Primary Care Medicine: Principles and Practice https://www.nytimes.com/video/business/100000005421 370/iphone-10th-anniversary-destroy.html The Present and Future of Primary Care: Optimizing Joy, Quality, Equity, and Payment Coleen Kivlahan, MD, MSPH Primary Care Medicine: Principles and Practice 1 Primary Care Medicine: Principles and Practice 2 The Present Burnout high but stable Practice and Care Redesign Experimentation Time to Vote EHR use for asynchronous and telehealth visits PC Shortage Collection of Social Determinants data Primary Care Medicine: Principles and Practice 3 Primary Care Medicine: Principles and Practice 4 1 10/11/17 Leading Together in Primary Care: Learning Lab
It’s Not Just Us What is Burnout? Overall prevalence of burnout was 41% Rates of burnout in our teams : physicians (49%), nurse care managers Exhaustion, depersonalization, low sense of (42%), MAs, LPNs (32%), and admins (36%) accomplishment Clinicians and staff are more likely to suffer burnout when we are part of under-staffed teams with frequent turnover , and when we have an over-capacity patient panel . Nearly half of all U.S. nurses and physicians Burnout prevalence was 30% lower for those working on fully staffed teams with no turnover and caring for an appropriate panel compared Contributes to lower patient satisfaction, worse patient other practices. safety, more likely to leave jobs, take sick leave, depression and relationship problems Helfrich CD et al, The Association of Team-Specific Workload and Staffing with Odds of Burnout Among VA Primary Care Team Members. JGIM July 2017 32(7): 760-66 Primary Care Medicine: Principles and Practice 5 Primary Care Medicine: Principles and Practice 6 Is There A Common Denominator? How Do we Fix It? System fixes: Germany, U.S., UK, and Swedish primary care doctors report higher-than-average levels of dissatisfaction Burnout improved with workflow interventions , and with targeted QI compared with other countries. projects . The vast majority of primary care doctors in the world are satisfied with their practice and income , but frustrated with administrative burden and insurance hassle. Interventions in communication or workflow lead to greater Dissatisfaction is far worse in countries with improvements in clinician satisfaction, and with a trend toward lower multipayer private insurance systems intention to leave. Linzer, M. A Cluster Randomized Trial of Interventions to Improve Work Conditions and Clinician Burnout in Primary Care: Results from the Healthy Work Place (HWP) Study. JGIM Aug 2015 30(8): 1105-11 Osbonr, R. Primary Care Physicians In Ten Countries Report Challenges Caring For Patients With Complex Health Needs. Health Aff December 2015 34( 12): 2104-2112. Primary Care Medicine: Principles and Practice 9 Primary Care Medicine: Principles and Practice 8 2 10/11/17 Leading Together in Primary Care: Learning Lab
Resilience to Burnout JOY HAS TO BE OUR PRIORITY Reasons we practice medicine: patient interaction and the intellectual Addressing burnout is necessary, but not sufficient. challenge Deploying curiosity is an opportunity with each patient We all believe that health is more than the absence of disease. Curiosity (continuous learning) is sensed by the patient and family, leading to improvements in both patient and physician satisfaction Well, joy in work is more than the absence of burnout. Curiosity, mindfulness and reflection, as daily renewal behaviors, may Joy in work is a shared responsibility at all levels of our organizations. constitute an effective antidote to burnout. Schattner, A. Measuring Burnout in Primary Care Staff. JGIM Aug 2015 30(8): 1062 (IHI President and CEO Derek Feeley Aug 2017) Primary Care Medicine: Principles and Practice 7 Primary Care Medicine: Principles and Practice 10 Proposal for New Quality Measurement in PC § Quality goals should use target ranges, not rigid targets § Include metrics that capture avoidance of excessive testing or treatment § Include attributes of primary care associated with better outcomes and lower QUALITY AND CARE REDESIGN costs (continuity, comprehensiveness) § Less emphasis on patient satisfaction scores and instead use patient-centered outcomes, such as days of avoidable disability § Peer-led qualitative reviews of patterns of care, practice infrastructure, and intrapractice relationships § Young, R et al. Ann Fam Med 15: 2(175-182) March/April 2017. The Challenges of Measuring, Improving, and Reporting Quality in Primary Care. 12 Leading Together in Primary Care: Learning Labs 3 10/11/17 Leading Together in Primary Care: Learning Lab
Practice Redesign Primary Care Medicine: Principles and Practice 13 Primary Care Medicine: Principles and Practice 13 Primary Care Medicine: Principles and Practice 14 Primary Care Medicine: Principles and Practice 15 4 10/11/17 Leading Together in Primary Care: Learning Lab
Observing Physician Time Use We Spend More Time Online In a study reviewing over 31M EHR transactions 2011–14 by 500 PCPs on 750,000 patients’ EHRs Another study: 4 specialties (FM, IM, Card, and Ortho) in 4 states (Ill, NH, VA, WA). 57 doctors observed for 430 hours Doctors logged an ave. of 3.08 hours on F2F office visits and 3.17 hours on desktop medicine daily. Physicians spent 27% of their days on direct clinical face time with patients and 49% of their time on EHR and desk work. Desktop medicine=patient portal messages, prescription refills or medical advice, ordering tests, sending staff messages, and reviewing test results. In the exam room: 53% on direct clinical face time and 37% on EHR and desk work. Over the study years, there was a decline in the time allocated to F2F visits, and an increase in time For every hour physicians provide F2F time with patients, nearly 2 additional allocated to desktop medicine. hours is spent on EHR and desk work within the clinic day. Staffing and scheduling in the physician’s office, as well as provider payment models for primary care practice, must account for this new work. Outside office hours, physicians spend another 1 to 2 hours of personal time doing additional computer and other clerical work. Tai-Seale, M. Electronic Health Record Logs Indicate That Physicians Split Time Evenly Between Seeing Patients And Desktop Medicine. Health Affairs April 2017 36(4): 655-662. Sinsky, C. Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann Intern Med Dec 2016 165(11): 753-760. 17 Primary Care Medicine: Principles and Practice Primary Care Medicine: Principles and Practice 16 19 Primary Care Medicine: Principles and Practice 20 5 10/11/17 Leading Together in Primary Care: Learning Lab
Telehealth Three types of services: store-and-forward (asynchronous communication), real-time video (synchronous conversation), and remote patient monitoring. Wearables Primary Care Medicine: Principles and Practice 19 Primary Care Medicine: Principles and Practice 20 Do Patients Like Televisits? Do Video Visits Cost Less? RAND study: commercial claims data on over 300,000 patients from three Interview study with adult patients following video visits with their years primary care clinicians at a single academic medical center. Total annual spending (costs to insurers and out-of-pocket payments by All patients reported overall satisfaction with video visits, with the patients) was $45 more/patient for people who used telehealth to treat acute URI than it was for F2F visits for the same condition. majority interested in continuing to them as an alternative to in-person visits. WHY? 88% of the telehealth visits represented people who would not have gone to a doctor otherwise ( NEW utilization ). Primary benefits were convenience and decreased cost . Some Only 12% of the telehealth sessions , the researchers concluded, patients felt more comfortable with video visits than office visits and amounted to a substitute for seeing the doctor . preferred to receive future serious news via video visit, in their own supportive environment. Ashwood, JS. Direct-To-Consumer Telehealth May Increase Access To Care But Does Not Decrease Spending. Health Aff March 2017 36(3): 485-491. Powell, RE. Patient Perceptions of Telehealth Primary Care Video Visits. Ann Fam Med May/June 2017 15(3): 225-229. Primary Care Medicine: Principles and Practice Primary Care Medicine: Principles and Practice 21 22 6 10/11/17 Leading Together in Primary Care: Learning Lab
Disruptive Innovation What are the Barriers To Adoption? Payment System : The current visit-based payment system Lack Of Integrated Tools : Some tools are not integrated with electronic records Financial Incentives : Pay for individual online visits, management fees to compensate for time spent in online patient care Chronic Disease Management: Using telehealth to m anage obesity, diabetes, high blood pressure, and high cholesterol is emerging Primary Care Medicine: Principles and Practice 23 Primary Care Medicine: Principles and Practice 33 Primary Care Medicine: Principles and Practice 35 Primary Care Medicine: Principles and Practice 36 7 10/11/17 Leading Together in Primary Care: Learning Lab
Primary Care Medicine: Principles and Practice 37 Primary Care Medicine: Principles and Practice 38 IOM’s Social Determinants of Health Primary Care Medicine: Principles and Practice 27 Primary Care Medicine: Principles and Practice 31 8 10/11/17 Leading Together in Primary Care: Learning Lab
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