June 10th, 2009 by AlanDappenMD in Primary Care Wednesdays
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Eight years ago, the Institutes of Medicine published a paper entitled Crossing the Quality Chasm: A New Health System for the 21st Century, which envisioned the future medical practices. Many of the concepts discussed were adopted and endorsed in years to come by the American Academy of Family Practice, The American College of Physicians, the American Medical Association, among others.
The five major innovations of care outlined by this study include:
1. A communication-centered practice model,
2. Information management,
3. Technology replacing office staff,
4. Reduced pricing and transparency in billing, and
5. Removing external conflicts of interest between doctors/providers and patients.
Complete adoption of these innovative concepts can cut at least 30% of primary care costs while significantly improving patients’ quality of care, and further reduce overall health care costs by offering immediate and highly accessible care that avoids emergency room visits, enhances wellness, manages chronic illness and diagnoses disease early. These cost savings and quality improvements are enabled by utilization of advanced communications and information technology that replace much of office overhead and staff, and encourage patients to seek the most cost-effective and convenient care possible. Many medical practices have adopted some of the recommendations, yet less than 1% have transitioned to complete and consistent adoption because they frankly have few financial incentives to do so.
These innovations are the cornerstones of retooling our broken healthcare system, and in turn can pave the way to “fixing” many of the issues plaguing this system. The five cornerstones provide for what so many Americans are clamoring for yet are unable to find: continuous access to a medical provider team thus enhancing patient access, control, and convenience of care; increasing the quality and speed of treatment; reducing the cost of care; creating transparency in pricing; and removing external parties that create conflicts of interest between doctor and patient and often interfere with providing quality and speed of care to patients.
I’ve built my own primary care practice on these five concepts, and while all can significantly lower costs while vastly improving the patient experience, I’d like to take a look at the concept I find to play a pivotal role: a communication-centered practice model.
A Communication-Centered Practice Model
Twenty-first century, day-to-day-primary care starts with the primary care provider being the first in line to answer a patient’s phone call or email. During this call or email, the provider reviews a patient’s history, and bearing in mind that the provider already knows has a professional relationship with the patient, then can make appropriate decisions. At least 55% of the time, the patient’s situation does not require an office visit, however instead involves going straight to the pharmacy for medications, going to labs for tests, getting an x-ray, or recommending a referral. In this model of practice, the doctor spends at least half the time of the time answering phones and emails, thereby providing immediate access and convenience to the patient.
If either the clinician or the patient believes there is a need for an office visit, the visit is arranged immediately. Patients can talk to their medical expert or an on-call member of the medical team 24/7. This instantaneous access can result in patients having most of their day-to-day issues addressed within 10 minutes of reaching the practitioner, and can expect care from their personal provider from home, work or anywhere in the U.S.
As mentioned above, over 50% of medical issues can be addressed by telemedicine, specifically by phone or email, as long as a patient-doctor relationship exists. This results in people being healthier and on the road to recovery much faster, thus not taking time off from work. Office hours are flexible and can be arranged day or night and any day of the week including weekends.
The importance, barriers to adoption, and the unexamined assumptions as to why 97% of all medical care currently occurs in a medical office and nowhere else has been reviewed in several of our prior postings:
Are Face-to-Face Office Visits Really Required to Provide the Highest Quality Care?
In Defense of Remote Access Medical Visits
The Commonplace Tool That Can Revolutionize Health Care
Telemedicine Care: A Malpractice Risk? Au Contraire …
Telemedicine Checks In On Chronic Health Care Problems
In the future, I plan on taking a look at the additional four cornerstones that need to have traction if the Obama administration hopes to restore vitality to the primary care system.
Until next time, I remain yours in primary care,
Alan Dappen, MD
June 3rd, 2009 by AlanDappenMD in Primary Care Wednesdays
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Between what is said and what is not, the truth lies in waiting. Palpate the silence. Hear the double meaning. Smell the hesitation. See the nostrils flare. Watch the direction of the gaze. Feel the tension.
The truth vibrates in myriad ways. It is deep, below the surface. Frank Herbert’s novel Dune illustrates the concept with fascinating fiction. Imagine a people –the Bene Gesserit — genetically bred and trained as seers into the unconsciousness, sensors of the truth, like breathing lie detectors. Little did I know that such truth seers are not just a part of fiction, and although a rarity, live and walk amongst us.
I have met such a seer. Towards the end of my residency training, a gifted psychologist was assigned to follow me as a routine part of our training. I’d become competent and efficient in administering my craft. “My doctoring will impress her,” I thought with some pomp.
Right before the first person we saw, she told me, “Pretend I’m not in the room.” Then, for the duration of the morning, she silently observed the patients I saw and my interaction all while in the back of the room.
After seeing a few patients, we’d break and talk. The patients I saw, I felt, were representative of standard primary care issues: Joe forgets to take his medication. Susan can’t quit smoking. Elaine has unexplained abdominal pain. My medical paradigm explained that Joe, like most people, can’t comply taking continuous medications. Susan is addicted, not interested in quitting smoking until she’s good and ready. Elaine’s pelvic pain is mysterious but not worrisome.
I’m stunned when, after my medical analysis, the psychologist paused, emitting a rueful smile. She sighed knowingly and responded, “Actually, Joe is angry at his wife and defies her by refusing to comply. Susan has unresolved issues with her father who’s probably an alcoholic. Elaine’s pain suggests sexual molestation.”
“Give me a break!” cried a voice from inside of me. And as the days rolled along there were other voices too. “I am a family doctor. This is not medicine! I don’t have time for this! Just what you’d expect from a psychologist; too much Freud!”
As the weeks turned, I reluctantly see her hit nail after nail on the head. She saw complex patterns in people’s behaviors and complaints that I’m too blind, and too unwilling, to see.
With this new, almost astonishing, dimension to medicine, I see, for the first time, art, compassion, insight, and intuition as equal partners to the formulas of science. I slowly wonder what it truly means to be called “a doctor,” when so much is missed in the science of “performance.” I am captivated, begging to know: How does she see? Can I learn? Is she gifted or crazy?
We are in the final days of my tutelage when we meet an enraged Sharon, in follow-up from the emergency room after a miscarriage. She didn’t know she was pregnant, began to bleed, and ended-up in the ER. She was pushed into a back room, left alone for a long time, bleeding heavily. She felt abandoned, angry, and humiliated. The ER attending staff, she insists to me, made her feel like a “slut.” I listen and then promise to investigate and call her back.
In the post-patient meeting I explained to the Bene Gesserit (as I now secretly called my psychologist mentor), “Delays occurred in the ER’s treatment of Sharon and she was over reacting but never in danger.”
“Right about the danger,” the Bene Gesserit concedes, “Wrong about what happened. Sharon had an affair her husband found out about it through the miscarriage.”
Having been humbled too many times, my resistance drops. “What did I miss can you show me?” I beg.
“You sense her over-reaction, her anger, yet dismissed it. Something else fuels her rage. Close your eyes. Pretend to be having a miscarriage right now. I’ll coach you through it.”
“This will be tough.” I think, “I am a man and can’t really miscarry and am sitting in the doctor’s lounge with plenty of colleagues enjoying this play acting.” I close my eyes and settle into a foreign reality. It doesn’t take long to be guided to bells ringing in my head. “I don’t feel like a slut.”
The Bene ignores me and continues, “The vibrations are always there if you tune your antenna to the right frequency. People are pools of water with surface and depth. Illness arises within a context. Ripples on the surface are the symptoms caused from objects thrown-in or vibrations from the past arising to the surface. To reveal this union between the physical and emotional bodies is a unique potential of a healer. “
Sharon’s husband visited my office three days later, chief complaint chest pain. The betrayal was written all through him and verified as forecasted by my mentor. Unnerved I began in earnest to train my own antenna as to reach my fullest possible potential as a healer, a potential only realized by committing the time to listen comprehensively, intuitively, respectfully needed to do so.
Medical care today is all about the quantitative: 10-minute office visits, performance-based measurements, and only the facts. Medical problems are often not simple algebra formulas where the sum equals its parts. Many times healing requires the art of listening, intuition, trust, insight, empathy, grace and even spirituality. It’s not neat, nor quantifiable, but many have journeyed through life enough to know it’s true. Even after all the science has spoken, the art hides itself in myriad ways, patiently waiting.
Until next week, I remain yours in primary care,
Alan Dappen, MD
May 13th, 2009 by AlanDappenMD in Primary Care Wednesdays
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“OK,” I can hear you say, “Enough about telemedicine. So what if you can prevent two-thirds of office visits by using the phones, or that it’s convenient for the patient and can start them on the road to recovery faster, or that it costs much less money than conducting an office visit, or that malpractice companies have accepted this delivery model.
I can see that you still side with the other non-believers in telemedicine, citing, “Telemedicine is no way to build relationship with patients. Problems abound with telemedicine: It’s too impersonal, patients could easily not be telling you the truth because you lose the “body language and facial expressions,” and it certainly can’t be useful for chronic illness. Maybe it’s good for the simple problems, but this has no place with complex or chronic medical care.”
I do, of course, have some rebuttals for you …
Let’s start with impersonal. In today’s world, we let our friends and family communicate with us constantly through phones and email, and I’ve yet to see how this has destroyed the intimacy of our relationships. So why do Americans anxiously wait up to four days for a doctor’s appointment to get their problem or question resolved and waste at least four hours of a day to get to the office simply to wait for an unpredictable time for a predictable 10-15 minutes of the doctor’s time when so many issues can be resolved remotely by phone? Furthermore, try convincing someone with a urinary tract infection (UTI) or that needs a prescription refill that their long wait, suffering, and run through the primary care funnel were “good for the relationship.” In fact, nothing is more personal that a doctor saying to their patients, “Here is my direct phone number, please call me anytime you need help.” Viewing telemedicine from this perspective determines that the “impersonal” concern is a ruse to protect doctor’s privacy at the expense of their patients.
What about the patient who is not truthful? Does a face-to-face visit make this less likely? In 30 years of work, several patients I know have not always been honest. Many of these people were attractively dressed, well educated and for awhile, fooled me badly. I saw them all face to face too. To this day, I have no idea what to look for when someone is trying to pull the wool over my eyes.
If people are going to hide the truth, they can do it in person just as well as over the phone. When a doctor becomes suspicious about a patient’s truthfulness through a pattern of calls and behaviors, then a scheduled office visit may help. However, forcing office visits based on a blanket rule of thumb of not trusting your patients means there is something fundamentally wrong with the doctor-patient relationship.
Lastly is the idea that chronic disease management isn’t appropriate through phones and email. Really? Let’s say you had diabetes, or hypertension, or high cholesterol, or cancer, or depression, just to name a few. With one of these conditions, you will be in contact with your health professional a lot more than you are now. Not only is your life more complicated, but the doctor wants you to consume 10% of your life waiting to see him in person because it’s good for him. Instead, many of these visits can be conducted easily anytime through phone calls and email.
Here are some examples:
#1. A phone call: “Mr. Doe this is Dr Dappen. I see a calendar reminder that you’re due for labs to check your cholesterol and to make sure the statin drug we put you on is not causing problems. I’ve faxed the order to the lab that is located close to you home, so stop by anytime in the next week and they’ll draw the blood. I should have the results in 24 hours after your visit to the lab, and we can review the report over the phone at that time and decide if we need to make any change.”
#2. An email from a patient: “Dr. Dappen, I’ve been worrying about my blood pressure readings. Over the past 3 weeks, they’ve been running consistently higher. Not sure why and until recently the home readings were doing great. Attached is the spread sheet of readings. Look forward to your input.”
In fact, examples abound of how chronic disease management conducted via phones and email is more efficient, reduces costs, and improves outcomes; I’d invite any Doubting Thomas to visit the American Telemedicine Association for further inquiry. An entire telemedicine industry is gearing up to manage chronic illnesses and most of the time it has nothing to do with patients visiting doctors’ offices.
When all is said and analyzed, the conclusion is really simple as to why the use of telemedicine is not more prevalent: no one wants to pay a doctor the market value for the time it takes to answer a phone and expedite an acute problem or manage a chronic health care problem. No money means no mission. This means no phones, no email. Don’t think about it. See you in the office. Why ruin 2400 years of tradition?
April 29th, 2009 by AlanDappenMD in Primary Care Wednesdays, Uncategorized
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In early 2006, four years into running my current medical practice, doctokr Family Medicine, I got a call from my medical malpractice carrier. Just weeks before I’d received a notice that my malpractice rates could go up by more than 25%. The added news of a pending investigatory audit was chilling. In 25 years of practicing medicine I’d never been audited.
“Is there a complaint, or a law suit against me that I don’t know about?”
“No,” the auditor told me over the phone, “We’ve never seen a medical practice like yours and feel obligated to investigate your process from a medical-legal perspective.”
“Great,” I thought, with a weary sigh. “I’m already battling the insurance model, the status quo of the medical business model, and slow adoption by consumers who are addicted to their $20 co-pay. All I’m trying to do is to breathe life into primary care and get the consumer a much higher quality service for less money than currently subsidized through the insurance model. And now this.”
The time had arrived to add the concerns of the malpractice companies to the list of hurdles to clear if a new vision of a medical care model was ever to catch flight.
I frequently am asked the question “Aren’t you afraid of the malpractice risk?” when I explain my medical practice model, which is based on the doctor answering the phone 24/7, resulting in the patient’s medical problem being solved by the phone more 50% of the time. The simplest counter to this question is to analyze the risk patients incur when the doctor won’t answer the phone. What happens when the doctor is the LAST person to know what’s going on with patients? The answer is obvious. But malpractice companies could have concerns beyond patient safety. Buy-in from the malpractice companies would be critical to the future viability of all telemedicine.
I prepared a summary paper, which included 12 bullet points, explaining how a doctor- patient relationship based on trust , transparency, continuous communications and high quality information systems significantly reduce risk to the person you’re trying to help.
Bullet 1: The industry standard is that 70% of malpractice cases in primary care center on communication barriers. My medical team deploys continuous phone and email communications and 7 days a week- same day office visits when needed between doctor and patient thus significantly reducing these barriers.
.
The remaining bullets could be summarized by the conclusions from the Institute of Medicine’s visionary book Crossing the Quality Chasm: A New Health System for the 21st Century using a table developed by The American Medical News when they reviewed the book. I carefully plotted our practice standards compared to the traditional business model as it stands today based on this table:
The auditor showed up, spent 4 hours reviewing our practice, electronic medical records, compliance to HIPPA, our intakes, on-line connectivity, procedures, and practice standards. While the auditor reviewed, I sat as unobtrusively as I could, feeling my brow grow damp with perspiration, as I carefully answered her questions. During the auditor’s time, I never moved to sway her to “my way.” I just let the data that I had accumulated from four years of practice do the talking.
Once the auditor left, I waited for two weeks for the results. By the time their letter arrived, I was scared to open it. The news arriving made me jubilant. The medical practice company announced a DECREASE in my premiums because we used telemedicine and EMR to treat patients so fast (often within 10 minutes of someone calling us we have their issue solved without the patient ever having to come in).
I will admit that I felt, and actually still do feel, vindicated by having my malpractice insurer understand fully the value that the type of telemedicine my practice offers to our patients: round-the-clock access to the doctor, speed of diagnosis, and convenience, which all led to healthier patients and lower risk.
Doctors answering the phone all day for their patients, it’s not just lower risk, it’s better health care at a better price. It’s a win-win-win strategy whose day is arriving.
Until next week, I remain yours in primary care,
Alan Dappen, MD
April 22nd, 2009 by AlanDappenMD in Primary Care Wednesdays
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By: Valerie Tinley, MSN, RNFA, FNP-BC
House calls have long been associated with primary care providers (PCPs), the proverbial “black bag,” and days gone by. Unfortunately, house calls are often just a memory or something we watch in reruns on the television.
Those people that best remember the prevalence of house calls, the elderly, may be the same population whose needs will bring house calls back from the brink of extinction and return them to the mix of services offered by PCPs.
House calls should be a core offering of PCPs, since by nature we help patients from cradle to grave. Therefore, some of these patients may not be able to come to see us because they are too old or too sick or immobile.
Why then can’t PCPs go to these patients? We certainly can solve the majority of primary care problems where our patients want or need to be seen, including in their homes, whether these problems are run of the mill day-to-day issues; or those associated with chronic, continuous care diseases; or even many urgent care issues.
Unfortunately house calls are rarely offered because many PCPs view them as too time consuming and therefore too costly to conduct.
The need for house calls for these populations will not go away. The populations that house calls can help include:
• those that are bed bound, very old, who want to age at home rather than a nursing home;
• those suffering from dementia;
• those recently discharged from the hospital, and unable to be mobile short term or long term; and
• those that are receiving hospice care.
Many of these people cannot leave their home, or more importantly, should not leave the home, to go to the doctor’s office for an office visit. It is important to understand how very expensive this is for the caregiver, in terms of time, lost hours on the job, effort and transportation costs, all to actually get them to the medical provider’s office, because their loved ones have problems with mobility or other hindrances.
The result? There are many in need of medical care that cannot receive it. This increases medical problems and mortality. When healthcare is ignored or foregone for the most routine of problems, more expensive and much more serious healthcare issues arise in its place.
A recent article in the New York Times reported that keeping geriatric patients out of the hospital and getting them the care the need at home can result in a cost savings of between 30% and 60%. In addition, a house call program, piloted by Duke University, has reduced the number of hospital admissions for those patients unable to get to the doctors office by 68% and the number of emergency room admissions by 41%. These patients are thereby healthier, and even safer, working with a PCP that makes house calls.
Several organizations currently offer house calls as a core part of their services offerings, like Urban Medical in Boston, or the practice I am with, doctokr Family Medicine. Also there are beginnings of pilot programs for house calls, like the one at Duke’s Medical School which was mentioned earlier.
But these are only a few providers, and the movement needs to be widespread. Our aged population needs it and we as primary care providers should be listening to their needs and providing for these needs. Otherwise, we are falling short.
Until next week, I remain yours in primary care,
Valerie Tinley MSN, RNFA, FNP-BC
