The Solo Practitioner: A Goner or an Up and Comer?

Through his Hamden internal medicine practice, Dr. Edward Rippel has become something of a pioneer. He takes his notes in a tablet computer and closely monitors patients with chronic conditions. Those who are overdue for a test get a reminder, part of an effort to more carefully manage patients' health.

Rippel isn't the first doctor to use electronic medical records or to practice as a patient-centered medical home, an increasingly popular concept in health care.

But unlike most of those who do, Rippel is a solo practitioner. And whether more physicians can be like him is a key question for the future of health care in Connecticut.

The way primary care is delivered is changing, from a system based on paper charts and payment schemes that reward doctors for performing more procedures to one that involves computerized records and paying doctors for coordinating care and keeping patients healthy. The federal government is leading a massive push for electronic medical records, while Connecticut has plans to encourage health care providers to become medical homes for Medicaid patients.

Both are costly, time-consuming changes that experts say are far easier for large medical groups than small, independent practices. In Connecticut, where eight of every 10 doctors work in a practice of four or fewer physicians, experts caution that the medical groups that have made significant changes are not representative of the state's health care providers.

Of the 91 providers recognized as patient-centered medical homes by the National Committee for Quality Assurance, or NCQA, most work at community health centers or in hospital-owned practices.

And then there's Rippel.

This year, he became the first solo practitioner in Connecticut to receive the highest-level medical home recognition from NCQA. He said he spent about $50,000 getting and implementing electronic medical records, but recouped the money in just over two years through increased efficiency, pay-for-performance programs, and changing the way his office works.

"I think it's actually something of a myth that you can only do this if you're a big practice," said Ellen Andrews, executive director of the Connecticut Health Policy Project, which recently produced a report on "early adopters" of medical homes.

Nationally, practices of one or two doctors make up 37 percent of the 2,314 medical practices recognized as medical homes by NCQA. Another 44 percent have three to seven doctors.

"It's hard to envision a small practice having the resources to do that. But people are doing it," said Dr. Robert McLean, a New Haven internist and rheumatologist and governor of the American College of Physicians' Connecticut chapter.

And in spite of the challenges, some say small practices could have an advantage when making major changes.

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