Transformation

I can cite a variety of transformational events or periods of time in my life:

- coming to faith in my youth
- moving to Aspen the summer after freshman year in high school
- going off to college at Mount Holyoke
- starting med school at Hopkins
- becoming an internist, through training in the Osler Medical Housestaff and early years in practice
- joining a group practice in 1999
- a shift in thinking on politics, largely driven by my experience as a doctor in the frontlines of the U.S. healthcare crisis
- leaving the group practice to start Green Spring Internal Medicine, LLC

When Green Spring Internal Medicine opened its doors nearly five years ago, we were ahead of most of the other practices in our neighborhood in terms of the use of health information technology.  Namely, we fully implemented eClinicalWorks as our electronic medical records and practice management system.  From scheduling, to note-taking during office visits, to ordering labs and diagnostic tests, and tracking disease processes, we have utilized various features of the software as they have been developed and have eagerly awaited the new versions.  Version 9 is especially anticipated, as it will help us to achieve "Meaningful Use", a set of well-conceived standards for utilizing computer systems to assist in patient care.  Medicare will provide a bonus to practices that achieve this over the next 4 years.  We are also looking forward to SaaS (:software as server") hosting which will allow me to securely access my records whenever I am away like I am now.

I am sitting in a large conference room at the Loew's Philadelphia Hotel at the National Patient-Centered Medical Home Summit.  It is the last day of a 4 day symposium focused on transforming the healthcare delivery system in primary care to the Patient-Centered Medical Home.  This model has proven success at improving patients' access to care, engagement in health, and patient satisfaction.  There are also some studies to suggest increased provider and staff satisfaction.  Perhaps most importantly, "Medical homes reduce costs through relationship-building."  stated Jeffrey Brenner, MD just now.

If any of you have really talked with me lately, you must know that the current status quo is not sustainable.  I have been seeing an average of 80 patients per week, bearing the challenges required of primary care mostly on my own shoulders with the help of a very small staff.  It has been too much, and there is need to change; however, the current system of fee-for-service healthcare has driven the speed of the treadmill up with no increase in compensation for my ever increasing pace of practice.  The faster the pace, the more impossible it is for me to achieve what every patient needs from his/her primary care office:

- a relationship with a devoted, undistracted personal healthcare provider
- cultural sensitivity and communication in a language that is understandable
- a listening ear, with adequate time to express concerns
- access to urgent appointments at reasonable hours
- screening for risky lifestyle choices
- screening for disease
- evaluation and management of acute issues
- thorough physical examination, at least periodically
- time to be heard when in the midst of a crisis
- mental health screening and counseling
- ability to provide feedback to the practice - complaints or suggestions
- thoughtful prescribing avoiding drug interactions, while reducing costs through generics
- authorizing necessary tests and medications
- access to lab and test results
- a written care-plan at the end of every visit
- coordinate healthcare, scheduling appointments and processing information from every entity related to health
- knowledge that the primary care provider has been communicating with specialists
- help negotiating the complex health insurance atmosphere
- ready access to specialty care when needed
- preferred methods of communication with office staff and providers
- ready access to community-based and internet-based health resources that are interactive and culturally sensitive
- ready access to medical records
- ready access to referrals and follow-up of the results
- a smooth transition to outpatient care after being hospitalized
- a way to state goals at the end of every visit and seamlessly report on success before/at the next visit
- a team-based approach to ensure that important information never slips through the cracks

The above is basically my job description, with the help of Erica and Halie.  Research studies suggest that a primary care doctor doing his/her job in total would work, on average, 21 hours per day!  I must say that I am not working 21 hours a day; yet, I cannot deny the impact of bearing responsibility, even though we have added tremendous efficiency via eClinicalWorks.

What is the solution?

Our transformation into a Patient-Centered Medical Home!

What is it?

Well, it has taken me the past 4 days at the conference to try to figure that out.

Patient-centered:  the idea that care revolves around the patient and not the doctor, focused on what is of greatest benefit, involving patients not only in their own care but also in how the practice works, finding ways to connect patients to one another in order to support health initiatives, empowering patients to actively engage in every aspect of his/her health

Medical: pertaining to every aspect of every patient's health in the context of his/her family, community, and the larger population

Home: a place for gathering... gathering of information, gathering together with one another.  It is a place for being in close relationship not only with the provider but with a whole team focused on care including family members and other sources of support to each patient,  What "home" does NOT refer to is an institution or a bureaucracy.  It is kind of like a "home page", and nothing like a "nursing home".

In the patient-centered medical home, the patient stands at the center with our practice team standing at his/her side, advocating for the best possible care and serving to translate, facilitate, and communicate.

We will be supported in our transformation process by the Maryland Healthcare Commission's Multi-Payor PCMH Pilot Program.  We have been selected as one of approximately 60 sites in the State of Maryland, varying from small practices to large group practices, from independent practices to hospital-owned practices, from private groups to community health centers.  Without becoming part of the pilot, I believe we would have lacked the leverage with insurance companies and would have been unable to afford the cost of the new model.  We long to become part of the solution and not remain part of the problem of unsustainable rising costs of the U.S. healthcare system.  The current system is unsustainable, and noone knows this better than primary care physicians; though, the government has lately taken notice.  Large businesses, like IBM, have also recently taken notice and are partnering in the process of transforming payment models.  Insurance companies need to engage in this process as well, because most practices will still have to function on the fee-for-service treadmill model while moving in the direction of the PCMH.

The most important partners I have are my patients.  I am looking forward to inviting patients into this process, not just by staying with us through the transition but also by providing valuable feedback to us.  We created an easy SurveyMonkey link on our practice website:  www.greenspringmed.com.  We have also assembled a GSIM Advisory Board comprised of patients.  Other future opportunities include participating in health groups which will probably focus on diabetes, obesity management, and smoking cessation.

After 4 days of ideas, there is still much to process.  I am looking forward to the change, inspired by the possibilities, somewhat daunted by the task that lies ahead, but borne up by the certainty that this is the right thing to do.