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Curbside Consult with Dr. Jayne 10/10/16

October 10, 2016 Dr. Jayne 3 Comments


I picked up an additional clinical shift this weekend to help out one of my partners whose travel was interrupted by Hurricane Matthew. Weekends in the urgent care world are always busy, especially on Sundays when people who have put off care earlier in the week decide they can’t wait until Monday to try to get an appointment with their regular physician. Others don’t have a regular physician and just see us when they’re sick. Another subgroup of patients tries to use us as their primary care home even though we’re really not equipped to do so.

When you’ve seen 40 patients in the first six hours of a shift, that’s a bad sign. Even with a scribe I couldn’t keep up, so we had to send up the bat signal and try to get more reinforcements. Flu season is moving into high gear, overlapping with a bad run of hand/foot/mouth disease for kids in our area. Most of our patients were acutely ill and we always try to move patients into exam rooms rapidly so that they’re not cross-contaminating each other in the waiting room.

For a while, things were backed up, though. Looking at the roster of patients in the waiting room, I couldn’t help but think that telemedicine would have been a good option for quite a few of them.

There are many conditions we treat regularly that can be diagnosed with accuracy based on the patient’s history and some targeted questions. Important data points are the duration of the illness, the specific symptoms, anything that has made it better or worse, and the patient’s health status and other existing conditions. Although the physical exam can confirm a working diagnosis, it usually doesn’t make a difference in the treatment plan for these patients.

Offering telemedicine services would have keep these patients at home where they could be recovering rather than potentially exposing them to other communicable diseases. In my area, however, insurance doesn’t cover telemedicine services, so they’re not being offered.

Assuming insurance would cover the services, our EHR isn’t equipped to handle telemedicine. It’s not just this system, though. The last three platforms I have used for patient care wouldn’t have supported it very well, either. The closest workflow they could offer was to couple the documentation pathway for a telephone call with some of the elements of a standard office visit. It certainly wasn’t a streamlined workflow and there wasn’t a good way to include video links or patient-provided pictures of rashes or other findings.

Although the new federal programs seem to encourage these types of alternative visits, it seems to me that many EHR vendors are just trying to keep up with all the reporting requirements and specifications of the new certification scheme and don’t have many development resources to shift into these kinds of nice-to-have workflows.

Some of the cases I saw today really made me think about how our country is addressing (or not addressing) healthcare delivery. We’re so focused on cost reform that we’re missing other significant factors that influence care-seeking behavior.

Many of our patients come to the urgent care due to access issues – they can’t get a timely appointment with their primary care physician or they can’t leave work during the hours the office is open. Although many employees have sick time benefits from their employers, the reality for many of the patients we see (as well as many of my friends and colleagues) is that it’s often difficult to use that sick time.

Employers put a variety of strategies in place to keep people from abusing the benefit, but those strategies can also function as a barrier to care. The rise of high-deductible health plans is also a barrier to care, and we sometimes see people with serious illnesses who have deferred coming to care because they can’t afford the deductible. It’s not an overall cost savings if the patient has to have an amputation because they didn’t have a $90 visit that could have mitigated the condition weeks ago.

We try to engage our patients and encourage them to follow up with a continuity physician, providing them View/Download/Transmit access to their note as soon as the physician completes it. We also have nearly-real-time surveys of patient satisfaction, which can be a bit unnerving when you receive an email with your rating before the patient is even out of the parking lot. It’s definitely a different world than what I thought I was getting into when I went into medicine.

I’m not sure how many patients actually engage via a records download, though. Although we can accept and consume inbound records, I’ve not seen any in the two years I’ve been working with this organization. I have had a couple of patients who have personal health records that they access on their phones during the visit and many who have accessed their pharmacy records to tell me about previous treatments if I can’t download them via our EHR’s pharmacy management link. But I’ve never seen a C-CDA and I’m betting that my staff would be confused if one turned up.

Our organization is growing steadily. We’ve doubled in size in the last two years. Although it’s great from a business perspective, when you really think about it, it’s terrible from a patient care strategy standpoint. Although patients come to us because it’s convenient and we’re fast and economical, we’re not a primary care office and we don’t handle preventive screenings or other universally recommended services.

I firmly believe that patients do best when they’re cared for by a physician and/or care team that knows them well and can manage their issues over time, looking for trends or linked events. This is what old-school family physicians used to do, before insurance companies pushed patients into networks based on costs and contracts. When I was in solo practice, I had patients who were forced to change primary physicians every year or two because their employer would change insurance plans or the insurance plan would change their roster of contracted physicians.

With the rise of the medical home movement in the last decade, you’d think this trend would be somewhat reversed, but we’re not seeing as much change as we need to solve the healthcare delivery problem. Physicians are stressed and don’t want to provide after-hours services without additional compensation and patients don’t want to pay for it.

We’ve thrown billions of dollars of technology at it, but it doesn’t feel like we’re much better off than we were before. Physician practices have been disrupted. Once they settle in, there is a tremendous opportunity to harness the technology, but now we’re seeing a second wave of disruption as providers and organizations change EHR vendors, often sending provider workflows back into chaos.

Programs such as the Comprehensive Primary Care Initiative and its successor CPC+ are trying to shift care delivery to the medical home model through additional payments and support, but it’s still tremendously difficult for organizations to make these changes, especially since they’re already coping with additional federal and payer regulations.

I’m not sure what the answer is, but it feels like we’re reaching the breaking point. Is anyone building the killer app that will help providers and care delivery organizations truly transform how we care for patients in the 21st century? Or will the regulators just keep tightening the screws? As we sit here on the edge of our chairs waiting for the next Final Rule, it feels more like the latter.

What do you think is the answer to truly reforming healthcare delivery? Email me.

Email Dr. Jayne.

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Currently there are "3 comments" on this Article:

  1. Perhaps a three tiered system would help address the problem with access and utilization. The concierge medicine model could work for both providers and patients across the board. In all cases, patients would subscribe to a provider’s practice and use that as their patient-centered medical home. In the first tier, patients might pay 100% of the cost. In the middle tier, it might be a mix of patient self-pay and commercial insurance. In the third tier, the government might pay on behalf of patients. This would help maintain continuity of care and promote wellness. The challenge would be to manage churning by patients between providers, but if tied to a calendar year or a plan year, that could be controlled.

  2. We are in the death grip of a hyper-regulated system, and we see no end in sight. Anyone with any experience with EHRs knows that simple EHRs and data systems in complex worlds like medicine takes years to make them safe, usable, efficient, secure and less burdensome. It also takes a massive support structure, simple things like batteries dead in a mouse, can disrupt an office for hours. To pile on VERY intensive data entering and manipulation and forced interop will never work, i.e. MACRA. We really need relief from massive CMS regulatory activity like MACRA, AAPM, etc. Every year that we waste precious time and resources with these activities pushes back real improvements. Its sad, but I don’t think anyone, even Andy Slavitt, has the guts to say enough is enough, lets get out of the way and let IT vendors work directly with MDs to figure this out. They are too busy back slapping themselves that MDs purchased EHRs (that they hate).

  3. IMHO, your best column to date. Meltoots hit the nail on the head about hyper- regulation. A truly free market would allow the best ideas to surface and proliferate.

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