Pediatrician Margaret Sherman

Since Arban treated his first Fayetteville patient, the ranks of primary care clinicians and support staff at Emory have mushroomed.

Today, Emory's Fayetteville clinic has seven full-time physicians, three part-time specialists, a midwife, and a support staff of 30. They join more than 100 family practitioners, pediatricians, internists, and obstetricians-gynecologists who practice in 15 clinics (now called health centers) in metro Atlanta.

Together, they make up Emory Primary Care - our bold venture into health maintenance and population-based care. From the outset, our goal has been to position Emory as the best place to go for high-quality, convenient health care from cradle to grave, inpatient to outpatient, whatever the diagnosis, wherever the patient.

To get there, Emory has invested more than $40 million in bricks and mortar, staffing, and other infrastructure to develop geographically distributed services. We've beefed up our investment on campus as well, housing primary care physicians in a new, state-of-the-art facility at 1525 Clifton Road. And we've become actively involved in our community, with such successful outreach programs as Emory's high-profile first aid stations at Turner Field, where Emory clinicians treated some 8,000 Braves fans and employees last year.

Already, we've seen results from these efforts. More than 350,000 patient visits are expected this year at Emory Primary Care sites, ranging from our smallest health center in Social Circle to our largest at Emory Clinic North. More than 42,000 of those patient visits to our centers will result in referrals to Emory specialists, with billed charges expected to top $50 million.

While we've come a long way in a short time, mapping the way to provide the best in primary care is still very much a work in progress at Emory.

"It's been a steep learning curve," says William Winkenwerder, Emory Healthcare's vice president for primary care. "Emory had never provided health care in so many different sites, and we discovered that it's more complicated to operate, set standards, and communicate in multiple locations. We had to figure out all the nuances of dealing with round-the-clock access to doctors, nursing protocols, triage, urgent care, and the sheer volume of patient visits."

As an academic center focused on specialty care, Emory also had never dealt with the larger numbers of patients seen typically in a primary care setting - 20 to 25 patients a day per doctor, (in pediatrics, 25 to 30). "Handling that kind of patient volume means we've got to answer the phone and get people in and out quickly and efficiently, without keeping them waiting," says Winkenwerder.

And while we're handling patients quickly and efficiently, we can never overemphasize the importance of kindness and compassion. A basic rule of thumb is that one of the most important persons in a clinic is the one who answers the phone or sits at the front desk. They can make or break a primary care practice. They must be friendly and helpful when patients come in, try to prevent problems from occurring, and check on patients who are waiting.

That's why training is especially critical to the success of our endeavor. "We realize that training for new staff in the past was probably insufficient," says Winkenwerder. "Now, we're focusing on training people before they go into their jobs, before they take the first phone call or interact with the first patient. We can't afford from a service perspective for people to learn how to do their jobs on the job."

Training is important for other staff as well - from medical assistants and billing and coding staff to nurses and physicians. For example, seminars on billing codes and the requirements of Emory's many managed care plans are helping clinicians and staff better process patients' requests and bills.

To make our practices more efficient so that physicians can concentrate on seeing patients, we're also changing our personnel mix - reducing the number of clerical staff when they leave their jobs while hiring more registered nurses to assist patients and field their questions.

Creating balance is an ongoing challenge, says William Branch, chief of internal medicine for Emory Primary Care and author of the "bible" of primary care, Office Practice of Medicine. "We're trying to get new patients into our system and seen by the doctor they choose, and at the same time maintain capacity for our current patients to be seen promptly," he says.

A task force, led by Judy Williamson, director of practice services for The Emory Clinic, and Katie Sparks, director of operations for primary care, is reviewing access issues that are critical to the best possible patient experience - from that first phone call to schedule an appointment, to what happens when the patient arrives at the clinic, to appropriate follow-up and accurate billing.

Through benchmarking with other primary care systems, Emory is determining best practices and standardizing procedures for coding, billing, and collections. We're still working out the bugs in our computerized appointment system to facilitate patient flow. And we're aiming for improved clinical information systems so physicians and staff in multiple offices can track and monitor patients more effectively, wherever they are in the system.

"We grew and added sites and doctors very quickly in the beginning," notes Winkenwerder. While he expects primary care to continue to grow, doctors and staff now will be added more strategically than in the past. For example, the original plan called for more than 300 primary care physicians. The number has been adjusted downward to peak around 150, possibly within the next four to five years, and will include some non-Emory physician partnerships. Agreements also have been reached for admissions to non-Emory hospitals.

"It seems naive now, but at first, our thinking was that all our primary care doctors could send all their patients to Emory, and particularly to campus. But that doesn't work except for patients on this side of town," says Winkenwerder. "People in outlying counties such as Cobb, Fayette, north Fulton, and Gwinnett are much less likely to come all the way into Atlanta. So Emory had to go to them."

And not only with primary care. With specialty care too.

The traditional primary care model offers primary care services only. Our new multispecialty models, such as Perimeter, Emory Clinic North, and Smyrna, offer both primary and specialty care, and physicians have privileges at hospitals near those centers. Emory Clinic North is the prototype for at least one or two additional multispecialty facilities that probably will be developed in south or east Atlanta.

"If patients come to us and expect to be seen by a primary care doctor who is conveniently located in the community, it makes sense that they also would like to see a specialist who is convenient to them," says Branch.

The multispecialty practice model is popular with both patients and clinicians, says pediatrician Margaret Sherman, who set up practice at the Perimeter Health Center a year ago. "It offers something to me professionally that I didn't get in a single specialty practice, and it's good for my patients, too," she says. Whether it's an otolaryngology consult to remove a bead from a small child's ear or a referral to a dermatologist about a particularly unusual rash, working closely with subspecialists has given Sherman a broader appreciation of what's happening in medicine. "That's something we offer the public that's different from what they're getting elsewhere," Sherman says.

Adds Sujatha Reddy, an obstetrician-gynecologist who practices at both Perimeter and the Emory Clinic North, "There's a lot of interaction among the doctors at our center. If I have a question on a lab result or a medication, there are internists here who will answer my questions or see my patient if necessary. We're consumer friendly, and that's how medicine should be."

"Like everyone else in primary care, we're working hard in a system that's challenging at the moment," Branch says. "As gatekeepers, the burden is on us to coordinate a lot of referrals and appointments that patients in the past have made on their own. In addition, we're anxious to be efficient and do a good volume of work and at the same time maintain our quality. That means we must spend time with patients and be thorough. We can still deliver high-quality medical care, but as the times change and there are new pressures, we may be pushed to do more."

Those challenges are further complicated by money issues. Primary care is still operating in the red and probably will for a few more years, Winkenwerder says. However, the losses are significantly offset by additional revenues through referrals to specialists, tests, procedures, and hospital admissions. (Nationally, each $1 in primary care services generates $7 to $9 for a multispecialty system.)

Through our reputation and more managed care contracts that are steering more patients to us, we're seeing the volume build. Patient visits per physician per day have risen from 10 some 18 months ago to almost 17 today. Emory Primary Care finances are improving, as are efforts to create efficient schedules to see more patients. Ultimately, to reach an optimal efficiency, physicians will need to see an average of 22 to 23 patients per day across the entire system.

Still, Emory Primary Care has put reigns on expenses and a freeze on hiring, reduced salaries, limited raises, restricted teaching during clinic hours in some cases, and curbed physicians' continuing medical education expense allotment.

In 3,100 survey responses (an average of 40 to 45 responses per physician), Emory earned a mean rating of almost 9 on a 10-point scale for patients' overall experience (using such criteria as care, wait time, parking, getting into the building, restrooms, and telephone access). More than 85% of the respondents said the personal manner of Emory doctors and staff was excellent or very good.

And to the delight (and amusement) of the pioneers blazing these new trails for Emory, the survey revealed that many Atlanta newcomers think of Emory as a primary care system. Couple that with our reputation for providing specialty care that nobody does better, and it's an unbeatable combination.

"We've still got a lot to learn," concludes Winkenwerder, but he is optimistic. "Primary care is important to Emory's success and the future. We have the opportunity to evolve into a true multispecialty practice group model that is unique in the marketplace. Our ultimate success will depend on our patience, a persistent effort to continually improve, and the cooperation and collaboration of all our physicians."

--Marlene Goldman

Seven years ago, The Emory Clinic consisted of mostly medical specialists based on Clifton Road and some at Crawford Long Hospital. To thrive in the future, Emory needed a managed care contracting office and to come together as a health care system.

"We needed to provide the community better access to our clinic and a continuum of care. Primary care was and is a prominent part of that strategy," says Rein Saral, CEO of The Emory Clinic.

"The economic fact was that with the increasing incursion of managed care, The Emory Clinic and Emory Healthcare were vulnerable by not having primary care," adds William Winkenwerder, vice president for primary care services. Currently, about 35% of Emory patients are insured by managed care plans, and that number is expected to rise sharply over the next few years. "We realized that in the future as more and more people got into HMOs and managed care plans, our ability to see those patients would be totally dependent on community doctors to send them this way and we couldn't depend on that anymore. Primary care is a key part of the piece of an integrated health delivery system, and we need that piece."

Primary care is still not a highly profitable component of our health care system, Winkenwerder says. "But to insure our success as an integrated health care system, we have to get patients. Our data suggest that many people still think they can see Emory doctors only by referral and that Emory sees only the sickest of the sick. Our marketing campaign seeks to change that perception by saying that when you see an Emory primary care doctor, you get access to everything that Emory has to offer."

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