The good doctor

Special to The Times

CONSUMERS have largely been in the dark when trying to choose a new doctor. They might want someone who is skilled, pays attention to their concerns and makes it easy to get an appointment. Instead, with little information to go on, they pick someone out of a directory whose office is conveniently located.

But a new emphasis in family medicine on providing quality care and pleasing patients is giving consumers more to go on. They can find out basic quality information about doctors -- such as how well they provide preventive care -- from some insurers, state health officials and private companies such as HealthGrades. And a few well-placed questions about the way a doctor runs his or her practice can give consumers a sense of the type of doctor-patient relationship they’ll have -- and, to some degree, the quality of care they’ll get.

“Times are changing, and people’s expectations of what they want from their medical care has changed, and we as practitioners are changing,” says Dr. Donald Klitgaard, a family physician in Iowa who, like doctors across the nation, has computerized his record-keeping, made it easier for patients to get appointments and helped his office staff become more efficient.


Odd as it may seem, simply calling prospective doctors and asking whether their office is computerized may turn out to be the best advice for finding a physician committed to patient care over the long term.

“The average consumer takes it as a given that doctors have these systems in place,” says Peter Lee, chief executive of the Pacific Business Group on Health, an employer coalition based in San Francisco. “They don’t know how much medical care today is not 20th century, let alone 21st century, in terms of how much doctors rely on paper instead of computers.”

Nationally, only about 20% of physician offices are computerized; the rest still rely on notoriously inefficient paper charts. But computers are an easy benchmark for quality. They can help a doctor not just keep track of files, but also send out prescriptions accurately and quickly, get lab results inserted into the record automatically and be reminded what the scientific evidence suggests is the next best step with a patient.

At the same time, for doctors to get the most value out of computers, experts say they need to use them as more than word processors; physicians should use features such as electronic reminders to prescribe a test or a medication, and change the way they practice as a result. “I believe it really does translate to better care,” says Robert Eidus, a New Jersey physician with a background in business and medical quality improvement. “But it’s not just that I have an electronic medical record, it’s how do you use it and how does it impact caring for patients.”

Oso Family Medical Group in Mission Viejo converted to an electronic medical record system in 2004, going through the expensive and painful process of converting thousands of paper files. But it was worth it, says Dr. Lee Burnett, an osteopath and partner in the five-doctor practice.

The change improved patient care and stopped the constant and inefficient search for file folders. “We had two people on staff whose jobs were just to find paper charts,” he recalls.

But simply asking whether a doctor’s office is computerized shouldn’t be the sole determinant in choosing a physician. Ultimately, in the new doctor-patient dynamic, patients should have easier access to their doctors when they need them -- in person, by phone or online.

Other aspects of this “new model” of family practice are largely invisible to patients but just as important: The staff acts as a team to improve patients’ health by making sure they follow up on medical advice and make it to appointments; the doctors base care on scientific evidence rather than instinct or habit; patients with chronic illnesses receive follow-up care; the practice follows up on test results and visits to specialists rather than waiting for the patient to track down that information.


‘Patient experience is key’

This patient-centered approach is considered a new measure of quality because it means patients will be more motivated to not only see the doctor but also accept the medical and lifestyle-change advice dispensed.

Patients who work with their doctors in a collaborative way, for example, are more likely to take care of themselves, according to a study of 24,609 adult patients with chronic or serious conditions.

The study, conducted by researchers at Dartmouth Medical School and reported in the Journal of Ambulatory Care Management in 2006, found that patients who participated in good collaborative care had better control of their blood pressure, blood glucose levels and serum cholesterol than those who were less confident in the information they received from doctors or their ability to care for themselves. “We’ve recognized for over a decade that the patient experience is key” to good healthcare, says Dr. Carolyn Clancy, director of the federal Agency for Healthcare Research and Quality. “Communication in primary care is critical. Eighty percent of diagnosis is getting a good history,” she says, and that requires a good relationship between patient and doctor.

Good, basic customer service is part of the package, because it gets patients in the door. The doctors at Oso Family Medical Group heard about the “new model” of family practice and that a first step is surveying patients to find out what they need. That yielded complaints about long waits and other annoyances.

“I’ve always loved them, they treat you like family,” says patient Josh Dryman, a 33-year-old who lives in Laguna Niguel. “But I had to wait an hour in the lobby and wait in the exam room another half-hour. Now when you go in, they get you in right away and the staff seems a heck of a lot friendlier.”

Hearing these and similar comments from the people on whom they depended, the five doctors changed their -- and their practice’s -- ways.

“We saw the marketplace evolve to be much more patient-centric, and insurance companies looking for specific measures of how happy patients are with your practice,” Burnett said. “We’re trying to be on the cusp of this.”

There isn’t a large body of scientific evidence linking family medicine modernization techniques to better patient care. But some studies are under way.

Researchers at the Medical University of South Carolina have been studying health outcomes of patients from about 100 medical practices that use the same medical record software, along with several elements of the new family practice model.

In a study of diabetics among 66 of those practices, researchers found measurable improvement in health status and linked that to specific techniques used by the practices, including an electronic medical record, a team staff model and a computerized system that keeps track of test results and referrals.

Meanwhile, 36 family practices around the country are studying their performance in a project sponsored by the American Academy of Family Physicians. It includes computerization, easier access for patients, websites and a team approach to providing the most efficient care that involves daily “huddles” among the practice staff. The idea is to prove whether the concept works in the real world, and whether it’s worth the investment. A report on the project, which ends in 2008, is expected early the following year.

One of the participants is Eidus, the New Jersey physician who spent a career working in academic medicine, HMOs and healthcare quality before hanging out a shingle five years ago as a family doctor in Cranford, N.J. He organizes his practice with an electronic medical record and offers patients a $30 “online house call” through an interactive website, along with extended hours on Thursday evenings and some Saturdays. “I designed the office from the standpoint of the patient’s perspective and what was going to make our practice best meet the needs of our patients,” Eidus said.

Harlan Clinic in rural Harlan, Iowa, is also among the growing number of practices betting that overseeing the overall health of its patients is more effective than providing episodic care. It keeps a diabetic educator and dietitian on staff and plans to add a health coach. “We can actively help them manage their disease,” says Klitgaard, a family physician at the clinic. “That’s comprehensive practice. That can and should happen in all primary care offices.”

That concept has become known as providing patients a “medical home.” However, a survey released last month by the Commonwealth Fund, a private foundation focused on improving healthcare practice and policy, found that just 27% of adults age 18 to 64 reported having all four elements of a medical home: a regular doctor or source of care; no difficulty contacting their provider by telephone; no difficulty getting care or medical advice on weekends or evenings; and visits that are well organized and run on time. The survey, conducted in 2006, involved 3,535 randomly selected, nationally representative Americans.

A 2003 Commonwealth Fund survey found that just 22% of primary care doctors rated “high” in their use of patient-friendly techniques. Just 18% used e-mail to communicate with patients. About half said they send reminder notices about preventive or follow-up care, and 64% said they provide same-day appointments.


Choosing based on quality

Quality “report cards” on doctors can also offer a guideline for patients choosing a doctor. Although the movement to provide such ratings has been underway for years, it’s thus far yielded mostly general information.

A 2004 study by the American Academy of Family Physicians found that patients generally want their primary care physician to meet five basic criteria: be in their insurance plan, be conveniently located, offer appointments within a reasonable amount of time, have good communication skills and have a reasonable amount of experience.

Some of those answers are easy to find -- a quick look in a provider directory can answer the insurance and location questions. But as more patients use health savings accounts that require them to pay out of pocket for doctors’ visits, they’ll likely be looking for more information about the value they’re getting for their money.

The company HealthGrades, for instance, collects public information such as education, gender and board certification about doctors around the country and, for 15 states, malpractice payments -- and charges a fee for the report. HealthGrades spokesman Scott Shapiro says the company does not expect to offer information about practice design (such as computerization) in the near future.

But the reports do note whether a doctor has received a quality designation from a private quality organization called Bridges to Excellence, which offers doctors a review and assessment of how they handle specific diseases such as stroke and diabetes. In some places, these ratings can earn doctors financial reward from employers.

Some insurance plans are also beginning to offer more detailed quality information about their doctors. A part of the Bridges to Excellence program, called Physician Office Link, identifies physicians who use methods considered by national healthcare quality experts to lead to better efficiency and quality. These include monitoring patients’ medical histories, working with patients over time, following up with patients and other providers and avoiding medical errors. Aetna, for one, identifies physicians who have paid to be evaluated by the program and been found to meet its standards.

Some states collect quality information and report it to consumers on websites. California’s Office of the Patient Advocate offers quality information online about medical groups developed by the Pacific Business Group on Health and the Integrated Healthcare Assn. ( The data, based on consumer surveys, include ratings on timeliness of medical care, quality of communication and helpfulness of office staff. However, the surveys apply mostly to large medical groups and include few individual or small practices.

Such information is becoming more plentiful as doctors, pressured by employers and insurers, open up more to scrutiny. “We’re still in baby steps on reporting on physician care,” Lee says.


Not just computers alone

Of course, a good doctor-patient relationship comes down to more than a single measure of quality or modernization. And different people want different things from a doctor. Nevertheless, having a doctor who takes pains to provide the kind of care patients need and want is arguably more likely to please them. It will require medical consumers to be willing to think through what they want, and ask questions even if that means asking a receptionist to put the call through to an office manager, nurse or the doctor.

For example, although it’s important to know whether a practice is computerized, Burnett says he wouldn’t necessarily avoid a practice based on that one factor. “Some doctors can’t afford it right now,” he says, particularly practices with just one or two doctors. And there is debate within the profession about the ultimate role of computers.

Many argue that their potential for revolutionizing the quality, safety and efficiency of care is overblown. In fact, a proportion of primary care doctors will probably never invest in them, predicts David Brailer, former healthcare IT czar for President Bush.

Speaking to healthcare journalists at a Los Angeles meeting in April, Brailer noted that about 20% of doctors have computerized their practices, while more than half are debating when, and how, to make the investment. Another 20%, he estimates, are older doctors who don’t believe the technology is worth the investment and will retire without having converted their paper files.

A patient can learn a lot about a practice’s philosophy by sensing whether the person answering the phone is open to answering questions, suggests Dr. Terry McGeeney, chief executive of the American Academy of Family Physicians’ project to study the real-world feasibility of the “new model” of computerized, patient-centered family practice.



Your questions, your concerns

Some questions to ask of a doctor’s medical practice:

* Do you have an electronic medical record?

* Would you use it to follow my care more efficiently?

* Do you use evidence-based practice guidelines to manage patients’ health?

* Can I get a same-day appointment with my doctor (or nurse-practitioner or physician’s assistant)?

* Do you offer extended hours on evenings or weekends if I can’t get off work?

* Does your staff work as a team to improve patients’ care?

* Can I get a quick question answered by phone or by e-mail?

* Do you do lab tests in your office or in some efficient way that won’t take up a lot of my time?

* How would I get test results back?

* How do you track patients with chronic illnesses?

Each patient must decide what is important about a potential doctor. These questions can give consumers a sense of whether the practice is at least thinking about providing patient-centered, quality care.


What to look for in a physician

Using quality information to choose a doctor is a relatively new phenomenon -- and one that few consumers are doing, according to a 2006 survey.

* Percentage of people who saw information in the last year comparing quality among doctors: 12%

* Percentage who used it to make a decision about a doctor: 7%

Source: Kaiser Family Foundation/Agency for Healthcare Research and Quality phone survey of 1,216 randomly selected, nationally representative American adults, 2006.

In another survey, people were asked what types of criteria they’d use to judge a doctor. Those surveyed were asked which of the following information would tell them a lot about the quality of a doctor:

* How many times a doctor has done a specific medical procedure (66%)

* Whether a doctor is board certified, that is, has had additional training and testing in his or her area of specialty (65%)

* How many malpractice suits a doctor has had filed against him or her (64%)

* How patients who are surveyed rate how well the doctor communicates (52%)

* Whether a doctor attended a well-known medical school or training program (37%)

* Whether a doctor has admission privileges to send patients to a particular local hospital (35%)

* Whether a doctor has been rated “the best” by a local newspaper or magazine (28%)

* Whether a doctor charges more than other doctors do (18%)

Source: Kaiser Family Foundation/Agency for Healthcare Research and Quality phone survey of 2,012 randomly selected, nationally representative American adults, 2004.