In June 2013, the American Medical News published an article titled, “Serious work put into making primary care fun again.” With an anticipated serious shortage of primary care physicians over the next 20 years, the article addressed how to improve the lot of primary care providers, stating in part:
“Amid alarming rates of physician burnout, hundreds of clinics nationwide are redesigning their practices with a goal in mind beyond improving the quality of care. They are aiming to make life as a primary care doctor enjoyable once more. Twenty-three of these clinics … describe practice innovations that can ease the chaos, administrative overload, miscommunication and computerized busy work that too often characterize primary care. These clinics find that planning visits ahead of time, delegating more tasks to nurses and medical assistants, holding daily meetings and using standing orders for recurring items not only improves patient satisfaction but also creates happier doctors.
“Physician satisfaction is an essential ingredient in transforming the delivery of medical care. … ‘All medical care, and especially primary care, is incredibly complex, creative work that requires willing, engaged participants and strong support to be successful. We use silly words like “joy” and “love” and “hope” because that’s what we need. We don’t need more rules or checklists or regulations.’”
Reviewing the recommendations from these clinics, it becomes obvious that SETMA is already doing all of the things they recommend, and SETMA believes the processes of care can be improved even more. In our May 9, 2013, Your Life Your Health, we discussed how to improve the quality of healthcare. It is obvious that the improvements we discussed will also improve the professional satisfaction of and decrease the stress upon primary care providers.
Remember our discussion of the question, “How many tasks can you get a provider to do?” The answer depends upon:
1. How important is the task?
2. How much time does it take?
3. How much energy does it take?
The key to getting more done is to determine what is important and only to do that, and then to make the completion of the tasks require less energy and less time.
How can we change the future?
Make it easier to do it right than not do it at all! Imitate Henry Ford, who automated the manufacturing of automobiles with assembly lines, and in so doing made it possible for those who made cars to afford to drive them. There are many aspects of patient care that can be automated without making care mechanical and impersonal. This principle can be expanded to all chronic conditions for which the patient is being treated and/or for all screening and preventive care the patient needs. In the future, all healthcare process will be evaluated for:
1. That which can and should be automated, all based on evidence-based medicine
2. That which requires human input based on patient-centered care
This will give the healthcare provider more time to focus on the patient – patient-centric – while fulfilling the processes (care) which we believe will improve the health (outcomes) and which will decrease the cost of excellent care.
Automating the care of patients with diabetes
Over the next two years, SETMA will examine the care given. The first step will be to automate the care of diabetes as much as possible. The effort to improve the care of patients with diabetes involves the fulfillment of “process measures,” which are tasks such as:
1. Has the patient had a hemoglobin A1c within the past three months?
2. Has the patient had a urinalysis in the past year?
3. Has the patient had a dilated eye examination in the past year?
4. Has the patient had an examination of the feet in the past year including a test of feeling in the feet?
5. Has the patient had a test for protein in the urine in the past year?
6. Has the patient had a flu immunization in the past year?
7. Has the patient had a cholesterol test in the past year?
8. Is the patient on a statin drug?
9. Is the patient on aspirin?
10. If the patient has protein in the urine, is the patient on an ACE Inhibitor or an ARB (blood pressure medicines that prevents protein in the urine or helps reduce it if it has already occurred)?
This effort also involves “outcomes measures,” which means to evaluate whether diabetes care meets established goals, such as:
1. Is the patient’s hemoglobin A1c below 7.0 percent?
2. Is the patient’s “bad cholesterol,” the LDL, below 70?
3. Is the patient’s blood pressure controlled below 130/90?
4. If the patient is overweight or obese, is he/she losing weight?
5. Is the patient devoid of complications and if he or she is not, has the worsening of the complication been arrested?
This effort also involves patient “lifestyle measures,” such as:
1. Is the patient exercising regularly and has the patient been given an exercise prescription in the past 90 days?
2. Has the patient been asked about smoking or exposure to tobacco smoke and if either is true has the patient been given help in stopping smoking?
3. Has the patient been given instructions on how to lose weight, how to read processed food labels and is the patient following a diet?
4. Has the patient been to diabetes education classes in the past twelve months?
5. Is the patient monitoring their own blood sugar at home?
6. Does the patient keep a blood sugar and a blood pressure log?
Improving patient and provider satisfaction and avoiding burnout by both
Most of these tasks can be “automated,” which means that they can be ordered before the patient comes to the clinic. When the patient makes an appointment, the electronic medical record automatically searches the patient’s record and sends the referrals for procedures, the orders for tests and at the same time creates the following documents:
1. A summary of the patient’s needed care for the nurse who will see the patient.
2. A summary of patient needs for improvement of care and for removing as much stress as possible from the provider, such as alerting the provider that the blood pressure, or the blood sugar, or the cholesterol, or other outcomes measures are not to goal.
3. A summary of tests, procedures or referrals that have been initiated for the patient. This summary will explain what has been ordered, where and when the care will be competed and an explanation of why the care has been ordered and the benefit of the care to the patient.
These steps will improve the quality of care for the patient and the quality of life for the provider. A great deal of stress will be taken off the provider who will have more time to spend with the patient giving attention to the patient’s interests rather than spending time fulfilling important but easily automated tasks. It is possible that this process will reduce the workload of the healthcare provider by 30 percent or more. If it does, it will be transformative to primary care.
Dr. James L. Holly is CEO of Southeast Texas Medical Associates, LLP (SETMA) in Beaumont.