To the Editor:

The December 2006 article "20 Ways to Keep Your Practice Growing" cites examples of tactics ophthalmologists and consultants employ to enhance patient interaction with the clinic. Suggestions range from the helpful (provide books instead of magazines), to those that demonstrate common sense (have every staff member who will interact with a patient introduce himself), to the controversial and risky (charging a fee for no-shows). Yet, these suggestions are best suited for practices heading toward obsolescence. Peter Drucker, who was to business management as Dr. Harold Ridley was to intraocular lenses, may have called these the tools of "today's breadwinner"—that is, a business that is destined to become yesterday's enterprise (Managing for Results. 2006).

Professional organizations and many consultants have adopted a wait-and-see attitude toward health-information technology. Physicians rationalize that they'll consider it but will wait to adopt it, implying that the technology is expensive, not perfected, demonstrates no easy return on investment, and has occasioned no patient demand for its deployment. Moreover, its adoption requires that a practice's operations be transformed. Economist Joseph Schumpeter called this "creative destruction": history has proven that the life cycle of business guarantees this inevitability.

It is my contention that tomorrow's practice must integrate a system of information technology to improve, innovate and create value for its patients and stakeholders. Everything else is artifice, only postponing the inevitable.

There are many instances cited in the article where an integrated practice management system, an electronic health record and a data management system would not only do the task more effectively (an "operations" concept) but also more efficiently (a "financial" concept). For example, Drs. Lisa and Amir Arbisser mention the personal touch of noting in the chart the name of the person who accompanies the patient. When recalled, this can enhance the patient's perception of the clinical experience because the doctor cared enough to "remember." I employ ChartLogic EHR software (Salt Lake City, UT) in my practice. Upon entering the exam lane, the screen shows a page for notes, where staff may add significant information patients have shared—e.g., the birth of a grandchild, a trip to Ireland, or the death of a spouse. Gestures of kindness are also remembered—e.g., the homegrown tomatoes that Mrs. Jones brought in last summer. It's a longitudinal history of events important to the patient. Commenting on it takes seconds; the patient's memory of the comment lasts much, much longer.

The notes screen is cleared with a single click of the touchpad. The underlying screen shows the Assessment and Plan from the previous exam—i.e., the "what is it and what am I doing about it" section of the universally accepted SOAP note. In seconds, I now "remember" this patient's problem and complaint. The plan may include tests ordered, special instructions given, or educational material watched or provided. Dr. Penny Asbell describes a similar time-saving tool albeit on paper with all of its attendant shortcomings.

The most troubling advice in the article deals with how to make the patient's waiting time "efficient." Efficiency as applied to the operation of a medical clinic all too often implies a zero-sum game that the patient usually loses. From DVDs to choice of television programming to the approach of how to acknowledge and apologize to the waiting patient, I see only opportunity—opportunity for my competition. I call this model the "Greatest Generation Model"—people who are old enough to remember waiting patiently for the doctor's house call. Baby boomers—the instant gratification, McDonald's generation—will tolerate waiting for the physician only if there is no alternative. Forget generations X and Y: you won't even get the chance to see them. As physicians spend less and less face time with patients, we are viewed increasingly as interchangeable commodities.

Dr. John S. Jarstad uses a system to determine the productivity of his technical staff. I don't doubt its value, but I question the additional administrative work that it adds to each workday. I wish that he had expanded on how this tool "saved his clinic more than $200,000 a year in improved efficiency." ChartLogic offers a tool called the Patient Tracker. On a small pop-up screen, each patient in the office is registered and assigned to an individual and a room. Before leaving an exam lane, I review Patient Tracker to see where I stand in the day's schedule; which exam lane holds my next patient (Patient Tracker tracks how long a patient has been waiting for me; the one waiting the longest is where I head); which technicians are where and how long they've been there (after a certain definable time has been expended, diminishing returns are realized in regard to the technician's effort); which patients are in the optical; and which are in the testing pods. Rather than reviewing at day's end, when it's too late to adjust workflow, Patient Tracker allows the practice administrator, each staff member and the physician a real-time command and control view of the workflow and its progress throughout the day. The staff and the doctors adjust accordingly.

John Pinto's suggestion (write a thank you note) can indeed make a great impression. However, labor, material and postage make it expensive. Our practice sends electronic thank you notes to each new patient and to the patient who recommended us. The EHR also allows me to provide a copy of the exam, typed and legible, for the patient's personal health-care file on completion of the visit. It costs the price of the paper and toner.

I agree with Dr. Jarstad: Doctors who refer into the office don't need to be reminded how pleasant their patient is. Our referral report is formatted to include the pertinent assessment and plan information while making a professional impression. It can be delivered by the patient, or it can be faxed or e-mailed before the patient leaves the office. The same applies to the ordering of lab tests, imaging studies and prescriptions.

These examples show how a system of technology can revolutionize the patient's perception of a medical encounter. But what does it cost? Fortuitously, Kevin Corcoran's December article, "The True Cost of New Technology" (p. 38) offers a blueprint for addressing this. As opposed to the technology addressed by Mr. Corcoran, health IT can be used to drive both the expense side of the practice and the revenue side (e.g., the marketing of the practice's cutting-edge capabilities will attract new patients). It is particularly valuable because it attacks the "fixed costs" of a practice—staff, chart storage space, malpractice liability, correspondence, etc. Indeed, most service-industry business costs are fixed. Little or no incremental costs are incurred when seeing the next additional patient. Most of the marginal revenue falls to the bottom line. Mr. Pinto has written extensively on this concept.

I admire any physician who works to improve his practice. In today's volume-driven health-care marketplace, even modest improvement can provide competitive advantage. Nonetheless, I would like to see an article address the real revolution in health care: the application of IT to enhance the care and satisfaction of our patients while improving the physician-owner's bottom line.

J.C. Noreika, MD, MBA
Medina, Ohio

(Dr. Noreika participated in the development of ChartLogic for ophthalmology.)