March 2003 • Volume 9 • Number 3 |
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BY SHIRL KASPER
 Hundreds of Missouri physicians -- more than 100 of them FPs -- gather in the state's Capitol in Jefferson City for White Coat Lobby Day Jan. 29, focusing on tort reform. |
Family physician Julie Wood, M.D., thought she had her future all planned. She finished her residency seven years ago and moved back to her hometown of Macon, Mo., intending to practice there until the day she retired.
Wood soon was delivering about 75 babies a year, with most of the deliveries covered through Medicaid. She admitted and delivered at the local hospital, but actually worked for an outreach clinic run by a larger hospital in nearby Columbia, Mo.
"I deliver babies. That's the favorite part of my practice,'' she said. "I wanted to deliver babies -- and watch them grow up."
But then the medical liability crisis hit, and Wood's malpractice premium soared from about $19,000 a year to $71,000.
Her situation worsened when the Columbia hospital decided to close its outreach clinics.
"We've basically had two big hits come at the same time," said Wood, president of the Missouri AFP. "They're saying our premiums may go up again, almost as much as they did recently. That's the thing: How long can we hold out here?''
In January, Wood announced that she was giving up her family practice -- and her hometown dream.
Wood is not alone. The need to shut down her practice was brought on by a liability crisis that is making national news. Following a New Year's Day walkout by surgeons in Wheeling, W.Va., more than 800 doctors in the Palm Beach, Fla., area walked off the job. In Mississippi, a dozen surgeons took leaves of absence from four Gulf Coast hospitals. And in New Jersey, a three-day physician slowdown early last month brought same-day surgeries and diagnostic procedures to a standstill.
 FP Julie Wood, M.D., of Macon, Mo., testifies to state legislators about skyrocketing medical malpractice premiums. |
In Texas, the governor declared a malpractice insurance emergency, and in Georgia, a new study indicated that one in five Georgia doctors was abandoning high-risk procedures. Statehouse rallies were making headlines, including one in Missouri, where an estimated 600 physicians, including Wood, turned out Jan. 29 for White Coat Lobby Day. Missouri doctors want to cap awards for noneconomic damages at $250,000, down from the current $547,000.
"It was very bittersweet to stand there in the rotunda (of the state Capitol),'' Wood said. "Everybody has a different worry to some extent, but it all boils down to the same problem: Access to care is going to be an incredible problem."
In Connecticut, AAFP Past President Neil Brooks, M.D., sent an Op-Ed piece to the Hartford Courant, saying that he was giving up his practice of 32 years because the liability crisis had "struck home.''
In rural Morrow County, Ohio, Brian Bachelder, M.D., president of the Ohio AFP, decided to stop delivering babies after his liability premium increased by $21,000 last year. Bachelder had been the only Morrow County physician providing obstetrical care.
In Florida, Miami FP Fleur Sack, M.D., "went bare'' last March --dropping her malpractice insurance after her premium reached $25,000 for $250,000 of coverage. In Florida, it's lawful to practice without malpractice coverage. "Basically, it doesn't matter,'' she said. "If you have $250,000 worth of coverage and you're sued for $10 million, you're still uninsured."
Sack, president-elect of the Florida AFP, believes that doctors who go bare see fewer frivolous lawsuits because the deep pockets of an insurance company are no longer there.
In rural Florida, FP Greg Sloan, M.D., of Chipley decided to go bare just last month after his malpractice premium went from $4,500 last year to $13,600 this year -- despite a blemish-free, 20-year career.
"It's just gotten to the point where we can't pay our staff and keep the doors open and pay those premiums, especially with the federal cuts with Medicare,'' said Sloan, who has been told his premium will mature out at $21,000 in a few years. "The thing now is, if I go bare and then have a claim against me, that would probably finish me off."
Physician activists may be making headway in some states.
At press time, New Jersey lawmakers had proposed a $300,000 cap on insurers' and physicians' liability for noneconomic awards, as well as a surcharge on health insurance companies to create a state fund to pay higher awards. Meanwhile, in Florida, Gov. Jeb Bush issued 60 recommendations to address the malpractice crisis, including a $250,000 limit on pain and suffering awards.
Yet there are still too many docs out there faced with questions about their future.
For Julie Wood, the answer came from Baptist Lutheran Medical Center in Kansas City: "Have you ever considered teaching?'' the program director asked her. Come June, Wood will be on the faculty of the center's family practice residency, a position that covers her insurance premium -- and allows her to continue delivering babies.
"Somebody used the word 'demoralizing,''' she said of her feelings about having to give up her hometown practice. "Not just the decision to leave, but the whole process of it ... . There are so many loops and hoops that I can't get through. It seems there are so many more hurdles every day that you can't get to your patients."
About one-third of all states are in a liability coverage crisis, estimates the AAFP Division of Government Relations. And as the crisis squeezes family physicians, constituent chapters are taking action.
Tort reform is a legislative priority for 33 chapters -- some in crisis and some acting to prevent a crisis. The AAFP is assisting them with information, for example, on the benefits of the Medical Injury Compensation Reform Act California passed in 1976.
Speak out!It's easy to send your U.S. representative good arguments for cosponsoring an AAFP-endorsed tort reform bill. The legislation was passed last year by the House, was not considered by the Senate, and now has been reintroduced in the House. The bill is known by its acronym, the HEALTH Act -- the Help Efficient, Accessible, Low-Cost, Timely Health Care Act, H.R. 5. The more cosponsors the bill gains, the more likely its passage. Go to Speak Out: AAFP Legislative Action Center at http://capitol.aafp.org/. Under "Action Alert!" open "HR 5 addresses professional liability insurance reforms." Proceed as directed to e-mail a message asking your representative to cosponsor the HEALTH Act. |
The AAFP is also championing legislation that passed the U.S. House of Representatives last year and was reintroduced last month. The Help Efficient, Accessible, Low-Cost, Timely Health Care Act would mandate reforms in all states' professional liability systems (see box below).
"It is time to act nationally on the threat to patient access to care posed by liability premium increases," said AAFP President James Martin, M.D., of San Antonio in a Feb. 6 statement on behalf of the HEALTH Act.
However, success on the federal front is by no means assured, even though President Bush has endorsed medical liability reform. Last year, the Senate failed to consider the HEALTH Act.
AAFP chapters are enlisting their members not only in federal lobbying but also in brass-knuckle local politics.
In Ohio, the legislature passed sweeping tort reform in 1996, only to have the law thrown off the books three years later by the state's Supreme Court. The Ohio AFP and other groups worked successfully last fall to help two Supreme Court justices sympathetic to tort reform win election.
Ohio AFP Executive Vice President Ann Spicer said the OAFP invited the candidates to speak at the chapter's annual meeting, repeatedly talked about the race in newsletters, and posted material on the chapter's Web site for doctors to download and give to patients. When the justices were elected, Spicer said, one put in her acceptance speech that "medicine had made the difference.''
"We like to say that we awakened a sleeping giant as far as the house of medicine goes," Spicer said. "I think that physicians in Ohio feel really empowered. ... I think they were amazed at the success they had."
In Texas, the Texas AFP featured the liability crisis on the cover of its magazine, Texas Family Physician; surveyed members; made medical liability reform its No. 1 legislative priority; and joined the Texas Alliance for Patient Access, which is pushing for reform.
Tom Banning, Texas AFP director of legislative and public affairs, said the issues center on the affordability and availability of insurance policies. "I think we had 18 or 19 liability carriers two years ago. We now have four in the state," Banning said. "You've got a system where you're either driving the insurance carriers out of the state or they're increasing their premiums to levels that are simply unsustainable for the physician."
The Georgia AFP has been encouraged by the recent appointment of FP Donald Thomas, M.D., of Dalton as chair of the state Senate Health and Human Services Committee. Thomas, a Republican, supports what in Georgia is being called civil justice reform.
"It's huge,'' Georgia AFP Executive Director Fay Fulton said of Thomas' appointment. "Legislators will cross party lines to discuss medical issues with the doctors who are elected officials.''
In Florida last month, Florida chapter EVP Tad Fisher was putting together an information kit for doctors. It included a "10 minutes a week'' initiative, encouraging doctors to spend that time sending an e-mail, making a phone call or talking to a patient about the crisis.
Fisher said FPs were particularly hard hit because of the capitation of their fees and managed care. "There's nowhere for a physician in this day and age to spread the cost," he said. "So you're looking down the barrel of 'Do I stay open? Do I fire my staff? Do I eliminate services that are risky? Do I eliminate patients who are considered risky?'''
BY JANE STOEVER
The four-months-late federal budget for 2003 contains three major victories for family practice and the Academy -- a Medicare physician fee increase (instead of decrease), funding for family practice training at about the 2002 level (instead of no funds), and a moderate increase for the Agency for Healthcare Research and Quality.
| James Martin, M.D. "The good news from Congress and the White House proves this: Political activism rather than local complaining can help us achieve our goals." |
Medicare payments for this year are up 1.6 percent (compared with the expected 4.4 percent cut), a change provided in the omnibus budget bill Congress adopted Feb. 13 and the president signed soon thereafter. The Academy and other medical groups had vigorously lobbied for fairer reimbursement.
"The AAFP commends the U.S. Congress for helping patients and physicians by passing provisions addressing the cuts in Medicare reimbursements for health care services for seniors," said AAFP President James Martin, M.D., of San Antonio in a news statement Feb. 14.
"We appreciate that our elected officials listened to the many family physicians and patients across the country who visited and called congressional offices to discuss this key health care problem," he said.
In addition to visits and calls, family physicians inundated lawmakers with e-mails. Medicare payments in 2002 plummeted 5.4 percent, a drop announced in fall 2001. Between Nov. 1, 2001, and Feb. 3, 2003, family physicians, patients and chapter executives sent Congress 15,103 e-mails on the topic via AAFP's Speak Out: Legislative Action Center.
"Having many thousands of family physicians respond to Congress on this issue shows the power and influence we can have as our lawmakers' constituents," said Martin.
Congress addressed the Medicare fee slippage for 2003 by giving the Centers for Medicare & Medicaid Services authority to correct projection errors made in 1998 and 1999. Effective March 1, 2003, this expected correction by CMS should yield a 1.6 percent increase in Medicare payments.
Title VII, AHRQ
The exact funding amount for family practice training programs in 2003 -- provided through the Public Health Service Act, Title VII, Section 747 -- was not known at press time, but the section as a whole received funding at about the 2002 level of $93 million.
Section 747 covers the primary care cluster, including training for family physicians, dentists and physician assistants. The administration's proposed budget for 2003 had called for zero funds for Section 747 (as does the 2004 proposed budget -- see the rest of this story).
The 2003 budget allows an increase of about 1.6 percent in funding for the Agency for Healthcare Research and Quality, the only federal agency charged with promoting research in primary care. The budget amount for AHRQ this year is about $302 million.
2004 budget proposal
Switch gears to the 2004 budget proposal from the White House. As did the 2003 budget plan, the 2004 proposal slates no funds for Section 747. However, it calls for strengthening community health centers and the National Health Service Corps and for diversifying the health care workforce.
Half of the physicians in community health centers are family physicians, said Martin in a news release last month. "We need to get the administration to recognize the role family doctors play in working in those centers." He added that Section 747 funding has helped create diversity in the workforce.
On the up side, however, the president's 2004 budget plan addresses the need for fair Medicare reimbursement. The document notes, "This budget proposes to adjust the formula to use actual data instead of estimates in current and previous updates. This would result in higher updates for the next several years."
According to staff in the AAFP Division of Government Relations, physicians and their medical societies put pressure on Congress, the Centers for Medicare & Medicaid Services, and HHS. Then the White House agreed to seek a solution.
"The good news from Congress and the White House proves this: Political activism rather than local complaining can help us achieve our goals," said Martin in an interview last month. "This is what it takes to continue serving our Medicare patients and to improve the practice environment for family doctors."
To reach writer Jane Stoever, e-mail jstoever@aafp.org.
BY SHERI PORTER
The AAFP Board of Directors stepped into the future Jan. 18 when it voted to proceed with a plan to establish a foundation that will develop, distribute and support an open-source electronic health record.
Word of the Board's bold proposition got out before the vote and caught the attention of the Wall Street Journal. The paper published a speculative story about the initiative Jan. 16, prior to the Board's meeting in Tucson, Ariz. "The AAFP project could be 'the keystone to the medical information revolution,'" said Paul Ellwood in the WSJ story. Ellwood is founder of the Jackson Hole Group, a health-policy brain trust that advocates electronic medical records.
The key to the development of the Health Information Foundation is the interest and cooperation of other medical associations.
"This is a multistep process, and this Board decision is the first of several significant steps that need to be taken," said Academy EVP Douglas Henley, M.D. "The project will not move forward unless we get other associations to join with us and do the external fund raising necessary to launch the foundation."
It was time for the AAFP to act, said David C. Kibbe, M.D., director of health information technology in the AAFP Socioeconomics Division. "There are many people and institutions in this country who understand that the lack of affordable EHR tools in the doctors' offices is the 'missing link' to a connected, integrated health care system. EHRs are one of the most important requirements to widespread quality, safety and efficiency improvements."
AAFP President James Martin, M.D., of San Antonio said the new foundation will "support development of an EHR system designed by physicians for physicians."
And at an affordable cost. The open-source model eliminates licensing fees, which typically drive up the cost to users.
Don't pull out your checkbook yet, cautioned Henley. Even if the foundation becomes a reality this spring, "it could be late 2004 before we'd see widespread software distribution," he said.
To read more about the project, go to http://www.aafp.org/ehr.xml.
Most Academy members are interested in an AAFP-sponsored electronic health record system, according to an online survey conducted by the Research and Information Services Division in January.
The survey was e-mailed to all active AAFP members with e-mail addresses on file with the Academy. Responses came in from 5,517 members, yielding a response rate of 15.5 percent, considered typical for an online survey.
Survey results were made available to the AAFP Board of Directors as they contemplated the EHR project. Some of the findings indicate high member interest in purchasing and implementing an EHR system. For instance:
(Note: Responders were e-mail users and thus were likely to be biased in favor of EHRs.)
If you're like most FP Report readers, you're a busy "skim" reader. When the printed FP Report hits your mailbox, you check out front-page stories and the highlights bar, then scan other headlines and look at just those stories that interest you. But you also like to read the occasional FP Report "special section," which has several stories that explore a single topic in depth.
Sound like you? If so, you'll be interested in a change coming to FP Report this April, when we start phasing in a concept called "electronic long -- print short," or ELPS. The printed April issue will have only four pages instead of the usual eight -- the right size, we think, for a skim reader. Each story will give you key points on the subject at hand. If you want more detail, you'll still be able to find it -- plus updates on some stories -- in FP Report Online. Bookmark this URL -- http://www.aafp.org/fpr/ -- for the times you want to access the information-rich online edition.
When the May issue arrives, you'll notice it's "business as usual" -- eight pages long. This variation between four and eight pages will continue for several months.
Come early 2004, we'll conduct a reader survey to find out how well ELPS is working for you. If four-page issues meet most readers' needs, all future FP Report issues will be four pages long. When we prepare special sections, they'll appear only in the online edition.
So stay tuned -- and let us know what you think of the change. You don't have to wait for the reader survey, either. Just send your comments to fpreport@aafp.org or mail them to the address shown in the staff box on page 2.
You should screen adults for type 2 diabetes if they have high blood pressure or high cholesterol, the U.S. Preventive Services Task Force said Feb. 3. The panel suggested the screening should be part of an integrated approach to reducing cardiovascular disease.
"So often, diabetes does its damage by leading to other illnesses such as cardiovascular disease," said HHS Secretary Tommy Thompson in a press release on the new recommendation. It marks the first time the USPSTF has recommended screening for type 2 diabetes.
An estimated 16 million people in the United States have type 2 diabetes, including almost six million who have not been diagnosed, said the task force. People at increased risk for diabetes include those who are obese, those who have a relative in their immediate family with the disease, African-Americans, Hispanics, American Indians and Alaska Natives.
The task force found insufficient evidence to recommend for or against routine screening for gestational diabetes in asymptomatic pregnant women.
"Identifying and appropriately treating women with more severe gestational diabetes reduces the number of women who have large babies, but the impact on important outcomes such as Caesarean section, complicated deliveries, or injuries to babies or mothers remains uncertain," said USPSTF Chair Alfred Berg, M.D., professor and chair of the family medicine department at the University of Washington, Seattle.
The AAFP Commission on Clinical Policies and Research will review the task force recommendations and evidence reports to determine whether to establish a policy on screening for type 2 diabetes.
The task force recommendations and materials for clinicians are at http://www.ahrq.gov/clinic/uspstfix.htm, under "New Releases in Preventive Services." Click here for more USPSTF news.
You can take your cue from the motto for this year's National Conference of Family Practice Residents and Medical Students: "Learn Well, Play Hard." This 30th anniversary event promises to be something special!
Make plans now to join your colleagues Aug. 6 9 in Kansas City, Mo., for what is still the only national meeting devoted to family practice residents and medical students interested in the specialty. It's the perfect venue for sharing your experiences and ideas in a relaxed atmosphere, talking with family practice leaders from across the nation, advancing your clinical skills and knowledge, and discovering what leadership and career opportunities family practice offers.
Gear up for four days of diverse and energizing educational workshops and procedural skills courses aimed at fa mily practice residents and medical students.
Any resident or student who attends can make a mark on AAFP policy by:
And AAFP members can further guide Academy policy by electing resident and student leaders and voting their conscience on resolutions developed to shape the future direction of the specialty.
In the exhibit hall, students can talk with representatives of family practice residencies from around the country, while residents can explore wide-ranging career placement opportunities. And once again this year, dedicated exhibit hall hours allow you time to take advantage of the hundreds of exhibits on hand without missing any of the conference's premier educational offerings.
Various community outreach projects offer you chances to make a real difference in the lives of Kansas City residents. And, as always, the conference's many social activities let you relax and have fun.
Be sure to visit the National Conference Web site at http://www.aafp.org/conference.xml for updates on what's planned for 2003. See you there!
It's easy to switch from receiving the printed FP Report by mail to receiving the e-mailed table of contents with links to the online issue. Just visit http://www.aafp.org/myacademy/. You'll be asked to give your password, then select "My Subscriptions" on the left. Click on "Publications Delivery Options" and choose how you would like to receive FP Report.
While you're at the Web page, you can update your e-mail address and fax number in your member record. And you can click to receive AAFP Direct, the biweekly source of "insider" news for AAFP members, by e-mail, fax or mail -- and to receive the e-mailed AAFP This Week, your best source of the latest news for family physicians.
You can also get news from the Academy right on the AAFP home page -- and it's updated every workday. Just go to http://www.aafp.org and click on any of the headlines shown in the upper left corner, under "News from the AAFP."
BY CINDY McCANSE
A little more than a year ago, the Robert Wood Johnson Foundation and an unlikely coalition of business and health organizations launched an unprecedented national advertising campaign highlighting the plight of America's uninsured.
The coalition includes such diverse groups as the American Federation of Labor-Congress of Industrial Organizations and AARP, Families USA and Commonwealth Fund -- and the AAFP. By signing onto the Covering the Uninsured initiative, each member signaled its dissatisfaction with the status quo. Go to http://www.coveringtheuninsured.org for more information on the coalition and its objectives.
"When you're uninsured, life turns out differently," the initiative's ads declare, offering an unabashed look at how health insurance coverage can literally mean the difference between life and death. A young girl in danger of losing her mother to cancer, a young boy whose father's life is threatened by heart disease. The images are evocative, bringing viewers face to face with the grim reality confronting more than 41 million U.S. residents -- eight out of 10 of them members of working families.
Last September, the coalition (now numbering more than 100 regional and national members) announced another first: a weeklong series of nationwide activities designed to draw yet more attention to the crisis.
Cover the Uninsured Week kicks off March 10 with an event in Washington and continues through March 16. Activities scheduled during the week include town hall meetings in cities across the country; educational forums at schools of medicine, nursing and dentistry; health fairs; presentations to business and labor leaders; and discussions with spiritual leaders of all faiths. The effort is being co-chaired by former presidents Gerald Ford and Jimmy Carter.
One goal of Cover the Uninsured Week is to raise public awareness of the dilemma faced by those whose lack of health coverage leaves them without a regular source of health care. Data from the 2001 U.S. Census Bureau report tell the story:
Several Academy chapters are slated to participate in Cover the Uninsured Week. For Kim Bullock, M.D., president of the District of Columbia AFP, participation will mean highlighting some of the results of another RWJ initiative specifically aimed at identifying health disparities that exist largely because of differences in access to health care across ethnic and cultural lines.
"I'm going to be working with Minority Health Communications. They are involved in a Robert Wood Johnson grant to look at health disparities -- specifically, four health indicators -- across all 50 states and the District of Columbia," said Bullock.
Minority Health Communications was the driving force behind the establishment of National Minority Health Month in April 2001.
Academy continues to champion health coverage for allThe AAFP's participation in Cover the Uninsured Week as well as its continuing efforts to bring the message of health care coverage for all to the U.S. Congress were touted in a Feb. 3 American Medical News opinion column by J. Edward Hill, M.D., of Tupelo, Miss. Hill, a family physician, is chair of the AMA Board of Trustees. Go to http://www.ama-assn.org/sci-pubs/amnews/amn_03/edca0203.htm to read Hill's article, which discusses a resolution passed by the AMA House of Delegates at its interim meeting last June. That resolution, which the Academy took the lead in developing, calls for the AMA to advocate a bipartisan congressional resolution to achieve health care coverage through a pluralistic system for all persons in the United States by Jan. 1, 2009. Visit http://www.aafp.org/fpr/20030200/14.html to read more about AAFP's role in passing the AMA resolution. To read AAFP's proposal, "Assuring Health Care Coverage for All," visit http://www.aafp.org/unicov.xml. |
"Here (in Washington), they've developed a detailed mapping of all the wards in the district that showed some interesting disparities in infant mortality and in the rates of cancer, HIV infection and cardiovascular disease," Bullock explained. "What I'm hoping to do is use that as a springboard for presentation during that (Covering the Uninsured) week."
In Chicago, members of the Illinois AFP will be on hand at a health fair scheduled for March 12 on the campus of Truman College. There and at satellite fairs to be held at other clinic locations around the city, physicians and other health professionals will be providing a wide range of services.
Screenings offered will include cholesterol tests, glucose screens, eye exams, blood pressure measurements and bone density tests. Community members attending can also update their vaccination profiles and receive educational materials about health promotion and disease prevention.
Syed Ahmed, M.D., associate professor in the Department of Family and Community Medicine, Center for Healthy Communities, at the Medical College of Wisconsin, Milwaukee, has seen the problem of being uninsured from both sides. His story appears on the coalition's Web site at http://coveringtheuninsured.org. Click on "Personal Stories" for a list of persons who have shared their experiences.
As a graduate student "barely scraping by" nearly two decades ago in Houston, Ahmed was injured in a car accident. Lying bleeding in the middle of the road listening to the ambulances coming closer, he said all he could think about was how he was going to pay the emergency room bill.
Ahmed now serves as director of Reach Out of Montgomery County, Ohio, where a network of volunteer physicians, nurses and others provide free health care two nights a week to people without health insurance. Nearly all of them, he said, are working poor who either are not offered health coverage through their jobs or, if they are offered insurance, don't make enough to afford the premiums.
"We are the richest country in the world, and we have a brilliant, technically advanced health care system. But if it doesn't reach all of our citizens, what good does it do?" Ahmed said. "Everyone in this country should have health insurance and access to affordable health care. I remember that feeling of helpless- ness when I needed treatment and I knew I couldn't pay for it. It breaks my heart to see my patients struggling with those feelings every week at our clinics.
"As a family doctor, I know ignoring an illness never cures one. And I know ignoring the uninsured issue will never cure it."
To reach writer Cindy McCanse, e-mail cmccanse@aafp.org.
BY TONI LAPP
Take note: March 9 15 is Patient Safety Awareness Week. But devoting a mere week to the issue begs the question: Shouldn't every week be patient safety awareness week?
Absolutely, say doctors, nurses and researchers who were interviewed for this story to get their insights on patient safety.
Susan Dovey, Ph.D., M.P.H., of the Robert Graham Center in Washington has made a career of studying ways to make primary care better. She worked on two studies of patient safety that were published in 2002.
"We now have a good understanding of the types of errors that happen in primary care," she says. At the top of the list are communication errors and office management/filing system errors, all boiling down to one point: not having information you need when you need it.
Value of self-assessment
Most recently published was a study Dovey led on error reporting that described a wide range of errors family physicians observe in their practices. What she has learned has been that the act of recording errors led to an examination of office procedures that many participants found enlightening.
Duncan Etches, M.D., of Vancouver, British Columbia, is a prime example. His nurse practitioner noted how difficult it was to locate data relating to patients' diabetes history in their files when his practice participated in a diabetes outcomes study for AAFP's National Network for Family Practice and Primary Care Research (done in collaboration with the Department of Family and Community Medicine at Baylor College of Medicine, Houston). Shortly after, Etches' practice switched to an electronic medical record system -- and the difference was dramatic. "Now such data can be abstracted with a click of a mouse," Etches says.
In fact, the ease of accessing the information allows Etches to run audits on various patient populations. "Most recently we ran an audit to see what our cholesterol control was in patients who had myocardial infarctions," Etches says. "We wanted to see whether we were following guidelines in achieving targets." What he found was that some patients with elevated cholesterol levels were not being treated. As a result, "some of the patients will be contacted," he says.
Systems of care
AAFP Past President Bruce Bagley, M.D., of Albany, N.Y., cites having tried-and-true systems of care as an important safeguard against practice errors.
Checklists should guide the treatment of patients with special needs such as diabetes or asthma, Bagley says. Know what tests patients are supposed to get and when they're supposed to get them.
"It's all about systems and consistency," he says.
Join AAFP's national research network, participate in studies on patient safetyInterested in doing periodic research in your practice to improve patient care and outcomes? Then consider joining the AAFP National Network for Family Practice and Primary Care Research. Through the network, you and your physician colleagues from across the United States can conduct research in such areas as patient safety, as well as in quality improvement, treatment and control of chronic diseases, and screening and prevention. Data collection for two upcoming patient safety studies begins in April. For application materials, contact Tom Stewart at (800) 274-2237, Ext. 3172, or e-mail tstewart@aafp.org. |
But above all, illegible prescriptions are probably the leading preventable cause of errors, says Bagley, whose practice relies on an EMR system.
If you're among the fortunate few doctors who have EMR systems, you already know the benefits -- legible patient records, immediate access to records, instant review of vital signs, printed prescriptions, automated drug-drug and drug-food interaction checking -- the list goes on.
However, the vast majority of physicians -- 95 percent -- do not have EMRs, according to a Jan. 20 article in the Wall Street Journal. So most physicians must work harder to achieve these safety checks.
"Filing, filing, filing"
If your office still uses paper files and those patient charts could talk, what would they say?
Would they describe myriad opportunities for misadventure? Of being misplaced? Of going through several sets of hands en route from clerk to nurse to physician? Would they tell of not having the most current lab reports filed within? Of waiting on your desk for hours until you transcribe notes?
Michael Hartsell, M.D., of Greeneville, Tenn., took part in Dovey's study of computer versus paper error-reporting systems, which was conducted in AAFP's national research network. He says the experience was "eye-opening."
"I'm not sure that I see EMR as the savior for errors, although it is a step in the right direction," he says. Going to an EMR system is not an option for Hartsell because of concerns over the interface with his practice's current billing system.
For Hartsell, the key to a safe practice is "filing, filing, filing." In his efforts to perform continuous quality improvement in his practice, he's asked his partners, nursing staff and clerical staff to report on what they see as safety issues. What they've found is simple: "Each time you introduce another step where someone has to interact with a patient's chart, then there is opportunity for error," Hartsell says.
In another effort to stay ahead of the flow on patients' charts, Hartsell completes all paperwork while in the exam room with the patient. This includes a quick survey of reports, letters, labs and ancillary data for accuracy, currency and authentication.
"The potential for errors occurs in everything you do every day," he says. "Error prevention becomes a mindset. It's something you get up and work on each day."
To learn more about quality initiatives to enhance patient safety, visit http://www.ihi.org. For more on AAFP quality initiatives, go to http://www.aafp.org/quality.xml.
To reach writer Toni Lapp, e-mail tlapp@aafp.org.
BY TONI LAPP
How incensed are AAFP members about states' use of tobacco settlement funds? Incensed enough to pass a resolution at the 2002 Congress of Delegates asking the AAFP to establish a scorecard on how each state is using the money -- estimated to total $206 billion over 25 years.
Greeneville, Tenn., family physician Michael Hartsell, M.D., author of Resolution No. 510, "Tobacco Settlement Monies and State Legislative Accountability," said he was motivated by growing anger with lawmakers' failure -- particularly in his own state -- to respond to what he calls the "tobacco pandemic."
"There should be collective embarrassment that our state is perceived as turning a blind eye to a generation of adolescents who are going to become addicted and their lives forever changed by this decision to use tobacco," said Hartsell. "In states that have used funds to make inroads against tobacco influence, there's going to be less addiction in that cohort of kids."
FACT: Every year nearly 2 million children under 18 try their first cigarette, and more than 730,000 become regular smokers, one-third of whom will die prematurely as a result. These children are the tobacco companies' valued "replacement smokers." (Source: Campaign for Tobacco-Free Kids)
AAFP's Commission on Legislation and Governmental Affairs followed through on Resolution No. 510 by sending a memo to chapter executives. The memo provided links (see box below) to the latest information on how the windfall is being used in a time of economic hardship for many states.
The information shows Hartsell is justified in his criticism: His own Tennessee, as well as Michigan, Missouri and the District of Columbia, contribute nothing from their settlement coffers for tobacco-use prevention.
"States have squandered the opportunity to counteract the marketing of tobacco companies by 'securitizing' settlement payments" -- selling bonds backed by settlement funds to investors, providing a quick infusion of cash that trades in on future payments -- said Tony Iallonardo of the Campaign for Tobacco-Free Kids.
FACT: The annual cost of treating tobacco-related disease exceeds $75 billion. (Source: Campaign for Tobacco-Free Kids)
Massachusetts, formerly lauded for its prevention and cessation programs, has had deep cuts in the programs -- 90 percent in 2002, said Iallonardo -- and the governor's proposed 2003 budget suggested eliminating funding altogether.
Most states have mixed records. In Illinois, educational materials funded by grants now sit on pallets. The state no longer has money to ship them. This is despite collecting $820.5 million in 2002 on tobacco revenue from cigarette taxes and tobacco settlement funds.
The news is only a little better two states east. Ohio, ranked 24th in tobacco prevention spending, has put 10 percent of its tobacco settlement funds into a trust fund and used the interest for prevention programs, said Ann Spicer, EVP of the Ohio AFP. Anti-tobacco marketing targets youths 11 to 15 years of age.
But there's still room for improvement in Ohio, said one Columbus family physician.
"I had a patient ask me the other day if he could get some tobacco settlement money help to quit smoking," said Sarita Salzberg, M.D. "Marlboro had just sent him a gas card! He had a very valid point -- at least Marlboro gave him something. All the tobacco lawsuit has done for him has made him pay more for cigarettes."
And although Ohio has not mortgaged its future settlement payments by securitizing, the funds are still in danger every time the state budget is negotiated, said Spicer. The Ohio Academy belongs to a coalition that fights to ensure that the legislature keeps its commitment to use 10 percent of settlement funds for prevention and cessation. Nevertheless, in 2001 the state diverted $240 million from the fund to fill a hole in the state budget, said Spicer, and the governor's budget proposal suggests diverting two years of payments to the trust fund to apply toward a state budget deficit. Diversion of the money for a third straight year is a setting a very dangerous precedent and calls into question the commitment of the state to prevention and cessation programs, said Spicer.
FACT: Tobacco use is the number one cause of preventable death in the United States, claiming more lives every year 400,000 than AIDS, alcohol, car accidents, murders, suicides, illegal drugs and fires combined. (Source: CDC)
There are some bright spots on the tobacco-prevention landscape: A few states have increased prevention funds. Hawaii more than doubled its funding to about $10 million, putting it at 95 percent of the CDC's recommended funding level. State Tar Wars coordinator Marti Taba, M.D., of Kailua said she has secured a grant for the anti-tobacco education program this year. "We've had Tar Wars in Hawaii for four years and never had significant outside funding until this year," she said.
Go online for tobacco information*Campaign for Tobacco-Free Kids special report on how states are spending their tobacco settlement proceeds: http://tobaccofreekids.org/reports/settlements/2003/fullreport.pdf Campaign for Tobacco-Free Kids report card on the rankings of state funding for tobacco prevention: http://www.tobaccofreekids.org/reports/settlements/2002mid/spendingchart.pdf CDC's Best Practices for Comprehensive Tobacco Control Programs: http://www.cdc.gov/tobacco/bestprac.htm CDC's tips on how to quit smoking: http://www.cdc.gov/tobacco/how2quit.htm AAFP patient education materials on smoking: http://familydoctor.org/ (enter "smoking" or "tobacco" in the search field) *Visit http://www.aafp.org/pdf.xml for information on accessing and reading PDF files. |
Four states -- Maine, Minnesota, Mississippi and Maryland -- meet CDC guidelines for state funding of tobacco prevention.
But health officials are poised to defend this record in Maine, ranked No. 1 by the CDC for meeting funding recommendations. "We are preparing for a very interesting fight in this next legislative session," said chapter executive Deborah Halbach. The Maine Academy belongs to a coalition that will lobby against diverting any settlement funds.
The anti-tobacco campaign in Maine includes cessation assistance in the form of a quit-smoking hot line that is staffed seven days a week. The idea is that smokers who are encouraged to quit by rising prices should be able to get assistance. In addition, community grants support stop-smoking programs, and anti-tobacco marketing that targets teens is found in publications and on the airwaves.
The bottom line, said Iallonardo, is that smoking is a public health problem, and state spending in response to health problems posed by tobacco pales in comparison to the enormity of the problem. But it's not too late to act, he said. "Even states that have securitized their settlement still have a need and responsibility to fund tobacco prevention."
To reach writer Toni Lapp, e-mail tlapp@aafp.org.
The U.S. Preventive Services Task Force in late January strongly recommended that sexually active women with an intact cervix be screened regularly for cervical cancer.
Specifically, women should begin receiving screening within three years of when they become sexually active or when they reach age 21, whichever comes first, said the task force report. They should continue regular screening until they are 65.
Women older than 65 with a history of normal Pap results and who are not otherwise at high risk for cervical cancer may safely discontinue regular screening, said the task force.
In addition to the proper ages at which to begin and end screening, the USPSTF recommendations also address appropriate screening intervals and screening methods. Although the report noted the evidence was insufficient to recommend for or against routine use of human papillomavirus testing as a primary cervical cancer screen at this time, trials are under way that should clarify the role of HPV testing in screening for cervical cancer.
Go to http://www.ahrq.gov/clinic/3rduspstf/cervcan/cervcanrr.htm to read the recommendations and supporting materials. The new recommendations are supported by the National Cancer Institute and are largely consistent with recommendations from the American Cancer Society.
The AAFP Commission on Clinical Policies and Research is reviewing the task force's recommendations and evidence reports and plans to issue updated AAFP recommendations later this year. Current Academy policy on cervical cancer screening appears in the AAFP Summary of Policy Recommendations for Periodic Health Examinations, available at http://www.aafp.org/x10600.xml.
Click here for other news from USPSTF.
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To the reader Write us a letter of 200 words or fewer (subject to editing). FP Report, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672; fax them to (913) 906-6089; call (800) 274-2237, Ext. 5230; or contact fpreport@aafp.org via e-mail. |
To the editor:
I've been spending a lot of time thinking about the future of family medicine. I think I do so because I'm always trying to improve my clinic's performance in order to survive economically. I believe family doctors will always be needed -- but there may not be as many as in the past.
Nurse practitioners are very good, but they lack the ability and scope to handle all that we have been trained for. Some of them do pediatric care, some provide women's wellness services, and some work in urgent care. I believe it is our duty to harness the power of midlevel providers and train them further in an area, so that they may allow us to continue to offer affordable care. Affordable care has always been synonymous with family medicine, and having midlevel providers as part of your team makes it so much easier to survive economically.
If we do not embrace this view, we may find ourselves in competition with midlevel providers, as we all know the costs of care are spiraling out of control. I believe there is a five- to 10-year window to do this. Let's not miss it.
Bruce Fearon, M.D.
Lee's Summit,
Mo.
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Review a new Online Case Study in Pain Management, available for two free hours of AAFP Prescribed credit. Go to http://www.aafp.org/cases.xml and click on "Case 2" on the left to view this interactive case study. Proven value: Enhance your knowledge of nutrition with Physician's Guide to Outpatient Nutrition (#939, $34.95). To order online, go to http://www.aafp.org/catalog/ and click on "Clinical Quality," then on the book title. |
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Proven value: Check out AAFP's cultural competency training tool, "Quality Care for Diverse Populations." To order online, go to http://www.aafp.org/catalog/ and click on "Practice Management" and then on "Quality Care for Diverse Populations Videotape and CD-ROM." The videotape version of the program (#723) costs $150; the CD-ROM (#724) costs $100. |
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Proven value: Order the POL Microscopy Atlas (#725, $98) for your office lab. Order online at http://www.aafp.org/catalog/. Click on "Clinical Quality," then on "Physician Office Laboratory Microscopy Atlas." |
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A shipping fee may apply; Kansas residents pay a 7.525 percent tax. |
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