Private Practice: The End of an Era or a Value Added Proposition?

-Kameron Gifford, CPC  10/11/13

The practice of medicine in America is changing rapidly under new regulations, greater enforcement and tightening reimbursement policies. We are seeing more and more physicians opting to sell their practices rather than the time honored tradition of “modify and adapt”.

This month marks a significant point in our journey down the road of “Healthcare Reform” for the entire industry, but to me, it means more than the opening of healthcare exchanges and the final countdown to ICD-10; it signifies the potential end of an era. 

Just as any other small business owner, my father has worked countless hours building his business from the ground up. Over the last 35 years, he has kept his patients healthy, managed employees, handled payroll and navigated numerous changes in insurance and healthcare reform. He has supervised residents, moonlighted in the Emergency Room, held medical directorships and worked hand in hand with managed care companies to improve their outcomes. 

On October 2^nd, at 70 years old, he sold his private practice to a “corporate medical group.” This sell was bitter sweet for me as I have come to know and care for each and every one of our patients.  As a child, I spent many summer days reading medical text books in his office and accompanying him on hospital rounds. As an adult, I was honored to work side by side with him as his office manager.

Today, I ponder the future experiences of my patients and the overall effect on outcomes. Who will “lead” their plight for wellness now? What does the commercialization of primary care mean for consumers? What is the ultimate number of dollars saved versus the experience of the care delivered? And how will corporate medicine ultimately affect future access?

Policies and procedures are a necessary evil in terms of practice management. For example, we did not accept walk-ins, but I never turned a patient away from my window. Would you shut the door on a friend in need? Of course not, even when it is inconvenient . When Mr. Hernandez’s grandson was visiting from New York, and was stung by a jelly fish, we worked him in, even though he was 17, and we did not see anyone under 18. This flexibility on the front line increases patient satisfaction and improves the overall experience of care. 

When you called the office, there was a 1 in 3 chance that I (the office manager) would answer the phone. Why, because during clinic, I sat up front and checked out every patient. Because this is the last step in the process, and ultimately your last opportunity to ensure that your “customer” leaves with a smile, or at least a clear understanding of what to do next. My “instructions” came in many different vehicles, but the over arching theme was “please call with questions, I am here to help and I care”.

Same day appointments were always available and “no show” patients didn’t exist. When employers changed plans and Mr. Jones forgot his insurance card, we still checked his blood pressure, and when Mrs. Allen accidentally enrolled in a plan we were not participating with, we continued her treating her all year without a charge. Why? Because after 15 years of care it was the right thing to do. Mrs. Allen only came in twice that year, but 5 years later she is still with us. When new members were added to our managed care rosters, we reached out to them, instead of waiting for them to contact us. All this was standard procedure, years before the ACA or quality incentives. 

My father ran his practice with strict protocols. He took the history of all new patients, personally. Our collection of new patient forms did not include the standard lists of boxes to check. His “standard” set of questions had been refined again and again through out the years to ensure a “yes” or “no” answer would be difficult. Instead of “do you drink?” it might be “what did you drink with dinner last night?” or "how much do you drink?" Antibiotics were never given out over the phone, and sinus infections were confirmed by a sinus x-ray before writing the prescription. All appointments for tests and specialists were made by us, without exception. Why? Because this ensured we always received the report, and would be able to remind them when and where they were to go. Diabetics and pre-diabetics were seen every 3 months fasting, and we tracked and monitored all LDL’s internally on a quarterly basis. Every  patient had a comprehensive physical exam, even before Medicare Wellness Exams were reimbursed. And when you came to our office for our physical, you met with doctor in his office, after getting dressed to discus the results. All of this, long before primary care came into the spotlight, and quality was ever mentioned in terms of payment.
So, what value has this acquisition ultimately added to the experience of care for my patients? Will the shiny new furniture and upgraded computers really have an impact on their health? And what about the "standards" of corporate medicine? Will the new spirometery machine really improve the overall health of the population, or will it's purpose be closer tied to revenue?

I can’t help but wonder what will be lost in translation from private practice to corporate medicine? If Mrs. Jackson calls without her hearing aids in, will a live person be there to assist her? Or will she be forced to fumble through an automated phone system? And if she gets a voicemail instead of a person, how will that ultimately influence her decision to seek or not to seek care?

Now consider for a moment the potential financial impact of 1 coronary event, or the prevention of 1 coronary event.  That phone call might have been our single opportunity to reduce the probability of a negative outcome.  

I am willing to bet that the magical point of sustainability in our healthcare system lies within both our past experiences and future capabilities. Perhaps the answer we are all searching so desperately to find is not black and white, but instead a mix of "old" and "new." As an industry, I believe that we need to embrace the collective experiences of those who have been on the front lines, and work together to create innovative solutions instead of closing the door on an era and such a wealth of intelligence.  There is no one that knows what your members need or want more than the person that answers the phone at your PCP’s office. I believe the most innovative solutions are yet to come.  What could this collective intelligence add to your current value proposition?

HBR: Redefining the Patient Experience with Collaborative Care

HARVARD BUSINESS REVIEW: by Leonard L. Berry and Jamie Dunham  |   9:30 AM September 20, 2013 

It’s a common patient complaint about the people involved in their care: “Sometimes the left hand doesn’t seem to know what the right hand is doing. I don’t feel everyone is working together.” To address this issue, nurses at ThedaCare employed lean techniques to create a patient-centered, team-based model that’s producing solid results.

Based in Appleton, Wisconsin, ThedaCare is a five-hospital health system with 26 clinics, other allied services, and more than 6,000 employees. It has been a pioneer in applying lean methodology in health care in order to tackle quality and cost issues. It began its lean journey in 2003 and has made considerable progress. For example, its accountable-care-organization partnership with Bellin Health, a health care system in Green Bay, Wisconsin, presently has the lowest cost per Medicare beneficiary among 32 pioneer ACOs, and the ThedaCare Physicians group was ranked first in quality performance statewide in 2013 by Consumer Reports.

ThedaCare opened its first “collaborative care” hospital unit in a medical-surgical unit at Appleton Medical Center in 2007 after 18 months of interdisciplinary planning led by nurses. A second was introduced in a medical-surgical unit at Theda Clark Hospital in Neenah in 2009, and a third in another medical-surgical unit at Appleton Medical Center in 2010. By 2013, all eight medical-surgical units in the two hospitals had been converted to the collaborative-care model.

The results to date show that the inpatient-care model is succeeding in improving safety, efficiency, and effectiveness. For the first three units, costs and length of stay declined, and quality and patient and nursing satisfaction improved. Some metrics improved immediately (within the first month); others over a period of six to nine months. A new process that required the pharmacist, rather than a nurse, to be responsible for “admission medication reconciliation” (a process that ensures that the patient’s list of medications that he or she is taking at home is accurate and can be used as a baseline for prescribing medication during his or her hospital stay) reduced the errors per patient admission to zero from between 1.25 and 1.5.

Team Care at the Bedside

The collaborative-care model replaces inconsistent, fragmented hospital care. A bedside-care teamcomposed of a physician (“medical expert”), nurse (“care-progression manager”), pharmacist (“medication expert”), and discharge planner (“transitional-needs coordinator”) collaborates — with patient and family input — to develop a single care plan that is continuously updated in daily team huddles. On admission, the team gathers the patient history, performs a physical assessment, determines an anticipated discharge date, and works backward from this date to build a coordinated plan of care.

Using evidence-based guidelines linked to the electronic medical record, the nurse manages the patient’s care progression, and the bedside pharmacist contributes to optimizing management of the medication. The physician leads the clinical assessment and planning process but as a team member/partner. The discharge planner assists the team in devising the best transition plan post hospitalization.

This patient-centered approach minimizes duplication of effort, puts people in roles that leverage their skills and accelerates clinical learning as teammates teach each other. Staff use “tollgates” — purposeful timeouts that are a lean concept — to analyze the patient’s status and remove obstacles in delivering care.

Struggles — and Lessons — from the Journey

Despite the progress, the collaborative care model has had its challenges and remains a work in progress. For example, program designers learned belatedly that the new model requires a different kind of unit leader: a team-builder, coach, and mentor. A “collaborative-care spread team” consisting of clinical experts in the model, a project manager, organizational development specialists, and others guide the nurse managers through their unit’s preparation and implementation phases, supporting their leadership development every step of the way.

One challenge that’s currently being addressed is how to both maintain essential standard work across units and accommodate the requirements of clinical specialties. Some adaptation for certain patient types, like the short-stay surgical patients, has been needed to continue to meet the model goals. As with the original design, these adaptations were made using lean tools for ongoing process improvement.

Another ongoing challenge is getting private-practice physicians who use ThedaCare hospitals to fully engage. To help address this issue, hospital medical directors meet with independent physician groups to share essential elements of the model and determine how they can be applied to doctors’ workflows. (Garnering the full participation of ThedaCare-employed physicians has gone more smoothly.)

ThedaCare’s experience with collaborative care offers salient lessons:

Start from scratch. ThedaCare started by designing a new delivery process rather than adding to the existing process. Starting fresh sparks uninhibited creativity; it encourages “why can’t we” instead of “we can’t” thinking.

Follow a methodology. The design team fully used lean methods such as rapid-improvement events, value-stream maps, and visual-management concepts. That ThedaCare turned to hospital nurses to lead the program design reflects the lean tenet of asking people closest to the work to improve it. (For more information on how to apply lean techniques in health care, see this article.)

Fully use the talent. Collaborative care addresses one of health care’s greatest sources of waste and defects: the underutilization of skilled labor. Too often, highly trained staff work below their scope of expertise — for example, doctors doing what nurses not only can do but also probably do better. Nurses coordinating patients’ care progression and pharmacists managing medications represent big wins for patients and other stakeholders.

Involve the patient. The voice of the patient was a critical input in developing the collaborative-care approach. Patients participated in rapid-improvement events and were members of the development team. Patients anxious to know when they would likely go home were the impetus to providing a discharge goal on admission and focusing on the course of care needed to meet that goal. Patients voicing distrust because they were asked the same question multiple times by different clinicians during their admission laid the foundation for an admission process conducted jointly by the care team.

Invest in intentional thinking. Another lean tenet is assessment before action. Two examples: the 18 months that ThedaCare spent planning the new model and the care team huddles before, during, and after patient visits to assess and reassess the patient’s care plan.

Support strategy with infrastructure. Changes in the hospital facility were made to implement the new approach. They included converting semi-private patient rooms to private rooms and replacing the traditional nursing stations with decentralized alcoves located just outside of the patient rooms, where teams can huddle  before and after visiting patients. A whiteboard was put in the patient’s room so staff could summarize the care plan, timeline, and other relevant information for patients and families. And the supply server was redesigned so it could be restocked outside patient rooms but would be easy for care providers to access medications (kept in locked compartments) and other things. This reduces the time that it takes for nurses to gather supplies, allowing them to spend more time with patients.

Communicate quality. In general, patients have basic expectations about their hospital experience — they want reassurance that providers care about them, communicate with one another, and are competent. Involving the patient in care planning, summarizing the plan on the in-room whiteboard, and following work standards that provide reliable outcomes communicate to patients that they are receiving quality care.

The progress to date of ThedaCare’s collaborative care model is evidence that patient-centered teamwork can improve the quality and lower the cost of care.

Follow the Leading Health Care Innovation insight center on Twitter @HBRhealth. E-mail us athealtheditors@hbr.org, and sign up to receive updates here.

http://blogs.hbr.org/2013/09/redefining-the-patient-experience-with-collaborative-care/

NextGen Healthcare and Availity Introduce Health Plan/Physician Data Sharing Program

by Business Wire via The Motley Fool Jul 23rd 2013 5:11AM
Updated Jul 23rd 2013 5:14AM

NextGen Healthcare and Availity Introduce Health Plan/Physician Data Sharing Program

Integrated EHR Environment to Foster Collaborative Coordinated Care

HORSHAM, Pa.--(BUSINESS WIRE)-- NextGen Healthcare Information Systems, LLC., a wholly owned subsidiary of Quality Systems, Inc. (NAS: QSII) and a leading provider of health care information systems and connectivity solutions, today announced the introduction of a collaborative care project with Florida's largest health insurer, Florida Blue, and Availity, a top health information network to improve health care delivery for Florida residents.

The program enables physicians to exchange clinical data and patient care summaries with the health plan through integration with the NextGen®Ambulatory EHR. The organizations are joining to make patient-specific clinical information accessible at the point of care to both providers and payers concurrently, helping them more effectively coordinate care for patients by flagging potential care gaps and care opportunities.

Three provider groups—Family Care Partners (Jacksonville), HeartWell, LLP (Miami) and Baptist Health South Florida—have agreed to implement the joint project to improve health care delivery and foster collaborative coordinated care for all Florida residents.

The goal of this program is to help providers better coordinate care for their patients by identifying potential gaps in care, lack of coordination among providers that might lead to less-than-effective provision of care, and the identification of other opportunities that would mitigate unnecessary care if certain pro-active measures are taken earlier in the plan of care for a particular patient.

Physicians will access the NextGen Ambulatory EHR to view patient care summaries and care reminders from Availity—information that gives physicians a more holistic view of the patient's medical history, at an opportune time in the patient encounter.

Additionally, the program will automate the exchange of care summaries back to the health plan for quality improvement reporting. The two-way integration at the EHR level automates the costly, manual exchange between providers and payers of critical clinical information necessary to support today's care delivery, as well as revenue cycle and emerging payer driven value-based payment models and quality improvement programs.

"Together with NextGen, Availity enables health plans and physicians to easily meet the dynamic clinical information exchange requirements for new value-based care models, while reducing the administrative cost of business between providers and health plans. Our strong partnership with NextGen will focus on delivering value to Florida Blue, physicians, hospitals, and most importantly, patients, while driving sustainable innovation in the delivery of health care, said Russ Thomas, chief executive officer for Availity."

"This project is an important step toward meaningful payment reform for both providers and commercial insurers. Together with NextGen and Availity, we are working to provide more cost-effective, better quality, patient-centric care to our patient population," said Daniel Choquette, director of information technology for Family Care Partners.

"Baptist Health South Florida is very pleased to be partnering with NextGen and Florida Blue to explore and assist in architecting what may be the future of health care with regards to patient management and data sharing," said Mimi Taylor, corporate vice president and chief information officer, information technology for Baptist Health South Florida.

"This program is a truly integrated, collaborative and strategic approach to providing more efficient, cost-effective care to our patient population," said Jeffrey Kaplan, chief operating officer for the Miami multi-site cardiology practice HeartWell, LLP. "We are pleased to be one of the medical groups chosen by Florida Blue to participate and look forward to working with NextGen Healthcare in this joint program to better identify a patient's health care needs while eliminating duplicative testing."

"We are very pleased to be supporting our clients in a path-breaking strategy to share data between payer and provider in an automated manner. Our hope is that patient care will be improved and providers' professional lives will be more organized," said Charlie Jarvis, Senior Vice President, Health Reform for Quality Systems Inc., NextGen Healthcare. "We are anxious to quickly move this demonstration into a network-wide and a future nation-wide strategy with all payers who support our client base."

http://www.dailyfinance.com/2013/07/23/nextgen-healthcare-and-availity-introduce-health-p/

Addressing the Empty Seat at the Healthcare IT Table: Next Steps in Patient Engagement

Written by Fauzia Khan, MD, FCAP, CMO and Co-founder, Alere Analytics | June 04, 2013

Social Sharing

The healthcare industry has made great strides in patient-centric, IT solutions such as electronic health records, personal health records, health information exchanges  and clinical decision support platforms. These platforms are finally enabling physicians, providers and payors to improve their care coordination, while increasing the quality of care for patients. While this is definitely an exciting time for healthcare IT, a very important group is conspicuously left out of the conversation — actual patients.

As we move toward value-based healthcare, there is a tremendous opportunity to engage patients in their own health. Meaningful use stage 2 and 3 has made patient engagement an industry buzzword and a checkbox to cross off, but active patient engagement could be a real game-changer. With real-time solutions such as CDS and mobile patient devices, as well as patients being engaged earlier in their own treatments, physicians would be able to provide personalized and immediate care recommendations, triggering earlier interventions, reducing avoidable errors, improving overall health outcomes and even lowering costs.

Despite all the potential benefits, we are still in the very early stages of empowering patients. The healthcare industry has made great strides in processing, accessing and reporting on patient data. But hospitals are struggling to overcome hurdles as they inch towards volume-to-value shift that requires  adopting data-based, outcomes-driven approach. Additionally, the challenge of interoperability is ever-present in today’s healthcare delivery system, often hindering the comprehensive capture and management of patient data and adding a difficult semantic layer to conveying disparate information in a simple and relevant manner.

So what's next for healthcare and increasing the role of the patient? The following are key areas to address to create a healthcare system that truly engages patients in their care process.

The role of connectivity

Although the healthcare industry has made significant strides in making sure that patient data can be captured, accessed and reported on in a timely manner, we still have a ways to go. Technology innovations have created a wealth of patient-centric solutions, but many of these innovations are struggling with how best to capture patient data and build a longitudinal care record needed to make the most informed, evidence-based decisions in real-time, and at the point of care and beyond. Once we have figured out the connectivity piece as an industry, clinicians will be able to focus on the best treatment plans using intelligent and actionable information to improve care quality while reducing costs for each patient. 

Utilizing  standards

In an effort to make data more actionable, CDS breaks down data into open formats and industry standards. These standards can specify the structure and semantics of "clinical documents," whether delivered through the EHR, PHR, HIE, or even device data, for the purpose of improved exchange between providers and their patients.

By using industry standards, data can not only be extracted easily from any format, but since the data is bi-directional, the information can also be pushed to any source, including the patient. For example through a rules-based system, the data can be redirected to any point, enabling doctors to engage with their patients and patient populations, both from a preventative and referential manner. This ability can assist clinicians manage their high-risk patient populations with chronic conditions such as diabetes, heart disease, COPD and many others.

Inviting patients to drive development

Despite all the attention paid to improving efficiencies around care, patients are continuously left out of the conversation when it comes to their own health. With ubiquitous use of mobile devices and more people opting for home healthcare, many patients want to take a more active role in managing their own health, so why not invite them into the conversation? As technology companies work to develop cutting-edge, patient-centric solutions, it will become increasingly more important to actually involve the patient in the process of developing their individualized treatment plan.

Increasing role of the "connected home"

Connecting hospital systems has been an IT priority, and during the last decade, a good amount of resources were focused on inpatient, outpatient, and ambulatory data integration and interoperability. Although we have just barely embraced this model in the clinical world, we can look beyond the hospital setting to see that these technology platforms could also be effectively used in the home as more telehealth options emerge each day for patients. Moving treatment closer to the individual closes crucial gaps, provides greater visibility, and accelerates decisions that lead to better outcomes. And with the surge of mobile technologies, internet and smart devices, the boundaries between the home, hospital, ambulatory and long-term care facilities will start to erode away and ultimately disappear.  

In addition to data interoperability, there needs to be an emphasis on information availability. Whether that data is delivered through an HIE, EHR or a smart device, patient data needs to be accurately captured and widely available. In the same way that CDS technologies facilitate decisions in the hospital setting, data in the home should also be actionable, comprehensive and increasingly accessible to patients, physicians and payors alike. This approach will allow for the best healthcare decisions to be made by both patients and providers, ultimately leading to better health outcomes. 

With new regulations pushing the healthcare industry forward to ensure better patient management and care, it’s clear that CDS will be influential to changing the way care is currently delivered in the hospital and beyond. The vision is clear: identify efficiencies, while maintaining high clinical quality to ensure delivery of the right care, at the right place and time. However, the execution seems to be elusive, and most hospitals do not know where to even start. 

As healthcare innovation continues, we must remember that the key is to deliver high-quality, collaborative patient care. This requires collecting, analyzing and sharing information, working across silos and engaging patients in an unprecedented and innovative manner. Likewise, it is our responsibility as technology providers to develop solutions that work together to enable transparency, collaboration and information-sharing. Like many shifts in healthcare, changes won’t occur overnight. It will take time. However, by making efforts today to move treatment closer to the individual, and involving patients in the development of technologies enabling this shift, we as an industry can accelerate decisions that can lead to better outcomes.

Fauzia Khan, MD, currently serves as chief medical officer of Alere Analytics, formerly DiagnosisOne, where she provides direction and leadership to develop practical and scalable technologies that allow clinical decision support and analytic capabilities to be seamlessly incorporated into clinical workflows. She has expertise and passion for algorithm design, knowledge acquisition and engineering as well as data mining and leveraging these capabilities to improve outcomes. Prior to forming DiagnosisOne, Dr. Khan was the director of informatics at UMass Memorial Medical Center with ten years of experience in the hospital practicing pathology. She is the author, editor and primary visionary of the “Guide to Diagnostic Medicine” (Lippincott Williams & Wilkins, 2002).