What are social determinants of health relevant to value-based care and primary care physicians?

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, 2018

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Study shows how persuasive design principles in primary care could improve data entry in EHRs

Accurate patient data is critical for the health of the patient as well as for record keeping and reporting for the primary care practice. Entering patient data can be time consuming and may not always be done in a timely manner. Even though electronic health records (EHRs) enable the primary care physician to enter data and update visit notes during the patient visit while continuing to stay focused on the patient interaction, many providers do not complete their notes right away.

Same day notes have been shown to be more accurate, but studies have also shown that only about half of clinicians seeing patients actually input those notes on the same day as the visit. A recent research study set out to determine how to encourage more primary care physicians to complete their EHR data entry on the patient visit day. The study objective incorporated the need to “find ways to influence clinician’s behaviors around data entry and data quality.”

In addition to the timing of the entry, the study found a need for encouraging EHR users to “enter a complete entry within the structured form, and encouraging error-free entries.” The study objective was to “to expose clinicians to persuasive design in order to modify their data-entry behaviors.”

Through a process of analysis and context definitions, the researchers “identified several persuasive design principles that could help change the data-entry behavior.” Some of the persuasive design elements included visuals such as a summary screen and badges “to encourage and normalize entering data on the same day.” In particular, the design incorporated a “same day badge” that was “programmed to display and reward the percentage of same-day entries.”

The researchers tested the persuasive design of the EHR with 53 users over a period of 16 weeks, including 8 weeks prior to the change and 8 weeks after. At the end of the post-change period, the team conducted an analysis and found that “the intervention increased the percentage of same-day entries by 10.3%.” Recognizing the limitations of their study, including the number of test subjects and the research timeframe, the researchers indicated that “Future work will involve exploring and evaluating the long-term impacts in greater detail as well as assessing iterative improvements to the design.”

Damien Neuman
November 12, 2018

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How primary care physicians could use EHRs for patient engagement in the future

Independent physicians use electronic health records (EHRs) to maintain accurate and timely patient medical records. Primary care providers can collaborate with specialty providers, making referrals and reviewing visit notes efficiently without waiting for faxes or returned phone calls. Primary care physicians also encourage their patients to view their own medical records and to communicate electronically through their portal, as they realize using an EHR for patient engagement can also be very effective.

However, a 2017 report published by the Government Accountability Office (GAO) explains that “relatively few of these patients accessed their records online, and patients typically did so in response to a medical visit.” The report specified that “health care providers that participated in HHS’s Medicare Electronic Health Record Incentive Program offered nearly 9 out of 10 patients the ability to access their health information online.”

Using an EHR for patient engagement can be effective in promoting communication and in encouraging patients to become more involved in their own plan of care. Primary care physicians can use EHRs to engage with their patients by discussing the challenges and the opportunities for the patient during the visit. Many patients actually prefer electronic communication, particularly millennials.

EHRs that offer patients the opportunity to communicate as well as to schedule appointments and pay their bills online will be more enticing to patients who prefer the convenience of electronic access. The key to communication through a patient portal is timely and accurate responses, of course. The primary care physician or a qualified member of the clinical staff must respond to the patient quickly to encourage patients to use the EHR more often.

The primary care physician can also use the EHR for patient engagement by proactively reaching out electronically. For example, the Elation Health Clinical EHR allows the provider to 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.

Damien Neuman
November 5, 2018

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What is shared-decision making?

Part of the challenge in providing value-based, quality healthcare to patients is having those patients follow care instructions, fill their prescriptions, and properly follow the primary care physician’s directives for additional tests or treatment. Human nature is such that we like to have input into decisions that affect our future. When patients have a part in the medical decision-making process, they are more likely to become engaged in their own healthcare.

Shared-decision making is just that. The primary care physician and the patient collaborate to make those decisions that impact the patient, including determining which tests to undergo, deciding on an effective and sensible treatment plan, and determining which medications will work best for the patient, based on the patient’s lifestyle and willingness to follow up on those decisions. These decisions must, of course, be “based on clinical evidence that balances risks and expected outcomes with patient preferences and values,” as described by Health IT’s National Learning Consortium.

The Consortium has found that when patients participate in the shared decision process, they are more engaged and that results in patients:

  • learning about their health and understanding their health conditions
  • recognizing that a decision needs to be made and are informed about the options
  • understanding the pros and cons of different options
  • having the information and tools needed to evaluate their options
  • being better prepared to talk with their health care provider
  • collaborating with their health care team to make a decision right for them
  • being more likely to follow through on their decision

The Agency for Healthcare Research and Quality (AHRQ) offers the SHARE approach for the primary care physician to actively engage the patient in shared-decision making:

Step 1: Seek your patient’s participation.

Step 2: Help your patient explore and compare treatment options.

Step 3: Assess your patient’s values and preferences.

Step 4: Reach a decision with your patient.

Step 5: Evaluate your patient’s decision.

Electronic health records (EHRs) can assist in the shared-decision making process as well. Patient portals and secure electronic messaging allow the primary care physician and the patient to communicate securely, so the patient feels free to ask questions, to seek clarification, and to provide input on healthcare decisions.

Greg Miller
October 31, 2018

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Preventative care v. preventive care

When physicians discuss immunizations and screenings with patients, they may refer to them as preventative care or as preventive care. In reality, there is no difference in the two terms except for the spelling. Both terms have been around for many years, although the term preventative has often been seen as a degradation of preventive. Of course, independent physicians and preventive care (or preventative care) are linked together as primary care practices typically emphasize those services to their patients.

Both terms have been used since the 17th century, when independent physicians and preventive care appeared in print slightly earlier than the association with preventative medicine. By the 19th century, however, the term preventative was looked at as “unseemly.” John Russell Bartlett was adamant when writing in A Dictionary of Americanisms, published in 1848, that preventative was “A corruption sometimes met with for preventive both in England and America.”

As recently as 1964, a letter to the editor of the JAMA Journal asked, when referencing the story of a professor who would fail his students for using “preventative” in the title of his class on preventive medicine, “Is it possible that preventative has become acceptable or respectable because many people prefer it to preventive?” The editor responded that “most people prefer the shorter and slightly more venerable form of the word.”

Whether it is referred to as preventative care or preventive care, it is critical for healthcare outcomes. Independent physicians urge their patients to keep on track with screenings and immunizations that can prevent debilitating conditions and catastrophic illnesses. Primary care physicians know that blood pressure checks, tests for diabetes, and screenings for cancers can detect illnesses before they become major issues for the patient.

Most preventive services are covered under insurance plans, direct care plans, and Marketplace coverages. When these services are available to the patient at no additional cost, it makes sense to stay on schedule with the preventive – or preventative – measures to ensure quality patient outcomes.

Greg Miller
October 29, 2018

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Patient motivation and engagement techniques for primary care physicians

Motivating patients to take their medications appropriately and to follow the plan laid out for their injuries, illnesses, or well care maintenance can be a challenge. Many patients are intrinsically motivated while others need additional encouragement and engagement from their primary care physicians. A number of techniques can help the primary care physician engage the patient more fully, including using electronic health records (EHRs) for patient engagement, communicating with the patient regularly, and using a unique approach called motivational interviewing.

EHRs for patient engagement give the physician and the patient the ability to communicate electronically. EHR tools, such as the Elation Patient Passport, offer an online portal for providers and their patients to securely share and communicate regarding their health information. Patients can access their visit summaries, medications, reports, and more online. Patients are also encouraged to ask their physicians questions to clarify follow-up instructions, for example.

The convenience in using an EHR for patient engagement can encourage patients to become more motivated to share additional information with their primary care physician and to follow their treatment plan after the office visit. Patients who prefer electronic communication may be more open to asking questions virtually.

Another technique that can help motivate and engage patients during the visit is the motivational interview, a conversation in which the primary care physician asks questions designed to encourage a hesitant patient to share additional details. The goal of the motivational interview is “not to solve the patient’s problem or even to develop a plan; the goal is to help the patient resolve his or her ambivalence, develop some momentum and believe that behavior change is possible.”

Motivating and engaging patients can be challenging but using techniques that make the patient more comfortable and that are designed to elicit questions and feedback can help the primary care physician better understand the patient’s situation and medical condition.

Greg Miller
October 16, 2018

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13% of patients live in an area affected by the primary care shortage

The primary care physician can be a critical factor in a patient’s healthcare outcomes. Playing a major role in patient care, the primary care physician is focused on well care, prevention, and early detection, monitoring a patient’s signs and symptoms and managing potentially adverse health conditions. Acting as a medical home for the patient, the primary care physician can take the lead in coordinating care, eliminating medication duplications, and reducing unnecessary tests and hospitalizations.

However, there is a growing shortage of primary care physicians across the country. A report published by UnitedHealth Group, “Addressing the Nation’s Primary Care Shortage: Advanced Practice Clinicians and Innovative Care Delivery Models,” shows that the shortage affects patients across both urban and rural areas. Statistics around the gaps in primary care access include:

  • Thirteen percent of U.S. residents (44 million) live in a county with a primary care physician shortage, defined as less than one primary care physician per 2,000 people.
  • Rural residents are almost five times as likely to live in a county with a primary care physician shortage compared to urban and suburban residents (38 percent vs. 8 percent).
  • Nearly as many urban and suburban residents live in a county with a primary care physician shortage as rural residents (21 million vs. 23 million).

The root of the shortage appears to lie in the career choices made by medical school graduates. The report states that in 2017, “only one in six medical school graduates – 5,000 out of 30,000 – selected a primary care residency program.” Primary care physicians who are currently practicing are aging out. According to the report, “over one-third of all physicians practicing today will be 65 or older by 2030.”

As the general population also ages, the demand for healthcare services will increase. The estimated shortage of primary care physicians could grow from 18,000 in 2018 to 49,000 in 2030, so the solution may be in nurse practitioners (NPs), physician assistants (PAs), and certified nurse midwives (CNMs), who “represent a growing part of the nation’s primary care workforce.”

Greg Miller
October 8, 2018

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Useful apps for primary care physicians

There seems to be an app for everything now. The choices can be confusing, particularly when the independent physician is searching for the most useful and most reliable options. Apps can provide a wealth of updated information for primary care physicians, but they can also be time wasters that take up valuable space on an electronic device.

A recent article in Physicians Practice highlights three apps that “are of significance to the primary-care specialties”:

ASCCP Cervical Screening Guideline App (ASCCP) – A simple app designed for easy, quick access with four buttons for screening, management, algorithms, and definitions. The primary care physician can enter data about a particular patient to see the ASCCP strategies for clinical approach. Available algorithms cover almost every possible patient situation and condition.

USPSTF Preventative Services Database App (AHRQ ePSS) – An app that is “one of the most extensive and data-driven list of screening guidelines for patients based on demographic data (age, sex, sexual activity, pregnancy and tobacco use).” The primary care physician can use this app to determine what the patient should be screened for, including “what is most likely to increase their morbidity or mortality in a particular age group” based on data as basic as demographics.

Guideline Clearing House App (Guideline Central) – Designed to provide the most relevant guidelines for the physician’s specialty area. The app is a “comprehensive guideline database that is searchable” and allows the primary care physician to tailor those guidelines to a “specialty or particular conditions, as well as provide access to useful tools and calculators relevant to the guideline in question.”

While guidelines for screening and treatment seem to change frequently, these apps can help the primary care physician get current information in real time, based on patient data or data regarding the patient’s condition. For the primary care physicians who want fingertip-accessible information, these apps can be very useful.

Greg Miller
October 8, 2018

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Artificial intelligence and primary care

A significant amount of data is being gathered now in the healthcare industry, by patients who wear personal health and fitness devices and by primary care providers who use electronic health records (EHRs) in their practice. Though individuals can use this data to assess a patient’s condition and to recommend treatment plans and medications, artificial intelligence (AI) may soon provide more extensive benefits to primary care.

Artificial Intelligence for Health and Health Care, a recent study conducted by JASON, an independent group of scientists operating through the non-profit MITRE Corporation, focused on “how computer-based decision procedures, under the broad umbrella of artificial intelligence (AI), can assist in improving health and health care.” The subsequent report from MITRE “argues that AI application in health could help clinicians provide the best possible care, thus making high quality health care services available to all, and could increase people’s engagement in their own health.”

AI can process much more data than any human could, enabling it to look at the bigger picture of population health, for example. One goal identified in the MITRE report is “accelerating the discovery of novel disease correlations and helping match people to the best treatments based on their specific health, life-experiences, and genetic profile.”

As to patients becoming more involved in their own healthcare, AI in the primary care practice and smart devices worn by those patients will become “increasingly interdependent.” The report notes that, “on one hand, AI will be used to power many health-related mobile monitoring devices and apps. On the other hand, mobile devices will create massive datasets that, in theory, could open new possibilities in the development of AI-based health and health care tools.”

A challenge in the implementation of AI in the primary care practice is the disparity between human input and pure statistical data processed by AI. The report acknowledges that most data “concerning an individual patient is mostly obtained in forms designed to be accessible to medical personnel.” The patient’s medical record contains images of x-rays and visit notes input by the primary care physician. JASON acknowledges that the shift to AI for primary care will probably not happen completely within the next 30 years but, looking farther into the future, it could be very helpful in patient care.

Greg Miller
October 3, 2018

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Imagining a primary-care focused advanced APM

An integral part of the Centers for Medicare & Medicaid Services (CMS) Quality Payment Program (QPP), the Alternative Payment Model (APM) is “a payment approach that gives added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.”

As reported by Modern Medicine Network, the Physician-Focused Payment Model Technical Advisory Committee (PTAC) voted in late 2017 to recommend that Health and Human Services (HHS) test the Advanced Primary Care (APC) APM developed by the American Academy of Family Physicians (AAFP), an organization with a membership of more than 84,000 actively practicing physicians. AAFP notes that the potential impact of a primary-care focused advanced APM could be huge.

Interviewing representatives of AAFP, author David Raths asked several questions regarding the need, structure, and impact of the APC APM. Amy Mullins, MD, AAFP medical director for quality improvement, responded that “there needs to be an AAPM that will be available for the majority of primary-care physicians to participate in as an alternative to MIPS (Merit Based Incentive System). Dr. Mullins noted that “it is difficult to achieve wide adoption of a payment model if it is too complex and has a high reporting burden. This is magnified if physicians are not getting paid for doing this work on all of their patients.”

Michael Munger, MD, AAFP president, further explained that primary care physicians typically are paid based solely on the patient visit time. Inequities start to appear in the procedural codes when the visit might entail discussing several chronic conditions with the patient but a single procedure such as a colonoscopy is worth three times as much. Additionally, primary care physicians typically spend time coordinating care with specialty providers or managing conditions between visits, for which there is no procedural code.

The proposed APC APM model also addresses social determinants of health, important factors in primary care. Dr. Munger explains that “You cannot do effective population health management unless you are addressing social determinants of health. The ability to risk-stratify your population to look for individuals who have food insecurity or transportation needs or who don’t feel safe in their neighborhood lets you target your resources better. It also allows patients to better participate in their own chronic disease management.” He adds that the proposed APC APM model “really does recognize the importance of a prospective, risk-adjusted population-based payment.”

Greg Miller
October 1, 2018

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