In Their Words: An Executive’s Perspective on the TCM Model

We are continuing our series of interviews with providers across the country as more and more practices adopt the TCM Model. In this edition we hear from Dr. Thomas DeMarco, Vice President of Peninsula Regional Medical Group (Maryland). He completed his degree at the University of Louisville, an internship at the University of Pennsylvania, and returned to the University of Louisville to complete his residency. Dr. DeMarco adopted the TCM Model in 2019. What follows are his reflections.

 


The TCM Model has changed our provider’s outlook on practicing medicine and increased their productivity.

3 MIN VIDEO

 

  

 

In Their Words: By the End of the Day On the EHR, My Head Was About to Explode

We are continuing our series of interviews with providers across the country as more and more practices adopt the TCM Model. In this edition we hear from Jim Kolp, DO, Board Certified in Family Medicine and Osteopathic Medicine. He completed his undergraduate work at the University of Cincinnati, completing medical school at the University of Akron and Ohio University, and a family medicine internship and residency at Ohio University. He is affiliated with The Christ Hospital Physicians (Ohio) and he adopted the TCM Model in 2019. What follows are his reflections.

 


We have happy doctors and happy patients. The doctors are more productive (they’re making some more money), patients are getting better quality time, and the hospital system is increasing its capacity. It’s a win-win-win!

3 MIN VIDEO

 

  

 

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.

Patients With Acute Needs Can’t Wait. Neither Can You.

In this first of a two-part look of the role of acute visits in primary care, we’ll discuss why offering this access is so important and will help determine the future of primary care. In the next blog, we’ll discuss what practice administrators and clinicians can do to effectively prepare for same day patients.

Here’s a question for you. What business would survive yielding up its most valuable and profitable product to a competitor? Not sure if your answer is different than mine, but I’m going to go with “none” or at least none I’ve ever heard about. Of course, there may be an exception, but I’m pretty sure primary care medicine isn’t it.

Getting back into the conversation

Before considering the benefits inherent in increased acute care access, let’s take a look at what’s generating part of the problem:

A short while back, I came across an online message from Aetna Health Insurance targeted primarily to its policy holders but also to the public in general. The information focused on the benefits, including convenience and out-of-pocket cost savings, of accessing retail walk-in clinics or urgent care centers instead of emergency rooms for non-life or limb-threatening conditions.

Based on average claim costs, Aetna made a strong financial case for using the clinics and centers through a straight comparison of the same non-emergent treatments. What was clear as I read the information was that primary care practices weren’t even in the urgent care equation, despite the fact that most of the conditions shown could be appropriately resolved on the primary care level.  Not being part of the conversation is an omission we should be addressing for a number of reasons that benefit patients and practitioners alike.

The most valuable visit of the day

In our practice, acute presentations were the most profitable segment of the day, providing the highest level of reimbursement per minute. In most cases they were also the quickest and among the most satisfying.  What we found was that the episodic care – specifically two acute visits a day – paved the way for employing a full-time MA or LPN which in turn, enabled us to see several more patients.

I want to emphasize that two same day visits more per day was all that was necessary to pay for one additional full-time employee. This extra staff member, trained with true exam room skills, not only helped provide our patients with the timely access they needed, but also helped restore my own work-life balance to a healthier and far more satisfactory level. With this addition, I could see 5-6 more patients per day while working fewer hours. Intentionally working to capture all the same day visits within a panel can transform this aspect of a comprehensivist’s practice from a loss leader to a profit center. 

While the majority of unscheduled visits are still reimbursed on a FFS basis, the continuing movement toward newer value-based payment models should continue to position acute treatment as a significant factor in improving the continuum of care and the bottom line.

The visit that helps strengthen the provider-patient relationship and significantly raises population health

Historical and contemporary medical literature are replete with articles, monographs and chapters on the role of the therapeutic relationship as the foundation for trust and open communication. And there’s a strong connection between this special relationship and treating acute care patients.

What we found was that the well-documented benefits of a strong provider-patient relationship as a major determinant in patient and staff satisfaction and compliance were enhanced even more by our commitment to bringing urgents in as quickly as possible. These encounters offer an excellent opportunity to grow the trust and overall level of engagement that, in turn, positively impact other visits for the same patient, including both preventive care and chronic condition management. Simply put, treating a sore throat on a Saturday morning is a significant part of a continuing relationship that can add substantially to the patient’s long term health.

In fact, my own experience leads me to believe that the most effective management of chronic diseases takes place when reliable access, including same-day access by the same provider, is consistent across the continuum.  On a very personal level, that same experience has convinced me that timely access can save the lives of patients who won’t go to the ER because they want to be seen by their own familiar and trusted doctor.

Access is key but it’s a sore throat, not a Starbucks moment

Timely access is at the absolute center of effectively meeting acute needs in the primary care setting. By “timely access” I mean access when the patient needs it provided by someone he or she knows and trusts. Sustaining that level of access requires a considerable amount of focus, and you may have to sacrifice catching up on your patient’s recent life story since unlimited time with one individual precludes access for another.

But looking at it from the patient’s perspective, even a short visit with a familiar provider is a highly desirable and valued experience. It’s also an experience we have to view as a necessity rather than a luxury. If people can’t get timely care from their regular provider they will go somewhere else for it, with the understanding that health may not be possible if it’s not on time. And in the process they will sacrifice money, trust, comfort and even a degree of competency for convenience, access and reassurance. 

Now that we have a sense of how vital it is to provide access to patients with urgent care needs, the second part of this blog will discuss the mechanics for making it happen. To be continued…

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.

All in Good Time (Management): Restructuring Primary Care Schedules

It’s impossible to ignore how much power time exerts over our lives. Our human existence is organized and controlled by the passing of time and how much we devote to each aspect, whether it’s study, work, sleep, play or relationships.

But why doesn’t this hold true in the context of primary care? As providers, we tend to ignore the parameters that time has in our normal lives once we enter the exam room. Time always has limits—but somehow we’ve come to consider the exam room as exempt.

And that’s where primary care loses its financial sustainability and the functionality of providing timely access when consumers need it most. More than half of primary care practices in the US are in chaos because they lack the structure and ability to keep up with demand—much of which is due to poorly managed time.

Health is often impossible if it’s not on time

We’ve made a huge mistake in primary care by not meeting our patient’s need for timely access. The urgent care industry was born and has resulted in rising expenses, decreasing quality, and marginalization of the primary care discipline as a whole. This loss of access has also devalued the provider/patient relationship. Fixing the ways that we think about time is an important step towards improving health and reaching the Triple Aim Plus One.

But no one really wants to talk about the issue of time because it’s so controversial. Providers don’t want to discuss time management because it seems too restrictive or at odds with their particular style. We think our work is too important to be subjected to time constraints or that we owe unlimited time to patients if they want it. But these kinds of perspectives ultimately make our other patients in the panel vulnerable and compromise our own professional viability.

Restructuring primary care schedules can easily handle the needs of 26 or more patients daily by utilizing a well-trained team, inside the exam room. Timely access is of the utmost necessity and a need that we can no longer avoid.

The Four Cs: The Balance of Robust Primary Care

What do healthcare consumers need from primary care?

That’s a question many healthcare industry leaders are asking. While the question itself is fairly simple, it’s challenging to adequately address. There are many ideas and strategies surrounding this topic, but my goal here is to describe the critical need for balance among the four elements essential to the creation and sustainability of a robust primary care system.  

We can easily visualize this need for balance by imagining the four legs of a table. If one is weaker, shorter than the others, or missing, the table will be unstable at best and nonfunctional at worst. Today’s American primary care system is somewhere between the two alternatives, but sadly we see lack of function more often than not.

Our society desperately needs the healthcare system to achieve the Triple Aim for improved population health, better individual wellness and more affordable care that won’t cripple the economy. Strong, effective primary care is the only route to get us there, but with our present imbalance the Triple Aim is impossible.

So let’s take a look at the four legs of the table—“The Four Cs”—that must be in balance for our primary care system to thrive. 

Continuous

The first essential element is a patient’s long term, continuous, personal relationship with a provider. This gives the provider a good knowledge base of the patient and the circumstances of his or her life, personality and medical history—all of which have an impact on health. This understanding of the patient’s personal life, in addition to the mutual trust that develops over time between the provider and patient, improves the provider’s decisions and facilitates more effective communication.

A healthy provider/patient relationship also leads to increased patient engagement. Engagement is vital because no matter how excellent care is, there will be little lasting impact to health if the patient is unmotivated and uninvolved.

Competent

Competent decision making is the second essential element and the strongest of the four legs in our primary care system’s current state.

A new emphasis on laboratory research developed with the advent of modern medicine in the late 1800s and beginning of the 20th century. The scientific approach to medicine became the norm, leading to what is now known as “evidence-based medicine.” This knowledge grounded in research has become the curriculum for medical schools.

Physicians in the US receive 7–10 years of medical education and training following their undergraduate degrees. We’re fortunate as a nation to have some of the best healthcare education in the world—particularly the training of comprehensivists who can address patients’ health with a whole-person orientation. The high level of training and expertise of comprehensivists, along with important interventions such as medications, imaging and labs, have created a primary care environment in which most patients have very successful outcomes.

Cost effective

Of all the disciplines of medicine, primary care is the most affordable. But this element of cost effectiveness isn’t utilized as much as it could or should be because of the lack of convenience (more on that aspect to follow in a moment). Personal knowledge of the patient—an attribute best developed within primary care—helps the provider avoid unnecessary tests or treatments, which can lead to significant savings for both the patient and society as a whole. And ongoing chronic care management lowers the risk of needing costly interventions later when a neglected disease becomes more severe.

Many consumers’ attitudes toward healthcare reflects the belief that no amount of money is equal to health. With that perspective, going to an urgent care center or the ER is a satisfactory alternative to seeing a personal provider. But it has gotten our society into trouble because we’ve devoted a tremendous amount of money to interventions that haven’t actually contributed to positive health outcomes.

Studies show that patients who see the same provider on a long-term basis have fewer ER and hospital admissions, have better control of chronic diseases (like diabetes, hypertension and asthma), live longer and cost the healthcare system less. Seeing a “familiar physician” is the most important thing a person can do for his or her health—and it’s the key to sustaining a cost-effective healthcare system.  

Convenient

Convenient access, the fourth element of robust primary care, is the leg that’s most often missing from the table. When access is poor, it doesn’t matter how much expertise the provider has, how strong the provider/patient relationship is, or how cost effective primary care is. If the provider isn’t available when care is needed, he or she offers essentially no value to the patient.

Because of this lack in primary care, we’ve seen the development of an industry of urgent care centers and minute clinics for the singular purpose of convenient access. This convenience has often come, however, at the sacrifice of cost effectiveness and comprehensive, relationship-based care, the context in which the best provider decisions can be made. We’ve also seen the use of Emergency Rooms change due to the lack of primary care access. Now every ER regularly deals with a high number of non-emergency issues at inappropriate costs to the patient or the payer, driving up overall healthcare costs.

If primary care is going to become a viable option for accessible care, practice hours must adapt. This is where innovation is needed, because practices need to be open 12 hours Monday-Friday and at least 6-8 hours on weekends. Sickness has no timetable, and patients need access seven days a week—for the sake of their health, work schedules, expense and positive outcomes. And contrary to popular opinion, it’s possible to do this in ways that not only open up patient access, but also enhance the provider/patient relationship and protect the work/life balance of providers.ncy issues at inappropriate costs to the patient or the payer, driving up overall healthcare costs.

A promising future

Primary care may be struggling, but it’s far from irrelevant. As we look at strategies to design a robust primary care system that meets the needs of our society, we must ensure these “Four Cs”—continuous, competent, cost effective and convenient—become intrinsic attributes of our primary care delivery.

The thriving primary care system we envision is still in the distance, but we can’t stop short. Now more than ever we must bring the essential elements of robust primary care into balance so we can offer the kind of care our patients need and deserve.

Strictly Business: The Professional Side of the Provider/Patient Relationship

You don’t have to be a member of the infamous Corleone Mafia family to understand there’s a difference between what’s personal and what’s business:

 provider/patient relationship, primary care, relationship-based care

But sometimes the lines are blurred, and distinctions are easier in theory than reality—especially within the provider/patient relationship of primary care.

This relationship can’t thrive without some measure of friendship. Where we need clarity, however, is understanding the difference between professional and personal friendship. We’ll take a look here at characteristics of a healthy provider/patient relationship, consequences of poor boundaries and how professional friendship promotes robust primary care.

The “familiar physician” at work

In my book Lost and Found: A Consumer’s Guide to Healthcare (co-authored with Dr. Paul Grundy), we discussed the impact of the “familiar physician” on patient health:   

“Keep in mind that a familiar physician may be the most valuable professional relationship you’ll ever have, seeing you through many of the stages and transitions of your life… Based on a considerable body of research, you’re more likely to live longer, live healthier, and spend less for medical care when you see your familiar physician on a long-term basis. No other single entity in medicine can help you achieve those outcomes.”

But it’s not always easy to translate value into practice. And if you’re a provider trying to deliver accessible, relationship-based care to your panel, you’ve got your work cut out for you, particularly when navigating the murky waters of professional versus personal friendship.

A provider’s responsibilities to patients (i.e. what he or she is paid to deliver)—personal connection, timely access and competent medical practice—can’t exist in isolation of one another. The balance of these three areas is essential to the robust primary care system required for our society and to the quality, cost-effective care patients need. And the latter two are crucial for reaching the Triple Aim.

Tried and true

Trust helps people relax, let down their guard and feel safe. That’s the kind of environment patients need, and it’s the most basic element of a strong provider/patient relationship. It develops over time as the patient relies on the provider’s expertise to make the best decisions, and the provider expects honesty and cooperation in return. They become true partners, working together for the patient’s well-being.

Every interaction should be focused on medical intervention while getting to know the context of the patient’s life—family issues, economic situation, employment and stress factors—in order to make the best decisions possible for his or her health. That knowledge of the patient beyond EHR data is critical to the quality of care delivered.

But the provider/patient relationship is also a business transaction, which is where it differs so dramatically from a personal friendship. It must be controlled by normal business parameters in order to protect individual interests and make the practice successful. That’s why we have medical records, quality benchmarks and medical liability for the patient’s safety and why the amount of time the provider spends with patients must be limited to maintain the quality of the product (i.e. medical expertise + time).

Don’t take it personally

Another important aspect of a professional friendship is that it serves a specific purpose—something a personal friendship doesn’t always do. A patient’s purpose for a relationship with a provider is to achieve or maintain health at a reasonable expense and receive help making decisions that will lead to continued wellness in the future. 

It can be difficult to keep patient health as the primary focus when a truly gratifying friendship develops. That’s why many providers struggle to keep their interaction within the confines of a professional relationship because they genuinely enjoy getting to know and caring for patients. Those relationships can even become a bit of a refuge for the provider from other stressors. But when personal dynamics take prominence in a professional friendship, they can destroy the very purpose of the relationship and lead to all kinds of bad outcomes. We’ll come back to that topic in a few moments.

Care must be honest and given in the patient’s best interests. Sometimes the most honest, caring thing a provider can do is tell a patient he or she has six months to live. That’s not an easy or enjoyable conversation, but it’s the best kind of care a provider can give to help the patient prepare for what’s to come. Without a strong commitment to act as a practitioner first and friend second, we risk losing the objectivity and candor required for those difficult conversations.

None of my business

During my years as family medicine provider, whenever I had a patient call me his or her best friend I knew that statement indicated one of two things. Either the patient was incredibly lonely and didn’t have much interaction with people beyond the brief and infrequent time with me, or the patient was possibly neurotic and inappropriately focused on what our relationship could provide. Those instances were good reminders of the need for wise interaction with patients to maintain a healthy professional friendship and avoid inappropriate reliance on me.

Disordered or disregarded boundaries can have serious consequences, whether unhealthy dependence develops or a lack of objectivity leads the provider to make faulty decisions. The first casualty is often lack of focus on the primary goal—the patient’s health.

As I’ve worked with practices around the U.S., I’ve observed many providers enter an exam room and spend 10–20 minutes socializing and only five minutes delivering medical care to a patient who’s in terrible health. The patient might appreciate the personal attention, but the interaction doesn’t facilitate better health as effectively as it could—and should.

Poor boundaries can also promote inappropriate behaviors such as control, abuse, relationships of a romantic or sexual nature, or improper prescribing of narcotics because the provider assumes undue responsibility for helping the patient cope with other areas of life.

On perhaps the most practical level, lack of appropriate time boundaries is simply destructive. The provider eventually loses his or her personal life because the workload is unmanageable, staff members get burned out, and financial viability for the practice is threatened.

Balancing act

Lack of appropriate time boundaries is detrimental for patients as well. We’ve become so out of balance as an industry that we’ve emphasized the quality of medical education without making the changes needed to facilitate patient access. Providers in the U.S. have some of the best education in the world, and yet our inattention to time has severely limited access for the patients who need our care. Unlimited time for one patient destroys access for another.

No matter how much trust exists between the provider and patient or how talented the provider is, the relationship fails the patient if timely access isn’t available when it’s needed. And more seriously, unavailable or delayed care can be detrimental to his or her health.

Primary care has become a quagmire because of its struggle to offer personal care within the context of poor business parameters. If we don’t understand the differences between professional and personal friendship, we won’t have the capacity to meet the needs of our patient panels and build financially sustainable practices. That’s why it’s so critical for us to get it right.

Business is business

Our care for patients should always be focused on strategies to improve their health in the context of appropriate boundaries. We can’t be great providers without creating an environment in which patients feel known and safe. That level of relational investment drew me to primary care, and the pleasure of caring for patients over time and helping them experience the best quality of life possible is what made me stay.

But like Michael Corleone in The Godfather, we have to remember that despite our personal involvement with patients, the revitalization of primary care through strong professional friendships must be strictly business.

₁ Lost and Found: A Consumer’s Guide to Healthcare by Peter B. Anderson, MD and Paul H. Grundy, MD with Tom Emswiller and Bud Ramey

New Book from Dr. Peter Anderson and Dr. Paul Grundy

Regardless of politics, personal opinions, or individual experience, it’s no secret that our healthcare system is broken and in desperate need of repair. And it’s become increasingly complex and frustrating, both for consumers and for those who provide care.

We’re excited to announce the release of a new book, co-authored by Dr. Anderson and Dr. Grundy, who bring a unique combination of personal experience and expertise to the quest for affordable and effective healthcare.

Lost and Found: A Consumer’s Guide to Healthcare is an up-to-the-minute guide designed to help consumers navigate the obstacles that stand between them and high-quality, affordable healthcare. Readers will learn about why primary care, more than any other aspect of medicine, will determine the quality of our healthcare as a nation. They’ll see the value inherent in a strong patient-physician relationship and how a “familiar physician” delivers the best preventive and acute care and chronic care management. And they’ll find out how to save money without sacrificing quality in today’s changing healthcare environment.

Advance praise for Lost and Found:

“Healthcare continues to get more complicated, confronting consumers again and again with critical decisions about health insurance, where to go, and how to get what you need from your medical care. There is an urgent need for helpful, unbiased information that isn’t selling something. Lost and Found provides trustworthy, practical advice on the major decisions that all of us have to make in getting the healthcare we want and need for ourselves and our loved ones.” 

— Edward H. Wagner, MD, MPH, Group Health Research Institute Senior Investigator Director (Emeritus), MacColl Center, Seattle, Washington

ICD-10: Moving the Healthcare Industry Forward

Most healthcare professionals’ blood pressure likely rose a little on October 1, 2015 with the launch of ICD-10. Bruce Japsen’s article in Forbes articulates much of the apprehension about the transition from ICD-9 to ICD-10. The concerns are significant: many physicians and practices aren’t adequately prepared, coding and billing errors are inevitable as the new codes are adopted and initial delays in authorizations and payments are likely.

The implementation is a massive undertaking for providers, system administrations, insurers and employers — and patients will absorb some of the effects as well. But in spite of its many hurdles, ICD-10 is a much-needed transition for the growth of the industry and for improved patient care. It’s also an important shift as healthcare moves away from a fee-for-service payment structure toward fee-for-value.

You’re speaking my language

Coding is the only standardized language shared between providers to communicate patient information. And without precise language, we can’t give a clear picture of a patient’s health. It’s fair to say ICD-9 conveyed fairly limited information. It might have been adequate 30 years ago, but as healthcare and technology have evolved, we need a greater level of detail for proper intervention and care coordination. ICD-10 provides the precision to describe a patient to any provider involved in his or her care.

The terminology and documentation process between ICD-9 and ICD-10 is similar, but the main difference is that there’s far more information captured by the codes of ICD-10. These new codes include the severity, risks and complications of a patient’s condition — data that has a significant impact on the way conditions are treated.

Documentation is becoming a significant element of care quality and helps facilitate the interoperability we need. Because healthcare crosses boundaries of time and providers, detailed, up-to-date patient records are critical. People travel and need care outside of normal weekday hours, and sometimes many providers are involved in the care of the same patient. A lack of specific information and clear communication poses real issues.

Better information leads to better care

One of the primary weaknesses of ICD-9 was that there was no way to differentiate between levels of severity for a particular condition. To give you an example of how this could impact the level of care, consider a patient with asthma. In the past, if a patient went to the ER suffering from an asthma attack, the only information reflected in his or her medical record would be the ICD-9 code for asthma.

Now that could be mild, intermittent asthma, which means the patient would only need a short treatment in the ER before being sent home, or it could be severe, persistent asthma, which means the patient could die from an episode if not properly treated. But according to the code in the patient’s record, the asthma would look the same, regardless of the severity. And without specific information about the patient, an ER physician could easily make a decision based off the limited details in the chart, and the prematurely discharged patient could die a few hours later.

And under the ICD-9 codes there was virtually no way to compare treatment plans for different levels of the same disease. If one treatment could be successful for a mild condition but a different option was needed for a more severe condition, the information reflected by the codes didn’t give a good indication which treatment to pursue for a severe case.

Now that severity is standardized, treatment effectiveness can be more correctly assessed. As Japsen points out in his article, ICD-10 will lead to better chronic disease management through better communication and evaluation. And all of this will result in better outcomes for our patients.

ICD-10 and the medical home

In the bigger picture, this is where technology meets the medical home. Now that we have the medical home model and electronic records, and because of the interoperability that’s coming between systems and providers, good patient care can’t happen without the EHR. And a patient being seen by his or her familiar physician, the PCP who provides care on a continual basis — in the context of a medical home — will lead to the most accurate medical information and documentation.

Change for good

ICD-10 won’t be an automatic or easy adoption — there will be a learning curve here. But for the most part, the number of codes physicians deal with on a regular basis will be limited by their specialty.

It’s a burden to change, and all change has costs and speed bumps along the way. But patients can’t get the care they need without accurate, comprehensive communication between providers.

ICD-10 is a consistent development toward industry goals like team-based care, interoperability and fee-for-value. And the bottom line is that ICD-10 is a real step forward for patient care, leading to better diagnoses, treatment and health outcomes.

© 2020 Team Care Medicine