Top Doctors 2009: The Doctor Is In

The idea alone horrified Group Health family doctor Harry Shriver: Answer his own phone—without a nurse screening calls first? Give patients his email address?

It’s not that Shriver considers himself too important for such mundane tasks. It’s just that from the moment he walked into the Factoria Medical Center clinic every morning until he left, he literally went from exam room to exam room the entire day almost without stopping. Typically he’d see as many as 22 patients a day, with problems from the simple—a case of the flu—to the complex—an elderly person with both diabetes and heart disease. When he wasn’t with patients, he was working his way through paperwork or wading through administrative details. Each day was, quite simply, grueling, and Shriver began thinking more and more about retirement.

Today, Shriver sees half as many patients in a day, and spends up to 30 minutes with each. That gives him time to really communicate with patients, to sort through health concerns, physical and emotional. He picks up the phone when his patients call, and he answers their emails.

He’s never been happier in his 35 years of practice—and he believes his patients have never been healthier. Emergency room visits are down for his patients and those of his fellow physicians at the Factoria clinic. Patients are following medical orders better and are more successfully managing chronic conditions. And Shriver, 65, has put off thoughts of retirement. “I’m having too much fun,” he says.

It’s all part of a relatively new approach to health care known as the “medical home” model, and for supporters, it holds the key to reforming the nation’s health care at a time when chronic diseases like diabetes are rising to epidemic levels, baby boomer health needs are skyrocketing and overall medical costs continue to spiral ever upward. It’s an approach also being pioneered in the Swedish Medical Center system. And it’s a version of a model that’s gaining attention around the nation.

Simply put, the medical home concept turns the current model of primary care—mostly provided by internists, family practice doctors and pediatricians—on its head. At present, the vast majority of primary care doctors are reimbursed per procedure or number of patients seen—not for how healthy they keep their patients. That means primary care doctors, who already receive some of the lowest reimbursements of any physicians, work long days stuffed full with patients, and are able to spend perhaps only seven to 10 minutes a visit with each person they see. Often, they’re double-booked: Two patients are in separate exam rooms with the same appointment time. Because they don’t get paid for it and they’re already burdened with paperwork, it’s difficult for primary care doctors to spend much time on the phone with patients, or to answer email.

In the medical home model, doctors are reimbursed, often on a monthly basis, for seeing fewer patients—in order to keep them healthier. (Group Health, however, as a member-only system, has a slightly different model, with most care provided through its network of doctors and facilities.) Savings for all medical home models come from several factors, including fewer hospitalizations and fewer costly visits to the emergency room; both of these decreases occur because patients are tracked more carefully. Also, more doctor-patient interactions occur—and more quickly—via phone calls or secure email, cutting down on the expense of office visits.

“The patients love it,” says Alicia Eng, the clinic operations manager for the Group Health Factoria Medical Center. Eng, who is a registered nurse with an MBA and a master’s degree in health administration, helped guide the clinic through the transaction from conventional practice to the medical home model two years ago.

One of the best parts of the new model is how time for email is built into the doctor’s day, she says. “Part of what people go to emergency room for is because they work during the day, have busy lives and can’t get in to see doctors,” she says. “Now they can email at a time convenient to them, and doctors can respond to them.”

Janet Nolte, a Group Health nurse who works in the Factoria clinic, likens the approach to a wheel with spokes. The doctor and patient are at the center of the wheel, and others—nurses, medical assistants, pharmacists—are the spokes that support that relationship. “The reason you go into nursing is because you really want to care for patients. This lets us also involve the patient in their care,” says Nolte, who spends much of her time working with diabetics in person and on the phone, from checking blood sugar levels to making sure patients have appropriate footwear to reduce sores, to reminding them to have their eyes checked regularly.

And according to studies by Group Health and others, that medical home model has meant better health and greater satisfaction for patients, and less burnout and more career satisfaction for doctors and nurses. It’s worked so well over the last two years at the Group Health Factoria clinic—and has proven to be no more expensive than traditional care—that the medical cooperative is rolling out the model to all of its 26 clinics in Washington and northern Idaho.

The glue that holds the program together is electronic medical records, which means all those on a patient’s health-care team can instantly access vital information when a patient emails, calls or visits. “In the end, the electronic medical record makes the model work,” Shriver says. There’s no irritating wait for a record to be pulled to check for a medication, or the results of prior tests or exams. Swedish relies on electronic records as well, and most proponents say it’s a necessary ingredient to keep a medical home model running economically and effectively.

“I’m wildly enthusiastic,” says longtime Group Health physician Suzanne Spencer, who says the amount of time she now spends with patients makes her a better doctor. “I think [this is] major. This is the reason I went into family medicine. Every single patient has a story.” And that patient’s doctor needs to hear that story so the best possible care can be provided, says Spencer, who was medical director of the Factoria clinic when the plan was rolled out.

Howard Hulin of Redmond, a patient of Dr. Shriver for more than 15 years, loves the new model as well. “It seems to be a little more personalized,” says Hulin, who is 69. He really likes being able to email his doctor. “It used to be you’d make phone calls and be put on hold. Actually, I’m surprised that if I email one day…that same day, most of the time, he answers me back...Before, it was more of a waiting game—you’d go in and wait to see him. Even with a minor problem, I had to go in and see him.”