Tag: BLOG POST

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.

In the first installment in this two-part look at the role of acute visits in primary care, we focused on the benefits of building this capability. In this continuation, we’ll discuss what needs to be in place in order to get there.

Improving access for acute, same day patients offers important benefits to practices and patients alike, but it takes a little thought and effort. The good news is, the mechanics are well within reach. I promise not to delve into queuing theory, wait-time metrics or any elements of what can be the surprisingly complex subject of medical scheduling. But I will share with you a bit of my own practice experience.

Opening up an adequate block of time at the end of the morning and another at the close of the afternoon…

…allowed us to better balance acute patient needs with organizational resources. What’s amazing is that these blocks were the easiest and most pleasurable part of patient visits for my clinical staff even though there could be 6-8 patients scheduled for each hour-long block.

This approach, which did not include a move to a true open access model, enabled us to stay on track with our scheduled patients and then see acutes collectively. Generally, it offered enough choice to accommodate individual patient schedules. If not, we could usually bring them in whenever they could make it and adapt accordingly because of the efficiency of our exam room process.

Utilizing high-functioning assistants who are empowered with the specific skills needed inside the exam room… 

…is the single most important factor contributing to timely and consistent access for acute care patients. By building a more effective team in the exam room, providers can focus on direct patient care, those things that are commensurate with training and skills – and not the non-provider activities that can represent up to 60% of the patient encounter.

For example, in the typical routine (non-acute) primary care visit, the provider spends 10-15 minutes with what would be considered exclusively provider responsibilities and 10-20 minutes with non-provider responsibilities. Now, with the staff handling all the non-provider responsibilities inside the exam room, the provider is free to move on and see the next patient much more quickly.

I’ve seen improved exam room protocols work effectively in my own practice and in scores of other primary care and specialty practices with which I’ve been involved on an educational and training level. However, it’s important to note that the kind of transformation needed for more acute care capacity as well as all other patient visits isn’t simply a function of adding personnel. It involves true process redesign and a commitment to culture change, with a bit of professional flexibility and patience thrown in.

Expanded hours… 

…have to be part of the solution if a patient’s need for access is going to be truly met by a familiar primary care provider. By building a more efficient team inside the exam room, increased productivity will allow for shortened shifts as well as fewer shifts per week. The result is that a small group of providers will have evening and weekend access collectively for their patient panels while promoting a very healthy work/life balance for providers individually.

Extended weekday and weekend hours and greater flexibility in overall scheduling are providing additional options and removing more of those times when, as the urgent care promotions put it, “your primary care provider is unavailable or you’re unable to make a timely appointment.” It’s not always easy, but an improved exam room process and the productivity that goes with this make expanded hours eminently doable.

Realizing that the time and energy spent on seeing more acute visits is not a distraction…

…but rather an opportunity with a range of inherent benefits is the most important step in preparing a practice for increasing acute visits.

Despite ongoing uncertainty in the direction of health reform, the four legs of the primary care table continue to be competence, continuity, accessibility, and affordability. A practice without timely access to a familiar provider when a patient perceives an urgent need is like a table with only three legs. Missing that access leg doesn’t make for productive quality-based primary care any more than it forms a solid, reliable and well-functioning table.

And speaking of tables, we’re leaving too much on them if we’re not ready to increase access for same-day, acute care patients.

There’s a prevailing opinion among providers that time is equal to care; the more time a provider gives a patient, the greater the level of care or genuine compassion he or she has. That’s just not true. The quality of care we provide to our panel is what determines success—not the amount of time we spend in the exam room.

Starbucks hasn’t come to the exam room

Our inappropriate focus on socializing with patients has led many of us to prioritize the unnecessary goal of what I call a “Starbucks moment.” We’re under the impression that patients want and deserve unlimited time to relax, catch up and discuss anything that’s on their mind during a visit, regardless of how long it takes. And perhaps some of us have come to believe we deserve a “break” too—a respite from the demands of our busy schedule, spent in the company of a patient with whom we have a genuine, enjoyable connection.

We must remove this idea of socializing from the context of appropriate medical care. The strength of a provider/patient relationship isn’t dependent on the amount of time spent with patients, it’s founded upon and maintained by the right balance between personal connection, timely access, and competent medical care. Personal involvement is critical for a provider to know the patient and make the right decisions for his or her care. But unlimited time not only fails to produce better health outcomes; it negatively impacts access for the rest of the panel.

Trust is the intangible component that makes the provider/patient relationship unique and health producing, not the amount of time spent together in the exam room. Patients generally consider provider competency a given because of the amount of education and training every provider receives, but timely access and communication are the key to building trust. No matter how good the provider, if she/he is not available to the patient, the patient loses trust. What patients want and need, besides competency, is timely access to a provider in whom trust has been developed – a familiar provider.

(A small caveat here. There will be instances when unlimited time is the right solution for patients with special circumstances or emergency concerns. But those exceptions shouldn’t drive day-to-day operations.)

Priority management

As I’ve written previously, time management begins with priority management. And if we’re going to fix primary care, we must begin by rethinking our priorities. So what are the exam room priorities for providers?

• Maintain personal involvement with each patient to create or sustain health

• Create access for the panel (in other words, see all the patients in the panel who need to be seen on a particular day) [links to TCM schedule content offer]

• Make the necessary medical decisions for patients when they need care rather than refer to another provider

• Empower clinical staff to accomplish all the ancillary (or non-provider) work inside the exam room

• Communicate with patients in a timely manner (accomplished with participation of the clinical staff)

None of the goals above challenge or threaten the personal connection between providers and patients, and they actually incentivize greater trust by giving patients the care they need when they need it. And all of these priorities address the concerns of the individual patient as well as the rest of the panel, leading to better population health and meaningful provider/patient relationships.

Keeping the main thing the main thing

Primary care providers must begin thinking in terms of time and work within appropriate boundaries to give patients the access and quality of care they need to become and remain healthy. This means reorienting priorities inside the exam room and elevating health-producing strategies over “feel-good” moments that don’t actually create health.

The value of this cultural change in the exam room has enormous potential to transform our primary care delivery. Reprioritizing the goals of the exam room will lead to the improved access, health outcomes and cost-effectiveness our patients, panels, systems and society so desperately need.

It’s impossible to ignore how much power time exerts over our lives. Our human existence is organized and controlled by the passing of time and how much we devote to each aspect, whether it’s study, work, sleep, play or relationships.

But why doesn’t this hold true in the context of primary care? As providers, we tend to ignore the parameters that time has in our normal lives once we enter the exam room. Time always has limits—but somehow we’ve come to consider the exam room as exempt.

And that’s where primary care loses its financial sustainability and the functionality of providing timely access when consumers need it most. More than half of primary care practices in the US are in chaos because they lack the structure and ability to keep up with demand—much of which is due to poorly managed time.

Health is often impossible if it’s not on time

We’ve made a huge mistake in primary care by not meeting our patient’s need for timely access. The urgent care industry was born and has resulted in rising expenses, decreasing quality, and marginalization of the primary care discipline as a whole. This loss of access has also devalued the provider/patient relationship. Fixing the ways that we think about time is an important step towards improving health and reaching the Triple Aim Plus One.

But no one really wants to talk about the issue of time because it’s so controversial. Providers don’t want to discuss time management because it seems too restrictive or at odds with their particular style. We think our work is too important to be subjected to time constraints or that we owe unlimited time to patients if they want it. But these kinds of perspectives ultimately make our other patients in the panel vulnerable and compromise our own professional viability.

Restructuring primary care schedules can easily handle the needs of 26 or more patients daily by utilizing a well-trained team, inside the exam room. Timely access is of the utmost necessity and a need that we can no longer avoid.