Mr. U, Crow's first patient the morning I arrive, has diabetes. He had gone undiagnosed for several years, by Crow's estimation, because he wouldn't see a doctor. Only when his symptoms became unbearable did he arrive in Crow's exam room. Now, three months later, his weight is down, his vision is no longer blurred, and he feels, he says, much better.

"We should maybe take a new picture of you since you lost all that weight," Crow tells him. And indeed, the photo on Mr. U's electronic file, which Crow has open on a laptop computer in the exam room, shows a man with much fuller cheeks than the one sitting on the exam table. Mr. U was happy when he first received his diagnosis, Crow recalls, because it meant that, finally, there would be a treatment plan, and some relief. For the first time — with his doctor's help — he would have some control over how he felt.

Today's visit is just a follow-up. Crow asks him some questions, ties up loose ends from his last visit, and sends him on his way with a few encouraging words. His prescription will be waiting for him at his pharmacy. FMST uses e-prescribing that allows the physicians to send prescriptions electronically to just about any pharmacy (and national pharmacy benefit managers) in the area with just a few clicks; refill requests can be sent electronically to pharmacies within seconds of their receipt by the physician. That process alone saves perhaps 60 staff calls a day to patients and pharmacies, by FMST's estimates.

The group's EMR also makes it immeasurably easier to manage patients, especially those with chronic illnesses. Crow says this is because it's easy to navigate and read, is always available, and records every relevant detail about a patient's care. The system also allows the doctors to send themselves alerts, reminding them to check whether a patient, say, followed up on a treatment plan or received a recommended test.

"I don't know how other doctors practice without it," says Crow, who has been certified by NCQA's Diabetic Physician Recognition program thanks to the data that Weyenberg was able to mine from their EMR. "People think I'm smarter. I'm no smarter than anybody else; the system makes us all smarter."

Yet the EMR is only one example of the practice's dedication to technological innovation. Its Web site, www.fmstexas.com, allows patients to request appointments online, gain access to their own medical records, and, for a small fee, e-mail questions directly to their physician. Patients may also choose between receiving test results via e-mail, or through a secure voice-mail service. Those who choose the phone service simply dial the number, then use a password to gain access to voice messages left for them by their doctor. No more phone tag.

"It's a dream come true for patients," says Crow. "They can't imagine the high-touch service they're getting."

Culture shock

Before beginning discussion of new symptoms, FMST doctors go over whatever it was they were talking about last time. Did that medication work for you? Have you been exercising more like you said you would? Are you still having trouble with insomnia?

A young law enforcement officer answers such questions for Weyenberg before describing the cold symptoms he'd been dealing with. The symptoms are so bad he figures he must have the flu. He doesn't; flu season hasn't started yet. And while there isn't anything Weyenberg can do for his cold except recommend his favorite over-the-counter remedies, his questions about prior issues might have turned up something of interest.

That's why each physician in the practice conducts exams in this same fashion. In fact, the doctors at FMST strive to do as much as possible in the same way, in both clinical and business matters.

"Variance costs money, and variance costs confusion," says Crow. "From an office efficiency standpoint, we always strive to do things the same way."

In fact, FMST has devised an organizational structure in which nurses and other staff must be candid with the physicians because there is no office manager. There are only two organizational levels: the physicians, and everyone else. Each staff member generally reports to the physicians. Employee reviews reflect all the physicians' views of each person's performance.

I was skeptical. How do staff know which physician to bring a specific question to? How do staff determine which physician really needs to be made happy on a given day? And how do they handle situations in which Dr. A wants them to do something one way, while Dr. B prefers it another way? How can a person's performance be fairly reviewed by committee — especially a committee of doctors, who are generally notorious for being set
in their own ways?

Staff told me that this is just not a problem. These physicians are so in sync with one another that there really is no difference among them in terms of their interactions with staff or their preferred ways of doing things.

"We like not having an office manager," says Finnye LaTour, an administrative employee who has worked at FMST longer than any other staffer. Indeed, over lunch, with the physicians out of the room, the employees universally agree that their flat organizational structure is a crucial key to their success, and most have horror stories of despotic managers at previous jobs.