Innovations in Medical Practice in WNC: Trillium Family Medicine Revisited

February 6, 2015

Innovations in Medical Practice in WNC:Trillium Family Medicine Revisited

By Rivers Woodward
(Third year UNC medical student and WCMS Foundation Board member)


Rivers Woodward

Trillium Family Medicine is one of a number of independent small practices in WNC that are successfully challenging conventional thinking about the capacity of small practices to be financially stable while growing and delivering quality care in a cost-efficient manner.  About a year ago, WCMS staff interviewed Dr. Mark McNeill about his innovative solo practice, Trillium Family Medicine. For last year’s article, see Mark’s model is “low overhead.” He maximizes the use of his web-based patient portal in order to keep costs down. A year later, and in the midst of the turmoil of health care reform, we thought we’d check back with him to see how he was faring. Your intrepid reporter for this update was Rivers Woodward, 3rd year medical student and WCMS Foundation Board member.


Dr. Mark McNeill

Rivers: Has your overhead changed since our last interview?

Mark:     Not significantly, we’re still pretty much on target of where we wanted to be with our overhead.  Even though we’ve become busier--our accounts receivable has increased twenty-five percent over the last year-- our overhead has only increased three percent. Normally when your business gets busier you have to invest in other things, but we honestly had the room to grow without adding more staff or adding more people. The main increase in overhead has been, as the practice has become more successful, to give the small staff I have a raise.  Having good staff who understands the model is important, and making sure that they are happy and well-compensated is imperative.

Rivers: Has your increase in accounts receivable been mostly due to increasing panel size or improved reimbursements due to PCMH status?

Mark:     All of the above. We definitely have more patients. We continue to grow by about 20 patients a month. We are seeing more patients now than we were one or two years ago. But we also received PCMH recognition in January. And the Blue Quality Preferred Provider Program through Blue Cross is a big part of our increased revenue.

Rivers: Did your portal help you with your PCMH recognition?

Mark:     Absolutely. Getting PCMH recognition is hard, no matter how you do it. I wouldn’t say it was easy, but it was definitely easier with the portal. The portal makes it easier for us to meet those measures for availability, access, and self-management. I know most practices do it without use of a robust portal, but I can’t imagine being a patient-centered medical home without it.

Rivers: Have you achieved meaningful use?

Mark:     Yes, we achieved meaningful use for 2013 and are on our way to achieving meaningful use stage 2 for 2014. We expect to get it again.

Rivers: And does the portal play a significant role in that as well?

Mark:     Absolutely. As meaningful use evolves, standards are becoming more difficult, particularly on the electronic side. You pretty much have to use a portal to be a meaningful user now. In the initial stages, you just had to have a portal, but there was no requirement that a certain amount of patients actually had to use it. You basically just had to turn it on; you didn’t even have to touch it. Now you need 5% of your patients to be actively using the portal. For us, 80% of our patients are actively using the portal. You need to be sharing electronic resources with 10% of patients and the portal makes that easy. About 30-40% of our patients utilize this component. As the electronic requirements for interacting with your patients online become more challenging, effective use of the portal makes it easier to achieve those mandates.

Rivers: In the portal itself, are there any new features you are looking at adding or expanding?

Mark:     We now have a smart phone app for the portal that accepts patient-entered biometric data.  I’m hoping to start using that for better patient engagement by having them record their blood sugars, blood pressures, and weights using the application. These are really important numbers to track for patients who suffer from diabetes, hypertension, metabolic syndrome, and coronary artery disease. Once patients enter the data, the app will allow me to import that information into the EHR. When the patients are here I can pull up the data and review all of the numbers that they have recorded. That’s going to be one more tool to get patients to take a more active role in managing their condition. It’s easy, so the app is removing barriers to patients’ taking that active role which makes it easier for us to work together.

Rivers: The 80% of patients communicating through your portal – has that increased since you first started?

Mark:     It has been about constant at about 80%. Ninety three percent of our patients are enabled to use it, but in reality it is about four out of five who actually use it. Other metrics that are significant: 75% of our appointments are scheduled through the portal. So only one out of four are scheduled via walk-in, follow-up while the patient is here, or via phone call. In three out of four cases, the patient does it themselves online and we don’t have to assist them. So that’s one aspect of a low-overhead office. When three out of four appointments are scheduled through the portal, my overhead is lower because I don’t have to hire a scheduler to answer the phones and manage my schedule.

Rivers: Do you keep appointments open every day for acute care?

Mark:     We publish to the portal more appointments than we expect to need 98% of the time. And that works - it’s only once every other month that all of the appointments are taken. When you have a low-overhead office, you don’t need as many patients in your panel to make a living. In a traditional office, you have to see 20-25 patients a day. To keep that number of appointments up, you have to make sure your schedule stays relatively full. You’re booking follow-up appointments well ahead of time to make sure your schedule stays full and you keep that revenue stream going. In a low overhead office, I only need to see twelve patients a day to make a decent income. So only having twelve patients a day makes providing those extra appointment slots easy.

Rivers: Is there a most popular or least popular function on your portal?

Mark:     Patients really like the portal. Yes, you’re going to get some resistance at first, but the aspect that I get the most comments about is the self-scheduling.  Most patients when they feel ill, it is in the evening and they decide they’re going to see the doctor the next day. That’s generally when the decision is made to see the doctor for an acute visit – around 9 o’clock the night before. And with a traditional office they’re anxious, wondering if they’re going to get in, and they’ve got to wake up early and start calling immediately in the morning, play the phone tree, maybe even leave a message. My patients can make the appointment online right when they decide they want to be seen. They log on to the portal right then, grab an appointment that fits their needs and go to bed knowing they are going to be seen the next day. The second thing that we get the most compliments about is the secure messaging function through the portal. Patients have the ability to message me through the portal and our goal is to respond to them within two business hours. They really appreciate having that level of access which helps build the relationship. They can get their questions answered and this helps build trust quickly because they know I’m there and happy to answer their questions.

Rivers: Can you talk about why a direct protocol is so important?

Mark:     The direct protocol is basically a standard of electronic exchange of health information. So all of the major EHR vendors are developing ways that different systems are going to be able to talk, and they have to do it through this direct protocol. It is supported for a couple of reasons. When all of the vendors are talking like this, it is going to increase our ability to exchange electronic health information quickly and easily. So we’re not duplicating tests and struggling with getting records.  We can actually exchange structured information. That’s just going to be much more powerful information.

Rivers: How do you believe your model will position you for participation in an ACO?

Mark:     To be a part of an accountable care organization, you have to demonstrate quality care in a variety of different areas. These are basically broken down into the patient and the caregiver experience, the coordination of care, the inpatient experience, preventative health, and population management. From the patient caregiver experience, if a portal is implemented appropriately, particularly in a low-overhead model, patient satisfaction rates can be very high. We monitor our patient satisfaction rates on an annual basis and our satisfaction rates are among the highest in the region – definitely the highest in my career. So when it comes to things like getting timely care, appointments and information, the portal makes that incredibly easy. The portal is going to help you excel at how well you communicate as a provider. Many other measures are going to involve tracking (population) data and intervening with those patients and making an effort to improve those data. That takes time and effort. In a small, low-overhead office, we do have that time. I think in general, when you are lean and small, you have more flexibility with your time. If all of these things suddenly change next year, I can turn on a dime.

Rivers: How does the very first patient encounter work?

Mark:     We don’t take new patients over the phone. We ask new patients to register on our website. They need to fill out some basic information, including their name and contact details.  When that gets submitted, it shows up in our electronic record.  We then email them their credentials to access the patient portal along with instructions on how to set up their first appointment electronically. So by the time they show up, they have already registered themselves on the portal and they have set up their own appointment. We’ve already set expectations from the get-go that this is how you are going to be interacting with Trillium. You have to make it simple and easy which we’ve done our best to do.

Rivers: Is there anything else that we haven’t touched on that you would like to talk about?

Mark:     At Trillium we recognize that the digital divide still exists. We know that Trillium could be self-selecting patients who are going to thrive on our model when we require that they register online. We know that, however we feel an obligation to the community that this model be accessible for everybody including older adults, and indigent populations.  Many of those individuals use the portal quite well. But the ones that don’t can still be in our practice.  The 20% that don’t use the portal tend to be low-income and/or older adults. And even though they can’t use the portal, they still benefit from it because these patients tend to be higher risk and need more time with me. I now have that extra time because I’ve streamlined my practice.  My medical education was funded by a significant amount of state and federal tax dollars so I feel that it is my responsibility to make sure my care is available to the most vulnerable in North Carolina.