Peck is quick to point out that championing change isn't always easy. "Some people love change, but we're a minority. It was hard because I would hear ideas and immediately see the possibilities - but the challenge is how to get your colleagues to see those possibilities and move forward," Peck recalls. For now, he says, IDCOP has become a "part of how we do business."

Independent thinkers

Outside the circle of IDCOP study sites, other forward-thinking physicians have been moving ahead with self-styled initiatives based on some of the same concepts. Charles Burger's primary-care practice in Bangor, Maine, has been integrating technology (electronic medical records and exam-room terminals, computerized decision support, and recently, e-mail), advancing the use of nonclinical personnel, and substantially involving patients in their own treatment decisions for about a decade. Putting those principles to work has enabled the practice, which is affiliated with Eastern Maine Healthcare, to care for an active patient panel of 5,000 — a number that just wouldn't have been feasible under the "old system," Burger says.

"If you're going to use technology right, you have to change the way you work, designing processes very carefully and saying, 'OK, we're going to train people to do this reliably,'" says Burger, who is a longtime advocate of computerized support in diagnosis and treatment.

"All of our training is very performance-based. Once people can do [a task], we let them do it. We tend not to pay too much attention to degrees and titles," says Burger, whose staff includes two nurse practitioners, one registered nurse (RN), and two medical assistants. Burger explains that the practice's specially trained medical assistants and the RN handle most of the work associated with physicals and wellness visits.

Telephone triaging and assessment are used in lieu of office visits whenever possible, with telephone follow-up built into the process. And when patients are seen in the office for initial visits or follow-up care, they are asked to input some of their own information, while medical assistants gather the rest. By the time he enters the exam room, Burger says, "most of the work is done, and all I have to do is sit down with the patient and say, 'Here are your symptoms and here is your data. Let's think about these things together.'" He contrasts this with the typical office visit, in which the physician spends two-thirds of his time gathering information and one-third analyzing it.

"That's just not very efficient," says Burger.

The final key element of efficiency at Burger's practice is his insistence on standardized, evidence-based care and processes. If the practice sees 500 patients with headache complaints in a given month, Burger says, "They will all have the same thing done on them." Information gathered in the process is stored in a relational database for potential use in future outcomes studies.

For Burger, the payoffs in efficiency are just as gratifying as the staff satisfaction and relationships that have developed over the years.

"We have exceptionally low turnover because if you were to ask the staff about their work, they have a strong sense that they own the practice," Burger says. "They really function as a self-managed team, and the electronic tools simply give them a greater ability to contribute."

Moving forward

Now that the theories of IDCOP have taken root, Kilo is moving on, translating his philosophies into a new practice model that he hopes will become nationally recognized. Last spring he and Steve Gordon, MD, created GreenField Health System, which is based on high-functioning "care teams" and supported by technological "knowledge management systems." Patients have multiple points of entry to the practices, including e-mail and group visits, and "patient coordinators" ensure patients receive the care and follow-up they need.

At inTandem, the prototype GreenField practice that opened in Portland, Ore., last June, convenience and customer service are palpable - starting with the presence of the greeter who escorts the arriving patient immediately to an exam or conference room (there is no traditional waiting room). Patients pay a $350 annual fee to join, which helps the primary-care practice defray the cost of providing services payers currently don't reimburse, such as e-mail for matters that don't require a one-on-one visit.

Elizabeth Muckler, MD, who joined inTandem in September after completing her internal medicine residency at UC San Francisco, says the practice embodies everything she was looking for in a practice opportunity, without the baggage she expected to find.

"When I looked at other practices they were all very traditional. My perspective is that the traditional structure's constraints and access difficulties make it impossible, time-wise, to give the kind of care that I want to give to my patients," she says.