Indu Subaiya Interviews Jamie Cesaretti, Member of the Florida Radiation Oncology Group

Jamie Cesaretti, MD, Member of the Florida Radiation Oncology Group, will join us on stage at Health 2.0 Spring Fling Matchpoint Boston May 14th during the Fireside Chats. He will discuss his partnership with Vitals, and the importance of similar partnerships as private practice groups adapt to the changing healthcare landscape. This interview is part of Spring Fling: Matchpoint Boston series. 

Indu Subaiya: Your private practice teamed up with Vitals; why did you decide to partner with a doctor review and rating site? And can you talk about how that partnership progressed?

Jamie Cesaretti: We found it’s more complicated than just getting content on, because if you are not found on the internet, all the money, time, and effort you spend on putting content up is for naught, because the patients aren’t finding you. We approached medical marketing groups who were all very expensive. We knew enough–and honestly, part of it was we would come to the Health 2.0 Conferences that you have in San Francisco, over the past 4 years, that really opened our eyes to what others were doing, and it offered more capabilities than what our kind of local medical marketer knew existed.

So that’s when you, me, Matt and my partner John Wells started our dialogue about possibly doing a conference directed toward independent physicians. And I think that meeting is the one where I met Jeff Cutler the second time, who is the very forward thinking Director of Business Development for Vitals. And what they had been doing — Vitals to that point, I think, is being engaged by institutions with very large marketing budgets like the Mayo Clinic or Pfizer, and he was interested in approaching a forward-looking doctor practice, like us. So our group and Vitals.com started on this adventure together before having a financial agreement in place where all of our doctors updated their profile and put their own content on.

Then we started directing patients to Vitals to review us after their interactions with us. It started to work; we were seeing patients who knew what we had put on the Vitals.com website. I think it took at least 8 more months to get the financial agreement in place.

Indu Subaiya: Wow!

Jamie Cesaretti: Yeah, and now we actually have proof; it’s a business, it’s a private practice. So I go back to my partners and say, “Hey, this amount is worth paying”, and I show them data. Now we are at the point where we can actually prove that we got three calls today and one appointment, as opposed to just kind of “eyeball seeing your face.” We’ve managed to coordinate to the point where we actually know where the call is coming from when, and if it manifests to the patient being treated.

An additional important factor is that we were not ambitious on an individual level, we were trying to be ambitious on a practice level.

This means we’re growing the program to not just include just the radiation people, but we have other clinical partners in urology, medical oncology, and pulmonary, who are our partners. And they are also seeing more calls. So it has been a very sort of value-added experience for us.

Indu Subaiya: Would you say that the group practice, if you will, is able to show a more personal side of its operation than say just a hospital-based service, because you are encouraging your colleagues to put up these profiles, and do you think consumers/patients are seeing, not just more of you, but a different side of the practice in terms of the individuals behind it?

 

Jamie Cesaretti: Very well put. This is a dominant trend. There is a well known political push towards consolidation of medical resources within American communities in order to “save money.” But this new reform is really not how the community members think. Most people really want to connect to their doctor, they want to know their doctor by their first name and see him or her in their community and at their schools. It’s those kinds of aspirations that patients want for the person who is caring for them. They want to know that their doctor cares about them and will be available when and if an emergency happens.

But sadly, the doctors are not the ones with the marketing budgets to try to show that side of themselves on the internet, television and radio? You end up having for-profit and non-profit institutions trying to send the message that they care and will be there in a time of need and then often just not delivering for the patients. Not to pick on any given institution but if you are offering the “best cancer care anywhere”, it’s just a logo and it’s appealing to someone who has never really engaged in complicated coordinated medical care. A consumer is attracted to the marketing and will often make the plunge with an, “Oh gee, this must be the best.” But what people are after–what they are seeing the doctor for in addition to their technical skills–is that emotional connection, to know the person cares and will be there for them in years to come, and sadly those institutions don’t really deliver what their marketing budgets promise on a personal level.

They can’t because they are not constructed as private businesses; they are constructed so the physician is treated as a productive unit within a complex web of incentives let by middle and upper level management.

Indu Subaiya: That’s an interesting point, because I think the other flip side of the coin, and we’ve had this conversation before, is some physicians see online profiles as threatening or scary. Can you talk a little bit about how your experience has been to date, either yourself personally or how your colleagues have taken to this new type of online identity?

Jamie Cesaretti: Study after study will show that when any given physician enters the room, they really want to like you and they want you to like them. If you show a naysayer the data about patient interactions they usually will come around and eventually concede after trying is a few times So as a doctor you are set-up to have a great review. You almost have to try to have a bad review. It’s not what most doctors think, “If I go out there and I am reviewed, I will be criticized and I will get defensive and angry or whatever.”

That’s not at all what actually happens. What really happens is, if you ask patients for a review, they are more than happy to do it. The vast majority [of reviews] are positive, and even if they are negative, they don’t tend to be negative about the doctor, they tend to be negative about some aspect of the experience like, “I waited too long”, or “somebody was grumpy”, or “the nurse said this to me and it didn’t make sense to me.” So they won’t actually criticize the doctor, unless there’s something very wrong.

Indu Subaiya: Right. And has any of the constructive feedback that may have come up been something helpful or has any of that led to tweaks or changes or improvements?

Jamie Cesaretti: Yeah, it has. The way one has a big modern private practice these days is you’ve got to let the actual physician sort of do what they do. They have to be able to mold the office in their vision. And so some of our offices are run by people who are just highly, highly efficient, too efficient, right? And then some of our offices are run by people who are not at all efficient.

And so it does give us a forum to address this: “Hey, you don’t have to both be wrong, right? We can learn from each other.” And usually (and I notice I am using a watchword called efficiency), most patients are angry if they have to wait or if they feel rushed. And you can sort of see how very efficient offices will rush people, and inefficient offices will just have them wait, but it’s basically the same complaint.

Indu Subaiya: That’s really interesting.

Jamie Cesaretti: Yes. I mean, they are intertwined. So it also helps the staff tune into the individual patient. To summarize, most of the problems are not doctors, they are problems with waiting or hurrying, and that’s usually around scheduling.

So what you can do is you can go back to the staff and say, “Hey listen, it’s clear patient X had this problem, and we’ve seen her twice, you guys need to slow down and remember these are people, right?” Often the staff members are not coming to the care scene with the same sensibility as the doctor, it’s a job–9-5, “I am out of here”, “this person is annoying me”…this would be a staff member potentially. And so you have to kind of remind the physician manager, because we have our physicians manage most of our practices that they need to go and talk to these people into being more sensitive or replace them.

Indu Subaiya: Right. And you have.

Jamie Cesaretti: It’s a long answer, but absolutely.

Indu Subaiya: So just as we wrap up here, one tangential question for you that doesn’t have to do with the relationship with Vitals, but the broader kind of health IT question: Your practice among others is grappling with an industry that’s changing very fast on the sort of IT front, and you guys have had a number of decisions to make; have you made your EMR decision finally, or where are you on that spectrum?

Jamie Cesaretti: We have done everything we possibly can to hold out till the very, very end–to the point of dissecting the rules to be able to do them piecemeal, which we can do. We will fulfill high tech, but it isn’t going to be one suite of answers. We think they have been too expensive up till now, and also those that are very inexpensive don’t really serve our needs.

We’re going to end up having each center have its own apparatus to actually run the practice–turn on the machine, do the quality assurance and the scheduling. And then they will have another [apparatus] that is more of the patient-centered, this is your EMR.

I think this is probably the problem with most medical practices, of how we think we are unique. There is radiation; the complexity of the data that we store, there’s no incentive for–name a vendor–to come up with one solution just for radiation that takes into account the quality insurance around the machine and amount of dose given and the day, and the different prescriptions for all of the different diagnoses. And so we haven’t really seen that.

Probably the one that’s the closest for us is Vision Tree. They’ve done the best job at doing the most to make it customized. What they have done is mostly do radiation as per our big inter-study group called RTOG. And that can even be laborious.

So what we have ended up having to do is use our vendors to run the machine and make sure quality assurance is fulfilled and billing codes are fulfilled. And then use another, sort of like the patient aspect. The vendors who are busy doing radiation oncology EMR are so set in their ways, and it’s such a lucrative business for them that I don’t think they saw this coming. I am not sure they knew how to execute it. And the things that we have seen that help people in our world, like Practice Fusion, are still far ahead of what our standard vendors are capable of.

We are probably representative of many specialty practices because we think we are unique. We use enormous amounts of data to carry out the treatments and there is no incentive for–“name a vendor”–to vendor”–to come up with one solution just for radiation that takes into account the quality insurance around the machine and amount of dose given and the day, and the different prescriptions for all of the different diagnoses. Probably the one that’s the closest for us is Vision Tree. They’ve done the best job at doing the most to make it customized. They have been very success at working with our fields big inter-group study organization called RTOG.

Indu Subaiya: Interesting! And then in your prediction, do you think the needs of specialty practices will diverge more or converge more in terms of health IT as we move forward?

Jamie Cesaretti: One knows what they want to hear from a specialist, it’s not hard. Orthopod–“I fixed his hip.” That’s it, that’s all they want to know, the primary care. Or for me–“I treated his prostate cancer, get PSAs every six months. Thank you.” That’s really all they want to know. They really don’t want to know the dose, the fraction, the side effects during treatment. I mean, they can know it, but it’s information overload and it’s not that relevant.

The solution I would hope for is just kind of this front-end, what a primary care specialist needs–what they need to know and sort of a patient translatable front-end also. But sadly, I don’t think that’s what’s happening. A lot of the vendors have available these needs of complex hospital systems. There is an unsaid expectation by the new healthcare reform laws that patients are expected to operate at a level of healthcare sophistication, that our public health educational system is nowhere close to delivering. Realistically how much does the average person get in terms of education about health? How about their health as they age? Maybe 10 to 15 minutes with a primary care physician every six months or a couple of years…there’s just no way.

Indu Subaiya: So lots of moving parts. We’ll be curious to see how this space evolves, just as you are. But yes, very clear that one size continues to not fit all, and an interesting point about how you guys are separating out the patient-interfacing aspects from the clinical/administrating aspects. Well, thank you and we look forward to seeing you in Boston!

Jamie Cesaretti: Looking forward to it!

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