Author: Stephen Moberg

Regardless of politics, personal opinions, or individual experience, it’s no secret that our healthcare system is broken and in desperate need of repair. And it’s become increasingly complex and frustrating, both for consumers and for those who provide care.

We’re excited to announce the release of a new book, co-authored by Dr. Anderson and Dr. Grundy, who bring a unique combination of personal experience and expertise to the quest for affordable and effective healthcare.

Lost and Found: A Consumer’s Guide to Healthcare is an up-to-the-minute guide designed to help consumers navigate the obstacles that stand between them and high-quality, affordable healthcare. Readers will learn about why primary care, more than any other aspect of medicine, will determine the quality of our healthcare as a nation. They’ll see the value inherent in a strong patient-physician relationship and how a “familiar physician” delivers the best preventive and acute care and chronic care management. And they’ll find out how to save money without sacrificing quality in today’s changing healthcare environment.

Advance praise for Lost and Found:

“Healthcare continues to get more complicated, confronting consumers again and again with critical decisions about health insurance, where to go, and how to get what you need from your medical care. There is an urgent need for helpful, unbiased information that isn’t selling something. Lost and Found provides trustworthy, practical advice on the major decisions that all of us have to make in getting the healthcare we want and need for ourselves and our loved ones.” 

— Edward H. Wagner, MD, MPH, Group Health Research Institute Senior Investigator Director (Emeritus), MacColl Center, Seattle, Washington

Most healthcare professionals’ blood pressure likely rose a little on October 1, 2015 with the launch of ICD-10. Bruce Japsen’s article in Forbes articulates much of the apprehension about the transition from ICD-9 to ICD-10. The concerns are significant: many physicians and practices aren’t adequately prepared, coding and billing errors are inevitable as the new codes are adopted and initial delays in authorizations and payments are likely.

The implementation is a massive undertaking for providers, system administrations, insurers and employers — and patients will absorb some of the effects as well. But in spite of its many hurdles, ICD-10 is a much-needed transition for the growth of the industry and for improved patient care. It’s also an important shift as healthcare moves away from a fee-for-service payment structure toward fee-for-value.

You’re speaking my language

Coding is the only standardized language shared between providers to communicate patient information. And without precise language, we can’t give a clear picture of a patient’s health. It’s fair to say ICD-9 conveyed fairly limited information. It might have been adequate 30 years ago, but as healthcare and technology have evolved, we need a greater level of detail for proper intervention and care coordination. ICD-10 provides the precision to describe a patient to any provider involved in his or her care.

The terminology and documentation process between ICD-9 and ICD-10 is similar, but the main difference is that there’s far more information captured by the codes of ICD-10. These new codes include the severity, risks and complications of a patient’s condition — data that has a significant impact on the way conditions are treated.

Documentation is becoming a significant element of care quality and helps facilitate the interoperability we need. Because healthcare crosses boundaries of time and providers, detailed, up-to-date patient records are critical. People travel and need care outside of normal weekday hours, and sometimes many providers are involved in the care of the same patient. A lack of specific information and clear communication poses real issues.

Better information leads to better care

One of the primary weaknesses of ICD-9 was that there was no way to differentiate between levels of severity for a particular condition. To give you an example of how this could impact the level of care, consider a patient with asthma. In the past, if a patient went to the ER suffering from an asthma attack, the only information reflected in his or her medical record would be the ICD-9 code for asthma.

Now that could be mild, intermittent asthma, which means the patient would only need a short treatment in the ER before being sent home, or it could be severe, persistent asthma, which means the patient could die from an episode if not properly treated. But according to the code in the patient’s record, the asthma would look the same, regardless of the severity. And without specific information about the patient, an ER physician could easily make a decision based off the limited details in the chart, and the prematurely discharged patient could die a few hours later.

And under the ICD-9 codes there was virtually no way to compare treatment plans for different levels of the same disease. If one treatment could be successful for a mild condition but a different option was needed for a more severe condition, the information reflected by the codes didn’t give a good indication which treatment to pursue for a severe case.

Now that severity is standardized, treatment effectiveness can be more correctly assessed. As Japsen points out in his article, ICD-10 will lead to better chronic disease management through better communication and evaluation. And all of this will result in better outcomes for our patients.

ICD-10 and the medical home

In the bigger picture, this is where technology meets the medical home. Now that we have the medical home model and electronic records, and because of the interoperability that’s coming between systems and providers, good patient care can’t happen without the EHR. And a patient being seen by his or her familiar physician, the PCP who provides care on a continual basis — in the context of a medical home — will lead to the most accurate medical information and documentation.

Change for good

ICD-10 won’t be an automatic or easy adoption — there will be a learning curve here. But for the most part, the number of codes physicians deal with on a regular basis will be limited by their specialty.

It’s a burden to change, and all change has costs and speed bumps along the way. But patients can’t get the care they need without accurate, comprehensive communication between providers.

ICD-10 is a consistent development toward industry goals like team-based care, interoperability and fee-for-value. And the bottom line is that ICD-10 is a real step forward for patient care, leading to better diagnoses, treatment and health outcomes.

EHR frustration has created a bit of nostalgia about the “good old days” of medical practice — the days before data entry dominated the patient visit.

Judy Mandell wrote an article in the Observer that addressed this frustration, felt by both patients and providers. The loss of eye contact, decreased focus on the patient and the amount of time (often a third of the visit or more) devoted to documentation has removed much of the relational element from the care equation.

While more than one physician would be happy to do away with the EHR forever, we know that’s simply not possible. Given the needs of our patient panels (including a large aging population), developments in medicine and the necessity of increased coordination between providers, the EHR is critical to competent and successful care.

The data entry clerk will see you now

But the breakdown occurred with an exam room delivery model that made the physician responsible for the EHR. When my system put me on the EHR back in 1998, it didn’t take long to realize I now had two patients in the exam room — and the most difficult patient was the EHR. It demanded the most time and was the most difficult, uncooperative and argumentative. And the real patient — the one who I was there to serve in the first place and who gave me the real pleasure of practicing medicine — no longer received my total focus because I was busy entering data into the computer.

Physicians are required to focus on the EHR because it must accurately reflect the patient visit — the circumstances, the details of that particular patient and why the physician made certain decisions. It’s impossible to remember all the information and make correct judgments without it. Not to mention the risk of massive fines or even prison time physicians can face if an audit of records finds inconsistent or fraudulent information.

Scribing: only a partial solution

Mandell’s article presents scribing as the answer to our exam room dilemma. While I agree that someone other than the physician should be responsible for documentation of the patient visit, I don’t believe a scribe is the ideal solution. Scribing can free up the physician from the EHR, which is a real benefit. But the scribe isn’t helping with any other clinical responsibilities, and the limitations of this role don’t provide enough assistance to fix the situation in which we find ourselves.

The best way to address this need is to have the scribing function performed by a clinical team member (a specially-trained nurse or MA) who can help the doctor accomplish the objectives of the visit. It’s not simply a matter of recording information, but assisting with the data collection, patient education and implementation of the treatment plan.

The intersection of meaningful use and meaningful care

Many doctors talk about a return to the traditional care delivery of the past, and that’s where we see new models emerging like concierge medicine and direct primary care. It’s understandable why this is attractive to physicians because it allows for smaller patient panels and enough time to focus on each patient and do the necessary EHR work. But we wouldn’t have enough physicians to provide the kind of primary care our society needs if they all migrated to a concierge model. Affordable, accessible primary care shouldn’t be a luxury.

Some might argue that it doesn’t matter whether or not patients see a doctor who knows them. But people respond differently when they’re treated in a personal way. While personalized service from a barista who remembers your name and coffee order or a car mechanic you trust provides a sense of familiarity and comfort, the advantages of a good doctor-patient relationship extend far beyond meeting an innate interpersonal need. The improved health outcomes make this relationship essential to comprehensive, quality care.

As much as we need enhanced technology and all the benefits of the EHR for better clinical delivery, the doctor-patient relationship remains a foundational element of meaningful care. That’s why we must turn the doctor’s attention away from the computer screen and back to the patient. Our industry’s move toward meaningful use depends on a delivery model that maximizes the value of a familiar physician and coordinated, team-based care. Because meaningful use — and any other efforts to improve quality, safety, efficiency and population health — will be most effective in the context of meaningful relationships.

If Apple’s 2015 Special Event on September 9 was any indication, our world has entered a new era of healthcare technology. Apple unveiled their latest developments to the AirStrip app for Apple Watch, designed to redefine mobile healthcare communication.

Apple isn’t the only company enhancing relationships between medicine and technology (just take a look at IBM and Google), but these latest capabilities have the potential to make a significant impact on the communication barriers that often exist between care teams as well as between providers and their patients. And based on the scope of Apple’s past success and appeal to business and the individual consumer, it’s likely that the company’s transformation of our digital world — and now healthcare — will only continue.

AirStrip and Apple Watch offer a unique combination of features to physicians. Once the physician is wearing the watch, he or she can be securely authenticated until taking it off. Doctors can collaborate with team members, view daily schedules, scroll through upcoming patients and information relevant to their appointments and view patients’ health status updates in real-time — all from their wrists. They can receive a message from a nurse containing an alert, waveform snippets, vital signs and lab results for a patient and then take action directly from the data (such as ordering a test) by sending a secure message to a member of the patient’s care team.

Apple has already partnered with the Mayo Clinic, Johns Hopkins and other leading systems to implement its healthcare technology as well as with industry vendors like Epic, facilitating HIPAA compliant, direct data transfer to patients’ existing medical records.

As a primary care physician, I always return to the irreplaceable value of the relationship between an individual and his or her familiar physician — an ongoing partnership of holistic, personalized care. There’s simply no rival for the quality provided by a physician who has knowledge of a patient that extends beyond EMR data points. And an app like AirStrip has the potential to help the familiar physician enable collaborative communication, convenient access and patient engagement like never before.

One concern is the question of how much data is too much data. Few physicians have the time available to review updates of each patient’s information and scroll through his or her vital sign waveform history on an ongoing basis. But in special cases, and particularly with chronically ill patients, the ability to view status updates in real time — without the patient even being in the exam room — could drastically improve chronic care management.

Technology can’t replace the care of a familiar physician, but it can help doctors be exactly that — familiar. Imagine a physician having the ability to remotely check a chronically ill patient’s heart rate and blood pressure in real time. Imagine a pregnant mother pairing her Apple Watch with a Sense4Baby fetal heart monitor to record a non-stress test that she can send in a message to her doctor from the comfort of her home. Tools that engage patients in their own health and improve the data transfer between all members of their healthcare team represent progress in the right direction.

Apple has both its champions and critics, and as with any technological advance, cautious adoption and gradual implementation are wise. But as the healthcare industry looks ahead at goals like interoperability and team-based care, we’re going to need new and better tools to help us deliver more efficiently and effectively. We simply can’t keep doing things the way we always have and expect improved results.

The complex, highly regulatory and often bureaucratic nature of healthcare isn’t the easiest context for new systems to take root, but it’s where we desperately need innovation. What seems clear from the movement of global giants like Apple and IBM is that personal and personalized healthcare technology is here and healthcare delivery must adapt to the changing environment. Change is often met with resistance (and physicians are notoriously averse to it). But it also offers opportunities for growth and creative solutions, from which the medical field and providers alike can reap great benefits.

When the Pickup Truck Meets the 18 Wheeler

Let’s take a quick look at what we know or at least what we may have read or heard.  A Rand Corporation study, presented in JAMA in 2014, compared a group of practices that had achieved patient-centered medical home (PCMH) recognition from the National Committee for Quality Assurance (NCQA) with a similar number of control practices that did not receive any special training. What the study reported, is that the medical home model was associated with only limited improvement within a range of quality measures and virtually no improvement in cost reduction.

No sooner were these findings published that proponents of the model cited dozens of private and public medical home-based examples where improvements in cost and quality had, in fact, been achieved and documented. Advocates also noted that the Rand study was based on a review of 2008 standards that have since been updated and was narrow in its focus, a limitation that is being addressed in new research that’s currently underway.

My personal experience as a primary care practitioner in a certified PCMH along with a great deal of observation around practices I’ve visited in various parts of the country over the past four years leads me to believe that the PCMH is a cornerstone of accountable care. It’s also a virtual requisite for meeting the Triple Aim of improving population health, the individual care experience and per capita costs.  At the same time, I think the section of the Rand report that suggests that “medical home interventions may need further refinement” may be right on  the money.

As we work with practices in how to effectively adopt a team care approach to primary care medicine, one of the essential building blocks for patient-centered care, we sometimes see administrators, practice managers, physicians and other staff who believe in the value of the medical home model and even imagine themselves to already be there or at least on the outskirts. In reality, they remain tied to the physician-centric approach of a traditional practice.

What they still haven’t accomplished is forming the kind of team where patients are able to develop a strong relationship with their doctor, clinical and non-clinical staff are empowered and trained to take on more aspects of care, particularly in the area of coordination and education, and physicians are enjoying a better work-life balance.

With these groups, I sometimes use the analogy of a six cylinder, gas fueled pickup truck being sufficient to meet the needs of their current practice but not adequate to power a medical home. Truly transforming the practice to a team care model and, ultimately, a patient-centered medical home requires more horsepower.  It’s time to get rid of the pickup and move toward a 12 cylinder diesel. The good news is that while investments in technology and staffing may likely be necessary, the proportional increase is not nearly as much as trading up from the pickup to the big rig.

Becoming a PCMH isn’t a matter of natural evolution. It takes the kind of concentrated effort along with the financial commitment I mentioned – particularly when it comes to additional staff – as well as the will to make the changes needed to go from doctor as point person to doctor as leader of a well-trained and high-functioning team.  It also takes the understanding that no matter how much you believe in the concept of team care and the medical home, no matter how solid your implementation plan, you still have to execute on it. And for that you’re likely to find that you just may need a bigger engine.