Practice of the Year: CH-CH-CH-CHANGES

It's not yet 8 a.m. when the calls begin and the patients start arriving. Family physician Christopher Crow has just stepped out of his office on his way to see the morning's first patient when the buzzing of his intercom stops him. A woman called, he's told, to inform the practice - not to ask, to inform - that she'd be bringing her husband, just released from the hospital after a weekend motorcycle accident, in for an examination.

Oh, and she has no money to pay, by the way.

"OK, that's fine," Crow, after a brief resistance, says resignedly. "That's a little annoying," he tells me, after some prodding, "for her to just assume we'll take care of him. But we will." They can afford the motorcycle, I note. Yes, Crow replies, wordlessly. Exactly.

Welcome to Monday morning at America's best-run practice, Family Medical Specialists of Texas (FMST). The three-physician group in Plano, a Dallas suburb, is our 2006 Physicians Practice of the Year. Yes, it still has its share of headaches, like pushy Mrs. Knievel, but everything here works so well that such minor irritations barely register.

What's so terrific about this group of three 30-something physicians?

Let's find out.

It wasn't long into my day with Crow and his colleagues, family physicians Matthew Weyenberg and Sander Gothard, that it started becoming clear why our judges chose their group to be our practice of the year. For one thing, this group's Monday morning, while busy, is not chaotic, as it is in many other primary-care offices.

That's in part due to FMST's same-day scheduling. Though not revolutionary, it is one small example of the group's forward-thinking patient-first philosophy.

Crow says he's baffled by practices that haven't adopted same-day scheduling, a relatively simple innovation to implement. How, he wonders, can a service business like a primary-care medical practice be so insensitive to things that make patients happy, such as convenient access? Patients are the customers, after all; taking care of them is how practices stay in business. What other business would erect barriers to customer access?

"You call a practice up for an appointment and they say, 'OK, we'll see you next Tuesday.' But I'm sick today," he says. "I don't understand that. It's like going into Burger King and ordering a cheeseburger and they say, 'OK, come back later, and we'll feed you.' But I'm hungry now."

FMST believes that everyone wins when patients can see their physician when they want. Patients are happier and healthier, and the practice is more successful.

It's one of the many ways that this group connects good practice management with good patient care. FMST didn't win our Practice of the Year competition because of its days-in-accounts-receivable data, or because of its EMR, or because the doctors make more money than most - although it does have enviable collections, it does make full use of an EMR and other technologies, and, yup, the docs are doing quite nicely, thank you.

Rather, FMST won this contest because its physicians understand that running a more efficient office tends to make them better doctors. And it makes for happier patients.

Young guns

Spend a day with this group, and you'll discover how practices should be run and how the successful ones will be run in 10 years, maybe five. FMST seems to ooze newness - even the physicians themselves, who range in age from 31 to 37.

"Here, we embrace change," Gothard says. "Embrace it. And that's how we've been successful. Everything we do is about change. ... We don't sit around and wait until we have to do things. We're proactive with change."

One of our judges, David Albenberg, MD, calls FMST the "mack daddy" of tech-savvy practices, and says he was knocked over by both its technological innovation and its empowerment of employees; but he adds, "What really got me with this practice was their focus on doctor-patient communication. These guys have it going on - video patient education, Web site portals for access to patient records, e-mail access to physicians, and e-newsletters all establish, build, and solidify the doctor-patient relationship."

FMST's physicians also got more than style points for thriving with a flat organizational structure that does not include a practice manager. Our physician judges in particular were impressed by the personal involvement of the physicians in practice operations. That involvement is so intense that it makes a manager seem superfluous.

Judge Juliet Breeze, MD, argues that because FMST is "truly physician-managed," it "combines the pursuit of clinical excellence and outstanding patient care with the ideals of a highly efficient and effective workplace." She adds that the physicians' "creativity, innovation, and eye toward efficiency appear to have created dramatic results for their staff, themselves, and most important, the patients."

What puts Family Medical Specialists of Texas a cut above the rest? Three very big factors:

• Its innovative and aggressive use of technology. Gothard, Crow, and Weyenberg are technologically savvy but not gadget junkies. They simply recognize that wise use of technological tools can achieve three outcomes: It can make their lives simpler, giving them more time with patients; it can make their office more efficient; and it can harness data on hundreds of patients to allow them to easily examine clinical trends and outcomes.

• Its insistence on an organizational culture that makes everyone personally responsible for overall patient experience, and thus for the group's success.

• Its successful linkage of patient care to office efficiency, employee and physician satisfaction, and financial success for the practice.

Tech talk

FMST's embrace-change philosophy's clearest manifestation is in its EMR usage. The group doesn't simply have an EMR; it exploits the technology (and others) to every advantage, from clinical reporting to chart-keeping, coding, billing - you name it.

FMST estimates it spent more than $100,000 on its GE Healthcare Centricity practice management and EMR systems, but the group says it got its investment back in about 18 months. The practice credits the technology with boosting each physician's income by as much as $80,000 a year, through a combination of improved overall efficiency, more accurate coding, and an increase in the services they provide. The EMR alerts doctors and staff to services patients need but haven't received. It's a happy coincidence that providing better patient care tends to be more lucrative to physicians.

Staff rave about the EMR. "I love it," says nurse Dawn Sanchez. "At first, I was a little intimidated, but now - oh, it's so much easier." Sanchez, a four-year veteran of the practice, began working there when it was still using paper charts. She had previously worked at other paper-based clinics. But she hopes she never will again.

"The biggest thing [pre-EMR] was taking a phone call," Sanchez recalls. "We'd have to go hunt the chart down to talk the patient. Sometimes the doctors would have it in their office when we needed it."

Patients like it, too. Brendan, a 30-year-old entrepreneur who was in the office for a physical, told me, "I'm a newbie at this practice, but so far I'm very impressed. It's the most technologically advanced doctor's office I've ever been to."

The technology also allows the doctors to examine their patients' clinical trends, comparing them with national averages through its participation in GE's Medical Quality Improvement Consortium (MQIC). Each night, through MQIC, de-identified patient clinical information is uploaded to a central repository housed by GE, which then aggregates the practice's data. The doctors can go online to see how their practice compares with other practices around the country on protocols recommended by the National Committee for Quality Assurance (NCQA).

Weyenberg, the practice's tech guru, shows me the comparison, which is displayed in a form clear enough for anyone - even a magazine editor - to understand.

The data enables to physicians to see the extent to which they are following protocols in the management of chronic diseases. One such disease of particular interest to FMST's physicians is diabetes, and its doctors were alarmed to discover at one point that only about 31 percent of their diabetic patients were getting their recommended eye examinations. That's below the 50 percent national average, and well below NCQA's 60 percent target. Weyenberg noticed this and sounded the alarm.

"We were at 31 percent, and thought, 'This is crazy,'" Crow recalls. "Now we're over 60 percent. But 60 percent is not acceptable to us."

Mr. U, Crow's first patient the morning I arrive, has diabetes. He had gone undiagnosed for several years, by Crow's estimation, because he wouldn't see a doctor. Only when his symptoms became unbearable did he arrive in Crow's exam room. Now, three months later, his weight is down, his vision is no longer blurred, and he feels, he says, much better.

"We should maybe take a new picture of you since you lost all that weight," Crow tells him. And indeed, the photo on Mr. U's electronic file, which Crow has open on a laptop computer in the exam room, shows a man with much fuller cheeks than the one sitting on the exam table. Mr. U was happy when he first received his diagnosis, Crow recalls, because it meant that, finally, there would be a treatment plan, and some relief. For the first time - with his doctor's help - he would have some control over how he felt.

Today's visit is just a follow-up. Crow asks him some questions, ties up loose ends from his last visit, and sends him on his way with a few encouraging words. His prescription will be waiting for him at his pharmacy. FMST uses e-prescribing that allows the physicians to send prescriptions electronically to just about any pharmacy (and national pharmacy benefit managers) in the area with just a few clicks; refill requests can be sent electronically to pharmacies within seconds of their receipt by the physician. That process alone saves perhaps 60 staff calls a day to patients and pharmacies, by FMST's estimates.

The group's EMR also makes it immeasurably easier to manage patients, especially those with chronic illnesses. Crow says this is because it's easy to navigate and read, is always available, and records every relevant detail about a patient's care. The system also allows the doctors to send themselves alerts, reminding them to check whether a patient, say, followed up on a treatment plan or received a recommended test.

"I don't know how other doctors practice without it," says Crow, who has been certified by NCQA's Diabetic Physician Recognition program thanks to the data that Weyenberg was able to mine from their EMR. "People think I'm smarter. I'm no smarter than anybody else; the system makes us all smarter."

Yet the EMR is only one example of the practice's dedication to technological innovation. Its Web site, www.fmstexas.com, allows patients to request appointments online, gain access to their own medical records, and, for a small fee, e-mail questions directly to their physician. Patients may also choose between receiving test results via e-mail, or through a secure voice-mail service. Those who choose the phone service simply dial the number, then use a password to gain access to voice messages left for them by their doctor. No more phone tag.

"It's a dream come true for patients," says Crow. "They can't imagine the high-touch service they're getting."

Culture shock

Before beginning discussion of new symptoms, FMST doctors go over whatever it was they were talking about last time. Did that medication work for you? Have you been exercising more like you said you would? Are you still having trouble with insomnia?

A young law enforcement officer answers such questions for Weyenberg before describing the cold symptoms he'd been dealing with. The symptoms are so bad he figures he must have the flu. He doesn't; flu season hasn't started yet. And while there isn't anything Weyenberg can do for his cold except recommend his favorite over-the-counter remedies, his questions about prior issues might have turned up something of interest.

That's why each physician in the practice conducts exams in this same fashion. In fact, the doctors at FMST strive to do as much as possible in the same way, in both clinical and business matters.

"Variance costs money, and variance costs confusion," says Crow. "From an office efficiency standpoint, we always strive to do things the same way."

In fact, FMST has devised an organizational structure in which nurses and other staff must be candid with the physicians because there is no office manager. There are only two organizational levels: the physicians, and everyone else. Each staff member generally reports to the physicians. Employee reviews reflect all the physicians' views of each person's performance.

I was skeptical. How do staff know which physician to bring a specific question to? How do staff determine which physician really needs to be made happy on a given day? And how do they handle situations in which Dr. A wants them to do something one way, while Dr. B prefers it another way? How can a person's performance be fairly reviewed by committee - especially a committee of doctors, who are generally notorious for being set
in their own ways?

Staff told me that this is just not a problem. These physicians are so in sync with one another that there really is no difference among them in terms of their interactions with staff or their preferred ways of doing things.

"We like not having an office manager," says Finnye LaTour, an administrative employee who has worked at FMST longer than any other staffer. Indeed, over lunch, with the physicians out of the room, the employees universally agree that their flat organizational structure is a crucial key to their success, and most have horror stories of despotic managers at previous jobs.

From time to time employees also review one another, in a fashion. FMST pays staff a bonus when the group meets certain collections targets: 12 percent of revenue above the goal goes back to the employees. Occasionally, the physicians will ask employees to rate one another anonymously, and they use these ratings to determine how to divvy up some of the bonuses.

This system also struck me as dangerous. Doesn't it create division among staff? Nope.

"We're very team-oriented and very family-oriented," says Sanchez. "Our personal lives come first, and when something happens in your personal life, they understand."

Access to the physicians, along with the financial rewards that come with success, allows each employee to feel a sense of personal ownership in the practice. There is no rivalry between the front and back office because the employees are trained in and work in almost all aspects of the practice.

But FMST's physicians are most proud of the fact that they work hard to tell staff how much they appreciate them. Monetary demonstrations are always appreciated, but it seems that simple exhibitions of respect are just as important. The doctors presented LaTour with a Rolex in appreciation for her long service, but none of the staff mentioned this when I was there. Instead, they wanted to talk about how hard the doctors strive to obtain staff input before hiring anyone new, and how they make everyone feel equal.

"They do a great job of hiring the right people, and they always stress that we're a team, a group," LaTour says. "No one's above or below anyone."

More change coming

Soon, FMST will be expanding to a new, larger office, adding several new physicians, with the goal of tripling the size of the practice within a year.

On tap is a plan to offer local companies - Dallas/Fort Worth is becoming a kind of boomtown for Fortune 500 corporate offices - VIP service for executives. They'd also offer on-the-spot health services to employees, even transporting workers from their offices to the practice and back.

The physicians have been consulting locally based executives about these plans, and they are getting very encouraging feedback, Gothard says.

Still, the physicians aren't sure how the expansion will play out long-term. Will they be able to maintain their family atmosphere and flat organizational structure with so many new bodies? Will their new physician colleagues be as like-minded as Gothard, Crow, and Weyenberg are?

They're hopeful but uncertain. One thing they do know is, as Crow puts it, "We've innovated out the wazoo for a three-physician practice," and this new plan just seemed to be the next logical step.

But with things going so swimmingly, why not just sit on their hands and enjoy the fruits of their labors? That just wouldn't be them.

"The very approach that has made us successful so far is what's driving these changes," Gothard says.

Bob Keaveney is executive editor of Physicians Practice. He can be reached at bkeaveney@physicianspractice.com.

This article originally appeared in the November/December 2006 issue of Physicians Practice.