Teamwork: AAFP, PA Groups Find Common Ground
I recently represented the AAFP at meetings with leaders from the American Academy of Physician Assistants (AAPA) and the Association of Family Medicine Physician Assistants (AFMPA), and I was honored to be an invited guest to the AAPA meeting in Boston a few weeks ago. The leadership of the AAFP and the AAPA have previously attended each other's board meetings to review proposed legislation at state and national levels. This is a critical interaction that allows our organizations to identify areas in which we can work together.
For example, in Boston, I learned about a proposal in Missouri regarding so-called assistant physicians, who are not PAs but medical school graduates who have not completed residency training. Not only does this proposed measure create potential confusion because of the title of these would-be health care providers, it also would create significant challenges in terms of how unlicensed providers should be designated, regulated and utilized.
|I recently met with leaders from the American Academy of Physician Assistants, including (from left) President John McGinnity, PA-C; President-elect Jeffrey Katz, PA-C; CEO Jenna Dorn; and Board Chair Lawrence Herman, PA-C.|
This issue was directly addressed by the AMA House of Delegates at its annual meeting last month. The AAFP delegation coordinated with our PA colleagues and testified about concerns raised by this issue. A resolution opposing the use of medical school graduates as assistant physicians was adopted with wide support.
Our common interests with the PA groups aren't limited to advocacy. PAs are trained in the medical model of care involving diagnosis and treatment, as are physicians, and they follow rigorous and standardized educational, certification and licensing processes. Last fall, we reached a unique arrangement with the AAPA, which was working to identify activities that would fulfill the performance improvement requirements for its new certification of maintenance program. The AAPA came to us seeking a collaborative agreement through which the AAPA could offer the Academy's four METRIC (Measuring, Evaluating and Translating Research Into Care) performance improvement modules within the AAPA's own learning management system.
METRIC is the AAFP's flagship performance improvement product line and is critical for lifelong learning and maintaining certification. This agreement has been finalized, and PAs may now purchase and access the AAFP's METRIC modules directly from the AAPA, which coordinates marketing and accreditation of the modules. This joint venture represents an important way to share resources and not reinvent educational wheels as we move toward quality improvement in continuing education. Moreover, this relationship reinforces the value that others see in our educational offerings.
This is all worth noting, in part, because 40 percent of AAFP members work with PAs, who assist us in ensuring that we provide effective care and improve our patient outcomes. Team-based care is important to meeting the goals of the quadruple aim -- improving patient outcomes, improving patient and provider satisfaction with the system, and doing so at lower cost.
Family physicians and PAs are working together not only at the practice level but also at the national level, and I look forward to further discussions and collaborations with these groups. Together we are making progress in providing better, more effective care for our patients.
Reid Blackwelder, M.D., is president of the AAFP.
Follow the North Star: Global Health Is Focus of New Wonca Group
A growing number of medical students, family medicine residents and new physicians are interested in pursuing global health experiences. In fact, more than 30 percent of U.S. medical students completed a global health rotation in each of the past four years.
|Polaris, the new and future physicians movement for Wonca North America, was one of the topics discussed when I attended the winter meeting of the College of Family Physicians of Canada's Section of Residents.|
In the United States, we are fortunate to have structured, well-developed clinical rotations and residency programs for our family physicians-in-training, but in many other countries, recent medical school graduates are often faced with the prospect of building their own family medicine experience. To address this need, the Europe region of the World Organization of Family Doctors, or Wonca, formed the first new physicians organization -- referred to as a young doctors' movement -- in 2005 to focus on networking and providing a platform to connect physicians across borders. Other Wonca regions have since followed this example -- all except the North America region.
The 2013 Wonca World Conference in Prague triggered renewed discussions about establishing a new and future physician movement in North America. Members of the AAFP, the College of Family Physicians of Canada and the Caribbean College of Family Physicians have worked together to establish the movement's framework, including its charter, name, logo and a governance structure. On May 19 -- World Family Doctor Day -- Wonca North America announced the creation of its new and future physicians movement, Polaris, to provide an avenue for the exchange of ideas and actual observational experiences in different countries.
Polaris is not simply a platform for launching medical mission work. Rather, it is a comprehensive forum for global health. In many of the discussions leading up to its formation, the difference between mission work and global health was emphasized, and organizers envisioned one possible goal of the program to be changing the perspective that medical missions are global health to the reality that medical missions are only a small part of global health.
Although mission work is often how physicians gain global health experience, family doctors practice in all parts of the globe, and the vast differences that exist among medical systems, available resources, patient populations and disease processes offer amazing learning opportunities that can enhance physicians' work in their own communities and offices.
A global view of patient care is becoming more necessary as both our demographics change and our health systems adapt, and family medicine is the natural home for that viewpoint. Two-thirds of family medicine residency programs now offer international rotations or electives, and even those without formal programs teach the skills and population management competencies needed to work in any community, which produces physicians who have interests and/or abilities well-suited for global health delivery.
Aside from skills development, simply connecting with family doctors in other countries provides a perspective that often helps open our eyes to new solutions and processes we can then use in our own programs and offices. For example, I was fortunate to be invited to attend the winter meeting of the College of Family Physicians of Canada's Section of Residents, where each residency program in Canada is represented. Polaris was simply a glimmer of an idea at that point, but the collaborative effort it represented was well-received.
Canada's postgraduate medical education system is much like that in the United States, but even so, these residents shared our interest in developing a more comprehensive patient approach. Canadians have rural patient populations that make some of our rural sites in the United States appear metropolitan. Not surprisingly, their medical education curriculum includes impressive didactic and skills sessions to meet the needs of students and residents who plan to work in remote settings. I came back to my residency program with ideas for improving our own training based simply on talking with Canadian residents. Imagine the progress we could make in our training if we were able to experience the many cultural variations and nuances that characterize family medicine across continents.
WONCA's young doctors' movements have already established exchange programs to enable their members to participate in observational experiences. Polaris could provide an infrastructure for setting up exchanges to and from North America.
Polaris is still being developed, and much remains to be decided. So if you are a family physician who is interested in global health -- whether you're a seasoned veteran or someone looking for a first global health experience -- take advantage of the many upcoming opportunities to be part of the discussion:
- At the National Conference of Family Medicine Residents and Medical Students, Polaris will be discussed during the global health networking session, which is scheduled for Aug. 8 in Kansas City, Mo.
- Attendees at the Family Medicine Global Health Workshop scheduled for Sept. 11-13 in San Diego, can see a presentation by representatives of the Vasco da Gama Movement, which is the European group for new and future family physicians. The event also will feature a networking session where Polaris will be a topic of discussion.
- An international networking session also will be held during this year's AAFP Assembly, which is scheduled for Oct. 21-25 in Washington.
Kimberly Becher, M.D., is the resident member of the AAFP Board of Directors.
Implementation Begins on Family Medicine for America's Health
Throughout the year, we have been using this space to provide updates on the Family Medicine for America's Health: Future of Family Medicine 2.0 project. I'm pleased to share that the planning portion of the project is now complete, and we are moving forward with implementation. Our Academy's Board of Directors recently pledged $12 million over the next five years to support implementation of both the strategic and communication plans.
In this latest update, you'll find an announcement of the members serving on the Implementation Committee, the naming of the new chair (former AAFP President Glen Stream, M.D., M.B.I.) and a summary of both the strategic and communication plans. Additional updates will be shared here as the project unfolds. Exciting times for Family Medicine!
Family Medicine for America’s Health: Future of Family Medicine 2.0
Organizational Update No. 7
We are pleased to report that the planning phase of the Family Medicine for America’s Health initiative has been completed. As a reminder, the purpose of this effort was to develop a multi-year strategic plan and communications program to address the role of family medicine in the changing health care landscape. To read earlier updates from Family Medicine for America's Health: Future of Family Medicine 2.0, please visit the project Web page.
The Boards of Directors of each of the seven original sponsoring organizations, plus the American College of Osteopathic Family Physicians (ACOFP), have approved both the strategic and communications plans. The eight organizations have pledged more than $20 million over the next five years to implement both plans, which are described in further detail below.
Moving forward, this effort will be known simply as Family Medicine for America’s Health. An Implementation Committee has been formed that will drive the next phase of this work. Representatives include:
- Glen Stream, M.D., M.B.I. – Chair (AAFP)
- Tom Campbell, M.D. (ADFM)
- Jerry Kruse, M.D., M.S.P.H. (STFM)
- Paul Martin, D.O. (ACOFP)
- Norman Oliver, M.D. (NAPCRG)
- Bob Phillips, M.D. (ABFM)
- Mike Tuggy, M.D. (AFMRD)
- Jane Weida, M.D. (AAFP Foundation)
Four additional members are being recruited for the Implementation Committee, representing the following stakeholder categories:
- Family physician in full-time practice (practice size of five physicians or fewer)
- Young physician leader in family medicine (five to seven years post-residency)
- Patient advocate
- AAFP chapter executive
Strategic planning consulting firm CFAR developed the strategy in an intensive eight-month effort that included:
- A strategy survey (taken by hundreds of family physicians, as well as by other primary care health professionals).
- Current state analysis of family medicine today and the role family medicine plays in the current health care environment.
- Identification of scenarios depicting possible futures for family medicine that were tested at a multi-stakeholder retreat attended by family physicians, other primary care health professionals, public and mental health stakeholders, policymakers and employers.
The framework of the strategic plan is organized according to a few guiding principles:
- Put the patient and family at the center – always.
- Now is the time for family medicine to take up a leadership role in primary care, including reforming payment in ways that make it possible for family physicians to offer patients and their families the highest quality primary care.
- Family medicine must clearly state its vision for the next five to seven years and pursue actions specifically linked to strategies in six critical areas: practice, payment, workforce education, technology, research and engagement.
- Family medicine can’t prove the value of primary care alone. Family medicine leaders must take a leadership role in building partnerships and alliances with a variety of stakeholders in the wider health care system – with patients, other primary care health professions and national policy organizations, among others.
The complete strategic plan will be published in an article in the Annals of Family Medicine later this year.
Communications consulting firm APCO Worldwide conducted extensive quantitative and qualitative research to develop an evidence-based communications program to demonstrate that family physicians are leaders in the new and evolving health care environment and advocates for patient health. (Detailed findings of the research are provided in earlier editions of the monthly reports.) The plan outlined the following goals:
- Position family physicians as leaders and central to the delivery of quality care for patients.
- Increase patient understanding of the value of primary care and of receiving primary care through a family physician.
- Improve patient engagement in prevention and health care management.
- Attract the best and brightest students to the practice of family medicine.
- Shift the payment model to support comprehensive payment reform.
Stakeholder perceptions of family physicians are favorable and higher than those of almost every other medical specialty. With these favorable perceptions come high expectations. The research showed that patients want and need a primary care physician – particularly a family physician – to be at the center of their health care.
A number of concepts and themes were tested for this effort. The winning theme will be launched in October at the AAFP Assembly in Washington, D.C.
This campaign will be used as an advocacy platform to communicate with consumers about their critical role in creating a strong primary care system that improves health. Research examined an exhaustive list of areas where stakeholders believe family medicine must focus. The four focus areas that emerged as most relevant and needed were: prevention and health promotion, health disparities, patient education and engagement, and chronic and complex disease management.
The communications strategy will drive broad, long-term social goals, while strengthening family medicine’s identity, cohesion and capacity to deliver on the triple aim (improving patient care and outcomes and lowering costs). The campaign will use integrated communications and will include policymaker outreach, workplace outreach, paid media, earned media placements, stakeholder engagement, corporate and organizational partnerships, and a strong online presence.
We will continue to provide regular updates on the implementation of this important effort. Watch these reports for opportunities to learn more and weigh in on the process.
Jeff Cain, M.D., is board Chair of the AAFP.
It Takes a Village: Become a Breastfeeding Advocate
Over the years, the Academy of Breastfeeding Medicine (ABM) has received significant leadership contributions from AAFP members, including past ABM officers Anne Montgomery, M.D., Julie Wood, M.D., and Tim Tobolic, M.D. AAFP member Anne Eglash, M.D., in fact, was a founding member of the ABM. But no AAFP officer had ever been invited to participate in the ABM's Annual Summit on Breastfeeding, even though our colleagues from the American Congress of Obstetricians and Gynecologists and the American Academy of Pediatrics have routinely attended.
But this year, for the first time in the event's six-year history, all the specialties that care for newborns and mothers were represented at the recent two-day summit in Washington.
Family physicians, including president-elect Julie Taylor, M.D., M.Sc., (right) have played an important role in the Academy of Breastfeeding Medicine. I met with her at the recent Annual Summit on Breastfeeding.
This breakthrough represented an important opportunity for the AAFP because attendees at this event included not only representatives of the medical professional organizations noted above, but also leaders from CMS, HHS and other governmental agencies; federal legislators; representatives from such diverse stakeholder groups as the W.K. Kellogg Foundation, Kaiser Permanente and the March of Dimes, as well as academics, state health officials and others.
Unfortunately, many of these groups have not coordinated their efforts with one another and were not aware of other groups' activities. In particular, these other stakeholders were not familiar with the important work the AAFP has done in the areas of breastfeeding support, advocacy and policy. Therefore, I saw at least part of my role in attending the event as helping to break down existing silos.
I found it encouraging that everyone present seemed to readily recognize this need. We forged new relationships, connecting to the right people to improve our collaboration. In between agenda sessions, people were talking, exchanging cards, and sharing resources and links. I felt a great deal of enthusiasm and energy throughout the entire event.
Best of all, this summit provided me another opportunity to help other groups understand who family physicians are and what we do. I was able to point to our unique role in taking care of these special patients, noting that because we are the only specialty that truly does cradle-to-grave care, we have multiple opportunities to talk not only about breastfeeding, but also the many diverse issues relating to rearing children.
An especially important message for attendees to hear was about our ability to educate not just the mother, but also the father and, perhaps even more essential, the maternal grandmother! Family physicians are truly the medical specialists who can pull everything together after the blessed event, because we see both mother and baby together at subsequent visits. With this kind of postpartum follow-up, we can directly impact the sad decrease in breastfeeding rates that occurs after women go home from the hospital. At the time of discharge, about 75 percent of U.S. women are breastfeeding, but that rate drops to roughly 28 percent within a few weeks of going home.
Family physicians can take the lead in addressing this critical public health issue because we understand that breastfeeding is really a family matter, not just a personal one. We witness the powerful role of relationships within families and with our practices every day, with every patient.
The ABM has a number of resources to support breastfeeding, just as the AAFP does. One of our resources, the Academy's breastfeeding position paper, is even now being updated as part of a regular evidence review by our Breastfeeding Advisory Committee. That update likely will be published in the fall and will be accompanied by an education campaign aimed at helping to create breastfeeding-friendly family physician offices.
Other resources family physicians may find helpful include the Baby-Friendly USA initiative and its 10 steps to creating breastfeeding-friendly hospitals. Even for family physicians who don't work in hospitals or provide obstetric care, it's still important to advocate on patients' behalf to ensure that that the first exposure during and after delivery reflects strong support for "the first food" and not formula.
It's also worth noting that 28 percent of all medical students in this country are members of the AAFP, so we have a unique opportunity to begin emphasizing breastfeeding benefits early on regardless of what specialty each student eventually selects. Moreover, our residencies are working to become breastfeeding-friendly for our trainees. This new policy is the result of resolutions passed by the 2013 Congress of Delegates that initially were brought forward by our students and residents.
Finally, I was able to share the critical need for all of us to network better with each other. Even in this meeting that focused on an issue of common ground, I still saw evidence of our fragmented health care system. Different groups don't always share as well as they could. This is one of our challenges in these days of advanced communications technology -- we can forget the power of face-to-face discussions. That is one reason I am so eager to say "Yes!" to these kinds of invitations. Nothing can beat actually talking with people in person.
That said, we need to recognize that the mothers and families of today are different, and I challenged everyone at the meeting to get comfortable with social media because it's one more avenue to increase awareness about breastfeeding.
One final note: Just as family physicians were critical to the founding of the ABM, so we are to its leadership now. The current president of the ABM is Wendy Broadribb, M.B.B.S., a family physician from Australia. Julie Taylor, M.D., M.Sc., a family physician on faculty at Brown University, will be taking over next year. I look forward to future opportunities for the Academy to interact and grow together with other stakeholders on this important issue.
Reid Blackwelder, M.D., is president of the AAFP.
Measles and Mumps and MERS, Oh my…
It's not hard for me to remember that it's that time of the year again because my daughters are frequently singing Olaf's song from the Disney movie "Frozen." "When life gets rough, I like to hold on to my dream, of relaxing in the summer sun, just lettin' off steam … in summer."
My family is heading to Hawaii for our summer vacation, and we won't be alone. After a harsh winter in many parts of the country, a busy summer travel season is expected. The American Automobile Association (AAA) estimated that nearly 32 million Americans traveled at least 50 miles by automobile during the Memorial Day holiday alone, and another 2.6 million traveled by plane. It marked the second-highest travel volume for the holiday in more than a decade.
Airlines for America, an industry lobbying organization, projects summer air travel will rise to its highest level in six years. Roughly 210 million passengers are expected to fly U.S.-based airlines from June through August, including a record 30 million passengers traveling internationally on U.S. carriers.
With that summer fun comes some potential risks. Measles remains common in many parts of the world, including areas of Europe, Africa, Asia and the Pacific. For example, the Philippines had more than 31,000 suspected cases of the disease (and 70 deaths) through May 20 of this year.
In an average year, only about 60 cases of measles are reported in the United States. Unfortunately, international travelers are bringing home more than just souvenir T-shirts. This year, the United States has had more than 300 cases of measles -- including 15 outbreaks covering 18 states -- reported since Jan. 1. That's the highest total since public health officials declared the disease eliminated here in 2000. According to the CDC, the vast majority of reported cases (97 percent) have been associated with either foreign visitors or U.S. travelers returning home from international trips.
Meanwhile, the CDC also reports that from Jan. 1 to May 2, 464 cases of mumps have been reported. That total already is higher than all the mumps cases reported last year.
Although nearly half of the measles importations have been linked to the Philippines, other cases imported into the United States have been associated with travel to other countries in Southeast Asia, Europe and what the World Health Organization refers to as the Western Pacific region and the Eastern Mediterranean region.
Measles isn't the only health issue for travelers and their physicians to think about. With new reports of infection caused by the novel Middle East respiratory syndrome coronavirus (MERS-CoV), many of my patients are now concerned about what they otherwise would have thought of as simply a mild cough or seasonal allergies. I, too, have found myself being more diligent in asking about travel history when confronted with patients who present with fever or upper respiratory symptoms.
Although few of us may remember seeing -- much less treating -- measles, even fewer have experience managing suspected cases of MERS-CoV infection. I remember the hypervigilance of our health care community in 2003 after the World Health Organization issued a global alert regarding the severe acute respiratory syndrome (SARS) outbreak, how we masked every patient who presented with cough, how there was a run on local pharmacy supplies of N-95 masks, and how every traveler returning from Asia was screened via infrared cameras on their entry into the United States.
The general public may be lulled into a false sense of security when infectious diseases such as measles, smallpox or polio are eliminated domestically or when a particular outbreak "dies out," as SARS did. It is our responsibility as trusted physicians to remain vigilant about global trends in communicable diseases and outbreaks. It is our role as patient advocates to ensure that our patients are protected from preventable illnesses in this global community. And it is our role as public health defenders to convince those who are reluctant to get vaccinated that it really is in their own best interests -- and the best interests of those around them -- to do so.
But one of the most difficult challenges in my daily practice is to know what advice to give when patients travel to locales unfamiliar to me. So when I ask my patients' their about summer travel plans, I breathe a sigh of relief if they mention some place like Japan or Cancun. But how about a honeymoon trip to Tahiti, the annual Hajj pilgrimage to Mecca, or a medical mission to Haiti?
Well, I recommend a quick search on the CDC's Travelers' Health Web page, which provides the latest information and advisories about communicable disease outbreaks around the world. It also has information -- searchable by country -- for both clinicians and lay travelers about vaccination requirements and other recommendations. You also can find travel tips for patients heading abroad (including the fact that they should be vaccinated at least six weeks before leaving home) on FamilyDoctor.org.
Armed with these invaluable resources, I can confidently advise my patients and protect my community from the latest outbreak of polio in Syria, dengue in Brazil and Ebola in Liberia.
So, when you see your patients this summer, don't forget to ask them about their travel plans.
Jack Chou, M.D., is a member of the AAFP Board of Directors.
White House Invitation Shows Importance, Recognition of Family Medicine
In our advocacy efforts, we often talk about the importance of being "at the table" when important discussions are taking place. The Academy is getting a good seat at that proverbial table more and more often.
Last week, I had the opportunity to represent the AAFP at a White House event for the second time in less than 18 months. This most recent trip was prompted by an invitation to attend the president's Healthy Kids and Safe Sports Concussion Summit, which brought together select medical experts and representatives from collegiate and professional sports organizations to address this serious problem.
|I attended the Healthy Kids and Safe Sports Concussion Summit May 29 at the White House.|
My previous White House invitation stemmed from the first lady's request that an AAFP representative attend a meeting about Joining Forces (a national initiative to support military service members and their families) along with the representatives from the Department of Defense, the Department of Veterans Affairs and other stakeholders. At that meeting, we addressed the challenges of providing care to special groups within our armed services, including service women and veterans needing mental health services.
I'm pleased that the administration is demonstrating an increasing recognition of the critical, foundational role that family physicians play in our health care system. Concussions, traumatic brain injury, mental health and women's health needs are significant health issues. Unfortunately, it is common for legislators and administrators to view these issues strictly in terms of subspecialty services, which can easily lead to fragmented care.
Family medicine is the only specialty that doesn't limit itself based on organ systems, disease groups, specific problems or age of patients. Instead, we are on the frontlines of managing all of these issues in our patients every day. One of the Academy's goals is to help those in leadership positions better understand who family physicians are and what we can provide. The fact that the AAFP is repeatedly being invited to meetings like these indicates our message is getting through.
During his remarks at the concussion summit, the president mentioned that although U.S. emergency rooms see roughly 250,000 children each year for head injuries, that doesn't include the number of children who are taken to see their "family doctor." I appreciate his recognition that family physicians are instrumental in the care being provided to children for such health issues. We are able to address the acute issues of affected children and the appropriate concerns of their families. We can educate these families and discuss how to prevent these injuries.
Perhaps even more important are our relationships within our communities. Family physicians provide numerous community services in many different venues, and 40 percent of our members provide some sports medicine services. Many are right there on the sidelines to educate coaches and teams.
Moreover, the direct connection we have with patients allows us to be there for the challenges created when someone has a severe concussion and its sequelae -- such as post-concussion symptoms and even career- or life-changing events. We are the only physicians with the combination of comprehensive education, extensive training and skills to handle complexity that allows us to care for all of our patients’ needs and help manage the impact on their families.
One of the promises that our officers and Board made to all Academy members was to continue to advocate that we be at the table and, thus, off the menu for such keenly important health care issues. I think we are well on our way in this regard. Our invitation to, and attendance at, these high-level meetings allow us to continue to educate those in health and government administration not only about the need for family physicians to be right at the frontlines, which we already are, but also to be respected in that critical role.
Thank you for all of your service and for all that you do. More and more people are recognizing the important work family physicians have always done, and they are starting to value those contributions appropriately.
Reid Blackwelder, M.D., is president of the AAFP.
Patient Portals: Useful Resource But Expensive Mandate
To spend money on a patient portal, or not to spend money on a patient portal right now: That is my dilemma.
I am in a three-physician family medicine practice. We have no physician assistants or nurse practitioners. Our small practice held off on buying an electronic health record (EHR) system, waiting for the Veterans Administration to release VistA (Veterans Health Information Systems and Technology Architecture) to the public domain. That system initially won many awards when fully supported, but licensing of proprietary modules is required for it to function correctly. Thus, we were forced into the commercial marketplace.
Our path took us to the EHR system that we have used for the past eight years. These have been expensive and emotionally taxing years. Our original trainer, sent by the vendor prior to implementation, gave us some bad information and advice. (Although the company eventually fired him, they still charged us for all the time he spent "helping" us.)
Last year, our server was hacked, causing it to crash. Three weeks and tens of thousands of dollars later, we were back up and running.
We have worked hard and diligently to do the right things. Before the words “meaningful use” even entered our lexicon, we participated with our local Medicare Quality Improvement Organization on a project involving colonoscopy, Pneumovax administration, mammography and flu vaccinations in our patient population. We finished either first or second among the practices for meeting goals set by Medicare.
Meaningful use stage one was our next project, and we successfully fulfilled that government mandate. Meaningful use stages two and three, as well as National Committee for Quality Assurance recognition for transforming to a patient-centered medical home, will be our next projects. All three require upgraded hardware and software, which we acquired after our server crash pushed us in that direction.
We also are considering the addition of a patient portal, which is a requirement of meaningful use stage two. I understand the importance of fluid patient communication, but the cost of complying with this requirement seems steep.
Initially, our vendor was going to charge $5,000 per physician, plus training and a per-use fee. A "use" could include an email, an appointment or a payment received through the portal, and there would be no way for us to limit a patient from inundating us at our expense. That price -- before the server crash, at least -- seemed unfathomable.
The vendor later decreased its asking price by roughly $8,000 to initiate, but the per-use fee and training costs still remain.
What to do? Could we run a parallel program on a free EHR with a free patient portal? Should we spend the kind of money that the vendor is charging? A patient portal has the potential to reduce the number of phone calls we handle, but it also could result in more electronic messages that require responses. Can we, and should we, charge our patients for electronic access to help defer the cost?
What is the return on investment of implementing a patient portal? A Kaiser Permanente study showed that outcomes for patients with diabetes and/or hypertension improved within two months with the use of secure patient-physician email. Another study involving Kaiser patients showed that those who enroll in a patient portal that allows secure messaging with physicians, access to clinical data and self-service transactions are more than two times more likely to stay with a practice than patients who do not use such online resources.
Still, I'd like to hear from my fellow small-practice physicians on this issue. I'd like to hear about your experiences in this brave new world of constant access and costs associated with electronic data. I look forward to learning people’s thoughts and, hopefully, coming to peace with a definitive decision.
Have patient portals helped your practice, and have they been worth the expense?
Rebecca Jaffe, M.D., M.P.H., is a member of the AAFP Board of Directors.
Agents of Change: ACOs Can Reduce Costs, Improve Care, Increase Income
Editor's note: During the AAFP's Scientific Assembly in San Diego, a panel discussion on practice transformation generated far more questions than the panelists could answer in the time allotted. This is the sixth post in an occasional series that will attempt to address the issues members raised -- including questions regarding accountable care organizations -- during the panel.
I recently attended a payment forum where family physicians expressed their frustrations with the existing health care system, as well as their hopes for the future. We discussed the need to repeal and replace the sustainable growth rate formula, payment for telemedicine and much more.
For every success story these FPs shared, there were others who talked about the challenges we face in primary care. It was a mix of dreams of the future and realities of the present.
One of those realities was the potential for change posed by accountable care organizations (ACOs). One physician grabbed the audience's attention by talking about his ACO, a group of about 40 physicians in Austin, Texas, that has negotiated a 5 percent positive payment differential with BlueCross and BlueShield.
Several physicians, in fact, talked of positive experiences with ACOs, which allow family physicians and other health care professionals to band together to pool data, develop best practices and make policy decisions that improve quality and reduce costs, and, ultimately allow them to negotiate contracts with the power of a larger group.
They didn't need to convince me. I'm the medical director and board chair of a fledgling ACO that received its charter from CMS in December. So far, we have nearly three dozen practices and about 50 physicians (mostly family physicians) on board.
CMS is encouraging ACO development by offering shared savings bonuses to participating practices. Those short-term incentives can invigorate and strengthen family medicine practices. But in the long run, ACOs will need to look beyond Medicare to thrive.
My ACO has already signed a three-year contract with Aetna that will pay fee-for-service, plus incentives for quality outcomes and cost savings as well as fees to cover the cost of administering the ACO. We're also in talks with two other large private payers with the goal of negotiating similar deals.
A representative of one of those payers told me his company sees itself transitioning from a traditional insurance model to a business based more on health maintenance. That revolutionary statement indicates that payers understand that fee-for-service is not the concept our future will be based on. Are we finally are on the verge of payment reform in this country?
We grew up with a health care system that had hospitals at the center of our medical communities, but that paradigm is about to shift radically, with primary care becoming the center of the health care delivery universe and hospitals becoming the satellites that orbit medical homes.
People resist change, especially when it doesn't benefit them. Health care and payment reform stand to benefit both primary care physicians and our patients. The need to change has been obvious for decades, but progress previously had been checked by political roadblocks. For the first time in my career, this shift is realistically achievable, and I'm doing my best to make the ACO model work.
So how does a family physician become the head of an ACO? There's no class or training that I'm aware of, so I did a lot of reading and networking and attended relevant conferences.
Maybe you don't want to run an ACO but you're interested in joining one and aren't sure how to get started. I was fortunate that in 2000, my small, rural practice joined an independent practice association, which became the basis of our ACO. Given that my experience might be the exception rather than the rule, I would suggest you look for a physician-owned and -operated ACO. If there are none in your area, look for an ACO that has primary care-led governance built into its operations. If other parties are in positions of authority, that ACO might not share your goals or want the kind of change you hope to be part of.
The patient-centered medical home (PCMH) was another topic discussed at the payment forum, and it's a vital part of the plans for our ACO. Our goal is for all the participating practices to achieve National Committee for Quality Assurance (NCQA) PCMH recognition within the next 12 months.
There has been a lot of concern from small practices about the cost and time needed to achieve PCMH recognition, but it can be done. My two-physician practice achieved Level 2 recognition by working together with other small practices in my area, and we have submitted paperwork for Level 3. Blue Cross and Blue Shield has pledged to provide a 5 percent positive payment differential for practices in our group that achieve Level 3 recognition.
There seems to be little question that fee-for-service is going to become a smaller and smaller part of how primary care physicians get paid in the future. We need to look at all the options available -- whether that be an ACO, direct primary care or something else -- and choose the best opportunity for our individual practices.
Finally, if you are interested in learning more about ACOs, or connecting with AAFP members who are participating in -- or leading -- ACO initiatives, you will be pleased to know that there are a number of family physicians interested in forming an ACO member interest group. At our most recent meeting, the AAFP Board of Directors approved the formation of member interest groups as a way to define, recognize and engage groups of AAFP active members who have shared professional interests. These groups will provide a forum for such members to have a voice in the development of Academy development.
If you are interested in participating in the formation of an ACO member interest group, contact AAFP delivery systems strategist Joe Grundy.
Lloyd Van Winkle, M.D., is a member of the AAFP Board of Directors.
Turn the Page: Saying Goodbye Not Easy for Graduating Resident, Patients
My residency is almost over. By this point in our careers, all graduating family medicine residents have spent four years in college, four in medical school and at least three years (sometimes four) in residency. You might think there would only be elation, joy and relief on the cusp of completing this grueling, 11-year process.
It has been years of 80-hour (or more) workweeks, cafeteria food (if you even have time to go there), missing your kids' school events, missing your spouse's birthday, being that relative who misses weddings, funerals and Mother's Day -- all while struggling to pay the bills. By this time in some other industries, we might have made a fortune by working such long hours, but instead we are in serious debt. Most of us owe more in student loans than we do on our mortgages.
| The bond a patient can develop with his or her family physician is amazing. Here I am with a patient who is interested in following me to my new practice -- more than two hours away.
So why would anyone sign up for the not-so-enticing path I just described?
Three words: the patient relationship.
As a medical student, you get limited exposure to continuity of care because rotations are usually eight weeks long, at most, so the number of repeated contacts with a specific patient or family is limited. Family medicine residency, however, focuses on relationships and caring for a patient across all settings, whether that be at the physician's office, a nursing home, the patient's home, a hospital or a hospice facility.
I've delivered babies and handed them off in the delivery room to a grandmother who is also my patient. Moments like that give you more enthusiasm and energy than a venti coffee ever could.
What I'm realizing as I near the end of my training is that patients get more than quality medical care from our interactions. They develop a bond with us that has far-reaching implications. My patients feel like they know me as a person, not just as a diagnostician. We have conversations about their priorities and how their financial and logistical realities relate to treatment. We grow to understand each other.
I don't think most patients in a residency training program realize how much we appreciate them. They quite literally provide the foundation for our specialty training. Most of us can remember our first patient in the office, our first well-child visit and our first reading of a patient's obituary. We remember the cards and notes patients send us, but most importantly, we remember how they humbled us with their complex medical cases.
I recently added a little spiel to each patient encounter I have about how I will be leaving the program and transitioning them to another resident in July. This conversation fails to get any easier with repetition.
I have had multiple patients cry. Several have stood up and hugged me, and a lot have asked for directions to where I am going next.
Through this process, I have noticed a difference between two groups of patients. Those who I inherited from a former resident (or from generations of residents in my program) smile and say I better pick a good physician to take my place. In contrast, the patients I acquired from the emergency room or hospital and brought to this practice during my residency -- many of whom had never had a family doctor before -- tend to enter a brief panic. I explain that the same attending physicians who have been joining our visits occasionally are still going to be here to precept the residents, that the incoming class of residents is wonderful, and that the same nurses will answer their phone calls. Some of those patients say that they don't want a new doctor, and they will drive the 2 1/2 hours to my new office to see me.
I've heard over and over, 'I've never found a doctor like you,' 'You listen to me,' 'You know my whole family.' They say they like being able to come with their kids to one big, long appointment for everyone. They like to see a face they know if they get admitted to the hospital. And women have told me they want to have the same doctor take care of them during and after their pregnancy and see their new babies.
To all of these cares and concerns, there's really only one reply I can give, and it's a reassuring one: That's family medicine. I am a family doctor, and they will get the same care and have the same opportunities across generations with their next family doctor. I am nothing special within family medicine; it's family medicine that is special.
There are more than 3,000 family medicine residents who will be graduating soon. What tips do you have for other third-year residents who are preparing to say goodbye to their patients? If you've had a particularly gratifying goodbye, please share your story in the comments field below.
Kimberly Becher, M.D., is the resident member of the AAFP Board of Directors.
Ask the Question: Screening for Alcohol Misuse Can Save Lives
I recently returned home from an incredibly inspiring weekend at the AAFP's Annual Leadership Forum and National Conference of Special Constituencies in Kansas City, Mo., but my good mood quickly faded when I found the local Chicago news filled with stories of yet another accident caused by drinking and driving.
A man driving an SUV entered the northbound lanes of Lake Shore Drive headed south and struck a taxi head-on. According to police reports, the man’s blood-alcohol content was more than twice the legal limit.
A young law student who was riding in the taxi died in the crash. She was reported to be an accomplished and big-hearted leader among students, was on schedule to graduate next month and had already received and accepted a job offer.
Sadly, she won't be graduating with her classmates or celebrating her accomplishments with her family. And her story, tragically, is just one of many.
In fact, the World Health Organization (WHO) said in a report released this week that alcohol contributed to 3.3 million deaths -- or 6 percent of all deaths -- worldwide in 2012. That staggering total means that roughly every 10 seconds, someone dies an alcohol-related death. Accidents, including car crashes, accounted for 17 percent of all alcohol-related deaths.
Here in the United States, excessive alcohol use is the third-leading preventable cause of death, claiming roughly 80,000 lives annually. Alcoholic liver disease is the second-leading indication for transplantation in the United States.
So what are we doing about it in our practices?
"Do you drink?" is a question we are trained to ask in medical school, but are enough of us actually asking it? According to the CDC, only one in six U.S. adults have ever talked to a health care professional about alcohol use. That's unfortunate because, according to the agency, alcohol screening and brief counseling can reduce the amount excessive drinkers consume by as much as 25 percent.
Of course, there are reasons why a primary care physician might hesitate to ask the question. Some physicians tend to shy away from questions about substance abuse. Not only can it be an uncomfortable topic, but some practices and communities lack adequate resources for treatment. It's also likely that some patients are less than forthcoming about their struggles.
Health care payers require us, and offer incentives, to ask every patient at every visit about certain other clinical issues, such as tobacco use, pain and asthma. In a health care environment where an office visit may be limited to 15 minutes or less, there are many issues to cover in a limited amount of time.
But considering that excessive alcohol use costs our country roughly $185 billion a year in health care costs, criminal justice expenses and lost productivity, wouldn't it make sense for alcohol use to be just as important a question as tobacco use when taking a patient's health history?
According to the WHO report, 7 percent of U.S. men and 2.6 percent of U.S. women are alcohol-dependent. More than 10 percent of men and more than 4 percent of women have an alcohol disorder, meaning either dependence or harmful use of alcohol. However, only 15 percent of people with such a disorder seek treatment, according to the National Institute on Alcohol Abuse and Alcoholism.
If none of those statistics grabbed your attention, consider that 10 percent of U.S. children live with an adult who has an alcohol problem. So what can we do to help patients and their families?
It's really very simple: We need to ask the question. The AAFP recommends that physicians screen adults for alcohol misuse and provide patients engaged in risky or hazardous drinking with brief behavioral counseling interventions.
Although time certainly can be a barrier during an office visit, there are many simple screening tools that are easy and quick to use. For example, the CAGE questionnaire consists of just four questions. The WHO's Alcohol Use Disorders Identification Test can be completed in as little as two minutes.
Once we've asked that difficult first question, these tools can help us determine whether a patient needs counseling. If your practice isn't equipped to offer counseling, take the time to inform yourself about the resources that are available in your community.
The third-leading cause of preventable death in our country is an issue we can't continue to be silent about.
Javette Orgain, M.D., M.P.H., is vice speaker of the AAFP Congress of Delegates.
Member Interest Groups to Provide Forum to Share Interests, Connection to Academy
I am really energized after attending the Annual Leadership Forum and the National Conference of Special Constituencies(NCSC) last week in Kansas City, Mo. These concurrent gatherings represent one of the most dynamic and innovative events the AAFP hosts.
The Annual Leadership Forum is a great opportunity for chapter-elected leaders, aspiring leaders and chapter staff from all over the country to attend practical and informative sessions and to network. It is one of the keys to helping our emerging leaders at the state level connect with each other and with the national Academy.
NCSC, originally the National Conference of Woman, Minorities and New Physicians, was created 24 years ago because certain member groups were underrepresented in Academy leadership. Over the years, constituencies for international medical graduates and physicians interested in gay, lesbian, bisexual and transgender issues were added.
Delegates write resolutions during the National Conference of Special Constituencies, held last week in Kansas City, Mo. During the event, the AAFP announced new opportunities for family physicians to form member interest groups.
In nearly 2 1/2 decades, NCSC delegates have written many resolutions that have challenged us as an Academy to creatively meet the needs of our members, as well as to improve the health of our patients. This year's conference was no different.
What is different, however, is the next stage in the evolution of this event. Prior to last year's Congress of Delegates, the Board of Directors convened a task force to explore the best way to create value -- including having a voice in the AAFP -- for all members. The task force made a series of recommendations to the Board last week. The Board approved all of the recommendations, and the Academy is moving forward with some exciting changes.
We have member groups with unique needs that are looking for ways their issues can be directly addressed, and a year ago, those members and the Congress challenged the AAFP to do a better job of recognizing the Academy's diverse membership.
The Academy has existing groups representing emergency medicine physicians and rural family physicians that have met for some time. However, our solo and small-practice physicians also are seeking a stronger voice, as are members who practice hospital medicine and those who are exploring direct primary care. There likely are many other groups, some of which we have yet to hear about.
So, here are some of the exciting changes we will see.
Next year -- the 25th anniversary of NCSC -- this annual meeting will again occur in Kansas City, Mo. However, it will be renamed the AAFP Leadership Conference for Current and Aspiring Leaders. The event will have two tracks, the Annual Chapter Leader Forum and the National Conference of Constituency Leaders. The groups will continue to meet in concert. Those of you who have attended in the past know that many of the leadership sessions presented during the forum have been scheduled at times when NCSC leaders also were able to attend. We'll continue this practice, which truly demonstrates our dedication to developing all of our leaders.
We anticipate that these member interest groups will become forums for our AAFP active members to share their mutual interests and address common concerns. We are setting in place a mechanism to begin requesting designation as a member interest group that will allow groups to really focus on what they hope to accomplish. They will be challenged to come up with a name for the interest group, first-year officers, at least 50 active members who support the application, interest group objectives, a description of how the interest group will further the AAFP's strategic priorities and a schedule of proposed first-year activities along with long-term goals.
Each member interest group will be connected with an Academy staff member and with the specific AAFP commission that seems most appropriate for that group.
The groups that presented resolutions 204 and 205 at last year's Congress -- which addressed the unique needs of family physicians in solo and small-group practices -- already have been given information on the application process for forming a member interest group, and we expect them to quickly move forward.
After one year, member interest groups have the option to petition the Board to transition to a member constituency.
Now, please bear in mind that because this is hot off the press, a link to the application is not yet posted online, but we will make an announcement in AAFP News when it becomes available.
Also important to note, a bylaws amendment from the Bylaws Work Group will be submitted to the Congress of Delegates that the member constituency seats to the Congress that currently exist be continued and not be reviewed by the Congress until 2020.
All of these recommendations build on the history of success and innovation that the Annual Leadership Forum and NCSC have always had. I look forward to seeing you in Kansas City next April for the 25th anniversary of this inspiring and energizing conference.
Reid Blackwelder, M.D., is president of the AAFP.
Medical Student Advocates Make Big Impression on Legislators at FMCC
When I sat down at my state's table at the Family Medicine Congressional Conference (FMCC) earlier this month, I was quite surprised to find two of my Quillen College of Medicine students already sitting there.
Melissa Robertson, left, and Jessica White, right, seniors at East Tennessee State University's James H. Quillen College of Medicine, met with legislators from their state -- including Rep. Marsha Blackburn, center -- during the Family Medicine Congressional Conference in Washington.
The AAFP provides two scholarships for students and two for residents to attend this annual advocacy event in Washington, which trains family physicians (and future FPs) to advocate for their patients and for family medicine. The AAFP Foundation also awards a student scholarship, so I thought perhaps these students -- Jessica White and Melissa Robertson -- had earned scholarships to attend. But as it turns out, they decided to make the trip from Tennessee at their own expense because they thought it was an important learning opportunity.
In fact, 55 students and residents from around the country attended FMCC this year. Their spirit and efforts give me great hope for our future.
FMCC provides a remarkable blend of advocacy education and skills development along with the chance to immediately put those learnings into action. On the first day of the conference, we heard from advocacy experts, representatives of federal health agencies, congressional staff and two legislators.
On the second day of the event, more than 200 students, residents and practicing physicians took what they had learned on day one to Capitol Hill to talk with legislators and staff about issues such as physician payment, education and workforce. One of the best parts of this conference is the opportunity to share personal stories with our legislators. There is no question these conversations have a big impact and are one of the reasons face-to-face meetings have such potential to make a difference in promoting our interests.
Legislators and congressional staff hear from the AAFP Board several times a year, but stories from members can be so important because they speak directly to legislators who are elected to represent their state and district and tell them how constituents are being affected by the various challenges family physicians face.
For example, Jessica and Melissa, two seniors who have matched into family medicine residency programs, were able to talk about important education issues during our visits. As we reviewed the key points from the previous day's advocacy training sessions, we realized their presence was especially serendipitous given their paths to family medicine.
Jessica matched in Asheville, N.C., just across the mountains from Quillen. She will join the family medicine residency at the Mountain Area Health Education Center(MAHEC), which is a teaching health center. These centers provide creative approaches to training family medicine residents based in the communities that most need them.
Under the Teaching Health Center Graduate Medical Education (THCGME) program established as part of the Patient Protection and Affordable Care Act, GME funds go directly to the centers. However, the THCGME program, which started in 2011, is only funded through 2015.
The program is now completing its third academic year, graduating its first cycle of residents and sending almost 300 primary care physicians into the workforce. It should come as no surprise, then, that extending funding for the teaching health centers program is one of the Academy's top legislative priorities during this congressional session.
Without such an extension, Jessica's residency program cannot guarantee her salary for all three years of her training. Accepting this offer represents a remarkable leap of faith on her part. It also provided a great example to the people we talked with about the importance of extending funding for these programs.
Melissa is a nontraditional medical student and former elementary school teacher, so she brings a critical, real-world perspective to both medicine and medical education. She came to the AAFP's National Conference of Family Medicine Residents and Medical Students two years ago and got the advocacy bug there. During that conference, she was elected to the Society of Teachers of Family Medicine's Board of Directors and now is serving her second term.
Melissa, who matched to our East Tennessee State University residency program in Bristol, has a real knack for asking common-sense questions that help cut through administrative layers. Her particular path has made advocacy issues such as student debt and the primary care salary gap extremely important in her world.
Together, the three of us considered the day's congressional visits and how to tell these stories in meaningful ways. First up was Tennessee Tuesday, which is a weekly breakfast during which Sens. Lamar Alexander, R-Tenn., and Bob Corker, R-Tenn., welcome everyone visiting from our home state to Washington. They are always excited to meet their constituents and were especially eager to meet these medical students.
Next, we met with Rep. Marsha Blackburn, R-Tenn. Jessica's family lives in Blackburn's district, so this connection immediately lent relevance to our advocacy stories in a way that had not happened in my previous conversations with the congresswoman. Our legislators certainly pay attention to their constituents, and we were able to get some unscheduled time and a photo opportunity with Blackburn.
Moreover, during a subsequent meeting with Blackburn's health aide, we were able to talk about topics in a totally different light because of the students' circumstances. This latter meeting also showed Jessica and Melissa the critical role legislative aides play in setting agendas for elected members of Congress.
We then met with Rep. Phil Roe, M.D., R-Tenn., who represents Quillen's district. Originally, we had been scheduled to meet his legislative aide, but when he heard there were two medical students from his district present, he immediately made time to meet with them. In fact, their stories were so compelling that he asked if we would walk to the Capitol with him because he had to vote, but he did not want to cut short his discussion with Jessica and Melissa.
Jessica’s story about her uncertain financial situation at the residency program in North Carolina grabbed Roe’s attention in a way my previous discussions with him could not, in part, because Christ Community Health Services in Memphis is one of more than a dozen residencies that are expected to start receiving THCGME funds beginning in the 2014-15 academic year.
As a nontraditional student who made a huge financial sacrifice to become a physician later in life, Melissa's story also sparked his interest immensely. He specifically asked her about her medical school debt and how that influenced her and other classmates in their specialty choice.
Roe also took notice when Melissa addressed another of our advocacy points -- the need to renew and increase commitments to GME, such as through Title VII funding, and to consider how we can increase the number of students choosing primary care specialties.
As he prepared to walk to the Capitol, Roe asked Melissa and Jessica whether they would come back to his office after he returned from the vote because he wanted to talk more with them.
After we finished talking with Roe, I left for a media interview and then headed out of town for the Minnesota AFP meeting. By this point, Melissa and Jessica were seasoned advocates, and I knew our messages were in good hands and would be heard in powerful ways. They went on the next visit on their own and later went back to Roe's office.
The three of us texted about the overall experience later, and we made plans to improve how we present the need for advocacy to students and our residents. In fact, Melissa is meeting with the Quillen Family Medicine Interest Group this week to talk about how to prepare for the Academy's resident/student conference scheduled for Aug. 7-9 in Kansas City, Mo. That is the "pay it forward" concept in action.
So, what can you do to pay it forward? In addition to the scholarship opportunities mentioned above, the Association of Family Medicine Residency Directors sponsors 10 scholarships for residents to attend FMCC. But we could do more. Family medicine residencies, departments of family medicine, state chapters and even individual practices can help send students and residents to FMCC. Exposing students and residents to advocacy, a critical part of how we can improve the care of our patients, can pay huge dividends for those FPs-in-training and for our specialty.
Reid Blackwelder, M.D., is president of the AAFP.
Changing the Conversation: What Would It Take to Make Using Our EHRs Truly Meaningful?
During one of the state chapter meetings I attended as a member of the AAFP Board of Directors, I asked participants if they were using electronic health records (EHRs). About 80 percent said they were. Then I asked the group how many of them were satisfied with their EHRs. Only a few hands went up. In fact, I heard some angry comments.
Administrative hassles are hindering family physicians. “Just one more thing,” is a common refrain, with the implication being that if there is one more thing to report or document -- or anything else that gets in the way of patient care -- it could be the “one more thing” that prompts a physician to quit.
ICD-10, the Physician Quality Reporting System, meaningful use -- how much more will it take before family docs just say no?
It's clear the creators of meaningful use had good intentions. The concept was intended to help physicians transition to EHRs. The carrot was financial. The money saved throughout the health care system by using EHRs could be shared with physicians, thus encouraging them to implement EHRs. (With the stick, of course, being a financial penalty for not complying.)
The idea was that going electronic would:
- improve patient care,
- decrease medical errors,
- improve office efficiency and
- avoid redundancy in ordering tests.
Having healthier patients, fewer medical errors, less testing and improved efficiency would net an obvious health care savings. In fact, researchers predicted in 2005 that health information technology would save the country more than $80 billion a year. Yet U.S. health care expenditures have continued to skyrocket due to many factors, including the health IT shortcomings.
So, did we go wrong somewhere?
Interoperability has been, and remains, a major stumbling block despite the Academy's hard work on the issue for more than a decade. Back in 2003, there was a lack of awareness among policymakers and EHR vendors that interoperability was even an issue. So, the AAFP worked with legislators, federal agencies and vendors to get it on their radar.
The AAFP knew standards were needed, so next, the Academy collaborated with other stakeholders to help create the ASTM Continuity of Care Record (CCR), a patient health summary that can be created, read and interpreted by EHRs developed by different software companies. That standard has become part of meaningful use.
As AAFP President-elect Robert Wergin, M.D., of Milford, Neb., recently pointed out in his blog on the topic, when a patient leaves a primary care practice for a subspecialist consultation, the respective EHRs at the primary care practice and the subspecialist’s practice aren’t necessarily able to communicate. This is a barrier to care coordination, and the Academy continues to work with the Office of the National Coordinator (ONC) for Health Information Technology on this issue.
This critical shortcoming is why the Academy was an early contributor and founding member of the direct exchange project, which allows physicians to send secure, confidential emails to other physicians.
Unfortunately, EHR developers have little incentive to change. The ONC recently issued a proposed rule for 2015 that included voluntary updates related to certification criteria, interoperability and regulatory improvements. In a letter to the ONC, the AAFP said that voluntary guidelines would create confusion about what is and isn't required, adding undue complexity to an already complex program. The Academy urged the agency to urge work with stakeholders to create better means than a voluntary certification program.
It seems unlikely that EHR developers are going to fix the issue of interoperability on a volunteer basis. But just think how much more “meaningful” my use of an EHR would be if it could communicate with the EHR of the radiologist or cardiologist across town.
Add to that the fact that many EHRs aren’t user-friendly at all. Documentation and reporting has become cumbersome, and being conscientious about keeping thorough electronic patient records results in less time for patient encounters. In fact, there have been indications that EHRs that satisfy meaningful use and appropriate coding protocols can:
- interfere with patient care,
in mixed patient outcomes,
- increase overall costs, and
- complicate office workflow.
The main thing that electronic records have accomplished is improved billing. But surely this isn't all we want to see come from this investment. We are seeking a system that would improve patient satisfaction and improve patient outcomes. The electronic record is a natural for following patients with chronic disease and surveying your patient population for health concerns.
While tracking specific metrics such as a hemoglobin A1c has improved with use of electronic records, tracking actual improvements in health has not worked so well. What would it take to make this happen?
It is estimated that one-third of health care expenditures overall can be attributed to unnecessary administrative burden. Of that, the time spent doing administrative work and documentation during a patient encounter has been estimated to be as high as 60 percent.
There is a section in the Patient Protection and Affordable Care Act -- Section 1104 -- that seeks to improve these hassles. This "administrative simplification" section was passed by Congress even before meaningful use reporting began. However, the same rules should apply. The section includes operating rules for HIPAA transactions, utilizing a unique identifier and setting up certain rules that would simplify reporting for health plans.
Wouldn't it be great to see a patient and not have to worry about how many bullets are included in the current history of illness? Instead, you could just look at the past medical history as it applies to the patient, review only symptoms that are specific to the patient's problem and pursue only clinical decision-making specific to patient care needs. Charting this way would involve minimal amount of physician time, and patient care documentation would be the purpose. The dual worries of coding and reporting would go away.
My practice is sending one of our physicians to an out-of-town course to become an EHR "superuser" so he can help the rest of us become more efficient in using our system. It seems odd that after years of medical training we need even more training to become IT experts.
Through our state chapter visits and other channels, the members of the AAFP Board of Directors have heard members' concerns -- believe me! We will continue working to ease administrative burdens. We are looking at ways to decrease the number of codes and the complexity of coding. In the meantime, we can all continue to educate ourselves so we can make best use of the current system.
So here's my final question: For better or worse, how has using an EHR changed your practice?
Daniel Spogen, M.D., is a member of the AAFP Board of Directors.
Regional Meetings Offer AAFP Chapters Chance to Share, Learn, Lead
You might already know that each fall, the AAFP's State Legislative Conference offers a national venue for family physicians, constituent chapter leaders and staff to come together to discuss state health policy issues and share best practices for tackling legislative challenges. And during the Annual Leadership Forum each spring -- the 2014 meeting convenes next week, actually -- chapter executives and staff from across the nation gather for leadership training and to trade advocacy tips and other insights with their counterparts in other states.
But what you may not know is that you might be able to find this same sort of interaction -- albeit it on a smaller scale -- within your own region.
I recently had the honor of serving as the AAFP Board of Directors' liaison to the Multi-State Forum in Dallas. There are a number of such events that gather several Academy chapters throughout the year. These events are different from state chapter meetings, but they do have some similarities.
Regional meetings for AAFP chapters offer an opportunity for leaders from several states to come together and share their challenges and solutions. Here I am with California AFP President-elect Delbert Morris, M.D., during the Multi-State Forum in Dallas.
Perhaps the most important thing to recognize is that “All politics is local.” For the AAFP, this means that big impacts start with the state chapters. I encourage each of you to consider how you are getting your messages out, and whether you have considered becoming a more active part of your state chapter to best advocate for your patients, your practice and your community.
Our chapters have many different venues for addressing the kinds of issues that may seem to be unique to individual states. Multi-State is an annual gathering in Dallas of the Arkansas, Arizona, California, Colorado, Iowa, Illinois, Kansas, Missouri, Nebraska, New Mexico, Oklahoma and Texas chapters.
Similar meetings include:
- Ten State Meeting: This event is held in February at rotating sites and involves the Connecticut, Illinois, Indiana, Kentucky, Massachusetts, Michigan, New Jersey, New York, Ohio, Pennsylvania and Wisconsin chapters.
- The Southeast Forum: Held in August at rotating sites, this meeting involves the Alabama, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, South Carolina, Tennessee, Virginia and West Virginia chapters.
- Western States Forum: This forum is meets each year to review resolutions slated to go to the AAFP’s Congress of Delegates and involves the Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, New Mexico, Nevada, Oregon, Utah and Washington chapters.
Typically, chapters select up to five members -- often those involved in leadership positions -- to represent their states at these regional meetings.
Unlike state chapter meetings, CME is not a main focus of these events, although there may be some sessions offered that provide educational credits. The most important aspect of these meetings, however, is for everyone to come together and share. This includes a focus on state legislative challenges and issues. In these sessions, chapter representatives discuss legislation in their states that may impact family medicine or that have been a focus of their chapter's advocacy efforts, including bills the chapters supported and those that generated concern.
Right now, many topics dominate our discussions nationally, such as physician payment, graduate medical education, malpractice and scope-of-practice issues. What is interesting is that at these group meetings, these issues are seen quite differently depending on the state that is presenting about them.
From my perspective, the most important benefit of these gatherings is the opportunity to share best practices. Most of these sessions offer a chance for chapter representatives to talk with one another about what successes they have had in different arenas. One of the biggest challenges for our national organization is how to help connect the chapters. In one important way, we need to make parallel in our organizations what we are asking for in our advocacy efforts. And we need to be sure that we are not duplicating our efforts. The more we can share opportunities, solutions and processes with each other, the better off we all will be.
Some of the other benefits of attending these meetings include the presentations they involve. For example, at Multi-State, we heard from Marci Nielsen, CEO of the Patient Centered Primary Care Collaborative, as well as our own Shawn Martin, AAFP vice president of advocacy and practice advancement. These speakers provided an outstanding framework for some of our discussions. In fact, these discussions preceded a recent JAMA article on the patient-centered medical home (PCMH) that suggested that the PCMH may not produce the outcomes we hoped for. However, we had a chance to consider more recent data than what was included in the article. This demonstrates the ability of these meetings to be on the cutting edge of important discussions.
These meetings also offer an opportunity to meet leaders from around the nation. Many future AAFP Board members and national officers saw some of their early involvement at these meetings and were able to hear the critically important broad view of issues that national leadership requires. But it is also important to note that the representation at these meetings often includes members who may not attend national meetings. These are state leaders who are essential to the function of our chapters. When I go to these sessions, I often meet people who are part of the national delegations, or who come to other national meetings; however, I am also blessed to meet many other family physicians who are working hard in their state chapters to make a difference for their patients, their state and their member colleagues. Ultimately, I leave these meetings feeling energized and optimistic about family medicine.
I am hopeful that you will discover the opportunities that are available to make a difference. Of course, you are involved now as you provide care for your patients and negotiate the challenges that you face every day. But I hope you realize there are also opportunities at the state chapter level to get involved beyond your practice. Step up and contact your chapter executive and move forward in your local leadership. From there, the next step as a chapter leader is to come to some of these larger gatherings where you can work with other family physicians to change things for the better. I look forward to seeing you at one of these meetings.
Reid Blackwelder, M.D., is president of the AAFP.
Tedious Paperwork, Government Regs: Why I Still Love Being a Physician
Today I had a busy day with a full schedule of patients. I struggled to chart my patients' complex histories in an electronic health record that has given me none of the efficiencies it promised.
I lost my lunch break to an administrative meeting, leaving me no time to get caught up from a hectic morning.
I filled out prior authorization forms for medications that a patient has already been on for six months. I completed more forms and insurance paper work than I care to remember and bemoaned the low reimbursement we are being paid for our visits.
I came home hoping to squeeze in time with my family but knowing that I also had hours of catch-up charting to do.
|When I left clinical medicine for a year, I discovered that I wanted, and needed, to come back.|
This is a typical day for me, and I'm sure other physicians can sympathize. There are a lot of reasons to feel frustrated as a doctor right now, and a recent article written by an internist in The Daily Beast outlines how difficult the job can be at times.
But I still love being a doctor, and -- despite the challenges, the paperwork and the burdensome regulations -- I know I'm not alone.
Next month will mark 10 years since I finished medical school and started my journey as a family physician. After residency, I worked at a federally qualified community health center, seeing patients from a wide range of cultural and socioeconomic backgrounds. It often seemed like my patients' problems were bigger than my prescription pad because I couldn't cure the poverty that was at the root of their medical conditions.
I thought I could do more for my patients outside of the examination room than inside, so I left clinical medicine. I spent a year in the federal government as a White House Fellow. In one sense, it was a breath of fresh air: no insurance forms, no call, no charting or EHRs and no worries about whether or not the sustainable growth rate (SGR) was going to be fixed. In addition to gaining a better understanding of how the government works, I also had the opportunity to work on issues such as breastfeeding, hunger and poverty at a national level.
When I started the fellowship, I didn't know if I would return to clinical medicine, but it didn't take me long to realize how much I missed seeing patients. I found myself seeking out clinical experiences, asking anyone with the sniffles if they had other symptoms or if they were taking any medications.
After a year away, I was excited to jump back into patient care. Providing primary care to patients is truly my calling.
I have to admit, I'm a glass half-full kind of person. Although I recognize all of the problems we face in medicine, I also see so much to be excited about.
The Daily Beast columnist pointed out that the majority of medical students typically pick high-paying subspecialties. She also wrote that primary care physicians are the janitors of the medical profession. How nice. The fact is that the number of medical students choosing family medicine has increased for five years in a row, and the number of U.S. medical graduates picking our specialty also is increasing.
It's true, however, that payment -- one of the AAFP’s top legislative priorities in Washington -- remains an immense challenge, both to our practices and to building student interest in family medicine. In a recent MedScape physician survey, family physicians ranked near the bottom of the physician salary scale, yet we had one of the most positive responses when respondents were asked if, given a chance, would they would chose a career in medicine again.
So what do we have to be optimistic about?
I am encouraged that for the first time there is a bi-partisan, bi-cameral proposal for a long-term SGR fix. (Congress hasn’t got the job done yet, but there is still hope.) And CMS, with input from the Relative Value Scale Update Committee (RUC), continues to address overvalued procedures, which shifts money within the Medicare fee schedule to other services, including those commonly done by primary care.
Last year, CMS created two new codes to cover transitional care management, and next year the agency plans to add a code for chronic care management. These new codes should benefit primary care physicians.
I also am hopeful about the prospect of alternative payment models that may actually reimburse physicians based on the value of care that we provide and not the number of people we see (a backwards system that incentivizes physicians to do more and increases medical costs). In addition, more and more practices are operating outside of the insurance framework altogether by providing direct primary care. This option is affordable to patients and puts the patient back in the center of the cost equation.
I am intrigued by the fact that technology and telehealth have the potential to revolutionize how we see patients and provide comprehensive care. Patient portals and virtual medical visits offer opportunities to reduce office visits and increase patient satisfaction.
It has been a joy to see so many patients who are now able to access care with me because they have insurance through the Medicaid expansion created by the Patient Protection and Affordable Care Act.
And for all of the political drama that health care reform has created, it also has opened up a real conversation about the strengths, weaknesses and future directions of health care in the United States for the first time in decades.
But the real reason I still love being a doctor is my patients. So although I could look at today as a tedious mess of charts, forms and administrative haggling, instead I see it as a tapestry of patient experience. I will soon forget the paperwork, but I won't soon forget talking with my patient as we learn her cancer may have returned, or congratulating my patient who lost 20 pounds and dropped his cholesterol by 50 points, or helping a couple start the process of adoption after a long battle with infertility.
In the Medscape survey, the average salary of all physicians was more than $200,000. Eight subspecialties had averages of more than $300,000. Yet when asked what the most rewarding part of their jobs was, only 10 percent of physicians cited money. The top response was "being good at what I do" at 34 percent, followed closely by relationships with patients (33 percent). "Making the world a better place" was third at 12 percent.
So what do I say to physicians who are burned out or dissatisfied? Perhaps it's time to look at other job options? Or maybe it's time to just take a break. When I left clinical medicine for a year, I discovered that I truly love it. It confirmed for me that I wanted, and needed, to go back.
But to do so, I had to do it in a way that was sustainable for me and my family and still allow me to enjoy patient care. That decision sparked my interest in joining the AAFP Board of Directors because I want to help make the world of medicine better for family physicians.
The profession of medicine truly is a calling to help others. I came into it knowing that sacrifices would occasionally have to be made and that patients would often have to come first. If one is in it for money or accolades, he or she likely will be disappointed. I find joy in being able to help my patients navigate their lives in sickness and in health so that they can get back to the joy of living.
Kisha Davis, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.
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