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Abstract

Keywords: Participatory medicine, patient-physician communication, EMRs, continuity of care, reimbursement.
Citation: Khozin S, Juhn G. Integrating a physical office with an online platform to improve continuity of care and expand patient-physician communication. J Participat Med. 2011 Jan 12; 3:e5.
Published: January 12, 2011.
Competing Interests: The authors have declared that no competing interests exist.

Introduction

If you were to start from scratch and design a medical practice that helped patients and physicians collaborate, reduced the inefficiencies inherent in traditional clinical encounters, improved patient access, and reinforced quality care–what would that look like?

Over the past several years, the health care industry has focused on a variety of strategies and models to address these issues, including electronic medical records (EMRs), clinical groupware, personal health records, patient registries, and medical homes. All of these are viewed as important pieces of the puzzle for creating integrated, high-quality health care delivery networks. Physician practices have started to more widely adopt electronic systems to track patient care, particularly around health maintenance and chronic conditions such as diabetes and heart disease. In 2010, data from Centers for Disease Control (CDC) and the National Ambulatory Medical Care Survey (NAMCS) found that 50% of office-based physicians in the US use some kind of an EMR system, up from 18% in 2001.^[1] In some respects, the trends are encouraging.

The problem is that most of these solutions must be embedded or retrofitted into existing practices that have workflows and processes that do not easily lend themselves to participatory medicine. Furthermore, the process of adopting an EMR system is an expensive commitment for most medical practices, with costs as high as $120,000 per physician in the first year of implementation.^[2] An even bigger impediment is the reimbursement structure of health care, which rewards volume over quality and leaves little room for physicians to explore innovative modalities that focus on enhancing the patient-doctor therapeutic relationship. Only a few physician practices have had the luxury of undertaking the necessary retooling of their practices to enhance clinical interactions, patient participation, patient access, and continuity of care, ingredients that are essential to increasing the quality of care in a patient-centric environment. It should, therefore, come as no surprise that the 2010 CDC/NAMCS report found that despite the increase in the use of electronic systems, only 10% of physicians have a “fully functional” EMR system that may enable them to meet the meaningful use criteria as defined by the US Department of Health and Human Services (DHHS).

For the past several years, coauthor Khozin has explored new approaches to addressing these challenges by developing a system that was designed from scratch to fully integrate office and online systems. His efforts were based on the hypothesis that improving health outcomes requires redesigning the care delivery paradigm so that it empowers both patients and physicians. This article describes the strategies he chose, practical experiences, challenges faced, and implications for future efforts.

Everyone Knows It: The Current System Is Broken

Our current health care system has left many patients and physicians frustrated. Everyone is aware of the problems–physicians feel like they are on a hamster wheel, especially in primary care, where the volume-driven system forces them to push patients through the office in increasing numbers as reimbursements continue to decline. Getting paid for delivered services is tied to an increasingly complex third-party reimbursement structure that can take the focus away from delivering a high-quality patient experience. Emerging data suggests that physicians in a typical primary care medical practice are increasingly strained by the volume of activities that are not reimbursed.^[3] In addition, the fear of malpractice lawsuits has created a culture of practicing defensively, a condition that can affect both care decisions and physician-patient dynamics, and drives up the costs of delivering care by creating a perceived need for performing excessive tests and procedures. An estimated $55 billion per year, or 2.4% of total annual healthcare spending, is attributed to medical liability system costs, including defensive medicine.^[4]

When patients and physicians are able to have good personal relationships, physicians can successfully leverage these relationships to promote excellence in chronic disease treatment and success in achieving self-management goals.^[5] Unfortunately, patient-physician relationships are often not strong enough or sufficiently effective to promote optimum care. Many patients are subjected to long waits at appointments, impersonal clinical encounters, and lack of appropriate and timely followup. It is difficult for many patients to effectively navigate through the health care system and, when they connect with providers, they often feel rushed and unable to fully engage.

The result is that both patients and physicians have a suboptimal experience in a health care system that is not designed to support easy communication, strong patient-doctor relationships, continuity of care, or effective care coordination. A new survey of nearly 2400 physicians conducted by the Physician Foundation and Merritt Hawkins from a broad range of specialties painted a chilling portrait, with 65% of physicians giving a negative view of their profession and 89% believing that the traditional model of independent private practice is either “on shaky ground” or “is a dinosaur soon to go extinct.^[6]”

A Different Approach

Recognizing the deficits of operating within the traditional third-party system, Khozin and his colleagues decided to experiment with a direct-payment model that allowed them to explore novel ways of optimizing the patient-doctor relationship, increase process efficiencies, and improve continuity of care. By creating a personal approach to care delivery, they examined the potential for true participatory contact.

Redesigning health care delivery to prioritize the patient-physician relationship requires radical changes. The patient and physician must change the way they think and act. Given the general challenge of changing behavior, a new relationship-focused approach needs to provide easy access and user-friendliness at every stage of care. The electronic systems that support the practice must be elegant enough to engage patients and robust enough to streamline complex data and task management processes.

To that end, Khozin built practices in Brooklyn and Manhattan with two key elements–a redesigned office experience and an engaging online platform–tied to a direct payment model. In this model, patients pay out-of-pocket for the access they need, whether it is a face-to-face visit or a half hour to chat online or by phone at scheduled times. For most routine primary and urgent care, the patient pays for the services they receive, and health insurance is only used for catastrophic coverage. Some patients, depending on the nature of their coverage, are able to bill their health insurance for access to the system.

Office Visits

The first step of the new model is providing a superior office visit experience. The initial visit is always onsite and face-to-face. This allows the physician and patient to establish a relationship while the physician conducts a physical examination and performs the necessary diagnostic tests. In Khozin’s model, the entire office visit environment has been designed to facilitate a healthy therapeutic relationship and to be conducive to an efficient workflow. There is minimal waiting because the system is not volume driven, and the online platform allows for accurate scheduling. The doctor greets the patient and they walk to the exam room together. Each room is fitted with computers that allow the physician to access the record easily, document findings, and share results with the patient.

Part of the reason that most patients don’t feel connected to their physicians may be because the typical office environment is not very pleasant. Many office spaces are stark, cold, clinical, and impersonal, and can serve to underscore the lack of a relationship with the health care team. Khozin designed a welcoming environment, including comfortable furniture, soft lighting, warm colors, and background music. His goal was to help the patient feel more like they were at a spa than in a clinical office. The space was pleasant, uncluttered, and supportive of an efficient workflow. The result is a clinical visit that is less intimidating for the patient and improves the likelihood of effective communication and an enhanced therapeutic relationship.

After the initial clinical encounter, the patient isn’t required to return to the physical space unless it is medically necessary. The patient-physician dialogue continues online.

Online Platform

In Khozin’s model, the purpose of the technology is to expand access and improve continuity and coordination of care within the context of an engaged relationship between the physician and the patient. This is done through a “Facebook-like” interface that also allows structured email communications, video chat, and instant messaging. After an office visit, the results of diagnostic tests are displayed to the physician on the platform. After physician review, the patient gets an alert, logs on, and gets the test results with explanatory notes from the physician: “Your LDL levels are great” or “This abnormal value is minor and nothing to be concerned about.” The physician can reassure, explain next steps, request a followup appointment, or provide a referral. The platform gives the physician an alert if the patient doesn’t follow up. If a new drug warning comes out, the physician can quickly send affected patients an email, and can determine whether the patient has read the email.

The tools are designed to enhance the experience for both the physician and patient, empowering them throughout each single episode of care. It is critical to emphasize that online tools designed for physicians and patients must be seamlessly interconnected in order to be effective within this model. An “empowered patient” without an “empowered physician” is less likely to achieve meaningful results. They cannot continue to operate in separate silos; the relationship must be reciprocal. It must also be more proactive than reactive. The ideal technological solution can begin to change the mindset and behavior of both patient and provider, assuming it is supported by an enhanced physical experience driven by a well-designed and welcoming office environment.

Many office-based EMR systems are designed primarily to capture billing codes for reimbursement purposes and provide easier access to patient histories and data across the health care team. Diagnostic codes as an instrument for billing (necessary in the third-party reimbursement model) do not always represent clinically relevant data that help the physician make better decisions. For example, a patient with a single, active medical problem may have tens to hundreds of coded diagnoses that appear in the EMR on their “problem list.” Many of these “problems” are of no current clinical significance, so any alerts or educational support automatically generated from the list tends to be confusing or erroneous. In Khozin’s model, the billing codes can be embedded in the background to be retrieved as needed, but the system only displays clinically relevant information.

Another fundamental challenge with existing systems is that they are often limited to data capture and retrieval, and may not facilitate communication within the platform. Effective communication is the foundation of any meaningful interaction, and the lack of good communication is one of the most notable deficits of many patient-physician relationships. The system that Khozin and colleagues devised allows the patient and physician to interact meaningfully in a secure environment that is compliant with the Health Insurance Portability and Accountability Act (HIPAA). All communications stay within the platform. When a physician logs on, they access all the emails from the patient and other physicians regarding that patient’s care. Every email trail is eventually closed and sent to a timeline. It then becomes an “episode of care.” Once closed, a patient can initiate a new complaint or issue at any time.

The only emails that leave the system and go through normal email channels are prompts to log in and access the system. If external emails were to contain actual discussion around the patient’s case (as frequently happens between physicians), the system could not leverage that communication, nor would it ensure privacy, security, and confidentiality. The process would be disrupted, the physician would lose track of the discussion, and all efficiencies would be lost. The only way for an online communication system like this to scale is if the physician is reimbursed for using it. Currently, most insurers only reimburse the physician for medical and surgical procedures and office visits.

Results

Since Khozin’s practices function as business units and carefully designed proof-of-concept experiments, the available results, beyond profitability metrics, are mostly qualitative. There were encouraging early indicators, including a strong trend towards a high level of patient and physician satisfaction achieved in a relatively short period of time, about six months after building the first medical practice. Two groups of patients, diabetics and those with coronary artery disease, appeared to benefit strongly from dedicated face time and easy online access. Many of these patients require a great deal of monitoring and support to achieve adequate control of their chronic disease and to prevent secondary complications. Patients’ blood pressure, blood glucose levels, and other relevant parameters were incorporated into structured email “visits” to guide both the physician and the patient in fine-tuning medications and instituting lifestyle modifications. Instant messaging and video visits served as convenient surrogates for office visits to address non-acute but clinically significant problems that patients with chronic diseases often face.

Two other groups seemed to benefit. Elderly patients and those with multiple medical problems often see their provider with a bag of medications and a long list of questions and complaints. In volume-driven scenarios, the physician may only have time in a single visit to address the top one or two complaints rather than sort out all the issues involved. In the new model, Khozin and colleagues were able to take the time required to eliminate unnecessary medications and create a personalized remote or “virtual” monitoring program for each patient during the initial visit. On formal surveys conducted, the main drivers of patient satisfaction included the longer-than-average length of office visits and the increased level of access and continuity of care achieved through virtual channels of communication.

Challenges

Khozin’s medical practice introduces a new paradigm where technology and process redesign permit the delivery of care in a more streamlined and patient-centric way. A recent McKinsey survey of 367 health care executives–representing payers, providers, and pharmaceutical companies–suggested that most of them were not prepared for the changing economic conditions and the evolving prospects for health care reform. This report found that those who felt prepared were the ones who knew how to “drive innovation in a wider range of areas, including product design, customer service, and information technology.^[7]” Health care organizations and physicians at the center of health care delivery must not only learn to “think outside of the box,” but also must garner the necessary resources that allow creative solutions for care delivery and patient interaction.

Unfortunately, even for physicians who are committed to rethinking care delivery and improving patient care, there are many barriers that make it hard to provide care in this new and innovative manner.

The first of these is technology. The market is saturated with hundreds of EMR/EHR/PHR systems. Many of these are inefficient and can disrupt the physician’s workflow, adding little improvement to care delivery. A recent systematic review identified the need for process redesign and the inherent inefficiencies associated with the use of technology (such as data entry) as two of the most important barriers to physician adoption of existing EMR systems.^[8] This is not from simple lack of insight by software vendors, but it illustrates that the needs and changing requirements of third parties (insurance companies) often supersede those of patients and doctors. As a result, many health IT systems end up mostly as “billing machines,” focusing on capturing charge data that satisfy the needs of payers, not providers and patients. Empowering the doctor-patient relationship, the foundation of delivering effective care, has rarely been the focus of health care IT. This may be the reason behind the paucity of compelling evidence on the use of EMRs and increased quality of care. In some cases, EMRs have been associated with either deterioration^[9] or lack of improvement in care quality indicators.^[10]

Practical health care IT should be intelligent, integrated, and interoperable. Intelligently designed systems prioritize the needs of patients and providers. An electronic platform with well-integrated features ensures a consistent and smooth operator experience. Interoperability stands as a prerequisite to deriving real societal value from health care IT and facilitates health information exchange among networks of patients and providers.

The second major barrier is financial risk. As mentioned previously, third-party insurance contracts restrict physicians in how they can practice and interact with patients. Deviating from these contracts often means significant financial risk to existing practices. Younger physicians who would otherwise be more likely to explore new practice modalities are also forced to enter the traditional volume-based system in order to pay for practice expenses and earn a reasonable income.

Implications for the Future

At present, physicians cannot explore alternative methods of care if their work is not recognized by the payment system. If, for example, they wanted to try new ways to use email, video, or chat as communication and access channels, they would have no way to do so unless they participated in a third-party pilot program. Since only the boldest and most entrepreneurial physicians will risk leaving the third-party system and venture out on their own, true innovation is likely to happen at a snail’s pace, or not at all.

There are many remaining unanswered questions. How likely is it that other physicians could replicate a similarly ambitious model? Do patients truly want the responsibility of being empowered? Khozin’s work is still evolving and he continues to explore the best approaches in a variety of settings.

The direct-payment blueprint has potential for a growing segment of the population, especially for primary and urgent care services. It’s also possible, and hopeful, that over time health plans will help drive new ways to reimburse care, increase efficiency, and improve participatory collaboration. If bundled payments become reality, virtual visits can be an important adjunct to care because physicians will be paid for an “episode of care” rather than each office visit. If Health Savings Accounts continue to grow in popularity, they could help drive the viability of virtual visits since patients could pay providers directly, assuming virtual visits are deemed qualified expenses. In the meantime, Khozin’s project and others will help define what is feasible and practical.

References

1. ^[1]Hsiao CJ, Hing E, Socey TC, Cai B. Electronic Medical Record/Electronic Health Record Systems of Office-Based Physicians: United States, 2009 and Preliminary 2010 State Estimates. Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/nchs/data/hestat/emr_ehr_09/emr_ehr_09.htm. Accessed January 4, 2011.↩
2. ^[2]Physician Practice EHR Price Tag. CDW-G. Available at: http://newsroom.cdwg.com/features/feature-12-13-10.html. Accessed January 4, 2011.↩
3. ^[3]Baron RJ. What’s keeping us so busy in primary care? a snapshot from one practice. N Engl J Med 2010;362:1632-1636.↩
4. ^[4]Mello MM, Chandra A, Gawande AA, Studdert DM. National costs of the medical liability system. Health Aff. 2010 Sep;29(9):1569-77.↩
5. ^[5]Stock S, Drabik A, Büscher G, Graf C, Ullrich W, Gerber A, Lauterbach KW, Lüngen M. German diabetes management programs improve quality of care and curb costs. Health Aff. 2010 Dec;29(12):2197-205.↩
6. ^[6]Health Reform and the Decline of Physician Private Practice. The Physicians Foundation. Available at: http://www.physiciansfoundations.org/uploadedFiles/Health%20Reform%20and%20the%20Decline%20of%20Physician%20Private%20Practice.pdf. Accessed January 4, 2011.↩
7. ^[7]Unprepared for Changes in Health Care: McKinsey Global Survey Results, July 2009. Available at: https://www.mckinseyquarterly.com/Health_Care/Strategy_Analysis/Unprepared_for_changes_in_health_care_McKinsey_Global_Survey_Results_2405. Accessed November 27, 2010.↩
8. ^[8]Boonstra A, Broekhuis M. Barriers to the acceptance of electronic medical records by physicians from systematic review to taxonomy and interventions. BMC Health Serv Res. 2010 Aug 6;10:231.↩
9. ^[9]Crosson JC, Ohman-Strickland PA, Hahn KA, et al. Electronic medical records and diabetes quality of care: results from a sample of family medicine practices. Ann Fam Med 2007;5(3):209-15.↩
10. ^[10]Linder JA, Ma J, Bates DW, Middleton B, Stafford RS. Electronic health record use and the quality of ambulatory care in the United States. Arch Intern Med 2007;167(13):1400-5.↩

Copyright: © 2011 Sean Khozin and Greg Juhn. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the author(s), with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.