Changes in Private Practice

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Dr. Allen Worrall: "I'm Dr. Allen Worrall from Fairbanks, Alaska and with me is..."

Dr. Don Shuwarger: "I'm Don Shuwarger and I'm from Forest, Virginia a suburb just outside of Lynchburg."

Dr. Allen Worrall: "Now we got together because we both changed our practice style several years ago. I mentioned on this network a year or so ago that I had gotten older and given up surgery and went into OB-GYN ultrasound. It's a fine profession for the aging physician who doesn't want to quit or can't afford to quit, and you also had a change."

Dr. Don Shuwarger: "Yes, about six years ago I moved to my current location from Houston, Texas. There was a big infiltration of managed care and it became a very fierce and competitive environment and one that I did not feel comfortable in so my wife and I looked for a new location and a new environment where we could practice medicine without as much interference from the third party payers. That's how we ended up in Lynchburg but since then a lot of things have changed for both of us - increasing reliance on ultrasound as a part of your office practice and then you've seen changes in ultrasound too. What sort of things are you doing nowadays with ultrasound that you didn't do six or ten years ago?"

Dr. Allen Worrall: "At our clinic we started out in the 1970's with an ultrasound machine which I think was made by ADR. It was a suitcase-type, little bitty screen, and we now have a very fine ATL 5000 machine. The machines have gotten much much better of course, the probes have gotten more versatile, and the things that we can do with ultrasound, for example, sono-hysterograms are very simple and an easy procedure that's safe. I've never heard of any complication from it and it's very, very helpful. The question of whether a patient has an endometrial polyp or a submucous myoma can be resolved with almost 100% accuracy."

Dr. Don Shuwarger: "Allen, don't you find it interesting when you do the sono-hysterograms that if the patient can see it at the same time it makes counseling and education just a breeze?"

Dr. Allen Worrall: "There's no question about that. We have a monitor on the wall for the patient and I can show them the image and show them the water going in and the polyp being outlined, and they can clearly understand what the problem is. Yes, it's a wonderful thing and the same thing is true in prenatal sonography when you find an anomaly or a possible anomaly you can show that to them and they can understand to some degree what the problem is."

Dr. Don Shuwarger: "How does your clinic store your ultrasound images?"

Dr. Allen Worrall: "With our ATL HDI 5000 we have the Magneto optical disk and the images can be stored digitally directly from the machine to this disk. I personally record all my exams on super VHS tape so I only use the Magneto optical disk if I see something interesting or something that I might want to put on the Internet or ask a question about as an attachment to an e-mail on the Internet."

Dr. Don Shuwarger: "Do you report to referring physicians by e-mail or through any other technological solution?"

Dr. Allen Worrall: "I use BABE software for both OB and GYN and BABE's prenatal version permits me to fax directly from my computer to the provider, and then I always send them a hard copy also. Otherwise, we just mail a report but the GYN software is just a beta copy, it's been in beta for seven or eight years and it doesn't have the fax."

Dr. Don Shuwarger: "Some people call that vapor-ware."

Dr. Allen Worrall: "Yes, it's very good. I enjoy it but they never did go to market with the GYN version. Of course, I produce a formal report on every scan that I do and that's very helpful I think."

Dr. Don Shuwarger: "Does your clinic do any resident education or continuing education?"

Dr. Allen Worrall: "No, we're in Fairbanks, Alaska and they do get residents up there for the emergency room at the hospital, and I think from time to time there may have been a few other residents farmed out from their program but we don't really have any medical school in Alaska."

Dr. Don Shuwarger: "In our practice we're primarily responsible for the education and training of first and second year family practice residents on OB and GYN. I think it's been very enlightening for them to come and watch, say, a sono-hysterogram so that they can actually identify the imaging with the disease process and then follow the patient to the operating room and learn the pathology. It gives them a sense of continuity as well as it helps demystify some of these conditions - submucous fibroid versus intramural fibroids and subserosal fibroids that a lot of the time these are just terms to them, when they can translate the terms into visual images and then transfer the visual images to things that they see at the time of surgery or treatment protocols and outcomes - it's a great teaching tool as well."

Dr. Allen Worrall: "Let's talk a little bit about some of the technology that's impacting our practices, for example, integrating e-mail or a website into your practice. Have you done anything in that direction?"

Dr. Don Shuwarger: "I think we've done a bit, everybody who works in our practice has a desktop computer from the medical assistant to the office manager and everywhere in between including our sonographer. Everybody who has a computer has an e-mail address and we use e-mail extensively within our reasonably small office. We only have three physicians, a physician assistant, and a full-time sonographer so there's not too many of us there and even within that small office environment we use e-mail extensively for intra-office communications. Often times we get unsolicited patient questions coming in by way of e-mail because our e-mail address is on our business cards, it's on our website, and it's on our patient literature so they know that we are available to them by e-mail. We'll get unsolicited questions like - I was in the other day and you asked me to do this, now just what was that for again and so we'll fill in the blanks or we'll answer questions regarding medication side effects or general questions. Of course, we try not to practice by e-mail, that wouldn't work too well but often times it saves a phone call, we can do it off line, you can answer it from home or from the hospital so it has really freed us up in many respects. I know a lot of people are concerned about confidentiality issues but my response to that is if the patient herself generates the e-mail question then she's taken on the responsibility of deciding what's confidential and what's not confidential. I don't initiate an e-mail conversation with the patient but I'll certainly respond to it, and if I think it gets into a particularly sensitive area, I'll often times just say that this topic may be too sensitive to talk about on e-mail and maybe this is something we better discuss on the phone or face-to-face and they're very accepting of that. They understand for the most part that e-mail is more like a bulletin board than a telephone. We also about a year ago started doing electronic patient records, and I was concerned up front about what the patient's acceptance would be about electronic patient records. Actually, patient acceptance wasn't the issue - they love it. They love it because no matter which of our physicians they see they know that that physician has a complete and accurate chart updated as of the very last moment because our electronic patient records are instantaneous and online. We don't have to wait for transcription for the data to appear so somebody could walk out the front door after a visit, get home, dial the nurse, and ask a question related to the visit - what was that blood test you ordered or what did he say that medicine was or any type of question. She has immediate and instant access to that data and the phone call is already logged in the electronic patient record system as well as the nurse's response to the phone call so we have a very good communications recording tool and instantaneous online regular patient records. The other thing was that in terms of security, I think, electronic patient records are far more secure than paper records. Every one of us employs some janitorial staff or perhaps some part-time staff and making sure that these people are not accessing records in an unauthorized way is a constant vigilance for us. At night when we leave there's only one way to get into the computer system and that's with a pass word and a user I.D., and I can assure you the janitor doesn't have that."

Dr. Allen Worrall: "Yes, that's a good point."

Dr. Don Shuwarger: "Also, if we had a catastrophic loss like a water main break in the ceiling or the ceiling caved in from snow or, God forbid, a fire wiped out the office, we would lose all our records all at once. With our electronic patient records that is almost an impossibility because we backup our records every single day. The backups go off site and they are contained on a small 4mm backup cartridge, which goes in the pocketbook of one of our staff members. That cartridge cannot be read on just your average home p.c., you'd have to have the same operating system and the same software that we have to read that cartridge so it's not useful to her. It's not useful to anybody that would get their hands on her pocketbook so for us to lose our patient data in a catastrophic way we would have to have that fire that I talked about on the same night that my secretary lost her pocketbook so I feel pretty comfortable with that."

Dr. Allen Worrall: "Yes, that's good. Did you have any trouble with doctor acceptance of the record?"

Dr. Don Shuwarger: "In the office, as you might be able to tell, I'm the technologically oriented physician, there are two other physicians and there is differing levels of acceptance. Some people are technologically challenged, shall we say, other people are sort of neutral to it, and some people are very embracing of technology. I think we cover the entire spectrum but, nevertheless, when the decision was made that this is what we were going to do and the opportunity to write on paper went away, then it's sink or swim. What you know is that physicians by nature are swimmers and not sinkers, and even the technologically challenged reached an excellent level of competence on our electronic patient records."

Dr. Allen Worrall: "Does an electronic system pay for itself or didn't you approach it that way?"

Dr. Don Shuwarger: "I think if I were to run the numbers that I would probably never ever be able to justify going to an electronic patient record because how can I convince myself that the improved documentation's going to get me better reimbursement without doing it? How can I prove to myself that the security of having backups of my patient records is worth it? How can I prove to myself that I'm seeing two or three more patients a day because my documentation is going faster and yet it's more complete if I don't do it? To some extent it is an issue of confidence or, if you will, a leap of faith. I don't think the time is too distant when medical practices will ultimately find themselves in the mode where they have to do this whether they want to or they think it's cost effective, they just have to do it, and I feel more comfortable that we have already taken the step. I feel comfortable where we are and what we're doing now with our electronic patient records is now we're saying - okay, we're on them, we're using them, they're working, now how more useful can we make them over and above their original purpose for us? What can we do to improve outcomes? What can we do for documentation, and what can we do for research - things that will help us help our patients that we never could have done with a piece of paper. So we're trying to take it to the next level."

Dr. Allen Worrall: "That's very interesting. I think we should probably end this interview now."

Dr. Don Shuwarger: "It was nice talking with you Allen."

Dr. Allen Worrall: "Thank you."