Empowering primary care through strong exam room teams

Peter B. Anderson, MD

The health care industry hasn’t been too kind to primary care physicians for many years. Perhaps some of the blame rests with our poor understanding of the necessity of primary care physicians to the general health of our society. The word “primary” is part of the problem, seeming to indicate a lower level of expertise and associated inferiority. But in reality, a primary care physician — more appropriately termed a “comprehensivist” — is the leader every patient needs for his or her health care team at every stage of life.

Despite the inequalities in compensation and respect previously experienced by primary care physicians, health care reform has positioned primary care at center of an incredible opportunity. It has empowered primary care physicians like never before to address the brokenness of our health care system, offering powerful financial incentives for chronic care management and providing the framework for increased coordination between providers. Unlike what we’ve been led to believe, there’s no better time than now to be a comprehensivist.

I’ve defined this role as “the familiar physician,” a clinician who provides convenient access in the context of a long-term relationship.1 This role requires whole-person care, patient panel health management and increased accountability and communication with other providers. But this level of care simply isn’t possible without innovation.

While many remarkable advances in recent decades have changed health care for the better, we’ve altered our primary care delivery method very little. We may have limped along with an insufficient process for a time, but we can’t keep trying to maintain our traditional model and expect to provide the accessible, convenient, relationship-based care patients need.

For too long we’ve accepted the idea that only the physician belongs in the primary care exam room. This mentality has isolated physicians and led to a delivery process that absolutely fails to make primary care accessible. And this failure of the delivery process is what prevents primary care from thriving.

Too many physicians are spending their time on data entry and other non-physician responsibilities that decrease their capacity to provide timely, focused patient interaction. Those exam room tasks — most notably accurate EHR documentation — are vital to the needs of the patient visit. The physician just shouldn’t be the person performing them. The lack of teamwork in the exam room has limited the reach of our services, ultimately driving patients to expensive emergency and urgent care because we’ve failed to provide the needed access.

Problems and solutions in the exam room
I know this reality all too well. Midway through 2003, my once successful practice was struggling to stay afloat in the midst of early EHR implementation and other major industry transitions. We were $80,000 in the red, and I was working more than 60 hours per week and wishing I’d never become a family doctor. My patients were frustrated by the poor access and rushed visits and my staff morale was low. All of my time at home was controlled by the need to get back to the computer to finish charts, and I seldom had unencumbered time with my family. To be perfectly honest, I hated medicine at that point.

I was desperate by the end of 2003 — I had to embark on a serious rescue mission. My previous 20 years in primary care had shown me the exam room was in critical need of innovation. Any possibility of saving my practice had to begin there. Simply working harder couldn’t fix the pervasive brokenness; I needed a completely new process.

I began with modest yet significant changes in my delivery process and I started training my nurses to take a more active role throughout the patient visit. Their increased involvement inside the exam room liberated me from non-physician work and quickly improved my efficiency and quality. I could once again practice the “art of medicine” instead of focusing disproportionately on ancillary tasks that kept me from providing the access and attention my patients needed. I was able to offer renewed focus on patients and address their needs with holistic orientation — the real reason I chose primary care. With the restoration of the doctor-patient relationship and the capacity to practice the best care of my career, I fell in love with medicine again.

Initially birthed from desperation, the Team Care Medicine Model emerged as the solution that saved my practice, renewed my joy of practicing medicine, and restored sufficient time for my personal life. Within a few years of implementation and refinement of the process, I realized the transformation made possible by this model could empower other physicians and their staff as well.

That began a journey of working with practices across the United States to create dynamic, high-functioning teams in the exam room that facilitate increased productivity, more accurate and timely data collection, and larger, more engaged patient populations. This revolutionary process allows physicians to focus on patient care and mobilizes nurses, licensed practical nurses, and medical assistants, trained as Team Care Assistants, to work at the full capacity of their licenses.

Teamwork makes the dream work
Team Care Assistants, or TCAs, perform a number of specific exam room responsibilities that enable physicians to spend less — but higher quality — time with each patient. We’ve developed several steps for each of these tasks that require initial training but quickly prepare clinical staff members to assume a more strategic role. The following skills capture the broad scope of the TCA’s responsibilities: visit control, data collection, presentation, scribing, ordering of plan, and visit closure. Those skills are put to work in the exam room.

Each step is executed in partnership with the physician and makes substantial improvements in workflow. With extra support in the exam room, physicians are freed up to do the work for which they are singularly trained. Clinical staff members gain a greater sense of professional satisfaction from increased interaction and education with patients instead of being relegated to “vital signs only” status. Patients become more engaged in their own health management because of their ongoing, convenient access to the same physician and care team.

While the adoption process takes some time and effort, well-trained TCAs can appropriately and expertly manage these added responsibilities and provide invaluable support to the physician throughout the entire visit. The differences between the traditional care model in contrast with the Team Care Medicine Model demonstrate remarkable gains in quality, productivity, profitability, and most importantly patient health outcomes. We saw these improvements in our own practice as we grew from seeing an average of 18 to 20 patients each day to 30 to seeing 35 patients per day. After witnessing these results, Dr. Kevin Hopkins of the Cleveland Clinic validated the value of this model.2

For the Team Care Medicine Model, we don’t encourage self-training. There are too many habits, too much variance, and too much time investment required to make the model successful by doing it yourself. We experienced this kind of failure firsthand for our first couple years as we tried to help doctors do it themselves. I do not think this model can be effectively developed by most physicians today due to the lack of time. When we learned this process, it took us about two to three years to really get decent at it. To project a shorter time period for self-training would be unreasonable. The position Team Care Medicine has taken as a company is to develop a turnkey training program so transformation doesn’t rest solely on the already overwhelmed physician’s shoulders.

Empowered to thrive
The goals of the Triple Aim must be accomplished if we’re going to embrace the opportunity health care reform has given primary care. Those goals will require change on every level of the industry to expand access and lower overall costs.

We’ve never needed innovation more than we do now. Increased coordination, access and communication, better care quality, and decreased costs can’t be achieved without a strong team approach and engaged patients in a well-functioning medical home.
Building strong teams will enable the best aspects of primary care and make it what it should be: timely, convenient, affordable access, and quality care delivered within the context of great doctor-patient relationships. Reorienting our approach around the goals of the Triple Aim, while equipping our clinical staff with the training to maximize their role on the team, will make primary care truly thrive.

References
1   The Familiar Physician: Saving Your Doctor in the Era of Obamacare by Peter Anderson; Morgan James Publisher 2014.
2   TEAM-BASED CARE: Saving Time and Improving Efficiency by Kevin D. Hopkins, MD, and Christine A. Sinsky, MD; November/December 2014 | www.aafp.org/fpm | FAMILY PRACTICE
MANAGEMENT.

Dr. Peter Anderson spent 30 years in active practice and later founded and now leads Team Care Medicine [http://www.teamcaremedicine.com], a consulting and training company. He is the author of three books and writes and speaks frequently on primary care issues and clinical care reform in the context of the Affordable Care Act.

This article was originally published in the Florida Family Physician. Reprinted with permission.