EHR pilot project provides FPs some playtime
Several AAFP members have been spending quite a bit of time playing in the sandbox lately. Not at the park, not playing with the neighborhood kids. These folks are in their medical offices tinkering with a new electronic health records system.
Last fall, the AAFP asked for volunteers for a pilot project to learn what it takes to implement an EHR system in a family medicine setting. Six physicians from across the country, along with technical support teams from MedPlexus Inc., Hewlett-Packard and Siemens Medical Solutions Health Services Corp., have been immersed in that project since January. The companies are partners in AAFP's EHR initiative, Partners for Patients.
Sandbox learning
AAFP Board member John Sattenspiel, M.D., of Salem, Ore., and the other five participants are currently in "sandbox mode." Sattenspiel has created four imaginary patients, including Mickey and Minnie Mouse. "This mode is a place where we can play with the software," said Sattenspiel. "I can generate notes, enter patient information and basically play around with it to my heart's content."
The sandbox period gives physicians a chance to learn the system, practice the flow and make mistakes before going into a live production mode, said Denny Koch, MedPlexus vice president of operations.
But the sandbox doesn't last forever. In the next few weeks, all the physicians will have to make their technology go live. "When they do, they're seeing real patients and using the system," said Koch.
To make sure they'll be ready, the physicians and support teams have regular phone conferences. The physicians can also access a private online site where they address problems and discuss solutions.
"Our family physicians are working together with some of the very best and innovative information technology companies to help design a low-cost, standards-based EHR option that could be used by many thousands of practices eventually," said David C. Kibbe, M.D., director of AAFP's Center for Health Information Technology.
Exploring the system
The EHR system being tested in the pilot is a work in progress. When a physician encounters a software glitch, the MedPlexus support team finds a fix, then supplies an upgrade via the Internet. "People are really responding to our needs. Every significant upgrade that MedPlexus has provided has been a dramatic step forward," said participant John Wilson, M.D., of Daly City, Calif.
Wilson can't wait for his EHR system to go live this month. "My only frustration is that I want the process to move even faster," he said. Wilson will start by entering every new patient he sees into an electronic chart. If that goes well, he'll add complicated patients who have long medical histories and medication lists. The final tier will be other established patients.
Equipment bells and whistles
The physicians realized early on in the pilot that built-in templates would save them time. "We came up with our most common diagnoses and created templates, and now we've got a small library to get started with," said Wilson.
The EHR system features an extensive internal messaging system, an HP Tablet PC TC1100 which is a pen-based tablet computer system that also allows for free-text entry into a note, and a powerful voice recognition engine "that will allow me to simply speak to my tablet and capture the fine nuances of the clinical visit," said Sattenspiel.
One of Sattenspiel's favorite components is the prescription-writing module. "I can generate a refill prescription with a couple of pen taps on my tablet," said Sattenspiel. The prescription is automatically faxed to the local pharmacy.
Hewlett-Packard provided nearly 30 computers -- Tablet PCs and D530 Business Desktops -- for the pilot. At the project's end, the physicians will have the option to buy their computers at a discounted rate.
Work-flow issues
One big question remains unanswered. How smoothly will implementation go?
"How much is it going to slow us down?" said Sattenspiel. "Docs are afraid of making a big change like this because even though we're drowning in charts with our current system, we're still able to do enough work each day to keep our practices financially viable."
The physicians in the pilot all share a concern about the time required for making the shift, said Sattenspiel. "So far, we all believe it's going to work."
The pilot project will conclude by the end of 2004. The information generated will then be compiled into a final report.
Other physicians involved in the pilot are Kenneth Bertka, M.D., of Holland, Ohio; Michael Peterson, M.D., of Herriman, Utah; Desiree Butter, M.D., of Pittsburgh; and Ronald Hughes, M.D., of Whitakers, N.C.
To reach writer Sheri Porter, e-mail sporter@aafp.org.
Smash, don't trash that computer hard drive
Maybe you've just switched to a new electronic health records system and invested in brand-new computers for your medical office. You aren't sure what do to with the old machines. Take a couple home for the kids? Donate several to their school and the church? Nobody would want that old model in the back room - might as well just dump it in the trash.
Wait! Before you do anything with old computers, think about personal patient information that could be retrievable on the hard drive.
The University of Illinois Medical Center at Chicago learned a hard lesson in February when dozens of its computers were found in a trash bin behind a medical building. A local television reporter pulled several computers from the pile and discovered that one of them not only worked, but also held more than 100 patient records readily accessible on its hard drive. Information about the patients -- including names, results of examinations and suggested treatments -- popped up on the screen.
What's the best way to ensure that personal patient information is not retrievable from a hard drive? "Why not just take a hammer and bust the puppy up?" suggested Don Branson, privacy official for the Kansas University Physician Corp. at the University of Kansas Medical Center in Kansas City. The same advice applies to a personal digital assistant, tapes, CD-ROMs and any other obsolete materials containing patient information, said Branson.
Overwriting and degaussing are other methods of erasing hard drives. But KU Medical Center's security administrator Shelli Crocker said her facility considers "physical destruction to be the most reliable way to ensure that there's no potential misuse of sensitive data left on the equipment." The university has a contractual agreement with an outside source for the disposal service.
If you want to take a computer home to the kids, a new hard drive will set you back less than $300. Isn't your peace of mind -- and the privacy of your patients -- worth that?
ABFP strives to put best foot forward on MC-FP
Would you like your chapter to have its own "private viewing" of the American Board of Family Practice's Maintenance of Certification Program for Family Physicians? All you have to do is ask, ABFP Deputy Executive Director Joseph Tollison, M.D., said recently.
Though well-received by many diplomates, the program has raised concern among some, and ABFP recognizes that, Tollison said. So the board is seeking opportunities to present information about the program to Academy chapters and other groups firsthand. "We're ready to go," Tollison said. "We'd like to go. Please invite us."
Speaking April 30 at a session during the Academy's Annual Leadership Forum-National Conference of Special Constituencies, Tollison explained that the maintenance of certification mandate is an initiative of the American Board of Medical Specialties and its 24 member boards.
"Thirty-five years ago, when the specialty started up and we began certifying (family physicians), FPs were ripe for revolution," said Tollison. "Now, family physicians are a burdened, beleaguered, badgered group of physicians, and it bothers us (at ABFP) that MC-FP comes at this time. So we're empathetic, but we still have to be committed to carrying it forward."
In acknowledging that the board's ultimate responsibility is to the American public, the ABFP regrets not emphasizing its long-held belief that it has 67,000 diplomates between it and that responsibility, Tollison said.
Feedback from AAFP leaders and rank-and-file members has helped ABFP make significant revisions to the program to better serve diplomates, Tollison noted.
Most recently, the two organizations have signed onto a memorandum of understanding regarding MC-FP. AAFP President Michael Fleming, M.D., of Shreveport, La., said the move benefits both groups by clarifying expectations.
"This (memo) sets down a group of mutually agreed-upon principles that allows us a definitive common ground from which to work," Fleming said in an interview after the ALF-NCSC meeting.
Meanwhile, at the grassroots level, many FPs remain wary of the new initiative. One FP, Indiana AFP President Richard Feldman, M.D., of Beech Grove, voiced his and his chapter's concerns during the April 30 session.
"I've been a residency director for almost 25 years," Feldman declared, "so I think I understand education."
MC-FP is not appropriate and it's not needed, he said. "The message we're sending is that what we've been doing (in terms of maintaining certification and demonstrating competence) is meaningless."
The Indiana AFP, Feldman said, will consider a resolution on the issue at its annual meeting in July. And Indiana isn't alone in this endeavor, he added, rattling off the names of two other constituent chapters with similar plans.
Why are some chapters willing to accept -- even embrace -- MC-FP, while others rail against it?
Fleming chalks it up to several factors: "How the concept was initially presented; how 'beaten down' a group feels; etc. But I really believe that how this process has been communicated - or even more, not communicated - has had the most powerful effect on support or acceptance and nonacceptance."
He noted that AAFP President-elect Mary Frank, M.D., of Mill Valley, Calif., recently attended the annual meeting of the Nebraska AFP - another chapter that had expressed chagrin about the new program. "She did a wonderful job of explaining our dealings with ABFP and settling some of their angst over the issue," Fleming said.
To reach writer Cindy Borgmeyer, e-mail cborgmey@aafp.org.
Bring it on!
Father-daughter FP team ready to tackle maintenance of certification
 FPs Warren Heffron, M.D., and his daughter, Kimberly Perkins, M.D., attend a session together at the Family Practice Board Review course in Kansas City, Mo. The two -- both scheduled to recertify this year -- will begin the new maintenance of certification process in 2005. |
AAFP Past Vice President Warren Heffron, M.D., of Albuquerque, N.M., and his daughter, Kimberly Perkins, M.D., of Apple Valley, Minn., share more than the usual genetic complement.
This July, you'll find them both taking the American Board of Family Practice recertification exam in St. Paul, Minn. - Heffron for the sixth time, Perkins for the third. Next January, they'll both enter ABFP's Maintenance of Certification Program for Family Physicians.
The two shared some thoughts about the new program while taking the Academy's Family Practice Board Review course April 23 in Kansas City, Mo. (For a refresher on the basics of MC-FP, visit https://www.abfp.org/moc/about.aspx.)
FP Report: Based on your current understanding of the MC-FP process, what do you think about the new program?
Heffron: I was vice president of the Academy at one time, and I was also president of the (ABFP) board, so I sat there last year (during debates on this topic at the 2003 Congress of Delegates) thinking, "I can see both sides of this."
|
WARREN HEFFRON,
M.D.: |
I've been a firm believer in recertification and in maintenance of competence and skills for years. We're doing that by being here taking this course: We're using it to study for the board exam, but we're also upgrading our skills with CME to apply to our practices and to teaching.
FP Report: What about the hassle factor some FPs see as an inevitable side product of including clinical self-assessment modules in the MC-FP process?
Perkins: From day one in medical school, we were learning based on patient cases. So if we're going to have to do it, at least it's something that's clinically relevant - something that we're going to learn from and that will make us able to treat our patients better. Also, with it being eligible for CME, it's not like it's going to be extra work that doesn't count for something.
FP Report: The whole maintenance of certification concept is said to have grown out of an overall decline in the quality of U.S. health care, including care provided by physicians. How do you respond to that?
Heffron: A perfect example of what this movement is about is the hypertension module (one of two self-assessment modules offered in 2004). For years, we've maintained (a blood pressure of) 140/90 was OK. Now we're having to get the word out that that's no longer acceptable; we need to treat down to 120/80. This is a way to get that message out so we are more aggressive in treating hypertension. So I think these things can be positive and help us all learn to practice better.
FP Report: It's fair to say the two of you represent different generations. Has that had an effect on how you view the transition to MC-FP?
Perkins: Dad, your generation would have had more autonomy in your day. I grew up training in a state that was highly managed care. So, as far as formularies are concerned and being in a system in which you're told, "These are the networks that we have and that you can interact with," it was already restricted. Also, having trained more recently, I'm used to jumping through the hoops and having requirements to meet.
Heffron: I'm thinking back to all the flak last year at the annual meeting and trying to remember if it was more physicians of my generation who were saying it was threatening; it may have been threatening for some. Overall, though, I'd say neither generation finds it threatening or something we disagree with.
FP Report: Any final thoughts on starting this new process?
Perkins: As far as being able to say, "Oh yeah, it's a good thing" -- we don't really know what's required yet. Right now, it's kind of nebulous.
Heffron: My prediction is that once we've all been through that first cycle, it'll all settle down and we'll say, "This is OK, I did it. I can do it."
It's the uncertainty; something new always creates a little anxiety.
Mood disorders monograph offers advice on antidepressant use
Some might have considered it bad timing that the FDA issued an advisory on the use of antidepressants the same week that an AAFP monograph about mood disorders was in production.
AAFP editors thought it a fortuitous convergence of events.
Although the warning did push back the release of the monograph, authors of Diagnosis and Management of Mood Disorders were able to address the FDA's concerns in the 24-page publication, which the Academy is mailing this month to active members.
Robert Gillette, M.D., medical editor of the American Family Physician monograph, made the decision to delay production in March so the authors could review the content in the context of the newly released FDA advisory. Gillette, a professor of clinical family medicine at Northeastern Ohio Universities College of Medicine in Rootstown, said he wasn't surprised by the FDA warning.
"We've known since the 1970s that patients in the depths of depression may be too disorganized mentally to commit suicide, but as they start to improve, they may be able to summon enough energy to complete the act," he said.
Gillette stressed the need to start with a conservative dosage and titrate as necessary. "Any antidepressant use is an experiment in terms of risks and benefits," he said. "You might start on a low dose and work up, or switch to different antidepressants if one doesn't work."
He also emphasized the key point made by the FDA: Stay in contact with the patient. The monograph suggests checking in at one-week intervals in the early stages of treatment with an antidepressant.
Because of the FDA advisory, makers of 10 antidepressants will change the labels to include stronger cautions about the need to monitor patients for the worsening of depression and the emergence of suicidal ideation, said Christine Parker, FDA public affairs specialist.
"The advisory and labeling changes are intended to apply to any physicians and other health care providers who use antidepressants in treating either children or adults," Parker said.
Contrary to suggestions made in the lay press that the advisory would have a sobering effect on family physicians' prescribing practices, Gillette said FPs should remain confident.
"It shouldn't be a deterrent," he said. "Anybody in need of antidepressants is significantly ill and needs what it takes to get the job done.
"I think that the FP should be expected to have the same quality of end results as a psychiatrist does. The standard of care is close follow-up, which should be the same for the psychiatrist as for the family physician."
Furthermore, an FP is often a patient's best choice. A stigma remains to seeing a psychiatrist, Gillette noted, or there may be financial obstacles to seeing one.
What's more, a psychiatrist often doesn't have the benefit of knowing a patient's overall history. Family physicians have long known - and the monograph makes clear - that depression frequently occurs in patients who have other illnesses.
The monograph is an element of the AAFP's 2003 Annual Clinical Focus on Prevention and is supported by an educational grant from Wyeth Pharmaceuticals.
To reach writer Toni Lapp, e-mail tlapp@aafp.org.
WEB EXTRA!
Prescribing tips for antidepressants
The FDA's advisory on antidepressant use should not deter the family physician who has the appropriate knowledge and will take the time to prescribe correctly, says Robert Gillette, M.D., medical editor for AAFP's monograph Diagnosis and Management of Mood Disorders. Here are his tips on prescribing:
Special constituencies tackle obstacles to good care
 A resolution suggesting a cultural competency theme in all AAFP CME programs struck a chord with Telita Crosland, M.D., of Dupont, Wash., left; Jack Chou, M.D., of Baldwin Park, Calif.; and Kim Yu, M.D., of Novi, Mich. The resolution passed after the word proficiency was substituted for competency. |
Attendees at AAFP's National Conference of Special Constituencies chipped away at the forces that erode high-quality medical care. A record 162 physicians, most of them representing constituent chapters, turned out for the NCSC April 29 - May 1. The meeting is held each year in tandem with AAFP's Annual Leadership Forum.
The five constituencies -- women physicians; minority physicians; new physicians; international medical graduates; and the gay, lesbian, bisexual and transgender constituency -- approved 45 resolutions that will be referred to the Board of Directors or the AAFP Congress of Delegates for further action. A sampling of NCSC's work follows.
Disparities in health care. Recognizing that minority medical students often return to underserved urban areas to practice, minority physicians sought to diminish health care disparities by increasing diversity among medical school applicants. Participants suggested avoiding the term affirmative action because some university affirmative action programs have recently come under fire. The final resolution asked the Academy to help identify lower socioeconomic status as a vital criterion in diversifying medical schools.
The minority constituency also asked the AAFP to support legislation on state and federal levels to provide tax credits for all physicians who provide medical care to underinsured and uninsured patients. The effort was seen as a way to decrease barriers to care and increase access to care for minorities and the underinsured and uninsured.
Certification. Maintenance of certification issues took center stage in the women physicians' constituency. Kim Konzak Jones, M.D., of Grand Forks, N.D. - population 1,000 - said requirements for the new Maintenance of Certification Program for Family Physicians would create real hardships for physicians in rural communities where Internet access may be slow or nonexistent. "Money is an issue; time is an issue," she said. "That's just rural America, but it's real America." The women physicians passed a resolution asking the Academy to continue discussions with the American Board of Family Practice regarding members' concerns about MC-FP cost and accessibility issues.
Call schedules. A discussion on equitable call schedules popped up in the women physicians' constituency. A rural physician said she and the one other FP at her hospital are credentialed in multiple clinical departments and are therefore asked to take call for multiple departments, creating a disproportionate call burden. Anne Montgomery, M.D., of Olympia, Wash., said she'd had similar experiences at both small and large hospitals. Ultimately, the issue was addressed by the joint constituency (a gathering of all the groups), which asked the Academy to develop a policy advocating equitable hospital admission call scheduling for FPs.
School bullying. The GLBT constituency moved to enhance AAFP's policy and position statement on violence by adding language addressing school bullying. Discussions focused on the disparity between growing awareness that bullying is a health issue among school children and the reality that many youngsters continue to endure harassment.
The resolution would put the Academy on record as recognizing the harmful effects of bullying due to socioeconomic status, race, color, national origin, sexual orientation, religion, gender, gender identity or disability. This is the only NCSC resolution referred to the Congress of Delegates.
Enhancing participation. To encourage peer participation, the IMG physicians called on the Academy to urge constituent chapters to "create a section on special constituencies incorporating all groups established at the national level."
To contact writers Leslie Champlin and Sheri Porter, e-mail lchampli@aafp.org and sporter@aafp.org.
Constituencies take on access to care, prescription limitations
Physicians attending the National Conference of Special Constituencies April 29 - May 1 issued a rallying cry against some entities' efforts to curb the cost of Medicaid by limiting the number of doctor visits allowed to Medicaid patients and the number of prescriptions provided to those patients.
The new physicians' constituency passed a resolution asking the Academy to "support medical necessity rather than insurance carriers or health care systems dictating frequency of patient visits." The resolution aims to ward off potential denial of service to patients who exceed visit limitations and the cascade of complications that could follow. For example, attendees said, regulators may expect physicians to provide free care for patients who exceed their visit limits, and physicians may become liable for poor outcomes that -- due to limited access to patients -- the physicians could not address.
Two resolutions approved by all of the constituency groups call on the Academy to oppose "term determination" of prescriptions by individuals or organizations that have no prescriptive authority and to oppose third-party payers' limitations on the number of prescriptions considered a covered benefit for individual patients.
The two resolutions were prompted by a trend in which government, insurance companies and health care providers have moved to control cost by limiting beneficiaries' doctor visits and prescriptions. Though most apparent among Medicaid patients, the trend also has affected people with private insurance, said attendees.
All of the constituency groups also passed a resolution asking the Academy to work vigorously to make prescription drugs more affordable. "Patient assistance programs are getting more and more restrictive as (pharmaceutical) companies merge," said Susan Kinast-Porter, M.D., of Monroe, Wis.
Coming this summer: enhanced Web site services that help with HIPAA
AAFP members will have access to free or discounted Web site services that can enhance patient communication and office efficiency, thanks to an April 30 agreement between the Academy and application service provider Medfusion Inc.
Through the agreement, all AAFP active members will have the opportunity to create free Web sites for their practices and offer direct access to the patient education materials on http://familydoctor.org. The sites also will provide access to Medfusion's patient communications capabilities on a per usage pricing basis -- capabilities designed for compliance with the Health Insurance Portability and Accountability Act.
The sites will replace those previously offered through AAFP to members, but will offer increased functionality and more options. Through their Web sites, members will be able to establish a range of secure communications, including patient preregistration, online bill payment, appointment requests, lab results reporting, prescription renewal requests and online consultations. A Web link enabling members to take advantage of the partnership is scheduled to go live this summer.
New FP panel aims to improve vaccination rates
Sometimes physicians find a curbside consultation invaluable. Hearing how colleagues navigate challenges can spark new questions, new solutions.
Such synergy came into play during the first meeting of AAFP's Immunization Collaborative Advisory Group. ICAG, a panel of 10 FPs, began meeting in March to discuss immunization issues. The panel explored, for example, where breakdowns may occur in achieving ideal vaccination rates. The FPs represent a cross-section of family doctors - male and female, urban and rural, from practices large and small. They will generate information, serving as the AAFP's eyes in the field - and indirectly, the CDC's.
One ICAG member said the AAFP had a lot to gain from the panel's discussions.
"This will get the Academy up to speed on the practical issues we're encountering," said Michael Hartsell, M.D., of Greeneville, Tenn., former president of the Tennessee AFP. "The day-to-day workings of office practice have tremendous competing agendas and pressures that can either successfully promote immunizations or, unfortunately, impede them."
The panel came about as a result of a cooperative agreement the CDC awarded AAFP in fall 2003. The agreement, "Strengthening the Immunization Message," is the first such collaboration between the AAFP and CDC.
As part of the agreement, the AAFP will create an annual report for the CDC, gleaning information from the advisory group.
At the inaugural meeting, ICAG participants discussed:
One of ICAG's tasks is to help develop a survey that will go to AAFP active members in the coming months. The instrument will probe to find out where members get their immunization news, whether physicians themselves get immunized against influenza and whether they require their staffs to be immunized.
The cooperative agreement between AAFP and CDC runs through September 2006.
To reach writer Toni Lapp, e-mail tlapp@aafp.org.
Immunization chart for kids has new flu policy
The AAFP has released its July - December 2004 Childhood and Adolescent Immunization Schedule. Because of the risk of influenza complications in young children, the schedule was updated to recommend influenza immunization for children 6 months to 23 months old, as well as for their household contacts. The vaccine is not recommended for infants younger than 6 months.
To view the new immunization schedule, go to http://www.aafp.org/x7666.xml. To read a news release about the strengthened influenza vaccine recommendation, go to http://www.aafp.org/x27263.xml.
The recommendation comes from the AAFP, American Academy of Pediatrics and CDC Advisory Committee on Immunization Practices.
National Guard, Reserve families depend on family physicians
The war in Iraq is sending many of America's family physicians into new medical territory. Their patients -- carpenters and plumbers, teachers and clergy, truck drivers and homemakers -- are leaving Main Street, U.S.A., and shipping out for active military service. To serve them and their loved ones well, family physicians are trying to bring themselves up to speed on military medicine.
"As a community provider, I don't have the same training as military physicians," said Lisa Corum, M.D., of Fort Mill, S.C., the new physician member of the AAFP Board of Directors. "The National Guard and Reservists are people in the community. They're not associated with a military base, so they're in the same situation as the military families, but they don't have the same support."
Among the supports not immediately available to these National Guard and Reserve families: commissaries that soften the financial blow of reduced income when a soldier moves from private sector to military pay; on-site counseling to cope with the stress of sudden single parenthood; legal aid services for such issues as power of attorney for spouses; and guaranteed access to medical care through on-base facilities.
As of April 21, the Department of Defense said 171,917 members of the National Guard and Reserve were on active duty.
On guard for symptoms
Many National Guard and Reserve families must go it alone as they face the socioeconomic, emotional and psychological challenges of preparing for deployment. Stress-related somatic ailments as well as anxiety, depression and other psychological symptoms crop up. And without support from their family physicians, many deployed families can decompensate, said Lt. Col. Lori Heim, M.D., of Southern Pines, S.C.
"For example, spikes in child and spouse abuse occur during the period before and after deployment," she said. "That's because this is a time when they are most afraid."
To prevent such incidents, watch for and address somatic symptoms - changes in sleep or appetite, stomach pain or headaches - throughout the deployment period, say military physicians. When signs of stress overload appear, physicians should inquire.
"I learned to ask about deployment whenever I see TriCare (the insurance for deployed Guards and Reservists and their families) or when I read in the record that the person is in the Guard or Reserve," said Viviana Bianchi-Martinez, M.D., of Davenport, Iowa. "Almost always, there's a relief that they are being asked and they can talk about it."
For tips and resources, see "FPs Have Resources to Help Troops and Families" at http://www.aafp.org/fpr/20040600/10.html.
Coming home again
When a soldier returns with an injury, the soldier's and family's medical and psychological health need attention. Military physicians often arrange for rehabilitation in distant Veterans Administration hospitals, but many soldiers may prefer to be treated at home to be close to family, said Bianchi-Martinez, who has made such arrangements for one of her patients. "He is undergoing rehab for a spinal cord injury," she said. "Once he was transferred to the U.S., I talked to the doctors at Walter Reed Hospital, then his case manager at the Milwaukee VA spine center. I called TriCare and organized for his care and rehab to be done at home instead of (his) having to go to Fort Campbell, Ky.
"We could do that because I made a few telephone calls. Never underestimate the power of a telephone call."
Many National Guard and Reserve families rely on family physicians to help them understand their loved one's injuries and the prognosis for recovery and rehabilitation, Bianchi-Martinez added.
Asked to name the most important contribution a physician could make to a soldier's well-being, one of Bianchi-Martinez's patients who had returned home from service responded, "For me to know that my wife has somebody who cares for her, somebody who cares for the kids. To know that they're in good hands helped immensely."
Ultimately, the greatest value is awareness, Bianchi-Martinez said. "We need to ask ourselves, 'Are we aware of these families? Are we aware of their pain, their sorrow and their pride in these soldiers?'"
To contact writer Leslie Champlin, e-mail lchampli@aafp.org.
WEB EXTRA!
FPs have resources to help troops and families
As National Guard and Reserve troops deploy overseas and return, family physicians can turn to several sources that provide information and support to ease the transitions.
Predeployment help
Among Web pages that offer information for families before deployment is http://www.afcrossroads.com/famseparation/. Designed for active duty Air Force, the site contains universally useful information such as helping children deal with separation and preparing for deployment as a single parent.
The American Red Cross also serves members of the military. For information, go to http://www.redcross.org/services/afes/0,1082,0_481_,00.html.
Post-deployment help
Family physicians also should watch for postdeployment health conditions that are unique to serving in the Middle East. Though most problems are detected during service, some do not present for up to six months.
Comprehensive information for clinicians and families about health issues is at www.pdhealth.mil.
Specific illness concerns are listed at www.pdhealth.mil/deployments/northern_watch/concerns.asp. Among them:
Psychological help
Psychological reactions to combat situations include posttraumatic stress disorder, survivor's guilt and depression. Information about PTSD is at http://www.psych.org/public_info/ptsd.cfm, http://www.pdhealth.mil/wot/background.asp and http://www.pdhealth.mil/wot/fact_sheet2.asp.
Redeployed soldiers can participate in a self-paced program that is part research into effective interventions for people dealing with military stress. Information is at http://www.projectdestress.com/.
Duty hour rules ripple across medical education
A simple rule to give residents more sleep has kept educators up at night. The rule limits residents' duty to 80 hours per week. Its fallout has bumped some medical students' work hours to 100 per week and left educators scratching their heads about ensuring the educational quality of the medical students' experience.
|
"Residents are
some of the main teachers for students, and when the residents go home, the
teaching stops." |
Family medicine has felt less pain than its surgery counterparts, but family medicine programs do feel the pinch, said Edward Bope, M.D., director of the Riverside Family Practice Residency of Columbus, Ohio, and former president of the Association of Family Practice Residency Directors.
"The issue comes up when other resident duty hours are imposed on us," he said, referring to rotations such as surgery. In other situations, family medicine residents may have moderate duty hours and may fill in for residents who've reached the 80-hour quota. "The other specialties are finding that the FP resident is a help in meeting call demand. That increases the quality of the experience for our residents," said Bope.
However, enforcing duty hour restrictions may limit medical students' access to resident supervisors.
Effect on medical students
Implications of the new rule from the Accreditation Council for Graduate Medical Education have rippled across medical schools. Some students say they're working harder; others say their educational opportunities have shrunk.
"The students' work increased to over 100 hours a week on average for the group in my clerkship, and remained that way until two months ago," said William Walsh, a student at Indiana University School of Medicine, Indianapolis, and student representative to the AMA Council on Medical Education. "The longest shift I put in was 44 hours consecutively."
Longer hours resulted partly from expectations that students would complete the nonmedical tasks formerly performed by residents, he added.
"After the ACGME program requirements came into effect, the medical student leadership started receiving reports from our fellow students," Walsh recalled. "I received over 100 complaints myself."
The problem was sporadic and depended on the rotation, said Danny Lewis of East Tennessee State University College of Medicine, Hampton, Tenn., student delegate to the AAFP Congress of Delegates.
"On a couple of rotations, the residents were allowed to go home at noon following call nights, while the students on call were required to continue clinical assignments and lectures until the midafternoon," Lewis said. "On another rotation, however, the student was treated as the resident and went home when the resident did post call.
"As a whole, we savored the opportunity to learn. As long as our duties contributed to learning, then we didn't seem to worry about it."
Walsh responded to concerns by writing a resolution urging the Liaison Committee on Medical Education to address the issue.
Adopted by the AMA Medical Student Section and House of Delegates, the resolution resulted in an LCME amendment to medical school standards. "In general, medical students should not be required to work longer hours than residents," the LCME amendment concludes.
Educational implications
Although one issue is being resolved, a second continues, said Bope.
"Many are concerned that cutting down hours will cut down the educational experience," he said.
Joe McDonald of the University of Kansas School of Medicine, Kansas City, chair of the AMA-MSS Governing Council, agreed.
"I've been hearing from students who've said they aren't learning as much, or some work fewer hours" as schools implement duty hours restrictions, he said. "Residents are some of the main teachers for students, and when the residents go home, the teaching stops."
ACGME is reviewing these issues and may tweak the rules during its September meeting, said Ingrid Philibert, ACGME vice president of field operations. Bope applauds the effort. "During this first year, we're trying to see where the truth is in all that we're hearing," he said. "We are learning how to better teach, how to make better use of residents' time. It's really a redesign of medical education. There's no quick answer. This is an evolving system."
To reach writer Leslie Champlin, e-mail lchampli@aafp.org.
Integrate physicians into biodefense through medicine-public health interface, says FP
A homeland security directive President Bush signed this spring seeks to enhance coordination of the nation's biodefense strategy by assigning responsibilities for specific duties among federal agencies. Shortly afterward, Homeland Security Secretary Tom Ridge reminded the nation's physicians of their biodefense responsibilities as "first preventers and first responders."
Ridge; HHS Secretary Tommy Thompson; and Deputy Defense Secretary Paul Wolfowitz, Ph.D., released a declassified version of the directive (available at http://www.whitehouse.gov/homeland/20040430.html) during an April 28 news briefing in Washington.
Among other items, the directive calls for the Homeland Security Department to establish a national biosurveillance group. The group would create a centralized system for collecting and evaluating information on bioterrorism threats.
Clearly, community-based physicians -- well-versed in recognizing and reporting diseases that threaten public health -- would be an integral part of such a system. "Health care providers and public health officers are among our first lines of defense," the directive acknowledged.
Ridge reinforced the message about health professionals' role in providing homeland security in an April 29 address at the annual meeting of the Federation of State Medical Boards in Arlington, Va.
"The medical community has responsibilities as first preventers and first responders -- critical elements of our nation's preparedness," said Ridge, referring to physicians' roles in the National Disaster Medical System (specially trained teams of medical professionals ready to activate during an incident) or as volunteers in the Medical Reserve Corps (retired health professionals augmenting local health officials' emergency response capacity).
Key to fully integrating community-based physicians into biodefense efforts is fostering recognition of the critical interface between medicine and public health, according to Doug Campos-Outcalt, M.D., M.P.H., clinical professor of family and community medicine at the University of Arizona, Phoenix.
A former medical director of the Maricopa County Department of Public Health, Campos-Outcalt has a special interest in bioterrorism and has served on the AAFP's Ad Hoc Terrorism Advisory Committee.
There's no question, said Campos-Outcalt: "Local doctors -- FPs and other primary care physicians -- should be a more integral part of the public health system. There's a lot that we could do better if medicine and public health were linked."
A study in the May/June Health Affairs that profiled the emergency preparedness status of a dozen communities nationwide helps drive home the need for such a link. Data gathered from visits to 12 nationally representative metropolitan areas between September 2002 and May 2003 found that progress had been made thanks to federal funds specifically slated for emergency preparedness activities, but "important challenges" remained.
"In most communities, the county health department became the lead organization for local preparedness planning and activities," the study noted. "Physician practices were reportedly less involved than other organizations in public health preparedness."
To reach writer Cindy Borgmeyer, e-mail cborgmey@aafp.org.
A trend?
Other specialists crowd primary care picture, study says
|
George Fryer
Jr., Ph.D.: |
Who's eating up primary care in your state? A new study suggests that a good chunk of it is being bitten off by physicians whose main specialty is not primary care.
This is the case in Colorado, where specialists outside primary care fields are providing as much as a third of the primary care medical services, according to a study by the Robert Graham Center in Washington. The study, "Specialist Physicians Providing Primary Care Services in Colorado," was published in the March/April Journal of the American Board of Family Practice.
Graham Center analyst George Fryer Jr., Ph.D., the study's lead author, said the results raise questions about the level of training and experience of the subspecialists providing primary care.
"The significant amount of primary care services provided by nonprimary care specialists should be taken into consideration when researchers and policy-makers are looking at workforce needs," Fryer said. "Are there enough primary care physicians available to meet the need? Our research suggests not."
The study identified as specialists those physicians whose main specialties were other than family medicine, general practice, general internal medicine or general pediatrics.
The research found that of the 47.9 weekly hours that specialists averaged in direct patient care, 12.5 hours were devoted to primary care activity -- defined as preventive care, routine physicals and treatment of common ailments.
About a third of the specialists devoted at least one-quarter of their time to primary care, and 26 percent spent half or more of their direct patient care time in primary care. The authors figured that specialists provided 33.5 percent of the primary care services in Colorado.
Other recent research revealed that the care specialists provide outside their field of specialization is of lower quality than that provided by primary care physicians. Patients may not be receiving the best possible primary care from the nonprimary care specialists, Fryer said. The Graham Center study did not directly measure quality but opens the door to studies on the quality differential, he added.
The research showed that the specialists providing primary care tended to be female, rural, either under 35 or over 64, and not board-certified. Further, osteopathic specialists were more likely to provide primary care services than allopathic specialists. Physicians in emergency medicine and obstetrics-gynecology were the most numerous specialists providing primary care.
The survey did not explore whether specialists' provision of primary care reflected professional choice or a need to fill available clinical time.
"Our study suggests that family physicians provide a service for which there is substantial demand," Fryer said. "By contrast, demand for the services of some specialists is not sufficient to assure robust patient caseloads.
"Our results suggest that specialists may be in oversupply."
To reach writer J. Michael Brodie, e-mail mbrodie@aafp.org.
The new Medicare cards are here, but how will they work?
New government-endorsed prescription drug discount cards took effect June 1. Elderly and disabled Medicare recipients are enrolling in the interim drug discount program through 73 Medicare-endorsed card sponsors.
Under the new program, a patient can select a card from providers such as the AARP, drugstores, insurance companies and HMOs. Beneficiaries pay an enrollment fee of up to $30. The program promises savings on at least one drug in each of 209 categories of commonly used medicines.
At press time, how the program -- and its accompanying paperwork -- would be handled in FPs' offices was anyone's guess.
Thomas Felger, M.D., of South Bend, Ind., sat in on a recent presentation on the discount card program given by the Centers for Medicare & Medicaid Services, or CMS. He came away uncertain as to the program's myriad subtleties. "What I can tell you is that we are really going to have to tailor medications based on coverage," he said.
"I fear this is not going to be a whole lot of help to our patients, and it might be a logistical nightmare," said Felger, chair of the AAFP Commission on Health Care Services. "Trying to manage differing levels of coverage for an array of drugs will mean more paperwork and could confuse patients."
HHS Secretary Tommy Thompson has hailed the cards as a way for seniors to save money.
"The power to save on prescription drugs is now in the hands of seniors and people with disabilities," Thompson said May 3.
But congressional Democrats are critical of the new card program, partly because it limits patients to one card, thus limiting their choices.
In related news, the discount card program has spawned drug card scams in several states, say officials at CMS and the HHS Office of Inspector General.
In response to these concerns, CMS is coordinating information with customer service representatives, call centers for Medicare contractors and State Health Insurance Assistance Programs.
To reach writer J. Michael Brodie, e-mail mbrodie@aafp.org.
Web resources for answering patients' questions
Your patients may ask you questions about the new Medicare discount card program. Some Medicare resources: HHS has links to price comparison information and other resources at http://www.medicare.gov. Medicare card fraud information is at http://www.cms.hhs.gov/media/press/release.asp?Counter=1018. Approved drug card sponsors are listed at http://www.hhs.gov/news/press/2004pres/20040325.html.
The AARP Web site at http://www.aarp.org/prescriptiondrugs/ has detailed drug card information.
Families USA, a national organization that promotes affordable health care, offers a "Medicare Rx Calculator" and articles on the discount program at http://www.familiesusa.org/.
Move into the future now! Tell FP Report your success stories
The Future of Family Medicine project gave birth to its report in late March, and family physicians are asking how to tackle the FFM recommendations. A few answers are bubbling up.
"I want a specific I can do Monday. It's time for me to do something," FP Lloyd Van Winkle, M.D., of Castroville, Texas, said at an FFM town hall meeting during AAFP's Annual Leadership Forum April 30 - May 1 in Kansas City, Mo. (The FFM report is online at http://www.annfammed.org/cgi/ content/full/2/suppl_1/s3.)
AAFP President Michael Fleming, M.D., of Shreveport, La., had answers:
Spinning off that third idea for what you can do Monday, tell FP Report what's succeeding in your office.
It might be steps you've taken that can help move you toward the FFM scenario AAFP Board Chair James Martin, M.D., of San Antonio described at the town hall meeting.
"In the early morning," said Martin, "you'll do e-mails, taking care of eight to 10 patients you've seen before. You'll be reimbursed for that. There'll be no long bus-station lines at your office. You'll be able to get off the hamster wheel and spend appropriate time on patients with more complex problems. In the afternoon, you'll have two or three group visits.
"By the end of the day, you'll have no stack of charts; the info will all be in your EHR system."
In the meantime, back to Monday.
Let FP Report know about a successful strategy at your office. Call associate editor Toni Lapp at (800) 274-2237, Ext. 5216, or e-mail tlapp@aafp.org. Share your success -- perhaps in doing office procedures, serving diverse populations, giving patients control of their health or grounding your care in evidence-based medicine -- and FP Report may tell your story.
2004 airlift will deliver medicine, education to republic of Georgia
 In this photo from the 1997 Physicians With Heart trip to the republic of Georgia, Matt Miller, M.D., then a resident at Indianapolis St. Francis Family Practice Residency in Beech Grove, Ind., offers a Beanie Baby to a young boy laid up in a hospital in Gori. |
Physicians With Heart is again poised to deliver its annual shipment of medical supplies, education and good will - this time to the former Soviet republic of Georgia.
PWH is a collaborative effort of the AAFP; AAFP Foundation; and Heart to Heart International, an Olathe, Kan.-based humanitarian aid organization. The dates for the 2004 airlift are Oct. 28 - Nov. 7.
Each year, the airlift brings tons of pharmaceuticals and other supplies donated by U.S. companies to a former Soviet republic with the assistance of the U.S. State Department. And each year, FPs join the airlift's volunteer delegation.
In addition to ensuring delivery of the donated supplies, airlift delegates participate in children's projects -- this year benefiting the Tbilisi Boarding School for Deaf Children and the Akhalgori Orphanage.
Participants also provide family medicine education to the country's health professionals. This year's delegation will sponsor symposia in Tbilisi, the republic's capital, and Kutaisi, the second-largest city. Trip organizers plan to offer Advanced Life Support in Obstetrics courses -- two provider courses and one instructor course -- as part of the educational fare.
This will be the second time PWH has visited the republic, says Daniel Ostergaard, M.D., AAFP vice president for international and interprofessional activities. Family medicine has taken root there, he notes, changing the educational expectations for this trip.
"When we visited in 1997, it was mainly, 'What's a family doctor?'" Ostergaard explains. "Now, they're looking for much more meat. They want information on faculty development. They've even asked for family medicine board review materials."
To join the volunteer delegation, contact Jeanne Fell at Heart to Heart International at (405) 787-5200, Ext. 102, or e-mail jfell@hearttoheart.org. Direct your questions about the delegation's educational efforts to Ostergaard by phoning (800) 274-2237, Ext. 4500, or e-mailing dosterga@aafp.org.
Got a question for an AAFP candidate? Go online to ask, get answers
The Congress of Delegates will elect new AAFP officers and members of the Board of Directors on Oct. 13 in Orlando, Fla. To see who's in the running, visit http://members.aafp.org/members/congress/candidates/ and use your AAFP ID number to log in. From there, you can link to individual candidates' Web sites.
Fire off questions for the candidates using the "Question/Answer Forums" and get responses online. But please remember: These forums are reserved solely for your questions and the candidates' responses.
Members wishing to air their views on topics are invited to join e-mail discussion groups hosted by the AAFP. Go to the Academy's home page at http://www.aafp.org/ and click on "E-mail Discussion Lists" under the "Membership" heading to subscribe.
Deadlines loom for conferences, grants
You might want to post some of these deadlines on your calendar. For details, call (800) 274-2237 and the extensions noted below, contact staff via e-mail, or check the Web sites.
Tar Wars. Register for the Tar Wars® National Conference by June 22. The meeting combines the Coordinator Leadership Conference and the National Poster Contest July 20 - 22 in Alexandria, Va. For more information and to register online, visit http://www.tarwars.org/x1748.xml.
Patient education. Note the July 5 deadline for submitting nominations for awards to be presented at the 26th Annual Conference on Patient Education Nov. 11 - 14 in San Francisco. The Patient Care Award for Excellence in Patient Education Innovation and the H. Winter Griffith Award for Excellence in Patient Education Materials will each be presented to an individual, program or organization. For information and applications, visit http://www.stfm.org/awards/pated.html#anchor87841. For resident and new physician grants and scholarships for attending the meeting, apply by Aug. 13, using the form you can download from http://www.aafp.org/pec.xml.
Assembly. The early registration deadline is July 14 for the AAFP Scientific Assembly Oct. 13 - 17 in Orlando, Fla. Sign up for it and you'll automatically be admitted to the 17th World Conference of Family Doctors, sponsored by Wonca, the World Organization of Family Doctors. Both meetings will be held in the Orange County Convention Center. If you miss the early-bird deadline, aim to register by Sept. 1, the cutoff date to sign up in advance for housing and for the Assembly. Go to http://www.aafp.org/assembly.xml for information and to register for the meeting.
Research. You may have creative ideas for a research project in a practice-based research network. Submit your proposal by Aug. 30 for a PBRN Stimulation Grant. For information, go to http://www.aafpfoundation.org/x445.xml.
Student scholarship. Chapter foundations may nominate students for the James G. Jones, M.D., Student Health Policy Scholarship by Oct. 11. This program will allow a student the attend the American Medical Student Association Political Leadership Institute to be held during January or February. For details, call Ext. 4457. For background on the scholarship, visit http://www.aafpfoundation.org/x263.xml.
Come to AAFP's online bookstore to order comprehensive reference books about family medicine. You'll find textbook selections in four categories: "Child and Adolescent," "Family Medicine," "Orthopedics" and "Patient Library." Discounts are available to AAFP members. Shop the bookstore at http://www.aafp.org/bookstore.xml or call (800) 944-0000.
Learn about other AAFP products and services -- including the Crash Course on Cash, Codes and Computers -- at http://www.aafp.org/fpr/20040600/new.html. To find out about documents available from the AAFP by fax, including meeting information, visit http://www.aafp.org/fpr/20040600/quickfax.html.
You'll also find other news online, including unabridged versions of some stories in this printed FP Report. For the added news, go to http://www.aafp.org/fpr/ and click on "June 2004."
WEB EXTRA!
|
|
|
Come to AAFP's online bookstore to order comprehensive reference books about family medicine. You'll find textbook selections in four categories: "Child and Adolescent," "Family Medicine," "Orthopedics," and "Patient Library." Discounts are available to AAFP members. Shop the bookstore by phone or at http://www.aafp.org/bookstore.xml. |
 |
|
Don't have time to travel to a CME course? Take advantage of AAFP Online CME Case Studies available at http://www.aafp.org/cases.xml. New cases on the Web site are "Case Study in Acetaminophen Overdose" and "Case Studies in Respiratory Diseases." After completing these cases, or any of the others on the Web site, and review your results, fill out the documentation and receive free CME credit. |
|
|
Proven value: Do you wish you'd learned more in medical school about the basics of financial management? AAFP's Crash Course on Cash, Codes & Computers Oct. 11 - 12 in Orlando could be just the boost you need. Become proficient in reading balance sheets and income statements, and take home tips on diagnosis and procedure coding that could improve your bottom line. This course targets physicians in small- to medium-size practices. Go to http://www.aafp.org/crashcourse.xml to register. Extend your stay in Orlando and attend the AAFP Scientific Assembly Oct. 13 - 17. For more information and online registration go to http://www.aafp.org/assembly.xml. |
 |
|
A shipping fee may apply; Kansas residents pay a 7.525 percent tax. |
WEB EXTRA!
|
||||||||||||||||||||||||||
FP Report is published by the
AAFP News Department.
Copyright © 2004 by
American Academy of Family Physicians.
