A Day in The Life of a Housecall NP
We were honored to be featured on the Barton Associates Blog about the life of a Housecall NP. We hope you enjoy the article as much as we did. Have a great weekend.
Use every minute because they’re not recyclable…
Medical professionals question cost, pace of electronic medical records
POSTED: 12:08 PM Tuesday, August 9, 2011
BY: Jennifer Larino, Staff Writer
TAGS: electronic medial records, Jenny Smith, Louisiana Health Care Quality Forum, Madelaine Feldman, Medicaid, medical records, Medicare, Nadine Robin, Ochsner Health System, Practice Fusion Inc., Robert Rowley, Scharmaine Baker
On a recent weekday morning, Scharmaine Baker sat in her vehicle and pulled up the day’s schedule for her mobile health care practice on her iPad.
Baker, a nurse practitioner with her own practice, spends her days weaving throughNew Orleansneighborhoods and visiting the homes of her elderly and homebound patients.
She carries the traditional stethoscope and blood pressure cuff. But she said it’s the iPad at her side and free, web-based electronic health record software that keeps her practice going, allowing her to draft visit notes, record blood pressure and pull up lab results from anywhere.
Baker used to track each patient on paper and then transcribe those notes to her computer before her 100-patient practice washed away after Hurricane Katrina. She bought her first electronic health record system in 2006 as her client base swelled to 500.
“It was crazy then. I was seeing five and six people at a time in a home,” Baker said.
Today, Baker is an enthusiastic early adopter of electronic health records as many private practitioners are still wading through the costs and mandates surrounding them.
In 2009, Congress set up standards and incentives to help providers achieve nationwide electronic medical record access by 2014. In four years, the federal government will start cutting Medicare reimbursements for physicians who have not implemented an electronic record system and features such as e-prescriptions.
Louisianais using $10.5 million in federal money to build a statewide medical records network to connect physicians and hospitals.
While the technology to link the two worlds stands at the ready, actually doing so will mean clearing cost and cultural hurdles.
The Louisiana Health Care Quality Forum will staff a resource center for physicians transitioning to e-records and oversee implementation of a network this fall.
Program manager Jenny Smith said the goal is to allow patients and physicians to access and store data, such as allergy information, prescription medications and lab work, on a central network and outside servers. The first phase will be live at select hospitals and physician facilities inLafayetteandShreveportby November.
“We’re taking a hybrid approach largely for hurricane preparedness reasons,” Smith said.
Smith said many doctors and hospitals aren’t ready to be linked into the network.
Though hospitals and clinics, such as Ochsner Health System, are moving to implement e-record systems this year, private physicians are still trying to figure things out.
Dr. Madelaine Feldman, a practitioner at a three-person private rheumatology group onNapoleon Avenue, said cost and complex federal mandates are barriers. The Uptown practice has spent $78,000 on its electronic health records system since 2008. Feldman said it has eased the prescription process and reduced paperwork.
“But it’s been over three years and we’re still finding things that we had no idea we had the capability to use,” Feldman said. “The learning curve on this is very shallow.”
To qualify for federal incentives, physicians have to follow standards. That includes using approved systems to write notes and electronic prescriptions, maintain electronic medication lists and electronically exchange information.
Feldman said the standards are complex and she knows several area physicians considering taking less money from Medicare rather than adhering to the standards. Her fear is replacing patient-doctor relationships with a mechanical system.
“Until we stick a brain into these computers that can think the way I think, you’re going to lose the art of medicine,” Feldman said.
Nadine Robin, program manager for the Health Care Forum’sLouisianaHealthInformationTechnologyResourceCenter, said Medicare and Medicaid incentives are tipping the cost and fear factors. Incentives can be as high as $63,750 paid over six years.
“People are realizing that these payments are real and that this is coming. It’s not something that’s going to go away while we go to sleep tonight,” Robin said.
The larger obstacle, she said, is changing habits. Robin noted the software is worthless without skilled physicians using it.
“That’s like assuming that if I gave you a copy of QuickBooks software, you could be an accountant,” Robin said.
For now, the initial use hurdle is simply getting the technology into the hands of practitioners. The next step will be linking dozens of software types to a larger network and deciding who pays for it.
Baker, the nurse practitioner, uses Practice Fusion, a free, advertising-supported software. Robert Rowley, chief medical officer at theSan Franciscofirm that created the software, said the technology is there to link to e-health networks, but connecting to isolated systems is cost prohibitive for his company.
“We can’t really be building interfaces for 1,600 different health information exchanges,” Rowley said, adding that he is skeptical private doctors using free software will pay to connect to an exchange.
Baker is thrilled by the idea of an e-health network. Still, cost is an issue for her practice. She has gone through three software programs in five years, paying as much as $1,500 per month before finding her current one.
Feldman, the rheumatologist, is also interested to see what changes the statewide network and widespread electronic health records will bring. But she’s reserved about the pace of the process.
“I wonder if 50 years from now people will look back and see these things called charts and view them the way we see drawings on cave walls now,” Feldman said, laughing. “Maybe that’s the way it will be. But for now, sometimes it’s fun being a caveman.”
The two-day format will be as follows: Beginning in 2010, the course will be offered on a Friday and Saturday of each month. In January & March, we will have two courses. On the Friday course dates, it will be a classroom day and on the Saturday course dates, it will be an actual Housecall day. Each day will be 8 hours which will give you the 16 hour credits from AANP.
Due to the nature of the Housecall, I can only accommodate two NP’s at a time. This will bring the total to three people entering a person’s home. Most of the patients surveyed for the Housecall program said that three is the maximum amount of visitors at any time from Home Health that they would be able to comfortably accommodate in their home.
Course Dates:
January
Fri. Jan. 22, 2010 & Sat. Jan. 23, 2010
Fri. Jan. 29, 2010 & Sat. Jan. 30, 2010
February
Fri. Feb. 26, 2010 & Sat. Feb. 27, 2010
March
Fri. March 19, 2010 & March 20, 2010
Fri. March 26, 2010 & March 27, 2010
I sure hope this helps. Please email me for questions. I look forward to sharing in this exciting healthcare delivery experience!
In October of 2008, I decided that I wanted to become a Community Care provider (La. Medicaid’s version of an HMO). I was told to apply because this area (New Orleans) was still considered a “provider shortage area” since Hurricane KATRINA and that “free-standing” Nurse Practitioner clinic’s would have no problem getting credentialed. So, I immediately filled out the paperwork and waited for a response while I ventured off to fight other battles. Alas, December 2008 arrived and I still have not heard a word from my “new” Provider Relations department. I pick up the phone and give them a call. I am now told that, “after reviewing your application Ms./Dr. Lawson-Baker, New Orleans is no longer a shortage area. We are only allowing physicians and/or NP’s if it is deemed a ‘provider shortage’ area.” “Oh”, is my response as my face becomes as flushed as a Louisiana Creole Tomato. Ms./Dr. Lawson-Baker, you are welcome to appeal, the attendant says… At this point, I am still speechless as I say, “Don’t worry, I will tell all my Medicaid Community Care patients to find another provider.” I hang up the phone.
Three months pass, and we are now in April of 2009. I muster the strength to appeal and discover that the program is now “under new management”. This could be good, I say to myself. Real good. Hence, I begin a renewed fervor round of calls and letters to the “new management team” to figure out the hierarchy and decide who to pester, in a pleasant, but consistent manner. I am given a name and I place my first call to the leader of the team in June of 2009. I am told that I should re-submit my application and “really explain” just what my practice entails. “No problem”, I say.
After a few application “do-overs” and phone calls (of course), on October, 1st, 2009, Advanced Clinical Consultants became the first NP-owned Community Care Clinic in the City of New Orleans. We were told that 1,000 patients may be assigned to our roster. We saw our first patient today and already have 9 patients “assigned” to the clinic. I still have my Armour on…HUMANA is still in view. I got to get that directory insanity fixed now. Stay Tuned…
In late December 2008, I decided I wanted to be a Humana Primary Care provider. I requested a credentialing packet, filled it out and sent it in. Early March, I received feedback/phone call from Bauer (not real name) requesting “clarification” as to what I was intending to do. She says, “I’m not sure what you are trying to do.” I said, ” I am requesting to become a PCP/NP with your insurance company.” She then said, very politely, “Well, Dr. Baker we just don’t do that. We don’t credential NP’s. Is this for you or your collaborator? I mean…we can link you to him and give him a second location??” So, I politely, say, “No maam…this is for me-the NP (I direct her to my website for clarification) to enable me to adequately serve my current Humana patients (who pay CASH to see me) and the new patients requesting my Housecall services.” We hang up and I don’t hear from her for a week.
Now, I decide I need to be forthcoming and a tad pushy. So, I begin calling Bauer every week. In my weekly calls, I gently ask her for status updates and overall progress in which she was always “waiting” on her boss to respond. Three weeks into my weekly call protocol, I start giving her the names of patients who are dis-enrolling from Humana because I am not a provider on their plan. I also start telling her that we are getting referrals from Humana clients on a daily basis, BUT since we are not on the provider list…sorry, they are told to find services elsewhere or dis-enroll. The final straw came when a Humana rep was in one of my patient’s homes and the patient said that they were not switching their plan to a HMO unless Dr. Scharmaine was on the plan. So, the rep calls my office and I give her an ear full as well as what has or has not been going on with Bauer. This rep then calls Bauer as if I had given her a fable or something. Later that day, Bauer calls me and says, “Dr. Baker, let me be clear. It’s not that we don’t want to add your practice. WE HAVE NEVER BEEN APPROACHED BY AN NP AND WE DON’T KNOW WHAT TO DO!” What! I said, “Ok. Well, where do we go from here?” “Let me get back with you, ” she says.
It is now Mid-April, I get a call from Bauer and she says, “we’ve got the green light to add you, BUT we don’t know what to call you?” “What?!”, I say. Bauer says, “I mean you would not be classified as ancillary and you are not a physician.” I say, “Why not call me a nurse practitioner?” “Let me get back to you, ” she says. Two more weeks pass and it is now late April when I receive a call from Bauer, she states, “We will figure out the particulars as far as what to call you or classify you as , but you will be a provider with a number.”
Today, six months later, I received a call from Bauer stating that I will be a participating provider with Humana beginning June 1st, 2009 as a Nurse Practitioner.
Take Home:
The moral of this true story is to never give up and keep pushing for the wall of resistance to break. It also helps to really-really want something because this passion will fuel your spirits when things are not happening as fast as you want them to.
It also helps to have a website or other marketing tools to give to the public, vendors, or political allies. This will not only show them that you are a serious contender, but it gives them something tangible to refer back to especially when they are not sure of “what” to call you. I say eliminate the guessing game…show and tell everyone that we are nurse practitioners and we are not going anywhere.
Well, as Lexi entered the building, I gestured for her to step in my office. I asked her how she honestly felt about Housecalls and she said that, “I am really more of an office person, even though this is a primarily housecall practice…I thought I could do it.” I say, ok “then this is not going to work for either of us.” “Ok” she says, “Will I get paid?” I tell her that by law I must pay her for the hours worked and that she will get paid. She then goes on to say that she really, really, appreciates what I do and if I have any office openings to consider her. I make no promises and tell her to stay for the day to help us finish packing equipment for the move.
We HUG and realize it is not a perfect match for either party.
An hour later, just as I start to pat myself on the back for having a great “firing moment”, I get a call from one of my patient’s telling me that they are wondering why they have been scheduled to go to a Cardiologist when they have been feeling fine? I place them on hold, and quickly gather all personnel to question the meaning of everything especially when an elderly, frail, client has made an unnecessary doctor’s visit. Alas, it is revealed that Lexi translated the wrong information on the wrong patient when she was making the appointment! With egg on my face, I profusely apologize to the family while they are leaving the wrong doctor’s office and assure them that it will never happen again. In the background, I hear the doctor saying, “She should buy yall lunch!”
In light of these developments, I had Lexi immediately escorted from the premises.
After a few hours of lethargy, I assembled my little black bag, Toughbook laptop, PDA, cell, vaccines, camcorder, camera and headed out to the “Quarters” to see my elderly homebound patients.
The first stop is “Ms. Lolli” 97 years young and as spicy as Cayenne. As soon as I hit the door, she says, “I got pepper tea, Barq’s, Diet cola, and Gin. What you havin’ today and then we can talk about the spider bite.” “I will take a Barq’s on the rocks” as I made it near her comfy rocking chair. We sat and chatted about her spider bite, the French Quarter Festival and everything in between as I sipped the cool Barq’s. I almost forgot she was my patient and I was actually working. I am glad I came to work today…just knowing that she was waiting with the door unlocked anxious to tell her story made my lethargy turn to glee.
Wow. The East is still really bad…4 years later. The progress in this area is incredibly slow. There is a McDonald’s, Popeye’s and a Waffle House for food options (that’s as healthy as it gets). This is important as we often eat on the road between stops for lunch. I’m disappointed, I felt that this area would be further along.
We saw 3 new patients. This is a lot because a new patient visit can usually last 90 minutes.
Oh well, gotta get some rest. I’m off early in the am to MA for and intensive Urinary Incontinence & Biofeedback course with Helen Carcio. I can’t wait to meet the 13 other NP’s. I just hope the weather is no longer zero degrees!
On the road again…
It has been a long time since we went on a housecall. So, today was a treat. We saw a total of 12 patients. This was a large amount for us, but we have a lot of catching up to do.
Later, we went to look at a satellite office on the Westbank after the housecalls were finished. This will give us offices on both sides of the Mississippi River.
I am looking forward to the bladder biofeedback course this weekend in CT. I can’t wait to enjoy the zero degrees weather and an opportunity to meet several entrepreneurial NP’s.