Oh, Baby!

Just what is it about OB/GYN Associates of Northwest Alabama that sets it apart?

I labored over that question (pardon the pun) as I sat down to report on this year's Practice of the Year competition - an annual event we introduced in these pages in 2002 to give our readers a chance to share their success stories.

It wasn't just that this practice has achieved significant, measurable gains since introducing an EMR in 1999 - or even that they were one of the first offices in a "technologically infantile" region to automate, according to executive director, Charlie Lathram. This year, 52 percent of Practice of the Year applicants had similar success stories with their EMRs and told us about them in detail. It's great to hear that the promises of technology are generally real and the results tangible. But it's not really news like it was a few years ago.

It wasn't that the group operates under a physician productivity and compensation formula that one of the contest judges called "the hardest management accounting tool to use but the best at ferreting out true costs and allocating them to doctors." Lathram likes the formula because it "gives physicians a choice in the way they practice." And Philip Wakefield, a physician who's been with the group for 19 years, insists it has instilled in the doctors "a better sense of cooperation and a better sense of each other's needs." Not only that, says Wakefield, "It encourages everyone to see their share of indigent patients without fear of monetary loss."

And it wasn't even that the practice sends a single rose to each patient in the hospital who's just had a baby. A nice touch, to be sure - coincidentally, runner-up practice River Rose OB does this as well.

What ties all the pieces together is a sense that OB/GYN Associates of Northwest Alabama simply does a terrific job at anticipating and responding to what its patients need - perhaps even before the patients know or ask.

Case in point: the group's Web site, www.obgyn-associates.org. It's got online appointment scheduling, online prescription refills, and all the pre-visit forms a patient would need, including consent for use and disclosure of health information and a detailed patient privacy statement to meet HIPAA requirements. There's the option to ask questions online about insurance coverage, or to translate information on the site into Spanish.

For now, Lathram says, traffic to the site is light and many features go practically unused. "We have patients in college in Tennessee, Mississippi - as far away as Virginia. For them to be able to request a prescription refill without making a long-distance phone call is very helpful," he says. The point is, just because the majority of its patients aren't Web savvy doesn't mean the site has to reflect that. The practice created a site with lots of patient-friendly features, rather than slapping together a bare-bones site that's not of much use to anyone.

In response to patient requests, the practice is following a slow, deliberate plan to add cosmetic procedures like laser hair removal and vein therapy to its list of services. "We have been hesitant, just from a time standpoint, because we're so busy in the practice of OB/GYN medicine," says Lathram. "And we wanted to do it in a way that didn't 'commercialize' medicine." Since purchasing the laser last January, the practice has been training its nurses, and Lathram feels they're sufficiently up to speed to start taking clients.

"We're starting to market [it] by giving discounts on the procedures for hospital nurses - to build clientele we may not have currently, but also to build good working relationships with the staffs of both hospitals we work with. And we have a segment of our [patients] who go to surrounding cities to have these procedures done. I think it will justify itself financially," he says.

For incoming patient calls and any other situation in which a patient needs an answer, "We have things that patients typically need available so we can answer that patient call the first time. We realize that our patients have busy lives and we like to provide alternatives to save time and administrative burdens along the way," says Lathram. "Patients can work us into their schedules, and not the other way around."

It's In the Bag

When it comes to the needs of its mothers-to-be, the practice really delivers the goods. It's called a Special Delivery Bag, and it's given to each patient at her first obstetric visit - a four-pound canvas tote bag filled with educational materials and discount coupons for everything on a Mom's list: maternity clothes, baby clothes and shoes, diapers, furniture, formula, vitamin samples, a safety kit with light socket covers - even a voucher for baby's first birthday cake.

Chief financial officer Lynda Rohling brought the idea to the practice from her days working in a hospital. More than 100 local and national businesses participate, and all staff members are asked to try to bring one or two new businesses on board. And when things slow down a bit in the office, say, on Friday afternoons, small groups of staff members gather to assemble the bags. "With six people working for about two hours, we can put 100 to 120 bags together," says Rohling.

"Lamaze provides a world of information [for the bag] in both English and Spanish," she adds. "Enfamil, the formula company, provides a book called Baby Grows, which shows the growth from conception to birth. The mothers ask for this book."

Not only is the Special Delivery Bag a selling tool for the practice, according to Rohling, "our mothers tell us it is a great way to be introduced to businesses and resources in the community." It tends to have an extended life, too: "I've seen them in Panama City [Fla.] being used as beach bags," she says.

Right People, Right Positions

Expectant mothers aren't the only ones who get special attention from the staff. Patient care coordinator Rosanna Ledbetter spends about five hours a week helping needy patients get the prescription drugs they couldn't otherwise afford through pharmaceutical company-sponsored patient assistance programs.

"I have about 150 patients that I work with. A lot of them are on fixed incomes. I help them complete the applications and gather financial information and documentation so they can get their medicine," says Ledbetter. One patient, who comes in to do paperwork with Ledbetter about every three months, is particularly grateful. "Whenever she comes in, she brings me a vase of flowers from her garden," Ledbetter says.

Ledbetter, an RN by training, has been at the practice for 13 years, and her position was one of many that changed following the practice's EMR implementation.

For example, says Lathram, "The EMR allowed us to take personnel who used to file charts and put them in different spots. We had a dramatic personnel reduction as a result, but we did not terminate anybody. We had some very good medical records staff that we began to use in the clinical area as runners or nurse's aides. They already knew the practice. ... Just teaching them the clinical side really cut back on the training of a new hire. And I love to hire from within.

"The biggest gain was to be able to use Rosanna in a different scenario," he adds. "Our clinic schedule is typically packed, and our physicians have little free available time to work [unscheduled] patients in. As patient care coordinator, Rosanna is like another provider. She sees walk-ins, follows up on lab results, gives hormone injections, counsels patients on everything."

Notably, Ledbetter has completed prerequisite work in becoming a board-certified lactation consultant. "In this area of the state, very few people have that designation," says Lathram.

The extra care and attention Ledbetter provides isn't lost on patients. "They know my number and name; they keep my pager number in their phone book. They know they can speak to me and get an answer," she says. "It's very rewarding when a mother calls to tell me that the breastfeeding is going well and the baby is thriving. I know that I had something to do with that and it makes me feel great."

A Community Approach

When patient demand for care grew in a nearby community, OB/GYN Associates responded by opening a satellite office. "There is certain community loyalty to both hospitals, so we wanted to participate with both [Eliza Coffey Memorial Hospital in Florence, Ala., and Helen Keller Hospital in nearby Sheffield]. In order to do that we had to have an office in both communities," says Lathram.

He says the satellite operates on a slightly smaller scale, with some diagnostic procedures and ultrasound, but not "the full gamut" like at the main office. Some staff are stationed there permanently; others rotate. The office procedures and systems are identical.

"We have one GYN-only physician stationed there, and one full-time nurse, plus one receptionist and one supervisor [at the satellite]," says Lathram. Doctors who are on second call work from the satellite, and to ensure proper staffing levels and a continuum of care, the physicians take their "nursing teams" with them.

"Each doctor has two nurses assigned to him," Lathram explains. "They have a primary nurse whose responsibilities include making sure H&Ps are done, records are where they need to be, the physician is where he needs to be, and keeping up with his schedule. The 'runner' keeps the rooms turned over. They interview the patient, perform documentation, and have that patient ready for the doctor to see."

This kind of teamwork functions on the administrative side, too. Front- versus back-office sniping is all too common among medical practices, but not here. "[Front-office supervisor Kathy Compton] and I sit down and talk a lot," says Rohling. We don't want to make individual decisions that will have repercussions for the other. We have great respect for one another."

Ledbetter adds, "We all work well together. We're more like friends, I guess."

And it shows in the long tenures of most of the staff. "I'd say the average employee has been here five to seven years," Lathram guesses. "We've got some employees here 25 years. Among my management team, I'm the newest - I've been here eight years."

It helps, too, that the practice offers a competitive benefits package that includes no-cost long-term disability insurance, life insurance, and a matching 401K plan. And there's a little bit of time set aside for fun.

"Every year we try to have a picnic at one of the physician's farms for employees and their families, with a barbecue and a hay ride. It's hard with this many people on staff, but we try to keep it as close to a family atmosphere as we can," says Lathram.

Money Talks

Of course, none of the detailed attention to patients or the harmony among the staff would matter much without the work of the physicians. And their satisfaction counts for a lot. One way the practice has addressed it is by altering its physician compensation formula to be friendlier to individual styles of working.

"Before, the profits and expenses were shared evenly among all the physicians," Lathram explains. "It caused a lot of dissatisfaction. The current formula provides a balance - it provides incentives for individual work, and does not consider specialization, length of time in practice, or payer mix. It does, however, allocate costs to the physicians based on utilization."

The new system, as Lathram says, allows physicians to decide whether to come in and work, or take some time off.

"We had physicians working at all different paces - some enjoyed time off more than others - and equal compensation was not appropriate in those situations. Now, if you take time off, you're not generating revenue, so no revenue is allocated to your inbox. At the same time, you aren't incurring variable expenses, so it doesn't necessarily hurt you to take time off.

"We came up with a point system, basically, in which we allocate points to the CPT codes the physicians perform. At the end of the month, we take all the revenue the doctors have generated and put it into two pools: one is split evenly so as to encourage teamwork - 'I'll see your patient, you'll see my patient.' The other pool is allocated based on each physican's pro-rata share of points generated toward the total number of points," says Lathram.

It works, according to Dr. Wakefield, to build cooperation among the physicians. For instance, when he wants time to see his child's baseball game, "I have a trade-off. I know I'll be covered, and I'll cover for the other guys when their kids are playing."

The practice, too, has remained relatively unscathed by sky-high malpractice premiums, which hit OB groups particularly hard.

"It's affected us negatively, of course," says Wakefield. "Our rates, while they have risen, have have not risen as agressively as in other areas. I sit on the board that reviews claims against our malpractice carrier; we meet quarterly and we fight very aggressively.

"And in the practice, we simply work smarter and we're very alert to risk management. People at the practice are very motivated to bond with patients."

Joanne Tetrault is special projects editor for Physicians Practice. She can be reached at jtetrault@physicianspractice.com.

This article originally appeared in the November/December 2005 issue of Physicians Practice.