10-30 am - Sinsky A. Sinsky, MD, FACP Nov 7, 2015 10:30a-11:30 a ... Landon, Reschovsky, ... Specialist Referral to Ancillary Services

MA ACP Annual Scientific Meeting November 7, 2015

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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


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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


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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


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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.


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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

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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?


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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


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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


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Places Where PC Physicians & Staff are Thriving?

• Where the work of primary care is do-able

• Enjoyable as a life’s vocation


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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


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• 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


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Mayo-Red Cedar arranges for pre-visit lab

Same day pre-visit lab (15 min)

ThedaCare


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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


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1. Chaotic visits with overfull agendas

Insurers

• Single co-pay lab/visit

Institutions

• Hold future orders

Regulatory

• Prescription 15 mo

Action Steps


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


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Mayo Red Cedar : New Model of Nursing (2:1)


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


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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


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The Doctor 1891 Fildes

Undivided attention

The Doctor 2015

Continuous partial

attention


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Team DocumentationNewport News

• What we all hoped for

• Team: 3:1 http://primarycareprogress.org/insight/3/profiles


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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


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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.


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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

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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%


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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


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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


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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


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Action Steps

Regulatory

• Team log-in

• Meaningful Use Stage 2

Institutions

• Staffing ratios


Technology

• Seamless transitions between users


4. Computerized technology that pushes more work to the clinician

• Verbal messages

• In-box management


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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


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• Verbal messages

• Inbox management

Fairview: Filtering Inbox

Reduce “backpack” 90min/d to few min


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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


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Semi-circular desk, APF

Iora Health, Dartmouth-Hitchcock


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Action Steps

Institutions

• ↓ message generation

• Nurses filter inbox

Regulators

• Modifications to accommodate teamwork

Technology

• Improved usability

• Team-based design


5. Teams that function poorly and complicate rather than simplify the work

• Co-location

• Huddles

• Team meetings

• Workflow mapping


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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


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Co-location at South Central Foundation, Alaska

APF, MassachusettsGeneral Hospital


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Daily HuddlesPrepare for a Smooth Day

Team MeetingsDo Work + Make Work Better


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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


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• Pre-visit planning

• Expanded rooming


• 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


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QI Metrics


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Rooming Checklist

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Making the business case


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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


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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


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Sir William Osler, 1893

“Medical care must be provided

with utmost efficiency. To do

less is a disservice to those we

treat, and an injustice to those

we might have treated.”

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Documents

10-30 am - Sinsky A. Sinsky, MD, FACP Nov 7, 2015 10:30a-11:30 a ... Landon, Reschovsky, ... Specialist Referral to Ancillary Services