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TEXAS FAMILY PHYSICIAN VOL. 70 NO. 3 2019

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INSIDE TEXAS FAMILY PHYSICIAN VOL. 70 NO. 3 2019

6 FROM YOUR PRESIDENT Accomplishments, challenges in a whirlwind year

16

8 NEWS BRIEF AAFP advises CMS on Patients Over Paperwork

Attack the WAC

Just like AAFP members, Texas family doctors say addressing administrative burden is their top priority for the Academy.

Check out these seven habits to reduce your work after clinic, or WAC.

By Sumana Reddy, MD; Peter Rippey, MD; Arnold Cuenca, DO; Sumi Sexton, MD; Troy Fiesinger, MD; Kenneth G. Adler, MD, MMM; and Brandi White

20

Stop burnout at the source: Delegate your burden

10 MEMBER NEWS Meet your Member of the Month for August | TAFP Board of Directors candidate bios

A Virginia family physician tells his story of turning his practice around and rediscovering the joy of family medicine by “equipping, empowering, and expanding” his clinical support team.

14 PRACTICE MANAGEMENT Five ways to cut down administrative burden

By Peter Anderson, MD, and James Anderson, MD

22 AAFP POLICY Principles for Administrative Simplification

24

ABFM: What’s next for MOC

The American Board of Family Medicine says they are listening to family doctor’s opinions and concerns about the Maintenance of Certification process, and they are committed to making changes.

By Ashley Webb and Elizabeth Baxley 4

TEXAS FAMILY PHYSICIAN [No. 3] 2019

30 PERSPECTIVE The health care zombie apocalypse

JONATHAN NELSON

16

FAMILY MEDICINE FACULTY OPPORTUNITIES Houston, Texas

Baylor College of Medicine has opportunities for clinical faculty who are board certified/eligible in Family Medicine and interested in providing inpatient services. In addition to joining an outstanding group of faculty who are dedicated to the care of a variety of populations, our faculty enjoy opportunities to participate in academic activities including medical student education and resident education.

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PRESIDENT’S COLUMN

TEXAS FAMILY PHYSICIAN VOL. 70 NO. 3 2019 The Texas Academy of Family Physicians is the premier membership organization dedicated to uniting the family doctors of Texas through advocacy, education, and member services, and empowering them to provide a medical home for patients of all ages. TEXAS FAMILY PHYSICIAN is published quarterly by TAFP at 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Contact TFP at (512) 329-8666 or jnelson@tafp.org.

OFFICERS president president-elect treasurer

Rebecca Hart, MD

Javier D. “Jake” Margo, Jr., MD Amer Shakil, MD, MBA

parliamentarian

Mary Nguyen, MD

immediate past president

Janet Hurley, MD

EDITORIAL STAFF managing editor

Jonathan L. Nelson

associate editor

Jean Klewitz chief executive officer and executive vice president

Tom Banning chief operating officer

Kathy McCarthy, CAE

advertising sales associate

Michael Conwell CONTRIBUTING EDITORS Kenneth G. Adler, MD, MMM Kate Alfano James Anderson, MD Peter Anderson, MD Elizabeth Baxley Arnold Cuenca, DO Troy Fiesinger, MD Kate Freeman, MPH Janet Hurley, MD Sumana Reddy, MD Peter Rippey, MD Sumi Sexton, MD Ashley Webb Brandi White SUBSCRIPTIONS To subscribe to TEXAS FAMILY PHYSICIAN, write to TAFP Department of Communications, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Subscriptions are $20 per year.

Articles published in TEXAS FAMILY PHYSICIAN represent the opinions of the authors and do not necessarily reflect the policy or views of the Texas Academy of Family Physicians. The editors reserve the right to review and to accept or reject commentary and advertising deemed inappropriate. Publica­tion of an advertisement is not to be considered an endorsement by the Texas Academy of Family Physicians of the product or service involved.

LEGISLATIVE ADVERTISING Articles in TEXAS FAMILY PHYSICIAN that mention TAFP’s position on state legislation are defined as “legislative advertising,” according to Texas Govt. Code Ann. §305.027.

The person who contracts with the printer to publish the legislative advertising is Tom Banning, CEO, TAFP, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. © 2019 Texas Academy of Family Physicians POSTMASTER Send address changes to TEXAS FAMILY PHYSICIAN, 12012 Technology Blvd., Ste. 200, Austin, TX 78727.

6

TEXAS FAMILY PHYSICIAN [No. 3] 2019

Accomplishments and challenges in a busy year

By Rebecca Hart, MD TAFP President out of the high stakes exam every 10 years, greetings colleagues. As I reflect on this but instead, maintain board certification year so far, it’s been a whirlwind! We have by answering 25 questions per quarter. I am seen major accomplishments, but huge pleased to report that the pilot program challenges lie ahead. Let’s recap where we thus far is going very well. I was recently are on several issues. part of the Commission for Continuing Accomplishments: The 86th Texas legislaProfessional Development at the AAFP tive session ended with a few significant wins Summer Cluster and was able to hear Dr. for family medicine. We retained our funding Newton express how the pilot was going. for the Family Medicine Preceptorship Program “Very well,” he said! and Physician Education Loan Repayment Diplomates are loving the freedom to Program. We successfully protected fundtake the test questions at their leisure, ing levels for existing residency training anywhere they want, even in their pajamas programs while the Legislature increased if they so choose. The graduate medical education test is open book but expansion funding by $60 you have to answer each million. And once again, Gov. Greg Abbott question in five minutes. we defeated challenges to signed into law You get immediate feedour scope of practice and back on whether you got turned back efforts by nurse Senate Bill 21 to stop the question correct, and practitioners to practice the sale of cigarettes, the answer is explained. medicine independently. e-cigarettes and other It’s actually a way to learn Among a number of continuously! public health victories, tobacco products to You must answer 60% one stands out as a parTexans younger than of the questions right to ticularly exciting change.

21. That’s a great win remain certified. And you Gov. Greg Abbott signed can opt in or opt out. You into law Senate Bill 21 to for the health of can still choose the exam stop the sale of cigaour patients! pathway. Of the pilot rettes, e-cigarettes and participants in the first other tobacco products cohort, 71% have chosen to Texans younger than to go with the quarterly questions and 29% are 21. That’s a great win for the health of our going to take the 10-year exam. Since it’s going patients! The law will take effect on Sept. 1. so well, we are hopeful the board will allow Our thanks to TAFP staff and our advoeveryone to opt in to the program at the concacy team, and especially to those of you clusion of the pilot. It’s not official yet, but the who took the time to testify for important outlook is promising. Do I hear a “Hallelujah”? issues at the State Capitol.

Challenges ahead: I see three major crises On the national front, a major win for challenging us now: 1) the opioid crisis affectfamily medicine doctors is that the ABFM ing our patients and our practices, 2) the is changing the rules on maintenance of never-ending primary care workforce crisis certification. The ABFM, under the new in Texas and the nation, and 3) an embarrassleadership of Dr. Warren Newton, finally ing maternal mortality crisis in the United listened to us as we sternly brought to their States. Let’s look at each of these and see attention the plight of the family doctor, how we are addressing each one. struggling with over regulation and buried The opioid crisis is in the news every with fees and paperwork and burnout. day. AAFP has issued a statement that was They approved a pilot program for highlighted in a recent issue of Texas Family MOC that involves a program of answering Physician. We now have a toolbox available questions on our own computers, in our to help us manage patients in better ways. homes. This will allow doctors to finally opt

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Organized medicine has responded very well to this crisis and already the number of deaths has gone down significantly.

The workforce crisis, the main issue I wanted to highlight in my presidential year, continues to be a huge issue for the state and our nation. But I am encouraged as I see the number of new medical schools and residency positions starting up, and even a new medical school (University of Houston) with a goal of graduating 50% of their students into primary care. We can’t get there fast enough. The maternal mortality crisis is multifactorial, and to understand its causes is the subject of many articles and task forces around the country. The paucity of physicians delivering babies in rural areas is just one of the many issues.

AAFP is taking this concern to Washington to highlight how the closure of so many rural hospitals has created huge deserts across the country with no maternity services. Mothers in some areas have to travel hours to get to a doctor. It’s getting worse, not better. But patients with such things as postpartum pre-eclampsia and postpartum hemorrhage are a large percentage of the deaths, and the American College of Obstetricians and Gynecologists is taking steps to begin training programs for nurses and doctors in all hospitals to ensure the early identification of these deadly complications.

Of course, we have many other challenges to face such as access to care, Medicaid reform, the lack of insurance coverage for our patients, and the humanitarian crisis at the border. These are some of the things we continue to battle for you at TAFP. My thanks to the fantastic staff here at TAFP for taking up these challenges and for helping us achieve our accomplishments. And my greatest thanks to all the volunteer physicians who are actively involved in TAFP and AAFP and TMA and the local medical societies. It is YOU who make all this happen!

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NEWS BRIEF

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AAFP guides CMS on administrative simplification efforts

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By AAFP News Staff

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TEXAS FAMILY PHYSICIAN [No. 3] 2019

AM 9/9/10 9:18

the aafp recently responded to a CMS request for information on how the agency should proceed in its efforts to reduce the crushing administrative burden that continues to overwhelm physicians in practice.

Specifically, the agency singled out its Patients Over Paperwork initiative in a request for public comment that was published in the June 11 Federal Register.

In an August 7 letter addressed to CMS Administrator Seema Verma, MPH, and signed by AAFP Board Chair Michael Munger, MD, of Overland Park, Kansas, the Academy noted that reducing administrative and regulatory tasks for family physicians is a top priority and referenced results of the 2019 AAFP Member Satisfaction Survey.

“Fully 74% of respondents said the time spent on administrative tasks has increased in the past year,” said the letter. Work associated with EHR documentation, prior authorizations for prescription drugs and quality measure reporting cause physicians the most consternation.

The letter signaled the Academy’s strong support for the initiative but added that more needs to be done so physicians “can devote more time to patient care.” To that end, AAFP urged CMS to “consult, adopt and adhere to” a list of joint principles on reducing administrative burden developed

by AAFP and five other medical organizations in 2018.

AAFP offered feedback to CMS on a variety of topics, including the following.

Reporting, coding, documentation requirements Regarding reporting and documentation requirements, AAFP called on CMS to work with specialty societies, physicians, patients, and health IT vendors on the development of performance measures, and urged the agency to implement registry and EHRbased clinical quality measures that were developed by the Core Quality Measures Collaborative.

The letter also requested transparency of methodology, simpler and standardized quality measure feedback reports, and quick delivery of feedback to physicians to they can “make changes to their practice and improve clinical care.”

Lastly, “CMS should prioritize development of measures that matter to patients,” said the letter.

AAFP also made recommendations on requirements for coding and documentation related to Medicare and Medicaid payment, and specifically asked CMS to “ensure that current clinical documentation requirements are revised or simplified” to capture essential elements of the patient encounter; furthermore, those elements should be “automatically captured” by the EHR “without the need for unnecessary and irrelevant documentation.”

The letter asked CMS to seek technical solutions to address the frustration physicians face with annual recoding of permanent patient conditions such as a limb amputation. And AAFP suggested CMS upgrade its infrastructure to support permanent patient conditions using EHR technology to summarize and aggregate such conditions.

Prior authorization procedures The biggest portion of the letter was devoted to prior authorization procedures— particularly those related to prescription drugs. AAFP noted that this particular area “is consistently listed as a leading burdensome administrative task,” and urged CMS to consult and abide by AAFP’s recommendations related to prior authorizations and step therapy.

The letter pointed out that the manual and time-consuming processes currently in use “burden family physicians, divert valuable resources from direct patient care and can inadvertently lead to negative patient outcomes” by delaying treatment.

“Family physicians using appropriate clinical knowledge, training and experi-

ence should be able to prescribe medications and order medical equipment without being subjected to prior authorizations,” AAFP said.

“Generic medications should not require prior authorization,” continued the letter.

AAFP also noted its displeasure with step therapy protocols and maintained that these should not be considered mandatory for patients who already are doing well on a course of treatment.

“Ongoing care should be continued while prior authorization approvals or step therapy overrides are obtained,” the letter said. Furthermore, “patients should not be required to repeat or retry step therapy protocols failed under previous benefit plans.”

AAFP also tackled prior authorization hassles frequently encountered by family physicians when requesting durable medical equipment for patients, in particular when prescribing diabetic supplies for Medicare patients.

AAFP argued that it should be acceptable for a physician to write a prescription for diabetic supplies to encompass syringes,

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needles, test strips, lancets, glucose testing machines and such, with the physician needing only to provide a diagnosis and an indication that the prescription is “good for the patient’s lifetime.”

Rural challenges AAFP also made a passionate appeal on behalf of rural family physicians and their patients, particularly related to CMS’ Meritbased Incentive Payment System reporting requirements.

The letter noted that many small rural practices have indicated to the Academy that they face significant barriers to implementing value-based care, including lack of staff time and insufficient financial resources to invest in health IT. “Rural practices do not have the resources to dedicate staff solely to MIPS reporting, as their staff is primarily involved in patient care,” AAFP said.

Furthermore, “one of the more concerning portions of MIPS is the promoting interoperability category,” AAFP said. The

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letter called on Congress and CMS to work together to remove legislative barriers that “restrain and complicate” the PI category.

“Congress should encourage CMS to simplify the scoring, remove health IT utilization measures and the ‘all or nothing’ requirement, and hold health IT vendors accountable for interoperability before measuring physicians on EHR use,” the letter said.

AAFP also asked CMS to “pursue thoughtful and appropriate e-prescribing flexibility that balances the need for security and efficacy with the challenges inherent in the practice of rural medicine.” Such barriers can be exacerbated by limited or inconsistent health IT capabilities, continued the letter.

Additionally, “there should be safe harbors for those prescribers who incur significant administrative burden and/or access issues to prescribing software,” AAFP said.

Source: AAFP News, August 13, 2019. ©American Academy of Family Physicians.

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9

MEMBER NEWS

COMING SOON ON TAFP’S

CME

August 2019 Member of the Month: Melissa Martin Jacaman, MD Laredo native returns to her hometown to help build family medicine residency program

By Kate Alfano

SCHEDULE Annual Session & Primary Care Summit Nov. 8-10, 2019 Nov. 6-7: Business meetings and preconference workshops

The Woodlands Waterway Marriott Hotel The Woodlands, Texas C. Frank Webber Lectureship & Interim Session April 3-4, 2020 Renaissance Austin Hotel Austin, Texas Texas Family Medicine Symposium June 5-7, 2020 La Cantera Hill Country Resort & Spa San Antonio, Texas

Born and raised in the border town of Laredo, Melissa Jacaman, MD, returned to her hometown after training at Christus Santa Rosa in San Antonio to help build a family medicine residency program, Laredo Medical Center—University of Incarnate Word, the first graduate medical education program in the city’s history.

She hopes the program will Melissa Martin Jacaman, MD increase access to care for the area’s patients, give residents top-notch training, and support the permanent physician workforce.

Kate Alfano: Who or what inspired you to become a physician?

Dr. Jacaman: My inspiration to become a physician is really a culmination of several aspects of my life. When I was about 10 years old, an aunt that I was very close to passed away after several years of battling cancer.

While I was too young to comprehend all that her medical care entailed, I most vividly remember how my aunt praised her care team for being compassionate and empathetic. I realized that I wanted to model a career where I could connect with people on a humanistic level and help guide them through difficult, but also happy, times in their lives. I have also always enjoyed math, science and problem solving. Being a physician allows me to combine my inquisitive personality with my desire to connect with others and practice a career I truly love.

KA: Can you describe your career path?

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TEXAS FAMILY PHYSICIAN [No. 3] 2019

MJ: Out of high school, I was accepted into the Partnership for Primary Care program of Texas A&M College of Medicine. Through this program, which focuses on mentoring students interested in primary care fields, I completed my undergraduate education at Texas A&M International University and then received my medical degree from Texas A&M COM. I then went on to complete residency at Christus Santa Rosa Family Medicine Residency in San Antonio. There I served as chief resident, which is where I discovered my love for medical education. I was fortunate enough to begin my career as a faculty member at Christus before moving back to my hometown of Laredo to serve as the Associate Program Director of a new residency program.

I would not have had the foundation needed to pursue this amazing endeavor without the support and mentorship I received from the faculty who trained me.

KA: What are you currently working on?

MJ: We are currently wrapping up the inaugural year of the Laredo Medical Center— University of Incarnate Word Family Medicine Residency. Our program, along with our sister internal medicine program, marks the very first time that the community of Laredo has ever had any graduate medical education programs. This venture is the result of several years of hard work, planning and collaboration between several community entities, and I am so blessed to be a part of the journey.

We are continuously working on ways to improve and grow our program. This has been an amazing year of growth for me both personally and professionally.

KA: What unique challenges are represented in your patient community?

MJ: The city of Laredo suffers from one of the highest rates of medically uninsured people in the country. This problem is compounded by the fact that we are a border city and serve as a harbor for a large number of immigrants from Central and South America.

Unfortunately, the patients we serve often present to us late in the stages of disease due to their lack of resources. Gateway Community Health Center is a Federally Qualified Health Center in Laredo and serves as one of the only options for health care for many. By embedding the continuity clinic for our residency program within Gateway, we hope to provide access to many more patients along with providing a great training experience for our residents.

Our hope is then that some of our residents will choose to stay and practice in our community after graduation.

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KA: What brings you joy in your work?

MJ: I find my utmost joy in teaching residents and watching their growth throughout their training. I feel that there is no greater service that I can provide to the field of medicine than to be a part of training compassionate, diligent and competent physicians that love what they do.

KA: Have you experienced challenges as a woman in medicine? How do you hope to affect change in your students?

MJ: One challenge that I have encountered so far in my career that I initially did not expect is the continued misconception about women in the health care field. Although the percentage of women physicians continues to climb and women have actually surpassed men in the 35 and younger age group, the title of “physician” is still largely viewed as predominately male.

I have had countless times where patients and other employees have mistaken me for a nurse, nurse practitioner, or physician assistant solely due to my gender. As we continue to evolve the culture of medicine, I hope to help train physicians that strive to be leaders in their communities and workplaces and are respected as such, regardless of gender or cultural background.

TAFP’s Member of the Month program highlights Texas family physicians in TAFP News Now and on the TAFP website. We feature a biography and a Q&A with a different TAFP member each month and his or her unique approach to family medicine. If you know an outstanding family physician colleague who you think should be featured as a Member of the Month or if you’d like to tell your own story, nominate yourself or your colleague by contacting TAFP by email at tafp@tafp.org or by phone at (512) 329-8666.

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MEMBER NEWS advertisement

Meet the candidates for TAFP Board of Directors

PRACTICE OPPORTUNITY IN NW SAN ANTONIO

At the Member Assembly on Friday, Nov. 8, during this year’s Annual Session and Primary Care Summit, members will elect three of their colleagues to the TAFP Board of Directors. Two members are running for two available at-large positions and one is running to hold the new physician position.

Well established Female Family Physician in N.W. San Antonio looking for a certified family physician with experience to

According to the TAFP Bylaws, a slate of candidates is proposed by the Nominating Committee. Candidates may also be nominated by local chapters provided the nominations are made at least 90 days prior to the election, and candidates may be nominated from the floor at the Member Assembly. The candidates profiled here are running in the contested elections but the Member Assembly will cast votes for all of TAFP’s elected positions, including officers and open board positions. If you have any questions about the nomination or election process, please contact Kathy McCarthy at kmccarthy@tafp.org.

NEW PHYSICIAN DIRECTOR Mary Anne Snyder, DO, is a Texas native from Tyler. After completing her medical degree at the Kansas City University of Medicine and Biosciences, she moved back to Texas to complete her family medicine residency at the UT Health Science Center in San Antonio.

She is currently practicing outpaMary Anne Snyder tient and inpatient medicine in San Antonio. Snyder is an assistant professor at the University of the Incarnate Word School of Osteopathic Medicine, where she is also a preceptor for students on clinical rotations, and she is the mentor for the family medicine interest group and DO Care International. She is the current TAFP Alamo chapter president and is an AAFP Advocacy Summit Key Contact. With TAFP she serves on the Commission for Academic Affairs, as well as for the Commission on Public Health, Clinical Affairs, and Research. She enjoys volunteering her time at health fairs, international medical outreach, and free clinics. She loves playing with her baby, baking, and traveling.

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TEXAS FAMILY PHYSICIAN [No. 3] 2019

work part time or full time with her. Please forward your résumé to bhenwood@henwoods.org and contact us at (210) 681-4685 to schedule an interview.

AT-LARGE DIRECTORS Brian D. Jones, MD, CPE, is the Chief Medical Officer for the Methodist Patient Centered Accountable Care Organization and the VP of Value Based Care for Methodist Health System in Dallas, Texas. He graduated from Texas Tech Health Sciences Center in Lubbock in 1997, completed a surgery internship at Methodist Brian Jones Heath System in Dallas in 1998 and completed his training in the UTSW/St. Paul Family Medicine Residency program. He received a Physician Executive Certification from the American Association of Physician Leaders in 2016. Within the Methodist Health System, he leads the clinical quality and provider engagement strategies and advocates for family physicians as crucial leaders in the transformation of care delivery from volume to value. He believes that family medicine is uniquely positioned to improve care quality, care efficiency and patient experience for our communities and for Texas. As a committed family physician, he still sees patients in a busy group practice in Cedar Hill.

Lindsay Botsford, MD, MBA, CMQ, is a family physician with Iora Primary Care in Houston. She is passionate about health care transformation, quality, leadership development, and decreasing the administrative burden. She served as medical director of MHMG Physicians at Sugar Creek in Sugar Land, Texas and faculty with Memorial Family Lindsay Botsford Medicine Residency Program for six years, where she practiced newborn, prenatal, and inpatient care. She is a graduate of Rice University and Baylor College of Medicine. She completed her residency training at Baylor College of Medicine’s Kelsey-Seybold Clinic and her MBA at the University of Houston. After being certified in medical quality by the American Board of Medical Quality, she was appointed to the NQF’s Primary Care and Chronic Illness Standing Committee in 2017. She has held local, state and national leadership, serving as Chair of the AAFP Commission on Quality and Practice in 2018 and helping to spearhead the creation of the TAFP Family Medicine Leadership Experience.

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QuitMedKit A HANDY APP FOR TREATING TOBACCO USE

The QuitMedKit© app was designed to assist health care providers in the effective counseling and treatment of tobacco dependence among their patients. This program provides state-of-the-art knowledge on behavioral counseling and pharmacological treatments for nicotine dependence.

Features: • Available in English, Spanish and Chinese • Follows the 5 As model for identifying and assessing tobacco users • Provides information on prescribed and over-the-counter medications used to treat tobacco dependence • Features graphic materials illustrating the health consequences of tobacco use to be demonstrated to the patient • Gives motivational interviewing, practical counseling and treatment tips • Adheres to the clinical practice guidelines Treating Tobacco Use and Dependence by the U.S. Department of Health and Human Services, Public Health Service, published in 2008

Download this free app today to help your patients reduce their nicotine dependence. Available in iTunes and Google Play.

QuitMedKit© was developed by Alexander V. Prokhorov, M.D., Ph.D., and Mario Luca, MS, both working at The University of Texas MD Anderson Cancer Center. Dr. Prokhorov has over 30 years of experience in conducting tobacco prevention and cessation research and is the author of a CME-accredited training program for health care providers aimed at optimization of smoking cessation counseling and treatment. He has authored and co-authored over 100 scientific publications in this area.

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6/5/19 2:10 PM

PRACTICE MANAGEMENT

WAC

is Wack: 5 ways to improve practice efficiency, increase revenue, and reduce burden

INBOX MANAGEMENT A physician’s inbox can be unruly and difficult to manage during the workday, resulting in multiple hours of WAC to complete burdensome clerical work. Most inbox messages can be handled by other team members in between patient visits, thereby reducing the administrative burden and WAC that physicians experience. Consider the three following categories when determining how to redistribute inbox workload.

1. Requests that require direct physician management 2. Messages that can be routed to other care team members, such as refills, referrals, patient questions, and portal messages 3. Messages that are not related to patient care or practice business and can be deleted EXPANDED ROOMING Expanded rooming protocols allow physicians to delegate tasks that an MA or nurse can do and frees up precious time during patient visits to focus on higher priority patient and physician concerns. Based on state specific scope of practice laws, an MA or nurse may: 1. Help the patient prioritize their list of concerns and begin the agenda setting process; 2. Perform medication reconciliation; 3. Screen for conditions or social needs based on practice protocols; 4. Update medical, family, and social history;

By Kate Freeman, MPH AAFP Quality Improvement Strategist

P

rimary care in the United States is becoming increasingly complex. The compiling evidence-based medicine practices, along with increased and disparate reporting requirements of quality measures to multiple payers, task family physicians with seemingly insurmountable responsibility during each patient visit and oftentimes leads to work after clinic—WAC. This can result in burnout, which is a critical concern as family physicians suffer from significantly higher rates of burnout than physicians in most other specialties. While there is no magical pill that increases physician wellbeing, improves practice efficiencies, and immediately generates a return on investment, here are five strategies you can consider implementing to whack the WAC! AGENDA SETTING Physicians see many patients with multiple complex chronic conditions daily. Physicians’ time is already limited during the patient visit, and the number of tasks family physicians are expected to cover in an office visit continues to grow. Best practices suggest setting a mutually agreed upon agenda between the physician and patient at the beginning of the appointment allows for an effective visit. Here are five steps to help you AGREE on the visit agenda.

1. Acknowledge patient’s list of concerns

5. Provide immunizations per standing orders; 6. Identify and arrange preventive care based on gaps through standing orders; and 7. Ensure room is prepared with necessary medical equipment for visit.

TEAM MEMBER CO-LOCATION Effective communication between care team members is essential to delivering high-quality care, but many important conversations in traditional practices often must occur at the end of the day. Co-location of care team members is a strategy that allows for verbal communication between the team in real time and results in a decrease in inbox clutter from electronic communication that would otherwise occur. Even if this strategy is not a reality for your current clinic layout, you may be able to implement other non-inbox communication tactics to increase efficiency. Some practices use walkie-talkies, instant messaging, or secure text messaging services to allow more rapid responses to questions that may arise during triage, rooming, and scheduling.

TEAM DOCUMENTATION Team documentation, or “scribing,” is a care model where a staff member assists a physician in real-time during an examination by documenting notes, orders, and referrals, and by queuing up prescriptions, thereby allowing the physician to be face-to-face with the patient. This model allows physicians to use their medical expertise to focus on patients while members of their teamwork at the top of their training and capabilities. Team documentation may be a solution for your practice—interested in learning more? The AAFP TIPS on Team Documentation is free to AAFP members.

2. Get on the same page 3. Recap top priorities 4. Ensure no additional concerns 5. Execute plan for next visit 14

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habits for reducing work after clinic

Imagine shutting your office door at the end of the day and not having any work that you need to take home.

These shifts in practice can help you reclaim your time.

By Sumana Reddy, MD, FAAFP; Peter Rippey, MD, CAQSM; Arnold Cuenca, DO, CAQSM, FAAFP; Sumi Sexton, MD; Troy Fiesinger, MD, FAAFP; Kenneth G. Adler, MD, MMM; and Brandi White

the administrative burden on family physicians is immense.

Prior authorizations, quality reporting, formularies, refills, signoffs, messages, documentation guidelines, and electronic health records can all frustrate physicians’ efforts to focus on providing high-quality patient care. These administrative hassles undoubtedly contribute to the rise in “work after clinic” as well as physician dissatisfaction and burnout.

A recent study of four specialties, including family medicine, found that physicians in ambulatory practice spend one to two hours each night on EHR tasks or paperwork – not to mention all the time they spend on these tasks during the workday.1 A separate study found that family physicians spend nearly 30 hours per month working on the EHR after hours, with activity peaking on weekends around 10 a.m. and again at 10 p.m.2 This has been dubbed “date night with the EHR.”3 But perhaps it doesn’t have to be this way. Changes are needed at the organizational and national levels to fix our broken system. But in the meantime, physicians have to find ways to regain some control over their time and not burn out.

This article will share practical steps physicians can take to improve efficiency and reduce the amount of time they spend working after hours. These strategies are based on our collective experience and offer a variety of approaches to the problem depending on your personal work style, your practice workflow, your priorities, etc. It is our hope that, by focusing on what physicians can control and applying sound principles to our work, we can reduce the burden and restore the joy of practicing medicine.

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1. PAY ATTENTION TO “HOW” AND “WHY” AS YOU START YOUR DAY How you start your day matters. We all know that arriving at the office late or with no time to prepare for the first patient visit can put us in catch-up mode for the rest of day. A more efficient approach is to arrive at the office with sufficient time before you start seeing patients so that you can look over the schedule, answer messages, or huddle with staff — whatever you need to do to get a jumpstart on the day. You could do some of this prep work at home before you come to the office if you prefer. The point is to put yourself in a more proactive position so you aren’t just reacting to situations all day and falling hopelessly behind.

But here’s the key to making this habit stick: Think about your end goal. Why do you want to be done with work when you leave the office? Be specific. For example, maybe you have young children and you want your evenings free so you can eat dinner together, go on a walk, and read them a story before bedtime.

Having a clear “why” will give you a compelling reason to show up ready for the day. It will also help you be more cognizant of how you are managing your time so you can balance out your attention to the needs of your patients and your practice with the needs of your family and yourself.

2. USE PREVISIT PLANNING

3. MAKE EVERY SECOND COUNT

Previsit planning can help you walk into each patient visit with all of the necessary information on hand, organized, and ready. It can take many forms, but there are two essential components.

Previsit labs and X-rays: Where possible, anticipate at the current visit what will be needed at the next visit and pre-order those labs or X-rays so the patient can obtain the needed tests a week ahead of the next visit in most cases. This ensures the results will be available for you to discuss with the patient at that visit and factor into care planning. This can save you time you would otherwise spend reviewing charts between visits or having staff contact patients to figure out what tests are needed, playing phone tag about test results, and searching for results during visits.

Visit prep: Have your medical assistants do a quick review of the patient’s record on the day of the visit (or the day before) to see what needs he or she may have and what prep work can be done. Creating prep sheets for common conditions can be helpful. For example, a diabetes prep sheet can help MAs identify which lab orders to set up ahead of time, which immunizations might be needed, and so on.

The time you have with patients in the exam room is short, so you have to make the most of every second. Using effective communication skills, such as building rapport quickly and not interrupting, can help the visit stay on track. Additionally, working with patients to set an agenda for the visit can help you avoid being derailed or blindsided late in the visit. Your frontdesk staff can gather the initial list of concerns from patients using a form they fill out ahead of the visit, and your MAs can help patients prioritize the list and reinforce the message that not everything can be handled in a single visit. When you enter the exam room, you can then quickly clarify what the patient hopes to accomplish today and negotiate as needed.

You also need to make the most of your time between visits.

These moments may seem insignificant, but how you spend them can reduce the amount of work waiting for you at the end of the day. For example, if the next exam room isn’t ready and you have a spare five minutes, find a task you can knock out quickly. Finish charting, complete a prescription refill request that requires your attention, answer a message, sign off on an order, etc. While you’re in the medical record, see if there are any other refills or tasks that can be done quickly, as this could save you time down the road.

Teach your team to do this as well. It’s about squeezing tasks into those little moments, instead of batching them for later.

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4. RETHINK WHO DOES WHAT Throughout your workday, you probably have moments when you think to yourself, “Why am I the one doing this task?” You then have two choices. You can either keep doing it, or you can consider delegating the task to the most appropriate person (or automating it if possible). For example, set up standing orders for when your MA can give certain vaccines, enter refills in the EHR for certain medications, or perform diabetic foot exams. MAs can also help with documentation (discussed later in the article), carry out needed screenings such as the PHQ-2 for depression, or educate patients about topics such as inhaler use.

If your staff aren’t working at the top of their licenses, consider whether it’s because they aren’t capable (meaning there’s a performance problem or training opportunity you need to address) or whether they simply haven’t been empowered to do so. Ultimately, their productivity and efficiency will affect yours, so it’s in your best interest to resolve these issues even if you aren’t their “boss.”

For those physicians working with medical students, don’t forget to use their skills to the maximum ability too. They can do patient call backs, spend extra time counseling patients while you move on to the next visit, and help look up information. This can be a learning experience for them and also helpful to you and your patients.

5. DOCUMENT LESS BUT BETTER When it comes to documentation, everyone has a different style – typing vs. dictating, documenting in the exam room vs. documenting later, team documentation vs. physician documentation, and so on. It’s OK to have a preferred style, but be cognizant of where your habits and your process might be failing you and be open to new ways to document more efficiently. This includes asking your most efficient colleagues what they do that helps speed up their documentation within your EHR. One of the most common problems is over-documenting. It’s easy to get compulsive when you have to worry about medicolegal risk, you’re trying to gather rich psychosocial information, and you feel pressured to check all the boxes you can. But not all EHR boxes need checking, and not all visits require that you write an opus. Instead, be brief, focused, and clear enough that someone looking at your note will understand your clinical reasoning and your plan. Overdocumenting not only wastes your time but can be problematic for other reasons as well. For example, think about whether you would be comfortable with, say, your patient or his podiatrist seeing your entire note detailing sensitive psychosocial issues. Remember that less is often more.

Wasted time spent clicking boxes and navigating lengthy dropdown menus just to complete a simple task is another common EHR complaint, described recently as “death by a thousand clicks.”4 In some cases, EHRs can be customized to reduce clicks if you tell your vendor what you need. For example, having certain data that you use most often displayed on the initial screen, instead of buried deep in a drop-down menu on a later screen, can save you from clicking or scrolling to review that information.

Additionally, EHR templates and macros can help reduce the amount of data entry required for tasks you perform routinely, and your EHR system might have some of these options already built in.

You can also create your own, or enlist the help of a colleague who enjoys this kind of work. Then, when you’re seeing a patient for a 18

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well-woman exam, for example, you can load the relevant template or use a macro that autofills key information, and simply adjust it as needed. This is faster than starting from scratch. Be aware, however, that overusing templates and macros can generate notes so lengthy that they’re practically meaningless.

The use of scribes (live or virtual) or team documentation can also help ease the documentation burden on physicians. In the team documentation model, nurses or MAs are trained to do more during the rooming process, so the record is started before you enter the room, and they can even assist with documentation throughout the visit.

Dictation is another option for saving time on documentation.

With a little practice using voice-recognition software, you can quickly dictate your notes directly into the EHR while in the exam room or immediately afterward. To improve the accuracy of speech recognition, make sure you use a good microphone placed close to your mouth, speak clearly and in complete phrases, and reduce background noise.

If you’ve dismissed in-room documentation because you believe it interferes with the patient interaction, you might want to give it another try, at least for your more routine visits. Consider the following tips: focus on the patient before you focus on the EHR, put the computer monitor where both you and the patient can see it as well as each other, get comfortable typing and navigating your EHR system (get help if you need it), and involve the patient in what you’re doing on screen (e.g., “Let’s see when you had your last mammogram” or “Let’s go ahead and order that test right now”).

Finally, whatever documentation method you use, make it a goal to finish your chart before seeing the next patient. Improve on the adage “Do today’s work today,” and aim to “Do this visit’s work this visit.”

6. TOUCH MESSAGES ONCE Whenever possible, have messages go directly to the person who should handle them, rather than having them all funneled through you. Fewer handoffs is a key principle in quality improvement, so your goal should be to have fewer people touching each message and minimize the number that you as the physician must handle.

Likewise, you should aim to touch each of your messages only once. Read it, take action (which may involve delegating it), and then move on to the next task.

Some portal systems can be set up to automatically direct messages to designated people based on the type of message (appointment scheduling, refills, patient questions, etc.), while other systems allow the patient to decide who receives the message. If you don’t have control over what lands in your inbox, you may need to enlist your nurse or MA to go through your messages first and handle what they can, leaving only those messages that require your attention.

Also, make sure you aren’t trying to handle things in messages that should be handled as office visits, such as communicating certain types of test results.

7. HELP EACH OTHER Having too much work after clinic is often a sign of a system or process problem, or perhaps even a workload problem. But sometimes, it is a sign of a struggling physician who needs help. For example, let’s say there are four physicians in a clinic, each with roughly the same number and same mix of patients. One physician is habitually struggling with work after clinic and is behind on

charting while the other physicians are generally on top of this work.

The physician’s lateness is problematic for the practice because it can affect billing and reimbursement as well as create liability issues if the physician can’t remember details when documenting many days after the visit.

If you see a physician struggling (or if this physician is you), the best approach involves empathy, mentoring, and accountability. The practice may need to set standards for when charts are expected to be closed – and enforce those standards. At the same time, a manager or colleague should work with the physician to figure out what’s going on, what his or her barriers are, and how to get back on track. Maybe the physician needs to have some time blocked out on the schedule to catch up on charting. Maybe the physician needs some EHR training or an MA to help with in-room documentation. Or maybe the physician just needs some coaching because he or she is trying to do too much in the exam room (for example, trying to address everything on the patient’s agenda, over-documenting, and not delegating tasks such as patient education). The barriers and solutions are going to be personal because we are all programmed differently, but most physicians will need some help figuring things out. Don’t let a colleague struggle alone, and don’t make the mistake of simply applying more pressure on an already pressured physician. There are a lot of good physicians who just need a nudge and some objective help to get past their barriers to better performance.

BALANCE, TRADEOFFS, AND AGENCY In the desire to be more efficient and reduce work after clinic, we have to be careful about what we may be sacrificing in the process.

If we’re gaining efficiency by for-going pleasantries with patients or staff, by taking shortcuts that could affect quality, or by working so hard that we’re at risk of burnout, then we’ve gone too far. Efficiency isn’t everything, and it requires balance and tradeoffs.

It can be challenging to figure out the habits that will serve you best in your aim to improve efficiency and reduce work after clinic. But the bottom line is this: Physicians are not powerless. Although reforms are needed at the national level and perhaps even within our own organizations, we do have agency. Believing we can affect our circumstances and make things better is the first step to actually doing so.

REFERENCES

1. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in four specialties.

Ann Intern Med. 2016;165(11):753–760.

2. Arndt BG, Beasley JW, Watkinson MD, et al. Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations. Ann Fam Med. 2017;15(5):419– 426.

3. Sinsky CA. Infographic: date night with the EHR. NEJM Catalyst blog. Dec. 12, 2017. https://catalyst.nejm.org/date-night-ehr Accessed March 21, 2019.

4. Schulte F, Fry E. Death by 1,000 clicks: where electronic health records went wrong. Kaiser Health News and Fortune. March 18, 2019. https://khn.org/news/death-bya-thousand-clicks. Accessed March 21, 2019.

WHAT’S BEING DONE TO ADDRESS ADMINISTRATIVE COMPLEXITY? Reducing the administrative burden on family physicians is a strategic objective of the AAFP. It has combined advocacy efforts with five other specialty societies, representing more than 560,000 physician and medical student members, and drafted the Joint Principles on Reducing Administrative Burden. The issues the AAFP is addressing include advocating for less onerous documentation and billing guidelines, interoperability of EHRs to support care across the continuum, a core set of primary care quality measures that would be used by all payers, reduced prior authorization demands, and other issues.

As part of its Patients Over Paperwork project, the Centers for Medicare and Medicaid Services recently made some changes to ease physicians’ documentation requirements: For the history and exam, physicians are now required to document only what has changed since the last visit or pertinent items that have not changed; they do not need to rerecord these elements if the record contains evidence that they reviewed and updated the previous information.

For both new and established patients, physicians no longer must re-enter information in the medical record regarding the chief complaint and history (including the history of present illness) that either ancillary staff or the patient have already entered.

Teaching physicians no longer need to personally document their participation in the medical record for E/M visits and to document the extent of their participation in the review and direction of services furnished to each Medicare beneficiary; the notes of a resident or other member of the medical team may suffice instead.

Physicians do not have to document the medical necessity of furnishing a visit in the home rather than in the office. If the encounter is medically necessary, where it occurs is immaterial.

This article originally appeared in Family Practice Management, 2019 MayJune;26(3):10-16. Reprinted with permission. Copyright ©2019 by the American Academy of Family Physicians.

www.tafp.org

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STOPPING BURNOUT AT THE SOURCE: DELEGATING ADMINISTRATIVE BURDEN

By Peter Anderson, MD, and James Anderson, MD

I was drowning

in a sea of administrative requirements. With the advent of the electronic health record at my health system, I moved much more slowly through patient visits and spent much of my time staring at the screen rather than making eye contact with my patients.

I poured more and more of my days (and my evenings) into tasks that did not require years of medical school and residency training.

Like all too many other family physicians, I was burning out.

My longtime nurse felt similarly worn out and when she turned in her resignation, it was the last straw—I knew I needed to figure out a better way of practicing medicine.

What I wanted was an experience more like a surgeon, who walks into the operating room with the patient prepared, the equipment ready, and the nurses available. That vision inspired me to tinker, experiment, and innovate to create a comprehensive primary care workflow that would allow me to focus just on the tasks that required my MD designation.

Equipping, empowering, and expanding my clinical support staff not only freed me up from administrative tasks that I should have delegated years earlier, it also allowed me to improve care and increase patient access. I was enjoying medicine again and was going home at night with my charts 100% current.

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My patients were delighted to find that they could now make same-day appointments for acute conditions rather than seeing a stranger at an urgent care center. System leadership at Riverside Health System in Newport News, Virginia, was delighted to see my financial profile flip from losing six figures per year to the most productive practice in the network.

In the ensuing years, the Team Care Medicine Model has been endorsed by the American Medical Association, the American Board of Internal Medicine, the American Academy of Family Physicians, and other health care leaders across the United States. The TCM Model reflects a handful of basic insights but, like individual steps in a dance, putting them all together in a cohesive, organic sequence takes good coaching and intentional practice. To be clear, it is not a set of tips and techniques to be selected Ă la carte based on personal preference.

The transformation starts with a major shift in mentality for the physician. Though medical schools rarely include the management training coursework included in an MBA program, physicians must embrace the reality that they manage a team. Their role can and should be less like the star player that needs the ball in their hands all the time and more like the team captain that raises the performance of the entire team through coaching and leadership on and off the court. [cont. on 23]

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AAFP POLICY In January, 2018, the AAFP Board of Directors adopted the “Principles for Administrative Simplification, a document intended to guide the Academy as it works with agencies and payers to reduce administrative burden. Later that year, the AAFP Congress of Delegates adopted the document as policy.

is denied, the reviewing entity should provide the physician with the criteria for denial. For medications, it should provide alternative choices to eliminate a guessing game.

PA for imaging services should be eliminated for physicians with aligned financial incentives (e.g. shared savings, etc.) and proven successful stewardship.

There should be a goal of eliminating PA for durable medical equipment (DME), supplies, and generic drugs.

Transitional steps include: • Limiting and reducing the number of products and services requiring PA

Principles for Administrative Simplification www.aafp.org/about/policies/all/principles-adminsimplification.html

The regulatory framework with which primary care physicians must comply is daunting and often demoralizing. Standardization is not required among public or private payers, and many physicians participate with 10 or more payers. Physicians are forced to learn and navigate the rules and forms of each payer. Thus, physicians spend countless hours reviewing documents and checking boxes to meet the requirements of health insurance plans. This is time that physicians could better spend caring for patients.

The regulatory framework for physician practices has driven operating costs up and caused reduced face time with patients. The administrative and regulatory burden is one of the top reasons independent practices close and is a leading cause of physician burnout.

Despite the good intent of underlying health care policies, the burden has expanded to an untenable level and is a significant barrier to achieving the Quadruple Aim. The American Academy of Family Physicians has devel22

oped the following prioritized list of principles on administrative simplification. Adherence to these principles will ensure that patients have timely access to treatment while reducing administrative burden on physicians.

1. Prior Authorization Physicians strive to deliver high-quality medical care in an efficient manner. The frequent phone calls, faxes, and forms physicians and their staff must manage to obtain prior authorizations (PAs) from prescription drug plans and durable medical equipment suppliers, and others impede this goal.

Principles: Activities requiring prior authorization (PA) must be justified in terms of financial recovery, cost of administration, workflow burden, and lack of another feasible method of utilization control.

Rules and criteria for PA determination must be transparent and available to the prescribing physician, at the point of care. If a service or medication

TEXAS FAMILY PHYSICIAN [No. 3] 2019

• Adopting a standardized form and process for PA among all payers • Requiring payers and pharmacy benefit managers (PBMs) that design PA specifically to save the payer or PBM money rather than benefit the patient to pay physicians for their time, as decided by the 2008 Merck-Medco v.

Gibson court case • Requiring payers to pay physicians for PAs that exceed a specified number of prescriptions or are not resolved within a set time period • Prohibiting payers from requiring repeated PAs for effective medication management for patients with chronic disease and PA for standard and inexpensive drugs

2. Quality Measures and the Need for Measure Harmonization Quality measures have proliferated in the past 15 years, leading to a significant compliance burden for physicians. Most of the measures are diseasespecific process measures, rather than more meaningful evidence-based outcomes

measures. With many family physicians submitting claims to more than 10 payers, the adoption of a single set of quality measures across all public and private payers is critical.

Principles: Quality measures should be focused on improving processes and outcomes of care in terms that matter to patients.

Quality measures should be based on best evidence and reflect variations in care consistent with appropriate professional judgment.

Quality measures should be practical given variations of systems and resources available across practice settings.

Quality measures should not separately evaluate cost of care from quality and appropriateness.

Payers should take into account the burden of data collection, particularly in the aggregation of multiple measures.

Payers should provide transparency for methodology used to rate or rank physicians.

All payers (Medicare, Medicaid, Veterans Administration, commercial insurers, ERISA plans, and any third-party administrator plan) should implement the core measure sets developed by the multi-stakeholder Core Quality Measures Collaborative to ensure parsimony, alignment, harmonization, and the avoidance of competing quality measures.

Quality measure feedback reports should be simplified and standardized across all payers to make them more actionable.

Quality measures should be updated regularly or when new evidence is developed. As new quality measures are adopted, sponsoring entities should sunset other quality measures.

Physicians should not be accountable for quality measures that they do not have the control over nor authority to improve.

3. Certification and Documentation Physicians want to efficiently order what their patients need to manage their disease conditions in a way that maintains their health. The current procedures surrounding coverage of medical supplies and services impede this goal and add no discernible value to the care of patients.

Principles: The physician’s order should be sufficient. Physicians should not have to sign multiple forms from various outside entities for patients to receive needed physical therapy, home health, hospice, or Durable Medical Equipment (DME), including diabetic supplies.

Physicians should not be required to recertify DME supplies annually for patients with chronic conditions.

Authorization for supplies should be generic so that physicians are not required to fill out a new form every time a patient switches brands, including but not limited to diabetic supplies.

Authorization forms should be universal across payers.

Data within the forms should be standardized to allow for automated EHR extraction and population of forms.

Physicians should not be required to attest to the patient’s status when the service is provided by another licensed health professional as is the case with diabetic footwear.

4. Medical Record Documentation Documentation burdens have increased dramatically, despite adoption of Electronic Health Records (EHRs). Documentation requirements for public and private payer programs and initiatives have escalated. Further, the Centers for Medicare and Medicaid Services (CMS) Documentation

Guidelines for Evaluation and Management (E/M) Services, established 20 years ago, do little to support patient care, and serve more as a framework to help physicians justify their level of billing (e.g. level 3, 4, or 5) than to help physicians diagnose, manage, and treat patients. Adherence to the guidelines consumes a significant amount of physician time, and does not reflect the workflow of primary care physicians. The guidelines were drafted for use with paper-based medical records, and do not reflect the current use and further potential use of electronic health records and team-based care.

The guidelines negatively impact the usability of EHR software programs.

The transformation starts with a major shift in mentality for the physician. Their role can and should be less like the star player that needs the ball in their hands all the time and more like the team captain that raises the performance of the entire team through coaching and leadership on and off the court.

Principles:

[cont. from 20]

As part of the Medicare Quality Payment Program, documentation guidelines for E/M codes 99211-99215 and 9920199205 must be eliminated for primary care physicians.

Changes must be made to the outdated E/M documentation guidelines and the Medicare Program Integrity Manual.

The changes should include the acceptability of medical information entered by any care team member related to a patient’s visit. This standard should be applied by all Medicare contractors, Medicaid, marketplace policies, and private payers.

The primary purpose of medical record documentation should be to record essential elements of the patient encounter and communicate that information to other providers. The use of templated data and box-checking should be viewed as administrative work that does not contribute to the care and wellbeing of the patient.

EHR vendors, physicians, and workflow engineers must collaborate to redesign and optimize EHR systems.

(2018 COD)

In the TCM Model, the clinical staff (registered nurses, medical assistants, etc.) take on a role called the Team Care Assistant. They execute six discrete steps in the patient visit. Crucially, the physician is only present for two of them. Much of the administrative work is performed at the beginning and the end of the visit, and is performed by the TCA rather than the physician.

When the physician is present, the TCA summarizes the preliminary medical information that has already been collected, in much of the same way that a medical student presents the patient’s case to the attending physician. Then the TCA scribes the very concise examination by the physician, freeing up the physician to hone in on the diagnosis and prescription without even touching the keyboard.

Because they operate extensively without the physician in the room, each TCA offers dramatically more leverage to the physician’s time than a scribe. Indeed, a high functioning TCM physician can be supported by up to four TCAs at the same time, while an individual physician never needs more than one scribe.

In recent years, the TCM Model has been adopted by a range of practices from coast to coast, including small federally qualified health centers and large integrated delivery networks. Physicians have learned to coach, to lead, and to delegate in the exam room; they’re reporting restored joy in medicine as they engage the patient rather than the computer screen and then go home on time with all their charts current. With improved clinic access, patients are delighted to get same day acute appointments with their own physician rather than an urgent care center. Executives are pleased by a strong ROI as the increase in visit volumes easily covers the conversion costs, not to mention the improved morale and retention of the physicians. This is just the beginning and I’m delighted that relief from administrative burden is beginning to restore primary care nationwide.

This article is reprinted with permission from The Ohio Academy of Family Physicians, Winter 2018 edition, and is available at: read.nxtbook.com/oafp/the_ohio_family_physician/winter_2018/cover.html. www.tafp.org

23

MAINTENANCE OF CERTIFICATION

ABFM: What’s new?

EXPLORING NEW OPPORTUNITIES AND APPROACHES TO FAMILY MEDICINE CERTIFICATION

By Ashley Webb, ABFM Director of Outreach and Elizabeth Baxley, ABFM Executive Vice President

R

equirements for maintaining board certification with the American Board of Family Medicine may feel elusive or confusing to busy family physicians who are juggling many demands and priorities. As we have had more opportunities to meet with you at your state chapter meetings, or by phone from our offices in Lexington, it is clear from your questions and feedback that we have an opportunity to improve our communication with you and your state chapter executives, in order to support your efforts to participate in the Family Medicine Certification process.

Over the years, we have alternatively heard messages of “please change” activities and requirements for certification to be more relevant and less burdensome, and “you are always changing things” and we can’t keep up with what we are supposed to know. Communicating effectively with over 90,000 board-certified family physicians across the U.S. is a challenge, indeed! But we are committed to working with you to answer your questions regarding the certification process, ensuring that information about your choices to meet requirements is easy and clear to understand, and to hear from you in ways that will help us improve Family Medicine Certification into the future.

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TEXAS FAMILY PHYSICIAN [No. 3] 2019

Through participation in board certification, family physicians are demonstrating their commitment to professionalism, lifelong learning, self-assessment of knowledge currency and identification of gaps, improving care in practice (regardless of practice type or setting), and regular assessment of cognitive expertise. We know that this matters to patients and the public, and we believe it matters to your peers within family medicine and across specialties. Mostly, we believe that it matters to you, as an individual physician participating in the process. The components of board certification map to these values, and ABFM has listened and learned from your feedback to continually enhance the process. So, let’s explore the requirements along with recent changes that we hope you will find to be helpful.

Family Medicine Certification is currently built on 10-year cycles, with three, 3-year stages and a 10th year in which cognitive expertise is assessed. Stage requirements include maintenance of an active, valid and unrestricted medical license and completion of 150 hours of approved CME credit every three years, as well as completing one knowledge selfassessment activity, one performance improvement activity and achieving 50 points through a combination of these activities. [cont. on 26]

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Today we recognize that it is far more common for family physicians to already be engaged in doing quality improvement in practice, and when that is the case, the goal of the Performance Improvement requirement is already being met.

We also appreciate that more options were needed for physicians whose practice scope and environment is different (hospitalbased, urgent or emergent care settings, locum tenens, hospice/ palliative care, sports medicine, etc.).

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TEXAS FAMILY PHYSICIAN [No. 3] 2019

I. Knowledge Self-Assessment is accomplished in one of two ways, each of which can be found in your Physician Portfolio: a. Knowledge Self-Assessment modules are topic specific and can be done on your own, or as part of a formal KSA study group at your state chapter or AAFP meetings, depending on your preference. Previously, these were referred to as SAMs (self-assessment modules) and included a linked clinical simulation. In response to Diplomate feedback, the simulation was de-coupled from the knowledge assessment in 2016, leaving the 60-question module with critiques and references for learning as what is needed to meet requirements for one KSA per stage.

Each KSA adds 10 certification points to your portfolio and with that you also earn eight prescribed hours of CME. KSA completion data demonstrates that each KSA averages 4-6 hours to complete. b. A relatively new option introduced in January 2017, Continuous Knowledge Self-Assessment, provides 25 questions through your Physician Portfolio per quarter that cover the breadth of family medicine practice.

Questions can be answered all at once, or a few at a time, in a manner that best suits your schedule, and are followed by the correct answer, a critique that explains each of the options, and references for further review when knowledge gaps are identified. There is also the option to comment on specific questions, if desired, and to review all comments— thus creating an online clinical discussion community. CKSA questions are similar in format to those seen on the Family Medicine Certification Examination. Once 100 questions have been completed over four quarters, a performance report is provided that will estimate the probability of passing the Family Medicine Certification Examination, along with a likely score. After successful completion of each quarter, 2.5 certification points and 2.5 CME credits are earned; after participating in four quarters of CKSA, you will have satisfied the minimum KSA requirement for that stage and earn 10 certification points. There is no formal scoring for this activity beyond what you may wish to utilize for your own purposes.

Average time for completion is one to two hours per quarter.

You can find more information about Self-Assessment and Lifelong Learning at www.theabfm.org/continue-certification/ self-assessment-and-lifelong-learning

II. The goal of the Performance Improvement requirement for certification is to demonstrate that, as a board-certified family physician, you can reflectively look at information about your practice, identify an opportunity for improvement, put an intervention in place, and re-measure to see if that change resulted in an improvement. When first established in 2004, this consisted of Performance in Practice Modules that were downloaded from the Physician Portfolio and completed using patient data and surveys.

Today, while a similarly-constructed activity is available for this requirement, we recognize that it is far more common for family physicians to already be engaged in doing quality improvement in practice, and when that is the case, the goal of the PI requirement is already being met. We also appreciate that more options were needed for physicians whose practice scope and environment is different (hospital-based, urgent or emergent care settings, locum tenens, hospice/palliative care, sports medicine, etc.). Finally, for those physicians who are no longer clinically active, it did not make sense to continue to require a clinically based PI activity.

As a result, the following changes have been made over the last five years to support greater choice and relevance while eliminating the need for unnecessary redundancy of work: a. The Self-Directed PI Project is best suited to an individual or small group of family physicians to report on a project already implemented in practice, or to provide a roadmap for creating a quality improve[cont. on 28]

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[cont. from 26]

ment project that is meaningful to their current scope of practice. As more Diplomates are learning of this option, the trend toward selecting this option has grown and the feedback has been very positive. The application process has been streamlined (averaging ~10 mins to complete) to require only the necessary information to demonstrate the cycle of measure, intervention and remeasure, and to attest to level of participation in the effort. More information about this can be found at in your Physician Portfolio. This pathway is ideally suited for family physicians in noncontinuity practice, as it allows selection of any area of improvement they wish to make, regardless of practice setting. b. For larger groups of family physicians (> 10), the Organizational PI Activity option is worth consideration. If you are participating in an ACO, CIN, health system network, or similarly constructed group of physicians who are working on improving care together, your organization can apply to be a sponsor for reporting your efforts in this work to the ABFM for your PI credit. Information about this option can be found at www.theabfm.mymocam.com/ extsponsor/. This pathway also allows for state chapters and other organized entities to become sponsors of Performance Improvement activities and to report on your behalf. c. If you are participating in NCQA recognition programs, a Practice Transformation Network, or CPC+, You may be able to receive credit for a certificate/recognition or award you have achieved for your improvement work (e.g. NCQA, CPC+, Practice Transformation Network, etc.). You can log into your Physician Portfolio and attest to your participation. d. If you are using ABFM’s PRIME registry to help you manage data from your EHR, you can select something you wish to improve on from what is already being measured on your dashboard, implement an intervention, and PRIME will remeasure and seamlessly submit your data to ABFM for PI activity credit using the PI activity within PRIME registry. e. The Residency Performance Improvement Program pathway is a means for residency programs to demonstrate their ability to develop and oversee the successful completion of PI projects for residents and faculty that meet the ABFM Family Medicine Certification requirements. Approved sponsors will be able to develop and oversee PI projects without having to submit an application for each activity for ABFM review. For more information go to www.theabfm.mymocam.com/respip/. f. Another exciting new option is the Precepting Performance Improvement Program. If you are teaching students or residents in your practice at a level of 180 hours of 1:1 during your 3-year stage, this option, developed through collaboration with the Society of Teachers of Family Medicine, allows you to receive PI activity credit for improving your teaching skills. Linking to an approved academic sponsor, who will help develop, oversee and report PI projects for teaching physicians, provides a pathway to earning your PI activity credit in a new way that supports the clinical preceptor, which is vital to the training of future physicians. More information about the Precepting Program is available at www.theabfm.mymocam. com/precepting/sponsors/.

III. Perhaps the most exciting new option offered by the ABFM is in the area of cognitive expertise. In December 2018, we launched a pilot of longitudinal assessment as an alternative to taking the one-day Family Medicine Certification Examination every 10 28

TEXAS FAMILY PHYSICIAN [No. 3] 2019

years in a secure test center. This approach, entitled Family Medicine Certification Longitudinal Assessment, is more aligned with adult learning principles, promoting more enduring learning, and greater retention and transfer of knowledge into practice, than infrequent, episodic examinations. ABFM prepared for implementing this option beginning in 2017, with the launch of CKSA, which tested the feasibility and performance of the platform and acceptance by Diplomates to the option of answering questions over time that promote assessment of current medical knowledge and clinical decision making. Like CKSA, FMCLA provides 25 questions per quarter, can be done on a flexible schedule and at the location preferred by the Diplomate, and permits the use of references as needed. Because FMCLA is a testing process, just like the one-day exam, the questions are timed and collaboration or discussion of items with colleagues is not permitted.

The pilot for FMCLA is two years in length and initially was limited to Diplomates whose current 10-year certification period would end on December 31, 2019. This process allows us to collect sufficient feedback and data to evaluate the quality, acceptability, and comparability of this approach to the one-day exam in assessing cognitive expertise. Participant feedback is being sought at multiple steps along the way, with the information supporting in continuous improvement of the process. We anticipate that the pilot will be successful and anticipate being able to offer the alternative for longitudinal assessment to currently certified family physicians who are seeking to maintain their certification going forward. More information about the program itself can be found at www.theabfm.org/family-medicine-certification-longitudinalassessment-fmcla.

Going forward, ABFM is interested in learning more from you regarding feedback on the current certification activities and ideas for new topics and programs that would improve the certification process. There are a number of ways for you to become more involved with the ABFM. One that may be of most interest and impact is joining our new virtual feedback group, the Engagement Network, where you can weigh in on a variety of topics through periodic short surveys and open exchange of ideas that will help ABFM staff and Board of Directors in making decisions about Family Medicine Certification and other ABFM activities.

We have recently launch a new website (www.theabfm.org) designed to provide clearer, more concise information in an easyto-navigate format with enhanced search capabilities. In 2020, we plan to release a redesigned Physician Portfolio, which we expect will make tracking your progress and selecting activities, as well as reporting on license and CME information, much easier. We will be seeking input from board certified family physicians at every step along the way of the design of the new portfolio; if you are interested in this, you can volunteer at the Get Involved link.

Finally, we plan to be working even more closely with your state chapter leaders and visiting as often as we can, to share updates and listen to your ideas. For more information, you can periodically check www.theabfm.org/about/connect-with-the-abfm to see if we are going to be in a location near to you.

Supporting family physicians, and the discipline of family medicine, is core to who we are at ABFM. If you have any questions or need help in planning or reporting your certification activities, our capable staff at the ABFM Support Center are here to help you at (877) 223-7437 or via email at help@theabfm.org.

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PERSPECTIVE

The health care zombie apocalypse

By Janet Hurley, MD there was once a time when I believed that organized medicine would play a major role in creating a sustainable health care product for our nation. Admittedly our organized medicine leaders have a lot of great ideas, many excellent skills, good relationships with lawmakers, and brilliant expertise.

However I learned with sadness as time progressed that the dysfunctions in Washington, D.C., and Austin are unlikely to lead to substantive health care changes. While our organized medical societies give wise advice, our lawmakers are not always listening.

I then turned my energies to the private sector and focused my leadership on a large integrated health care system that emphasized and respected high-value primary care. I had hoped that these kinds of systems could leverage their medical homes, medical neighborhoods, and IT systems to more optimally coordinate care and reduce waste. Yet once I entered that world, I became aware of the massive regulatory burden facing our hospitals today. The relentless push to become a Joint Commission-accredited, “high reliability organization” with “zero harm” is commendable, yet requires the hiring of multiple levels of safety officers, nursing leaders, and administrative leaders, and the development of many more “clicks” in the electronic medical record that leads to massive nurse burnout rates in our country.

I also learned about the army of IT analysts that are required to make our behemoth electronic health record work.

When we decide to add a new EHR module to do something cool for our clinicians, we spend a ton of money yet our hired IT analysts still have to work huge numbers of hours to “build it” in our system.

And it is not the hospital’s fault! Hospitals did not design EHRs to be unwieldy beasts and hospitals did not ask for countless regulations to be heaped on their shoulders. When you couple this with the legal requirement to treat unfunded patients without any hope of payment, they naturally look for new ways to get paid such as facility fees, DSRIP, URIP, intergovernmental transfers, 340 B Drug Pricing, and other modalities. Watching this tap dance for money and seeing the vast number of people needed to choreograph the routines is disheartening.

So then I focused my energy on value-based contracting.

I have read about organizations that are effectively controlling costs by leveraging the power of the premium dollar to do unique things for patients such as care coordination, nurse

navigation, transition of care processes, home visits, hospital at home, social work support, transportation assistance, and sometimes even housing and food assistance. These examples of Medicaid, Medicare, commercial, and FQHC pilots have truly bent the cost curve for their populations, yet sadly we have had sparse penetration of these plans in Texas. Some hospital systems are trying to lead these initiatives, yet struggle because the total dollars of value-based payments are a tiny fraction of what they get paid with fee-for-service, and they must consistently balance the desire to lower costs with the desire for steerage to their brick-and-mortar assets which may or may not be the lowest cost and highest value location for care.

I did not start my medical leadership experience as an advocate of a single payer system and I certainly do not feel that model is perfect. Yet wouldn’t it be easier if nearly everyone had some sort of coverage, so hospitals would not have to waste so much energy on the tap dance of getting paid? Wouldn’t it be easier and likely less expensive to simply pay doctors more to see Medicaid patients, rather than diverting them to federally qualified health centers? Wouldn’t it be better to mandate that EHR vendors play an active role in ensuring their upgrades work across their entire product and not have to be “built” into each client’s platform at the expense of the client? Wouldn’t it be better for our nation and our state to invest more money on social services like housing and subsistence income subsidies rather than to spend so much on the health outcomes of poor health behaviors? Sadly, I don’t think the political climate is anywhere close to adopting any of these principles and the alternatives do not bode well for our nation.

So what advice should I give to practicing family physicians to prepare for the possible health care apocalypse? Simply this—keep doing what family medicine does best! Regardless of what disaster awaits, family physicians will continue to be the most valuable asset to our health care system providing the most benefit to the highest number of patients at the lowest cost. As patients cannot afford their deductibles, they can still see us to manage 90% of their problems. As patients lose insurance altogether, they can find some of their best health care advice in our exam rooms. As patients face health care crises they can’t afford, we can provide comfort in their suffering.

Regardless of what the future brings, family medicine is part of the solution.

Wouldn’t it be easier if nearly everyone had some sort of coverage, so hospitals would not have to waste so much energy on the tap dance of getting paid?

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TEXAS FAMILY PHYSICIAN [No. 3] 2019

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