NEJM -- What's Keeping Us So Busy in Primary Care? A Snapshot from One Practice - 0 views
content.nejm.org/...1632
community-desktop PCMH evidence-based-medicine outcomes-based medicine EHR software healthcare research productivity
shared by Steve King on 03 May 10
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Primary care practices typically measure productivity according to the number of visits, which also drives payment.
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dhtobey Tobey on 03 May 10This study is directly related to the TrustNetMD mission, but could also be useful for other EBM-related and OBM-related community desktop solutions.
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Several studies have estimated the amount of time that primary care physicians devote to nonvisit work.1,2 To provide a more detailed description, my colleagues and I used our electronic health record to count units of primary care work during the course of a year.
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Greenhouse Internists is a community-based internal medicine practice employing five physicians in Philadelphia. In 2008, we had an active caseload of 8440 patients between 15 and 99 years of age.
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Our payer mix included 7.2% of payments from Medicaid (exclusively through Medicaid health maintenance organizations), 21.5% from Medicare (of which 14.0% were fee-for-service and 7.5% capitated), 64.7% from commercial insurers (34.5% fee-for-service and 30.2% capitated), and 6.5% from pay-for-performance programs.
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I wonder how this breakdown compares with national/urban averages? Also how are these trending? Is the pay-for-performance increasing dramatically? I would think so based on what we are hearing.
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Throughout 2008, our physicians provided 118.5 scheduled visit-hours per week, ranging from 15 to 31 weekly hours each. We regard this schedule as equivalent to the work of four full-time physicians, with physicians typically working 50 to 60 hours per week. Our staff included four medical assistants, five front-desk staff, one business manager, one billing manager, one health educator (hired midyear), and two full-time clerical staff. Our staffing ratio was approximately 3.5 full-time support staff per full-time physician. We had no nurses or midlevel practitioners.
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From the little I know this is a typical primary care scenario - very poor leverage of professional staff, meaning no use of nurses or midlevel practitioners to leverage physician time and expertise.
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We use an electronic health record, which we adopted in July 20043 and use exclusively to store, retrieve, and manage clinical information. Our electronic system came with 24 "document types" that function like tabs in a paper chart to organize documents, dividing clinical information into categories such as "office visit," "phone note," "lab report," and "imaging." Since all data about patients is stored in the electronic record (either as structured data or as scanned PDFs) and each document is signed electronically by a physician, we are able to measure accurately the volume of documents, which serve as proxies for clinical activities, in a given time period.
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Each of these document types could become a "LivingPaper" creating a "LivingRecord" vs. the current EHR... Steve have you discussed something like this with TNMD?
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The volume and types of documents that we receive, process, and create are listed in Table 1
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Telephone calls that were determined to be of sufficient clinical import to engage a physician averaged 23.7 per physician per day, with 79.7% of such calls handled directly by physicians.
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Wow! I never would have guessed that telephone calls were such a significant part of the physician day. Does the EHR provide a CRM for call-logging?
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Of these calls, 35.7% were for an acute problem, 26.0% were for administrative purposes
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Physicians averaged 16.8 e-mails per day. Of these electronic communications, 59.3% were for the interpretation of test results, 21.7% were for response to patients (either initiated by patients through the practice's interactive Web site or as part of an e-mail dialogue with patients), 9.3% were for administrative problems, 5.0% were for acute problems, 2.8% were for proactive outreach to patients, and 1.9% were for discussions with consultants.
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60% for interpretation of test results!!! Opinion management ranks as the highest use of electronic communications. THIS IS OUR SWEET SPOT! We need to find this type of data for research scientists.
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Each physician reviewed 19.5 laboratory reports per day, including those ordered through our office (which are delivered to us through an electronic interface and are automatically posted to the database of the electronic health record as numerical values) and those ordered outside our office (which enter our chart as scanned PDFs and are not posted as numerical values). The work cycle of responding to a laboratory result includes interpretation by telephone, letter, or e-mail. (Our office sent 12,541 letters communicating test results, about a third of which were sent by e-mail.) For noninterfaced laboratories, we must decide which values need to be entered manually into the electronic health record by a staff person; the values of scanned results cannot be graphed or searched without this step. Laboratory results frequently trigger a review or adjustment of a medication, which requires access to accurate, current medication lists with doses.
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How difficult would it be to integrate LivingPaper with existing EHRs and/or lab systems. Since EHRs are still in the "early adopter" phase, perhaps we can address some of the most critical needs making EHR use unnecessary, or perhaps this is a HUGE joint opportunity with Microsoft's healthcare division.
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Each physician reviewed 11.1 imaging reports per day, which usually required communication with patients for interpretation. Such review may require updating problem lists (e.g., a new diagnosis of a pulmonary nodule) or further referral (e.g., fine-needle aspiration for a cold thyroid nodule), which generates additional work, since results and recommendations are communicated to patients and consultants.
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Each physician reviewed 13.9 consultation reports per day. Such reports from specialists may require adjustments to a medication list (if a specialist added or changed a medication), changes to a problem list, or a call or e-mail to a patient to explain or reinforce a specialist's recommendation. Some consultation or diagnostic reports relate to standard quality metrics (e.g., eye examinations for patients with diabetes) and need to be recorded in a different manner to support ongoing quality reporting and improvement.5
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Before our practice had an electronic health record, we employed a registered nurse. After the implementation of the electronic health record system, much of the work that the nurse performed could be done by staff who did not have nursing skills, and by 2008, we no longer employed a registered nurse. However, on the basis of the analysis described here, we have hired a registered nurse to do "information triage" of incoming laboratory reports, telephone calls, and consultation notes — a completely different job description than what we had before.
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Most interesting! This is the conclusion we came to and presented to TNMD as a business plan concept -- become the triage service through outsourcing/insourcing RNs supported by the community desktop system.
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Our practice is participating in a multipayer Patient Centered Medical Home demonstration project7 (which allowed us to hire our health educator). This project is overseen by the Pennsylvania governor's office and funded by the three largest commercial insurers and all three Medicaid insurers in our region
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