctor signs it. When it's electronic, it's done,” Dr. Friedman said. With a few clicks and a printout, a physician can quickly take care of a Medicare patient on 12 different prescriptions that need to be shipped to several locations.

Physicians using an EMR can check drug interactions when looking at their patients' prescriptions. In addition, online preventive notices can remind physicians of what needs to be done for each patient. “And any work you do provides income,” he said.

An EMR also can point out errors in coding. “A lot of times, we find out that the doctor has been undercoding. It's not fair to give back to carriers and the government. That's a lot of lost income,” Dr. Friedman said.

“It continues to amaze me that 90% of physicians are not” paperless, he said. People traveling on planes “would never put up with a pilot navigating by the stars.”

No-Show Rate Plummets When Patients Go Online

Patients favor online systems that provide a 24/7 service for appointments. “By integrating with the Internet, you get patients to do things for themselves without staff,” Dr. Friedman said.

His practice, Murray Hill Medical Group, developed its own software so that patients could sign in online, make their own appointments, refills, or referrals, or pick a physician or location. Dr. Friedman is now marketing the software for use by physicians who use compatible electronic medical record systems.

Patients get a tracking number plus three e-mail reminders about their visits. For annual exams, the e-mail will remind them not to eat or drink for 8 hours prior to the visit.

If it's a Sunday night, a patient who has forgotten the time of a Monday appointment can look up the visit online instead of becoming a “no show,” he said. The practice estimates that 35%–45% of all of its appointments are made online, and the no-show rate with Internet appointments is less than 1%.

Murray Hill Medical Group has open-access scheduling, so most appointments are scheduled within 24 hours. “We always add on more hours. Patients can always get in because that's how we make a living. We're not going to make them wait 3 weeks.” The electronic system makes it easy to fill up slots when patients drop out of appointments.

Physicians have long struggled with patients having online access to their practice, Dr. Friedman said. “They have a problem with letting patients see their open schedule slots.” In addition, “they think patients are too dumb, they'll abuse the system, [or] they don't know what they're doing.”

But patients are smarter than you think, he said. Of Murray Hill's patients, 95% have Internet access, and other data point to widespread access to online services. A 2003 Harris Interactive poll found that 80% of all patients use the Internet to search for information.

SAN FRANCISCO — There is a cost-effective way to go paperless and make a profit for your group medical practice, Jeffrey P. Friedman, M.D., said at the annual meeting of the American College of Physicians.

Dr. Friedman, an internist and founding partner of Murray Hill Medical Group in New York, increased office appointments—and saved $238,000 annually in staff pay and benefits—by installing an electronic medical record (EMR) system and integrating the new technology on a gradual basis, cutting down on staff and phone time.

Patient registrations grew rapidly (currently at 18,000), and salaries for the group's physicians in 2004 were two to three times as high as the national average, Dr. Friedman said.

Murray Hill Medical Group started out in 1992 with just a few partners and associates, one exam room for each physician, and no ancillary help. The practice utilized a local, small electronic billing package. Over the years, the Murray Hill filled its space, adding more partners, associates, and equipment, and in 1998 acquired an EMR system. The practice added online bill paying this year.

The practice now has 35 doctors, an office lab, and a technician who oversees the fully automated practice. “Our employee/doctor ratio is very low,” Dr. Friedman said.

Installing an EMR system does cost money, “but a major thing physicians need to understand is that you have to spend money to make money,” Dr. Friedman said. In his experience, “those bucks are not out of control” if invested in the right kind of system.

When considering software vendors, it's important to visit practice sites that are using installed systems. He suggested that physicians look at big vendors that are likely to be in business at least 10 to 20 years down the road. “This is a big investment, because whatever one you buy you're going to live with for a long time,” he noted. The problem with medical records is that if you decide to dump one, “you can't convert the data from one system to another.”

In conducting research with vendors, Dr. Friedman got a general idea of what it would cost to install an EMR system, “including the whistles and bells.” The per-doctor cost was $30,000–$50,000, including training.

“A lot of people spend that much on a car every few years,” he observed.

Training should ideally take place during the slow season, from the end of June through early September.

Murray Hill physicians went through 3 months of formal training during such a period.

The practice hired university and medical students to preload diagnoses, medicines, and vaccines into the new EMR system.

Physicians won't be able to get everything into the record, “but you'll find that over the years the important stuff's there,” Dr. Friedman said.

Conversion to an EMR system should take place gradually, he cautioned. A staff of two physicians, for example, should take turns going online.

“You should have cross coverage so physicians are not out seeing patients while they learn how to use system,” he advised.

Dr. Friedman added that it's crucial to practice with the software before going live with the system. Within 1 to 2 weeks, Murray Hill's physicians had learned the system and regained their usual level of efficiency. Many become even more efficient after going online, Dr. Friedman noted.

In addition to handling appointment scheduling (see box), the system helps automate prescription refills.

“The patient does it, the doctor signs it. When it's electronic, it's done,” Dr. Friedman said. With a few clicks and a printout, a physician can quickly take care of a Medicare patient on 12 different prescriptions that need to be shipped to several locations.

Physicians using an EMR can check drug interactions when looking at their patients' prescriptions. In addition, online preventive notices can remind physicians of what needs to be done for each patient. “And any work you do provides income,” he said.

An EMR also can point out errors in coding. “A lot of times, we find out that the doctor has been undercoding. It's not fair to give back to carriers and the government. That's a lot of lost income,” Dr. Friedman said.

“It continues to amaze me that 90% of physicians are not” paperless, he said. People traveling on planes “would never put up with a pilot navigating by the stars.”

No-Show Rate Plummets When Patients Go Online

Patients favor online systems that provide a 24/7 service for appointments. “By integrating with the Internet, you get patients to do things for themselves without staff,” Dr. Friedman said.

His practice, Murray Hill Medical Group, developed its own software so that patients could sign in online, make their own appointments, refills, or referrals, or pick a physician or location. Dr. Friedman is now marketing the software for use by physicians who use compatible electronic medical record systems.

Patients get a tracking number plus three e-mail reminders about their visits. For annual exams, the e-mail will remind them not to eat or drink for 8 hours prior to the visit.

If it's a Sunday night, a patient who has forgotten the time of a Monday appointment can look up the visit online instead of becoming a “no show,” he said. The practice estimates that 35%–45% of all of its appointments are made online, and the no-show rate with Internet appointments is less than 1%.

Murray Hill Medical Group has open-access scheduling, so most appointments are scheduled within 24 hours. “We always add on more hours. Patients can always get in because that's how we make a living. We're not going to make them wait 3 weeks.” The electronic system makes it easy to fill up slots when patients drop out of appointments.

Physicians have long struggled with patients having online access to their practice, Dr. Friedman said. “They have a problem with letting patients see their open schedule slots.” In addition, “they think patients are too dumb, they'll abuse the system, [or] they don't know what they're doing.”

But patients are smarter than you think, he said. Of Murray Hill's patients, 95% have Internet access, and other data point to widespread access to online services. A 2003 Harris Interactive poll found that 80% of all patients use the Internet to search for information.

SAN FRANCISCO — There is a cost-effective way to go paperless and make a profit for your group medical practice, Jeffrey P. Friedman, M.D., said at the annual meeting of the American College of Physicians.

Dr. Friedman, an internist and founding partner of Murray Hill Medical Group in New York, increased office appointments—and saved $238,000 annually in staff pay and benefits—by installing an electronic medical record (EMR) system and integrating the new technology on a gradual basis, cutting down on staff and phone time.

Patient registrations grew rapidly (currently at 18,000), and salaries for the group's physicians in 2004 were two to three times as high as the national average, Dr. Friedman said.

Murray Hill Medical Group started out in 1992 with just a few partners and associates, one exam room for each physician, and no ancillary help. The practice utilized a local, small electronic billing package. Over the years, the Murray Hill filled its space, adding more partners, associates, and equipment, and in 1998 acquired an EMR system. The practice added online bill paying this year.

The practice now has 35 doctors, an office lab, and a technician who oversees the fully automated practice. “Our employee/doctor ratio is very low,” Dr. Friedman said.

Installing an EMR system does cost money, “but a major thing physicians need to understand is that you have to spend money to make money,” Dr. Friedman said. In his experience, “those bucks are not out of control” if invested in the right kind of system.

When considering software vendors, it's important to visit practice sites that are using installed systems. He suggested that physicians look at big vendors that are likely to be in business at least 10 to 20 years down the road. “This is a big investment, because whatever one you buy you're going to live with for a long time,” he noted. The problem with medical records is that if you decide to dump one, “you can't convert the data from one system to another.”

In conducting research with vendors, Dr. Friedman got a general idea of what it would cost to install an EMR system, “including the whistles and bells.” The per-doctor cost was $30,000–$50,000, including training.

“A lot of people spend that much on a car every few years,” he observed.

Training should ideally take place during the slow season, from the end of June through early September.

Murray Hill physicians went through 3 months of formal training during such a period.

The practice hired university and medical students to preload diagnoses, medicines, and vaccines into the new EMR system.

Physicians won't be able to get everything into the record, “but you'll find that over the years the important stuff's there,” Dr. Friedman said.

Conversion to an EMR system should take place gradually, he cautioned. A staff of two physicians, for example, should take turns going online.

“You should have cross coverage so physicians are not out seeing patients while they learn how to use system,” he advised.

Dr. Friedman added that it's crucial to practice with the software before going live with the system. Within 1 to 2 weeks, Murray Hill's physicians had learned the system and regained their usual level of efficiency. Many become even more efficient after going online, Dr. Friedman noted.

In addition to handling appointment scheduling (see box), the system helps automate prescription refills.

“The patient does it, the doctor signs it. When it's electronic, it's done,” Dr. Friedman said. With a few clicks and a printout, a physician can quickly take care of a Medicare patient on 12 different prescriptions that need to be shipped to several locations.

Physicians using an EMR can check drug interactions when looking at their patients' prescriptions. In addition, online preventive notices can remind physicians of what needs to be done for each patient. “And any work you do provides income,” he said.

An EMR also can point out errors in coding. “A lot of times, we find out that the doctor has been undercoding. It's not fair to give back to carriers and the government. That's a lot of lost income,” Dr. Friedman said.

“It continues to amaze me that 90% of physicians are not” paperless, he said. People traveling on planes “would never put up with a pilot navigating by the stars.”

No-Show Rate Plummets When Patients Go Online

Patients favor online systems that provide a 24/7 service for appointments. “By integrating with the Internet, you get patients to do things for themselves without staff,” Dr. Friedman said.

His practice, Murray Hill Medical Group, developed its own software so that patients could sign in online, make their own appointments, refills, or referrals, or pick a physician or location. Dr. Friedman is now marketing the software for use by physicians who use compatible electronic medical record systems.

Patients get a tracking number plus three e-mail reminders about their visits. For annual exams, the e-mail will remind them not to eat or drink for 8 hours prior to the visit.

If it's a Sunday night, a patient who has forgotten the time of a Monday appointment can look up the visit online instead of becoming a “no show,” he said. The practice estimates that 35%–45% of all of its appointments are made online, and the no-show rate with Internet appointments is less than 1%.

Murray Hill Medical Group has open-access scheduling, so most appointments are scheduled within 24 hours. “We always add on more hours. Patients can always get in because that's how we make a living. We're not going to make them wait 3 weeks.” The electronic system makes it easy to fill up slots when patients drop out of appointments.

Physicians have long struggled with patients having online access to their practice, Dr. Friedman said. “They have a problem with letting patients see their open schedule slots.” In addition, “they think patients are too dumb, they'll abuse the system, [or] they don't know what they're doing.”

But patients are smarter than you think, he said. Of Murray Hill's patients, 95% have Internet access, and other data point to widespread access to online services. A 2003 Harris Interactive poll found that 80% of all patients use the Internet to search for information.

Ads Influence Prescribing

Direct-to-consumer advertisements appear to have an impact on physician prescribing practices, a study by Richard L. Kravitz, M.D., of the University of California, Davis, found (JAMA 2005;293:1995–2002).

A total of 152 family physicians and general internists were recruited from solo and group practices and health maintenance organizations to participate in the study, which focused on advertising for prescription antidepressants.

Standardized patients were randomly assigned to make 298 unannounced visits, presenting either with major depression or adjustment disorder with depressed mood. When the patients with depression made a general request for an antidepressant, only 3% of the physicians prescribed paroxetine (Paxil). However, when they asked for the prescription by name, 27% were given a prescription for Paxil.

And patients with adjustment disorder symptoms were more likely to receive a prescription for an antidepressant if they made a brand specific request (55%) versus a general request (39%).

E-Prescribing Standards

Medicare should adopt a program-wide system of uniform national electronic prescribing standards for its new prescription drug benefit, according to the Pharmaceutical Care Management Association (PCMA). A uniform national standard is key to maximizing the participation of private plans in the Part D benefit and in helping to reduce regional variations in health care delivery and outcomes, PCMA said in comments to the Centers for Medicare and Medicaid Services on its proposed rule for Medicare e-prescribing standards.

“PCMA believes that Medicare e-prescribing holds the potential to transform the health care delivery system,” PCMA President Mark Merritt said in a statement. “Regrettably, a 50-state patchwork approach would increase costs, decrease efficiency, and severely undermine the promise of e-prescribing.” The organization also urged CMS officials to pre-empt duplicative and conflicting state laws that could increase costs.

CMS: Pay for Performance Works

Preliminary data indicate that pay-for-performance is improving quality of care in hospitals. A 3-year demonstration project sponsored by the Centers for Medicare and Medicaid Services is tracking hospital performance on a set of 34 measures of processes and outcomes of care for five common clinical conditions.

Reports from more than 270 participating hospitals on their experiences during the project's first year show that median quality scores improved in all of the clinical areas. For example, scores increased from 90% to 93% for patients with acute myocardial infarction; from 64% to 76% for patients with heart failure; and from 70% to 80% for patients with pneumonia.

These early returns demonstrate that using financial incentives works to deliver better patient care and to avoid costly complications for patients, said CMS Administrator Mark B. McClellan, M.D.

New Medicare Wheelchair Policy

Ability to function is the primary criteria in the CMS's new national coverage policy for power wheelchairs and scooters. The criteria look at how well the beneficiary can accomplish activities of daily living such as toileting, grooming, and eating with and without using a wheelchair or other mobility device. The criteria are “part of our efforts to ensure that seniors who need mobility help will get it promptly, and that we are paying appropriately for mobility assistive equipment,” Dr. McClellan said in a statement.

The coverage policy is one element in Medicare's year-old effort to improve the coverage, payment, and quality of suppliers for wheelchairs and scooters. That effort was launched after Medicare spending on mobility equipment rose to $1.2 billion annually.

Uninsured Rates Among the States

Minnesota has the lowest uninsured rate among employed adults (7%), followed by Hawaii, the District of Columbia, and Delaware, each with uninsured rates of 9%. The states with the highest rates of uninsured residents include Texas (27%), New Mexico (23%), and Florida (22%). The report was conducted by the Robert Wood Johnson Foundation, which analyzed 2003 data from the Centers for Disease Control and Prevention.

While some states fare better than others, the problem is pervasive among workers in every state. More than 20 million working adults do not have health insurance. In eight states, at least 1 in 5 working adults is uninsured, and in 39 other states at least 1 working adult in every 10 does not have health coverage.

Unhealthy Habits

Very few Americans are doing all they can to maintain a healthy life, according to a nationally representative survey of 153,805 adults (Arch. Intern. Med. 2005;165:854–7).

Mathew Reeves, Ph.D., of Michigan State University, East Lansing, found that only 3% followed four steps that define a healthy lifestyle: not smoking, holding weight down, eating adequate amounts of fruits and vegetables, and exercising. Women tended to follow these steps more than men, as did whites compared with minority populations. But no one group came close to what is necessary to lead a healthy life, Dr. Reeves said.

When assessed individually, these health statistics didn't look as grim: Seventy-six percent of the respondents said they didn't smoke, 23% included at least five fruits and vegetables in their diets, and 40% maintained a healthy weight.

Ads Influence Prescribing

Direct-to-consumer advertisements appear to have an impact on physician prescribing practices, a study by Richard L. Kravitz, M.D., of the University of California, Davis, found (JAMA 2005;293:1995–2002).

A total of 152 family physicians and general internists were recruited from solo and group practices and health maintenance organizations to participate in the study, which focused on advertising for prescription antidepressants.

Standardized patients were randomly assigned to make 298 unannounced visits, presenting either with major depression or adjustment disorder with depressed mood. When the patients with depression made a general request for an antidepressant, only 3% of the physicians prescribed paroxetine (Paxil). However, when they asked for the prescription by name, 27% were given a prescription for Paxil.

And patients with adjustment disorder symptoms were more likely to receive a prescription for an antidepressant if they made a brand specific request (55%) versus a general request (39%).

E-Prescribing Standards

Medicare should adopt a program-wide system of uniform national electronic prescribing standards for its new prescription drug benefit, according to the Pharmaceutical Care Management Association (PCMA). A uniform national standard is key to maximizing the participation of private plans in the Part D benefit and in helping to reduce regional variations in health care delivery and outcomes, PCMA said in comments to the Centers for Medicare and Medicaid Services on its proposed rule for Medicare e-prescribing standards.

“PCMA believes that Medicare e-prescribing holds the potential to transform the health care delivery system,” PCMA President Mark Merritt said in a statement. “Regrettably, a 50-state patchwork approach would increase costs, decrease efficiency, and severely undermine the promise of e-prescribing.” The organization also urged CMS officials to pre-empt duplicative and conflicting state laws that could increase costs.

CMS: Pay for Performance Works

Preliminary data indicate that pay-for-performance is improving quality of care in hospitals. A 3-year demonstration project sponsored by the Centers for Medicare and Medicaid Services is tracking hospital performance on a set of 34 measures of processes and outcomes of care for five common clinical conditions.

Reports from more than 270 participating hospitals on their experiences during the project's first year show that median quality scores improved in all of the clinical areas. For example, scores increased from 90% to 93% for patients with acute myocardial infarction; from 64% to 76% for patients with heart failure; and from 70% to 80% for patients with pneumonia.

These early returns demonstrate that using financial incentives works to deliver better patient care and to avoid costly complications for patients, said CMS Administrator Mark B. McClellan, M.D.

New Medicare Wheelchair Policy

Ability to function is the primary criteria in the CMS's new national coverage policy for power wheelchairs and scooters. The criteria look at how well the beneficiary can accomplish activities of daily living such as toileting, grooming, and eating with and without using a wheelchair or other mobility device. The criteria are “part of our efforts to ensure that seniors who need mobility help will get it promptly, and that we are paying appropriately for mobility assistive equipment,” Dr. McClellan said in a statement.

The coverage policy is one element in Medicare's year-old effort to improve the coverage, payment, and quality of suppliers for wheelchairs and scooters. That effort was launched after Medicare spending on mobility equipment rose to $1.2 billion annually.

Uninsured Rates Among the States

Minnesota has the lowest uninsured rate among employed adults (7%), followed by Hawaii, the District of Columbia, and Delaware, each with uninsured rates of 9%. The states with the highest rates of uninsured residents include Texas (27%), New Mexico (23%), and Florida (22%). The report was conducted by the Robert Wood Johnson Foundation, which analyzed 2003 data from the Centers for Disease Control and Prevention.

While some states fare better than others, the problem is pervasive among workers in every state. More than 20 million working adults do not have health insurance. In eight states, at least 1 in 5 working adults is uninsured, and in 39 other states at least 1 working adult in every 10 does not have health coverage.

Unhealthy Habits

Very few Americans are doing all they can to maintain a healthy life, according to a nationally representative survey of 153,805 adults (Arch. Intern. Med. 2005;165:854–7).

Mathew Reeves, Ph.D., of Michigan State University, East Lansing, found that only 3% followed four steps that define a healthy lifestyle: not smoking, holding weight down, eating adequate amounts of fruits and vegetables, and exercising. Women tended to follow these steps more than men, as did whites compared with minority populations. But no one group came close to what is necessary to lead a healthy life, Dr. Reeves said.

When assessed individually, these health statistics didn't look as grim: Seventy-six percent of the respondents said they didn't smoke, 23% included at least five fruits and vegetables in their diets, and 40% maintained a healthy weight.

Ads Influence Prescribing

Direct-to-consumer advertisements appear to have an impact on physician prescribing practices, a study by Richard L. Kravitz, M.D., of the University of California, Davis, found (JAMA 2005;293:1995–2002).

A total of 152 family physicians and general internists were recruited from solo and group practices and health maintenance organizations to participate in the study, which focused on advertising for prescription antidepressants.

Standardized patients were randomly assigned to make 298 unannounced visits, presenting either with major depression or adjustment disorder with depressed mood. When the patients with depression made a general request for an antidepressant, only 3% of the physicians prescribed paroxetine (Paxil). However, when they asked for the prescription by name, 27% were given a prescription for Paxil.

And patients with adjustment disorder symptoms were more likely to receive a prescription for an antidepressant if they made a brand specific request (55%) versus a general request (39%).

E-Prescribing Standards

Medicare should adopt a program-wide system of uniform national electronic prescribing standards for its new prescription drug benefit, according to the Pharmaceutical Care Management Association (PCMA). A uniform national standard is key to maximizing the participation of private plans in the Part D benefit and in helping to reduce regional variations in health care delivery and outcomes, PCMA said in comments to the Centers for Medicare and Medicaid Services on its proposed rule for Medicare e-prescribing standards.

“PCMA believes that Medicare e-prescribing holds the potential to transform the health care delivery system,” PCMA President Mark Merritt said in a statement. “Regrettably, a 50-state patchwork approach would increase costs, decrease efficiency, and severely undermine the promise of e-prescribing.” The organization also urged CMS officials to pre-empt duplicative and conflicting state laws that could increase costs.

CMS: Pay for Performance Works

Preliminary data indicate that pay-for-performance is improving quality of care in hospitals. A 3-year demonstration project sponsored by the Centers for Medicare and Medicaid Services is tracking hospital performance on a set of 34 measures of processes and outcomes of care for five common clinical conditions.

Reports from more than 270 participating hospitals on their experiences during the project's first year show that median quality scores improved in all of the clinical areas. For example, scores increased from 90% to 93% for patients with acute myocardial infarction; from 64% to 76% for patients with heart failure; and from 70% to 80% for patients with pneumonia.

These early returns demonstrate that using financial incentives works to deliver better patient care and to avoid costly complications for patients, said CMS Administrator Mark B. McClellan, M.D.

New Medicare Wheelchair Policy

Ability to function is the primary criteria in the CMS's new national coverage policy for power wheelchairs and scooters. The criteria look at how well the beneficiary can accomplish activities of daily living such as toileting, grooming, and eating with and without using a wheelchair or other mobility device. The criteria are “part of our efforts to ensure that seniors who need mobility help will get it promptly, and that we are paying appropriately for mobility assistive equipment,” Dr. McClellan said in a statement.

The coverage policy is one element in Medicare's year-old effort to improve the coverage, payment, and quality of suppliers for wheelchairs and scooters. That effort was launched after Medicare spending on mobility equipment rose to $1.2 billion annually.

Uninsured Rates Among the States

Minnesota has the lowest uninsured rate among employed adults (7%), followed by Hawaii, the District of Columbia, and Delaware, each with uninsured rates of 9%. The states with the highest rates of uninsured residents include Texas (27%), New Mexico (23%), and Florida (22%). The report was conducted by the Robert Wood Johnson Foundation, which analyzed 2003 data from the Centers for Disease Control and Prevention.

While some states fare better than others, the problem is pervasive among workers in every state. More than 20 million working adults do not have health insurance. In eight states, at least 1 in 5 working adults is uninsured, and in 39 other states at least 1 working adult in every 10 does not have health coverage.

Unhealthy Habits

Very few Americans are doing all they can to maintain a healthy life, according to a nationally representative survey of 153,805 adults (Arch. Intern. Med. 2005;165:854–7).

Mathew Reeves, Ph.D., of Michigan State University, East Lansing, found that only 3% followed four steps that define a healthy lifestyle: not smoking, holding weight down, eating adequate amounts of fruits and vegetables, and exercising. Women tended to follow these steps more than men, as did whites compared with minority populations. But no one group came close to what is necessary to lead a healthy life, Dr. Reeves said.

When assessed individually, these health statistics didn't look as grim: Seventy-six percent of the respondents said they didn't smoke, 23% included at least five fruits and vegetables in their diets, and 40% maintained a healthy weight.