No Common Sense Family Doctor post this week

I will be busy preparing a presentation on blogging and using social media tools for the Family Medicine Education Consortium's Northeast Region Meeting in Hershey, PA and also laying the groundwork for a big announcement early next week (how's that for a teaser)? If you can't wait that long to get your blog fix, there will be a new post on my Healthcare Headaches blog on USNews.com tomorrow or Wednesday. See you all in November!

Improving care with electronic health records

For most of my career, I kept track of my patients' health histories by scribbling hand-written notes in a paper chart. For a healthy child, I'd include dates when vaccines were given; for an adult with, say, diabetes, I'd make sure to jot down a recommended schedule of blood and urine tests as well as foot and eye exams. A majority of primary care physicians, in fact, still use this kind of tracking system—despite research suggesting that these handwritten flowsheets aren't just inefficient, but extremely vulnerable to errors. Some say the solution lies in simply switching to electronic medical records.

After all, paper charts don't automatically update themselves when, say, the Centers for Disease Control and Prevention makes a new vaccine recommendation. An electronic medical record system can do that and can also allow test results to be emailed or transferred automatically into a patient's chart; paper charts rely on office administrators to input them by hand, which can lead to mistakes. I, myself, have occasionally forgotten to record that a vaccine was administered during the chaos of a busy work day. Nor did I have any systematic way of knowing how many of my patients were actually receiving the preventive and chronic care they needed.

But the latest research suggests that electronic health records don't necessarily improve care unless they include interactive features: They should make it easier for doctors to implement proven guidelines for good care, providing the necessary shots and screenings, follow-up exams and treatments to help patients live longer with chronic diseases or to prevent these diseases altogether. Ideally, these records should include a software tool that periodically culls through patients' records looking for gaps in care such as who is overdue for a cholesterol screening or flu vaccine. The system would then send out reminders to patients to come in for a test or appointment.

Kaiser Permanente added such a tool to their electronic medical record system several years ago and found that it works to improve care. A study published last month in the American Journal of Managed Care found that the support tool brought more diabetes and heart disease patients in for health screenings, vaccinations and medication adjustments. After three years, for patients with diabetes, the percentage of care recommendations met every month increased from 68 percent to 73 percent; for heart disease patients, the percentage rose from 64 percent to 71 percent. Another study found that the tool helped more healthy patients get recommended screening and exams for preventive care. Bottom line: This support tool lowers the rate of skipped appointments and gaps in care.

This is great news if you use Kaiser Permanente for medical care, but what if you don't? Well, you can probably expect to see some significant changes at your doctor's office over the next three to five years. Physicians who take advantage of government financial incentives to set up electronic medical record systems must prove they're making "meaningful use" of the data from the health records, meaning that they've improved patient care as a result.

But now is a good time to ask your doctor about how your records will be handled in the future. Will a fail-safe system be implemented to ensure that you don't miss crucial office visits or screenings? If you see more than one doctor on a regular basis, find out if your primary care clinician—the one responsible for coordinating all of your care—uses a system that's compatible with the systems your specialists use. This will make it far easier to transfer test results and updates to prescriptions back and forth between various offices. Otherwise, the responsibility for keeping your medical chart up to date will fall on your shoulders. If you're not satisfied that your doctor is staying abreast of all these technological changes, you might want to consider switching to another practice.

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The above post was first published on my Healthcare Headaches blog at USNews.com.

Family medicine leadership

A recent commentary in the New England Journal of Medicine by family physicians Thomas Bodenheimer and David West examines how the city of Grand Junction, Colorado has managed to provide above-average quality health care with Medicare costs that are 24% lower than the national average. The explanation that Grand Junction residents are simply healthier that residents of other U.S. jurisdictions doesn't hold water. So what differences in the health care system of this community can be credited for its remarkable results - and applied to other communities across the country? Bodenheimer and West answer:

We believe that seven interrelated features of the health care system that may explain the relatively low health care costs could be adapted elsewhere. These are

leadership by the primary care community;

a payment system involving risk sharing by physicians;

equalization of physician payment for the care of Medicare, Medicaid, and privately insured patients;

regionalization of services into an orderly system of primary, secondary, and tertiary care;

limits on the supply of expensive resources, including specialists, beds, and equipment;

payment of primary care physicians for hospital visits; and

robust end-of-life care.

Although these innovations are mostly common sense, the perverse financial and political incentives that drive the U.S. health system (before and after the implementation of this year's reforms) present obstacles to many of them, from equalization of physician payment (requiring fresh infusions of dollars from tight state and federal budgets) to the appallingly inaccurate portrayal of end-of-life care as "death panels" (see my previous posts here and here).

We're just two weeks away from a midterm election that will likely alter the national political landscape, but no matter which party ends up with a legislative majority, patients and physicians can't look to the parties for sensible health policy solutions. To improve population health in this country, the professionals who care for the "folks" - family physicians and other primary care clinicians - need to lead the way by advocating for changes that will give every community a fighting chance to replicate the successes of Grand Junction.