COVID-19 – Expanding Telehealth

COVID-19 – Expanding Telehealth

Written by Bruce Korus, Founder of Korus Health Innovation | Posted March 27, 2020

Introduction

Our COVID-19 crisis is greatly impacting all Americans, particularly our healthcare workers.  We want quick answers to our COVID-19 questions.  Primary care providers (PCP’s) are using telehealth to improve access, but are challenged to meet the surging demand.  This crisis will be a catalyst to future expansion of telehealth services. 

While sheltering in place, I decided to write this article about the COVID-19 crisis and expansion of telehealth services.  I expect this will be the first in a series of articles about how this crisis is impacting our health system and all Americans.

Growing Crisis

American COVID-19 cases are increasing more rapidly than other countries (Country by Country graph).  We will soon have more cases than China, Italy, or Spain.  Our COVID-19 cases are growing exponentially, with New York State reporting nearly 50% of total cases (Source – Worldometer).  During the past week, total US cases have increased from 6,400 to 54,800 (as of March 24th).  Cases are doubling every 3 days!

Due to delays in testing, I believe we have significantly underreported our COVID-19 cases.  New York has increased their testing from 1,000/day to 16,000/day.  As other states ramp up their testing, I expect we will see their numbers grow exponentially. 

Utilizing Telehealth

During this crisis, telehealth can help us provide more convenient and safe health services.  Providers face great risks in contracting coronavirus, due to exposure to undiagnosed patients.  Telehealth enables providers to minimize contact with COVID-19 patients.  On the other hand, patients want to avoid a clinic waiting room full of potential COVID-19 patients.  Telehealth provides patient visits at home on their smart phone.

I reviewed health systems offering telehealth services in the SF Bay Area, Seattle Puget Sound, Milwaukee, and Philadelphia (all places where I have lived).  Kaiser now provides more telehealth visits (through email, phone, and video visits) than in-person visits.  Although Kaiser has a well-established telehealth program, their video visits represent a small percentage of total telehealth visits.

Americans want to know, “How can I quickly get answers to my COVID-19 questions?”  These health systems offer on-line symptom checkers and/or provide a phone number for initial screening and recommended next steps.  Telehealth visits may be scheduled or provided on-demand.  Because of increased demand, consumers can expect delays in arranging virtual visits with longer than normal wait times.

Expanding Telehealth Services

Health systems are ramping up telehealth services as quickly as possible.  A major barrier to expanding telehealth has been the limited payments.  In response to this crisis, the federal government has passed emergency regulations to improve telehealth payment and licensure requirements for Medicare services. 

Our limited primary care provider (PCP) staffing will be a major challenge.  We have a shortage of PCP’s with many working part-time to improve their work-life balance.  Many PCP’s are over-whelmed by current practice demands and will have difficulty adopting new technology during this crisis.  Health systems are freeing up PCP time by deferring elective visits and closing some of their clinics. 

Well-established telehealth programs, such as Kaiser, Providence, and Penn Medicine, should have an easier time ramping up their services.  They can offer the options of email, phone, or video visits.  Their PCP’s are already very familiar with their telehealth systems.  National telehealth companies want to quickly hire more PCP’s.  But with our shortage of PCP’s, it may take months rather than weeks to hire additional PCP’s.

Summary

We must effectively utilize the time of our PCP’s, since they are at high risk for contracting COVID-19.  We can more easily increase email and phone visits, rather than video visits.  According to Dr. Ezekiel Emanual, we have fourteen days to defeat coronavirus and flatten the curve.  After working through this crisis, we will determine how best to utilize telehealth and expanded care teams in providing more convenient, affordable health services.

Bruce Korus is the Founder of Korus Health Innovation.  Expanded primary care teams will use telehealth to shift services from hospitals & clinics to homes & smart phones.  Please send your comments to bruce@korushealthinno.com

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Team Building vs. Building a Team

Team-Based Care Models Are Not the Solution to Physician Burnout

All across the US, well-meaning administrators seeking solutions to physician burnout are turning to Team-Based Care (TBC) Models. Few understand that TBCs were not created for the purpose of combating physician burnout or restoring joy in medicine. Rather, they were developed in response to new payment models that incentivize gains in the overall health of the patient. 

According to the Agency for Healthcare Research in Quality (AHRQ), “the primary goal of [Team-Based Care] is to optimize the timely and effective use of information, skills, and resources by teams of healthcare professionals for the purpose of enhancing the quality and safety of patient care”. While admirable and important, the primary intended beneficiary of TBC Models is the patient, not the physician.  

Team-Based Care Misses the Mark

Team Based Care and Burnout
Team-Based Care models place the patient at the hub of all functions and take the power away from the team.

The “team” in Team-Based Care refers to the primary care provider in addition to a host of adjacent healthcare professionals, such as care coordinators, triage nurses, pharmacists, and behavioral health professionals. For patients with complex health needs, coordination among these various providers is critical to good outcomes. However, when it comes to the mental well-being of the primary care provider, the TBC exacerbates the problem by adding more collaboration tasks and communication requirements to an already overwhelming workload.  

A host of evidence points to excessive administrative burden and EHR data entry tasks as the primary drivers of physician burnout. Providers report that they spend much of each visit typing on the keyboard rather than looking the patient in the eye. Most cannot keep up with their charts during clinic hours, but instead try to catch up in the evening, depriving them of rest and a personal life.

Any cure for physician burnout must involve relieving the provider of a meaningful portion of this administrative burden, allowing them to focus on the patient and on the actual practice of medicine for which they were trained. Such assistance must come inside the exam room, where the history is collected, the exam is documented, and the charts are updated. With its focus on an outside the exam room team, TBC is barking up the wrong tree.

Scribes Fall Short in Team-Based Care Models

Many systems have turned to scribes as a mechanism to take the keyboard out of the hands of the providers, freeing them up in the exam room. While this approach clearly yields some benefits, it doesn’t fundamentally change the equation for the providers that still perform virtually the entire visit themselves. Schedule delays and long hours remain a problem, as the scribe is little more than a “human app” attached to the EHR, which still must be directed at all times by the provider.

Team Care Medicine Cures the Illness

In order to truly change the game for providers, they must be freed to focus exclusively on the parts of the patient exam that require someone with their level of training. Everything else must be delegated to qualified team members. 

The Team Care Medicine (TCM) Model is built around this commonsense insight. In the TCM Model, the clinical assistants work ahead of and independent of the physicians. For instance, the clinical assistants gather all of the patient’s preliminary data, including chief complaint data, before the physician enters the exam room. They then present it to the physician verbally, in front of the patient, similar to how a resident presents a patient to their attending physician. The clinical assistants manage the EHR, including the capture of physical exam findings and recording of the diagnosis and treatment plan, thus freeing the physician to focus solely on the patient. The physician can then move on to the next patient, leaving the clinical assistant to provide patient education and close the visit. 

The TCM Model enables the provider to spend less time on each patient, and thus see more patients per day. In order to keep the provider fully occupied at this higher level of efficiency, most practices hire one additional MA per provider. The cost of this additional team member is easily covered by the 20-40% increase in provider productivity, and by improved provider satisfaction and retention as they re-engage personally with their patients during the exam and no longer take charts home in the evening.  

A Purely Logical Solution

The principal drivers of physician burnout are found inside the exam room, so any solution must also transform the process and responsibilities inside the exam room. While there are admirable goals and benefits to a Team-Based Care Model, healthcare leaders seeking a solution to physician burnout would do well to consider the commonsense and empirically validated approach: the TCM Model.

Growing numbers of primary care physicians across America are struggling to make the business end of their practice work.

Preventing Physician Burnout

Physicians are burdened by an incredible amount of stress from not only their work but also from rising operating costs, new technology, increasing administrative burdens, and growing demands from patients. This takes an obvious toll on physicians and can lead to low-quality patient care, medical errors, and can cost the healthcare system billions of dollars every year. 

So, can anything be done to prevent physician burnout? 

Learn to spot the warning signs

Whether in yourself or in a coworker, it’s always a good idea to be able to identify the signs of burnout and determine where these signs cross the line between regular but manageable work stress and burnout. That’s where our previous article, What is Burnout, and the Maslach Burnout Inventory (MBI) come into play. According to the MBI, there are three symptoms common among most physician burnout cases:

Emotional and physical exhaustion

Emotional and physical exhausting is the most common sign of burnout, which is when someone is worn out and depleted from work but unable to recharge during non-work hours. 

Depersonalization

Depersonalization is a symptom that often comes out in the form of cynicism, frustration, and a negative or callous attitude. Often, this is displayed in a physician’s sudden inability to connect with patients and constantly finding themselves blaming others. 

Physicians are burdened by an incredible amount of stress. So, can anything be done to prevent physician burnout?
Source

Reduced sense of accomplishment

During this stage of physician burnout, the physician starts to doubt their qualifications see themselves as incompetent. They’ve lost confidence in their skills as a physician and start to believe that patients would be better off not under their care. 

As you are watching for these signs, be mindful that physician burnout looks different in different physicians. For example, male physicians and female physicians display these signs in different ways

Physicians are burdened by an incredible amount of stress. So, can anything be done to prevent physician burnout?
Source

Sometimes, the constant discussion of burnout in healthcare becomes burnout in and of itself, giving physicians a sense of hopelessness in thinking that there’s no stop to this epidemic, that it’s an inevitable part of this job. But, there is a way to counter burnout and it starts with Team Care Medicine and restructuring the healthcare organization’s framework. It starts with deconstructing the various points of stress and instead promotes strategies that improve the organization’s balance. 

If you’re ready to learn how to do this within your own organization, sign up for one of our 30-minute live webinars. Within this time, you’ll learn the basics of our trademarked and proven TCM Model and understand the path to launching our program to fit your own organization.

Measuring and Managing Physician Burnout

Measuring and Managing Physician Burnout

Physician burnout is widely recognized as a challenge not only for physicians, their families, and their colleagues, but also for the US population that depends on access to engaged and effective healthcare providers. The World Health Organization recently defined burnout as 

A syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: 

1) Feelings of energy depletion or exhaustion.

2) Increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job.

3) Reduced professional efficacy. 

Burn-out refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life.”  

Despite near-universal awareness, the problem is poorly quantified.

Measuring Burnout

Quantifying the prevalence and severity of burnout is inherently difficult. First, burnout is an internal experience that can only be described by the person suffering from it. Second, burnout is a continuum rather than a binary state.  

The Maslach Burnout Inventory (MBI) is the most commonly used measure of physician burnout. The MBI delineates burnout according to three components: emotional exhaustion, depersonalization, and reduced personal accomplishment. However, the cutoff criteria of what constitutes burnout and where to delineate low, medium, or high severity is subjective and varies widely in academic literature.

Other measurement tools have emerged to improve upon the MBI, whether by framing some of the questions negatively or by addressing the high cost of the MBI materials. Alternative approaches include the Copenhagen Burnout Inventory, Oldenberg Burnout Inventory, Patient Health Questionnaire-9 (PHQ-9), Stanford Professional Fulfillment Index, and the Well-Being Index.  

The vast array of diagnostic tools and cutoff points can be dizzying, but they all point to the same high-level conclusions:

#1 Burnout affects healthcare providers at higher rates than the overall population

In a 2014 study, approximately 54% of physicians reported at least 1 symptom of burnout, almost twice the rate of the general U.S. working population. Physicians explain that an heavy load of bureaucratic tasks and excessive work hours (especially take-home work) are the primary contributors to emotional exhaustion, depersonalization, and reduced job satisfaction.  After all, they “didn’t go to medical school in order to enter data in the EHR.”  

#2 Burnout affects primary care providers at higher rates than specialists

In an Archives of Internal Medicine article, researchers noted “substantial differences in burnout were observed by specialty, with the highest rates among physicians at the front line of care access (family medicine, general internal medicine, and emergency medicine).” Confirming this result year in and year out, the annual Medscape survey across 29 specialties consistently places Family Medicine and Internal Medicine in the top 5 for burnout and bottom 5 for happiest at work. 

#3 Burnout is reported at higher rates for women than men 

Among US physicians, women report burnout at 25% higher rates than men. Researchers note that women may be more likely to admit to psychological problems and seek help than men. Women also disproportionately assume childcare and family responsibilities, increasing the cost of challenges to work-life balance.

Healthcare executives must seek solutions to the root causes of burnout – excessive clerical tasks borne by the provider and the take-home work that results. Without a change, provider turnover will continue to climb and patient access will continue to erode.

What is Physician Burnout?

What is Physician Burnout?

Physician burnout has become a national epidemic with multiple studies proving that about half of all doctors suffer from at least one of the three common symptoms associated with this condition. Physician burnout negatively impacts quality of care, patient safety, physician and patient turnover rates, and patient satisfaction in addition to increasing the number of medical errors that have become common in the United States. According to a Mayo Clinic Proceedings study by Daniel Tawfik, MD, medical errors are responsible for 100,000 to 200,000 deaths each year. However, research connecting physician burnout to these errors is limited. 

Up until pretty recently, the most prevalent approach to reducing medical errors was to fix the workplace safety by adding in more checklists for physicians to complete and adding in “solutions” like yoga and breathing exercises for the physicians. Tawfik’s study shows that this is insufficient, comparable to placing a Bandaid over a large gash. Fixing these medical errors starts by addressing physician burnout, understanding what it is, how to identify it in yourself and your colleagues, and finding ways to prevent it. 

Defining Physician Burnout

An accurate comparison for physician burnout is that energy is like a bank account that can have a positive or negative balance. Every time a physician engages in the activities of their life and medical practice, he or she withdraws energy and the balance decreases. During times of rest and rebalance, energy is deposited, causing that balance to increase. The problem comes when it dips into a negative balance. The account doesn’t close; instead, energy is still spent (in this case working) despite the fact that the currency (energy) is, in fact, depleted. 

Burnout is a long-term stress reaction characterized by a series of symptoms we will later discuss that is a result of a constantly depleted energy account and with a negative balance over time. Yes, a physician can continue to function and work in this state but as only a shadow of the doctor that he or she is when the account has a positive balance. 

Signs & Symptoms of Physician Burnout

The industry-wide accepted standard for burnout diagnosis is the Maslach Burnout Inventory that was developed in the 1970s by Christina Maslach and her colleagues at the University of San Francisco. She described burnout as “an erosion of the soul caused by a deterioration of one’s values, dignity, spirit, and will.” The three distinct symptoms most commonly associated with physician burnout:

Symptom #1: Physical and Emotional Exhaustion

The physician is feeling both physically and emotionally drained, depleted, worn out, and unable to recover during non-working hours. This is by far the most common symptom of burnout and is the one most physicians identify with when taking burnout prevalence surveys. A thought process that the physician suffering from physical and emotional exhaustion may identify with is, “I’m not sure how much longer I can go on like this.”

Symptom #2: Depersonalization

When physicians display this symptom, it often comes in the form of cynicism, a need to vent about their patients or their job, and a negative or callous attitude. Doctors in this stage are feeling so emotionally drained that they are not emotionally available for their patients or anyone for that matter. 

Symptom #3: Reduced Sense of Personal Accomplishment

In this stage of physician burnout, you may begin to doubt the meaning and quality of your work and see yourself as incompetent. A piece of internal dialogue commonly associated with this symptom is thinking, “What does it matter? My work doesn’t really serve a purpose anyway,” or even, “I’m afraid that if I don’t change something, someone is going to get hurt and it’ll be all my fault.”  

Effects on patients, practice, and physicians

Physician burnout affects all parties involved: the physician’s patients, the practice, the physician’s family, and, of course, the physician him/herself. Physician burnout is directly linked to a series of unsavory consequences that you definitely want to keep out of your practice:

  • Lower patient satisfaction due to poorer quality of care
  • Higher physician and staff turnover
  • Higher and more severe medical error rates and malpractice risks
  • Physician alcohol and drug abuse and addiction
  • Higher physician suicide rates

There is a higher risk of death by suicide for both female and male physicians relative to other professionals but goes widely underreported. 

Physician burnout fits with the old adage “death by 1,000 paper cuts.” It can happen slowly over time, each day and each task exacerbating the physician’s condition until it comes crashing down with a trigger like a lawsuit, a tragic circumstance in one’s personal life, a significantly damaging medical error, etc. If left untreated, physician burnout will only erode the mental health of doctors and threaten patient care. 

Our Love/Hate Relationship with Provider Productivity

Our Love/Hate Relationship with Provider Productivity

This is the first in a series of communications on productivity and its far-reaching effects on our individual futures and the future of healthcare. In upcoming blogs, we’ll examine the link between productivity and an effective medical home, discuss some of the impediments to greater productivity and then see what it looks like in the exam room.

The driving factor in lack of access

There’s always talk about improving access, but low productivity, the driving factor behind reduced access, doesn’t get much respect. It should. It’s estimated that 38 percent of primary care visits in 2015 were unnecessarily diverted from the PCP office to the ED, urgent care centers and retail clinics. That’s a lot of lost visits, to the detriment of the practice – and especially to the patient because fragmented, limited care is no substitute for the kind of cost-effective quality that comes with continuous, comprehensive care.

What’s to love about productivity?

Getting back to our love-hate relationship with productivity, the “love” part is a matter of economics. While there are some exceptions, compensation has historically been based on the number and intensity of services provided. Metrics and methodologies can vary, but for the most part, the more patients seen, the more the likelihood of financial success. Although we continue moving toward fee for outcome-based payment models and next-era indicators for productivity, the wRVU standard remains in place for the majority of employed physician and physician owner practices.

And what is it that we hate?

As it turns out, there’s a darker side to this straightforward work-pay relationship. For primary care providers who already feel maxed out, it’s the vision of the hamster wheel. You hear the word “productivity” and you think of an industrial age assembly line, complete a conveyor belt, bringing endless numbers of patients in and out of the exam room. This scenario may be a bit extreme, but a system that incentivizes volume without supplying support staff with the specific skills need in primary care exam rooms can end up creating a negative impact on the missions of preventive medicine, wellness, education and basic patient care itself.  As a result, productivity is not only distinct from, but may also be anathema to quality and service.

If that isn’t bad enough, increased productivity carries the threat of overwhelming the already fragile work-life balance that providers often struggle to maintain. That’s why discussions of productivity can create concerns in the areas of both professional and personal satisfaction.

Why greater productivity is a necessity

In recent blogs, we’ve talked about how pursuing the Institute for Healthcare Improvement’s Triple Aim remains critical for maximizing overall health system performance and a reliable constant in the ever-changing map of healthcare. We’ve also discussed the value to primary care providers of capturing more acute care patients who might otherwise seek to have their medical needs met at retail clinics or urgent care centers due to limited access at their provider’s practice. The common element in both of these objectives and the most effective way to achieve this improved productivity.

However, without a corresponding increase in the kind of efficiency that supports productivity – and in turn leads to greater access – our ability to attain the Triple Aim, along with our hopes for meeting the needs of acute care patients will never reach fruition. And as we will discuss in the next blog, neither will our ability to bring the medical home to an effective reality.

Uncommon Bedfellows: Access, Expanded Hours, and Provider Wellness

Uncommon Bedfellows: Access, Expanded Hours, and Provider Wellness

In the first installment in this two-part look at the role of acute visits in primary care, we focused on the benefits of building this capability. In this continuation, we’ll discuss what needs to be in place in order to get there.

Improving access for acute, same day patients offers important benefits to practices and patients alike, but it takes a little thought and effort. The good news is, the mechanics are well within reach. I promise not to delve into queuing theory, wait-time metrics or any elements of what can be the surprisingly complex subject of medical scheduling. But I will share with you a bit of my own practice experience.

Opening up an adequate block of time at the end of the morning and another at the close of the afternoon…

…allowed us to better balance acute patient needs with organizational resources. What’s amazing is that these blocks were the easiest and most pleasurable part of patient visits for my clinical staff even though there could be 6-8 patients scheduled for each hour-long block.

This approach, which did not include a move to a true open access model, enabled us to stay on track with our scheduled patients and then see acutes collectively. Generally, it offered enough choice to accommodate individual patient schedules. If not, we could usually bring them in whenever they could make it and adapt accordingly because of the efficiency of our exam room process.

Utilizing high-functioning assistants who are empowered with the specific skills needed inside the exam room…

…is the single most important factor contributing to timely and consistent access for acute care patients. By building a more effective team in the exam room, providers can focus on direct patient care, those things that are commensurate with training and skills – and not the non-provider activities that can represent up to 60% of the patient encounter.

For example, in the typical routine (non-acute) primary care visit, the provider spends 10-15 minutes with what would be considered exclusively provider responsibilities and 10-20 minutes with non-provider responsibilities. Now, with the staff handling all the non-provider responsibilities inside the exam room, the provider is free to move on and see the next patient much more quickly.

I’ve seen improved exam room protocols work effectively in my own practice and in scores of other primary care and specialty practices with which I’ve been involved on an educational and training level. However, it’s important to note that the kind of transformation needed for more acute care capacity as well as all other patient visits isn’t simply a function of adding personnel. It involves true process redesign and a commitment to culture change, with a bit of professional flexibility and patience thrown in.

Expanded hours…

…have to be part of the solution if a patient’s need for access is going to be truly met by a familiar primary care provider. By building a more efficient team inside the exam room, increased productivity will allow for shortened shifts as well as fewer shifts per week. The result is that a small group of providers will have evening and weekend access collectively for their patient panels while promoting a very healthy work/life balance for providers individually.

Extended weekday and weekend hours and greater flexibility in overall scheduling are providing additional options and removing more of those times when, as the urgent care promotions put it, “your primary care provider is unavailable or you’re unable to make a timely appointment.” It’s not always easy, but an improved exam room process and the productivity that goes with this make expanded hours eminently doable.

Realizing that the time and energy spent on seeing more acute visits is not a distraction…

…but rather an opportunity with a range of inherent benefits is the most important step in preparing a practice for increasing acute visits.

Despite ongoing uncertainty in the direction of health reform, the four legs of the primary care table continue to be competence, continuity, accessibility, and affordability. A practice without timely access to a familiar provider when a patient perceives an urgent need is like a table with only three legs. Missing that access leg doesn’t make for productive quality-based primary care any more than it forms a solid, reliable and well-functioning table.

And speaking of tables, we’re leaving too much on them if we’re not ready to increase access for same-day, acute care patients.

Reprioritizing Exam Room Goals

All in Good Time (Management): Reprioritizing Exam Room Goals

There’s a prevailing opinion among providers that time is equal to care; the more time a provider gives a patient, the greater the level of care or genuine compassion he or she has. That’s just not true. The quality of care we provide to our panel is what determines success—not the amount of time we spend in the exam room.

Starbucks hasn’t come to the exam room

Our inappropriate focus on socializing with patients has led many of us to prioritize the unnecessary goal of what I call a “Starbucks moment.” We’re under the impression that patients want and deserve unlimited time to relax, catch up and discuss anything that’s on their mind during a visit, regardless of how long it takes. And perhaps some of us have come to believe we deserve a “break” too—a respite from the demands of our busy schedule, spent in the company of a patient with whom we have a genuine, enjoyable connection.

We must remove this idea of socializing from the context of appropriate medical care. The strength of a provider/patient relationship isn’t dependent on the amount of time spent with patients, it’s founded upon and maintained by the right balance between personal connection, timely access, and competent medical care. Personal involvement is critical for a provider to know the patient and make the right decisions for his or her care. But unlimited time not only fails to produce better health outcomes; it negatively impacts access for the rest of the panel.

Trust is the intangible component that makes the provider/patient relationship unique and health producing, not the amount of time spent together in the exam room. Patients generally consider provider competency a given because of the amount of education and training every provider receives, but timely access and communication are the key to building trust. No matter how good the provider, if she/he is not available to the patient, the patient loses trust. What patients want and need, besides competency, is timely access to a provider in whom trust has been developed – a familiar provider.

(A small caveat here. There will be instances when unlimited time is the right solution for patients with special circumstances or emergency concerns. But those exceptions shouldn’t drive day-to-day operations.)

Priority management

As I’ve written previously, time management begins with priority management. And if we’re going to fix primary care, we must begin by rethinking our priorities. So what are the exam room priorities for providers?

  • Maintain personal involvement with each patient to create or sustain health
  • Create access for the panel (in other words, see all the patients in the panel who need to be seen on a particular day) [links to TCM schedule content offer]
  • Make the necessary medical decisions for patients when they need care rather than refer to another provider
  • Empower clinical staff to accomplish all the ancillary (or non-provider) work inside the exam room
  • Communicate with patients in a timely manner (accomplished with participation of the clinical staff)

None of the goals above challenge or threaten the personal connection between providers and patients, and they actually incentivize greater trust by giving patients the care they need when they need it. And all of these priorities address the concerns of the individual patient as well as the rest of the panel, leading to better population health and meaningful provider/patient relationships.

Keeping the main thing the main thing

Primary care providers must begin thinking in terms of time and work within appropriate boundaries to give patients the access and quality of care they need to become and remain healthy. This means reorienting priorities inside the exam room and elevating health-producing strategies over “feel-good” moments that don’t actually create health.

The value of this cultural change in the exam room has enormous potential to transform our primary care delivery. Reprioritizing the goals of the exam room will lead to the improved access, health outcomes and cost-effectiveness our patients, panels, systems and society so desperately need.

Hope for Atul Gawande and Doctors Across America

Hope for Atul Gawande and Doctors Across America

In a recent New Yorker article entitled, “Why Doctors Hate Their Computers”, popular author and surgeon Dr. Atul Gawande skillfully explores the pain caused by the electronic health record (EHR) system at his hospital system in Massachusetts. Sadly, he concludes the piece with a vague exhortation that we must “insure that people always have the ability to turn away from their screens and see each other,” while offering no tangible solution to the long hours, lost patient connections, and burnout that he observes around him. Fortunately, proven solutions exist and they’re right under his nose.

Familiar Problems

In his typical, accessible style, Gawande explains how “a system that promised to increase my mastery over my work has, instead, increased my work’s mastery over me.” Finding records and adding new information to the EHR has consumed more and more time and attention, resulting in significant take-home work and frustration by doctors. Meanwhile, patients and physicians alike are frustrated that the personal connection has been lost as eye contact is replaced by staring at the computer screen. It’s a familiar refrain by doctors all across the country as burnout approaches epidemic levels.

Band-Aid Solutions

In an effort to unshackle providers from the EHR, some have hired scribes to document the patient exam. Gawande describes the approach exquisitely, saying “This fix is, admittedly, a little ridiculous. We replaced paper with computers because paper was inefficient. Now computers have become inefficient, so we’re hiring more humans.”  The problem, of course, is that scribes don’t fundamentally change the equation for the provider; they’re basically just a very expensive voice recognition software that’s “installed” on the the computer through the keyboard.

Answers in Plain Sight

As a doctor himself, it’s not completely surprising that Gawande only speaks in terms of individuals rather than teams. Even as he interviews doctors, patients, office managers, hospital administrators, and even a virtual scribe/MD in India, Gawande fails to connect with any of the thousands of nurses and medical assistants (MAs) that work in the same exam rooms as the doctors at his hospital. All too often these colleagues are overlooked by the doctors they serve. Nevertheless, the path to restoring the joy of the doctor-patient relationship, to a healthy work-life balance, and to overall career satisfaction is to engage with these nurses and MAs, to invest in them, and to begin to work as a true exam room team. This is the critical answer in plain sight.

Change isn’t easy. Providers must be persuaded to delegate many tasks and to re-conceptualize themselves as team leaders, rather than solo performers. In order to practice up to the limit of their license, MAs need thoughtful coaching and equipping. Only then can they take on new functions, like independently collecting patient data and then presenting the patient’s case to the provider (in the presence of the patient), much like a med student on rotation. Implementing a comprehensive exam room workflow that includes steps like these (e.g. the Team Care Medicine (TCM) Model) is attainable with the guidance of an experienced implementation consulting partner. That’s the real hope for Gawande and doctors across the nation.

The Exam Room Team: Where Provider Productivity and Access Begin

The Exam Room Team: Where Provider Productivity and Access Begin

In this final segment of a four-part series on productivity that’s included a discussion of the negativity often associated with the word “productivity”, the impact of low productivity on the medical home and five factors that function to hold productivity down, we’ll take a look at the exam room process and why it hasn’t been universally improved through a team approach.

So far we’ve created four separate blogs to look at different facets of productivity. Why are we banging this particular drum so loudly? Because to extend the analogy, in the great symphony that is the contemporary American health system, productivity is one of the most harmonious instruments we have.

Beyond its historical relationship to compensation-related metrics, productivity is the key to primary care access, including (and sometimes especially) acute or same-day appointments which might otherwise end up in urgent care or the ED.  On an even larger scale, the improved access that comes with greater productivity is a key factor in meeting current and future patient demand and consequently, the needs of our healthcare system itself. So how do we help assure that this capability will be in place? The exam room is the place to start.

Getting behind the team

The thing to keep in mind about team-based care is that it’s simple. At least in concept.  The provider’s role in the primary care exam room focuses on what she or he is uniquely qualified to do by way of training and experience. It includes performing exams, determining diagnoses and setting up treatment plans. Virtually everything else from collecting and presenting medical data to supporting the treatment plan and closing the visit, is delegated to one or more “team care assistants” including nurses, medical assistants or other well-trained clinical staff. Like I said, the basics are simple once you get past the misconceptions that are still held.

Three myths about the team care delivery model

Myth #1: Your staff can’t get proficient at the needed skills. With appropriate and adequate training, clear performance expectations and ongoing communications, staff members can effectively handle the required tasks – and can direct more of their time and attention to those activities than a physician could.

Myth #2: Having additional people in the exam room interferes with the patient-provider relationship. What we’ve found over a number of years and in an extensive number of practices is that freeing up the physician to focus entirely on the patient, (without non-clinical distractions), dramatically strengthens that vital bidirectional bond.

Myth #3: Patients don’t want anyone but the doctor in the exam room. Again, experience and related research indicate that patients overwhelmingly appreciate the extra time and attention directed to them by a larger care team.

The real change is cultural

Once again, I would emphasize that the concept of a team-based, patient-oriented exam room isn’t tough to understand or even assemble, especially once you get past those three myths. But waiting on the other side is the single, most substantial challenge to this exam room team – the historical and still potent strain of personal independence and self-assurance that exists among providers, whether they are employed or in private practice. While the potential need for staff hiring, as well as some role realignment and workflow redesign, requires effort and resources, the idea that many providers prefer performing a one-person play in the exam room instead of acting in an ensemble continues as the greatest obstacle.

In an upcoming blog we’ll look at the “Why do what I do best when I can do it all?” clinician culture and what can be done to transform it into an effective foundation for team care.

© 2020 Team Care Medicine