Before I give my annual RVU update, I’m going to turn the mic over to Russell Libby, recent Buzzy Vanchiere Award recipient, in a piece that I’ll entitle “The Ghost of Independent Practice Future.” Some of these…predictions will certainly come true.
It was 11 AM and I had already seen 10 of my prescheduled appointments. I had decided to come into the office to see a seven year old boy who had been complaining of abdominal pain overnight. He had vomited once, but then had kept down some fluids and was febrile to 102. He had been healthy and was complaining of intermittent periumbilical pain over the last several days and had seemed to just be over a URI that started last week.
I put on my glasses and slipped the ear-mic over my ear and tapped the sensor on the front of the right stem to activate the EMR. Google Glass was where the real HIT progress started, but it was the need to free up the physician after all those years of EMR creep where it just was about capturing charges for an RVU based care and payment system. EHR development turned into decades of building platform on top of dysfunctional platform adding unsustainable expense, impossible regulatory impositions, and technical impediments that made the patient exam an incidental part of the office visit. It was amazing that trillions of dollars invested in that rudimentary technology was initially thought to be able to create a meaningful database on patients and the population, but it turned out to be a manipulative tool that was used by local and regional entities to control data and in that way capture whatever portion of the $3 plus trillion of health care dollars spent in our country in those days.
The way I see it, a process that had started as a way to improve care and demonstrate outcomes ended up being a tool to subordinate and control physicians. Initially it was that they could generate the orders that would generate the most margin and volume, but as the payment models changed, it was physicians as leaders of the health care team who could create cost efficiencies that would result in profit from population health insurance plans that the hospitals and health systems created around themselves. Still, the hard costs of these entities and the evolution of portable technology and ambulatory surgical care started to drive revenue away from the bricks and mortar. Only the systems that could truly partner with physicians thrived and the others found themselves looking for a national partner like Mayo, Cleveland, or Hopkins. As the cost and experience of turnover of employed clinicians began to take its toll on the profession and the patient-physician relationship, there began a migration back into physician led integrated medical groups.
So, just before entering the exam room, I looked into the lens where the EMR display screens are displayed. There was a time when I had to use a remote scribe who was on the other end of the ear-mic and who would either load the screens that had the patient recent history and any pertinent information related to the chief complaint for this visit. The software has become much more intuitive and is very sensitive to my voice commands much like Dragon had become before it became was acquired by my EHR. I tapped the mid shaft of my glasses and the relevant screens became visible. I asked the system to read me the assessment on his last IPA-at-Night visit which was 2 weeks prior and was attributed to constipation. He had been given a care regimen with reminders on his and his parents’ cell phone IPA app. Our care coordinator follow up the next day reported success and that he was back at school that morning. I double tapped and the template for abdominal pain, prompted by the CC, was loaded.
I had started my office day at home sipping coffee and answering a few email follow-ups and directing the appropriate staff person to activate the home based routines we package for all new patients. We deal with the fairly straight forward things like possible strep with a home kit that requires a swab of the tongue and uses a PCR type of technology that is read by a box that contains weight based antibiotic dosing. If the test is positive, the box opens and the antibiotic, with instructions, is conveniently there so treatment can begin immediately. Although it is a 5 day once daily course, reminders are part of the IPA app that is activated by the positive test and noted in the patient chart. It has become a relatively standardized approach to more common typically uncomplicated problems like strep, asthma, and UTI’s. It certainly saves the family a trip to the neighborhood CVS which ends up taking a lot of time and has lost its credibility as a place for care as IPAcare and other competitive merged groups with better clinicians and easier access have taken over. CVS, Walmart, and Walgreens are now the owners of most of the small local hospitals which have taken a beating as technology has evolved and most of the available insurance options have very limited benefits for care outside of the competing provider groups like IPAcare.
It was my day to be at the office and it started off with the telemedical visits that I usually schedule before 9 AM and after 4 PM. I will have 5 visits an hour, mostly for psychopharm follow-ups and monitoring chronic care conditions like asthma and diabetes where I can review medication use and look at a week’s worth of data from the related wrist watch apps that monitor vitals, O2 saturation, blood sugars and other parameters. Using care pathways and providing families with easy to follow care plans, we have really been able to cut down on emergency room use and hospital based care. Our hospitalists have pretty much been reduced down to intensivists at the hospital and most have either gone to primary care or become “extensivists,” taking care of observation level admissions in the IPA’s 23 hour care center or performing home visits with bedside lab, imaging, and respiratory and infusion equipment.
So as I started to get a more detailed history from my patient’s parent, I tapped the front left of the glass stem which recorded the questions and answers, putting them into the template as I went through its prompts. It is amazing how the combination of spoken word to text has evolved, especially with its key word phrasing and how the medical record software has embedded current guidelines to make sure I ask all of the relevant questions as key historical and physical findings prompt it. I was able to get a picture of my patient’s pale and uncomfortable appearance by using the squint shudder. There is also a video feature, but I rarely use it unless I feel there is something it will contribute for comparative viewing or when there is a unique event like a seizure right there in front of me.
He told me he had never felt sick like this and he could not lie down on his back. I grinned to myself that a seven year old could put it in a lifetime perspective. I started my physical exam in the ritualistic fashion I always do so I do not forget any body part. I identify what I am examining and note the positive and negative findings as I go by stating them out loud. I find the patients and their parents like that because it lets them know what I am thinking and it gives the record a more accurate representation unlike the checklists we used to use and not necessarily validate that qualified us for E&M payments. I did use the video to observe his response to palpating his abdomen and with his winces and rebound response, it was clear to me that he had a peritoneal process that would likely be appendicitis.
The IPA had joined a regional collective that negotiated incredible deals for all kinds of supplies, DME, and office equipment. We leased a hand held high resolution ultrasound device that can be used in a variety of ways. At first it was marketed as a way to diagnose pneumonia although it was not so easy for those of us who only did the 2 hour CME program. They improved the resolution and we developed a direct telemedical connection with the radiology group who our IPA has contracted with and it added an incredible dimension to auscultation. As the medically dedicated connections improved, we were able to develop other supportive and consultative ways to provide better, more efficient, timely, and cost effective care. We now routinely echo children during the first and fifth year of life to identify any cardiac anomalies that were not severe enough to be identified earlier. We do three way consults with our pediatric cardiologists who are there for hands-on consults or home visits in their “cardio-van.”
I had used the U/S several times for abdominal pain, but, surprisingly, never looking for a peritoneal process. I got the radiologist and pediatric surgeon on the telemedical connection and actually conducted a four way consult. It did not take long for the diagnosis I suspected to be made and because it was not yet perforated, we were able to arrange transport to the pediatric surgical center where the surgeon was located and he could perform a laparoscopic procedure, observe him over night and send him home with follow up home care for 24 hours. I think back to the archaic ways in which we handled these cases not so long ago with ER intervention, then CAT scans, OR scheduling, and often several days in the hospital where it was so easy to catch something even more catastrophic.
It was fortunate that I was able to get this taken care of so efficiently. To be able to avoid complications and cost related to exposure to different care settings and interventions is just what our population health contracts strive for. Using our contracted physicians and facility, decreasing recovery time so the family could get back to its routines, and getting the Press-Ganey approval ratings will improve my health scores and help the IPA in its contracting and marketing. Although we used to rely on capturing the gain share from a standardized case cost, we now have that built into the total health insurance premium which we manage through the IPA. The evolution of private insurance exchanges that were developed in response to the ACA gave us an opportunity to develop the credentials for narrow networks that were so contentious when they started. That experience evolved into direct contracting with employers and other groups. IT has worked out pretty well for us.
I was in practice for more than 30 years when I realized my pediatric office needed to focus on where things were going, not just trying to cope with the moment. We were lucky to join up with a primary care IPA and invested in the infrastructure that worked because health care was looking for better solutions than having insurance companies and mega health systems be the source of health care evolutions. It needed to be physician directed and the allocation of resources needed better stewardship. Technology has facilitated the process, giving virtual linkage between regions and physician practice setting. It has also given us tools to work with our patients in ways we never contemplated. It is amazing what impact it has had on medical education and the evolution of ancillary health professionals, but that will be the subject of another report.