It’s been almost 16 years since we started this incredible journey as the medical practice known as athena women’s health and the Birthplace. Since then, we’ve veered off in different but amazing directions. (See the reunion of the early athenistas from athena women’s health photographed, right). Jonathan has led the evolution of athena into a force of 2400+ athenistas all dedicated to creating a national health backbone in order to make health care work as it should, Todd Park (athena’s co-founder) is serving as the CTO of the United States and then there’s Mitch Besser.

Mitch was one of the physicians who led our birth center’s small team of caregivers, all dedicated to making a real difference. Since we last worked together Mitch has gone on to serve as the co-founder of mothers2mothers (m2m), an exemplary non-profit group that works to eliminate the transmission of HIV from mothers to babies and keep mothers alive.

m2m trains HIV-positive mothers as “Mentor Mothers,” (photographed, left) creating a new tier of health care providers to support overburdened medical systems in sub-Saharan Africa. Although pediatric AIDS has been virtually eliminated in the developed world, there are still almost 900 babies born every day, unnecessarily facing a life shadowed by HIV/AIDS. To date, m2m has reached more than one million mothers across nine countries.

Earlier this week, athena hosted a fundraiser for m2m. We helped raise funding to keep the Tanzania program operational. And we are evaluating putting athenaClinicals, our cloud-based electronic medical record, and athenaCommunicator, our patient communication portal, in the more than 400 m2m sites to help the caregivers capture and report on critical social history and stay in touch with clients so they remain in care. If we’re successful in this endeavor athena will be operational in three other parts of the world – India, Haiti and Africa.

As a new mom, I know how blessed we are in the United States to celebrate Mother’s Day without the threat of HIV hanging over our children. We can show our gratitude by saving other lives.

If you’d like to learn more about this incredibly special organization, please visit www.m2m.org.

Today, in the third and final entry (see Parts I and II) of Pierre Valette’s journal from Haiti, we experience the first fully electronic patient encounter at the St. Boniface Hospital and learn more about 16-year-old Mamaille; she had been crushed by a falling building at a Port-Au-Prince school, abandoned on the Haitian border, and eventually brought to St. Boniface.

When reading Pierre’s entries, I can’t help but think of how fortunate we (U.S. citizens) are to have the level of health care that we do in the U.S. Sure, there are many things we need to improve (such as data sharing and the ability to shop for care), but those pale in comparison to the day-to-day struggles some Haitian caregivers and patients have to overcome. – Michelle, Social Media Manager

My last day. Our fifth day here.

We now have running cold water. Yesterday, the plumber made the eight-hour round-trip drive to Port-Au-Prince to buy a new pump for the water cistern on the hospital roof. This means we no longer have to carry buckets from the well in the courtyard up to the bathroom to bathe or flush the toilets. We may have lacked running water over the past few days, but the rhythm of the hospital never dissipates. Each day, hundreds of patients arrive as they always do—on foot, by motorcycle or via donkey—to receive the level of care that only the St. Boniface Hospital can provide.

Over a dozen babies have been born since we arrived. Three babies are in the NICU (Neonatal Intensive Care Unit), kept thriving by ventilators powered by ever-humming power generators. In the small pediatric ward all beds are occupied by children suffering from HIV, malaria or other ailments that plague Haiti. Their parents sit by their sides. At night, they curl up with them on their beds to sleep.

Dr. Desiree arrives late for his electronic health record (EHR) go-live today after performing an emergency C-section in the hospital’s operating room, supplied with donated equipment from a Florida hospital. Without taking a breather, he comes straight from the OR to our makeshift training area, a big smile on his face, ready to begin his first electronic encounter for the Spinal Cord Injury (SCI) Program. He will be seeing Mamaille (photographed, right), the 16-year-old girl abandoned on the Dominican border about two years earlier. Though she seems healthy by all appearances, Mamaille currently suffers from persistent infections caused by her wounds. In fact, on our third day here, when Jackie Mow, head of the athenahealth video team, filmed two of the SCI kids going to the nearby school (carried in their Walkabout wheelchairs due to the school’s lack of ramps), Mamaille had to stay behind because her wounds had become irritated.

Dr. Desiree logs onto athenaNet and is now ready to see Mamaille in his office, conveniently located across an open walkway from Mamaille’s room. There’s just one hitch. No Mamaille. Realizing that she might be photographed, Mamaille is delayed in her room, unsure of what earrings to wear. She fusses with a bag full of earrings she has made over the past year—the output of the SCI’s vocational program that has taught her basic jewelry-making skills. The normally soft-spoken Dr. Desiree calls out to her from across the hallway. Je m’habille,—I’m getting dressed—she yells back. A little white lie. Appearances are important here in Haiti—especially to Mamaille.

With the perfect set of earrings dangling from her ears, she makes her way to see Dr. Desiree’s office. To start, he encounters a small problem entering her name. Seems he hasn’t perfected the “Search Patient” function on athenaClinicals, entering far more letters than necessary. Jamie Mercurio, another member of the athenahealth implementation team, shows him that he only needs to type a few letters of her last name. He enters “L-E-J.” Mamaille LeJeune’s record immediately pops up.

Dr. Desiree takes her vitals and enters the discrete data into the system. As he talks to Mamaille, he selects the patient’s chief complaint and quickly documents the history of her present illness—all in Creole. At the end of the encounter, he enters her prescription into the system. It’s a short visit. More of a test than anything else. Dr. Desiree is slowed down a little by having to visually scan the screen for fields he’s not yet familiar with, Jamie helping him search for the prescription he needs. But with very little training and only a modest amount of assistance, Dr. Desiree successfully documents the encounter into athenaClinicals.

As Mamaille leaves the exam, Jamie and Dr. Desiree exchange a high five. Dr. Desiree did it! The St. Boniface Haiti Foundation’s SCI Program has its first electronically documented patient care experience. One small step for EHRs, one giant leap for health care in the Third World countries.

I ask Dr. Desiree what he thinks. He confides that the process took a little longer than “de documenter avec un stylo.”— to document with a pen. “Is it worth it?” I ask. “Bien sur”—of course—he responds. He’s confident that he and the care team at St. Boniface Hospital will soon develop the muscle memory needed to use the EHR efficiently.

That learning curve will be worth it as athenaClinicals begins to provide the data needed to track progress and coordinate care more effectively. Betsy Sherwood, coordinator of the SCI program couldn’t be happier. For months she’s known that this experiment in implementing electronic health records at the SCI Program could only succeed if Dr. Desiree was on board. He was indeed and has taken the first step. The staff can now follow his lead.

It’s a good day. The cloud did what it was supposed to do—bring rural Haiti an efficient and effective means of documenting, tracking and managing patient care across all care providers. Dr. Desiree is satisfied. And I can now go take my first shower since we arrived.

Look for a guest post from SCI program coordinator Betsy Sherwood later this month where she’ll speak in greater length about health care in Haiti and the day-to-day struggles physicians are faced with.

On Monday, athenahealth announced the St. Boniface Haiti Foundation as our 2013 Vision Award winner. We honored St. Boniface for their 30-year effort to improve the lives of Haiti’s underserved by providing high-quality, affordable health care and education in the rural region of Fond des Blancs.

In addition to recognizing St. Boniface with the award, athenahealth is partnering with the Foundation to implement our cloud-based electronic health records system—their first EHR—in rural Haiti. In fact, we currently have a team of athenistas in Haiti helping the Foundation get started. During their time there, our VP of Content and Communications, Pierre Valette, will share his experiences for you all. – Michelle, Social Media Manager.

It’s our third full day here.

We’ve had no running water since we arrived on Saturday at the St. Boniface Hospital in the rural region of Fond Des Blancs. The jugs of potable water in the kitchen ran dry last night (a few had gone missing over the weekend). Other than “splash showers” from buckets of cold well water, we haven’t bathed since we arrived. We’re all in good spirits, though. The electric generator is working, and the cell tower up the hill is delivering a strong Internet signal, ready to connect our friends to the cloud. So, athenahealth’s bold experiment to bring cloud-based electronic health records (EHRs) to the rural clinic where we are staying is—so far—working.

Over the past few days, athenahealth’s three person training team—Chris Vignare, Jamie Mercurio, and our very own Haitian translator, Jasmine Etienne—has been a giving crash course in athenaClinicals, our cloud-based EHR, to the Haitian and American teams who run the St. Boniface Hospital’s Spinal Cord Injury Program. The program, started three years ago after the worst earthquake in Haitian’s History, is the only one of its kind in the country of Haiti.

As the hospital ambulance drove our team the four-and-a-half hours from the Port-Au-Prince airport, Jackie Mow, our cameraperson, wondered why the clinic was set up in such an inaccessible area. The question became more pointed as we covered the final 20-kilometer stretch along a rutted, dusty dirt road that let us into the mountains.

The answer is simple: no other health care organization, not even Partners in Health, volunteered to take on the care of the many post-earthquake spinal cord-injury patients who require intensive physical and psycho-social care for the rest of their lives. Sadly, though, in the case of most third-world spinal injury patients, post-trauma life expectancy is only 12-24 months, according to Dr. Inobert Pierre, the Director of the St. Boniface Hospital.

The hospital had no experience in treating spinal cord Injury patients. But they took on the challenge because it’s in the Foundations’ charter to care for the neediest of the needy in Haiti—no matter how difficult the task. Few could be considered more needy.

On Sunday, we met Mamaille (pictured, left), a 16-year-old girl typical of many patients here. On January 12, 2010, she was crushed by a falling building at a school in Port-Au-Prince, considered dead by her family who lived in a rural province, and sent to a poorly equipped hospital in the Dominican Republic. There, the untrained workers shaved her head, eventually abandoning her on the Haitian border. Mamaille was then picked up by aid workers, her ankles eaten by rats, and eventually brought to St. Boniface’s ground-breaking Spinal Cord Injury Program.

Like all but one of the 60 patients in the program, she has beaten the odds. Three years after her injury, she’s thriving in the Program, which offers her psychological counseling, physical therapy, schooling, wound care and a supportive community.

By all measures, the Program is a health care success story—with many caregivers throughout the country seeking to follow its model. One thing the program lacks, however, is an efficient way to track patients across all care providers and measure the success of the program. That’s where this athenahealth pilot comes in: The implementation team is down here in Haiti to install athenaClinicals, which requires only a laptop, electricity, and an Internet signal. We might not have running water this week, but the hospital has all the required resources to make athenaClinicals fully functional—including templates created in Creole by the athenahealth Professional Services team.

As I write this journal, I have been watching four social workers who have just learned to log onto athenaNet and register a patient for the first time. Two of these caregivers are in wheelchairs, graduates of the program and now members of the full-time staff. One of them, Maxsony, just gave me two thumbs up. “It’s easy,” he said. And we’re thrilled to hear that.

Operating a small business in today’s economy is difficult. Small, privately owned physician practices must have their financial house in order to provide high-quality medical care. The truth is most physicians are ill-equipped to survive in a very tough business environment. We spend years training to take good care of our patients, but have no idea how to balance a budget or run a practice effectively. How can we best improve practice management, delivery of care, patient communication, financial health… all at the same time?

What’s required to make it all work?
A stable practice needs to do two things: Control costs and maximize revenue. Obvious, right? But it’s true.

Controlling costs is difficult but manageable—and with the right staff, it can be done. I’d like to discuss that second part, but with an added challenge: Maximizing revenue while simultaneously improving care.

In today’s ever-changing economic environment, small practices must continually look for ways to increase revenue stream. The system demands it.

Reimbursement rates are, to some degree, out of our control. We can negotiate but are often left with whatever insurance companies or the government is willing to pay. Since most of us still operate within the fee-for-service model, the vast majority of our revenue comes from office visits. Some practices can try to charge for additional services, but most fees aren’t reimbursed by major payers and end up falling to the patient. This is a pattern we’d like to avoid.

So, with fixed reimbursement rates and overhead, how can you increase your bottom line?
With schedule density. By increasing patient flow through your office. There are two ways to accomplish this: 1. Gain new patients; and 2. Increase the number of visits from current patients. Word-of-mouth is the best way to achieve that first goal, but growth doesn’t happen overnight. That second goal is what’s really worth focusing on. And it’s more beneficial for everyone.

Seeing patients more often can be not only financially rewarding, but it also promotes better care—it is far more cost-effective to keep people healthy than to treat them when they’re sick. Insurance companies know this and will often reimburse better for a health maintenance exam than an acute illness visit.

Let’s get healthy patients into the office and keep them healthy.
And let’s get patients with chronic illnesses into the office so their illnesses can be managed. This approach can cut overall costs, improve the general level of health across a population and result in better financial success. It is a classic win-win.

How can we get this done?
Our office has found that athenaCommunicator, athenahealth’s patient communication solution, can be a great driver of both health and revenue. By using athenahealth’s reporting features, our pediatric office has been able to sort through our population to identify patients who have not been in recently for well-child exams, and contact those with chronic diseases such as asthma.

We started by running reports and placing “ticklers” into the computer to have athenaCommunicator call and e-mail families, to remind them of any routine health maintenance visits. We also used the patient communication system to contact all asthmatic patients during the fall, to encourage them to come in for their flu vaccines.

With these two automated actions, we both increased our schedule density (to just short of capacity) and did “the right thing” by improving care for a specific at-risk population—and our patient population in general.

The next step—to enable us to see patients more often—occurs on an ongoing basis. Here’s how we do it: When a patient checks out, if their next appointment is not made on the spot, a tickler is automatically placed into athenaCommunicator to remind the family of the next recommended visit.

For well-child care, this is timed to call and e-mail the family in 10 months, so they can set an annual-visit appointment. For asthmatics, that reminder is set for every 6 months.

We use a similar process for other acute illness states and well-baby exams. In the two years since we started this process, open appointment times at our practice are rare, and we’ve received a tremendous amount of positive feedback from our families.

Good care and financial stability, together. What a novel concept. It may sound cliché, but the athenahealth message is true: Our practice really is “Better Now.”

Dr. Drasnin is an athenahealth client specializing in pediatric medicine at Englender, Sper, Drasnin, MDs, in Cincinnati, Ohio.

About a month ago I had the opportunity to talk to an insurer about a potential new urgent care location. They seemed excited until one point when the conversation turned to the topic of rates. That’s when they made this statement: “Most of what you do is convenient care anyway.”

The cynic in me realized this was just a negotiating ploy to keep me from asking for a rate increase. But their comment did get me thinking.

Probably the toughest question about urgent care is, well, “What is urgent care?” Ask a gathering of 10 urgent care professionals and you’ll probably get 10 different answers. Why? We have certification and accreditation programs all defining urgent care. We have a national organization that represents our field, and a recently formed College of Urgent Care Physicians. Surely this stands for something.

But the assertion that we are just “convenient care” providers struck a nerve.

When I opened our first urgent care facility, I thought we were ahead of the curve. With our background in emergency medicine, I thought we offered better care than “family practices billing themselves as urgent care.” Yes, I was an urgent care snob.

Then, I went to my first urgent care conference. Confusion set in as I realized that urgent care ran the gamut from small, single-site family practice/urgent cares trying to survive in a tough market, to urgent cares that seemed like mini Emergency Departments, with immediate access to on-site ultrasound and CT scans. Wow. I was more confused than ever. Where did we fit in? Were we doing urgent care “right”? All these people said they had an urgent care center, but with different models, in all sorts of communities across the nation.

Over the next few years, our center continued to grow and I continued to ask those two lingering questions: “What is urgent care?” and “Are we doing urgent care correctly?” I think I started driving my partners nuts. We got our certification from the Urgent Care Association of America (UCAOA) and have begun pursuing accreditation from the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). Surely we must be on the right track.

Now, whether she knew it or not, this insurance company rep had gotten to me. How would I respond—how should I respond—the next time I was accused of providing “convenient care” instead of urgent care? After a full month of contemplation, I had my answer.

The comment that the insurance rep may have intended as a putdown is actually an honor. Yes, a part of any urgent care’s activity is convenient care. From those small, single-site centers to the large corporations, we all provide a convenience to patients: timely effective medical care they may not otherwise be able to get. We prevent people from becoming sicker and ending up as an ED admission. We enable patients to receive care without taking a day off from work. We allow families to get care on their schedule, not just weekdays from 9 a.m. to 5 p.m., like the rest of the nation.

With this reflection, I realized that there are so many different urgent care models because each urgent care provider has found the best way to deliver care in their community. The key is providing access to care. Who has it right? We all do.

To survive in these tough times, we have to know our customers’ needs. So the next time I am accused of providing “convenient care,” I will proudly answer “Yes.” All of us together provide convenient medical care when we provide our community access to quality care. As urgent care centers, our diversity is truly our strength.

Dr. John Kulin is an athenahealth client who practices emergency medicine at Occupational Medicine South in Manahawkin, New Jersey.