Increased EHR time associated with quality ambulatory care

Conrad L Flick, MD

[This study] is interesting. [It] showed that in primary care, there are not enough hours in a day to complete all the tasks that we are supposed to do and required to do. It sadly again documents that a 0.5 full-time equivalent (FTE) is doing 60 minutes of “pajama time” work, which means for full-time physicians, the average is 2 hours of work after leaving the office — EVERY SINGLE DAY! In this study, the average provider was only a 0.54 FTE, and it appears that none of them were a 1 FTE, so wonder how this would come out in such a settle. Their results show that the more time a physician spends in the chart, the better many metrics are, but only in certain areas. I believe this is because of the areas without much change — [such as] measuring A1C and lipid control, [since] these are pretty much simple to do and not time-intensive activities — I call them point and click, order it and measure it. The others — hypertension, diabetes control and making sure screenings are done — [are] time intensive and require figuring out the motivations of those needing those services and getting them to do the lifestyle changes and take the time to do them, things that are pretty much out of our control — advise, educate and hope we get the results we want to meet the metrics and hopefully improve their health and outcomes.

The other thought is that doctors who spend more time with their patients face to face and thus in the computer and after office time are possibly more diligent (and/or more OCD) about certain activities, and that pays off in meeting more metrics. Since burnout relates to more computer time, the fix is more time with every patient or less patients per session (not less patients in a panel per se) at the same payment as less time and more patients.

I do wonder about panel size in this study. Increase in panel size is clearly related to decrease in access to care, but primary care is unfortunately a business that makes “widgets,” and our “widgets” are patients, but not things we can do the same thing on each time, because the product when it arrives in a primary care office is not uniform like in normal production lines. Our base product comes with numerous base problems, some stable and some not, and many new issues, all presenting with various behavior and social determinant of health issues, some visible and some not, that affect our ability to get them through the assembly line and out on the other in “finished,” as judged by an insurance company or other outside entities measurements, which then hold the physician responsible for the outcomes.

In this study they talk about panel sizes with an average of 829, with the highest being just over 1,100. Most full-time physicians have panel sizes well over 1,500. Mine is over 2,000. I think the more relevant question is how many patients per session the doctors see, as that is more of a measure of how busy they are day to day — not panel size or FTE. There are risk scores noted, but that score seems more Epic-driven and not the risk adjustment factor scoring that CMS and others use to determine how “sick” or complicated a patient might be. In general, I think you can easily say that the longer a provider has been in practice, the more complicated the patients are — as a population, the older the sicker and more services needed in relationship to a younger population.

I agree with their thoughts that this underscores the need for team-based approach and to figure out better technology strategies to help, but more that we HAVE to change the payment structure toward primary care if we are looking for better outcomes that require more time intensive efforts to obtain. The thought that the new E/M codes can allow clinicians to bill based on time alone is not much help, as the high overhead of primary care (even before addition of more metrics to complete and need for larger team) makes it difficult to survive as a competitive practice under the old or new system without some other changes to our current system, which is an entirely different story, but related. The country and health care system need more primary care physicians, but they do not want to pay them adequately in comparison to our specialists, even when studies show that the way to control the cost of care in the U.S. and in providing better health is to have more primary care. We cannot entice more medical students into it now due to the pay discrepancy to other specialists and the high burnout rate due to requirements and pressures of the current systems. The bottom line is that in the current models of care and value-based health care models, the current payment for services is inadequate and without the incentives to achieve the goals for management of certain conditions that are very time intensive in the office and out of the office in managing and controlling certain conditions, and the lifestyle changes and motivational issues needed by patients.

I don’t see this study having any clinical implications in the short term with a lot of questions being brought up as above. What is alluded to is that to get better outcomes, providers need to spend more time with patients face to face or virtually, and to do this, providers must thus have fewer visits per session (and smaller panels than are normally needed to keeping the business financially solvent). However, it might just be that more diligent physicians are spending more face-to-face time and doing better (but also more likely to burn out). If this is the case, how do we get more diligent medical students and more diligent primary care doctors? And how do we keep them from burning out? Shared savings is not a long-term solution for various reasons — first, they are not upfront payments to put in the infrastructure needed to achieve the goals (more staff and fewer patients) and you can never rely on shared savings to pay off debt that occurred; and second, shared savings gets smaller year after year as you get better and better, and most see it really as diminishing return over a short number of years.

Capitation may help, but independent practices will always be at a disadvantage on knowing whether payments are adequate or not compared to insurers or CMS. Some blend of up-front support and incentives for doing the right things, but certainly not punitive measures like risk and paying back monies. To me, the most important thing about meeting metrics is having processes in place in a clinic to address those things being measured and with proven strategies to achieve them that a team within the clinic are doing as a whole, care management to help those not reaching goals by trying to determine the [social determinants of health] and the behavioral health issues that might limit them reaching those goals, and trying to figure out the motivation needed to get there. Our system wants that, but do not want to pay for it much up front and want primary care, one of the lowest paid medical specialties, to take some risk if we don’t control the costs (when CMS and insurers still pay hospitals and specialists fee-for-service and thus make more money by doing more things and primary care is supposed to change that!).