Wednesday, November 21, 2018

Small Practice

Small Practice

My Triple Aim of Medication Assisted Treatment for Opioid Addicted Patients

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by HANS DUVEFELT, MD

My second foray into Suboxone treatment has evolved in a way I had not expected, but I think I have stumbled onto something profound:

Almost six months into our in-house clinic’s existence, I have found myself prescribing and adjusting treatment for about half of my MAT patients for co-occurring anxiety, depression, bipolar disease and ADHD as well as restless leg syndrome, asthma and various infectious diseases.

Years ago, working in a mental health clinic, we had strict rules to defer everything to each patient’s primary care provider that wasn’t strictly related to Suboxone treatment. One problem was that many of our patients there didn’t have a medical home or had difficulty accessing services. Another problem was that primary care providers unfamiliar with opioid addiction treatment were uncomfortable prescribing almost anything to patients on Suboxone.

The Doctor- Patient Relationship and the Outcomes Movement

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Screen Shot 2015-10-01 at 9.46.12 AMIn a recent Harvard Business Review article, authors Erin Sullivan and Andy Ellner take a stand against the “outcomes theory of value,” advanced by such economists as Michael Porter and Robert Kaplan who believe that in order to “properly manage value, both outcomes and cost must be measured at the patient level.”

In contrast, Sullivan and Ellner point out that medical care is first of all a matter of relationships:

With over 50% of primary care providers believing that efforts to measure quality-related outcomes actually make quality worse, it seems there may be something missing from the equation. Relationships may be the key…Kurt Stange, an expert in family medicine and health systems, calls relationships “the antidote to an increasingly fragmented and depersonalized health care system.”

In their article, Sullivan and Ellner describe three success stories of practice models where an emphasis on relationships led to better care.

But in describing these successes, do the authors undermine their own argument?  For in order to identify the quality of the care provided, they point to improvements in patient satisfaction surveys in one case, decreased rates of readmission in another, and fewer ER visits and hospitalizations in the third.  In other words…outcomes

Independent Practice Equals Higher Satisfaction

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Tom Guillani

Thinking of starting a new practice?  Is the lure of independence calling to you?  There are more reasons than every why independent practice is a great option. Being your own boss is not only easier than it once was, it can actually make you happier.

Independent physicians have many more options available to help them today than they used to. Affordable technology has revolutionized private practice from EHRs to easy-to-use practice management and billing software, adding flexibility to staffing and simplifying paperwork needs. And, the increased availability and ease of outsourcing has further reduced the burden of running your own practice. Physicians can now choose to outsource inbound calls, reminder calls, pre-authorizations, marketing, and of course, billing. In addition, independent providers can transition to new agile practice models such as concierge and hybrid that can offer higher incomes and smaller patient census and reduce some of the headaches associated with traditional practice structures.

Added to the fact that starting and running a private practice is now easier than ever, is the higher level of happiness experienced by independent physicians. In fact, a study done by Medscape in March 2014 reported that 74% of self-employed doctors are satisfied in their practice and that of the physicians who left employment in favor of independent practice, 70% felt happier in their new practice while only 9% were less happy being self-employed. Seventy-four percent of these self-employed doctors also said that their opportunity to practice quality medicine met or exceeded their expectations.

There are many factors contributing to these high satisfaction rates in independent physicians but one of the biggest is the control these doctors have over their practice, their schedule, their treatment of patients, and their destiny. A survey in Hospital Topics on the impact of practice arrangements on physician’s satisfaction backs this up, reporting that physicians who work for HMO’s have much less autonomy and decision-making power than self-employed physicians. And, the report by Health Affairs found that 85% of doctors in private practice felt free to control their schedules compared to only 39% of HMO physicians.

Self-employed doctors also avoided the pitfalls of employment cited by the Medscape study while the doctors working for hospitals and group practices listed administrative headaches, added rules, and a more limited income potential as reasons for dissatisfaction in their careers. It’s easy to see why the 2014 Great American Physician Survey conducted by Physician’s Practice found that over half of independent physicians would do things the same way all over again. This isn’t to say independent providers done have regulatory challenges or administrative responsibilities. However, they have more control over the day-to-day operations and administration, eliminating frustrating bureaucracy.

Better, more affordable, easier-to-use technology, simple outsourcing options, greater autonomy and control, and higher levels of satisfaction…all of these factors make private practice a more attractive option than ever. So, if you are considering starting a new medical practice, now is the time. Just remember, doing it right from the beginning will save you from unnecessary stress, making the process of opening your new practice a much more enjoyable experience.

By joining the ranks of independent physicians, you will be in control of both your practice and your life. You will be free to set your own schedule, manage patient care to your standards, work with a staff of your choosing, and have the final control over your income potential. All new practices will face challenges along the way but you will find a wealth of resources to make your life easier and guide you to success in your new venture.

Tom Giannulli, MD, MS, is the chief medical information officer at Kareo. He is a respected innovator in the medical technology arena with more than 15 years of experience in mobile technology and medical software development. Previously, Giannulli was the founder and chief executive officer of Caretools, which developed the first iPhone-based EHR.

A Radical Policy Proposal: Go Easy On Older Docs

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flying cadeuciiThrough Dec. 15, federal regulators will accept public comments on the next set of rules that will shape the future of medicine in the transition to a super information highway for
Electronic Health Records (EHRs).  For health providers, this is a time to speak out.

One idea:  Why not suggest options to give leniency to older doctors struggling with the shift to technology late in their careers?

By the government’s own estimate,in a report on A 10-Year Vision to Achieve an Interoperable Health IT Infrastructure, a fully functioning EHR system, for the cross-sharing of health records among providers, will take until 2024 to materialize.The technology is simply a long way off.

Meanwhile, doctors are reporting data while the infrastructure for sharing it doesn’t exist.  Now, for the first time, physicians will be reporting to the federal government on progress toward uniform objectives for the meaningful use of electronic health records.  Those who meet requirements will be eligible for incentive payments from Medicare and Medicaid, while those who don’t may face penalties. In addition, audits are expected to begin in 2016.

How I Use P4 Medicine to Maximize Patient Engagement

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Molly MaloofThe healthcare industry is changing as new models of care and reimbursement emerge. One of these approaches is P4 Medicine. P4 Medicine stands for predictive, preventive, personalized, and participatory. This approach deeply resonates with me because the philosophy is aligned with how I have been developing my medical practice, which is focused on optimizing health and avoiding disease. In my opinion, P4 Medicine is one of the best models for maximizing patient engagement.

The earliest manifestation of P4 Medicine began eight years ago at the Institute of Systems Biology when Dr. Lee Hood, MD, PhD, a physician scientist and creator of the automated gene sequencer, recognized that the application of systems biology to medicine would fundamentally alter our understanding of health and disease. This model has merged three powerful aspects of science and technology:

Self-Driving Cars are Like Most EMRs

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by HANS DUVEFELT, MD

Drivers are distracted klutzes and computers could obviously do better. Self driving cars will make all of us safer on he road.

Doctors have spotty knowledge and keep illegible records. EMRs with decision support will improve the quality of healthcare.

The parallels are obvious. And so far the outcomes are disappointing on both fronts of our new war against human error.

I remember vividly flunking my first driving test in Sweden. It was early fall in 1972. I was in a baby blue Volvo with a long, wiggly stick shift on the floor. My examiner had a set of pedals on the passenger side of the car. At first I did well, starting the car on a hill and easing up the clutch with my left foot while depressing and then slowly releasing the brake pedal with my right forefoot and at the same time giving the car gas with my right heel.

I stopped appropriately for some pedestrians at a crosswalk and kept a safe distance from the other cars on the road.

A few minutes later, the instructor said “turn left here”. I did. That was the end of the test. He used his pedals. It was a one way street.

Three times this spring, driving in the dark between my two clinics, I have successfully swerved, at 75 miles (121 km) per hour, to avoid hitting a moose standing in the middle of the highway. Would a self driving car have done as well or better? Maybe, maybe not.

Every day I get red pop up warnings that the diabetic medication I am about to prescribe can cause low blood sugars. I would hope it might.

Almost daily I read 7 page emergency room reports that fail to mention the diagnosis or the treatment. Or maybe it’s there and I just don’t have enough time in my 15 minute visit to find it.

For a couple of years one of my clinics kept failing some basic quality measures because our hasty orientation to our EMR (there was a deadline for the incentive monies to purchase EMRs) resulted in us putting critical information in the wrong “results” box. When our scores improved, it had nothing to do with doing better for our patients, only clicking the right box to get credit for what we had been doing for decades before.

Our country has a naive and childish fascination with novelties. We worship disrupting technologies and undervalue continuous quality improvement, which was the mantra of the industrial era. It seems so old fashioned today, when everything seems to evolve at warp speed.

But the disasters of these new technologies should make us slow down and examine our motives. Change for the sake of change is not a virtue.

I know from my everyday painful experiences that EMRs often lack the most basic functionalities doctors want and need. Seeing a lab result without also seeing if the patient is scheduled to come back soon, or their phone number in case they need a call about their results, is plainly speaking a stupid interface design.

I know most EMRs weren’t created by doctors working in 15 minute appointments. I wonder who designed the software for self driving cars…

Hans Duvefelt is a family doctor in Maine. This piece was first published at his blog A Country Doctor Writes

Why Doctors should Recommend Quantified Self Technologies for Their Patients

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The United States population suffers from staggering numbers of lifestyle related diseases. We know the situation is not improving. Recent research found that over half of the country has prediabetes or diabetes. The facts don’t lie—the vast majority of the US burden of disease are due to lifestyle.

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Photo Credit: Dr. DArriush Mozzafarian

People know they should eat less and exercise more, but they don’t. They don’t because without the right knowledge and direction, behavioral change is really hard. Doctors also know they should be advising their patients on lifestyle, but they don’t.

My Doctor Just Gave Me His Cell Phone Number …

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flying cadeuciiThat’s right…it really happened.

At the conclusion of a recent doctor visit, he gave me his cell phone number saying, “Call me anytime if you need anything or have questions.”

In disbelief, I wondered if this was a generational thing – and whether physicians in their late thirties had now ‘gone digital’.

My only other data point was our family pediatrician, who is also in her late thirties. Our experience with her dates back nearly seven years when my wife and I were expecting twins.  A few pediatricians we met with mentioned their willingness to correspond with patients’ families via email as a convenience to parents.  The pediatrician we ultimately selected wasn’t connected with patients outside of the office at that time, but now will exchange emails.

ONC’s Interoperability Plan: a Day Late and $19bn Short

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Screen Shot 2015-10-21 at 8.40.34 AMEarlier this month, the Office of the National Coordinator for Health Information Technology released an update to Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap. The roadmap was first announced back in January, and the changes shared this month aren’t significant.

Ultimately, it calls for all healthcare providers nationwide to be able to send and receive electronic clinical information by the end of 2017.

This is a good plan on the surface, although it comes six years and millions of dollars late, and like other programs it may be more cumbersome that it first seems. Essentially, there are three facets:

1) Data standards to format and request/receive data

2) Incentives (again!)

3) Governance

Despite the intention to move data across the Union, each state will have the right to create its own unique rules on how to manage the exchange of information. This is a problem as we have seen before in the simple Case of e-prescription routing. A few states make it almost impossible to send e-scripts and layer on their own special form of bureaucracy. This inhibits the ultimate goal of reducing costs and errors and increasing Efficiency at the expense of both providers and patients.