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If you want a glimpse of where family medicine is headed in the not-so-distant future, hang out with the next generation of FPs for a day. At the Trident Family Medicine Residency Program, residents recently told FP Report -- in no uncertain terms -- that they will settle for nothing less than electronic health records in their future practices.
The coverage in this issue -- part three in a series on the new model of care proposed in the Future of Family Medicine report -- shows how training residents with EHR technology will change the specialty of family medicine. You can access the report at http://www.annfammed.org/cgi/content/full/2/suppl_1/s3.
Residents speak out
A stroll through the Trident clinic yielded residents eager to share their thoughts about how the information technology in place here has affected their ability to provide top-notch patient care, and ultimately to go out and find a job.
Third-year resident Rick Wall, M.D., said he appreciates being knowledgeable, not awed, about new technology when interviewing for a job. "It's a good selling point for me because I can ask intelligent questions about the topic," he said. "Some places where I've interviewed have told me they'd like their next partner to be EHR-savvy."
Chief resident Ann Rodden, D.O., said when she interviews, she asks whether the practice has implemented an EHR system. "If the physicians don't have an EHR system, they at least have to be open to getting one, or I cross them off my list," she said.
Third-year resident Priscilla Holtzclaw, M.D., was surprised to hear that Trident is in the minority when it comes to family medicine programs offering on-the-job EHR training. "Really?" she said. "I don't know how we'd pass patient information between us if we didn't have an EHR."
EHR advantages abound
 First-year resident Blake Leslie, M.D., shown here with patient Sheila Wright, said this about residents training with EHRs: "I didn't look at any residency programs that didn't have an EHR system in place." |
Access. Access. Access. All of the residents can access a patient's record electronically whether they're in the clinic, at the hospital across the parking lot or at home. Chief resident Amy Black, M.D., appreciates home access. "When I'm taking a phone call at home from a patient, I can pull up that record instantly, so I don't have to go over the person's entire life history to answer, Can I take this product safely with the medications I'm on?'" she said.
With electronic patient notes, the agony of attempting to decipher colleagues' scribbles is a distant memory. "Everybody can read everybody else's notes. We've eliminated errors caused by bad handwriting," said Black. And the use of templates imbedded into the EHR makes information easy to find because the template is the same for everyone. "I'm not hunting for information," said Black.
No one here misses "missing" charts. "Other places I've ever been, folks spent a lot of time looking for charts," said Rodden.
William Hueston, M.D., family medicine department chair at the Medical University of South Carolina, Charleston, shared what he tells colleagues when they admit letting their fear of computer crashes curb their EHR appetites: "Yes, computers go down occasionally, and when they're down, we're 100 percent down. But all other days we have 100 percent of our charts."
Culture of medicine changing
Hueston also applauds computerized records for reducing the mental strain physicians face. "The culture of medical education is that we rely on memory," said Hueston. "We make errors because we don't look things up -- and we don't look things up because it's a sign of weakness." EHRs get physicians away from memorizing and move them "to the wisdom of knowing what we need to know," said Hueston.
There are enough computers for the program's 34 residents to be online simultaneously, so there's no excuse for not taking advantage of online medical databases.
Hueston is pragmatic about the shift from paper to an EHR system. "It's a tool," he said. "It doesn't change medicine. It makes the practice of medicine easier."
To reach writer Sheri Porter, e-mail sporter@aafp.org.
 Trident's library is shrinking because of easy access to online information. Chief resident Amy Black, M.D., said the books get dusted more often because they don't get used much. |
The reason some physicians don't understand how to evaluate their quality of care is because they have paper charts and don't know what level of care they currently provide," said Lori Dickerson, Pharm.D., associate professor and assistant residency program director at Trident Family Medicine Residency Program in Charleston, S.C.
"Physicians tend to overestimate the degree of quality they provide; an electronic health record gives a more accurate estimate," she said.
The second- and third-year residents participate in Trident's Clinical Scholars Program, which gives them an opportunity to evaluate and improve patient care using information gleaned from electronic patient records.
Putting data to work
The residency program uses Physician Micro System Inc.'s Practice Partner software and participates in PMSI's Practice Partner Research Network.
Network participants export patient data (stripped of all personal health information) to the network each quarter, and that data, collected on hundreds of quality indicators, is sorted by statisticians and fed back to the submitting physicians quarterly.
The latest report to Trident from the network included statistics on the proportion of:
If Trident's numbers sit below the national benchmark, that's impetus for improvement, and that's where the residents go to work. In small teams, they select areas of interest, search electronic records for a pattern to isolate a problem and then suggest an action that may lead to a solution.
Quick results a bonus
"This (EHR) is an incredible tool," said Dickerson. By making ever-so-slight adjustments in office procedure, staff can quickly evaluate progress. "You don't wait for two years, you wait for six weeks," she said. "The EHR allows everybody on the health care team to be involved in quality."
Residents finalize their projects and present results to during at least two meetings in the spring. All projects are approved by our the institutional review board for human research, said Dickerson, and the Clinical Scholars Program fulfills the Residency Review Council's requirement that all residents must be involved in practice-based learning and improvement.
To reach writer Sheri Porter, e-mail sporter@aafp.org.
Trident Family Medicine Residency Program's love affair with computerized records (see "Residents hold key to future") goes back to the program's roots. According to the current residency director, Peter Carek, M.D., the founding department chair's insistence on implementing computerized patient records in 1973 resulted in the installation of an IBM mainframe "that took up two offices at our downtown site."
"It was so big, it needed its own air conditioning," said Carek.
A far cry from today's high-tech computers, the mammoth machinery merely saved physician notes in electronic form; the notes were then printed out and inserted in the patients' paper charts.
Roll the calendar forward to 1991. Under the direction of (then) department chair Cleve Hutson, M.D., Trident took a giant leap into the electronic health record system it uses today.
The program has secured federal grants, most recently one grant from the Health Resources and Services Administration that will be put to use in the Clinical Scholars Program (see "Data collection equals quality improvement").
Over time, the department has seen significant cost savings, much of that in reduced personnel, said Hutson. The records room staff dropped from four people to just one. A typing pool of eight secretaries used to tap out notes; now a single person inputs data.
Better coding also puts more money in the bank. "Residents are notorious for undercoding," said Carek. "We've noticed an increase in patient care revenue, and I attribute that to more accurate coding." Templates built into patient charts give coding prompts.
Hutson said the residency's underlying theme has always been the computerized record. "We wanted to establish something here at this program that residents could take with them," said Hutson, who at 73 still sees patients and doesn't want to remember life with paper charts. He awaits the day when all physicians and all hospitals are electronically linked. "That reality is not as far away as people think," said Hutson. "The technology is here; all we have to do is grab it."
To reach writer Sheri Porter, e-mail sporter@aafp.org.
According to AAFP data, nearly 30 percent of family medicine residencies are using some form of electronic health record. There's much work ahead to meet the Future of Family Medicine recommendation that every family medicine residency implement an EHR system by the end of 2006.
John Bucholtz, D.O., of Columbus, Ga., past president of the Association of Family Medicine Residency Directors and chair of FFM's Task Force 2, said he "fussed real hard" to include that one date in the report.
"We wanted program directors to have a firm, weighty recommendation to take to their hospitals back home to help influence the argument to invest in this technology," said Bucholtz.
Director of the Columbus Family Medicine Residency Program, Bucholtz has recently overseen successful implementation of the residency's EHR system. He said he knows firsthand the benefits of better quality measurements, increased patient safety, more accurate documentation for increased reimbursement, and happier patients and physicians.
If you have any doubts about the ripple effect residents can have on family medicine's future, think about this, said Bucholtz: "Residency graduates who are early (EHR) adopters will yield a cohort of 3,000 family medicine graduates yearly, all of whom will be well on their way to implementing the new model of care."
And that's a lot of good role models available to reach out and help colleagues along.
To reach writer Sheri Porter, e-mail sporter@aafp.org.
Open access scheduling. Online appointment setting. Electronic health records. Such is the stuff of the Future of Family Medicine project's new model of care.
Physicians who implement such features can increase their productivity and their compensation, says Stephen Spann, M.D., of Houston. Spann chaired FFM's Task Force 6, which was charged with studying the financial viability of the new model of care.
"But this is not just about money," said Spann. "We sincerely believe the new model will improve quality of care, patient satisfaction and physician satisfaction as well as practice financial performance."
A consultant, The Lewin Group, conducted an economic modeling exercise to illustrate the financial impact of the new model with the current pay structure. The modeling exercise was based on a typical family medicine office, comprising five FPs. Isolating 10 features from FFM recommendations that would be easy to model, Lewin predicted there would be a 26 percent increase in an FP's compensation as a result of implementing all 10. Similarly, an FP putting the 10 features in place could decrease his or her workweek by six hours and maintain the same compensation as before, said Spann, or could work the same hours as before and have the same income but gain more time for patients.
The key is to take action, said AAFP Board Chair Michael Fleming, M.D., of Shreveport, La., a member of Task Force 6.
"This doesn't mean that doctors can practice the way they've been practicing and make more money," he said. "It's going to require change. We have to make those changes on faith."
Those changes will not be painless.
According to the Task Force 6 report, the cost to transition to the new model will be anywhere from $23,442 to $90,650 per physician, depending on the loss of productivity associated with implementing an EHR system. "But the biggest investment is the willingness to change," said Fleming, who predicted that the financial benefits of the transition would be realized within a year.
Spann noted that the 26 percent increase in compensation was estimated using the current pay-for-service structure. An even larger increase could be gained from a mixed-payment structure, which the Academy has been investigating through talks with CMS and private insurers.
Task Force 6 addressed not only the microeconomic impact, the effect on individual physicians, but also the macroeconomic impact, on society. "If every patient in the country had a primary care physician and received primary care, total U.S. health care costs would be reduced 5.6 percent," based on Lewin's projections, said Spann.
The final report of the task force, published in the November/December Annals of Family Medicine, can be found at http://www.annfammed.org/.
To reach writer Toni Lapp, e-mail tlapp@aafp.org.
Forget about health care legislation. If you want to ensure patients' access to care and your own reimbursement for providing that care, follow the money.
That was the advice from political observers who predicted "an unbelievably challenging year" for health care policy. Family physicians can achieve their political goals, but only if they keep their eyes on state and federal budget legislation, Victoria Wachino, health policy director for the Washington-based Center for Budget and Policy Alternatives, said during the AAFP State Legislative Conference here Nov. 5 - 6.
"The number of poor in America is increasing rapidly, more rapidly than any time in the recent past," said Wachino. A family of three earning $15,670 a year live in poverty, according to current federal guidelines, "and the number of children in extreme poverty, which is 50 percent of the poverty level, is rising very rapidly," she said.
Medicaid, the assumed safety net, has begun to fray under states' budgetary stress. And the current federal deficit, coupled with tax cuts and growing demand from an aging and uninsured population, is likely to shred that net a bit more, according to Wachino.
"We're going to have deficits for years to come," she said. "What does that mean to access to care? It means just about everything."
Dual budgetary stresses mean "you're going to have to be playing tennis on a lot of different courts -- on the state level and on the federal level," she said. "You're going to need to be extremely, actively involved in the federal budget process. Watch the budget legislation; it's not going to be framed as health care legislation. But it's going to have a big impact on health care."
Family physicians' patients stand to win or lose in the budget process. About 77 percent of active FPs take Medicaid patients, according to the 2004 AAFP Practice Profile survey.
Medicaid costs rank second in state expenditures, making them a target for cutbacks when states are under pressure, said another conference speaker, Barbara Lyons, vice president and deputy director of the Kaiser Commission on Medicaid and the Uninsured. Already, states have moved to aggressively limit their Medicaid outlays. Since 2000, states have sought waivers to Medicaid regulations in order to reduce benefits or shift costs to beneficiaries. Nearly half the states have implemented higher costs and procedural barriers to Medicaid eligibility, said Lyons.
At the federal level, Congress will consider ways to stem the cost increases, said Wachino. Rep. Joe Barton, R-Texas, has announced his intention to introduce what Wachino called a "significant federal Medicaid reform bill, most likely incorporating Medicaid block grants," during the 109th Congress. Other members of the House have broached the topic of capping Medicaid entitlement spending, she added. A final option is reconciliation, a legislative process that is difficult to track because it sets across-the-board deficit reduction targets over multiple years.
Tom Banning, director of legislative and public affairs for the Texas AFP, agreed with Wachino's belt-tightening forecast. "Congress wants fiscal accountability, and if that means redoing the whole system, then (their attitude is) so be it," he told conference participants.
To reach writer Leslie Champlin, e-mail lchampli@aafp.org
The discrepancy between compensation paid for family physicians' clinical expertise in maintaining patient health and that paid to procedure-based specialists to treat an unprevented illness may begin to blur in the next decade.
That's because Medicare and managed care officials have begun to acknowledge the higher-quality outcomes and lower costs that result from family physicians' services, said AAFP Board Chair Michael Fleming, M.D., of Shreveport, La.
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MICHAEL FLEMING, M.D.: |
Research consistently demonstrates that "people who have a continuous relationship with a physician have better outcomes with less cost," he said. But as fewer medical students choose family medicine, the prospect for a shortage in primary care looms. Already, rural and inner-city areas have grappled with long-term physician shortages, Fleming observed.
"The only way this situation is going to change and the only way we're going to prevent a crisis in access to care is to value the care that family physicians bring to the system," said Fleming. "The responsibility is on the payers, because if they don't act, there will be a serious issue on access to quality economical care in the future."
Fleming said government and payers have acknowledged their responsibility for changing the system to attract more students to primary care.
"During deliberations for the Future of Family Medicine Task Force 6, we had payers at the table, and they all agreed the responsibility is on them" for changing the system, he continued. "We are hoping that several will agree to demonstration projects that pay for quality and for performance, and that will do exactly what we say should be done in the Future of Family Medicine report. It can't happen soon enough."
To reach writer Leslie Champlin, e-mail lchampli@aafp.org.
What is going on in family medicine? Demand is up, say surveys, but compensation may be down. Productivity is up. Bewildering as they seem, economic and workforce data do portend growth for family medicine, at least in the long term, say many health care observers. They point to physician workforce analyses and to income and recruiting surveys to support their forecasts.
Demand for family physicians
Among the signs of growth: Demand for family physicians has risen. Family medicine was the fourth most heavily recruited specialty, according to the 2003 Survey of Hospital Physician Recruitment Trends, published by Merritt, Hawkins & Associates. Forty-five percent of all hospitals were actively recruiting family physicians. Moreover, only recruitment for orthopedic surgeons, radiologists and cardiologists topped the search for family physicians, said Curt Mosely, vice president for business development at Merritt, Hawkins.
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HELOISE POVEY: |
The data ring true for Heloise Povey, executive vice president at Russell Johns Associates, which places recruitment advertisements for the medical community. Between January and August, recruiting classifieds for family physicians jumped nearly 13 percent over the same period in 2003, according to Povey.
"Everyone is recruiting," she said.
Ironic twist in demand
Mosely thinks hospitals' revived interest in family medicine stems from recognition that subspecialists -- particularly hospital-based, procedure-focused specialists -- rely on primary care physicians for referrals.
"Now that the hospitals are getting these subspecialists in place, they're asking, Where are our referrals?'" said Mosely. "They need family physicians for referrals."
Ironically, demand for FPs exceeds that for other primary care physicians because of the perceived shortage of subspecialists, he added. Internal medicine residents increasingly have gone into subspecialty fellowships, strangling the influx of new primary care internists. The result, Mosely surmises: more demand for family physicians.
"There's more need for family physicians because of the subspecialty shortage," he said. "Internists are doing cardiology work, pulmonology work. We used to see internists do 50 percent primary care work. But now we're seeing internists so tied up (with subspecialty work) that people are going back to family physicians so they can have a primary care doctor."
Mixed compensation picture
The picture for FP compensation remains mixed. Some surveys show that FP incomes dropped slightly recently, while others indicate an impressive increase.
Merritt, Hawkins reported that, despite a 35 percent increase in FP recruitment contracts, the average offer for FPs in 2004 was $144,000, down about $2,000 from last year. Likewise, the AAFP 2004 Practice Profile Survey reported FPs' average income in 2003 was $140,000, down $2,000 from 2002.
The Medical Group Management Association's 2004 Physician Compensation and Production Survey offered a better compensation picture, noting salary offers for FPs without obstetrics ranged from $125,907 to $234,961, with a median offer of $150,267.
However, MGMA noted, all primary care specialties continued to grapple with mediocre income.
The disparities may reflect the current distribution of primary care physicians, say analysts. Some point to a primary care shortage that continues to plague more than one-third of U.S. counties in rural and inner-city areas and drives up demand for family doctors. Those high-demand areas, generally populated with lower-income residents, cannot afford to sweeten recruitment efforts with higher pay, they say.
Others -- such as Merritt, Hawkins analysts -- say sluggish compensation reflects a good balance between supply and demand for FPs.
"We do not anticipate that demand for family physicians will accelerate rapidly and believe that the current supply of family physicians generally is adequate to meet demand in most areas," the Merritt, Hawkins report says. Though the overall supply of family physicians is in balance with demand, "the notable exception is rural and some inner-city areas, many of which have a long-standing shortage of primary care physicians and specialists," says the report.
To reach writer Leslie Champlin, e-mail lchampli@aafp.org.
"Mandatory reading." "Once-in-a-generation opportunity." "A compelling vision for the future." Welcomed with these phrases and more, the Future of Family Medicine report gained family medicine the national spotlight in April. The report called for a new model of care with a "personal medical home" for each patient, open access scheduling, electronic health record systems, professional development and practice-based research. The report garnered praise from groups including the Institute of Medicine and the Council of Medical Specialty Societies. News media, including USA Today, covered the report. A sixth FFM task force, dealing with practice finance, released its recommendations in early December (see story, page 1).
Committed to acting on the FFM report recommendations, AAFP and the family of family medicine started work on implementation plans. AAFP took responsibility for making six of the 10 recommendations reality.
Section 747 of Title VII in the Public Health Service Act struggled to survive through much of the year, but it may have turned the corner thanks, in part, to family physicians' efforts. Family physicians who serve as AAFP key contacts inundated legislators with information on the importance of Section 747, which supports training in primary care medicine and dentistry. By August, the Senate Appropriations Committee recommended $90.7 million -- up from $81.7 million for 2004 -- for Section 747 for 2005. The House Appropriations Committee had recommended $64 million in July. At press time, the legislation awaited reconciliation between House and Senate versions before going to the president for his signature.
Interest in family medicine picked up, according to March 18 National Resident Matching Program numbers: 78.8 percent of family medicine residency slots filled, an uptick of 2.6 percent over 2003. The results bode a potential turnaround for the specialty, said Academy leaders.
Insurance companies threatened the viability of family medicine training when they cited teaching activities as justification for refusing liability coverage to FPs and facilities that taught medical students. Meanwhile, CMS demanded repayment of graduate medical education funds from residency training programs that used volunteer preceptors. Quick action by AAFP constituent chapters reversed insurers' actions, and AAFP and the Association of Family Medicine Organizations mobilized in October to craft a model agreement that would meet CMS criteria for retaining volunteer preceptors.
AAFP coordinated the May 21 - 22 Student Interest Summit to identify strategies that could affect student interest in family medicine. Topics discussed: mentors and role models, medical school admissions processes, and medical school curriculum. Participants devised action plans to tackle the key factors they identified.
Almost 7,000 family doctors from 96 countries gathered in Orlando, Fla., Oct. 13 - 17 for the AAFP Scientific Assembly and 17th World Conference of Family Doctors (sponsored by Wonca, the World Organization of Family Doctors).
AAFP and the American Academy of Pediatrics in March released an otitis media guideline with recommendations on appropriate use of antibiotics and pain management. The guideline offers advice on diagnosis and management of the condition in children from 2 months through 12 years of age.
During a year when vaccine shortages plagued the health care system, the AAFP joined in developing clinical guidelines that helped ensure an adequate supply of pneumococcal conjugate vaccine for infants and children, and it communicated to members the CDC's prioritization guidelines for providing influenza vaccinations.
Family physicians gained access to asthma and allergy point-of-care tools when AAFP posted them and several other valuable resources online at http://www.aafp.org/asthmaallergyguide.xml. The materials, which include a 32-page Asthma and Allergy Resource Guide and updated guidelines from the National Asthma Education and Prevention Program, are part of the Asthma and Allergy Resources for Family Physicians program. The program also developed models for implementing evidence-based medicine in day-to-day practice.
With the number of children's visits to FPs falling, AAFP in August launched a Task Force on the Care of Children by Family Physicians. The Robert Graham Center in Washington conducted an evidence-based study and analysis for the task force to use in its work.
The Annals of Family Medicine received resounding affirmation of its success when the National Library of Medicine selected it for inclusion in Index Medicus and MEDLINE. The NLM action means Annals titles and abstracts are available to people conducting searches in the library's databases.
The Congress of Delegates, during its Oct. 11 - 13 meeting in Orlando, Fla., voted for AAFP to establish a federal political action committee by June 2005. Under bylaws to be created by the AAFP Board, the PAC board would include at least three AAFP directors and would report to the AAFP Board annually, and no PAC funds would be used for political advertising.
Thomas Weida, M.D., of Hershey, Pa., (now) speaker of the AAFP Congress of Delegates, spoke to Medicare's Practicing Physicians Advisory Council Feb. 23 in Washington. Weida called on PPAC -- which issues recommendations about Medicare to the HHS secretary -- to recommend that CMS design a care model in which primary care physicians manage Medicare patients with multiple chronic diseases and that CMS test the use of a care management fee.
Eighty AAFP national and constituent chapter leaders, key legislative contacts, and members made the case for congressional support of Title VII funding, Medicare graduate medical education funding and health care for the uninsured during the AAFP Family Medicine Congressional Conference May 19 - 20 in Washington.
The Academy provided support to legislative initiatives that began their trek through the subcommittee, committee and floor debate process. Among them: the Medicare Prevention Act, which incorporates AAFP's suggestion to grant CMS the authority to review Medicare-covered preventive services in the light of U.S. Preventive Services Task Force recommendations and to alter reimbursement accordingly.
Likewise, the Academy threw its support behind the Geriatric and Chronic Care Management Act, which endorses the care management fee concept and calls for an upfront payment for assessment and care management of Medicare beneficiaries.
Family medicine saw some progress in convincing legislators of the need for national medical liability reforms. The Academy gave strong support to the Help Efficient, Accessible, Low-cost, Timely Healthcare Act, or the HEALTH Act, approved by the House of Representatives March 31. However, the Senate blocked the companion bill in July.
The Academy didn't wait for tort reform before acting to help members cope with medical liability insurance premiums. In a May 19 letter to CMS Administrator Mark McClellan, M.D., Ph.D., the Academy called on CMS to calculate the Medicare fee schedule so that it accounts for the growing cost of professional liability insurance. The final 2004 Medicare fee schedule increased professional liability insurance relative value units by 21.7 percent.
AAFP leaders met with McClellan July 22 to discuss corrections to the Medicare fee updates, the need for a care management fee, graduate medical education funding and electronic health records. McClellan expressed interest in the concept of a care management fee for family physicians engaged in long-term patient care.
AAFP members took the reins of organizations and agencies. Among them: Bruce "Ned" Calonge, M.D., M.P.H., of Denver was named chair of the U.S. Preventive Services Task Force; J. Edward Hill, M.D., of Tupelo, Miss., was chosen president-elect of the American Medical Association; AAFP Past President Warren Jones, M.D., was named executive director of the Mississippi Division of Medicaid; and Academy EVP Douglas Henley, M.D., was named to the federal Certification Commission for Healthcare Information Technology.
On the leading edge of those working to resolve national health concerns, the Academy's Americans in Motion initiative took aim at obesity by challenging physicians and patients to improve their health with better nutrition and more exercise. The initiative gained national attention when AIM joined with the U.S. Department of Interior's Get Fit With US campaign during the campaign's June 5 kickoff in St. Paul, Minn. The federal government sought AAFP support when Michael Suk, M.D., J.D., M.P.H., spoke during a Robert Graham Center-sponsored primary care forum. A White House fellow, Suk was working on "Meridian 2004: Initiatives in Public Health and Recreation," which links public health with recreation.
Recognizing that childhood obesity is a pervasive problem, the AAFP collaborated with the Agency for Healthcare Research and Quality to develop two educational DVDs, released in September.
BlueCross BlueShield on May 13 agreed to establish a working group on developing projects that test the cost-effectiveness of health care management through a personal medical home. Many BlueCross BlueShield plans might consider working with AAFP, primarily through constituent chapters, to create demonstration projects that test the care management model.
AAFP joined several medical organizations to help plan for rebuilding Iraq's health care infrastructure. During a Sept. 25 - 26 meeting in Washington, Daniel Ostergaard, M.D., AAFP vice president for international and interprofessional activities, collaborated with Senate Majority Leader Bill Frist, M.D., R-Tenn.; U.S. Surgeon General Richard Carmona, M.D., M.P.H.; and Maj. Gen. Darrell Porr, M.D., a family physician who represents all of military medicine to the Joint Chiefs of Staff.
During the past 12 months, the AAFP became an indisputable leader in promoting electronic health records. Academy efforts to ensure affordable EHR systems for members blossomed as 58 companies clamored to sign the statement of principles undergirding AAFP's Partners for Patients initiative launched in November 2003.
 Having their say at the health information summit, clockwise from top: David Brailer, M.D., Ph.D., HHS' technology czar; HHS Secretary Tommy Thompson; Sen. Bill Frist, M.D., R-Tenn.; Rep. Nancy Johnson, R-Conn.; and Academy EVP Douglas Henley, M.D. |
Some constituent chapters participated in an AAFP survey in May. Forty percent of respondents (all active members) said they were either completely converted to EHRs or were in the process.
AAFP expanded member services in April with an agreement with Medfusion Inc. to provide free Web sites (see story, page 7).
AAFP communicated closely with members of the U.S. Congress as they worked on legislation to encourage physicians to implement EHRs. Among the results: introduction of the Quality, Efficiency Standards and Technology for Health Care Transformation Act and the National Health Information Technology Adoption Act.
National political, regulatory and information technology leaders identified the AAFP as the "go-to" organization for guidance on IT legislation and national certification standards. In May, the HHS National Committee on Vital and Health Statistics' Subcommittee on Standards and Security sought AAFP testimony on developing standards for e-prescribing, and CMS awarded a $100,000 grant to the Academy's EHR pilot project. In July, during a health information summit, HHS' national coordinator for health information technology, David Brailer, M.D., Ph.D., lauded the Academy as "one of the most entrepreneurial associations that I know of," adding, "their Center for Health Information Technology is innovative, experimental and sets the pace."
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Mary Frank, M.D.: 'In D.C., we're known as the doctors who talk about their patients' |
She may be the AAFP's first woman president, but Mary Frank, M.D., of Mill Valley, Calif., doesn't dwell on it. Instead, she's all about the issues facing family physicians and their patients, from electronic health records to health care coverage for all. She discusses some of these issues in this interview.
Q: How do federal legislators view the Academy's lobbying efforts in Washington?
A: We have a very good image in D.C. because we're known as the
doctors who talk about their patients. That has stood us in good stead because
no matter what we're advocating, it always starts with: "This is what patients
need, and that's why we're asking for it" -- whether it's an EHR, a public
health initiative, preventive care or a change in Medicare coverage.
I think we've become more assertive in our lobbying efforts in the past couple of years. And with the recent Congress of Delegates decision to have the AAFP develop a political action committee, our efforts will really jump into high gear soon. Hold on for the ride!
Q: How do you see EHRs and other technology helping family physicians improve patient care?
A: From a quality point of view, EHRs provide a knowledge base, allowing physicians to assess their performance in such areas as asthma or diabetes care, managing congestive heart failure, or immunizations. If one of those areas is not where a physician wants it to be, he or she can make a change -- implement a clinical guideline, for example -- and then go back and remeasure. This capability is also essential in any sort of pay-for-performance environment.
Electronic technology can also impact patient safety by helping avoid medication mistakes due to unclear handwriting, as well as by giving physicians ready access to information on drug-drug interactions or drug recalls, for instance.
Finally, EHRs can add to the body of family medicine research by enabling investigators to pool aggregate data into a single database. If you pull together data from AAFP's 55,000 active members -- think what that means in terms of the ability to translate bench research into clinical practice and interventional research!
Q: What is the Academy doing to link research, CME and quality improvement?
A: The Academy's Task Force on Linkages -- that is, on linking together science, CME and quality -- has developed a vision statement and a statement of principles the AAFP Board of Directors approved in August. The Board is also looking at tools and outcomes associated with this process. Increased quality of care and improved health outcomes for patients are the desired outcomes, and the tools to get us there are things such as building CME into more of a process with measurable outcomes. Another tool is a broader research base in family medicine, so we're looking at research around guidelines, as well as outcomes research and office systems research.
I think the message for the members is this: You don't have to go buy an EHR, then next week do the quality improvement process, then the following week submit the data to your insurance company, and then the week after that start on another project. Look at one part of this you can start with now. You might begin by doing a quality improvement project in your office that you don't necessarily need an EHR for. It might be as simple as counting up over the next six months how many people you refer for colon cancer screening.
It's a process of transformation and renewal. Think of it as a wheel where you can start at any point and just move around the circle. Start with the part you're familiar with and build on that, because then you'll see how the next part fits in. Just take it one step at a time.
Q: What opportunities are available for the AAFP to push for health care coverage for all?
A: Politically, I think 2005 may be the year to do this, simply because the first year of any president's term is the only "opportunity" year. After that, the focus shifts to upcoming elections.
There's starting to be more talk about covering the uninsured, especially within the house of medicine. For example, health care coverage for all was the platform J. Edward Hill, M.D., a family physician, ran on when he was named president-elect of the AMA.
Our members are becoming more savvy about this issue and about involving their patients, who are going to be on the forefront of forcing change. Look at what's happening: the shift among insurers toward preventive care -- that basic care package that's part of our Health Care Coverage for All plan.
Q: What would you like to see family medicine do to attract and retain high-quality medical students?
A: Most people who come into medical school saying, "I'm going to be a family doctor," they're going to become family doctors. We want to nurture those people. The most effective way to do that is through one-on-one, ongoing contact with family doctors within and outside the medical school -- people who will listen to those students when they have doubts about their specialty choice and who will talk with them about it.
More importantly, we need to look at the people we're admitting to medical schools. Students who choose family medicine are different. They have a different kind of commitment to people, and they frequently have a broader type of personal background in terms of what they've done with their lives.
We need to engage students when they're college undergraduates -- or even earlier -- tell them the story of family medicine, support their admission to medical school, and then keep them on track. That's where the nurturing comes in.
Here's an Internet trip worth taking. Jump on the AAFP's information technology Web site and you'll find "a place to foster the EHR community within the AAFP," said Steven Waldren, M.D., assistant director of AAFP's Center for Health Information Technology.
The Web site has recently undergone a facelift and is the perfect place in cyberspace if you're an AAFP member looking for accurate and reliable information about electronic health record resources.
"Been there, done that," you might say. Well, the Web site's fresh new look debuted in October, so if you've not visited lately, put http://www.centerforhit.org at the top of your "to do" list.
Areas of the Web site tagged "AAFP Members Only" require your member ID number, so keep it handy when you log in.
Members still wrestling with whether to "tech up" should click on "Quick Start Guide" and sign up to communicate with colleagues on an EHR e-mail discussion list, complete an EHR readiness assessment form and ponder the stages of EHR adoption.
According to Waldren, one of the hottest new clicks on the Web site is an area offering members the opportunity to read and write EHR product reviews. To date, more than 80 reviews have been posted on the site, which requires that reviewers articulate reasons for their pro and con assessments of EHR products. If you're utilizing an EHR, why not join your peers by submitting a review of your system?
"Members say to me, I want to discuss EHR systems with physicians like me in practices like mine,'" said Waldren, and the CHIT Web site offers that possibility.
Family medicine is about the people, not the paperwork, says Max Bayard, M.D. But too often, business problems distract physicians from their medical focus and interfere with patient care. That means family medicine residents must learn the science of business so they can practice the art of medicine, he says.
A creative response is up and running at the Johnson City (Tenn.) Family Practice Residency Program, which Bayard directs. The program has implemented a practice management curriculum that aims to transform residents into entrepreneurs who have time for patients, professional development, community involvement, and family and friends. Bayard and James Holt, M.D., medical director, and Cathy Peeples, M.P.H., CME program coordinator at East Tennessee State University, Johnson City, teach the practice management curriculum.
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"Practice management is not just about the money." -- Max Bayard, M.D. |
"Practice management is not just about the money," said Bayard. "It's about the system that results in quality patient care and a rewarding practice for our residents' future. Medical students have a dream practice. This dream is rapidly replaced by reality. We wanted our residents to get the dream back."
To that end, Bayard, Holt and Peeples introduce second-year residents to basics: types of medical practices, curriculum vitae preparation, physician recruiters, licensure processes, contract fundamentals, and the history and financing of America's health care system.
The second-year residents then establish mock practices. They name their practices and develop mission statements; define their patient populations and practice locations; and develop business plans that include budgets with first-year income and revenue plans, defined office procedures and detailed marketing strategies. The residents create floor plans, job descriptions for all staff, and schedules for medical and nonmedical staff. And they attach a cost to each position.
Residents who've completed the mock practice experience said it successfully linked the business of medicine to their ideal practices. As a result, they said they could anticipate practicing family medicine with open eyes.
"You had to brainstorm about practice management difficulties," resident Lydia Thorp, M.D., said about the program. "You never know the difficulties you will face until you are actually dealing with them."
Moreover, the mock practice highlights business planning details that residents don't often consider, said resident Shawn Southwick, D.O.
For example, he said, "we had to look at how many codes we expected each month and what reimbursement for those codes would be."
Residents' response to practice management curricula about 10 years ago indicated the need for innovation, said Bayard. "Eighty-nine percent of program directors surveyed felt their practice management curriculum was average to very effective. Only 10.5 percent felt it was not effective. But in a 1994 survey of recent graduates of family practice residencies, respondents said 94 percent of practice management-related topics were either only slightly covered or not covered at all."
For more information on the mock practice, contact Bayard at bayard@mail.etsu.edu or (423) 439-6487.
Market forces, fiscal restraint and the changing economic status of Americans will determine the outcome of legislation affecting Medicaid, medical liability insurance and physician reimbursement during the 109th Congress. That is the gist of a post-election assessment of the political environment and its potential impact on family medicine.
The assessment, presented to the AAFP Board of Directors during its Nov. 16 - 21 meeting in Kansas City, Mo., can be read at http://www.aafp.org/2004scan.xml.
To the editor:
In the September FP Report, the article "Common Office Emergencies May Demand Creativity" shows an ammonia inhalant ("smelling salts") being used as a treatment for fainting. Patients who feel faint are almost always having a vasovagal reaction, with cerebral hypoperfusion caused by vagal-mediated bradycardia and hypotension. The proper treatment is to lay the patient down or place them in Trendelenburg position, possibly administering atropine in severe cases.
Wafting a poisonous gas under a fainting patient's nose does nothing to reverse the underlying pathophysiology and is dangerous. If the patient has asthma, severe bronchospasm may result, worsening the situation. Ammonia in the eye can cause severe corneal injury. On the skin, ammonia can cause an alkali burn.
Canadian health authorities have stopped the sale of ammonia inhalants, and I urge all family physicians to rid their offices of these inhalants. The ampules and pads should be removed from first-aid kits and should not be used by paramedics or hospital personnel. I further urge the FDA to follow Canada's lead and stop the sale of these inhalants in the United States.
Ronald Reynolds, M.D.
New Richmond, Ohio
To the editor:
I thoroughly enjoyed reading your article in the August issue of FP Report about Dr. (Susan) Andrews' paperless office ("EHR Improves Work Flow, Patient Care"). I would go one step further and invite you to visit my office in Pennington Gap, Va. Like Dr. Andrews, I utilize an electronic medical records system; however, my setup differs somewhat from hers. I use a tablet PC for my interactions with my patients. Our patients love the system and the care they get.
I am hoping through this article, and hopefully others to come, that my physician colleagues will see the true benefits of utilizing an EMR for their practices. I suppose I am selfish in asking for that, but it sure would be nice to receive old records from another physician in a "legible" or typewritten format.
My hat is off to the AAFP for promoting something that President Bush is trying to put into action.
Scott Litton Jr., M.D.
Pennington Gap, Va.
WEB EXTRA!
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At the request of family physicians yearning for
hands-on procedural skills training, the AAFP is offering a new CME course.
Make plans today to attend one of two offerings in 2005 of Procedural
Skills: Hands-on Opportunities. The course debuts Feb. 20 - 21 in Houston
and repeats July 18 - 19 in Portland, Ore. Participants can choose sessions in
these topic areas (selecting from one to four topics): joint injection;
cardiology stress testing, parts one and two; colonoscopy, parts one and two;
and skin biopsy techniques. Go to
http://www.aafp.org/proceduralskills.xml
for easy registration for either site. Beat the early-bird deadlines of Jan. 19
for Houston and June 17 for Portland and save on the registration fee.
The AAFP now offers members a free practice Web site
program through Medfusion Inc. Create a practice Web site and take
advantage of various benefits, including your choice of an available domain
name at familydoctor.net, free trial offers of Medfusion's content management
system, and preloaded patient education information and daily health tips from
AAFP. Want to upgrade your site? You can do just that by paying discounted
rates for enhancements such as access to Medfusion's secure patient
communication features. For more information or to create a Web site, visit
http://www.aafp.org/membersites.xml
or contact Medfusion Inc. at (877) 599-5123.
Proven value: Didn't attend this year's Scientific
Assembly? You can still reap CME benefit from the sessions. The AAFP is posting
complete versions of 19 lectures presented during the Assembly at
http://www.aafp.org/x29530.xml.
Among the highlights of the online offerings: four Annual Clinical Focus
sessions, including the keynote lecture "Genomics and the Family Physician:
Realizing the Potential" by Francis Collins, M.D., Ph.D., director of NIH's
National Human Genome Research Institute. Other topics include "Asthma in
Children," "Hypertension Update," "End-of-Life Issues" and "Perspectives in
Pain Management." Each lecture is acceptable for up to 1.5 Prescribed CME
credits, for a possible total of 28.5 free credits. Refrain from double
dipping: If you obtained CME credit for the lectures in Orlando, Fla., you
cannot apply for additional credit for the same course online.
Proven value: If athletes make up a portion of your patient population, you'll benefit from attending Sports Medicine: Strategies for Treating Athletes Jan. 31 - Feb. 5 in San Diego. Broaden your approach to management and treatment decisions on topics ranging from head injuries, running injuries, and foot and ankle injuries, to infectious diseases and substance abuse in sports. Hands-on procedural skills opportunities are also available. This course may assist individuals preparing for the certification or recertification exam leading to a Certificate of Added Qualifications in sports medicine. Online registration is quick and easy at http://www.aafp.org/x14481.xml. Register before Jan. 3 and beat the early-bird deadline.
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A shipping fee may apply; Kansas residents pay a 7.525 percent tax. |
WEB EXTRA!
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FP Report is
published by the AAFP News Department.
Copyright © 2004 by American Academy of Family Physicians.
