Taking some of the pain out of pain management
A new law went into effect here in Washington state this week – a law regarding requirements and safety checks for prescribing chronic opioids for patients. I was surprised to learn that our state has one of the highest death rate from prescription opiates, and that of all the opiates methadone appears to be the worst.
When the new law went live on Monday, we were already in compliance. Knowing that the law was coming, our primary care department, and our clinic in particular, have been developing a system to deal with the new requirements and have been trying it out for a few months. As with everything else we do, we knew this needed to flow and to have a sequence that everyone follows in a standard way.
We started with the requirement that all providers do CME or other self-study program on the latest evidence-based recommendations for chronic pain management. Some of us have done the AAFP modules on pain management, and our organization is sponsoring a whole day CME event on the topic this month; that program will include the specifics of the Washington state law as well.
Fortunately, the specifics of the law seem to follow evidence-based guidelines. It requires regular (at least annual) visits for each patient to review the risk for addiction or abuse, to discuss the "contract" or agreement about the prescriptions and the rules, do a drug toxicology screen and an assessment of function and pain control, and to provide education about the medications and screening for side effects.
Our system as it is evolving is for our staff and our central pharmacy (which helps with refills and chronic medication monitoring) to note when patients are due to be seen to get refills for chronic opioids and to have the patient scheduled for a linked visit with our clinic pharmacist and the MD. Our schedulers, RNs and MAs as well as the pharmacists are on board to do this scheduling piece correctly.
When patients arrive for the visit, a medical assistant takes them to the lab for a point-of-care urine drug screen and then rooms them with vitals. We've developed a standard rooming template for the visit, which is imported into the record and prompts staff and physician to follow protocol.
The pharmacist then goes in with the patient to do most of the visit and fulfill most of the requirements. By the time the pharmacist is finished, the urine screen is ready, and the pharmacist does a hand off (preferably in front of the patient, but at least in person), noting any red flags and recommendations and giving the results of urine screen. Before the doctor enters the room and reviews the pharmacist's recommendations and the drug screen with the patient, if no changes are anticipated, the doctor gives the go ahead to the pharmacist to ready and print the prescription for 3 months (if that's the interval approved) and have them ready for him or her to sign by end of visit.
What I really like about this so far is that patients are all getting the same good quality review and care, and I can spend a little more time with the patient going into some depth about comorbidities with the pain and medications. Our pharmacist is so good at this that I can take her recommendations and, after some discussion with the patient, make a meaningful decision about continuing or changing the therapy.
I'm sure we will continue to refine the process with repeated PDSA cycles and change as we learn, but it's far more organized than what we've done in the past. The worst scenario in the past tended to be when a patient on chronic opioids also had depression or another chronic condition, and we would try to address everything in one visit. Now we devote the entire visit to the pain management and can decide if it's once a year or more often, depending on the patient.
Coping with incoming patient records
When I started practicing in 1991, the cry was that insurance companies were requiring too much paperwork and that it wasn't adding value to the patient's care. But even without that, we would always have to deal with patients' questions after the visit and their calls between visits, with lab and test results, and with prescription refills. Now, in a primary care medical home model, we are the providers 24/7 in an continuity of care spectrum, and we have to learn how to handle that kind of practice. We used to say "I sell my knowledge and training, and everything requires an office visit." We now need to have visits only for those things that need face-to-face time and the laying on of hands for an exam or for comfort and condolence.
In our practice, we define all the work we perform outside the visit as indirect care. That includes prescription refills, answering questions by phone or e-mail, handling faxes, reviewing lab results, going over outside medical records and specialist consultation notes, completing forms, reviewing physical therapy notes and nursing home requests, and anything else we deal with that's outside the "face-to-face" encounters.
My primary care colleagues and I have spent considerable time and resources, using "lean" methodology, to determine how much indirect care each of us has every day and to work out ways to incorporate that into our daily work and avoid huge batches and backlogs. We found that the average is, at a minimum, 110 pieces per day. Holy crap, Batman!
This is why many primary care doctors work 2-4 hours into the evening, take work home, come in early, work on weekends or just plain get behind. Of course, getting behind results in repeated calls from patients and various other sorts of rework, and it results in dissatisfaction for all – patients, physicians and staff. In some instances, of course, it also delays crucial care or response to really bad results.
I'm going to be writing a few entries about how we deal with the indirect care in my clinic. Today, I'll start with how we handle outside medical records that arrive in our mail room. The sight of these wasteful tomes, and the thought that I would have to comb through pages and pages of single-sided print to glean the numbers and other nuggets of information I need, used to fill me with dread and loathing. We don't scan outside records into our EHR, so we have to selectively enter important information into the Health Maintenance Module – the outside labs and the problem and allergy lists, as well as any important results summaries and recommendations.
Currently, when a new patient's records arrive, one of our medical records/customer service reps (CSRs) goes through all the paper to reconcile the problem list, take any data on health care maintenance (preventive care dates and results), and where there is simply a consult note from a specialist, take the assessment and plan. The CSR then enters all this into the EHR. Then the paper records come to me with a top cover and I go through and highlight with yellow marker anything else that should be entered. I can generate a message for the patient if follow-up is needed. We have been trying this with our internist/geriatrician who receives way more than her share of this on complex patients who have moved to our community to be near their adult children. I am finding this to be very streamlined and can keep up on a daily basis, instead of adding the piles of paper records to bigger piles of things waiting for a time when I can finally peruse them.
I'm wondering how those docs who actually just scan all this in are doing. I would hate to see all the wasted data in those pages perpetuated in our system. For now, I prefer this information mining and documentation. Until the day when patients actually get their records exported to a flash drive from wherever they receive care, or have a web portal where all their information is collated, we're doing incremental improvements.
How do you handle incoming records in your practice? Have you found ways to ingest all that information quickly? If your practice scans the paper, I'd be particularly interested in hearing your rationale.
Stay tuned for more on the flow of indirect care.
Practicing without a safety net
We had a partner leave the practice this summer. We are looking for the right person to hire, and in the meantime, we're sucking it up, the way we all do when we're short-handed. We're committed to great access, so this has meant adding in a bit of time here and there and using our e-mail and other team resources (pharmacist, RNs) to help deliver care without visits when appropriate.
We've maxed out our flow system of doing indirect care while also doing patient care (more about that in my next post). But I can only imagine what it would be like if we didn't have a flow system at all, and if we didn't have such dedicated staff members – staff members who are cross-trained to do so many things.
But I don't want to whine because despite the temporary strain, I still love going to work.
Something else weighs on me more: the state of Americans' health coverage. Yesterday, Saturday, I saw a middle-aged guy with asthma who hasn't been able to afford his steroid inhaler and who has no insurance. He doesn't qualify for low-income programs because somehow his unemployment benefits put him over the line. So he's been suffering an asthma exacerbation for a month.
Next I saw a 30's something guy who had lacerated the tip of his finger cutting aluminum with a saw. As I finished up the sutures, lining up the cuticle and nail borders, he asked, "Any idea how much this is going to cost?" He has a decent job but no health insurance coverage.
It's a kind of encounter I'm having two or three times a day, and I'm not in the inner city or a rural, underserved, economically depressed area. I can get many patients covered by our own organization's "charity care" plan for full coverage. Some we can get on the Washington State Prescription plan for affordable medications. It takes me back to my residency in a clinic that served Hispanic and other underserved immigrant populations. I learned a lot about social work then, and we had a part time social worker, so doing this several times a day didn't faze me. But that was 1990 at the SeaMar Clinic in Seattle. This is now.
We've been hard at work aligning tasks for all staff members and getting ever closer to the point where physicians do only physician work – as witness our ability to absorb the work of a departed colleague with minimal pain – and here I find myself needing to direct a bit of social work. Thankfully we have a local nonprofit social work organization that helps immensely.
But really, back to the guy with asthma: how can it be that there are no generic steroid inhalers that a person with no insurance can afford when that alone could keep him out of the office and the ER?
Supporting your support staff
The New York Times web site recently carried a blog entry about medical receptionists and the important role they play in patient care and the emotional well being of patients. It made me think how, years ago, we decided to train all our behind-the-scenes, downstairs medical records people to be customer service representatives, which is the role in our practice that includes reception. We took a dedicated group of staff that had never had direct patient contact, always working behind the scenes, and brought them to the front lines. They received extensive training (and still do!) in computer skills, telephone skills, making appointments, coordinating referrals, helping the physician/MA teams manage patient e-mail and phone requests, and handling frustrated, angry or just plain sick people one on one. Most of them have continued as customer service reps – an advance in level and pay grade as well as title – and they have continued to grow in skills and confidence.
The importance of training reception staff in people skills can hardly be overemphasized. The staff in our practice has evolved in this, and they do a terrific job. But at first it was like throwing them to the wolves. The job description needs to include this human element, and the training should be done before they ever sit on the front line. We all know that how you are greeted at the door of someone's home (in this case, their medical home) sets the stage for the entire visit.
One of my colleagues from the TransforMed National Demonstration Project was telling me about his receptionist, who was very smart, eager to learn and take on new responsibilities, curious and organized. He said he wished she was a nurse or MA. I asked him why he didn't create a new job description and title for her and train her to do everything she was capable of. At the end of that day, he was going back to give her a new job, title and raise! Practice and staff and patients benefit when staff members are trained and employed to the peak of their abilities.
The fourth of July parade
This past weekend, our practice had many team members participate in our community's annual Independence Day parade and street fair. Twenty years ago, there was little team spirit for this kind of thing, and if the doctors didn't sponsor and participate nothing happened. Now our team morale is so great that for the past few years, staff members volunteer every year to take on recruiting and organizing our participation in different events. Volunteers also come forward to organize us for the annual MS walk, Relay for Life and community health fairs. I've been reflecting on this and how amazing it is to have staff that enjoy their work, co-workers and community enough to volunteer their time and to cheerlead the rest of us into participating as well.
More than ten years ago, we had nurses who voted to unionize. After several years that issue was laid to rest. There have been many changes in staff personnel since then, but the biggest change is that we began actively showing our appreciation for staff by training them to their highest skill levels, offering advancement and more training, thanking them, sharing patient satisfaction data with them, showing them how they make a difference, and making sure that their work is relevant, valuable and obviously beneficial to patient care. Staff are so used to things changing regularly now (i.e., changes that make their work better and more valuable and changes that are well thought out as standard work), that change no longer leads to fear and low morale.
It's a nice place to be, and we have the tools and processes for continuing to manage our employees this way. I'd be happy to discuss our approach with anyone who has morale problems or change management issues.
Reluctantly and skeptically, our group launched into Advanced Access in 2000. Many in the group didn't think it was possible for us to achieve or applicable to our practice. The rest of us worried that working down the backlog would be too painful. One year into the process, a colleague came to my office and said "this doesn't work for an internist's practice – anywhere in the country!" But we were asked to take a huge leap of faith and jokingly talked about it in AA terms: "I am a schedule control freak, and I am powerless to control the scheduling of my patients."
At the time, I was the only female doctor in our practice, and over the years I had gotten to the point where my patients had to wait 3 months for a preventive care exam and 2 to 3 weeks for an appointment. My practice was closed to new patients. I dreamed of the day my patients could get in when they wanted or needed to but had never experienced that freedom – freedom from messages like "Could you work so-and-so in? and "Needs to get in sooner," and freedom from patients saying things like "Well, when I made the appointment it was for X, but that's gone, so today I want to talk about Y," and "I can't ever see you when I'm sick." And the lists they brought to visits were so long! Of course, the three-week wait gave them time to write down a lot of questions.
Now I'm in my 11th year of advanced access. I was reflecting the other day on what it really means. It is so much more than having some openings in the schedule every day. Being part of the TransforMed NDP, and trying to create a truly patient-centered practice, I had had to broaden my concept of access to include ways of meeting patients' needs other than through office visits.
Yep, that meant e-mail, phone calls, team members such as pharmacists and RNs who could help with chronic disease care, and highly trained MAs who could take care of things that didn't need a doctor visit. My focus in leading our group was to require an office visit only if the patient preferred it and/or the problem required an exam or face to face discussion of a serious or complex matter. We realized that nothing but the office visit was reimbursed, but our organization supported us for several years in trying innovative ways to do this. We're now trying some pilot programs with insurers to reimburse for care rather than visits for certain conditions (diabetes and depression, first off).
I wish I could say that I get home earlier every evening (I don't) or that I'm less tired at the end of the day (I'm not). But the practice is much more enjoyable and rewarding, and I've been open to new patients for 2 years now. There is much satisfaction in seeing patients when they are sick or injured (that is, when they need to be seen!); in meeting new patients; in being able to communicate with patients through e-mail; in having RNs who co-manage patients with diabetes, patients with depression or CHF, and post-hospital visits; and in having a pharmacist who can see and manage patients for hypertension and lipid or insulin follow up visits. As part of our access commitment, we have highly trained schedulers, who can also order the pre-visit tests needed for the visit. We have amazing communication between front desk to back office.
Working as a team in flow all day has made this, my 20th year in practice, a very rewarding one. Which led me to reflect that having same day available appointments is just the tip of the Access iceberg. The depth of the practice improvement that comes with it is enormous. We work at it constantly, it is ever changing and always in progress.
Good luck! It's a great journey.
The making of a GREAT medical assistant
I am a female family physician in my 20th year of practice. During my first 6 years of practice, I had one RN who worked with me – the same one every day. Subsequently our practice has hired medical assistants (MAs) to work with the physicians and RNs to do chronic care management, wound care, RN procedures and patient education and to help the physicians manage their panel of patients with chronic conditions or frail health status.
I used to firmly believe that I needed the same MA all the time (except for sick or vacation days) to create a great system and strong patient relationships. I've noticed in the past year, however, that things have been utterly smooth and pain free even with MAs rotating through. Recently I've been struck that almost every single patient (20-24 per day) comments on how much they liked the MA, how great she was, how helpful, confident and professional she was, and what great humor she showed. Though I generally work with the same MA, this occurs on days when other MAs float through as well.
When I have presented our team-based practice model at national meetings, I've heard many physicians say "well, we all know that getting a good MA is about one in a thousand" or "how do you find good people like this? We can't get them where I practice."
I know from experience that, over a decade ago, before we had any standard training and professional development programs for MAs, some physicians in my own practice accused me of always taking the good people so that my team's morale was high and the team efficient, and theirs not.
So why are our MAs so great? They almost all have come straight out of their 6 month training programs, done an externship with us and then stayed on. So it's not years and years of experience.
We have developed a training program for MAs that delves step by step into "standard work." (I will elaborate.) While they are externs, they follow one of the competent, established MAs awhile then start to do some of the basic routines. Once hired, it's the same, except that they are doing the work with coaching from the MA trainer. They all have the standard work manuals, which are like checklists. Whenever new standard work comes out, it is taught to all MAs and physicians so that both know how a new bit of work will flow.
The MAs and physicians are side by side in "flow stations," which we created out of what were physician offices. This allows enhanced communication, hand offs, feedback (both ways), and reinforcement of standard work. The MA/physician dynamic duo has never been so strong!
But that's just part of the answer. I will just briefly let you in on a secret we've found. The standard work lists, which include such things as this sequence:
- Take labels for patient visit and apply to the fee slip.
- Walk to the lobby and call the patient by formal name.
- Wait for the patient and walk with them (not far ahead) to the exam room.
- Help them be seated, hang up coat, relax. Greet formally and explain that before the visit with physician you will be updating their prescription lists and health care maintenance.
- Wash hands. [And there is detailed training on hand washing as well.]
- Open the EMR, explaining to the patient that you are accessing their online chart.
- Click on Medication Profile, and update their prescription and OTC meds.
- Click on Health Maintenance Module and see what's due. Discuss with patient to verify it's correct. Check off the items due on the patient visit work sheet; fill out any lab orders that are due.
- Then open the Ad Hoc for vital signs.
- Take patient's BP, Pulse, height and weight (if appropriate), and temperature or SaO2 (if appropriate)
- Wash hands.
In training this way, each MA develops an automatic sequence for rooming, which gives them great confidence, and the ability to interact warmly with the patients. They know what they are doing, they KNOW their job and don't get criticized by physicians for not doing it their own way.
Knowing their job, knowing all the steps, knowing why it's important and valuable and knowing it improves not only the patient's care and satisfaction but the flow and time of the physician in the visit gives our MAs a degree of confidence and freedom to establish a human touch that is simply amazing.
I thought of an analogy. Anyone who's ever bought a new car or rented or borrowed a different car faces a similar set of issues. How does the ignition work? How do you turn on the wipers and the lights? How does the climate control work? How do you open the trunk or the hood? Where is the gas tank opening to fill it? How does the seat move, how do the windows open, how do you lock them? How does the seat belt work? I've felt like an idiot in some cars when I can't figure out how to turn on the lights or wipers driving in traffic, even though I'm a completely competent driver. Taking time to go through every step and actually perform the tasks until it becomes automatic is key. That's standard work.
This reminds me also of learning to play the guitar. The necessary motor skills are learned in tiny increments before one can play a chord or finger pick. It's attention to detail that allows all of us to be competent at a job or avocation.
By the way, we have done the same thing with RN work, diabetes care management and physician flow through the day. In fact, we create standard work for anything new we implement. And everyone has to go through hand washing training and audit, step by step.
All this just came to me as I was reflecting on my patients commenting on how delightful my MA was, no matter which MA I'm working with. She is; they all are, and they've been allowed to blossom because they know that what they do is correct, standard and valuable.
Welcome to Flow
“Flow is completely focused motivation. It is a single-minded immersion and represents perhaps the ultimate in harnessing the emotions in the service of performing and learning. In flow the emotions are not just contained and channeled, but positive, energized, and aligned with the task at hand” (Wikipedia).
The hallmark of flow is a feeling of spontaneous joy, even rapture, while performing a task. Colloquial terms include being present, staying on the ball and “keeping your head in the game.” Read this blog for how this applies to practice in the medical home.
The focus will be on teams, harmonious coordination of patient care, the benefits to patients, staff and physicians, tools for achieving flow, lean thinking, and my musings from daily experiences in this regard.