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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
From the eyes of an industrial engineering prof.
You have hit the nail on the head!!!
Getting paid what we are worth!
Commentary on Beasley article
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Ben-Tzion Karsh, Madison, WI Asst. Professor, Industrial and Systems Engineering, UW-Madison
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I’d like to weigh in from a different perspective – that of a professor of industrial and systems engineering (specialty in human factors engineering) who studies health care quality and safety. I’d first like to disclose that Beasley and I are research collaborators, though I had no part in this particular study. Also, though I study health care, I have no medical training, so my comments come from my observations and experiences. One of the things that I immediately thought of upon reading the results had to do with the limits of human information processing. It was a bit scary to think that family docs might have to perceive, process, integrate and make decision about close to 4 different problems (in the case of those over 65) or even up to 5 (in the case of diabetics) problems during a single visit. Not only are these numbers not reflected in billing codes, but they suggest to me that, perhaps, many patient encounters operate at the edge of what is reasonable for a single physician to process and solve during a single encounter, given the time constraints of a typical visit. With each problem, the doc has to identify that the problem exists, determine the nature of the problem and the cause, and determine what to do about it. With each additional problem, the answer to each of those steps becomes complicated and confounded by the other problems. This poses a serious data management and decision making problem, again, especially given typical time constraints. In such cases, people tend to rely on many of the well-researched rules of thumb to help guide decisions, but these rules are thumb are not in any way necessarily accurate. This all translates into potential compromises in quality of care that are NOT the fault of the physician doing his/her best or of the patient who cannot necessarily help the fact that they have so many problems! This is just bad system design in that the system of care is designed without consideration, or at least effective support, for the performance needs of the doctor! So, what should be done about this? The gut reaction is typically –TECHNOLOGY! An EMR or decision support system (or both) can, if designed correctly, provide some help. If designed correctly, an EMR system can help the physician locate pertinent information quickly which can improve problem identification and solution accuracy and speed. If not designed correctly, an EMR can slow down the entire process, increase the likelihood of entering the wrong information in the wrong place, etc. A decision support system, if designed well, can help a physician to strategize about the best course of action given the multiple, interacting problems. A poorly designed decision support system will provide the physician with unwanted advice, impractical advice, etc. Perhaps new patient interaction processes are needed (a more low tech approach). Knowing that patients have multiple problems, perhaps methods need to be developed to better facilitate problem extraction from patients at the start of the visit so the physician has the bulk of the time to strategize about how to solve the problems. I don’t have an answer, but I do know that we are dealing with a problem that will impact human (the physician) performance. Now that we know (though I suspect all of you have known) that FPs face this many problems per visit it is time to study ways to make that situation manageable for effective and safe care. That means not just focusing on technological solutions, but also studying the nature of care encounters, the type of information needed for problem identification and solution, the methods of decision making............ Competing interests: None declared |
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Edward C. White, M.D., Cleveland, OH, USA Family Physician, Southwest Family Physicians, Inc.
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The treatment of "the PATIENT with multiple problems" rather than just "multiple problems" is what we do... Thus accounting for under-reporting of diagnoses, and consequently being 'underpaid' for the amount of time spent. Thanks for this study. I hope it is seen and considered by those responsible for 'medicare guidelines'! Competing interests: None declared |
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Kin Snyder, MD, Colorado City, CO USA Solo Private Practice-Rural
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This was an excellent study in demonstrating how complex the routine practice of family medicine can be. Rarely do patients present to their FP with just one problem to be "fixed". The problems that are presented are often intermingled and the treatment of one problem can effect the status of another or the medications used to treat another. As noted, the billing often doesn't reflect the thought and analysis put into the treatment of one or many concomitant problems. By appropriately documenting all of the patient's ongoing problems and illnesses, the average visit for an established patient would easily be skewed towards the 99214 E&M code. However, the CMS and insurance companies have used scare tactics to imply that any physician who doesn't fall within the "bell curve" of coding risks being subjected to allegations of "fraud and abuse". The truth is if all physicians coded appropriately for the management of these multiple problems we encounter, especially with elderly, Medicare patients, the bell curve would appropriately have a 99214 code as the most commonly filed E&M code. Only if we all document appropriately (esp. the ROS in the CMS guidelines) and code accordingly will we have the collective effect of shifting the curve to the right and thus getting paid the proper and rightful reimbursement for the services we provide. But if we continue to allow fear to coerce us into "downcoding", then we will never be recognized economically for the value of the service we provide to this nation's health, both physically and mentally. Competing interests: None declared |
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Henry Bloom, MD, CCFP, ABFP, University Heights, Ohio, USA Clinical Associate Professor of Family Medicine, Case Western Reserve School of Medicine
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To the Editor, The findings by Beasley, et al (1), that Family Doctors log an impressive average of 3.2 problems (including problems of others in the family) when seeing a patient the doctor knows, but only 2.4 problems when the patient is not known, speaks to the essence of Family Medicine. It helps quantify the issues of Comprehensiveness, Continuity and Family. It shows the difference in Comprehensiveness, and, presumably, Quality of Care when seeing patients and families with, or without Continuity. What we would like to know is how these numbers change depending on both the size, structure, and style of practice. Where the style of the practice is to maximize the Continuity, by having the patient and family see the same doctor most of the time, is the number of problems (either of the identified patient or of other family members) dealt with per encounter (Comprehensiveness) increased? In practices which do Physical Exams regularly, and/or which book more time for each encounter, is Comprehensiveness increased? As we go from solo (yes there are a few of us left out here) to small group, to larger group, does that affect the Continuity and therefore the Comprehensiveness? It is my observation that size (and expense, which usually goes up with size) of practice inversely correlates with time spent, with Continuity and with Comprehensiveness. But this needs to be studied. Does the presence of an Electronic Medical Record (EMR), touted presently as the magical answer to all problems, have any impact, positive or negative, on Continuity, or Comprehensiveness? The answers to these questions, in turn, highly affect what we think about the recommendations of the Future of Family Medicine Project (FFMP). That project, with its emphasis on "teams," and EMR, seems to be laying out a blueprint for large groups, and large expense (e.g. the cost for the EMR), both of which would seem to militate against adequate time or Continuity to be Comprehensive. Worse, if, we do away with appointments, as the FFMP suggests, will there be either the time or Continuity to be Comprehensive? In fact, the FFMP sounds like a perfect description, not of the future, but of present day Urgent Cares, which are the antithesis of Continuity and Comprehensiveness. Finally, to rigorously look at Quality, we should find ways to see whether the Comprehensiveness actually translates into problems effectively dealt with or just touched on. Henry Bloom, MD, CCFP, ABFP Clinical Associate Professor of Family Medicine Case Western Reserve School of Medicine Fairmount Circle Medical Building -208 20620 North Park Blvd. University Heights, OH 44118 mxm74@cwru.edu 1. Beasley JW, Hankey TH, Erikson R, et al. How many problems do Family Physicians manage at each encounter? A WReN study. Annals of Family Medicine. 2004;2:405-410. Competing interests: None declared |
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