Delegates Have Their Say on Practice Enhancement Issues

More than three dozen chapter and member constituency delegates, alternates and members testified on resolutions submitted to the Reference Committee on Practice Enhancement, with some offering written testimony before the COD officially convened and others presenting their views during an Oct. 3 virtual hearing.

Here’s a rundown of topics discussed and how delegates voted on them.

Primary Care Standards of Ethics and Equity

A resolution introduced by the Hawaii AFP called for the Academy to develop a set of principles establishing appropriate ethical standards in primary care technologies, with the goal of applying these standards to companies selected to partner with the AAFP Innovation Lab. 

The resolution further directed the Academy to involve members in creating the principles, outlined areas that should be explored, and called for a report back to the 2021 COD.

Both written and verbal testimony presented on the measure was firmly in support of the resolution’s intent, although one speaker pointed to the $46,000 fiscal note attached to it.

Safeguarding data collected from a diverse panel of patients is paramount, several commenters noted ― specifically, ensuring that technologies such as artificial intelligence/machine learning don’t reinforce unconscious biases and exacerbate health inequities across different populations. Setting appropriate ethical standards and guardrails as part of the AAFP’s work with industry vendors is essential to guaranteeing transparency and protecting both patients and the integrity of the profession.

Also key to this effort, members testified, is ensuring members are aptly represented. That’s reflected in the substitute resolution delegates adopted, which stipulates that the AAFP “establish a work group with a wide representation of membership to develop a set of principles for primary care technologies to apply to companies partnering with the AAFP.”

Specific factors the work group should evaluate, according to the substitute measure, include data collection modes, the use of anti-bias algorithms, equitable access to and ease of use by smaller physician practices, technological transparency, level of AAFP financial investment, and patient privacy concerns.

Furthermore, work group members should consider issues such as

• how to prevent the commodification of primary care through technology,
• how to humanize technology within the scope of primary care,
• how tech companies should work with primary care and
• what the AAFP’s relationship to the tech industry should be.

Finally, the adopted resolution calls for a report back to the 2021 COD on the principles.

Prescription Cancellation Functionality in EHRs

Another resolution submitted to the reference committee sought to increase the implementation of prescription cancellation functionality in EHRs used in outpatient practices.

Introduced by the Utah AFP, this measure also drew overwhelming support, with virtually every commenter stating it would improve patient safety, particularly by reducing the risk for polypharmacy.

Briefly, the resolution asked the AAFP to

• engage with regional and national pharmacy chains to request that they work with physician practices to enable prescription cancellation functionality;
• educate members “through articles, toolkits and other forms of educational campaigns” on the potential benefits of this functionality;
• support members’ efforts to engage directly with their pharmacies to implement cancellation functionality; and
• ask EHR vendors to collaborate with FP practices to enable this type of functionality.

A number of those who testified declared that prescription cancellation functionality in EHRs should already be an industry standard ― from both a patient safety perspective and because it would greatly decrease practices’ administrative burden. And given that widespread implementation of this functionality would benefit physicians of all specialties and their patients, one commenter even suggested that the AAFP should not bear the costs associated with achieving this goal alone.

During the virtual reference committee hearing, a member of the AAFP Board conveyed the Board’s support for the measure, saying it was important that the Academy provide leadership in this area. That member offered slightly amended language, which the committee included in its substitute measure. Those changes were to delete the reference to regional pharmacy chains in the first resolved clause, remove the reference to specific educational resources in the second resolved clause and note in the third resolved clause that the AAFP outreach would be to “major” EHR vendors.

The substitute measure was included in the committee report’s consent calendar, which delegates unanimously adopted during the Oct. 12 COD business session.

Patient Access to Pharmacy Services

A resolution from the Michigan AFP sought to ensure all patients have ready access to pharmacy services by calling on the Academy to work with licensing bodies to “prohibit any and all pharmacies and pharmacy chains” from rejecting handwritten prescriptions in favor of solely electronic orders. A second resolved expanded that to include working with Congress and CMS to the same end.

Testifying in support of the resolution, one speaker noted that Walmart had recently announced it would no longer accept written prescriptions for controlled substances. That, said the member, impedes physicians’ ability to use their prescriptive power in accordance with valid medical practice.

Proponents of the measure pointed to the sizeable financial investment associated with implementing an EHR system ― both the initial cash outlay and ongoing maintenance costs. Moreover, in some areas, EHR use may not be feasible due to sketchy or no access to broadband internet.

Citing challenges involved in balancing the advantages of electronic prescribing with the need to ensure all patients ― particularly those in less well-resourced areas ― can access needed medications, one member suggested referring the measure to the AAFP Board for further consideration.

That proposal was welcomed by a Board member who participated in the hearing, saying it would allow issues with the wording of the measure to be resolved.

Based on the totality of the testimony, however, the reference committee chose instead to offer a substitute resolution that addressed both “the complexity of the issues and the specificity of the original resolved language, which might restrict the AAFP’s ability to act.”

Accordingly, the measure delegates ultimately adopted directs the Academy to “develop a policy for appropriate accommodations for prescription-receiving entities to accept handwritten prescriptions when electronic prescribing is not feasible.” It also calls for the AAFP to advocate with CMS, state licensing boards and major pharmacy chains “to encourage acceptance of written prescriptions” in such circumstances.

Telehealth Payment Issues

Two separate resolutions that came before the committee dealt with various aspects of telehealth. The first of these, introduced by the Idaho AFP, asked the AAFP to

• advocate with CMS and commercial health plans to make permanent the telehealth coverage and payment policies enacted during the current Public Health Emergency,
• ensure site-of-service payment parity with established patient office visits of like duration,
• provide payment parity for audio-only telehealth visits conducted in lieu of in-person visits, and
• standardize eligible patient originating and distant sites of service to include home and work settings.

The second measure, jointly submitted by the Michigan and Minnesota chapters, focused solely on payment parity for virtual and in-person visits.

Not surprisingly, both measures received unanimous support, with one member referring to telehealth as the “hidden gem” that allowed family physicians to continue caring for their patients during the pandemic, when face-to-face visits were not possible.

Another member, who spoke during the reference committee hearing, acknowledged that the Academy and other groups are, in fact, pursuing these goals through legislative and regulatory means, but stated that delegates’ action on the issue would further drive home its importance. Rural health centers and federally qualified health centers must be allowed to provide distant site services, this member stated, adding that payment parity for audio-only telehealth services specifically benefits physicians practicing in rural areas.

The members of the reference committee agreed with a number of those who testified that the two resolutions could and should be combined, offering a substitute measure that encompasses the specific topics raised in both, while adding a resolved clause that the AAFP advocate to CMS and commercial insurers that primary care telehealth services “occur within the context of a comprehensive primary care relationship.”

Other Issues

The reference committee also considered a number of Board reports dealing with various AAFP policy issues, including deletion of outdated policies, revisions to certain existing policies and position papers, and adoption of new policy statements

• opposing the use of restraints on incarcerated women during labor,
• calling for coverage of vitamin D supplementation for infants by third-party payers,
• opposing credentialing and privileging decisions about family physicians being made by “nonphysician practitioners,”
• denouncing hospital privileges or credentials being considered a requirement for insurance participation,
• opposing restrictive covenants in employment contracts as disruptive to the patient-physician relationship,
• identifying valid and useful performance measure criteria and outlining appropriate and inappropriate use of performance measures, and
• supporting family physicians’ access to accurate and reliable point-of-care testing.