Invitation for Practicing Primary Care Physicians

Health care is currently experiencing tremendous turbulence. The old ways of doing things are about to give way to new ideas and new models, or perhaps just refurbished old models, and at the heart of it all is primary care. The old hope of care management has been rebranded to advocacy for care coordination, because the term coordination sounds more benign and better aligned with the increasingly vocal patient engagement movement.  After all, empowered patients do not wish to be managed, but they do expect that someone will coordinate their informed decisions and preferred courses of treatment. Unlike management, which implies a paternalistic approach to patient care, coordination implies efficiency with no loss of freedom of choice. From a public relations perspective, this is a brilliant change of messaging content.

Care coordination is also the main ingredient in patient-centered care, by far the most overused buzz word of health care transformation. Other than individualized coordination, patient-centered care should be delivered by care teams, guided by population based medical evidence and measured by aggregated, process and outcome, population based statistics. The main vehicle to facilitate such change is the Patient Centered Medical Home construct as defined by the numerous NCQA accreditation requirements. Since Medical Homes require care teams of various capabilities, engaging in the coordinated sport of health care delivery, it is recommended that primary care physicians operate in large systems and facilities, where qualified team members are readily available, and a steady paycheck is guaranteed for the team doctor.

Medical Homes require state of the art computer technology to facilitate coordination, evidence based protocol enforcement and statistically meaningful measurement of compliance and outcomes. Health care computer technology adoption is being encouraged by the federal government through the well-publicized Meaningful Use series of incentives and penalties. The equally well-publicized complexity and prohibitive costs of health care computerization imply that large system are much better suited for widespread deployment, thus freeing their physicians, who have already been relieved of financial uncertainty, to better concentrate on the labor of managing the provision of health care. The quintessential problem of physicians being too busy seeing patients and having no time to deal with administrative, financial and technology demands, is thus resolved.

If you are reading this, and are experiencing an uncontrollable urge to through the computer against the wall right about now, you obviously are able to find a few minutes in your busy schedule to surf the web, read blogs, forums and maybe browse the news pages. Perhaps once in a while you even post a short comment here and there, most likely anonymous. Perhaps you are a social media maven, tending to your own blog or facebook/twitter presence. Most likely this is not the case because maintaining a web presence is pretty hard work. One thing is certain though; you most definitely have at least one opinion regarding the turmoil of our health care system and the particular circumstances surrounding your chosen profession.

So if you feel the need to express your thoughts, once a day, once a month, once a year, once in a blue moon, or when it can be contained no more, I would like to offer you a safe and easy way to do just that. Although this page’s title implies technology, you can see that much of the content is actually geared to the plight of primary care in small, private settings, which has been my personal passion for many years. This little blog has been my home for well over a year now, and I would like to invite you to make it your home too.

Anytime you feel the need to write, on any health care related subject, just type it up (or use your dictation tool) and email it to me. It could be a long essay or a short note, and it does not have to be Shakespearean prose either. All materials will be promptly posted, unedited, uncut, with no judgment and no commentary, anonymously if you so desire. You will not reach millions of readers, but you will reach quite a few influential folks active in the health care field, and I will do my best to spread the word. This is an open invitation, with no strings attached, no expiration date, no exclusions, no rules, no guidelines, no protocols, and with a simple goal of providing an outlet for the voice of practicing primary care physicians who have been largely silent and “too busy seeing patients” for way too long. I view it as a service.

Feel free to forward and share with others. The first such post from an anonymous MD, who was the inspiration for this service, will appear here on Monday, July 18.

So Many EHRs and So Expensive….

There are currently 386 software packages certified by an ONC approved certification body as ambulatory Complete EHRs, which means that the software should allow the user to fulfill all Meaningful Use requirements and possibly qualify the proud owner for all sorts of CMS incentives. There are 204 more software packages which are certified as ambulatory EHR Modules, and a proper combination of these packages could result in a Complete product, which if used appropriately could lead to the same fortuitous results.

There are 423 distinct manufacturers of ambulatory EHRs and EHR modules on the federal list. Most are software vendors, or wannabe software vendors, but a fair amount are facilities that developed an EHR for in-house use and had it certified. These are not really available for purchase. A very large number of listed vendors offer niche products for distinct specialties, such as optometry, oncology, behavioral health, etc. All that said, there is still an inordinate number of EHR “choices”, or so the story goes. By comparison, since we all love car analogies, there are 1,310 individual trims currently sold in the U.S., and around 50 car manufacturers overall. If you ask an average citizen on the street to name their top 10 cars, chances are that you will get a Honda Accord, Toyota Camry, a Caddie, maybe a Ford truck, a Beemer, a Porsche and perhaps even a Beetle. You are not likely to hear anything about a Tesla or a Coda and rarely will anybody mention a Scion. Automotive modules are not widely sold for home assembly, so there is no parallel lesson there. One way or another, we manage to find our way when it comes to automobiles.

When it comes to EHRs, if you ask an average health care worker, including HIT experts, to create a top 10 EHR list, most will have trouble coming up with more than three or four, but generally speaking, you will end up with Allscripts, eClinicalWorks, Next Gen, maybe Epic, GE or Cerner, and sometimes Amazing Charts or e-MDs. Rarely, you may get the name of a newer or a more regional product and perhaps a specialty specific EHR as well. This doesn’t sound too daunting now, does it? At least no more daunting than shopping for a car. What about the Teslas, Codas, Fiskers or even Scions and Kias of the EHR world? Aren’t we missing out by not exploring every single innovator on that long list of hundreds of complete products and the collection of modular bits and pieces? Perhaps the next great thing, the diamond in the ruff, is already on the list….. Perhaps it will get added next week, or next month, or next year….

Perhaps, but I wouldn’t lose any sleep over it. Innovation is about more than using a web browser or an iPad to deliver the same old content, and those olden EHRs are teeming with innovation. The three committed partners for the cutting edge Surescripts-AAFP Physicians Direct collaborative platform are SOAPware, Amazing Charts and e-MDs, all on the “legacy” list. Cerner is positioning itself to replace Google Health in a very innovative consumer facing move. eClinicalWorks has a peer-to-peer communication system that has not been duplicated yet. Through the grapevine I hear that GE and e-MDs are both working feverishly on the next generation of EHRs. And the list goes on. In this day and age of massive regulatory demands, all EHR vendors must devote quite a bit of effort to compliance. Those with capacity for additional innovation are usually the well-established and well-capitalized companies, which are the same companies that amassed incredible expertise in health IT over the years. Speaking of the innovative Direct Project, it may be instructive for some to do a little homework on its originators (hint: it wasn’t two guys in a garage).

How about the widely advertised astronomic costs of these “legacy” EHRs? Why pay so much money for software when the new models are so much cheaper? Stories about doctors spending $250,000 in just the first year are not uncommon. Not sure what those doctors purchased, but whatever it was, they shouldn’t have bought it. eClinicalWorks, one of the top selling “old” EHRs, can be purchased for $250 per provider/per month. Can it get cheaper than that? Sure. Amazing Charts, another golden oldie, sells for less than $85 per provider/per month. The various ad-supported freebies notwithstanding, the next best thing would be for someone to pay the customer to use the software. Are there any new and bare bones EHRs on the federal list that sell for less? None that I know of. But maybe bare bones products are actually better, or simpler to use. Although “lees is more” is the new battle cry of health care, a little bit of complexity goes a long way. Guess who are the only recipients of the Surescripts White Coat Quality awards in ePrescribing (denoting commitment and achievements in the areas of safety and accuracy)? Two old eRx companies and two old EHRs – e-MDs and NextGen.

What about service? With the current flurry of EHR shoppers, largely driven by Meaningful Use incentives, those household name EHRs are flooded with new customers. The lines are long and customer service is spread thin. Should you go across the street and be treated like a king, since you probably are the only customer of one of those new bare bones vendors? If the lines are long at the Toyota dealer, should you go across town to the Kia dealer and pay the same amount of money that would get you a Camry for a minuscule Kia Soul?  It is also worth remembering that since the ultimate goal is exchange of information, when hospitals and various exchanges start building interfaces in earnest, the waiting lines will be reversed. Those using EHRs with the largest market presence will be first in the interoperability line.

Last, but not least, what if tomorrow the perfect EHR is invented and you are stuck with the product you bought today? Here is where the car analogy stops working. If they invent a car that runs on water from the garden hose, chances are that you can trade your Toyota Camry in, lose a lot of value, but rather easily drive out in your brand new bubbly water car. Switching EHRs is hard. It’s not impossible, but it is expensive and fraught with peril. Since I can assure you that none of the EHRs currently on the federal list are the holy grail of EHRs, and there is none of those on the horizon either, you will take this risk on, no matter what you buy today. You need to decide if your odds are better with an established, “old” company that may charge you quite a bit of money to migrate data out of their EHR, or if you prefer to deal with a company that just vanishes into thin air one evening and the only thing left is a disconnected phone and perhaps a colorful website loaded with flash banners telling you how much money you can get in incentives from Uncle Sam. Of course, you don’t have to buy anything. You can just stand on your front porch, holding your garden hose, waiting for an impending miracle. And miracles do happen…..

Full Disclosure: I have no financial interest in the products mentioned in this article, or any other EHR software.

Process Centered Medical Home

A new study on Patient Centered Medical Homes has been published in Health Affairs and we have a new, but predictable, indictment against small independent primary care practice. The study authored by Rittenhouse, Casalino, Shortell et all, is descriptively titled “Small And Medium-Size Physician Practices Use Few Patient-Centered Medical Home Processes", and follows an earlier 2008 study that surveyed large medical groups.  The study is surveying practices with 1 to 19 physicians, and in a nutshell, small practices, particularly those owned by physicians, are less likely to have medical home processes incorporated in their workflows. On average, the bigger the practice, the more likely it is that medical home processes are used, and the likelihood increases if the practice is owned by a hospital or an HMO. Hardly surprising, but the enlightenment is, as usual, in the details.

The patient centered medical home model is based on the seven joint principles stated by the various primary care associations as follows: personal physician, whole person orientation, physician led care team, coordinated care, quality and safety focus, increased access and payment reform. Both studies quoted above were restricted to measurement of processes indicative of only four out of the seven principles. Personal physician for each patient and whole person orientation were left out, and so was the payment reform principle, although some measures of external incentives in support of medical home processes were considered.

The existence of physician led care teams was ascertained based on the existence of “a group of physicians and other staff who meet with each other regularly to discuss the care of a defined group of patients and who share responsibility for their care”. Not sure why, but solo and 2 doc practices were not even asked this particular question.

Care coordination was measured through the use of electronic medical records, electronic prescribing, and electronic access to notes from specialists, hospitals and emergency departments, use of registries and existence of nurse care managers. Small practices scored badly on all except electronic receipt of external documentation. It seems that even without EHRs, they somehow manage to get the information needed for proper transitions of care.

Quality and safety were measured by several process improvement methodology questions and typical quality of care measures. Small practices showed measly participation in quality improvement collaboratives and had almost no “Rapid-cycle quality improvement strategy” (no idea what that is and I bet few if any survey respondents did either). Solo and two doc practices were not very good at collecting data from their EHR and scored poorly on use of clinical decision support. However, they held their own when it came to providing physicians with feedback and provided patient education as well as the big boys. They were also par for the course on sending patient reminders. The major “surprise”, noted by the study authors, was how much better those tiny practices were at incorporating patient feedback and generally listening to patients. The 1 -2 docs scores in this sole patient-centered category surveyed, were twice as large as the largest practices, across the board, hands down, no contest.

Finally increased access was measured by availability of group visits and email exchange with patients. Not sure why group visits was chosen instead of same-day access and afterhours access, and as you would expect solo practices don’t do too many group visits. But, lo and behold, they are excellent at emailing patients - a full order of magnitude better than large practices.

By aggregating all survey responses, the study concludes that only 21.7% of medical home processes are used amongst practices of 1 to 19 physicians, with the 1-2 doctors segment lagging at only 18.6%, the 13 -19 group exhibiting a respectable 32.7% and the rest somewhere in between. Since the results are presented in a slightly different manner, it is a bit hard to compare these small to medium practices to the large medical groups surveyed in 2008, but it seems that there too, the largest of practices were more likely to implement more medical home processes with the possible exception of listening to patients, which came in lower than anything in the new survey. The authors suggest that one could look at these results “as a glass one-fifth full, or four-fifths empty”, depending on one’s level of optimism. I would like to suggest a different perspective on this particular glass.

The biggest concern regarding both studies must be the omission of the first and most important principles of the patient-centered medical home: the personal physician for each patient and the whole person orientation. While I do understand the difficulty in measuring the latter, it is pretty straightforward to survey and measure the former. The only two measures in this survey that are indicative of how patients are viewed and treated (minding patient feedback and email with patients) show clear advantages to the independent solo and two physicians practice. I would add that by definition, a solo practice should score around 100% on the personal physician rubric. And as the authors noted in their 2008 article “although infrastructure components are important to ensuring that care is coordinated, integrated, safe, of high quality, and accessible, at the heart of the PCMH is the personal physician and a team of professionals providing first-contact, continuous, and comprehensive care. This focus on primary care adds a qualitatively different dimension to the model. From the patient’s perspective, a medical home is not simply a combination of disease registries, reminder systems, and performance measurement. A medical home is a familiar place, with familiar people, that delivers high-quality, well-organized care that is accessible in time of need”.

So perhaps a more accurate conclusion for this study would be that larger practices, particularly those owned by hospitals and HMOs, are better at implementing processes, while smaller practices, particularly independent ones, are better at patient centeredness. Of course, it should ultimately be up to patients to decide between process orientation and patient orientation.