Author: Stephen Moberg

What Does the Doctor-Patient Relationship in Your System Look Like

Written by Stephen Moberg. Posted in Articles.

Are you building an environment that supports the doctor-patient relationship, improves the exam room experience and increases patient satisfaction?

Despite a growing interest in some of the “soft” skills related to medicine and the enduring hope that reform will provide a more fertile ground for change, healthcare has generally transitioned away from the time when physicians developed strong interpersonal bonds with patients. You can blame time restraints, the depersonalization potential of the EMR and the way doctors are paid. But whatever the cause, the fact remains that the doctor-patient relationship has suffered.

Unless your organization is moving toward concierge or direct care, making the most of an abbreviated time period in the exam room is going to be part of your future. One way to get there is to improve the physician’s role in the interaction by focusing on his or her bedside manner. While there are differences of opinion on the degree to which certain people skills can be taught and learned, the range of tutorials, classes and training sessions related to this non-clinical but highly important area of medicine would seem to suggest that nurture has an equally strong footing with nature.

But some limitations remain difficult to overcome. Every physician has a different personality. Some are more communicative than others. Some are better listeners. Some are simply more empathic. So if you’re looking for total consistency in physician behavior within your organization, there’s a good chance you’re going to be disappointed. On the other hand, you can help level the playing field through a common approach in the exam room that can increase the opportunity for a successful encounter. And a lot more.

It starts with moving from the traditional medical practice model to team-based care. This more collaborative approach has been shown to increase practice productivity and overall efficiencies, improve access and increase gross patient revenues in the practices that implement it. At the same time it enables physicians and patients to maximize the time they spend together.

By delegating those responsibilities that don’t require direct physician involvement – data collection, documentation, certain aspects of education, reinforcement of the treatment plan and most follow-up information – to trained and empowered clinical assistants, the doctor is freed up to do what he or she is singularly qualified to do.  At the same time, when the various elements that make up the exam room encounter are shared, the doctor is able to direct her or his full attention to the patient.

This focus means more actual time spent with the patient as well as a perception of more “quality time” based on the removal of distractions. It also means you’re able to rely on objective measures like templates and protocols, staffing strategies and a commitment to a team care model rather than the subjective, and not always consistent, nature of individual personalities.

The result is a range of benefits that cover everything from economic stability to professional satisfaction while, ultimately, strengthening the doctor-patient bond, one of the more elusive but important determinants of quality outcomes.

Team Care and the Triple Aim

Team Care and the Triple Aim

Written by Stephen Moberg. Posted in other.

Going Big by Starting Smaller

The relationship between healthcare costs and the overall economy exists on a number of dimensions, all of which are difficult to decipher by anyone who doesn’t have a serious background in economics. But the one thing we all know is that spending in healthcare has historically risen faster than inflation and just about everything else. Here’s a good way to put it into perspective:

If other consumer prices had increased at the same rate as healthcare costs have since 1945 a dozen eggs would cost around $55. If you wanted to drink some milk with your omelet you’d have to spend $48 dollars for a gallon. At those prices, the consumption of eggs and milk would be unsustainable and so are healthcare costs. And that’s what one-third of the Triple Aim is all about.

Developed by the Institute for Healthcare Improvement, the Triple Aim is a frame work of three health-related dimensions that are designed to be pursued simultaneously – improving the patient experience including quality and satisfaction, improving the health of populations, and reducing the per capita costs of healthcare.  While each represents its particular challenges, if you’re providing clinical care or managing primary care providers, you know that the financial component offers some particularly tough hurdles.

First of all, as Donald Berwick, MD, former Administrator for Centers for Medicare and Medicaid Services reminds us, there’s a significant amount of information to gather in order to hit the cost target of the Triple Aim. Not only do all relevant expenditures have to be captured, which is no easy task in its own right, but costs also have to be appropriately indexed to a range of local market considerations. It’s going to involve an effort that will include not only the practices you’re working with along with others across the country, but also policy makers and insurers. It will also have to include new reimbursement streams that will incent provider organizations to continue delivering quality care at a lower cost.

This is a tough challenge, but I think it’s one that can be overcome. What I worry about more is the obstacle to the cost component of the Triple Aim – as well as the other two dimensions – represented by a lack of adequate coordination across the full spectrum of care. The Institute of Medicine cited this concern, also, stating that “… measures of both cost and care across the continuum are impeded by the fragmentation of delivery itself.”

I have long believed that healthcare reform begins on the cellular level – practice by practice – and this particular issue is no exception. While we’re waiting for the policy makers it’s our responsibility to take on the fragmentation problem and the best way I know of doing it is through a well-coordinated team approach to care.  On the macro level, it’s a team that ranges from emergency rooms to specialist referrals and everything in between that extends across the delivery system and over time. But on that cellular level that I mentioned, it begins in the practices you manage with a better way to train and empower staff to enable primary care physicians to do what they do best, with less distraction from charting and documentation as well as EMR data entry. To be even more specific, it begins in the exam room.

In my own experience, a physician-led, patient-centered team is a goal that can be achieved with less time and effort than you might think. So as you look at the Triple Aim as a worthy aspiration, but one that seems too lofty to reach, you can start by breaking it down into its three components then break it down again into smaller pieces – like a team-based exam room process – that you can start working on right away to ultimately reduce the costs of care while improving individual outcomes, community health and the fiscal strength of your practices or group.

How Redesigning the Exam Room can Change Healthcare

How Redesigning the Exam Room can Change Healthcare

Written by Stephen Moberg. Posted in Articles.

What does the space shuttle Challenger explosion, Anatares rocket explosion and exam rooms have in common?  One thing is for certain; the two explosions embedded a cautionary tale of defective O-rings deep into our national psyche. Overlooking a very small component within the total system could result in catastrophic failure.

As someone prone to look for metaphors in just about anything, I wondered if there was some type of O-ring equivalence in the world of medicine. Granted, the exam room may exceed the O-ring to the solid rocket booster ratio terms of actual proportion, but it’s still a very small part of a $2.9 trillion health care system – and one, I think, that offers a perspective on why that system isn’t working well and how it can be improved without waiting for government action.

On its most essential level, the exam room is where the patient-physician bond is forged, a relationship that can never be overemphasized as to the improved quality it imparts to individual and population health. When it’s at its best, the exam room includes more than one person to assure that the physician can remain focused on the patient, not on the EMR. It also offers an indication to the patient that he or she has access to a clinical team to enhance care coordination.

Sequentially, the well running, team care exam room represents a critical component in the Patient Centered Medical Home, which supports a more effective delivery model for primary care medicine, which in turn, forms the foundation of healthcare reform itself. And on the more personal level, the exam room is where we are most likely to gain our greatest sense of satisfaction in practicing medicine, along with the financial remuneration that makes it all possible.

I’m not exactly sure of how directly the O-ring and the exam room correspond in terms of failure potential, but I do know that in many practices some re-design is in order. Most of those practices will need some onsite support to reach the optimal level of efficiency. But however you choose to improve your exam room process, it’s time to start.

You may not feel like you’re changing the U.S. healthcare system right away, but there’s a very good chance that you will change the way you practice medicine while you gain more enjoyment in the process.

What does your exam room need most?

Written by Stephen Moberg. Posted in Articles.

Chances are an Improvement Will Work as Well as a Re-invention

If you’ve followed previous blogs it won’t come as a surprise that I put a lot of emphasis on the exam room not only as a key element in an individual practice, but also as a critical step in strengthening primary care medicine itself. As the path to healthcare reform becomes increasingly difficult to clearly follow, it’s a safe bet that I’ll focus on the exam room even more as one of the aspects of the medical world over which we can actually exert control.

Of course, whenever we make changes in any part of the way we have practiced in the past there’s always going to be someone who tells us, “Don’t re-invent the wheel.” If you’ve been given that familiar advice lately, roll this over in your mind:

The research and engineering team that helped develop steel belted radial tires certainly didn’t re-invent the wheel. They didn’t even re-invent the tires that go on the wheel. But they certainly improved them. In the process countless lives were saved over the years from blowout-related accidents. And a lot of people never had to endure the stress of getting a flat tire on a dark and lonely highway.

There’s a pretty direct analogy with the exam room. What we’ve been doing has kept things moving along, but “road conditions” are getting more difficult. This is due to the increase in individuals with health insurance, the expanding population of older adults with multiple health issues and the increased demands of documentation. Let’s face it, the EMR has not been the panacea we hoped for with regard to improving either patient care or workplace conditions. All of these factors have melded into an increasingly difficult scenario.

There’s also that inconvenient shortage of PCPs that we read so much about. It probably stems from a combination of burnout and earlier than expected retirement as well as a growing lack of enthusiasm for Primary Care, a field that’s high on work load and comparatively shorter on reimbursement.

That’s why I keep talking about the exam room and the benefits of a coordinated team approach to care based on deep protocols, a physician willing to make changes and a well-trained and empowered staff that serves as a data gathering and information resource. A staff specifically trained to function inside the exam room to let you focus on patients, not computers. It’s not only a place to start, it’s a place where we can truly make a difference in a relatively short amount of time – especially when compared to the wholesale reconstruction of a broken healthcare system.

Clinicians tend to be intelligent and highly capable people. Most of us, however, are not inventors. But we can all be improvers. The good news is that you can be a highly successful physician on both a professional and personal level without re-inventing the wheel … as long as you keep making it better.

Overcoming Ongoing EMR Challenges

Overcoming Ongoing EMR Challenges

Written by Stephen Moberg. Posted in Articles.

The AAFP Seeks Needed Improvement Through Legislative Action

As a practicing Family Medicine physician I was an early adopter of the electronic medical record (EMR) so I have long and personal experience with its advantages and disadvantages. Now, while working with practices across the country to help them transition to an effective Team Care model, I am also keenly aware of the compatibility and integration problems brought about by the plethora of different vendors and systems.

I know I share this EMR frustration with most primary care doctors, so it was particularly gratifying to see the efforts that the American Academy of Family Physicians (AAFP) is now directing toward solving some of the major challenges. The EMR is the sharpest two-edged sword in health care. In the midst of an aging population with multiple chronic diseases, the EMR is a critical tool in keeping vast amounts of data organized and available for competent care. Yet not using this tool appropriately has dramatically weakened the entire industry.

Over the years, the AAFP has actively sought lawmaker assistance to help heal various aspects of our healthcare system. The current resolution presented by the AAFP board calls for members to encourage federal policymakers and CMS to create “significant and compelling incentives and disincentives for all electronic health record vendors to enhance their current EHRs in specific ways, including:

  • Enabling interoperability

  • Adopting a standard format for patient health information

  • Creating a user-friendly interface

  • Providing capacity to facilitate chronic disease management

The obvious precedent for this type of action is, of course, the Medicare and Medicaid EHR Incentive Programs which provide financial payment for the “meaningful use” of certified EHR technology. While that initiative has made some strides toward increasing electronic medical record use and overall effectiveness, the ability of one system to speak to another is vital for the successful exchange of information. Any obstacles in the way of that objective will have to be overcome, especially as we move toward new delivery and payment models.

Without interoperability, the health information system, and in large part our healthcare system itself will remain fragmented.

Leonard M. Finn, MD, an AAFP board delegate from Massachusetts and author of the resolution asked a recent Academy board member audience of more than 100 people if they were happy with their EMR. About four or five individuals raised their hand.

In response, he said that in over the decade since they came into relatively common use, “Electronic medical records still fail to help us do what we want them to do – provide a truly higher level of care for our patients. No bank, no airline, no major manufacturing concern would tolerate the quality of the software that most of us have to work with. In particular, interoperability and standard formats for patient health information should have been present when EMRs first came on the market.”

We can’t change that past, but we have a good shot at the future. Our hope now is that the problems of healthcare information exchange, which Dr. Finn mentions, can be rectified as lawmakers listen to our combined voices. Please join with the AAFP in helping to move this initiative forward.

The PCMH Gains an International Flavor

The PCMH Gains an International Flavor

Written by Stephen Moberg. Posted in other.

Paul Grundy, MD named Ambassador for Healthcare Denmark

While the direction of U.S. healthcare reform continues to include an air of uncertainty, one thing we can be sure of is that internationally, new ideas related to primary care medicine in general and the patient-centered medical home in particular, are coming soon.  And a good part of that prediction is based on the fact that Dr. Paul Grundy was recently designated as one of the 12 original ambassadors for Healthcare DENMARK, a gateway for international stakeholders to experience the Danish healthcare system and its innovative healthcare solutions.

Dr. Grundy is IBM’s Global Director of Healthcare Transformation and was a co-founder and president of the Patient-Centered Primary Care Collaborative, an organization birthed when IBM and other major US employers reached the unhappy conclusion that they were not getting what they paid for and acknowledged that the quality and price of healthcare were headed in opposing directions. Dr. Grundy has spent much of the past decade working with an international network of world class businesses, thought leaders, industry experts and medical practitioners.

In the process he has helped spread new perspectives and develop effective strategies for achieving better, more sustainable health and social outcomes at lower costs – with primary care at the vanguard. The PCMH has been an important part of his tireless advocacy and outreach.

As one of the participants in a recent Healthcare DENMARK ambassador summit, Dr. Grundy took part in presentations and panels that directed Danish strategies to international healthcare issues – of which primary care with a strong patient-centered focus was at the forefront – while also lending an international perspective to Danish health issues.

In a blog following the summit, Dr. Grundy noted that “Denmark offers some of the best primary care in world. As an ambassador for Healthcare DENMARK I will be taking the lessons learned and sharing them with my colleagues in the United States and other parts of the world. We can learn from international health systems, especially Denmark’s, which has been focused on a robust base of primary care for decades.”

Dr. Grundy goes on to urge us to look outside our own experience and notes that despite the high points of the U.S. healthcare system we are not among the leaders in population health. Our costs remain unsustainable, health coverage continues to be uneven and primary care itself is not assured of a thriving future.

As we move hesitantly at times toward true healthcare reform, the lessons to be learned from Denmark, a nation with exceptionally high patient satisfaction gained at significantly less cost when compared to American healthcare, can be enlightening and valuable.

And if you’ve admired the focus and passion exhibited by Paul Grundy so far in his efforts to promote primary care as the foundation or our healthcare system, stay tuned. Because it looks like after years pursuing that objective, he’s still going strong.   Learn more at www.healthcaredenmark.dk.

Gathering and Combining Our Strength

Written by Stephen Moberg. Posted in other.

A New Initiative Designed to Keep Primary Care Front and Center

Through the eyes of an individual physician, watching the major organizations representing primary care bring together their collective resources and energies is a gratifying and empowering experience. From the perspective of primary care practices across America and our field of medicine in general, it’s a unique opportunity to develop improved strategies and communications for the future.

Toward that objective we received some promising news late last month from Family Medicine for America’s Health, a coalition of  primary care organizations (see the list below) that shares a basic vision of the role primary care medicine should play in heath care reform, regardless of the form it may ultimately take.

The timing couldn’t be better. While political alignments and agendas may shift and change, it is more important than ever for primary care to take a leadership role characterized by a calming and steady presence. At the same time it is critical for our specialty to maintain a high profile and a clearly heard voice within the context of an ongoing national conversation.

At the forefront of the Family Medicine for America’s Health initiative is Health is Primary, a multi-year strategy development effort and communications campaign. The campaign will use advertising, news media outreach, a diverse range of online communications, workplace programs, partnerships outside of medicine and stakeholder outreach to provide information, increase awareness and foster action in support of primary care.

The ability of this campaign to demonstrate the value of primary care in delivering on the Triple Aim of better heath, better care and lower costs is another benefit that the eight leading physician groups that launched this innovative effort expect to be communicated:

American Academy of Family Physicians

American Academy of Family Physicians Foundation

American Board of Family Medicine

American College of Osteopathic Family Physicians

Association of Departments of Family Medicine

Association of Family Medicine Residency Directors

North American Primary Care Research Group

Society of Teachers of Family Medicine

I hope you’ll join me in applauding these organizations for providing the leadership and vision needed to help move primary care forward as we all adjusts to the changing landscape of health care reform. This collaborative venture has some ground to cover in its attempt to more fully position primary care as the foundation of the U.S. health system. But I think you’ll agree that it’s an excellent beginning.

Team Building vs. Building a Team

The Difference Between Building a Team and Team Building

Written by Stephen Moberg. Posted in Articles.

In The Boys in the Boat, a masterful account of the University of Washington’s eight-oar crew in the 1936 Olympics in Berlin, author Daniel James Brown offers an insight into what it takes to develop a gold medal-winning team. He also describes the frustration of the university’s rowing coach who kept trying to put together the best combination of people, a task he finally realized relied on temperament, personality and other intangibles as much as it did on physical strength and rowing skills.

Each time he assigned nine young men to a racing shell – eight rowers and a coxswain – he was fulfilling the basic requirement of building a team. But only when he found people who shared common goals, and then sublimated some, but not all, of their personal interests toward those goals, did he engage in true team building. Simply put, he learned that building a team was an action while team building was a concept and a vision.

As you’ve probably already guessed I think there’s a strong analogy between a well-rowed racing boat and a team approach to primary care medicine.

For over a decade, team building has been at the core of our efforts to help clinical practices transition from a traditional physician-centric model of work distribution to a shared-care approach like Team Care Medicine. Toward that end we are inspired by the work of Thomas Bodenheimer, MD, a Family and Community Medicine practitioner and faculty member of the University of California-San Francisco Medical Center. In his study of high functioning primary care practices, Dr. Bodenheimer shared what he considered to be the key elements of team building:

  • Defined Goals — overall organizational mission statement and measurable operational objectives

  • Understandable Systems — both clinical and administrative

  • Labor Division — clear definition of tasks and clear assignment of roles

  • Training and Cross-Training — for the functions that each team member regularly performs and for other roles

  • Solid communication — structures and processes

In keeping with those elements, and in order for our training strategy to be as effective as possible, it needs to go beyond re-engineering the patient-physician interaction in the exam room. That’s why we also support and guide the physician’s participation in mentorship, delegation, communications, role playing and other team building initiatives. In the new model of primary care that’s built around patients and delivered by teams, these skills are becoming more and more essential.

Because whether you’re racing an eight-oar racing shell through the water or providing primary care that’s comprehensive, preventive, efficient and effective, there’s no substitute for pulling together.

The Momentum Continues

Written by Stephen Moberg. Posted in other.

Patient-Centered Medical Homes are Expanding in Geography and Numbers

Although the concept and basic principles of the medical home were introduced as far back as 1967 by the American Academy of Pediatrics, the current delivery system innovation represented by the Patient-Centered Medical Home (PCMH) is of more recent vintage. And while this model of team-based, coordinated care has many advocates, no one has served as more of a singular champion for the PCMH than Paul Grundy, MD.

As IBM’s Global Director of Healthcare Transformation and the president of the Patient-Centered Primary Care Collaborative, Dr. Grundy has spent much of the past decade working with an international network of thought leaders, industry experts and medical practitioners. In the process he has helped spread new perspectives and develop effective strategies for achieving better, more sustainable health and social outcomes at lower costs – with primary care at the vanguard.  The PCMH has been an essential part of these efforts.

In a recent post on his LinkedIn page, Dr. Grundy noted that the integration of the PCMH into the fabric of health reform continues moving toward a tipping point. Along with its importance as a major component of Accountable Care Organizations, Dr. Grundy added that more and more stakeholders are encouraging the development of PCMH care delivery through programs in which payers, health systems and even employers offer financial incentives to medical practices that gain PCMH designation.

Outside the U.S. Dr. Grundy references similar growth and expansion citing a Canadian example in which demonstration projects in Ontario were so successful that the PCMH model is now being rolled out nationwide. “The first evidence is in,” he writes, “and what we’re seeing is the potential – and the reality – of a system where we pay less for comprehensive, integrated care in which primary medicine, formatted as a PCMH, takes on more responsibility for raising the quality of care, increasing access and providing preventive services.”

As primary care practitioners, our ability to advance the PCMH model will require a strong foundation to assure effective implementation. My experience within my own family medicine practice as well as my work as a consultant and trainer has strengthened my sense that the solid foundation needed will rely on changes in the exam room. The most important of these changes is a closely coordinated, team care approach that, among its other benefits, enables physicians to focus on patients instead of data entry.

I believe these changes are critical, and I share Paul Grundy’s assertion that the PCMH is too important to our future as primary care physicians, to the future health of our patients and to our collective future as a nation not to give it every opportunity to thrive.

Teamwork in the Exam Room

Going Solo Doesn’t Work in the Operating Room

Written by Stephen Moberg. Posted in Articles.

It Doesn’t Work in the Exam Room Either

This surgeon walks into an operating room and nobody is there except the patient. If that sounds like the beginning of a joke consider that the patient waiting for the procedure wouldn’t find it very funny.

A successful surgery requires the close cooperation of a number of operating room personnel. It relies on their familiarity with their specific roles, their preparedness and their ability to execute their responsibilities quickly and confidently. On the most basic level, they’re working together as a well-trained and experienced team.  As it turns out, the primary care exam room responds well to that same scenario.

What’s been taking place in what I have referred to as the “primary care operating theater of performance” is all too often a solo act with the physician spending much of his or her time collecting and verifying relevant medical data, completing documentation, implementing the treatment plan, carrying out any needed patient education and closing the visit.

By re-assigning these important but essentially routine tasks that don’t require direct physician involvement to appropriately trained members of  a coordinated care team, doctors can focus on direct interaction with patients – instead of keyboarding EMR data – while using their specific expertise and training for vital medical issues. The results are physicians who experience more challenge and greater satisfaction as well as more satisfied patients and staff.

The team care approach also provides the foundation for increases in the number of patients seen in a day with subsequent increases in revenues. The other important benefits reported by practices using a team care model are reduced stress levels among physicians, a restored or new sense of joy with practicing medicine and the always appreciated increase in personal time.

There are a number of activities that lend themselves well to the lone wolf approach. Things like reading, painting, writing, cooking, certain types of exercise or reflecting on the greater meaning of life come to mind. But when it comes to exam rooms, it’s becoming increasingly evident that the team care model is the way to go.

Contact Us

Team Care Medicine, LLC
P.O. Box 1743
Yorktown, VA 23692
Phone: 757-812-9279

Quick Links

© 2024 Team Care Medicine, LLC