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A '21st century model' of primary care

For KershawHealth doctors, it's all about 'your story'

Posted: March 1, 2011 4:43 p.m.
Updated: March 2, 2011 5:00 a.m.
Martin L. Cahn/C-I

Doctors Michael Nienhuis and Vanessa Wideman stand at the nursing station at KershawHealth Primary Care at Elgin. In a growing trend, Nienhuis and Wideman are employed by KershawHealth, which they say allows them to focus on communicating with and providing better health care for their patients.

Michael Nienhuis and Vanessa Wideman came to medicine from two very different directions. Yet, the two KershawHealth Primary Care at Elgin physicians got into medicine for the same reason: to help people.

Nienhuis’ background wasn’t even in medicine. No one in his family is a doctor.

“I’m a former social worker and majored in English. I worked in Lexington with an aging clientele dealing with mental illness and numerous health issues,” said Nienhuis (pronounced “Neen-house”).

As he became more and more involved in dealing with gerontology health issues, medical school beckoned. Already holding degrees and a gerontology certificate from the University of South Carolina (USC), he entered USC’s school of medicine and performed his residency at Palmetto Health Richland Memorial Hospital.

Wideman, on the other hand, knew she wanted to be a doctor as far back as sixth grade and thought about being a pediatrician. With that foundation, she received her B.A. and a certificate in human development from Duke University in North Carolina before going on to earn her M.D. at the University of Alabama School of Medicine in Birmingham. Wideman also performed her residency there, moving from pediatrics to internal medicine and, finally, family practice.

Birmingham is home to the NASA Marshall Space Flight Center and neighboring Space Camp.

“We had ‘rocket scientists’ -- some (doctors) get nervous around patients like that -- all the way down to people without much formal education,” said Wideman.

 The two doctors met in 2007. Wideman brought one of her children to see Nienhuis, who was operating a practice in Columbia. The two got to talking, realized they had similar doctor-patient philosophies and decided to start working together. In early 2010, they joined KershawHealth, with Nienhuis taking over the Healthcare Place at Elgin. Wideman followed several months later when the practice moved to the Elgin outpatient center and was renamed KershawHealth Primary Care at Elgin.

Their similar philosophy, as described on the practice’s new website, is “all about relationships.” Or, as Nienhuis puts it, “It’s all about your story.”

“Everybody has a story,” said Nienhuis, “and our ability to extract that story allows us, hopefully, to make a positive difference in our patients’ lives. As a social worker, I learned to meet the patient where they ‘are.’ If you are seeing a highly educated patient, take your cues from them. When you see someone with, maybe, only a grade school education, you don’t talk down to them, but you can’t talk to them the same way. In both cases, you have to adjust so they feel comfortable enough to open up and understand what we’re telling them.”

The object, Wideman said, isn’t for them to sound smart.

“It’s to get to the point, say, with a diabetes patient, where they say, ‘This is the first time I really understand the importance of getting a handle on this,’” said Wideman.

Nienhuis said, thanks to technology and the Internet, patients are more informed today.

“It’s a less paternalistic approach -- there are fun things about that, but it can also be more challenging,” he said.

Wideman agreed, adding, “If I see what they print out (from the Web), I can see what search terms they’re using so I know what they’re thinking.”

A new generation

Nienhuis and Wideman are a new generation of doctors who are choosing to be hospital employees. Theirs is what KershawHealth Vice President of Marketing and Community Development Joseph Bruce called a “21st century practice.”

There appears to be a national trend -- one held up by numbers in South Carolina -- of more medical school graduates not starting their own or joining established private practices. A Medical Group Management Association (MGMA) report indicated that between 2005 and 2008, the national rate of physician-owned medical practices dropped from 68 to 46 percent. Instead, according to information provided by KershawHealth, the MGMA estimates that half of all primary care physicians are now employed by a hospital or health care management association.

A MGMA graph shows a distinctive downward trend for physician-owned practices versus a similarly distinctive upward trend for hospital-owned practices during the study period.

Numbers are slightly different in South Carolina. A 2009 S.C. Hospital Association survey found that physician-owned practices still accounted for 48 percent of all practices; 32 percent were owned by health care systems while 19 percent were operated under hospital contracts.

“KershawHealth has recognized and responded to (this) trend … to ensure we are able to carry out our mission and to provide adequate primary care for the citizens of Kershaw County,” said President and CEO Donnie Weeks. “This also allows us to recruit the best physicians available -- whether in family medicine or other specialties -- and to give them the support they need to provide excellent patient care. It’s a model for success.”

Wideman said joining KershawHealth as employees was, on one hand, a lifestyle decision.

“As a female physician … I’m a mother, a wife and am dealing with those types of things. I need to be there for them,” she said.

At the same time, Wideman noted changes coming from the insurance industry and healthcare reform are causing struggles around patient length-of-stay and discharge issues, among others.

Nienhuis said such issues are becoming increasingly complicated.

“Dealing with both in- and outpatients (simultaneously) is very challenging. This is all we do,” he said of seeing patients in a physician office setting. “We do better than someone juggling both. On the flip side, there is (a hospitalist) in the hospital all the time.”

“This lets them focus on what they want to do,” added Judy Ferrell, KershawHealth’s marketing manager.

Wideman agreed, saying their relationship with the hospital lets her and Nienhuis focus more on preventative medicine and patient education.

“It’s why we gravitated to outpatient and family medicine,” said Wideman.

“It frees us up to have KershawHealth managing the practice,” said Nienhuis. “We can just focus on the patients. We’re dealing with human beings. We want to be efficient, but if we only go by institutional measures, you’re trading quality for efficiency with the least amount of dollars. We’re happy with this model instead; it works great for us.”

Technology for humans

One of the things that makes it possible for Nienhuis and Wideman to be such hands-on, patient-focused doctors is technology. KershawHealth Primary Care at Elgin has access to electronic medical records (EMRs), the ability for doctors to be simultaneously logged in at multiple computer stations and, coming soon, a patient Web “portal.”

Nienhuis said being fully tied in to KershawHealth’s EMR system, combined with immediate access to the outpatient center’s lab downstairs, can streamline things for both patients and doctors.

For example: a patient who already has an appointment with either Wideman or Nienhuis, but needs a blood test run before seeing the doctor.

“You could come in 45 minutes before the appointment, have blood drawn and get the results in real time -- they’d be ready by the time you see me or Dr. Wideman,” explained Nienhuis.

Additional tests can be ordered through the same system.

“It’s a bit more seamless,” he said. “For imaging, we can just go downstairs. We have access to KershawHealth’s MRI and CT scanners, and the images pop up on my screen as soon as they’re available.”

In the past, Nienhuis said, a patient might have tests run and not hear back about results.

“They would think ‘they didn’t call, so I must be OK.’ This way, we can discuss the results and move on. And if they need hospitalization, I can just pick up the phone, notify the hospital and even transmit information to them,” he said.

Utilizing EMRs, the practice and hospital can more efficiently communicate back and forth about patients.

“The biggest errors come during transfers, through communication lags. Here, we’re all on the same system,” Nienhuis said.

The same goes for the urgent care center, also housed at Elgin, said Wideman.

“I might have a patient who went to urgent care last night. Notes about that visit will be on my computer when I come in the morning. Sometimes, that patient will call to let me know what happened -- this lets me beat them to it,” Wideman said. “We all work together.”

At the same time, there’s nothing like the human touch. Nienhuis said urgent care doctors will often come upstairs to fill in the gaps about a patient’s visit.

“Basically, it’s an extension of our office. As long as patients know we know what’s happening, they feel secure.

It’s all part of being an “integrated management care team,” as Bruce put it.

The person responsible for making that happen is the office’s practice manager, Frank Scarmardo, who agreed having EMR access makes the physicians’ work more efficient.

“They can access the system from anywhere within the hospital, other facilities on our network and even from home,” said Scarmardo. “This summer, as part of an upgrade, we’re looking at smart phone capability. A doctor might be at dinner at a restaurant and get beeped on their iPhone, for example. They can access that information right there at the table. They could refill prescriptions and not have to get up.”

There is even some thought of providing physicians with iPads with access to their own office records from within the hospital system.

Bruce said one of the most exciting things coming to Elgin’s primary care practice is the installation this summer of the patient “e-portal.”

The eClinicalWorks Patient Portal will, among other things, provide patients their “own health care page” on the practice’s website, said Bruce.

Scarmardo said a file server will be installed in May or June to handle the new portal. When completed, he said, it should provide patients -- and Nienhuis and Wideman -- with an array of benefits.

“The e-portal appeals to a certain generation of patients,” said Scarmardo. “The current Medicare population is over 65 and, within that group, patients have varying degrees of computer ‘savvyness.’ The younger generation prefers that method of communicating with anybody -- that’s just the way it is. It’s the younger generation that is taking care of mommy and daddy that wants to communicate electronically.”

Scarmardo said there are a number of benefits depending on what aspects of a patient’s medical record each physician determines they want to open up to their eClinicalWorks page.

“It can range from an entire record to just portions depending on the sophistication of the patient. The physician may not want to share blood test information with a patient who doesn’t understand such things -- it could be detrimental,” said Scarmardo.

On the other hand, he said, there are “perfect patients” who could handle a lot of online pre-registration processes, for example, filling out preliminary paperwork before they ever enter the primary care office’s doors.

“And when it’s complete, it goes into the record instantaneously,” Scarmardo said. “It doesn’t get lost; it’s exactly as it was filled out.”

Another benefit could be immunization records.

“If you’re a mother who wants to know the dates for each of your five kids, you can look them up and get what you need to enroll them in school,” said Scarmardo.

Other examples of what could end up on the eClinicalWorks portal: patient satisfaction surveys, family histories and perhaps the ability to request an appointment.

“A patient could get on the portal and pick an appointment (date and time) that might be open, which would then be confirmed by the staff. What’s important is that it gives patients choices,” Scarmardo said, pointing out that an appointment wouldn’t be automatically scheduled -- staff would have to see if the appointment was appropriate based on the patient’s needs.

There’s also the chance for truly customized education modules on the patient’s e-portal page -- information about a new hypertension drug only on those patients’ pages, for example -- appointment histories, the ability to request prescription refills (with, again, human intervention) and, further down the line, creating graphs of how different drugs have helped you.

It’s the relationships

Nienhuis and Wideman said the goal is to create better-informed patients. More importantly, the technology doesn’t get in the way but, rather, helps in achieving an even higher goal: having healthier families.

“It’s a lot of fun for us,” said Wideman. “A woman comes in and then brings -- OK, drags -- her husband and kids. Soon, we’re treating her mom and dad, too.”

She said that’s a more effective health care model because they end up working with the whole family.

“It’s not just medicines, it’s psycho-social -- you’re dealing with the in-laws, spouses, kids. You’re dealing with the patient better; it makes you understand what’s going on,” said Wideman.

Nienhuis said 50 percent of health issues stem from lifestyle.

“What’s going on in their lives” he said…

“--affects how they deal with their illness,” finished Wideman. “We’re definitely more like detectives.”

For Nienhuis, it’s the relationships -- the stories -- he wants to discover.

“If you’re really going to get really involved in a patient’s health, it’s not just knowing what medicines they’re taking,” he said. “The interviewing skills I learned in social work have really helped. You have to listen to what the patient isn’t telling you.”

Nearing the end of their first year at the Elgin outpatient center, the two physicians are looking ahead to the future. That could include welcoming a third partner.

“We still have an equal amount of (unfinished) space so, depending on growth -- which there certainly is -- we only anticipating expanding here,” said Nienhuis. “It’s a terrific location. We even have patients from Bethune and Camden hop on the highway and come down.”

Ferrell said the practice is “perfectly positioned” to deal with increased patient access by Baby Boomers.

Bruce said in order for KershawHealth to remain true to its health care mission, it will likely build on the Elgin primary care model. He said KershawHealth is “mindful” of the trend to more hospital-employed physicians.

“We will be sure every part of the county has the primary care physicians it needs,” said Bruce.

His concept of the “21st century practice” has played out well for Nienhuis and Wideman, they said.

“KershawHealth did a great job of understanding what we need as physicians and listening to what we feel our patients need from this practice.

“They designed everything with patient care in mind, and that’s not always what you see. We’re very proud of that,” said Nienhuis.

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