— Nancy Girard, DO, Family Medicine
Village Family Clinic & Wellness Center is a primary care micro-practice with around 1,000 patients. Kristina Garrido, ARNP, is the owner and solo primary care clinician who delivers excellent medical and emotional care to her patients and has developed a very loyal patient base. She sees patients of all ages and often cares for entire families.
Kristina Garrido walked away from her last medical practice and started her own medical clinic because the personal and financial burdens were too great. In particular, the Electronic Health Record and Practice Management systems were creating too many workflow problems and costing her and the three other partners too much money.
After discovering the Ideal Medical Practice (IMP) concept of establishing low overhead expenses by utilizing technology, Kristina opened her own primary care micro-practice outside Seattle, Washington. As the technological foundation of her practice, Amazing Charts provides Kristina with an affordable, easy-to-use EHR that integrates lab reports, ePrescribing, scheduling, and more. By decreasing expenses and creating more efficient care, more time can be spent with patients. Research shows this leads to higher patient satisfaction and better health outcomes.
After twelve years as an Advanced Registered Nurse Practitioner (ARNP) and nearly 20 total years in nursing, Kristina Garrido has witnessed many changes in healthcare. But few have had a greater impact on her professional life than the transition from paper charts to Electronic Health Records (EHRs).
Kristina Garrido, ARNP, holds a B.S. in Nursing from Idaho State University and Master’s Degree in Nursing from Seattle University’s Primary Care Nurse Practitioner program (1998). She spent five years as a Navy nurse to fund her undergraduate and graduate degrees. She is certified as a Family Nurse Practitioner by the American Nurse Credentialing Center. Garrido is also actively involved with the Ideal Medical Practice (IMP) movement and serves as a mentor to other nurse practitioners.
In 2003, Garrido was a full partner in a primary care practice with three other clinicians. The office manager was tasked with finding an EHR system, even though the manager was not technically savvy when it came to EHRs and did not have any experience actually documenting patient notes. The office manager and partners considered several large vendors, including Practice Partners and Epic, but eventually selected Misys (now known as Allscripts-Misys Healthcare Solutions).
“EHRs were new to primary care, so the decisions was difficult since we had no experience with computer charting and did not know what to expect,” says Garrido. “And I certainly had no idea how expensive it was going to be until it was too late. Initial setup was around $50,000 which, at the time, seemed about average for an EHR. In the following years, we were paying about $8-9,000 a month for Misys to ‘lease’ us its EHR and Practice Management solutions. Essentially they just backed up our patient charts, aging reports and accounts receivables. We still had to handle the actual data input and billing ourselves.”
The practice also purchased three-day training sessions from Misys, which were delivered at the office on two separate occasions, six months apart. “This training consisted of a non-medical person advising the clinicians and nurses on the proper use of the system. On the second training visit, the same representative observed everyone using the EHR and then recommended building macros when something took too many clicks. So we were responsible for revising the system to suit our needs.”
For Garrido, high cost and chart revisions were just the beginning of the problems with Misys. “We did not subtract any employees as a result of the new technology,” she recalls. “In fact, our staff was as busy as ever, scanning lots of paper labs, tests and referral notes, and printing out prescriptions for faxing because we could not fax digitally from the system. Misys was so hard to use that I’d be at the office until eight o’clock at night because I couldn’t finish my charts during the day. And then the server would crash because it was trying to backup data while I was using it. I was definitely not getting my money’s worth.”
Garrido once attended a Misys users conference to learn more about the system because “technical support was unavailable after the initial setup and it was so expensive since we were charged on a per incident basis. We would call Misys tech support and tell them the server was having problems; the only alternative we were offered was rebooting in the middle of the day with patients sitting in the exam rooms.” When the practice’s server continued to crash on a regular basis, Misys recommended and installed a “programmed" server that cost approximately $30,000.
“So after all the money we spent on the first server, and all the time I spent designing macros to streamline the system, I still ended up crashing the very expensive ‘programmed’ server they sold us,” declares Garrido. “To make matters worse, after one year, we were still essentially using paper charts. We would print the note from the EMR, and then stick it in a file with referral letters, lab results, and other pieces of paper. Even after we had totally converted to electronic records, I ultimately ended up leaving the practice because as one of the top two revenue-generators and one of the four owners I had to give up about 20% of my revenue just for the practice software! And that made the overhead expenses too much for me to handle.”
Before leaving the partnership, Garrido spent several months thinking about how she really wanted to practice medicine. “I wanted to be able to spend adequate time with patients when they needed it, which meant seeing fewer patients per day,” she says. “I also needed to pay my bills, so I had to find a way to do the same work in a less costly and more efficient manner.”
In the summer of 2008, Garrido discovered the Ideal Medical Practice (IMP) movement, which promotes the concept of the micro-practice to deliver superb care in a fiscally sustainable practice. On a message board, she found an “office technology blueprint” used by other like-minded healthcare providers. The blueprint recommended exactly which hardware and software components to purchase, including Amazing Charts as the Electronic Health Record system.
“I wrote up a business plan describing everything I planned to do with the Village Family Clinic & Wellness Center and exactly how I was going to do it, and six months later I got a $20,000 start-up grant for EHRs from the State of Washington,” explains Garrido. “In January 2009, I purchased and installed Amazing Charts, which cost just $995, leaving me plenty of funds to buy hardware and other software applications.”
Garrido continues: “I found Amazing Charts very fast to set up and easy to learn. The patient chart page was so clear, I began documenting and setting up macros immediately with no formal training. After nearly two years in solo practice, I have found Amazing Charts easy to customize and understand, and the technical support has been outstanding.”
When asked about her three favorite features of Amazing Charts, Garrido names six features: “The immunization feature is very helpful because I get free vaccines from Washington State and Amazing Charts makes it simple to track specific lot numbers. ePrescribing in Amazing Charts produces much more professional looking prescriptions than Misys – whose scripts essentially looked like MS-Word documents – and includes patient demographics and insurance information on the prescription. I love being able to free-type subjective thoughts in Amazing Charts so my narrative doesn’t get lost in a lot of check boxes and drop downs. I also dictate directly into Amazing Charts notes using Dragon Naturally speaking. At home, I can remotely connect to Amazing Charts on my server and see patient records or get lab results thanks to the LabCorp interface that came free with Amazing Charts.”
Today, Garrido’s thriving primary care practice is fully paperless...and even phoneless. All communication with patients and other clinicians is done over the Internet using email, or text messaging on a cell phone. Patients make appointments online using AppointmentQuest, where they can also fill-in in their demographics, which Garrido imports directly into Amazing Charts.
Garrido has approximately 2500 patient visits per year – far less than the average primary care clinician. With total receipts of around $250,000 and an extremely low overhead, Garrido can make a comfortable living and still get home in time for dinner with her family.
“The traditional model for primary care is broken because you end up working your fingers to the bone trying to see 25 or 30 patients a day for 10 or 15 minutes each, and most of your hard work goes to pay the overhead for the clinic,” calculates Garrido. “As the only decent EHR for such a low price, Amazing Charts is helping lead a revolution in healthcare – one that enables me to see just 10 patients per day and spend quality time with each one, resulting in better health outcomes."
Garrido concludes: "Amazing Charts helps me maintain a healthy balance between life and work because I am not at the clinic until late at night. It also enables me to run my own primary care practice instead of returning to a salaried position. I’m happier than ever, seeing more of my family, making more money than before, and excited about the future with Amazing Charts.”