One day this past spring, I met with a patient for our standing care management appointment. She’s been coming to our clinic for 5 years, and during our conversation, I asked my usual questions. When I asked her how she was feeling, she told me something I didn’t expect.

The patient shared that her mobility was getting worse. She said it was getting hard for her to leave her home, because she couldn’t manage the step down from her porch. We continued the conversation, and I addressed her other concerns. But after the appointment, I got to thinking. How could we make it easier for her to leave her home?

I didn’t have to wait long for an answer. Later that week, my granddaughter was telling me about her day in school, when we suddenly had an idea. Her class could build a ramp for our patient!

I contacted Aaron Haselwood, the Industrial Arts teacher at Fredonia High School, about building a ramp. He joined in right away. He thought it was a great way for the students to learn and help the community.

Here’s Aaron’s story on how his students built the ramp:

When Tara reached out to me, I thought it would be a perfect project for my class. This is my first year teaching this class, and I can already see that the students are getting a lot out of it. They’re learning skills, gaining confidence, and earning certifications, all while giving back to the community.

The ramp was a class project, but five students took the lead on building and installing it. We spent about two class days on this project. On the first day, we met with the patient to discuss our plan, and then took measurements. We built the ramp in our workshop and installed it on the second day. The ramp didn’t cost the patient anything, because we used leftover materials.

My class already has projects lined up for next year, and we’re excited to continue helping more people in the community.

This ramp has helped my patient become more independent. She feels safer when she enters and exits her home. The ramp, combined with her exercise regimen, has reduced the patient’s risk of falling. She has not had a fall yet. I’m so glad that thanks to care management, our patient feels comfortable telling me her concerns. And I’m just as happy to know there are resources and people in our community eager to address them.

Here at Aledade, we talk a lot about getting out beyond the four walls of the practice – because that’s how you get a window into the real challenges that a patient faces every day. They might be challenges we couldn’t have seen if we kept doing business the same old way. And sometimes, if we fix those, everything else can fall into place.

One of our partner practices proved this not too long ago. Dr. Syed Zaidi has been working in the town of Ripley, Tennessee for the past 20 years – providing care to the families around Ripley through his independent practice. And thanks to Aledade, he was able to care for them with some new tools.

In 2016, Dr. Zaidi started offering Chronic Care Management to some of his Medicare patients. This meant that a care management team would check up on his patients with more complex chronic conditions, making sure they had their medications and to try to get ahead of anything that could go wrong.

One patient had been in care management for a while, but Dr. Zaidi and his team weren’t seeing any changes. Neither he nor the patient felt like they were really making progress.

Then one day, the family opened up, and shared the real challenge they were living with every day. They were homeless. For several weeks, the entire family had been living out of their car – joined by a few animals they had adopted as pets. Their home had been infected with mold, making it uninhabitable, and they didn’t know where to turn.

That’s where the care management team and Dr. Zaidi’s whole practice jumped in. They helped the family find a safe place to live. Through community resources, they secured donations and raised money to provide the family everything from new mattresses to new clothes. And, since the family’s new home couldn’t take pets, Dr. Zaidi’s team even found good homes for every one of the animals. Today, the family’s healthier, and the patient’s chronic conditions are under much better control.

Chronic diseases are only going to get more challenging in the years to come. In 2012, the CDC estimated that one out of every two adults in the U.S. had at least one chronic condition. One in every four U.S. adults had two or more. And 86 percent of all of U.S. health care spending in 2010 was for people with at least one chronic medical condition. Chronic care management – by actually connecting patients with an active and engaged care management team – can tackle a daunting challenge for our health care system, and open up new possibilities in lowering costs.

But most of all, CCM helps our patients live better lives. Thanks to CCM through Aledade, we found out about this family’s situation. And thanks to the compassion and drive of Dr. Zaidi and his care management team, this family got back on their feet and back on the road to better health.

As the Care Manager at the Winston Clinic and a Nurse Practitioner by training, I’ve taken the lead in working with our high-risk patients, as well as those with uncontrolled chronic diseases.

When a patient is identified as “high risk”, whether that’s by Aledade or by a provider, we place the patient’s name on my desktop, and add it to our list of patients who should receive care management. Usually, these are patients who need support for a hospital discharge, or have had a new diagnosis. Sometimes, they’re patients who will need support over a longer time period. One of our new programs is to place patients with uncontrolled chronic disease onto care management before we even refer them out to a specialist.

I have multiple patients who say they benefit from care management, and their clinical numbers show the same thing. But there are two patients who stand out the most.

One was placed on care management for her diabetes. In the past three months, she’s made huge steps forward. She had been diagnosed as diabetic for more than a decade, she’s been on insulin and Metformin for some time and her HgBA1C level hit 15.3. Our clinic was just about to refer her to an endocrinologist, until I asked specifically if she could be referred to Care Management services instead.

On our first care management call, I started by just asking her why she thought her sugars were high. The patient told me that she didn’t know – she wasn’t eating any sweets or white bread. She had no idea that different fruits, vegetables and drinks were driving her sugars up. When I asked what her providers had taught her, she said she felt stupid for asking them questions, and they had assumed she already knew.

I also asked her why she wasn’t taking her insulin. It turns out she had been placed in the hospital once before for hypoglycemia because she had taken too high of a dose of insulin. She was worried about putting herself through that again.  Over the course of several phone calls and an office visit to train her how to manage her diabetes, the patient told me she feels much better about her ability to manage her diabetes.

Her last A1C reading was 11.5. That steady decrease is a win for the practice, and a win for our patient! But we’re not stopping there – we are still working together to lower these numbers this even more!

The other patient who stands out to me was diagnosed with prediabetes. She was due for an Annual Wellness Visit (AWV), so we brought her in. I gave her a health risk assessment, where she remarked that she felt unwell today. But she wasn’t very specific. Then I saw that her PHQ9 – a depression health questionnaire – was off the charts. I put the diabetes aside for a second, and started using some of my coaching skills to help her to open up.

She told me that she was suicidal on most days. Her mother had died three weeks before, and often she would lay in bed and cry all day. She had missed her previous day’s counseling appointment, and wasn’t scheduled to see her outpatient counselor for another several weeks.

I determined that she was not suicidal at that moment, and began to use some of our health coaching strategies. I asked her if she could picture herself happy. She said she could not. She said the only reason she hadn’t killed herself is because she didn’t want her girls to lose their grandmother and their mother in the same year.

Needless to say, we talked a lot. In the end, she decided that she could commit to one change. She would spend time each day trying to picture herself happy. And during the few times a week that she felt happy, she would write down what she was grateful for. As soon as the patient left, I called the counselor, and she called the patient for a phone visit immediately. She’s visited her counselor multiple times.

I have spoken with the patient every week over the course of several weeks. She felt that I wasn’t judging her during the first visit, that I actually cared about the “other stuff”, even though she was there to discuss her diabetes.

Just recently, I asked her how she was feeling.

She responded, “I think I can be!”

I said, “You lost me. You can be what?”

“One day,” she said, “I think I can be happy!”

She has had several bad days since then, and several good days. Through the ups and the downs, I think I’m getting as much from her as she’s getting from me. And I know I would have missed out on this experience if we were not making the effort to reach out to our patients.

I believe in the power of the AWV and care management calls, because I’ve seen it in these two patients, and many others. Here at Winston Clinic, we will continue to support our high-risk patients and patients with uncontrolled chronic diseases through care management and having open, honest conversations.

Drew Brees, the quarterback of the NFL’s New Orleans Saints, the first quarterback to bring home a Super Bowl trophy to the Pelican State, has a pretty simple formula for success: “When you wake up,” he says, “think about winning the day. Don’t worry about a week or a month from now – just think about one day at a time. If you are worried about the mountain in the distance, you might trip over the molehill right in front of you.”

Every morning, not far from New Orleans, there are a few more Louisianans who wake up thinking about how to win the day. They’re the team at the practice run by Dr. Bryan LeBean – a primary care physician who’s been serving in the community of Lafayette for 23 years. And they have a name an NFL quarterback would appreciate – “Team LeBean.”

Just recently, Dr. LeBean’s practice joined the Aledade Louisiana Accountable Care Organization – to find new ways to provide better care to the families in Lafayette, while keeping the practice’s independence. Working closely with other practices in the area, Team LeBean shared some of the tactics and strategies that worked for them – how to properly conduct an Annual Wellness Visit, some ideas for good care management.

They also borrowed a few good ideas, one of which has paid off every morning. Before starting each day, Team LeBean sits down for a Daily Huddle. The entire care management team runs through a few standard questions, and then covers any other topics that came up.

They start by looking at how many AWVs have been scheduled for the day, and how many patients are in the hospital or recently visited the Emergency Department – information that they can find right on the Aledade app.

They then take a look at a few patients with chronic conditions – like diabetic patients, especially those in need of an eye exam, and patients enrolled in tobacco cessation. After running through a few other items, they wrap up by focusing on any particular patient complaints or concerns – always keeping an eye on how today can run even better than the day before.

That’s how you win the day. By working closely together – practices like Team LeBean, their patients, and Aledade are winning the day. And they’re well on their way to a better health care system with strong, independent primary care practices suiting up in the quarterback role they were always meant to play.

In a Health Affairs blog post yesterday morning, Donald Fisher and Chet Speed from AMGA took a hard look at some of the obstacles on the path to value-based care. Building off a survey of their membership and a close look at the Billings Clinic in Montana, Wyoming, and the Dakotas, they found that it’s often tough for practices to get the right data at the right time. They worry that commercial payers aren’t moving as aggressively toward value-based payments – especially in local markets. And they say that reporting requirements are too burdensome.

They’re taking a clear-eyed look at many of the challenges that primary care doctors are facing every day as we move to a health care system that rewards high-quality care. But if we look too hard at the obstacles, we can miss some opportunities.

Here’s what we’re seeing at Aledade:

Commercial Payers are Gearing Up for Value-Based Payment

http://www.aledade.com/moving-ahead-with-payment-reform-in-commercial-markets/

Commercial contracts around value-based payments aren’t everywhere just yet, but they’re on the move. Take this recent analysis from Leavitt Partners –  Medicare may get the most attention, but a larger proportion of lives covered by an ACO come from commercial contracts, and they’re growing at a rapid pace.

Take two examples:

  •  Cigna established CareAllies, a service company that works with provider organizations of all types to improve patient outcomes and raise the quality and affordability of health care.
  • Humana has a well-established value path called the Accountable Care Continuum that moves its Medicare Advantage providers away from fee for service towards global capitation.

Right here in Aledade, we’ve been working with commercial partners – like Highmark and Blue Cross Blue Shield, covering more than 70,000 lives, to connect them with high-quality care through the physicians in our ACOs.

This kind of movement across the market empowers purchasers as well. Now they’re empowered to push their payers towards value-based contracting.

Reporting Requirements Absolutely Need Standardization

http://www.aledade.com/the-importance-of-quality-measures-for-accountable-care/

Just as important as standardization is a shift in focus. We and our partner physicians must focus on getting value out of measurement. Asking ourselves the question “How can we use this measure in our practice to ensure better outcomes for our patients?” No doctor wants to be filling out multiple, confusing and often duplicative quality reporting requirements and there is a lot of work to do in standardization. However, we need to do our part and shift our mindset from compliance to outcomes.

Data Access is a Solvable Problem

http://www.aledade.com/aledade-gets-the-data-flowing-to-pcps/

Fisher and Speed focus on accessing data, but that’s only the first step. We agree that practices need to get the data. That’s why, at Aledade, we focus on connecting to HIEs to deliver data to practices. But practices then need to derive insights from that data. At Aledade, we developed an app that integrates all of a practices’ clinical and claims data, giving doctors a full picture of their patients’ care. And finally, practices need to act on the data, as it guides them to deliver high-quality, coordinated care.

As we grow, Aledade continues to develop relationships with stakeholders throughout the national and local health care markets to equip our ACOs with the data they need. A big part of this is working with Health Information Exchange networks (HIEs) in the communities our ACOs serve.

They can even partner with other practices. One idea that’s started to take shape here is the idea of a virtual group – a group of physicians who can band together online to improve the quality of their care, and be scored as a group for the purposes of the Merit-based Incentive Payment System under MACRA. Our experience has been that these efforts do benefit from the economies of scale and a data “utility” that serves virtual groups and physician practices is an idea whose time has come.

Aledade is here to navigate these obstacles

http://www.aledade.com/growing-together-and-learning-from-our-partner-physicians/

We agree that these obstacles are real. We hear about them from our own partner physicians every day. But they don’t necessarily need to slow our journey toward a value-based payment system. Everybody needs a partner in this era – and a key part of the transition to value is that partnership doesn’t have to be driven by ownership, but can be driven by shared values and centered around the patient.

Whether it is a partner like Aledade who is transitioning practices from volume to value right now or partners like the recently announced support for the Quality Payment Program who help practices get ready for the transition to value, practices are not in this alone.

Trust and good relationships with patients are essential in providing high quality healthcare. A key factor in this equation is being available for patients when they have questions or concerns. This availability is especially important for patients dealing with chronic illnesses or other health issues. Opening an avenue for these patients to have access to care, even outside the clinic, can greatly enhance the trust they feel and the relationship they share with their provider.

Like many others, our clinic is in a state of evolution as we make the transition from a traditional fee-for-service model into a more comprehensive care setting for our patients. We decided last January to begin offering Chronic Care Management as a resource to reach some of our most at-risk patients. Right away it became obvious the success of the program was going to hinge on finding the right person as a liaison between patient and provider. It had to be someone the patients felt comfortable talking to and someone I could trust. It was a very difficult leap of faith, but I decided there was no better choice than Susan Williams, my nurse of 15 years. Susan already has good relationships with all of my patients, and they trust her. I promoted her to the position of Care Manager, and we began enrolling patients.

With Susan leading the way, our patients immediately embraced the program, and we have seen many of our most in-need patients begin to manage their health more effectively and efficiently. We have over 80 patients under management, and only two have discontinued the program.

We launched a new cell phone line so patients in the program could access Susan directly. She carries the phone during office hours so that patients no longer need to speak to the receptionist. They no longer worry about not getting a call back or if their message is lost in translation. If there is a problem, Susan comes to me directly, and we decide whether the patient needs to come to the office or if we can handle the problem remotely.

It became immediately evident, once these patients knew they could get an answer quickly, their tendency to run to the emergency room decreased. Susan began keeping a list of patients who were seen in the office on the same day they called and spoke to her. While this is a number that never shows up in the data, we have counted over 40 occasions since last June where the patient called asking if they should go to the emergency room, and instead they were seen in the office. Even if they actually do need hospitalization, I can admit them to our hospital directly from my office, avoiding the time, stress, and extra cost of a trip to the emergency room.

A specific example of the effectiveness of the program involves a patient who had an outpatient procedure to replace his pacemaker battery. The following day he spiked a high fever and called the number provided by the cardiologist. He was unsuccessful at reaching any of the clinical staff and was told he would get a call back, which never came. Instead of going to the local ER, he called Susan. She informed me of the problem, and I had her call the Cardiology practice. She was quickly able to get the physician on the phone and direct admission was arranged under the care of the patient’s cardiologist. With a simple call, an ER visit was avoided and care was provided quickly.

Aledade ACOs emphasize the special relationships small practices have with their patients, and their guidance helped us launch this beneficial care management program. Our patients value the personal relationship they have with Susan, and we have direct evidence the program has led to better health outcomes and lower hospital and ER utilization by our patients.

President Trump’s administration has made it clear that they plan to greatly alter, if not repeal, the Affordable Care Act. To both sides of the political isle it may come as a surprise that altering the Affordable Care Act will likely have little impact on a core outcome of health reform: the fact that private insurance companies increasingly pay primary care providers for improved health outcomes. Since the presidential election, we have met with a dozen payers in both red and blue states: Arkansas, Florida, Louisiana, Mississippi, Missouri, New Jersey, Pennsylvania, Utah, and West Virginia. Not one payer has mentioned that they plan to stop their efforts, or pull back resources dedicated to moving physicians away from the fee-for-service paradigm and towards paying for outcomes. In fact, every payer we meet is intent to continue to innovate by paying providers in a manner that lowers cost and improves health.

A key piece of the Affordable Care Act created the Medicare Shared Savings Program, and private payers quickly followed with their own efforts to move physicians to shared savings contracts. Years later, private payers continue to dedicate significant resources to move providers away from fee for service and towards value payments. And payers have committed to move all of their providers, across all business lines (commercial, Medicare Advantage, and Managed Medicaid), to value. This investment has been significant. For example, Cigna established CareAllies, a service company that works with provider organizations of all types to focus on improved patient outcomes and better health care quality and affordability. Similarly, UnitedHealthcare (via Optum) has gone further and purchased providers in order to create high value networks and their own Accountable Care Organizations. Humana has a well-established value path (the Accountable Care Continuum) that moves its Medicare Advantage providers away from fee for service on a path towards global capitation. Each of these national payers have undertaken vast strategic efforts that require significant resources for staff and infrastructure, and a change in culture.

Commercial payers believe, and have the data to demonstrate, that paying for value lowers their cost and improves the health of their members. For example, UnitedHealthcare has noted up to 6 percent lower medical costs across a range of value-based care programs, and overall, commercial ACOs have lower expenses per Medicare enrollee and slightly higher quality-of-care scores.

Despite the threat of repealing parts or all of the Affordable Care Act, our payer partners continue to move ahead with their payment reform efforts. The political battle over Obamacare has had no impact on payers’ dedication to reform provider payments; the future of primary care provider payment remains value-based. Though there is still much unknown about the potential repeal and replacement of the Affordable Care Act, the future of physician payment reform is clear.

In the primary care setting, physicians are constantly faced with the challenge and opportunity to care for patients who bring numerous and diverse needs into the clinic.

Behavioral health is one particular challenge that can make providing value-based care difficult. A recent report from the Commonwealth Fund highlighted this challenge and noted that high-need adults with a behavioral health condition struggle to receive adequate care, yet, at the same time, these patients have much higher health care costs.

Aledade understands the importance of integrating behavioral health care into the primary care setting. By striving to understand and meet all of the needs our patients have, we successfully help them receive higher quality care at a lower cost.

In fact, recently, I saw the importance of our behavioral health care coordination in action. A patient of Dr. Annil Sawh of the Orlando Medical Group in Aledade’s Florida Central ACO was utilizing the Emergency Department (ED) at a very elevated rate. This patient was abusing prescription opioids, and when she ran out, went to the ED to seek more medication.

Some people suggested Dr. Sawh should ‘fire’ the patient due to the high ED utilization, but Dr. Sawh was committed to providing her with the care she needed. Dr. Sawh tried setting up a “contract” with the patient, gradually limiting the number of pills she could receive. However, the patient ultimately continued drug-seeking behavior with other providers. She attended a drug rehabilitation program, but as is often the case with opiate abuse, she relapsed quickly after release from the program. Refusing to simply drop the patient from his care, Dr. Sawh turned to Aledade for some additional guidance.

The Aledade Central Florida ACO Executive Director, Sheila Fuse, suggested that Dr. Sawh request a consultation with me. I recommended that Dr. Sawh try treatment with Suboxone, an FDA approved medication for opiate dependence.

This intervention was highly successful. Before being treated with Suboxone, the patient conducted seven ED visits over the span of three months, but she has since avoided ED visits altogether over the past few months.

This patient broke the self-destructive and costly cycle of abusing opioids and making too many ED visits. She now works with Dr. Sawh to help a family member, with a similar set of problems, improve her life situation and break the cycle as well.

Aledade’s impact goes beyond the regular discussions we have with our physician partners.

Each month, I visit with care managers at the Green Spring Internal Medicine, one of our ACO partner practices in Maryland, to discuss psychiatric issues that come up in their care setting. During these visits, I provide advice and learn important lessons from the care managers at Green Spring that I can then take to Aledade practices across the country.

The Aledade depression toolkit is another example of how we help providers understand how to manage behavioral health conditions. This toolkit includes a comprehensive packet on how to treat depression, information on how to manage medicines, and guidance for care managers when psychiatric conditions arise.

Following the recent, serious flooding in Louisiana, Aledade was able to recommend resources for trained disaster relief counselors. Another small success was helping to facilitate better communication between a community mental health center and one of our Aledade practices in Kansas, to improve the referral process for primary care patients needing mental health treatment.

In the upcoming year, some upcoming initiatives involving behavioral health will include supporting our primary care providers in their efforts to offer advance care planning so that patients can face terminal illness in a manner consistent with their wishes and values, and we also aim to increase behavioral health-specific care management throughout our network of providers.

By placing a focus on quality behavioral health care, Aledade is giving providers and patients the tools necessary to manage these issues in the primary care setting. It’s a pleasure to work with physicians like Dr. Sawh and the providers at Green Spring as we all strive to ensure our patients receive the best possible care. Together, we will continue to develop effective ways to keep patients engaged and give them the health outcomes they deserve, while reducing the challenge of treating behavioral health issues in a primary care setting.

For over twenty years, I’ve been blessed to receive exceptional care from Dr. Chiarito, my primary care physician at Mission Primary Care Clinic in Vicksburg, MS. I’m a retired English professor, I’m a minister of the Presbyterian Church (USA), and I’m someone who’s had plenty of engagement with the health care system over the last few years. This includes having my hip joint replaced and, recently, having surgery on my shoulder. With the help of Dr. Chiarito, I have also recently lost a significant amount of weight.

I remember meeting Dr. Chiarito, when she was still in medical school, observing at the Mission Clinic. In the years since joining the practice, Dr. Chiarito has been someone I depend on for my medical care. I have never had a better relationship with a doctor. Dr. Chiarito’s warm, outgoing personality helps me know that my medical needs will be supported, and her personal touch with patients is noteworthy. Once, when I was in a skilled nursing facility, Dr. Chiarito came by to check on me, and she brought me some delicious figs from her garden!

In addition to Dr. Chiarito, I’ve also grown close to one of the nurses, Melody, who helps me take proactive measures to prevent future health problems. Examples of these measures include the flu and pneumonia shots I receive and the Prolia shots Dr. Chiarito prescribes for osteoporosis prevention.

I am enrolled in the Mission Clinic’s Care Management Program. Mary, the Care Manager, helps address my unique health concerns and works in partnership with me to identify and implement ways I can positively impact my own health. She calls me once a month to check in, and we have a conversation about changes in my health as well as any health-related questions I may have. Her monthly phone call is a source of confidence and peace of mind. If there is something bothering me, Mary arranges an appointment for me right away.

One example of Mary’s dedication to managing my health stands out. After my shoulder surgery, my physical therapist had a few questions for my surgeon. Unfortunately, my physical therapist had trouble reaching him. Mary called the surgeon every day for a week, and she was able to get the answers needed to continue my physical therapy. Without getting the right physical therapy in a timely manner, my recovery could have been severely impacted.

I encourage everyone to have a primary care physician and build a relationship with their doctor and the rest of the practice staff. The Mission Clinic team has greatly improved my health, and they have positively impacted my life. Because of the relationships I have with everyone at Mission Clinic, I feel confident asking questions, and I know I am receiving the best care. Dr. Chiarito, Mary, and Melody are partners in my care, they help me get all the right information, and they determine the best plan for me. Mission Primary Care Clinic gives me a great sense of being personally looked after, and, with their help, I am confident many healthy years are ahead!

Dr. Salvatore Volpe, MD, FAAP, FACP, CHCQM, a member of the Aledade Primary Care ACO, was selected by the Patient-Centered Primary Care Collaborative (PCPCC) as the 2016 recipient of its National PCMH Practice Award. Dr. Volpe is the chief medical officer at the Staten Island Performing Provider System and has run his own primary care practice in New York for more than 25 years. Below he explains his unique approach to running a primary care practice and how it’s changed over the years.

For me, a primary care physician and Staten Island “settler,” being recognized at the same ceremony as Dr. Paul Grundy and Dr. Edward Wagner is like being on stage with the Mickey Mantle and Joe DiMaggio of my profession.

Dr. Grundy is the godfather of patient-centered medical homes, or PCMHs, while Dr. Wagner wrote the book on Chronic Care and Care Coordination.

I am honored to receive PCPCC’s award, as I see it as a lifetime achievement award (even though I’m still practicing). And, I am humbled to be recognized, because all I ever set out to do was run a solo-physician primary care practice in my home town. Lastly, I am proud of the award as it marks how far my practice has come since its founding 25 years ago – especially our advances in care delivery, quality, and technology.

In my view, my practice has always been a PCMH in principle. However, it’s been a long-term, step-by-step process: achieving PCMH status, becoming the first solo-practice to achieve PCMH NCQA Level 3 in the nation, becoming chief medical officer of State Island Performing Provider System, and joining an Aledade ACO.

Through this, I have come to appreciate three keys to running a high-performing PCMH primary care practice: technology, care management and communication, and patient relationships

When I founded my practice there was no EHR. I used a medical manager practice system for billing and appointments, and that was it. However, I took advantage of a little-known feature in the system called notes, a place to leave details similar in length to a tweet today. With this, I could keep track of test results, reports, and patient information. I saved a lot of health care spending and improved patient health by having access to these notes whenever I got a call – during or after office hours.

When I finally got an EHR system in 2005, it was both a commitment and a risk. Not only was it a hefty investment for my small practice, but it would require hours of learning and workflow adjustment until my staff and I were fully comfortable with its utilization. The investment was worthwhile though, and many EHR system updates and other IT tools later, today I have technology that empowers my practice with data, insight, and analytics never before imagined. Due to this, I’ve become an advocate for EHRs and health information technology, which has lead me to many advocacy roles, including at the NYS Medical Society HIT Committee, the New York Chapter of HIMSS, and assisting Dr. Mostashari and the Aledade team in developing population health technology tools.

One area that improved technology has helped significantly is care management and communication. Through our EHR, HIE, and population health tools, my practice can better collect, manage, and analyze the patient information we need. A good example of this – involving both patient-to-provider and provider-to-provider communication – occurs when one of my patients is admitted to the hospital. Once notified, I call the hospital to speak with the ED doctor or hospitalist to coordinate care – by sending patient records, explaining health history, requesting a discharge summary, and letting patients know to follow up with my practice.

Today, population health management is driven by patient data and technology tools. I can use the EHR and care management tools to assess which patients are at risk due to chronic disease, recent ED or hospital visits, or even flu season, and ensure we are managing the risk. This means communicating with the patient via the phone, to check in or schedule a visit; during a visit, about health needs or prevention; or, for my practice, throughout our community.

Modernization and technology has certainly impacted my practice greatly, but it can only do so much. Primary care, like many professions, still comes down to the people. I pride myself on personal communication and relationship with my patients. My inspiration comes from the lesson of my parents, who, rather than being physicians, were blue-collar workers, but that took care of their friends and neighbors in the community. This example is how I operate my primary care practice. My patients are part of my community, as I live 15 minutes from my practice, and see them at church and the grocery store. Patient relationships like this are important for improving care as they build trust, as well as encourage open communication about health concerns – both mental and physical.

I consider primary care physicians to be the project manager of health. It’s through this approach, including my continued focus on advancing technology, care management, and strong patient relationships, I have been able to successfully lead a solo-physician primary care practice for over 25 years. Recognitions are always a gratifying surprise, and they only further motivate me to improve my practice and care for what matters most – my patients.