10-30 am - sinsky a. sinsky, md, facp nov 7, 2015 10:30a-11:30 a ... landon, reschovsky, ......
TRANSCRIPT
MA ACP Annual Scientific Meeting November 7, 2015
1
Finding Joy in Primary Care
MA ACP Annual Scientific MeetingChristine A. Sinsky, MD, FACP
Nov 7, 201510:30a-11:30 a
Agenda
• Introduction: Framing thoughts burnout
• Studies
– AMA Rand: Physician Career Satisfaction
– ABIMF: In Search of Joy in Practice
• Discussion
MA ACP Annual Scientific Meeting November 7, 2015
2
Two Doctors and a Patient
Program Director GeriatricsUConn
“Working in clinic has become so painful that I have decided to leave my beloved patients—unbearable to think about.”
Gail M Sullivan, MD
MA ACP Annual Scientific Meeting November 7, 2015
3
General InternistMGH
Speaking of performance measures: The little things have become the big things—I fear our roles as healers, comforters, and listeners are being lost.”
2008
Ben Crocker, MD
On a recent visit to a new doctor I believe we made eye contact twice—upon her arriving and leaving.
And yet, I am much more able to receive advice
From people I feel are thinking of me
as a person
rather than just
the next patient. http://www.npr.org/blogs/health/2013/08/13/211698062/doctors-look-for-a-way-off-the-medical-hamster-wheel?live=1 and AndieDominick in Patient Listening: A Doctor’s Guide, Loreen Herwaldt
MA ACP Annual Scientific Meeting November 7, 2015
4
Nearly ½ of MDs Burned Out
General Internal Medicine
Family Medicine
Arch Intern Med 2012; E1-9
http://www.medscape.com/features/slideshow/compensation/2013/public
Burnout affects Patients
Physician burnout is associated with…o ↑ Mistakes
o ↓ Adherence
o Less empathy
o ↓ Patient satisfaction
Sources: Dyrbye. JAMA 2011;305:2009-2010.; Murray, Montgomery, Chang, et al. J Gen Intern Med 2001;16:452–459.;
Landon, Reschovsky, Pham, Blumenthal. Med Care 2006;44:234–242.
MA ACP Annual Scientific Meeting November 7, 2015
5
Burnout Costs Organizations
Physician burnout is associated with…o ↑ Malpractice risk
o ↑ Part time
o ↑ MD and staff turnover
Replace PCP costs $250,000 o (1999)
Am J Man Care Nov 1999:5(11):1431-1438Am J Man Care Jul 2001;7(7):701-713Health Serv. Res. Oct 2004;39(5):1571-1588Med. Care Mar 2006;44(3):234-242Journal of Applied Psychology, Vol 73(4) Nov 1988, 722-735 http://psycnet.apa.org/?&fa=main.doiLanding&doi=10.1037/0021-9010.73.4.727
10
MA ACP Annual Scientific Meeting November 7, 2015
6
11
Burnout Costs Physicians
Physician burnout is associated with…o ↑ Disruptive behavior
o ↑ Divorce
o ↑ CAD
o ↑ Substance abuse/addiction
o ↑ Suicide
Why does joy matter?
MA ACP Annual Scientific Meeting November 7, 2015
7
http://well.blogs.nytimes.com/2012/08/23/the-widespread-problem-of-doctor-burnout/
1 in 2 US physicians burned out implies origins are rooted in the environment and care delivery system rather than in the personal characteristics of a few susceptible individuals.
Physician Career Satisfaction
• Quality: Major Driver of Satisfaction
http://www.rand.org/news/press/2013/10/09.html
MA ACP Annual Scientific Meeting November 7, 2015
8
Physician Career Satisfaction
• EHR: Major Driver of Dissatisfaction
– Too much time per task, clerical
– ↓ Face-to-face time
– ↓ Quality of visit note
http://www.rand.org/news/press/2013/10/09.html
In Search of Joy in PracticeCo-Investigators
• Christine Sinsky- PI
• Tom Bodenheimer-PI
• Rachel Willard
• Tom Sinsky
• Andrew Schutzbank
• David Margolius
MA ACP Annual Scientific Meeting November 7, 2015
9
Places Where PC Physicians & Staff are Thriving?
• Where the work of primary care is do-able
• Enjoyable as a life’s vocation
MA ACP Annual Scientific Meeting November 7, 2015
10
Clinica Family
Health Services
Group Health Olympia
Multnomah
County Health
Dept
South Central
Foundation
Univ of Utah-
RedstoneNewport News
Family Practice
Cleveland Clinic-
Strongsville
Quincy, Office of
the Future
West Los Angeles-
VA
La Clinica de
la Raza
Clinic Ole
Sebastopol
Community
Health
Martin’s Point-
Evergreen Woods
Harvard Vanguard
Medford Brigham and
Women’s
Hospital
North Shore
Physicians GroupMedical Associates
Clinic
Mercy Clinics
ThedaCare
Fairview Rosemont
Clinic
Mayo Red Cedar
Medical Center
Allina
Site visits to 23 high-performing practices(most PCMHs)
Mass. General
Hospital
Joy in Practice
WorkflowTask distributionPhysical space Technology
Challenges
Chaotic visits
Teams function poorly
Inadequate support
Time documentation
EHR →work to MD
MA ACP Annual Scientific Meeting November 7, 2015
11
• Pre-visit planning
• Pre-appt labs
• Systematic Prescriptions
Challenges Innovations
1. Chaotic visits with overfull agendas
MA pre-visit call
Agenda, Med review Depression screen Advanced directive
Fairview: Care Model Redesign
MA ACP Annual Scientific Meeting November 7, 2015
12
Mayo-Red Cedar arranges for pre-visit lab
Same day pre-visit lab (15 min)
ThedaCare
MA ACP Annual Scientific Meeting November 7, 2015
13
Pre-visit Labs
• 89% ↓ phone calls (p<0.001)
• 85% ↓ letters (p<0.0001)
• 61% ↓ additional visits (p<0.001)
• ↑ patient satisfaction
• Save $24 per visit
Crocker B, Lewandrowski E, Lewandrowski N, Gregory K, Lewandrowski K. Patient Satisfaction With Point-of-Care Laboratory Testing: Report of a Quality Improvement Program in an Ambulatory Practice of an Academic Medical Center. Clin Chem Acta 2013; 424:8-12.; and personal communication/poster 3.4.14;
also http://ajcp.ascpjournals.org/content/142/5/640.abstract
http://ajcp.ascpjournals.org/content/142/5/640.full
Annual Prescription Renewals
• “90 + 4”
• Physician time
– 0.5 hr/d
• Nursing time
– 1 hr/d per physician
• 40 million PC visits/yr
200,000 PCPs x 220d/yr x1 visit/d
MA ACP Annual Scientific Meeting November 7, 2015
14
Challenges Innovations
1. Chaotic visits with overfull agendas
Insurers
• Single co-pay lab/visit
Institutions
• Hold future orders
Regulatory
• Prescription 15 mo
Action Steps
Challenges Innovations
2. Inadequate support to meet the patient demand for care
Sharing the care among the team
• 2:1 or 3:1
• Rooming protocol
• Between visit
– Health coaching
– Care coordination
– Panel mgm’t
MA ACP Annual Scientific Meeting November 7, 2015
15
Mayo Red Cedar : New Model of Nursing (2:1)
Challenges Innovations
2. Inadequate support to meet the patient demand for care
Action Steps
Educators
• MA, nurse: MI, SMS
Institutions/Regulators
• Staffing
• Scope of practice ↑
Payers
• Fund non-MD services
MA ACP Annual Scientific Meeting November 7, 2015
16
Challenges Innovations
3. Vast amounts of time spent documenting care
• Team documentation
• Assistant order entry
I used to be a doctor. Now I am a
typist.
Personal communication. Beth Kohnen, MD,
internist Fairbanks, AK 8.3.11
MA ACP Annual Scientific Meeting November 7, 2015
17
The Doctor 1891 Fildes
Undivided attention
The Doctor 2015
Continuous partial
attention
MA ACP Annual Scientific Meeting November 7, 2015
18
Challenges Innovations
3. Vast amounts of time spent documenting care
• Team documentation
• Assistant order entry
Team DocumentationNewport News
• What we all hoped for
• Team: 3:1 http://primarycareprogress.org/insight/3/profiles
MA ACP Annual Scientific Meeting November 7, 2015
19
Team documentation at Cleveland Clinic
Kevin Hopkins M.D.
Team DocumentationCleveland Clinic
• Pre-visit (nurse)
– Med Rec
– Agenda, HPI
• Visit (nurse + MD)
– med,lab, x-ray orders
– followup
• Post-visit (nurse)
– Reviews visit summary
– Health coaching
• MD � next patient
MA ACP Annual Scientific Meeting November 7, 2015
20
Team DocumentationCleveland Clinic: Stonebridge
• New Model
– 2 MA: 1 MD
– 2 pt/d cover cost
– 21 → 28 visits/d
– 30% ↑ revenue
– Spread to others
– We’re having FUN
The MA’s are more fully engaged in
patient care than they have ever been and
they enjoy their work…They have
increased knowledge about medical care in
general and about their individual patients
in particular.
Kevin Hopkins M.D.
MA ACP Annual Scientific Meeting November 7, 2015
21
Collaborative Care at Bellin
MedicationRefill
Chronic Disease
Management
PROVIDER
Test Results
AcuteVisits
PreventativeVisits
Patient Orders/Triage
RNCMA/LPN
Referral to Specialist
Referral to Ancillary Services
Managing Messages, Test Results, Calling
Patients
Paper Work
OLD MODEL OF PATIENT CARE
42
MA ACP Annual Scientific Meeting November 7, 2015
22
Team DocumentationBellin Health Green Bay
• New Model
– 2 MA: 1 RN: 1 MD
– Extended care team
– ↑ Breast, colon and
cervical cancer rates
– 8.3% ↑ in margin
(from -2.2% to 6.1%)
Bellin Results
Quality Metrics (screenings)
Breast Screening
Baseline 55.37%
Goal (6 months) 58.13%
Actual 59.51%
Cervical Screening
Baseline 69.61%
Goal (6 months) 73.09%
Actual 78.64%
Colorectal Screening
Baseline 79.41%
Goal (6 months) - 83.38%
Actual- 83.5%
Financial Metrics
(operating margin for Dr. Jerzak)
Baseline – negative 2.2%
Goal – negative 1.2%
YTD Actual – positive 6.1%
MA ACP Annual Scientific Meeting November 7, 2015
23
Team DocumentationUniversity of Utah: Redstone
• 2.5 MA: 1 MD
I get to look at my patients and talk with them
again. We’re reconnecting…. Our patient
satisfaction numbers are up, our quality metrics
have improved, our nurses are contributing
more, and I am going home an hour earlier to
be with my family..
Amy Haupert MD, family physician, Allina-Cambridge
11.29.11 personal communication
MA ACP Annual Scientific Meeting November 7, 2015
24
Office Practice of the FutureQuincy Family Practice
• 2 MA: 1 LPN: 1 MD
David ReubenUCLA
• “Physician Partners”
– Scripts/COE
– Charting/Charge
• JAMA IM 5.14
– Pt satisfaction
w/MD time ↑
– Save 1.5 hr/4hr
• Training Academy
Innovation
MA ACP Annual Scientific Meeting November 7, 2015
25
Team Documentation
• Six sites
• Similar results
– Access 20-30% ↑
– Costs covered
– Satisfaction ↑
– Quality metrics ↑
– Physician
• home hour earlier
• no work at home
The miracle of scribes is that I
rediscovered what I didn’t even know
I had lost—the beauty of
reconnection with my patients. It is
so much fun. I haven’t had fun in
the clinic in years.
Mark Linzer, MD General internist, Hennepin County, MN
2.17.15 personal communication
MA ACP Annual Scientific Meeting November 7, 2015
26
Challenges Innovations
3. Vast amounts of time spent documenting care
Action Steps
Regulatory
• Team log-in
• Meaningful Use Stage 2
Institutions
• Staffing ratios
• Assistant order entry
Technology
• Seamless transitions between users
Challenges Innovations
4. Computerized technology that pushes more work to the clinician
• Verbal messages
• In-box management
MA ACP Annual Scientific Meeting November 7, 2015
27
The worklist is unbearable. I spend 1.5 hours
clearing out my worklist before leaving and
another 1.5 hours at home after the kids go to
bed.
Primary Care Physician, Des Moines, IA; 2011
ER
• 10 hr shift
• 44% data entry
• 4000 clicks
• 28% pt care
PCPs
• 11 hr day
• 50% computer– COE, inbox
• 20% patient– 1/3 screen
gaze
4000 clicks per day
Am J Emerg Med 2014;31(11):1591-1594
MA ACP Annual Scientific Meeting November 7, 2015
28
Challenges Innovations
4. Computerized technology that pushes more work to the clinician
• Verbal messages
• Inbox management
Fairview: Filtering Inbox
Reduce “backpack” 90min/d to few min
MA ACP Annual Scientific Meeting November 7, 2015
29
Fairview: Filtering Inbox
Reduce “backpack” 90min/d to few min
Line of Sight
Verbal messaging at Fairview rather than series e-messages going round and round the office
MA ACP Annual Scientific Meeting November 7, 2015
30
Semi-circular desk, APF
Iora Health, Dartmouth-Hitchcock
MA ACP Annual Scientific Meeting November 7, 2015
31
Challenges Innovations
4. Computerized technology that pushes more work to the clinician
Action Steps
Institutions
• ↓ message generation
• Nurses filter inbox
Regulators
• Modifications to accommodate teamwork
Technology
• Improved usability
• Team-based design
Challenges Innovations
5. Teams that function poorly and complicate rather than simplify the work
• Co-location
• Huddles
• Team meetings
• Workflow mapping
MA ACP Annual Scientific Meeting November 7, 2015
32
Flow station at North Shore Physicians Group
HP: Saves 30 min/day/physician
Printer in every room University of Utah Redstone
HP: Saves 20 min/day/physician
MA ACP Annual Scientific Meeting November 7, 2015
33
Co-location at South Central Foundation, Alaska
APF, MassachusettsGeneral Hospital
MA ACP Annual Scientific Meeting November 7, 2015
34
Daily HuddlesPrepare for a Smooth Day
Team MeetingsDo Work + Make Work Better
MA ACP Annual Scientific Meeting November 7, 2015
35
Challenges Innovations
5. Teams that function poorly and complicate rather than simplify the work
Action Steps
Institutions
• Co-location
• Line of sight
• Space for huddles
• Time for meetings
MA ACP Annual Scientific Meeting November 7, 2015
36
• Pre-visit planning
• Expanded rooming
• Team documentation
• Prescription management
• Pre-visit lab
• Team meetings
• PCMH
• Lean
• Culture change
Transformation Toolkits
• Panel mgm’t
• Burnout
• Huddles
• EHR implementation
• Inbox mgm’t
www.stepsforward.org
MA ACP Annual Scientific Meeting November 7, 2015
39
Team Documentation
Checkback 2011
APF: pt centered, team-based and mindful of care team well being.
The biggest difference -- is team, culture and time. Time with patients to better understand who they are, their story
I wouldn't trade that for anything. I'm loving it.
Ben Crocker, MDInternistMGH
MA ACP Annual Scientific Meeting November 7, 2015
40
Our Work Going ForwardHow can we contribute to transformation
“Working in clinic is unbearable”
“I’m loving it”
Entrusted and empowered by tech, team, policy
What patients want is that
deep relationship with a
healer;
this is the foundation upon
which we need to build
healthcare.
Paul Grundy, MD
IBM, PCPCC
personal communication
1.30.09