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Comprehensiveness is Killing Primary Care

In most other human activities there are two speeds, fast and slow. Usually, one dominates. Think firefighting versus bridge design. Healthcare spans from one extreme to the other. Think Code Blue versus diabetes care.

Primary Care was once a place where you treated things like earaches and unexplained weight loss in appointments of different length with documentation of different complexity. By doing both in the same clinic over the lifespan of patients, an aggregate picture of each patient was created and curated.

A patient with an earache used to be in and out in less than five minutes. That doesn’t happen anymore. Not that doctors and clinics wouldn’t love to work that way, but we are severely penalized for providing quick access and focused care for our well established patients.

Why is that?

Our Quality mandates have ended up creating perverse roadblocks and disincentives for taking care of the simplest needs of our patients. Any time we don’t screen for depression, alcohol use, smoking and readiness to quit, obesity, immunization status, blood pressure control and so on, we lose brownie points and, increasingly, money.

This is happening near me:

The primary care practices of Maine Coast Memorial Hospital in Ellsworth Maine have lost many, if not most, of their providers in recent years after some belt tightening due to running the clinics at a loss. They are not able to see new patients for six months or more. BUT the hospital is actively promoting its walk-in urgent care center – and they don’t seem to have trouble staffing it, and don’t appear to be losing very much money on it.

Bangor, Maine, home of a small Catholic Hospital and a 400+ bed hospital with a level 2 trauma designation, cardiac surgery, neurosurgery and many other specialties, has a severe lack of primary care doctors in spite of having a Family Medicine residency. Yet, a private out-of-state company is building a brand new freestanding urgent care center a couple of blocks from the Catholic hospital.

Quick and easy acute care visits visits could generate revenue with positive cash flow for primary care practices, especially for Federally Qualified Health Centers with their flat rate reimbursement, but possibly for all practices if CMS’ new proposal to scrap differentiated Evaluation and Management codes becomes reality. But the requirement to weigh down the simplest visits with all those screening requirements eliminates the incentive to nimbly meet patients’ need for access.

The end result will be that primary care providers will become chronic care providers only, and care will be fragmented so that anything profitable will be siphoned off to freestanding entrepreneurs or hospital owned profit centers. Meanwhile primary care practices risk becoming more and more of a millstone around their hospital owners neck because all their patient visits are more complex and costly than the reimbursement scheme can support.

And more and more providers will be tempted to jump ship for the easier work and greater predictability of a Doc in a Box career.

The only solution is to acknowledge that Family Medicine and all primary care is meant to assess patients over the continuum of time. You don’t have to fix the whole person when all they ask for is some penicillin for their strep throat.

Sometimes you need to be quick and sometimes you need to be slow. Without the freedom to adapt, in a patient centered way, to the situation each patient presents with, primary care risks going under.

Primary Care Needs a New Business Model

Primary Care visits are never quick; we don’t give much advice over the phone or online; and we prioritize the Government’s and insurance companies’ public health agenda over our own patients’ concerns.

Imagine healthcare as a retail customer experience for a few minutes:

Imagine you’re going to Walmart to buy a bag of dog food, a new coffee maker or to equip a small kitchen in your newly built mother-in-law apartment.

1) You’ve bought dog food there before, so you know exactly where it is. You just want to quickly grab a bag and get out of there.

2) You have a rough idea of where the coffee makers are; you know some brands you trust, but you might have one or two questions before you select one, and if they don’t have one you like, you might get it somewhere else. Or, you might even check their website to see which models they carry.

3) For the new kitchen, you have a list, but know you probably haven’t thought of everything, so you plan to walk down the aisles in the kitchen and home departments. You plan to spend a fair amount of money, so you might be on the lookout for special sales or promotions. But, you definitely don’t want someone else to choose all the items for you.

Can Walmart meet your needs in all these situations? Probably yes.

Now, think about how your doctor’s office works:

1) Can you quickly get in and out if you have a simple problem like conjunctivitis?

2) Are they able to give you information on what your options are for a recurring shoulder dislocation; could they refer you to a shoulder specialist without first waiting weeks to see your primary care doctor?

3) You have lots of issues and try to get an appointment to deal with them all at once; you think of it as a physical, but last time you had a physical, your doctor brought up all kinds of things you don’t particularly see as priorities for yourself.

Here are the existing realities of Primary Care:

We can’t afford to just see you for something quick. Our quality indicators, which more and more will determine how we get paid, will go down if we don’t screen you at every visit and offer interventions for depression, smoking, alcohol misuse, hypertension, weight management, immunization needs and much more.

We won’t refer you without seeing you, and we often hesitate giving you medical advice over the phone. Our providers are not scheduled for anything else besides seeing patients, because the rules of how we are paid still emphasize face-to-face visits over “population management”. So our providers are busy all day long seeing patients for visits that could have been simple but are loaded up with mandatory screenings and interventions and our medical assistants, besides being busy with all our screening questionnaires, are discouraged from giving medical advice they aren’t formally trained to provide.

Is there a doctor shortage?

We are said to have a doctor shortage. We have an aging population with more and more chronic diseases, like diabetes and heart disease. The need for skilled and experienced medical providers is continually increasing.

We have no Public Health system to speak of in this country, so the Government, through Medicare and Medicaid, has mandated that health care providers do the things the Public Health system does in other countries.

This is, plain and simple, what is clogging up the works in healthcare today: Too much non-doctor work is crammed into each patient visit, and we can’t charge for giving advice or directing care except in a face-to-face visit.

You don’t need to go to medical school to give immunizations, tell people smoking is bad for you, explain that “low fat” foods cause obesity, or promote regular exercise. You don’t even need to be a doctor, PA or NP to screen for high blood pressure – only to treat it. (Some pundits, in utter desperation, have suggested we send pharmacists to school to learn how to treat hypertension, but there are of course plenty of licensed medical providers who are able and willing to do that if we get freed up from the less-skilled tasks I just listed above.)

Patients and doctors have no control

Now, why are we doing all those things we do if they are so inefficient? Quite simply, whoever pays us has the power to define our work. We call that “Health Insurance”, but that is not exactly what we are dealing with. Insurance, for home, auto or employer liability, has nothing to do with predictable events or minor issues. Your car insurance doesn’t pay for oil changes or tire wear, not even for a minor paint scratch. But somehow that is what we expect health insurance to cover for our bodies. In terms of auto insurance, most people probably figure an insurance job carries an inflated price tag and lots of paperwork. The same is true for health care, which should not be a surprise to anyone.

For example, years ago the overhead cost of insurance billing for each primary care doctor was reported to be $80,000. That, put very plainly, is money that patients and employers are ultimately paying through premiums and deductibles.

And all the mandated screenings are there because Medicare in particular has the right to micromanage doctors’ work because they are paying for healthcare visits, which could be quicker and less costly if patients had control over their healthcare spending.

How could we do better?

We do three things in primary care, each with its own workflow and, really, each with its own economics.

1) We could do our part of Public Health more effectively. Allow us to promote immunizations and other primary preventions outside our already crammed fifteen-minute visits. Pay us a per patient per year stipend to reach out to target populations through mail, phone web or, when appropriate, in person about general health issues. Stop imagining we can do all of it and still treat diseases, acute and chronic, in our measly fifteen minutes. Right now, that is just clicking boxes with little actual substance. Use some of the Government money that should have been spent on a working Public Health system if you want us to step in and do the Government’s work.

2) Make it economically feasible for medical providers to oversee patient care by acknowledging that reading incoming reports, answering phone or web inquiries and coordinating care with specialists and hospitals are essential parts of being a medical home for patients. Such activities should not be unpaid services eked out at the expense of lunch, bathroom breaks or dinner with our families.

3) Allow us to define each office visit together with our patients. It is insulting to everyone involved to have to interrogate someone with a splitting headache, twisted ankle or bleeding laceration about their diet and alcohol habits. I could see many more patients if I could delegate those things to outreach staff or simply not do it every visit. Right now we are made to act as if we will never see that patient again. I was trained to provide care over time, in a relationship based practice. That is proven to be an effective and fiscally sound way to deliver healthcare.

The third task is the only one that makes sense to pay us for on a per-visit basis, whereas the first two deserve their own payment method. Personally, I wonder if the first few hundred dollars worth of Primary Care visits are worth churning through the expensive bureaucratic insurance machinery, or if it wouldn’t make more sense to just allow each patients a set amount of spending at their discretion.

I am not writing about privately financed, Direct Primary Care or Concierge Medicine. Those obviously exist, and may work well for many people, but the healthcare payment options for most Americans are what desperately need fixing.

Only if we acknowledge that Public Health, Population Health and Face-to-Face visits are three separate aspects of health care can we move forward in reforming Primary Care. And only if we recognize and reimburse physicians’ non-face-to-face work fairly will we see the improved customer service and doctor-patient communications we are now only paying lip service to.

(This would also help reduce physician burnout, in case anyone didn’t realize that!)

Where would Google be if we had to make an appointment to sit down with a search consultant and pose our questions, fifteen minutes at a time? It may be an outlandish analogy, but healthcare needs some shaking up…

Pneumonia is a Disease. Is High Cholesterol or Osteoporosis?

So much of what we do today in medicine falls in the gray zone between treating disease and manipulating risk. I am not sure how many “patients” and how many “providers” fail to ponder or make the distinction.

(I put “patients” in quotation marks, because I wonder if we should use that word for people who aren’t sick…)

In many cases, we have ended up with disease-like names, and drug based treatments, for these risk factors. In reality, many other things besides drugs can modify these risks, but our “scientific” paradigm mostly recognizes double blinded trials of medications and undervalues other approaches.

Cholesterol and heart disease are prime examples of how simplistic and ignorant we have been and how “medicalized” our thinking has been:

While extremely high cholesterol sometimes is a genetically determined abnormality, for example Friedrichsen’s hyperlipidemias, garden variety high cholesterol is a laboratory abnormality that evolves and can change according to a person’s diet and lifestyle.

For decades now, we have treated “high” cholesterol with statin drugs, and we now have statistical “proof” that they reduce a person’s risk for strokes and heart attacks. This is the case even for people with “perfect” cholesterol, but the absolute risk reduction isn’t as impressive as the relative one. After all, half of next to nothing isn’t as impressive as half of a very large number.

But, and we know all this although we don’t talk enough about it, since non-statins like ezetimibe (Zetia) can also lower cholesterol without giving anywhere near the same degree of risk reduction, it’s not really about the cholesterol reduction at all. Every day I rattle off to patients that the statins stabilize and prevent rupture of cholesterol plaque, prevent plaque buildup in the first place, prevent blood clots via a mechanism different from aspirin and prevent contraction of the little muscles in the walls of coronary arteries that cause coronary spasm. And I explain that although we know these mechanisms exist, we can’t measure their effects in patients. I also mention that in older persons, a Mediterranean diet causes about the same risk reduction as statin drugs do in middle aged people. It lowers cardiovascular mortality by 30% compared with the old standard low-fat diet.

The new lipid guidelines have a calculator that provides a ten year cardiovascular risk. That helps people by providing a risk number they can relate to, but then the “experts” arbitrarily decided that people with 5 or 7.5% ten year risk should be on low or high dose statins, respectively. The only problem is that all men over 67 or so should be on drugs. Common sense gets in the way of adopting that one, at least in my book. When age as a risk factor outweighs the truly variable measures, like blood pressure, shouldn’t we modify or scrap our disease paradigm?

Another example of a questionable “disease” is osteoporosis. The average woman’s bone density enters the osteoporosis range somewhere around age 80, and the average 60 year old woman has osteopenia. The universality accepted “T-score” compares everybody to a 30 year old. The “Z-score”, on the other hand, compares women to individuals their own age. Today’s guidelines suggest labeling the average baby boomer woman as having a disease, and also many women with better than average bone density. So we are told they are candidates for more or less scary but certainly not innocuous medications.

That reminds me of my residency days, when I would get my hand slapped if I didn’t put every postmenopausal woman on estrogen, because she was obviously estrogen deficient, and we even had the blood tests to prove it. The theory was that since older women had more heart attacks than younger women and the biggest difference(?) between them was their estrogen levels, all we had to do to wipe out heart disease in postmenopausal was to supply them with a lifetime supply of estrogen.

What happened, as the Women’s Health Study demonstrated, was that older women on estrogen plus progesterone (to protect from overstimulation of her uterus lining and subsequent endometrial cancer) had MORE heart attacks, strokes, breast cancers and blood clots than those who allowed their natural aging process to continue.

Today, the same thinking takes place with men and testosterone as the pharmaceutical industry continues its quest for the fountain of youth.

The ultimate question is to what degree aging is a disease and whether it should be the priority of the medical professions, pharmaceutical industry and our insurance system to fight it.

Medical Records for Amnesiacs

I wish CMS and my EMR would stop treating me and everyone who reads my office notes as if we were all amnesiacs.

I also wish they would recognize that primary care is not something that happens only once, in a fifteen or thirty minute visit, and never again.

If we accept these two premises, we are a long way toward health care, or at least primary care, reform.

Before EMRs I used to secretly smirk inside at how much better family physicians’ medical records were than internists’:

Family doctors had the patient’s active problems and their medical, surgical, social, family and health maintenance history on the inside left of the chart, along with medications and allergies. Our office notes, filed in reverse order to the right, were to the point and only dealt with the things we had time to talk about that day. But the background information was always in view and on our minds. We even used to scribble little side notes, like the names of pets and grandchildren, hobbies or favorite travel destinations and sports teams. The problem list helped us see our patients as individuals, not just “the chest pain in room 1”.

Internists, I thought, were like bag people. They carried all their belongings with them, or, they told each patient’s story over from the beginning in every visit, like this:

“This 62 year old male with a 40 pack year smoking history, psoriasis on methotrexate, well controlled diabetes, hypertension, prior myocardial infarction with two bare metal stents and ongoing Plavix therapy, current EF 59%, has a history of mild GERD managed with OTC omeprazole and a history of a normal colonoscopy at age 50 has a baseline hematocrit of 39 but was recently rejected at a company blood drive due to a low hematocrit. He comes in today for a swollen left knee.”

(Every office visit would start about the same way, and almost every visit would touch, at least briefly, on each diagnosis.)

Oh well, when EMRs came into being, the internists’ office note, albeit in bullet form, came to be the model we all follow. Sure, we have side bars with some background information, but all the background information shows up in every single office note, even though all that history is visible on the same computer screen or only a click away.

Somebody seemed to think doctors are all amnesiacs, and that we really need the thumbnail sketch of every patient, every time. Or (Gasp!) some of us may have wanted to give the impression that we truly ask about all that history from scratch at every visit just to score a higher reimbursement.

Of course, the internist way of story telling is modeled after the hospital record, which tells the story of a distinct “episode of care”. And now hospital thinking has crept into and contaminated primary care with disastrous consequences.

The primary care record doesn’t just tell stories of separate “episodes of care”; it is more like a quilt of many story lines, which play out simultaneously and over extended periods of time at different speeds.

Why, then, are our office notes modeled after institutions that deliver nothing but episodic care, and who view a returning patient as a treatment failure?

Primary care is practiced over time; we have more than one opportunity to ask those sensitive questions, offer that immunization or have that talk about smoking or obesity. In fact, there is a right time and many wrong times for most things in life. The right intervention at the wrong time can be insensitive, insulting and counterproductive.

In today’s office visits, we force our way through laundry lists of items our patients never asked us to cover, and we are obligated to fill up our office notes with them.

The cumulative effect of bulking up the office note with historical data that belongs in a sidebar, and the misguided idea that primary care doctors may have only one single shot at delivering preventive care and all the social interventions the Government has now shifted from the public health sector to the health care sector have caused primary care to slow down to a crawl.

Because we are so stuck on the idea that we must provide comprehensive care in every single visit with extensive documentation of what is almost a spinal reflex for experienced physicians, we are seeing many fewer visits than we used to.

We are turning away patients in need of primary care and we are limiting patient access to timely care by making it too cumbersome for primary care practices to see patients for simple problems like sore throats, ankle sprains and rashes. This results in unnecessary emergency room visits and fragmentation of care through the use of unconnected urgent care facilities.

Here is a solution to the mess we are in:

Put those items that are not immediately relevant to the chief complaint or diagnosis of today’s visit in side bars and flowsheets, which would give summaries and timeline documentation of all our efforts at comprehensive care over time. Then, let us refer to these when we make an entry or simply review their contents, but please deliver us from the onus of including every detail of it in every visit. Even if we auto-import them, it makes our own office notes too long to even have time to review the next time we see a patient. And when we get outside records on patients transferring in, it is impossible to find anything relevant in the reams of printed notes we get, because every visit runs 6-8 pages and each one contains virtually the same information.

Let us do well by the patients we are entrusted to care for by paying enough attention to the problem they’ve come to see us about, instead of touching everything in a superficial, perfunctory manner and accomplishing little or nothing except creating an illusion of comprehensive care only meant to impress or placate insurance billing people and public health bookkeeping types. You can only cover so many topics in fifteen minutes.

Why Can’t We Speak Our Own Language?

My voice recognition software insists on typing “when needed” when I say “PRN”, and the other day I saw an orthopedic note that said “before meals joint”. I was sure that the straight-laced orthopedic surgeon was not intending to tell the world anything about anybody’s cannabis use. Instead, it was obvious he had spoken the words “AC joint”, meaning acromioclavicular (on top of the shoulder). But AC can also mean “before meals”, (ante cibum).

Hospitals and health care credentialing bodies make us use plain English instead of medical terms and abbreviations. They say it is to avoid confusion. I think it often creates confusion when doctors are forced to speak as if we didn’t know medicine.

Why are we singled out for this dumbing down? Why are we robbed of the language of our own craft?

How would it be if the tech industry couldn’t use abbreviations like LCD, LED and HDTV?

What if Wall Street outlawed terms like hedge, spread and spot market?

What if military jargon was verboten in the war rooms of the Pentagon?

What if coaches weren’t allowed to scream any technical terms to their teams from the sidelines?

Do we really think a jargon free, plain speaking world will move with greater accuracy and with anywhere near acceptable speed if we remove the majority of the new language our progress was built on?

Dropping the SOAP Note

The SOAP Note isn’t what it used to be, and what it has become needs to be scrapped, because it has made the office practice of medicine cumbersome and unsafe.

In simpler times, when medical records were written by and for doctors, the SOAP Note represented a significant leap forward in terms of expanding and organizing office notes, and also notes from emergency rooms and walk-in clinics. Prior to that, notes sometimes only documented the diagnosis and the treatment, not how those were arrived at.

With S for Subjective, O for Objective, A for Assessment and P for Plan, the reader could instantly find exactly what he or she needed to know from a colleague’s medical record entries.

These days, medical records contain a lot of data that is mandated by outside parties – CMS, ACOs, PCMH/NCQA, the Joint Commission, and now even local states, like Maine.

EMR vendors have inserted these mandated items in sometimes very illogical places in the medical record, and they have also infused bookkeeping items where they probably work best for billing purposes, but definitely not to document clinical thinking.

Some examples:

I see many ER notes that don’t clearly state the patients “Chief Complaint”. I see that they got there by private vehicle, gave the history themselves, didn’t need an interpreter, had already had all their baby shots and were not yet ready to quit smoking, but I’ll be darned if I can figure out what brought them out in the middle of a snowstorm to see somebody in the emergency room.

In the SOAP Note, anything observed during the visit instead of told to us, such as vital signs, heart sounds, blood tests and in-house X-ray findings would go under Objective. Tests ordered but not expected back until later went under Plan.

In the EMR I work with (or under?), there is no Objective and no Plan. There is Exam and Treatment.

That difference isn’t subtle.

The tests I do in-house are ordered and resulted under Treatment, after I have already stated under Assessment what the diagnosis is. That makes no sense. A chest X-ray doesn’t treat anything. The antibiotic I prescribe goes there, too, so at least that makes sense. But essentially, the logical and chronological order of my notes has been hijacked by non-clinicians.

More static items like past medical history, family and social history used to go on the inside left of paper records, where they could be referenced and updated on the fly. Now, just like in a hospital admission note where the patient is presented as if they had never been seen before, they are prominently displayed in every single office note.

That is one of the fundamental differences between a paper office note and an EMR note; the former is pertinent and the second is comprehensive, because the note presumably has to document that the doctor mentally went back over known historical facts and considered their possible relevance for the problem at hand with the speed of expertly trained thought and hard earned experience.

It didn’t seem enough to keep the background data separate and simply state “I considered the Past Medical, Surgical, Social and Family history in handling the patient’s issues in today’s visit”.

Even if someone I stitched up ten days earlier just comes back to have the stitches removed, the second office note reads as if a stranger just walked through my clinic door.

In such a case, a visit that lasts less than five minutes from the doctor’s point of view requires verification of all the data that isn’t likely to have changed in ten days, and the office note is just as long as the original note about the chainsaw cut or their first get-established visit – seven pages of 99% irrelevancy for a simple suture removal.

The mandated add-ons’ presence in every single office note has created a clear and ever-present danger that time-pressured clinical staff and physicians will miss critical information and put patients at risk for clinically incomplete care, even though I’m sure the non-clinicians’ intent at some point was to ensure the opposite.

All these additions have inflated and cluttered up the SOAP note to the point where I think it is high time we reclaim a space, however small, inside the office note for strictly medical documentation that is immediately pertinent.

This nugget notation needs to be near the top of our computer screen, so we don’t have to scroll, even to get from the beginning to the end of it.

We must accept that the office note serves the needs of many people and bureaucracies, but if we don’t make it serve us better, we’ll drive ourselves into the ground and at least some of our patients into their graves because we might miss critical things in the overinflated medical records of today.

The Meaningful Use Paradox

Our clinic is worried about qualifying for this year’s Meaningful Use incentive payments. We have this hastily purchased EMR that was supposed to make life easier and quality better for all of us. The EMR vendor got paid a long time ago but we are still dealing with the administrative burdens imposed by our new system.

By attesting that we can use this thing reasonably properly, we can receive some Government incentive monies, which even under the best of circumstances don’t even begin to make up for all the extra expenses and productivity losses we have incurred through going digital.

What we are up against is a product that doesn’t do, or doesn’t easily do, what we were told it could. And the vendor isn’t working real hard to help us achieve Meaningful Use.

I know how things could get better:

Every quarter, impose a rebate of 25% of each EMR purchase price, paid by the vendor to each practice that isn’t able to use their product as promised. That would place the problem where it belongs, instead of with the hapless consumer. I think that would speed up product improvement and tech support a whole lot.

Compare today’s struggle to achieve Meaningful Use with what happened with faulty General Motors ignition switches, exploding Takata airbags and polluting Volkswagen diesels. Nobody blamed the consumer for such problems.

Why, then, are medical providers held responsible for having bought, under pressure, less than functional electronic medical records?

Make the EMR vendors attest instead of us!


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