In a recent New Yorker article entitled, “Why Doctors Hate Their Computers”, popular author and surgeon Dr. Atul Gawande skillfully explores the pain caused by the electronic health record (EHR) system at his hospital system in Massachusetts. Sadly, he concludes the piece with a vague exhortation that we must “insure that people always have the ability to turn away from their screens and see each other,” while offering no tangible solution to the long hours, lost patient connections, and burnout that he observes around him. Fortunately, proven solutions exist and they’re right under his nose.

Familiar Problems

In his typical, accessible style, Gawande explains how “a system that promised to increase my mastery over my work has, instead, increased my work’s mastery over me.” Finding records and adding new information to the EHR has consumed more and more time and attention, resulting in significant take-home work and frustration by doctors. Meanwhile, patients and physicians alike are frustrated that the personal connection has been lost as eye contact is replaced by staring at the computer screen. It’s a familiar refrain by doctors all across the country as burnout approaches epidemic levels.

Band-Aid Solutions

In an effort to unshackle providers from the EHR, some have hired scribes to document the patient exam. Gawande describes the approach exquisitely, saying “This fix is, admittedly, a little ridiculous. We replaced paper with computers because paper was inefficient. Now computers have become inefficient, so we’re hiring more humans.”  The problem, of course, is that scribes don’t fundamentally change the equation for the provider; they’re basically just a very expensive voice recognition software that’s “installed” on the the computer through the keyboard.

Answers in Plain Sight

As a doctor himself, it’s not completely surprising that Gawande only speaks in terms of individuals rather than teams. Even as he interviews doctors, patients, office managers, hospital administrators, and even a virtual scribe/MD in India, Gawande fails to connect with any of the thousands of nurses and medical assistants (MAs) that work in the same exam rooms as the doctors at his hospital. All too often these colleagues are overlooked by the doctors they serve. Nevertheless, the path to restoring the joy of the doctor-patient relationship, to a healthy work-life balance, and to overall career satisfaction is to engage with these nurses and MAs, to invest in them, and to begin to work as a true exam room team. This is the critical answer in plain sight.

Change isn’t easy. Providers must be persuaded to delegate many tasks and to re-conceptualize themselves as team leaders, rather than solo performers. In order to practice up to the limit of their license, MAs need thoughtful coaching and equipping. Only then can they take on new functions, like independently collecting patient data and then presenting the patient’s case to the provider (in the presence of the patient), much like a med student on rotation. Implementing a comprehensive exam room workflow that includes steps like these (e.g. the Team Care Medicine (TCM) Model) is attainable with the guidance of an experienced implementation consulting partner. That’s the real hope for Gawande and doctors across the nation.

In this final segment of a four-part series on productivity that’s included a discussion of the negativity often associated with the word “productivity”, the impact of low productivity on the medical home and five factors that function to hold productivity down, we’ll take a look at the exam room process and why it hasn’t been universally improved through a team approach.

So far we’ve created four separate blogs to look at different facets of productivity. Why are we banging this particular drum so loudly? Because to extend the analogy, in the great symphony that is the contemporary American health system, productivity is one of the most harmonious instruments we have.

Beyond its historical relationship to compensation-related metrics, productivity is the key to primary care access, including (and sometimes especially) acute or same-day appointments which might otherwise end up in urgent care or the ED.  On an even larger scale, the improved access that comes with greater productivity is a key factor in meeting current and future patient demand and consequently, the needs of our healthcare system itself. So how do we help assure that this capability will be in place? The exam room is the place to start.

Getting behind the team

The thing to keep in mind about team-based care is that it’s simple. At least in concept.  The provider’s role in the primary care exam room focuses on what she or he is uniquely qualified to do by way of training and experience. It includes performing exams, determining diagnoses and setting up treatment plans. Virtually everything else from collecting and presenting medical data to supporting the treatment plan and closing the visit, is delegated to one or more “team care assistants” including nurses, medical assistants or other well-trained clinical staff. Like I said, the basics are simple once you get past the misconceptions that are still held.

Three myths about the team care delivery model

Myth #1: Your staff can’t get proficient at the needed skills. With appropriate and adequate training, clear performance expectations and ongoing communications, staff members can effectively handle the required tasks – and can direct more of their time and attention to those activities than a physician could.

Myth #2: Having additional people in the exam room interferes with the patient-provider relationship. What we’ve found over a number of years and in an extensive number of practices is that freeing up the physician to focus entirely on the patient, (without non-clinical distractions), dramatically strengthens that vital bidirectional bond.

Myth #3: Patients don’t want anyone but the doctor in the exam room. Again, experience and related research indicate that patients overwhelmingly appreciate the extra time and attention directed to them by a larger care team.

The real change is cultural

Once again, I would emphasize that the concept of a team-based, patient-oriented exam room isn’t tough to understand or even assemble, especially once you get past those three myths. But waiting on the other side is the single, most substantial challenge to this exam room team – the historical and still potent strain of personal independence and self-assurance that exists among providers, whether they are employed or in private practice. While the potential need for staff hiring, as well as some role realignment and workflow redesign, requires effort and resources, the idea that many providers prefer performing a one-person play in the exam room instead of acting in an ensemble continues as the greatest obstacle.

In an upcoming blog we’ll look at the “Why do what I do best when I can do it all?” clinician culture and what can be done to transform it into an effective foundation for team care.

As a quick update, this is the third in a series on provider productivity. So far we’ve talked about how “productivity” became a bad word and the negative impact of low productivity on the medical home model. Now, we’ll look at five specific factors that are causing productivity’s ongoing slide. In the final blog of the series, we’ll see what a different approach in the exam room can do to improve the situation.

Let’s look at the numbers. Since 2000, individual primary care physician productivity in terms of patient visits per week has fallen by 35% for family physicians and 28% for general internists with both groups still working 52-54 hours per week (1-3). In 2016, on average, family doctors saw 85 patients per week and general internists 76 patients per week (3). This decline comes in the face of a growing need and decreasing numbers of primary care physicians, a combination that doesn’t bode well for reversing the trend. Right now, we’re producing enough visit slots for only 65-70 percent of people who need access to primary care. Imagine if farms in America produced only enough food for 70% of our population. While a range of factors contributes to this decreasing productivity, below are what I’ve identified as the five main reasons.

5 Reasons Why Provider Productivity is Declining

1. An Aging Population

Given the numbers of baby boomers and their impact on healthcare, older adults with multiple chronic conditions, reduced physiologic reserve, and high expectations continue to challenge our practices. Delivering effective care for this large segment has demanded changes in everything from practice environment and staffing to training and scheduling. It’s also required so much time that the same-day urgent needs of the patient panel have been de-emphasized, sending patients elsewhere for episodic care from an unfamiliar provider.

2. Electronic Health Records

Few technological advancements come without unintended consequences and EHR systems are no exception. As an early adopter, I can attest to benefits in aiding patient care as well as improving the accessibility of documentation. But I (and quite a few other physicians as noted in an Annals of Internal Medicine study summarized in a June 2016 NEJM Journal Watch) can also bear witness to some of the problems related to workflow changes and disruption. The bottom line is EHRs may be critical for quality care in 2018, but the extensive time required for documentation has had a negative impact on productivity to the point where it’s fair to wonder if the potential slow-down is always balanced by the gains.

3. Individual Provider Issues

This particular barrier to productivity runs the gamut, but there are some common threads: For example, ignoring well-established business norms like reasonable visit limits will decrease the chances for an efficient and productive practice; Non-clinical socialization is also a slowdown. We all feel good about sharing a Starbucks moment but it usually comes with the caveat that someone else is denied access; Unreasonable patient expectations are another productivity slammer. We’re glad to have satisfied patients, but we sometimes let their expectations define the encounter, overriding our own goals for the visit; Finally, there are those deeply ingrained habits of independence – including the belief that the exam room is the sole domain of the physician.

4. Economics 101

It’s no surprise that quite a few practices are skating on thin financial ice. Rising operational costs and lower profits combine to compromise staff size and capabilities, which in turn, puts yet another obstacle on the road to productivity. Some administrators equate financial sustainability with limiting staff when, in fact, the opposite may be true. One reason providers are spending more than 60% -70% of their time in the exam room doing non-provider work is because they can’t afford to increase staff. This non-provider work generates almost no revenue – so not a business model you’d want to pursue.

5. Administrative Burdens

Non-medical work requirements have burgeoned since the era of managed care. The regulatory framework we operate in, particularly in areas like prior authorizations, formularies, network restrictions, quality metrics, PCMH and Meaningful Use requirements, have created a mountain of paperwork and practice hassles, all of which demand a substantial amount of time from the provider. These responsibilities combine to remove primary care providers from direct patient contact, a result that once again hampers productivity.

What to do?

These five factors have played a major role in decreasing provider productivity (despite working the same number of hours) over the past two decades. But take heart. Although these issues don’t lend themselves to an easy fix there is one area where you can exert a meaningful degree of control on productivity – your own exam room. And that’s where we’ll be going in the next blog.

Footnotes:

1) Exclusive Survey: Productivity Takes a Dip; November 18, 2005, Medical Economics

2) Medical Economics Exclusive 2012 Productivity Survey; October 25, 2012, Medical Economics

3) 88th annual Physician Report: Ambivalence Wreaking Havoc in Primary Care; April 25, 2017 Medical Economics

This is the second in a series of communications on productivity and its impact on our individual futures and the future of health care. Last time we discussed why “productivity” has a negative connotation. Now, we’ll examine the direct relationship between low productivity and the success of the medical home model, with the next post focusing on the barriers to greater productivity. Finally, we’ll see what improved productivity looks like in the exam room.

Why aren’t medical home results more uniformly positive?

Just so we are clear, the evidence gathered after a decade of medical home operation is promising, especially in terms of chronic care management, mortality, decreased ED visits and hospital admissions. At the same time, it remains insufficient and at times, equivocal. For me, the medical home, though it didn’t have a formalized name yet, is the reason I became a primary care physician. So why, after so much investment and effort, aren’t practices that are certified medical homes experiencing more dramatic improvements?  Well, here are five factors that are holding us back and all of them are related to reduced productivity.

5 Reasons Why Low Productivity is Slowing Us Down

1. Low access for a high number of people

Low productivity and reduced access to a medical home go hand in hand – and by low, I mean 14-18 patients a day. Timely, appropriate access both for the acute and chronic needs of a provider’s panel is a requisite for any effective medical home. Lack of needed access is especially critical since it impacts so many patients. In 2015, over 35 percent of primary care visits were not seen in primary care practices. That means a large segment of the population couldn’t access the benefits they could otherwise receive from a medical home.

2. A negative impact on quality

With more than a quarter of all appropriate primary care office visits currently going to Urgent Care Centers and Retail Clinics due to access and convenience issues, quality is being thwarted. The fragmented, limited care of UCCs and RCs cannot produce the same outcomes as continuous, coordinated and comprehensive care, and the literature is replete with studies showing that an on-going relationship with the same care team yields increased longevity and healthier lives, along with lower costs. 

3. Decreased patient engagement

Access when and where it’s needed is a strong determinant of trust, and relationships built on trust are much more motivational and collaborative. When rapid access is limited because productivity is low, patients are far more likely to seek care in settings where the lack of a relationship impacts everything from compliance to personal accountability and patient satisfaction.

4. Inadequate finances and staffing

The downward spiral continues into financial issues, with a focus on the leakage of acute care visits – often the most patient-pleasing and profitable of the day. Losing this income source due to low productivity/reduced access undermines the financial viability of medical homes. High productivity also creates the only reliable, long-term source of capital to supply the staffing requirements of a high-performing medical home as well as the revenue streams needed to assure acquisition of needed technology.  

5. Increased risk of burnout

A wide scope of studies indicates that chronic work disruption caused by providers doing non-provider activities, and the productivity loss that results, are prime factors in clinician burnout – with the corollary that providers are most fulfilled when they can focus on patients. PCPs in medical homes are spending more than 60% of their time doing non-provider work. Having more staff with the right skills can go a long way toward reducing or eliminating this aspect of burnout. And once again, low productivity and its companion, low efficiency, are the culprits. 

Join us in the next post when we’ll look at the barriers that many providers face on the path to higher productivity.

This is the first in a series of communications on productivity and its far-reaching effects on our individual futures and the future of healthcare. In upcoming blogs, we’ll examine the link between productivity and an effective medical home, discuss some of the impediments to greater productivity and then see what it looks like in the exam room.

The driving factor in lack of access

There’s always talk about improving access, but low productivity, the driving factor behind reduced access, doesn’t get much respect. It should. It’s estimated that 38 percent of primary care visits in 2015 were unnecessarily diverted from the PCP office to the ED, urgent care centers and retail clinics. That’s a lot of lost visits, to the detriment of the practice – and especially to the patient because fragmented, limited care is no substitute for the kind of cost-effective quality that comes with continuous, comprehensive care.

What’s to love about productivity?

Getting back to our love-hate relationship with productivity, the “love” part is a matter of economics. While there are some exceptions, compensation has historically been based on the number and intensity of services provided. Metrics and methodologies can vary, but for the most part, the more patients seen, the more the likelihood of financial success. Although we continue moving toward fee for outcome-based payment models and next-era indicators for productivity, the wRVU standard remains in place for the majority of employed physician and physician owner practices.

And what is it that we hate?

As it turns out, there’s a darker side to this straightforward work-pay relationship. For primary care providers who already feel maxed out, it’s the vision of the hamster wheel. You hear the word “productivity” and you think of an industrial age assembly line, complete a conveyor belt, bringing endless numbers of patients in and out of the exam room. This scenario may be a bit extreme, but a system that incentivizes volume without supplying support staff with the specific skills need in primary care exam rooms can end up creating a negative impact on the missions of preventive medicine, wellness, education and basic patient care itself.  As a result, productivity is not only distinct from, but may also be anathema to quality and service.

If that isn’t bad enough, increased productivity carries the threat of overwhelming the already fragile work-life balance that providers often struggle to maintain. That’s why discussions of productivity can create concerns in the areas of both professional and personal satisfaction.

Why greater productivity is a necessity

In recent blogs, we’ve talked about how pursuing the Institute for Healthcare Improvement’s Triple Aim remains critical for maximizing overall health system performance and a reliable constant in the ever-changing map of healthcare. We’ve also discussed the value to primary care providers of capturing more acute care patients who might otherwise seek to have their medical needs met at retail clinics or urgent care centers due to limited access at their provider’s practice. The common element in both of these objectives and the most effective way to achieve this improved productivity.

However, without a corresponding increase in the kind of efficiency that supports productivity – and in turn leads to greater access – our ability to attain the Triple Aim, along with our hopes for meeting the needs of acute care patients will never reach fruition. And as we will discuss in the next blog, neither will our ability to bring the medical home to an effective reality.