This week, the American Academy of Family Physicians (AAFP) took a bold stance in a report regarding the future of primary care in the US by reinforcing its endorsement of the Patient-Centered Medical Home (PCMH), specifically led by physicians. The report was supported by other large national physician organizations including the American Academy of Pediatrics, the American Medical Association, and the American Osteopathic Association. The report took a close look at independent nurse practitioners as they have had political swing in a number of arenas to lead primary care teams and practice independently of a physician. Without surprise, the American Academy of Nurse Practitioners (AANP) "ripped" and responded (because if they did not "rip", then a number of members probably would have wondered why). Turf battle? Probably. In the best interests of the patients? Hopefully. Does this solve any current problems? Doubtfully.
I am currently in a Family Medicine Residency which is a National Committee for Quality Assurance (NCQA) Level 3 Patient-Centered Medical Home - the highest level attainable for Medical Home recognition. Our "reimbursement" for services provided is not fee-for-service, but based on capitation (per member per month). Our Medical Home is made up of several physicians, residents, interns, nurse practitioners, physician assistants, registered nurses, and medical assistants. We also have booking/check-in clerks, two case managers, a social worker, a diabetic nurse educator, a pharmacist, a psychologist, coding managers, and a medical home business manager. This is the interdisciplinary team that I work with everyday.
My experience is n = 1.
The physicians and nurse practitioners all have a specific panel of patients assigned to each of them. Each provider is known as their patients' primary care manager (PCM). If the PCM is unavailable and the patient wants to be seen, they will only see providers from our Medical Home team. PCM continuity is maintained as a metric for providers to reach certain goals and rewarded throughout our command if a certain percentage of continuity is achieved over a set number of days. The ability for a patient to be seen within 24 hours as well as the 3rd next available for acute and established appointments is also tracked. A number of many other performance-tracking measures are in place to monitor our ability to care for our patients - the most important being patient satisfaction.
Since starting our Medical Home model, ER utilization has decreased and more importantly, patient satisfaction has increased. Because our primary care payment is based on capitation, we are also not incentivized to see 30-40 patients in a day, allowing us more time to see our patients. We also have mid-level providers and ancillary staff to take care of the many things that should never enter the examination room. We use a secure electronic messaging system which allows our patients the ability to send messages 365/7/24 to our support staff regarding refills, triage, and arranging appointments.
Our Medical Home team has a team leader. At any time, it can be a nurse, a physician, or whoever is available to take charge and make sure our patients are cared for.
This is the point.
Whether or not it needs to be a physician or a nurse practitioner - the evidence is definitely lacking. However, when looking at the IOM report for nursing and the AAFP report for the future of primary care, the only thing that really sticks out to me is the idea that we should be working together in collaboration.
The national organizations can spin their reports and backlashes however they would like. Unfortunately, this is what media will do for a news story.
All I know is, from my n=1 experience, physicians and nurse practitioners, as well as the many other people involved with our patients listed above, all need to work in collaboration to provide better, more advanced and evidence-based primary care. Independent practice by nurse practitioners does not achieve this. Independent practice by physicians with limited staff does not support this.
You can go to battle to defend your turf, your ego, or whatever else may get in the way of your patients.
My medical home team is going to go to battle for our patients. With my n=1 experience, I am proud to say that this is worth fighting for.
So, who is the leader in the Patient-Centered Medical Home? The answer is easy - our patients. And they deserve the right for increased access to a team of providers - physicians, nurse practitioners, not practicing independently - who all need to be leaders in advocating for the patient's ability to achieve a healthier life.
Thursday, September 20, 2012
Monday, September 10, 2012
Through a Patient's Eyes
I recently came across a Harvard Business Review article detailing an approach to attribution of health care costs around unit of time measurements. That is, if a physician makes so many dollars per hour, then time spent on a minute by minute basis can be calculated. Taking into consideration extender and staff involvement on a unit basis, as well as disbursed cost of overhead, equipment, and other expenses - the cost of a single patient visit could be directly and specifically quantified.
I'm not so sure costs and time spent can be broken down quite so easily. However, this motivated me to consider how patients view time spent by family physicians "with" and "on" them. In an indirect way, I started to question the value and commitment that our patients see within us. Though it is clear that we are not transparent with costs in medicine, I have a suspicion that we are even worse in regards to the transparency of how we utilize our time.
So think for a moment, and put yourself in a patient's shoes. We have all been there, at one stage or another. How much time is really perceived as being dedicated specifically to them? Through the course of an office visit in which a patient is first greeted by a receptionist, nurse, or even a computer terminal. Next up is the inevitable waiting game. The physician visit can be the big finale. But while patients may see the lightshow - I'm not convinced they totally appreciate the prep time and cleanup for the event.
Obviously, tremendous practice-to-practice variation exists. I would never attempt to lay down a blanket statement in regards to work flow and visit dynamics. Rather, I have three specific inquiries:
1) How do patients personally perceive the doctor-patient interaction?
2) To that end - how much of patient perspective is ignored in systems development?
3) Should work transparency be valued as much as cost transparency?
I gather that most do not realize the amount of time spent on paperwork outside of the exam room - billing, coding, pre-visit prep, as well as note completion. This says nothing for time spent on CME, private reading, and newer interfaces with email and phone interactions. I think as physicians, we have done a poor job of demonstrating our actual time spent "per patient"; when the modern visit may mask much of what is done behind the curtain.
How will this interaction and perception change as we drop live EMR into the middle of the patient-physician dynamic? The immediate goal is to increase accuracy and efficiency in note-taking, and provide an at the point of care tool for documentation. Intriguingly, the time spent to make this process more evident has often had the opposite effect - instead of patients feeling more "thankful" for the perception of increased time, they may feel cheated that time isn't spent on face-to-face interaction and counseling.
Certainly, generational and cultural differences are at work here - as are physician preferences in interaction style. However, I think it is worthwhile to take my three aforementioned questions into consideration as we move toward more full adoption of HIT. In recent decades, patients have voiced an increasing discontent with the amount of time spent with their doctors. I think we stand to continue to agitate this discontent if we neglect to acknowledge the patient perspective as a priority in episodic visits.
The next step, then, is to transform this perception from episodes of interaction into a spectrum of continuous oversight and care. I suggest that we should be clear in our efforts, and drive transparency of work to be equivocal with transparency of cost. I believe this to be a huge step in the direction of generating global and perceptively steadfast models of care.
I'm not so sure costs and time spent can be broken down quite so easily. However, this motivated me to consider how patients view time spent by family physicians "with" and "on" them. In an indirect way, I started to question the value and commitment that our patients see within us. Though it is clear that we are not transparent with costs in medicine, I have a suspicion that we are even worse in regards to the transparency of how we utilize our time.
So think for a moment, and put yourself in a patient's shoes. We have all been there, at one stage or another. How much time is really perceived as being dedicated specifically to them? Through the course of an office visit in which a patient is first greeted by a receptionist, nurse, or even a computer terminal. Next up is the inevitable waiting game. The physician visit can be the big finale. But while patients may see the lightshow - I'm not convinced they totally appreciate the prep time and cleanup for the event.
Obviously, tremendous practice-to-practice variation exists. I would never attempt to lay down a blanket statement in regards to work flow and visit dynamics. Rather, I have three specific inquiries:
1) How do patients personally perceive the doctor-patient interaction?
2) To that end - how much of patient perspective is ignored in systems development?
3) Should work transparency be valued as much as cost transparency?
I gather that most do not realize the amount of time spent on paperwork outside of the exam room - billing, coding, pre-visit prep, as well as note completion. This says nothing for time spent on CME, private reading, and newer interfaces with email and phone interactions. I think as physicians, we have done a poor job of demonstrating our actual time spent "per patient"; when the modern visit may mask much of what is done behind the curtain.
How will this interaction and perception change as we drop live EMR into the middle of the patient-physician dynamic? The immediate goal is to increase accuracy and efficiency in note-taking, and provide an at the point of care tool for documentation. Intriguingly, the time spent to make this process more evident has often had the opposite effect - instead of patients feeling more "thankful" for the perception of increased time, they may feel cheated that time isn't spent on face-to-face interaction and counseling.
Certainly, generational and cultural differences are at work here - as are physician preferences in interaction style. However, I think it is worthwhile to take my three aforementioned questions into consideration as we move toward more full adoption of HIT. In recent decades, patients have voiced an increasing discontent with the amount of time spent with their doctors. I think we stand to continue to agitate this discontent if we neglect to acknowledge the patient perspective as a priority in episodic visits.
The next step, then, is to transform this perception from episodes of interaction into a spectrum of continuous oversight and care. I suggest that we should be clear in our efforts, and drive transparency of work to be equivocal with transparency of cost. I believe this to be a huge step in the direction of generating global and perceptively steadfast models of care.
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