Scherger is vice president of primary care at 289-bed Eisenhower Medical Center, Rancho Mirage, Calif. He came from the University of California at San Diego, joining Eisenhower specifically to develop a patient-centered medical home model of primary care. "Eisenhower has invested in excellent specialists, but people complain that they don't have a primary care doc," he says, noting that the retiree-heavy Palm Springs metropolitan area has only about 60 percent of the primary care physicians it needs. His job is to attract more of them, and his strategy is to make primary care the highly personal and rewarding job it ought to be, rather than the rushed, crowded, paperwork-filled grind that it so often is.
Theoretically, a medical-home style practice should create a better work environment for physicians and deliver more effective care to patients. As of last month, theory became practice with the launch of Eisenhower 365, a full-blown medical home in a slick new building in La Quinta, Calif., that also contains an imaging center, a lab, and a radiation oncology center.
Claim to Fame
One of Scherger's claims to fame is being on the Institute of Medicine committee that released the 1999 report heard around the world (or at least around the country's health care organizations): To Err is Human: Building a Safer Health System. Asserting that as many as 98,000 patients die annually from preventable medical mistakes, the report sparked tremendous interest in clinical and decision support information systems to support patient safety. Ever since, he has been working toward an opportunity to build an ideal primary care practice, and now he's finally got it. "They're letting me walk the walk," he says.
Scherger's practice model is based on that of Greenfield Health, a nationally known medical home practice in Portland, Ore., that grew out of the Idealized Office Redesign projects at the Institute for Healthcare Improvement, Cambridge, Mass. It's built on several principles, all of which require a robust I.T. infrastructure:
* Continuous care based on continuous communication between patient and physician, rather than episodic care based on visits.
* "Strategically proactive," rather than reactive, care, with an information system that tracks patients' conditions and health needs and lets the physician act to head off problems before they develop. "You need a good registry that lets you know who hasn't had a colonoscopy or pneumonia vaccine," Scherger says.
* Care managed primarily by the patient rather than the doctor, and aided by access to medical record information and educational materials and programs. "It's the same transformation as money management, where you used to have a broker do the trading, but now they're just an advisor and you do the actual trading," Scherger says.
A practice structured in this way has these changes for physicians:
* Relatively small patient panels of about 900 per physician, rather than the thousands that now are the norm.
* No more than half a dozen patient appointments per doctor per day, compared with 15 to 20 in an average family practice.
* As much time as necessary-perhaps one or two hours a day-answering messages from patients, and a commitment to get back to every patient within 24 hours.
A New First Tier
"Our new first tier is online care, and patient visits become a secondary activity that's done selectively," Scherger says.
Eisenhower 365 started on a trial basis last summer with five doctors (including Scherger), and quickly signed up several hundred patients. Because the model was in test mode, they didn't pay the $595 per-person annual administrative fee that's in effect now that the program is in full swing.
It's that fee that makes the departure from conventional practice financially feasible. However, Scherger isn't sure how patients will react, though he's optimistic that the fee will be included in the deductible for high-deductible health plans, and also can be paid for through a health savings account.
The I.T. infrastructure that makes the new care model possible is based on a combination of technologies. These include Eisenhower's ambulatory EHR, a hospital information system, an assortment of departmental systems and a patient portal.
Patients are likely to demand different levels of information, and it's Eisenhower 365's job to figure out how to customize for each one, says family physician Gregory Pecchia, D.O., the practice's director of informatics in addition to participating as a physician. His role is to work with Eisenhower Medical Center to make sure the information from its various systems is available in a form that will enable the medical home model to work the way it should.
"We'll probably see some sophisticated patients who want all of their data viewable at all times, including recent imaging and test results, and we'll do what we can to make all that available to them," Pecchia says. "But we also expect to find patients who want something more filtered and easily understood. Rather than looking at all their data themselves, they will want it to be turned into knowledge and wisdom. They may not want to see their morning glucose reading in their PHR without first having their clinician let them know the implications of whatever that result might be. We put the patient in charge of how they want us to communicate with them."
Snowbirds Flocking in
Eisenhower's patient population includes a significant percentage of snowbirds, retirees who escape cruel northern winters by moving to the desert, only to fly back home in the spring. While some of them may balk at paying the annual administrative fee for a doctor they see less than half the year, both Scherger and Pecchia assert that the electronic nature of the medical home will make it easier for the commuters to get the continuity of care they now lack.
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