PookieMD's Blog: Where Physicians Learn About the Business of Medicine

Annals of Internal Medicinehas a nice study on the ability of ”structural capabilities” to improve  primary care.  Let me translate: structures are systems implemented in a practice, such as EMRs, paper based reminders, on site language interpreters etc.  They are mechanisms a practice puts in place to improve quality and efficiency of care.

So what works?

An EMR is helpful to bring up scores on some HEDIS measures such as: screening for breast cancer, colorectal cancer, and chlamydia, and diabetic eye care and nephropathy monitoring.  Even at that, it only improved scores if it was a “frequently used multifunction” EMR–meaning that xray reports, labs, med lists, problem lists and specialist notes were ALL on the EMR.  If the EMR was underutilized, or not as functional, it would generate lower HEDIS scores.  So, if your practice is getting an EMR, better make sure you get a highly functional one and actually use it!

Systems to remind patients to obtain necessary screening  improved HEDIS scores, but paper notes to physicians were not helpful.  (Now why is that?  The authors speculate that is may represent practices that have barriers to optimal care.)  Having an interpreter on sight wasn’t particularly helpful either, nor was a multilingual practitioner.

Having frequent (at least quarterly) meetings where quality of care was discussed led to higher HEDIS scores as well.

So simple steps to improve quality of care at your practice:

1. If you are getting an EMR, get a highly functional one that includes multiple functions such as labs, x-rays, medication lists, notes etc, and use it.  Best if subspecialists use it as well.  (Don’t ask me how you are to accomplish that!)
2. Have frequent meetings on how to improve HEDIS measures such as screening for cancer and diabetic monitoring.
3. Send reminders to patients to get their screening done.

Right now, that’s all that has been studied and shown to work.  What works for your practice?

The American College of Physicians, the national organization for Internists, has issued a monograph addressing and encouraging the use of Nurse Practitioners as primary care providers.  The comprehensive monograph encourages Nurse Practitioners to enter the field of primary care, and advocates the use of the “Patient-Centered Medical Home.”  Basically, the idea behind the “home” is that nurse practitioners deliver the care, and there is a physician on the “team” who “collaborates” with the nurse practitioners.  Interestingly, one of ACP’s goals is “to serve the professional needs of the membership, support healthy lives for physicians, and advance internal medicine as a career…”

Gee, if I were a young resident, I would want to spend 4 years in medical school, then 3 more years as a resident to be the supervisor of a bunch of Nurse Practitioners.  (Not!)   Supervising Nurse Practitioners, no matter how skillful or knowledgeable they are, will NOT encourage young physicians to enter primary care.  We become doctors because we want to do MEDICINE, not because we want to supervise those who are actually seeing patients.  Furthermore, who wants the increase in liability that “collaboration” will bring?  You can bet that the physician will be liable for everything the Nurse Practitioners do.  Boy, sounds like a swell deal to me!

No, being the top of the supervisory pyramid is a detractor, not an enticement.  I think this ridiculous monograph will encourage more medical students and residents to become specialists.   The way I see it, most residents pathetic enough to actually be interested in internal medicine will become specialists.  The Nurse Practitioners will deliver primary care, and then refer the complicated patients to the Specialists.  Not exactly an efficient way to deliver care, but maybe this way internists will actually get paid to think, which is what this specialty is all about.

And here I thought the ACP was my advocate?!  Why are they cutting us off at the knees, diluting our specialty and selling our souls?  Why are they not lobbying for internal medicine and primary care to be appropriately reimbursed, and rewarded for thinking, rather than doing?

Why didn’t I do dermatology?