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Leading Together in Primary Care: Learning Lab 4/2/18 1

Primary Care Medicine: Principles and Practice

Primary Care Medicine: Principles and Practice 1

The Present and Future of Primary Care: Optimizing Joy, Quality, Equity, and Payment Coleen Kivlahan, MD, MSPH

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We Are Primary Care (2015 MEPS data)

§ Independent practices serve 55%, hospital-owned practices serve 19%, and nonprofit/government/academic-owned serve 20% of all patients in USA. § Solo practices 25% of patients, practices with 2–10 physicians served 53% of patients. § 41% served in PCMHs. § Practices with EHRs cared for 90% of patients, using secure messaging with 78% of patients. § Practices participating in ACOs/capitation served 45% of patients § Primary care patients in the South, compared to the rest of the country, had less access to nearly all practice capabilities, § Uninsured patients were less likely to be served at a practice that used an EHR (adjusted difference, 9% [95% CI, 2– 16]). § 10% smoke, 58% employed, 29% mean BMI, 60% self rated health excellent/VG, 38% public insurance/uninsured, 47% with HTN, 16% with DM, 15% with cancer

2015 MEPS data Journal of General Internal Medicine, 04 December 2017. pp 1–6. Characteristics and Disparities among Primary Care Practices in the United

• States. David Michael Levine

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What Makes Us Great?

§ Six attributes of care delivery distinguished the high-value cohort (attained statistical significance)

• decision support for evidence-based medicine
• risk-stratified care management
• careful selection of specialists
• coordination of care
• standing orders and protocols
• balanced physician compensation

Exploring Attributes of High-Value Primary Care,

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Time to Vote

How often do you communicate with your patients through a patient portal?

a) Daily b) Weekly c) Never

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How often do you use telehealth visits to replace office visits?

a) Daily b) Weekly c) Never

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Do you use a scribe or its equivalent in your practice? §Yes §No

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Overall, based on your definition of burnout, how would you rate your level of burnout:

1) I enjoy my work. I have no symptoms of burnout 2) Occasionally I am under stress, and I don’t always have as much energy as I

• nce did, but I don’t feel burned out

3) I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion 4) The symptoms of burnout that I’m experiencing won’t go away. I think about frustration at work a lot 5) I feel completely burned out and often wonder if I can go on. I am at the point where I may need some changes or may need to seek some sort of help

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I am in primary care and am excited to go to work on most days: §True §False

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I am actively engaged in practice redesign at my care site: §True §False

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The Present

Burnout high but stable Practice and Care Redesign Experimentation EHR use for asynchronous and telehealth visits Documentation burden Continuity importance

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What is Burnout?

Exhaustion, depersonalization, low sense of accomplishment Nearly half of all U.S. nurses and physicians Contributes to lower patient satisfaction, worse patient safety, take sick leave, depression and relationship problems at home and work

It’s Not Just Us

Overall prevalence of burnout was 41% Rates of burnout in our teams: physicians (49%), nurse care managers (42%), MAs, LPNs (32%), and admins (36%) We are more burned out when we are part of under-staffed teams with frequent turnover, and when we are over-empanelled. Burnout prevalence was 30% lower for those working on fully staffed teams with no turnover and caring for an appropriate panel compared

• ther practices.

Helfrich CD et al, The Association of Team-Specific Workload and Staffing with Odds of Burnout Among VA Primary Care Team Members. JGIM July 2017 32(7): 760-66 Primary Care Medicine: Principles and Practice 14 Primary Care Medicine: Principles and Practice 15

System fixes:

Burnout improved with workflow interventions, and with targeted QI projects. Interventions in communication and workflow Dissatisfaction is far worse in countries with multipayer private insurance systems

Osborn, R. Primary Care Physicians In Ten Countries Report Challenges Caring For Patients With Complex Health Needs. Health Aff December 2015 34( 12): 2104-2112; Linzer, M. A Cluster Randomized Trial of Interventions to Improve Work Conditions and Clinician Burnout in Primary Care: Results from the Healthy Work Place (HWP) Study. JGIM Aug 2015 30(8): 1105-11

How Do we Fix It?

The VA’s efforts to Reduce Burnout? Share the Work!

§ PCP burnout was positively associated with PCP reports of performing two discrete tasks without reliance on team members: (1) intervening on patient lifestyle factors (p = 0.002) and (2) educating patients about disease-specific self-care activities (p < 0.001). § Other variables significantly associated with PCP burnout (p ≤ 0.05) included team communication, team knowledge and skills, satisfaction with team, age, female gender, and years of practice. § The extent to which PCPs share responsibility for 14 discrete primary care tasks with

• ther team members and which tasks were performed by the PCPs without reliance on

team members are associated with PCP burnout.

Journal of General Internal Medicine January 2018, Volume 33, Issue 1, pp 50–56 Primary Care Tasks Associated with Provider Burnout: Findings from a Veterans Health Administration Survey Linda Y. Kim

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Resilience to Burnout

We practice medicine for the patient interaction and the intellectual challenge Deploying curiosity is an opportunity with each patient Curiosity (continuous learning) is sensed by the patient and family, leading to improvements in both patient and physician satisfaction Curiosity, mindfulness and reflection, as daily renewal behaviors, may constitute an effective antidote to burnout.

Schattner, A. Measuring Burnout in Primary Care Staff. JGIM Aug 2015 30(8): 1062 Primary Care Medicine: Principles and Practice 7

Joy Has to be Our Priority

Addressing burnout is necessary, but not sufficient. We all believe that health is more than the absence of disease. Joy in work is more than the absence of burnout. Joy in work is a shared responsibility at all levels of our organizations.

(IHI President and CEO Derek Feeley Aug 2017)

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Face to Face Visits, remember those?

“We physicians often root our hope in our patients’ outcomes, feeling confident when they recover, and we leave ourselves open to despair when outcomes are not good. In fact, it is the shared journey, the ever-evolving process, which offers both patient and doctor an

• pportunity to grow, learn, and discover. Therein lies hope for patient and clinician alike.

In these profound moments, we bear witness to the relationship in an act of fidelity, not to the outcome, but to the Other. Our perspective shifts away from ourselves. It is here in this moment of deep empathic connection that many of us find hope and meaning that remains not only the patient’s greatest solace but also the clinician’s best remedy to burnout. In our willingness to be open to the unexpected, to be surprised, we must relinquish control and give the gift of curiosity, or even suspended disbelief.”

Finding Hope in the Face-to-Face. Jennifer Y. C. Edgoose, MD, MPH1⇑ and Julian M. Edgoose, PhD2 Ann Fam Med May/June 2017 vol. 15 no. 3 272-274

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QUALITY AND CARE REDESIGN

Proposal for New Quality Measurement in PC

§ Quality goals should use target ranges, not rigid targets § Include metrics that capture avoidance of excessive testing or treatment § Include attributes of primary care associated with better outcomes and lower costs (continuity, comprehensiveness) § Less emphasis on patient satisfaction scores and instead use patient-centered

• utcomes, such as days of avoidable disability

§ Peer-led qualitative reviews of patterns of care, practice infrastructure, and intra-practice relationships

§ Young, R et al. Ann Fam Med 15: 2(175-182) March/April 2017. The Challenges of Measuring, Improving, and Reporting Quality in Primary Care.

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What Patients Say About Us

§ Most of us are measured based on our patient experience/feedback. Is it reliable? § 4 items in CAHPS Physician Communication assessed based on adjustment impact

(1) gave easy to understand information (2) knew important information about the patients’ medical history (3) showed respect for what the patient had to say (4) spent enough time with the patient. (5) patient would recommend the PCP to family and friends, and patient rate the doctor from 0 to 10 from worse to best possible doctor

§ Researchers used standard adjustors in CAHPS data analyses (age, sex, race/ethnicity, education, and self-reported health status) AND added additional metrics to test impact on scores § There was a statistically significant change in doctor’s experience scores with age (older people rank us higher), any prior visit with that doctor, medical skepticism, global life satisfaction, symptom bothersomeness, BMI, and marital status.

JGIM 2017 Dec;32(12):1323-1329. Reliability of Physician-Level Measures of Patient Experience in Primary Care. Joshua J. Fenton et al

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Continuity Really Matters

§ 4.4M pts > age 65 in England § Older patients who experienced more PCP discontinuity of care had a higher risk of an emergency hospital admission § Patients with lower continuity of care had significantly higher odds of admission, and an encounter with a PCP other than the assigned one was associated with increased risk of admission within 30 days § Odds ratio for those experiencing least continuity was 2.32 (95% CI, 1.48–3.63) relative to those experiencing most continuity § CONCLUSIONS: Marked discontinuity of care contributes to increased unplanned hospital admissions among patients aged 65 years and older.

Ann Fam Med. 2017 Nov;15(6):515-522. Continuity of Primary Care and Emergency Hospital Admissions Among Older Patients in

• England. Tammes P et al.

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Practice Redesign

Observing Physician Time Use

Another study: 4 specialties (FM, IM, Card, and Ortho) in 4 states (Ill, NH, VA, WA). 57 doctors observed for 430 hours Physicians spent 27% of their days on direct clinical face time with patients and 49% of their time on EHR and desk work. In the exam room: 53% on direct clinical face time and 37% on EHR and desk work. For every hour physicians provide F2F time with patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time doing additional computer and other clerical work.

Sinsky, C. Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann Intern Med Dec 2016 165(11): 753-760. Primary Care Medicine: Principles and Practice 17

Another study: 4 specialties (FM, IM, Card, and Ortho) in 4 states (Ill, NH, VA, WA). 57 doctors observed for 430 hours Physicians spent 27% of their days on direct clinical face time with patients and 49% of their time on EHR and desk work. In the exam room: 53% on direct clinical face time and 37% on EHR and desk work. For every hour physicians provide F2F time with patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time doing additional computer and other clerical work.

Sinsky, C. Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann Intern Med Dec 2016 165(11): 753-760.

We Spend Much More Time Online

In a study reviewing over 31M EHR transactions 2011–14 by 500 PCPs on 750,000 patients’ EHRs Doctors logged an ave. of 3.08 hours on F2F office visits and 3.17 hours on desktop medicine daily. Desktop medicine=patient portal messages, prescription refills or medical advice, ordering tests, sending staff messages, and reviewing test results. Over the study years, there was a decline in the time allocated to F2F visits, and an increase in time allocated to desktop medicine. Staffing and scheduling in the physician’s office, as well as provider payment models for primary care practice, must account for this new work.

Tai-Seale, M. Electronic Health Record Logs Indicate That Physicians Split Time Evenly Between Seeing Patients And Desktop

• Medicine. Health Affairs April 2017 36(4): 655-662.

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Half of Our Days

§ Researchers used electronic health record event log data and time-motion observations to identify areas for improvement in supporting family physicians’ allocation of time for patients. § More than one-half of a physician’s 11.4-hour work day is spent in the EHR—both during and after clinic hours. Nearly one-half of this time is spent in clerical and administrative tasks. § Clinicians spent 5.9 hours of an 11.4-hour workday in the EHR per weekday per 1.0 clinical full-time equivalent

• 4.5 hours during clinic hours and 1.4 hours after clinic hours.
• Clerical and administrative tasks including documentation, order entry, billing and coding, and

system security accounted for nearly one-half of the total EHR time

• Inbox management accounted for another 25%

Arndt BG et al. Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations. Ann Fam Med. 2017;15(5):419–426

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Scribes Save Doctors

§ Clinical trial that randomized family physicians to alternating weeks with and without an electronic health record scribe. § (Can YOU imagine?!?....) § Having a scribe:

• improves physician satisfaction with face time with patients
• time spent with charting
• increased the proportion of charts that were closed within 48 hours
• charting accuracy, and
• had no effect on patient satisfaction

Gidwani R, et al. Impact of scribes on physician satisfaction, patient satisfaction, and charting efficiency: a randomized controlled trial. Ann Fam Med. 2017;15(5):427–433.

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Telehealth

Three types of services: store-and-forward (asynchronous communication), real-time video (synchronous conversation), and remote patient monitoring.

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Do Patients Like Televisits?

• Interview study with adult patients following video visits with their primary

care clinicians at a single academic medical center.

• All patients reported overall satisfaction with video visits, with the majority

interested in continuing them as an alternative to in-person visits.

• Primary benefits were convenience and decreased cost. Some patients

felt more comfortable with video visits than office visits and preferred to receive future serious news via video visit, in their own supportive environment.

Powell, RE. Patient Perceptions of Telehealth Primary Care Video Visits. Ann Fam Med May/June 2017 15(3): 225-229.

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Do Video Visits Cost Less?

RAND study: commercial claims data on over 300,000 patients from three years Total annual spending (costs to insurers and out-of-pocket payments by patients) was $45 more/patient for people who used telehealth to treat acute URI than it was for F2F visits for the same condition. WHY? 88% of the telehealth visits represented people who would not have gone to a doctor otherwise (NEW utilization). Only 12% of the telehealth sessions, the researchers concluded, amounted to a substitute for seeing the doctor.

Ashwood, JS. Direct-To-Consumer Telehealth May Increase Access To Care But Does Not Decrease Spending. Health Aff March 2017 36(3): 485-491. Primary Care Medicine: Principles and Practice 21

Cancer Screening Decisions through your Portal

§ 55,000 patients using a patient portal in a prospective observational cohort study. § Participation open to patients who might face a cancer screening decision (mammogram, PSA, CRC) § In 1 year, one-fifth of the portal users (11,000 patients) faced a potential cancer screening decision. § Among these patients, 21% started and 8% completed the decision module. Half shared responses with their PCP § After their next office visit, 60% thought their clinician had seen their responses, 40%+ reported the module made their appointment more productive and helped engage them in the decision § Many patients face decisions that can be anticipated and proactively facilitated through patient portals.

Ann Fam Med. 2017 May; 15(3): 217–224. Harnessing Information Technology to Inform Patients Facing Routine Decisions: Cancer Screening as a Test Case Alex H. Krist, MD, MPH

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Disruptive Innovation

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We Wearables

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AI and Us

§ The Human Diagnosis Project allows primary care doctors to plug into a collective medical superintelligence, helping them order tests or prescribe medications according to the recommendations of specialists all over the world. § Human Dx’s natural language processing algorithms mines each case entry for keywords to funnel it to specialists who create a list of likely diagnoses and recommend treatment § The algorithms comb through all the responses to check them against previously stored case reports § The network uses them to validate each specialist's finding, weight each one according to confidence level, and combine it with others into a single suggested diagnosis,

• ffering CME credits

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What is A.I. Doing for Us Now?

§ Image classification: helping dermatologists with cancer vs harmless spots, diagnose rare genetic conditions with facial recognition, assist in reading medical images § Mine text data: Mining our EMRs, patient and doctor entered data into large data repositories § Mine our wearables and integrate it with medical records. Mine our data for early depression or suicide risk § Medication robots, smart bottles and packaging § Chatbots are now trained in cognitive behavioral therapy concepts and are helping people. And human therapist avatars are listening and being told things humans are not.

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CURIOSITY I N N O V A T I O N JOY AND

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What Beatles single lasted longest

• n the charts?

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A 23 year old white female previously healthy and thriving in an Ivy League university developed fatigue, nausea, intractable vomiting and

• myalgias. She became ketotic and acidotic and was admitted to the ICU

with each episode. She was evaluated extensively by 5 specialists and no etiology was found. No evidence of self-induced vomiting. All lab testing, including testing for inborn errors of metabolism, is negative. She has persistent nausea. She appears psychologically healthy.

Are you curious?

New Competencies in Primary Care

A new level of medical generalism demands: Instant access 24/7 to our patients Direct/concierge care Broader use of more team members More use of technology and wearables Provide integrated data on well being that patients value Focus on social determinants of health Attention to our communities

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What is Needed in a New Vision

• 1. Generalist physicians will increasingly focus on high

acuity/high complexity patients: including end of life care, comorbid illnesses and atypical presentations, other team members will manage lower acuity patients.

• 2. Relationships will be fostered by teams and technology. Task

redistribution is now required in primary care. Workforce shortages will mandate panel size increases.

• 3. Primary care will address health behaviors and social

determinants of health for their patients.

• 4. Payment will support primary care and reward non visit-based care

in order to encourage population based care strategies.

Russell Phillips MD Center for Primary Care at Harvard 2017 SGIM meeting Primary Care Medicine: Principles and Practice 42 Leading Together in Primary Care: Learning Labs 52

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