Can the “little guy” still make it in healthcare? A conversation with Dr. Doug Hansen

Dr. Doug Hansen, a primary care physician in suburban Denver, possesses a fairly unique perspective on healthcare IT. He is the founder and Medical Director of a group called Altitude Family and Internal Medicine, a small yet rapidly growing practice with two locations, one in Littleton and one in Lakewood, Colorado. He is also a member of the board for Colorado Health Neighborhoods representing about 3,000 physicians in Colorado of various practice sizes and structures. 

Since its inception nine years ago, Altitude Family and Internal Medicine embraced technology as a means of delivering the best care to its patients at the lowest expense possible. We contacted Dr. Hansen to learn about the practice’s IT journey and to hear his thoughts relative to the evolution of small-practice healthcare technology in Colorado. 

(Editor’s note: To hear audio excerpts of this interview, click on the media player buttons that run throughout this article. This interview is part one of a two part series. Part two will be published December 7, 2015.)

Free: Given your considerable knowledge of the healthcare community in your region, how would you describe the overall mindset of organizations today, regardless of their size?

Hansen: Without a doubt, the common denominator is a shared focus upon medicine. We are really centered on quality-based, efficient evidence-based medicine. I think that is the biggest commonality we have no matter the size of the organization.

In terms of being a little bit different, we are a very progressive practice. Both progressive in terms of our medicine and progressive in terms of our use of technology, our attempts at patient outreach, patient engagement, all these things are really pertinent to what we do. We are very much a wellness-based practice. We tend to be a little bit contrary to what might be a little bit more common place with in the market. We try not to reactive. We try to be very proactive in our patients’ health as a goal and so. Again, I think when we opened 10 years ago, we saw technology as a tool that we really needed to leverage in order to reach our goals and metrics both in terms of quality and just the type of patient care and the type of patient engagement and customer service that we wanted to offer.

We also saw how the technology was rapidly evolving so we understood the need to evolve along with it. We have always reached out to our patients electronically with the technological capacities we had at the time. However as we moved into early 2014, we saw that the technology that we relied on when we opened was not the same technology that we wanted moving forward. We started to lose some of that functionality that we always sought, so we made some important changes. 

Free: So, can you take me back 10 years ago and describe how the industry was utilizing technology?  

Hansen: I’d say that back then everybody was talking about technology, but nobody was using technology in a meaningful way. That was the big thing.

10 years ago, I think the data at the time said only three percent of practices were using technology with any reasonable efficiency or reasonable meaningfulness, which was just terrible. Back then, what we had in terms of electronic health records, practice management components and everything else were really just these big empty databases that people had to try to make work in a somewhat useful ways. It was an uphill battle to say the least. 

The thing we were really looking for at the time was a way to replace the paper chart and replace it in a way that was much more useful for physicians. Trying to track down records in a paper chart was difficult. Sometimes, you were kind of searching for a needle in a haystack even in the most reasonably organized paper charts. We knew technology offered a better way of record keeping and we had a lot of options. Unfortunately, we had a lot of options that had significant limitations. Some organizations did not really know what to do about this problem so they had to wait for a solution to present itself. We did not want to take that more-passive approach because we knew our patients and our caregivers could obtain great benefits from leveraging the latest technology, no matter its limitations at the time.  

We opened up with an in-house, or an EHR that we hosted ourselves in-house. It worked very well for a number of years, [it] didn’t have a lot of the bells and whistles that we want from technology today, but was very useful. We actually opened our second practice about four years ago now and continued using the same EHR and that is where we started to see some bottlenecks in the technology piece. Hosting an EHR, and having access to that in two locations, we had to do some pretty aggressive things for a small practice, like build a fiber tunnel between our two practices and really have some aggressive hosting capabilities in-house.

As you look at how the technology has evolved now, it seems like that was not something that you should take on.

Free: What would you attribute to the apparent disconnect 10 years ago regarding technology that existed between the all the parties involved: government, vendors, providers and even the patients? 

Hansen: What it came down to, and I think there is still a pretty large disconnect in certain ways, but I think a lot of it really comes down to the idea of what is the meaningful use of technology? The government has defined what they view as meaningful use and they are seeing in some places they have been correct, but in some places they have been incorrect. Doctors are trying to define what they feel is meaningful, and patients have a very different idea of what they feel is meaningful. I think that was, and is still, one big disconnect.

I think the second thing is what you were mentioning that is the ability to integrate. People have been talking about integration since the beginning of EHR. It seems like, to some degree, the big problem with integration early on was that, and this might even flow through to today, but one of the big problems was that if you were a private company building medical technology, if you truly made your system, gave it the ability to integrate with other systems or interface with other systems and spread data very easily, then you potentially could lose your market share because it would be easy for doctors or hospitals to switch from one technology to another. So I think that caused some significant limitations on the industry. Now, with the government getting more involved in the idea of integration and interoperability, for sure i think there is some improvement there, although we still find that can be quite tough from a system-to-system standpoint.

Free: Many inside and outside our industry tend to think in very broad strokes when it comes to changes regarding the use of technology. This generalized mindset can sometimes overlook important differences that ought to be considered. What are some of the challenges, those technology-related or not, that are unique to small practices that maybe some in our industry do not fully appreciate?

Hansen: There is a lot of stuff that’s unique to small practices, but what we are seeing in Colorado is this idea of the death of the small private practice.

There is a lot of financial pressure on small groups, a lot of practices are going out of business, being purchased by hospital systems or insurance companies or larger groups like that. First and for most, a lot of practices are just looking at survivability right now. When you are looking at survival, you really have to have a strong infrastructure in place and strong ideals in terms of making it through that.

There are going to be struggles. For example, ICD-10 is going to be a hurdle. As a small practice, you want your technology partner to be taking a leadership role in that transition to ICD-10. The United States is far behind the rest of the world in transitioning to ICD-10, but we are doing it in a little bit less controlled fashion as well.

There are some thoughts out there that there could be some substantial shifts in revenue during this transition and that there could be some problems in getting that revenue in. So smaller organizations are going to need strong technology partners that are going to be able to put them in a place to make their coding transition less problematic. The ICD-10 hurdle needs to be lowered as far as it possibly can for small practices, otherwise, they may not around in the future.

That threat level to the survival of small practices is something that I do not know if many in our industry truly appreciate.