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The 20-Minute Visit

Bruce P. Barnett, MD, JD, MBA

Chief Medical OfficerReceiver's Office of Legal

AffairsCCHCS

(adapted from “The 20 Minute Medicare Visit” by David B. Reuben, Professor UCLA )

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This lecture and all opinions expressed by the lecturer are his/her opinions alone and do not represent the opinions of nor endorsement of the CCHCS, CDCR, California State Government or any other organizations. Any republication, retransmission, and/or reproduction of all or part of any materials presented herein is expressly prohibited, unless the copyright owner of the material has expressly granted its prior written consent to so republish, retransmit, or reproduce the material. All other rights are reserved.

Disclaimer and Disclosure

• I have been asked to speak here today, While I am an employee of California Prison Health Care Services, my comments have not been reviewed or approved by CCHCS and do not necessarily reflect the views of the Receiver.

• No one involved in this CME activity has any relevant financial relationships with commercial interests.

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Overview of Talk

• What’s the problem here? – Patient Backlog, Inadequate Quality of Care

• Costs of Problem? – professional, personal, economic

• Fixing the problem– Changes you can make on Monday– Longer term practice redesign changes

• Examples of practice redesign

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The Problem

Physicians are unable to provide high quality of care for conditions affecting persons with multiple co-morbid conditions within the context of busy primary care practices.

“Feeling the Squeeze”

• Medical Economics, Oct 10, 2011• Typical PCP sees 93 pt. per week

2010• FP 96 vs. Internist 92• Week is “50 hours” – includes

admin.• Note decrease from 107 for FP

(2008)• 2011 daily encounter average is

18-19 patients per day.

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“25 to 30 minute norms”

• Free world patients visit infrequently with “pent up” lists.

• Docs need more time for more complaints

• 15 minute visits less common today

• Productivity for physicians age 50-60 is 5-10% higher than younger and older docs

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E H R – boon?

• Productivity initially slows with electronic record

• Long term productivity improves, so long as practice can survive the early backlogs.

• Younger physicians have advantage in using E H R

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Barriers to good health care

• Insufficient cognitive capacity• Not enough time• The health care system isn’t a

system• Assumptions and priorities are

wrong• Team dysfunctions

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Insufficient cognitive capacity

• Too much to know–During 2001, the US National

Library of Medicine added more than 12,000 new articles per week to its on-line archives

–To maintain current knowledge, a healthcare provider would need to read• 20 articles per day• 365 days per year

» Shaneyfelt TM. JAMA 2001; 286:2000-2601

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Insufficient cognitive capacity

• Too much to know• Too much to remember

–Heart failure management• 10 ACEIs• 7 ARBs• 3 Beta-blockers• 2 aldosterone antagonists

–All with different starting and target doses

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Not Enough Time

• Assuming – practice size 600 patients– age and chronic disease distribution of

US prison population requires visit each month

– Co-morbid psychiatric conditions– following guidelines for 10 chronic

diseases; – 14 patients per 8 hr. day

• Would take 40 days per month!• Plus time for management of other

problems..

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The Health Care System isn’t a System

• Duplication–Reordering tests rather than

looking for results• 34% sometimes or often

• Unavailability of needed clinical info• 72% sometimes or often

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 2005

E H R – from frying pan….• E H R does not necessarily

address system flaws• E H R may slow rather than speed

patient care if system issues not addressed.

• E H R inefficiencies make it even more critical that other efficient processes be deployed

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Wrong Assumptions (no evidence)

• Physician alone is responsible for clinic productivity

• Having more time to spend with patients is best method for improving quality

• Higher quality of care often/sometimes requires seeing fewer patients

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Fixing the Problem

• Ground rules• Run a more efficient practice

–Things you can do on Monday–Longer term changes: practice

redesign

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Ground rules (assumptions)

• Follow-up visit cannot take more than 20 minutes

• Comprehensive/initial no more than 30 minutes

• General medical care cannot be compromised

• No electronic medical record• Office staff can provide some help

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Run a More Efficient Practice

1) Delegate data collection

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Physician-PatientEncounter

$$$$

Office Visit

Out-of-Office Preparation

$$

$

1. Reduce time but increase effectiveness/efficiency of the inner circle

2. Always push to outermost possible circle whenever possible

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Delegation to Patients

• Pre-visit questionnaires– Initial–Follow-up

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Pre-visit Questionnaire

1. Past medical history- Current medications- Drug allergies- Surgical & medical hospitalization- Social history (habits, sociodemographics)- Preventive services, including lifestyle

2. Safety checklist

3. Advance Directives

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Pre-Visit Questionnaire• Specific questions on:

–Vision–Hearing –Dentition–Falls–Urinary incontinence–Nutrition–Depressive symptoms–Functional status

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Follow-up Questionnaires

• General– 2 most important issues– Mini-review of systems– Other doctors they have seen– Medications

• Condition-specific– Keeps issues on the table– Monitors adherence and response to

treatment– Prompts asking questions about next

steps

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Delegation to Patients

• Pre-visit questionnaire– Initial– Follow-up

• Lists• Diaries

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Delegation to Office Staff

• Screening/Case identification• History gathering

– Following up on triggers• Medications/allergies• Enhanced vital signs/physical

exam– Orthostatic blood pressure readings– Visual acuity testing

• Patient education

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Run a More Efficient Practice

1) Delegate data collection

2) Minimize data recording time· Dictation· Templates· Computerized medical

records

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Strategies for Savings Time in Clinical Practice

3) Keep information needed for decision-making readily available

• Pocket guides• PDA programs• Useful books• Computer retrieval system

4 ) Delegate plan execution• Network of health professionals• Health educators

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Longer Term Practice Redesign Changes

• To improve care, change must focus on three key levels–patient–provider–practice

• Must fundamentally change the office visit

• Does not need to be expensive

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Practice Redesign (adapted from Reuben (ACOVE-2)1

• Case finding (identification of chronic illness)

• Delegation of data collection• Structured visit notes that lead

physicians through appropriate care processes

• Patient education • Connect to on-site resources

Reuben, DB. Restructuring Primary Care Practices to Manage Geriatric Syndromes: Accessing Care of Vulnerable Elders (ACOVE-2 study) JAGS 51:1787-1793; 2003

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Structured Visit Note

• History items and simple procedures (completed by office staff)

• More detailed H & P, ordering tests (completed by physician)

• Impression and plan (completed by physician)

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Patient educational materials

• Assembled for each condition• Readily available to the clinician

to facilitate treatment• On site resources • Follow-up visit sheet

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Flexibility

• Must address all conditions • Flexibility in administration and

content–Decide how much of the intervention

is performed by staff rather than physicians

–Can modify content and supporting materials

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Pitfalls that impair perfomance

• No “buy-in” • Failure to delegate data collection• Not enough recognition of

inadequate practices with subsequent modification

• Not enough patient empowerment• Not enough co-worker

empowerment

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The Bottom Line

• Practice redesign can improve the quality of care for challenging patients

• Change requires champions and commitment to change

• Not rocket science - but hard work• Your patients and you stand to

benefit from change - or bear the costs of business as usual