The End of the Beginning: The Redesign Imperative in Family Medicine Joseph E. Scherger, MD, MPH Blanchard Memorial Lecture May 2, 2005

A Selective History of Family Medicine

The 1960s Age of Specialization Age of Specialization Decline of General Practice Decline of General Practice Millis and Willard Reports Millis and Willard Reports The Beginning of Family Medicine The Beginning of Family Medicine

The 1970s Rapid Growth of the New Residency Programs Rapid Growth of the New Residency Programs Family Medicine’s Greatest Generation Family Medicine’s Greatest Generation Family Medicine as Counterculture Family Medicine as Counterculture

The 1980s Rapid Rise in Health Care Costs Rapid Rise in Health Care Costs Rapid Rise in Specialty Reimbursement Rapid Rise in Specialty Reimbursement Modest Decline in Family Medicine Interest Among Medical Students Modest Decline in Family Medicine Interest Among Medical Students Family Medicine Argues for Academic Parity Family Medicine Argues for Academic Parity

The 1990s Managed Care Controls Health Care Costs Managed Care Controls Health Care Costs Family Medicine Back in Favor Among Medical Students Family Medicine Back in Favor Among Medical Students Family Medicine Tainted by the Gatekeeper Role and Harmed by the Backlash Against Managed Care Family Medicine Tainted by the Gatekeeper Role and Harmed by the Backlash Against Managed Care Family Medicine Integrates Academically Family Medicine Integrates Academically

The New Millennium Quality Chasm Exposed Quality Chasm Exposed Cost Inflation Resumes Cost Inflation Resumes Consumer Driven Health Care Consumer Driven Health Care Family Medicine Under Stress Family Medicine Under Stress The Decade of Health Information Technology and Transformation in the Process of Care The Decade of Health Information Technology and Transformation in the Process of Care The Transformation of Family Medicine? The Transformation of Family Medicine?

What the Gods Want to Destroy, They Give 40 Years of Success Peter Drucker

A Big Question for Primary Care Range of Services OR Relationship Centered Care?

Family Medicine’s Core Identity Five characteristics form the foundation of the family medicine identity: Deep understanding of the dynamics of the whole person Deep understanding of the dynamics of the whole person Generative impact on patient’s lives Generative impact on patient’s lives Talent for humanizing the health care experience Talent for humanizing the health care experience Natural command of complexity Natural command of complexity Commitment to “multidimensional accessibility” Commitment to “multidimensional accessibility”

The Value of Family Medicine Direct Observation Study – Stange, et al. Direct Observation Study – Stange, et al. Greenfield and Rosenblatt ` Greenfield and Rosenblatt ` Barbara Starfield’s Work in Primary Care Barbara Starfield’s Work in Primary Care Phillips and Green – Graham Center Phillips and Green – Graham Center Relationship Center Care – Epstein, Miller, Crabtree, et al. Relationship Center Care – Epstein, Miller, Crabtree, et al.

So What is Wrong? Not What We Do, But How We Do It Our Process of Care is Ineffective and Obsolete

Why? The Brief Visit Model is an Acute Care Model We Now Do Preventive Care, Chronic Illness Management, a Biopsychosocial and Family Systems Orientation

Family Medicine’s Care Model No Longer Fits the Work We Do

The Brief Visit Busy Office Schedule Model of Family Medicine Must Be Replaced By a New Process

“I can’t do what I came to do – help people through a variety of difficult problems. I don’t have the time to do the job right.”

“We are not doing a good job, and it’s not our fault. Our care model is faulty.”

Outcomes in Hypertension NHANES JNC VI OlmsteadCounty Aware 73% 73% 68% 68% 61% 61% Treated 55% 55% 54% 54% 45% 45% Controlled 29% 29% 27% 27% 17% 17%

“The Medical Community Should be Embarrassed if Not Ashamed” Claude Lenfant Director, NHBLI Lancet 1999;354:747

The Medical Office is a Bottleneck of Episodic Care Which Does a Poor Job of Healing and Meeting People’s Health Care Needs.

DAILY SCHEDULE 2005 Thursday January 30, 2003 Daily Schedule Dr.. Wellbetter

Hamster Care

“Productivity Expectations in Primary Care Will Continue to Undermine the Identification and Treatment of Depression if They Fail to Take Into Consideration the Factors that Influence Such Care” Baik, et al. Ann Fem Med 2005,3:31-37

Doctors Need Time To Heal The great failing of managed care today is its blindness to the importance of time for high quality care. Kenneth Ludmerer

Family Medicine’s Catch-22 Undervalued and Underpaid Undervalued and Underpaid Must Generate Visits and RVUs to Survive Must Generate Visits and RVUs to Survive Lack the Resources to Redesign Lack the Resources to Redesign Lack the Power to Change How We Work Lack the Power to Change How We Work

Entropy in our Family Medicine Residency Programs

Where is the Revolution? Complacency – Primary Care and Family Medicine will come back in style. This is just a cycle Complacency – Primary Care and Family Medicine will come back in style. This is just a cycle Powerlessness – I have little control over the work environment, especially with the schedule, productivity and finances Powerlessness – I have little control over the work environment, especially with the schedule, productivity and finances

They Say Time Changes Things, but Actually You Have to Change Things Yourself Andy Warhol

Family Medicine Will Not Solve Its Current Problems Family Medicine Will Move On to a New Care Model

The Future Of Family Medicine Depends Entirely On The Quality Of Care That We Deliver

Lean Thinking Kaizen – Continuous Incremental Improvement Kaizen – Continuous Incremental Improvement Kaikaku – Radical Improvement Kaikaku – Radical Improvement It is time for Kaikaku in Family Medicine

Family Medicine – Core Functions We Manage Relationships We Manage Relationships We Manage Knowledge We Manage Knowledge We Manage Resources We Manage Resources We Provide Skills We Provide Skills

New Model of Family Medicine Characteristics  Personal medical home  Patient-centered care  Team approach  Elimination of barriers to access  Advanced information systems  Redesigned offices  Whole-person orientation  Care provided within a community context  Emphasis on quality and safety  Enhanced practice finance  Commitment to provide family medicine’s basket of services

The First Rule of Redesign Crossing the Quality Chasm Care is Based on Continuous Healing Relationships New Model of Family Medicine Personal Medical Home

Health Care Becomes Continuous Patients Live Their Health and Illnesses Every Day Patients Live Their Health and Illnesses Every Day Quality Health Care Offers Continuous Access and Engagement Quality Health Care Offers Continuous Access and Engagement Patients Will Drive the Innovation Patients Will Drive the Innovation Patients Will Have Their Medical Records Patients Will Have Their Medical Records Patients Have Access to All Medical Information – The Return of the Public Library Patients Have Access to All Medical Information – The Return of the Public Library Patients Will Communicate Far and Wide for Care Patients Will Communicate Far and Wide for Care

Information Technology Changing Medicine Patient Information EHR, All Clinical Data Communication Digital Connection of Patients with Caregivers Knowledge Management and Decision Support Tools

WiFi Structured Knowledge Data Center Local Office Server Always-on Internet Sources -- Publish Daily to Web FDA, CDC, NIH CDER, LMRP Institute of Medicine, NDC World Health Organization US Preventative Task Force… PDA Real-time knowledge architecture Room 3 Printer Room 1 Printer Room 2 Printer Natural Handwriting

Young Can’t Imagine Life Without Online Access Associated Press December 5, 2004

The New Communication Interactive Web Site For: Lab Results And Other Data Lab Results And Other Data Arranging Preventive Services Arranging Preventive Services Chronic Illness Care Chronic Illness Care Behavioral Coaching Behavioral Coaching Group Visits Group Visits Minor Acute Problems Minor Acute Problems

Improved Outcomes Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Resources and Policies Community Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Health Care Organization Chronic Care Model

Chronic Care Delivery Models Planned, systematic approach Planned, systematic approach Attention to information and self- management needs of patients Attention to information and self- management needs of patients Multi-disciplinary teams Multi-disciplinary teams Extensive coordination required across settings and clinicians, and over time Extensive coordination required across settings and clinicians, and over time Unfettered and timely access to clinical information is critical Unfettered and timely access to clinical information is critical

Planned Care Care is based on evidence Care is based on evidence Decision support is built into the work flow Decision support is built into the work flow Nothing drops through the cracks Nothing drops through the cracks Patient and Disease Registries Patient and Disease Registries Individual and Population based care Individual and Population based care Patient and care team are on the same page Patient and care team are on the same page Patients are activated to better manage their conditions Patients are activated to better manage their conditions Stepped-up care/resources tied to patient need Stepped-up care/resources tied to patient need

Five Core Educational Competencies for 21 st Century Quality Health Care (IOM) Provide Patient-centered Care Provide Patient-centered Care Work in Interdisciplinary Teams Work in Interdisciplinary Teams Employ Evidence-based Practice Employ Evidence-based Practice Apply Quality Improvement Apply Quality Improvement Utilize Informatics Utilize Informatics

A New Vision of Family Medicine Responsibility for a Population of Patients Responsibility for a Population of Patients Manage Needs and Demands With a Continuous Process Manage Needs and Demands With a Continuous Process Prioritize Conditions and use a Team Approach Prioritize Conditions and use a Team Approach Take the Time to be Effective (Time to Heal) Take the Time to be Effective (Time to Heal) Change our Concept and Application of Productivity Change our Concept and Application of Productivity

A New Model of Office Practice 50% More Caring Interactions Each Day 50% More Caring Interactions Each Day Unhurried Office Visits Each Day Unhurried Office Visits Each Day Advanced Access – Do Today’s Work Today Advanced Access – Do Today’s Work Today Patients Get All the Time They Need Patients Get All the Time They Need Patients Receive the Excellent Care Patients Receive the Excellent Care

How? An Interactive Practice Website An Interactive Practice Website 40-60% of Patient Needs Handled Online or by Telephone 40-60% of Patient Needs Handled Online or by Telephone Electronic Health Records with Imbedded Knowledge Management Tools Electronic Health Records with Imbedded Knowledge Management Tools Great service Great service

Concierge Care for Everyone? Fewer Patients per Family Physician Fewer Patients per Family Physician Continuous Availability Continuous Availability Focus on Comprehensive Care Including Prevention Focus on Comprehensive Care Including Prevention Enhanced Professional and Patient Satisfaction Enhanced Professional and Patient Satisfaction Is Concierge Practice the Custom Invention that will lead to the Model of the Future? Is Concierge Practice the Custom Invention that will lead to the Model of the Future? American Society of Concierge Physicians is now the Society for Innovative Medical Practice Design American Society of Concierge Physicians is now the Society for Innovative Medical Practice Design Make it Affordable Make it Affordable

Alan Dappen Doctokr Practice in Vienna, VA – A New Communication Model Doctokr Practice in Vienna, VA – A New Communication Model Communication Begins with Telephone or Communication Begins with Telephone or Patients 1000 Patients 20 Messages Handled Daily 20 Messages Handled Daily 4-5 Visits per Day 4-5 Visits per Day 1-2 House Calls 1-2 House Calls Payment by Time of Service Payment by Time of Service Website and Newsletter Website and Newsletter

Greenfield Health 5 Internist Practice in Portland, OR 5 Internist Practice in Portland, OR Chuck Kilo as Leader (IHI Experience) Chuck Kilo as Leader (IHI Experience) Interactive Website, Web Messaging, Telephone and Selective Use of Office Visits Interactive Website, Web Messaging, Telephone and Selective Use of Office Visits Physician Spends Half Day Seeing Patients – Visits 30 Minutes or Longer Physician Spends Half Day Seeing Patients – Visits 30 Minutes or Longer Half Day Messaging Half Day Messaging Volume is 20% Visits, 40% Telephone, 40% Web Messaging Volume is 20% Visits, 40% Telephone, 40% Web Messaging $395 Annual Fee, Discount for Families $395 Annual Fee, Discount for Families

Kaiser Permanente HealthConnect 24 Hour Access to Accurate and Comprehensive Health Care Information and Services

Relationship Centered Care What is the 21 st Century Application?

From Chaos to Care: The Promise of Team-Based Medicine David Lawrence, MD

Financial Models for the New Model Shift of telephone to (time saver, $ neutral) Shift of telephone to (time saver, $ neutral) Reduce unnecessary visits (more $ in high demand office, less $ in lower demand) Reduce unnecessary visits (more $ in high demand office, less $ in lower demand) Payment for virtual care (Web Visit Charges) Payment for virtual care (Web Visit Charges) Prepaid service fee, monthly ($30) or annual ($360) Prepaid service fee, monthly ($30) or annual ($360) Prepaid Contracts Prepaid Contracts Pay for Performance incentives Pay for Performance incentives Billing for Group Visits Billing for Group Visits

Finances Follow Innovation The New Model is More Efficient Better Faster Cheaper!

Change Is Disturbing When It Is Done To Us. Change Is Exhilarating When It Is Done By Us Rosabeth Kantor Harvard Business School

Change Principles Use Strong Leadership and Create the Environment for Change Use Strong Leadership and Create the Environment for Change Focus on Teaching and Learning Methods Focus on Teaching and Learning Methods Use Mentoring and Targeted Interventions Use Mentoring and Targeted Interventions Create Capacity for Change Create Capacity for Change Use Data to Drive Improvement Use Data to Drive Improvement

Getting to a Quality Driven Practice Easy stuff Less commitment Difficult Deep commitment Attend meeting to learn Join an discussion group Incremental improvement of office systems Redesign subsystems Redesign of all systems

New Model Practice Resource Center Being Started by AAFP to be a Catalyst for the Future of Family Medicine Being Started by AAFP to be a Catalyst for the Future of Family Medicine Financial Resources to Begin a New Service Company Financial Resources to Begin a New Service Company National Demonstration Project of up to 20 Practices, Including Teaching Practices National Demonstration Project of up to 20 Practices, Including Teaching Practices

Substance is enduring, form is ephemeral. Failure to distinguish clearly between the two is ruinous. Success follows those adept at preserving the substance of the past by clothing it in the forms of the future. Preserve substance; modify form; know the difference. Wise Words from Dee Hock

Family Medicine’s Hinge of Fate MacArthurORChurchill?

We Are Witnessing The Birth Of Modern Medicine How About the Rebirth of Family Medicine?