Team Care and the Triple Aim

Team Care and the Triple Aim

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.

What does your exam room need most?

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

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

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.

The Momentum Continues

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

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.

Examining the Exam Room

Examining the Exam Room

Be Sure to Look for Symptoms in the Waiting Area

As an integral part of the diagnostic process, medical practitioners have relied on visual cues throughout history. Even today, the amount of information that can be gathered through technologically-unaided observation is astounding. As it turns out, the same kind of criteria applied to a primary care waiting room can tell us a great deal about the health of a physician practice in general and the condition of the exam room in particular.

For example, the most basic observation can reveal that waiting rooms are often full of disgruntled people, some of whom have taken to posting videos documenting long waits – which takes negative word-of-mouth to a whole new level. It gets even worse as we occasionally hear of patients who bill their physicians for loss of productive time. While those kind of extreme measures remain rare, the fact is that wait times perceived as being overly long correlate with everything from patient satisfaction and medical compliance to return show rate and overall attitude toward clinicians and staff.

But while the waiting area manifests the symptoms, the problem often lies in the exam room, the very place that patients are anxiously waiting to enter.

Behind those closed doors you’ll still find doctors looking at a computer screen instead of the patient, creating a scenario that neither party considers to be satisfactory. And because the practitioners may be slowed down by the quirks or intricacies of the particular EMR platform, more critical minutes are spent accomplishing less for the people in the exam room – while those in the waiting room … wait.

The typical doctor-centric exam room process isn’t doing the physician any good, either, resulting as it often does in longer days, more work taken home and financial liabilities related to reduced capacity.

The good news is that a “healthier” exam room and, subsequently, an improved waiting room experience can be achieved with some restructuring of the exam room process. And it starts with a specially-trained assistant, generally an RN or protocol-backed MA taking over the data entry portion for the current episode of care while also serving as an information resource for preventive care.

There are a lot of reasons why waiting rooms back up, ranging from the complexity of care and multiple health issues to patients running late, but we’re kidding ourselves if we don’t recognize that wait times are an important issue that will only get worse as coverage continues to expand.

And we’re doing our patients — and ourselves — a disservice if we don’t look for solutions in the exam room.

Physician Burnout

Rx for Physician Burnout

Making the Right Changes on the Front Line of Medicine

In a comprehensive analysis published recently in the Archives of Internal Medicine, more than 7,000 physicians were surveyed on their quality of life and job satisfaction.  Almost half of them reported at least one symptom of burnout and the overall rate was considerably higher than other U.S. workers even after adjusting for a range of appropriate variables.

The doctors described their symptoms with words like “overwhelmed”, “exhausted”, “detached” and “frustrated”.  Drilling a little deeper into the analysis many reported spending a significant amount of time dealing with administrative tasks and EMR-related documentation, all at the expense of direct interaction with patients.

Not surprising for those of us who have practiced or are currently practicing primary care medicine, the highest rates of burnout occurred at what the study called “the front line” of health care, a category that includes family medicine and internal medicine.

The reasons behind these results are related closely to the larger picture of practicing medicine in today’s struggling and transitioning healthcare environment. As in most complex situations the challenges are far easier to articulate than the means to address them.  But one thing stands out clearly. If the problem is on the front line then at the very least, we have a place to start. For most of us, that front line is the exam room and the broken processes occurring in it.

Reducing Physician Burnout

There are a number of practice initiatives that can help reduce the risk of physician burnout. Few if any have the potential to work as timely or effectively as the team care approach. Having a trained and protocol-directed team care assistant in the exam room, an RN or an MA, to intake preliminary patient information and interface with the EMR frees up physicians to maintain eye-to-eye instead of eye-to-screen contact.  This important capability, despite its decidedly low-tech status, strengthens the personal connection to patients which remains one of the most effective quality-generating factors in medicine

Re-structuring the exam room experience through care coordination holds the potential to positively impact physician and staff satisfaction, patient satisfaction and overall quality of care. At the same time it can improve the financial picture for the practice and readily amortize the cost of any additional staff.

Simply put, the result of this effective counter to physician burnout is healthier doctors, healthier patients and a healthier overall environment in which to practice medicine with increased joy and a greater sense of accomplishment.

Physician House Call

Is there a doctor in the house?

The Renewed Interest in House Calls Includes a Please for the Familiar Physician

It may not be a full-scale “back to the future” movement, but by every indication the return of the physician house call is a small but growing phenomenon in primary care medicine. In part, this revival is expanding because of the “Independence at Home Demonstration”, an ACA-generated test program studying the effectiveness of treating chronically ill people at home, primarily those with limited mobility.

Early reports and common sense are telling us that this now rare but once common practice can play a role in significantly reducing healthcare costs while also improving the quality of care for many frail elderly and chronically ill patients.

Despite the fact that Medicare changes have made house calls more readily billable, it’s still a practice model that simply isn’t economically viable for the significant majority of practitioners, at least not yet. But even if you’re not reaching for your black bag and heading for the car, don’t fail to understand what else is at play. In fact, if you listen carefully, you’ll hear within the house calls comeback a clearly expressed plea for the familiar physician.

That’s because physician home visits represent less hurried and more satisfactory encounters for patients and physicians alike. There’s an opportunity to truly connect with people and as a consequence, the potential to develop a stronger patient-physician bond.

It’s tough to create a true home-like setting in our exam rooms, although a little attention to detail and comfort always helps. What we can do, however, is re-invent the exam room experience, through a physician-led team care approach that lets doctors focus on their patients once again, and not on a keyboard.

It’s an opportunity to strengthen relationships with patients, increase staff and patient satisfaction, improve the overall financial picture and restore much of the pleasure you may have lost in the practice of medicine. Transforming the exam room isn’t the same as a house call, but it just might be the best of both worlds.

We all know the EMR/EHR is essential, but if you do not use it right, it can be a sharp two-edged sword that can destroy your practice

Fix the Bottleneck and All of Primary Care Changes

Recently I had the honor of appearing on CBN TV and the 700 Club with healthcare reporter Caitlin Burke in her segment Your Doctor Could Be a Total Stranger Soon. Among the many topics we discussed was the challenge of EMR’s, and how physicians list the electronic medical record as one of the key culprits to the accelerating primary care crisis. She’s right. We all know the EMR is essential, but if you do not use it right, it can be a sharp two-edged sword that can destroy your practice. I have been there. I was spending more time looking at the computer than my patients. I dropped from 35 patients a day to 20 patients a day and dozens of my patients could not get in to see me when they needed me. I was losing $80,000 a year, everyone was unhappy with the chaos – my staff, the patients and my family that hardly knew me. I knew the problem was in the exam room. That’s where the bottleneck forms. So for me, I was so frustrated I knew I had to innovate – or retire. So I took myself off of the computer and brought my nurses into the exam room with me. I trained my nurses to do everything I used to do with the patient’s preliminary medical data, and ask all the right questions for both this episode of care and the prevention questions so important to older people. This began to change things immediately. I was able to see more patients, seeing all of the urgent call-ins every day. We increased our available appointments to 35 a day, completely turning around the finances of the practice. Our nurses loved it, and the quality went straight up. And most importantly, I got my life back.

You never see a judge leave the bench and do the stenography for a trial. You never see a surgeon come in the OR without his scrub nurses. And you should never see a highly trained primary care doctor spending more time looking at a computer screen than the patient.

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