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Read and follow for news and research in family and internal medicine.
Income is increasing for family physicians but burnout may be as well, according to a report published by the American Academy of Family Physicians (AAFP). The report points out that family medicine was not officially recognized as a medical specialty in the US until 1969. Over the past 50 years, family physicians have made significant progress in certain areas but are still faced with a number of challenges.
Data gathered by AAFP shows that “the income gap between primary care and non-primary-care physicians has decreased from 44.6 percent in 2011 to 41 percent in 2015.” The report indicates that family physicians’ income is increasing slowly but steadily and the amount of time they spend in direct, face-to-face patient care is down slightly.
DISTRIBUTION OF FAMILY PHYSICIANS BY ANNUAL INCOME
The AAFP report emphasizes that “First-contact, person-focused, comprehensive, coordinated care – the hallmark of family medicine – is becoming even more important as the health system transitions to value-based payment.” Farzad Mostashari, MD, former National Coordinator for Health IT and now chief executive officer of Aledade states that “small, physician-owned practices have a lower average cost per patient, fewer preventable hospital admissions and lower readmission rates than hospital-owned practices.”
Patients value the time spent with their family physician, particularly those in independent practices. However, AAFP found that provider burnout rates are increasing, noting that “an alarming 63 percent of family physicians meet the criteria for burnout, compared with 54.4 percent of all physicians. When asked how they feel about the current state of the medical profession, 50.5 percent of primary care physicians report positive feelings.”
AVERAGE HOURS SPENT PER WEEK IN PRACTICE
Though a physician shortage still exists, more medical students are choosing to enter family medicine. The number of students matched with family medicine steadily increased from 2006 to 2016, the latest data available. The AAFP report notes that “continued recognition of the value of primary care, and continued increases in income, will play a vital role in family medicine’s ability to grow and to attract more medical students.”
Ripley Hollister, MD, FAAFP, a Colorado Springs, Colo., family physician and board member of the Physicians Foundation, noted in the report that “with time, as family physicians adjust, frustrations will lessen and satisfaction will rise. Family physicians have a long history of adapting to change, and the new generation of physicians appears to have more optimism.” Mostashari suggested that family physicians “will need to ingrain it into their culture and continually refocus on why they are doing the work – for patients.”
Damien Neuman February 19, 2019Read
Not surprisingly, primary care patients want to be seen and treated as human beings rather than just another patient with a medical record number. They desire a relationship with the physician and consistent treatment, whether being seen in person or communicating with the practice before and after the visit. The “patient experience of the future” should revolve around the primary care physician truly getting to know the patient and to provide resources to make healthcare more convenient for that patient according to a recent survey conducted by West’s Engagement Center Solutions.
The survey found that patients’ top priorities and physicians’ priorities do not always align. Although providers indicate they are working on many aspects of the healthcare experience that are important for patient satisfaction, patients place higher priority on certain areas. For example, 49% of the patients responding to the survey indicated that efforts to communicate out-of-pocket costs for services were “essential to improving patient satisfaction.” Providers ranked this topic almost last in their priority list.
The patient experience of the future should also include convenience for the patient, in scheduling appointments and in communicating with primary care physicians. 41% of the patients responding to the survey indicated that making it easy to schedule appointments would improve their satisfaction with their healthcare provider. Appointment reminders sent out via a patient portal can also help encourage patients to keep their appointments.
As to the visit experience, 50% of patients participating in the survey said that shorter wait times in the physician’s office would improve satisfaction. The patient experience of the future might include electronic notifications when the provider is running behind or when the patient might experience a long wait time.
During the visit, the patient experience of the future should include adequate time for the patient to ask questions and clarify diagnoses and care instructions. Currently, according to the survey results, “One quarter (27%) of patients do not have a strong sense that their providers care about them as individuals, and nearly one in five patients (19%) are not positive that their providers are focused on improving their health.”
Damien Neuman February 6, 2019Read
Timely follow up by the primary care physician after a patient’s visit to the emergency room (ER) may be the key to reducing return ER visits as well as hospitalizations. Ideally, the provider and patient will have an established relationship, enabling the primary care physician to initiate the follow up and possibly even avoid the need for the patient’s initial ER visit. However, even if the patient finds it necessary to be seen at the ER, the follow up with the primary care physician can be a critical point in the long-term outcomes for that patient.
According to a study published by the US National Library of Medicine (National Institutes of Health), 50% of all hospital admissions are a direct result of patient ER visits. The study investigated the impact of a “rapid-access-to-primary-care program” at New York-Presbyterian / Weill Cornell Medical Center in terms of health outcomes, cost savings, and the provider’s ability to engage ER patients in continued primary care and preventive measures.
Patients who feel the need to visit the ER may not be covered by insurance or may not have an established relationship with a primary care physician. The study found that a rapid-ED-to-primary-care-access protocol “has the potential to save costs over time.” This type of timely follow up by the primary care physician “can also provide a safe and reliable ED discharge option that is also an effective mechanism for engaging patients in primary care.”
Research has established that “regular primary care is associated with a number of health benefits including increased receipt of preventative services and better chronic disease management.” When the patient follows up with a primary care physician promptly after an ER visit, the opportunity also exists for the provider to engage that patient in long-term primary care. Establishing a medical home can be critical for patients with chronic or complex conditions, in particular.
The study found that “a rapid-ED-to primary-care follow-up program can provide a safe and reliable ED discharge option that is also an effective mechanism for engaging patients in primary care. Such primary care engagement has the potential to lead to further containment in overall healthcare costs, as well as to improved patient care and health outcomes.”
A rapid-ED-to-primary-care-access program may allow EPs to avoid admitting patients to the hospital without risking ED revisits or subsequent hospitalizations. This protocol has the potential to save costs over time. A program such as this can also provide a safe and reliable ED discharge option that is also an effective mechanism for engaging patients in primary care.
Damien Neuman January 28, 2019Read
As the Centers for Medicare & Medicaid Services (CMS) continues to shift its reporting and reimbursement programs to accommodate over-burdened physicians, there continue to be challenges for the primary care physician in providing value-based care.
CMS initiatives that involve more financial risk – for potentially greater rewards – are accompanied by reporting requirements and value-based care measures that may be difficult for some independent physicians to achieve. A report published by ArborMetrix found that “Provider groups and health systems face real limitations accessing data and developing the infrastructure and engagement necessary to succeed under new paradigms.”
Tackling physician barriers to value-based care in 2019 will involve:
Taking advantage of available technology. Electronic health records (EHRs) enable the independent physician to manage patient data and to easily coordinate care for patients. Elation’s EHR solution is designed for the primary care physician to holistically evaluate the patient population with a longitudinal record that trends vitals and lab values over time. The physician can quickly identify patients who aren’t meeting goals based on custom care management protocols, Meaningful Use objectives, or specific document tags, and easily schedule a follow-up appointment to address any potential gaps in care.
Establishing partnerships with community service providers. For those patients who face their own challenges in accessing healthcare, primary care physicians can coordinate with area organizations to facilitate the delivery of value-based care. As Healthcare Informatics explains it, “Social determinants of health often prevent certain populations from accessing care in a timely and cost-effective manner. However, the shift to value-based care, coupled with a willingness of companies across industries to integrate technologies into each others’ platforms, is creating new and interesting collaborations to address some of these disparities.”
Getting involved and providing feedback on value-based care requirements. CMS typically issues draft or proposed rulings with a comment period for physician input. Take advantage of those opportunities to review those documents and submit feedback and input that could make a significant difference in the value-based care landscape.
Damien Neuman January 22, 2019Read
The earliest patient records, dating back to “antiquity,” were created for instructional and educational purposes at least 4,000 years ago. Written case history reports were found to have been developed for didactic purposes by medieval physicians. The forerunner of modern medical records, researchers have discovered, “first appeared in Paris and Berlin by the early 19th century.” It was not until the 20th century that “a clinical medical record useful for direct patient care in hospital and ambulatory settings” was developed and used regularly.
By the early 20th century, healthcare providers were charting patient visit notes and medical history to be used in the treatment of those patients. According to an article published by Rasmussen College, “Documentation became wildly popular and was used throughout the nation after healthcare providers realized that they were better able to treat patients with complete and accurate medical history. Health records were soon recognized as being critical to the safety and quality of the patient experience.”
Patient charting was standardized by the American College of Surgeons (ACOS), which established the American Association of Record Librarians. Today the association is known as the American Health Information Management Association (AHIMA). Paper patient charts were handwritten and kept in files on specially designed shelves until the mid to late 20th century, when new technology was being developed.
Throughout the late 20th century, patient charting began to be moved into electronic systems. The electronic health record (EHR) was originally developed for hospitals and universities, but by the 1980s, more focused efforts were made to increase the use of EHR among medical practices. While manual patient charting and filing was vulnerable to errors, the Centers for Medicare & Medicaid Services (CMS) recognized that the EHR “can improve patient care by:
• Reducing the incidence of medical error by improving the accuracy and clarity of medical records.
• Making the health information available, reducing duplication of tests, reducing delays in treatment, and patients well informed to take better decisions.
• Reducing medical error by improving the accuracy and clarity of medical records.”
Patient charting has advanced significantly in the past 4,000 years. In the 21st century, patient data can be accessed and shared seamlessly among providers caring for the patient, through EHRs. The primary care physician now has the ability to coordinate care electronically and accurately, ensuring the highest quality outcomes.
Damien Neuman January 9, 2019Read
Preventive screenings occurred at a higher rate under value-based care than with physicians in a fee-for-service arrangement, according to the latest report published by Humana, a healthcare payer. The Value-Based Care Report published annually for the past five years, examines the physicians within the Humana system and their impact on patients. Chronic condition management also improved with the value-based care model.
The report cites the example of breast cancer screenings, in which “patients affiliated with physicians in value-based care agreements had a higher frequency rate of breast cancer screenings (78 percent) compared to patients affiliated with physicians in fee-for-service (69 percent) and fee-for-service plus bonus agreements (69 percent).”
An increase in preventive screenings was also found among patients in value-based care for osteoporosis management, rheumatoid arthritis management, blood pressure control management, statin medication adherence, high blood pressure medication adherence, and adult BMI assessment. 83% of patients showed improved adherence to statin medication in value-based care, as contrasted with 79% of patients in the fee-for-service model. Medication reviews for older adult patients were reported at 96% in value-based care and 88% in fee-for-service care.
Humana reported that their physicians practicing in “value-based agreements had more favorable results than physicians in fee-for-service agreements in all HEDIS (Healthcare Effective Data and Information Set) Star measures.” Further, the report states, “Focusing on prevention and the whole health of their panel population allows physicians and their care teams to work more strategically to improve the care of their patients, thus keeping them home and out of the hospital and emergency room.”
Emergency room visits and hospital admissions were also significantly lower in the value-based care models than with fee-for-service physician practices. Proper and timely preventive care has been shown to have a significant impact on hospital stays as well. Overall, the report states, “physicians who practice value-based care are achieving higher rates of patient engagement in preventive screenings, medication adherence and management of chronic conditions as measured by HEDIS.”
Damien Neuman December 14, 2018Read
Reimbursement challenges, changing preferences among younger patients, and an aging population who need expanded access were all topics in a recent panel discussion on the current and future state of primary care in this country. The discussion took place among participants in the Cleveland Clinic 2018 Medical Innovation Summit and involved a look at the possible future of primary care.
Experts on the panel included Anil Jain, MD, VP & Chief Health Information Officer, IBM Watson; Peter Antall, MD, President & CMO, American Well; Joe Schrick, Vice President Fitness Segment, Garmin; Bonnie Clipper, Vice President of Innovation, American Nurses Association; and Nirav Vakharia, MD, Vice Chair, Population Management, Cleveland Clinic.
The general consensus was that primary care is changing and is faced with a number of challenges, particularly those around reimbursement and the time spent on earning those payments. Physicians are being asked to focus on value-based care, which may involve extensive reporting and adhering to new regulations established by the Centers for Medicare & Medicaid Services (CMS) for their Medicare patients. The panel discussed their view that physicians are spending too much time on administrative work, which takes away from the time they can spend with their patients.
Additionally, the varying demands and preferences of the generations was discussed. Millennials and younger patients are very technology-oriented. They tend to take advantage of wearables and apps, prefer telemedicine over in-person visits, and engage in technology that monitors their health and fitness. The challenge with this dependency on technology, noted the panel, is that there is no primary care physician involved to coordinate care that may be necessary for an injury or illness.
On the other end of the generational spectrum, as the patient population ages, more elderly patients are finding they cannot access primary care for various reasons. A tendency toward chronic and complex conditions in older patients requires more of the primary care physician’s time and, again, reporting requirements at the CMS level for incentives and reimbursements.
The panel moderator, Dr. Jain, noted that “We know that primary care is under siege. We have a lot of transformation happening in health. Primary care doctors and primary care practitioners are being asked to deliver high quality and high value care. But they’re not being given all the necessary tools to do so.”
Damien Neuman December 10, 2018Read
About half of all physicians experience burnout, according to multiple studies conducted of physicians who work in hospital settings, for large practices, and for themselves. However, when studies are conducted of independent physicians specifically, that burnout level tends to be significantly lower. A limited study of independent primary care physicians published recently in the Journal of the American Board of Family Medicine found that their burnout rate was only 13.5 percent.
An article published in AMA-Wire suggests a number of reasons for the lower burnout rate among independent primary care physicians:
Autonomy. Independent primary care physicians have more control over their administrative tasks, their work hours, and their overall working environment. This control helps reduce the amount of stress that may typically be found in a hospital or other healthcare facility, in which the primary care physician reports to a higher administrative level. The AMA article points out that previous studies have determined that “low work control and low autonomy has been linked with higher levels of burnout.”
Deeper relationships with patients. Along with that autonomy comes the ability to spend more time with patients, to communicate with them outside the office visit, and to get to know them better. Engaging with patients is the primary focus of most independent physicians’ work, so developing that deeper relationship with patients may lead to higher levels of job satisfaction and lower levels of burnout.
Fewer work hours. Independent primary care physicians establish their own office hours and have more control over their work schedule than those working for larger practices or for healthcare facilities. Exhaustion is a significant factor in burnout, so fewer work hours contribute to less stress and fatigue.
Higher adaptive reserve scores. The researchers who conducted the study of independent primary care physicians defined “adaptive reserve” as the independent physician practice’s “internal capacity for organizational learning and development.” The organizational capacity for change and for growth is much higher in an independent primary care practice and that can also lead to lower rates of physician burnout.
Damien Neuman December 3, 2018Read
Millennials comprise the group of people born in the last twenty years of the twentieth century. Although specific birth years vary from one generational expert to another, millennials were born between about 1981 and the turn of the century. There are about 83 million millennials in the US. This group of people has grown up immersed in technology, with a completely different view of the world than their Generation X or Boomer parents. Moving from job to job, from city to city, is not unusual for this group. They look for expediency, convenience, and immediate rewards.
Millennials also have a different view of medical care than the older generations. While a Boomer may develop a long-lasting relationship with a primary care physician, a 2017 survey conducted by the Employee Benefit Research Institute, a Washington think tank, and Greenwald and Associates found that 33 percent of millennials did not have a primary care physician. In that same survey, the researchers found that only 15 percent of those age 50 to 64 did not have a regular doctor.
Speed and convenience are the primary concerns for millennials, particularly in regard to how they access healthcare. In fact, these trends are being seen in other age groups as well. As internist Ateev Mehrotra, an associate professor in the Department of Health Care Policy at Harvard Medical School, noted in a recent Washington Post article, “Younger patients are unwilling to wait a few days to see a doctor for an acute problem, a situation that used to be routine.”
Millennials also want connectivity. Primary care physicians who offer the ability to communicate electronically, to access telehealth services, and to make appointments online or through an app will be more attractive to that busy age group. Those appointments also need to be speedy and on time. A millennial typically wants to be seen the same day or the next day and does not want to be kept waiting when the appointment time arrives.
Millennials prefer the convenient access of an urgent care or even an emergency room for their healthcare services. Primary care physicians such as Mott Blair, a family physician in Wallace, N.C., are adjusting to their patients’ preferences, including reaching out to millennials who need the holistic and consistent healthcare that is not typically available at urgent care centers.
Damien Neuman November 29, 2018Read
Providing value-based care requires a focus on overall health outcomes for the patient, a shift from the traditional fee-per-visit model of care that is focused on individual office visits. The primary care physician must look at the complete picture of a patient to understand what factors impact that patient’s current condition and future health. In addition to the usual factors of genetics, diet, and exercise, social determinants of health can also affect the patient’s well-being.
Social determinants of health include socioeconomic factors, education level, economic environment, job opportunities, and social supports, “conditions in the places where people live, learn, work, and play” that “affect a wide range of health risks and outcomes.”
Socioeconomic factors are significant social determinants of health. Patients who are low-income may be challenged with finding a job because of the economic environment in which they live, a lack of education or training, or other reasons related to their background or environment. When considering socioeconomic factors, the primary care physician must understand whether an order to eat healthier can actually be carried out by the patient who may face challenges with being able to purchase high quality food.
Simple access to healthcare can also be a barrier for the primary care physician’s patients. Transportation may not be available or the patient may not be able to afford transportation to the provider’s office. Providing value-based care to these patients may require innovative solutions such as electronic communication or telehealth provided through a satellite location.
Social supports are important to the patient impacted by social determinants of health. The primary care physician may need to reach out to family or the community, while adhering to HIPAA regulations, to encourage the patient to continue to take advantage of the quality healthcare and to follow the care plan laid out by the physician.
Social determinants of health can significantly impact a patient’s well-being. Providing value-based care to such patients will require outreach and continued support on the part of the primary care physician.
Damien Neuman November 14, 2018Read