DPC News

Op/Ed: What We Didn’t Talk About at the First Direct Primary Care Summit

By Dr. William Shupp, DPC Physician, Madison, WI

OCTOBER 13, 2013 – I attended the first ever Direct Primary Care Summit in St. Louis, MO, and it was an excellent event.  Many of the pioneers of this model of care were there, including Qliance, Iora Health, Atlantis Medical Group, and many others.  We talked about a lot of success stories, and there was productive dialog on basic nuts and bolts.  I will have a blog post soon on some of the great things we talked about, but first I want to bring up some Big Ideas that we didn’t talk about.

To put it simply:  We understandably focused on how to be successful, but we never got to any discussion on how to really utilize this model to deliver better healthcare.  Ideas are great, but implementation is what matters.  In this blog post, I will cover the topics I discussed with other Direct Primary Care doctors (DPCs) at the conference.  None of the presenters talked about these things.  I want to give concrete examples of how these issues are being addressed by myself and other DPCs.  This is much longer than my usual posts.

True Patient Engagement is Hard to Do

As I’ve mentioned before, Patient Engagement is touted as the next big wonder drug.  Kaiser Permanente found an 88% reduction in mortality among patients enrolled in a patient engagement program after their first heart attack.  This study is quoted as a way for Direct Primary Care to improve outcomes.  Here’s the problem: the tools they used in the study aren’t available for individual clinics (DPCs included).  Here’s what they did:

  1. They used agreed-upon clinical care guidelines which were built into their EMR
  2. Activities such as lifestyle habits and modification, medication management, patient education, lab results, and adverse events were all recorded and coordinated across a team that included the patient.
  3. A team of physicians, nurses and pharmacists had access to this information, as well as the patient.

This all sounds great.  However, people aren’t used to recording their lifestyle or medication adherence in a patient portal.   And, if they wanted to, these tools aren’t publicly available.  This brings me to my next point:

Electronic Medical Records aren’t Designed for Direct Primary Care

I was happy to see that PracticeFusion had a booth at the event.  My own EMR, ElationEMR, sent an employee to check out the event and talk with DPCs about their needs (thanks!).  I tested roughly 20 EMRs, and I chose Elation because it has the smoothest and most clinically oriented interface I’ve ever seen.  But, it is designed for an episodic, clinic-based model of care.  With DPC, I can remove the clinic from the center of the healthcare universe.  Goals can be tracked and achieved out in the real world.  We need an integrated set of tools to do this.

I propose that EMRs need a database-driven collaborative tracking tool, which I’ll refer to as a “Health Goals List” (commonly referred to as a “Problem List,” including in my EMR).  This needs to be collaborative with the patient, and it needs built in tools to ensure that evidence-based care is planned and executed.  This is actually a novel concept — a “Problem List” is usually not shared with the patient and does not have any system to ensure evidence-based goals are set or achieved.  Instead, it stores billing information so it’s easier for clinicians to make a bill at each clinic visit.  For example, if a patient should be getting diabetes labs at regular intervals, the “Health Goals List” should be able to trigger this event and make sure it gets addressed at the proper time, regardless of whether a clinic visit is scheduled.  This should be integrated with the external tools that are already available.  Here are some examples of the tools that I use and want to integrate: 

  1. Lifestyle change:  If a patient wants to take 6,000 steps a day and exercise for 30 minutes a day, they can wear a FitBit or a Jawbone UP.  This will automatically track their information and sync with an online portal.  This should be able to sync with their “Health Goals List.”  This isn’t a trivial request, as I will discuss in Prediabetes management later in this post.
  2. Collaborative decision making: There are already some great tools for this, but it’s a relatively new concept.  The HealthDecision.Org website can clearly graph out a patient’s risk of having a heart attack, and how it will change over time.  I can interactively show how to improve their risk through lifestyle management and medication if needed.  Patients should be able to be truly informed of risks and benefits, and make a decision that’s consistent with their values.  This can and should be linked with an EMR.
  3. Evidence-based guidelines: There’s an open source clinical decision support tool called OpenCDS which can integrate evidence-based guidelines using patient data.   The goal is to empower clinicians (and patients!) with a system that ensures all evidence based guidelines are addressed.  Ideally, this kind of system should be built into the “Health Goals List” of a patient.  If someone doesn’t want to follow a guideline, that should be an option.  But, time constraints and a lack of accessible information should not be the reason for missing a guideline, as is often the case in a rushed fee-for-service care model.
  4. Evidence-based screening: The USPSTF has a tool that can quickly show up-to-date screening recommendations for a patient based on their age, gender, smoking status, and sexual activity.  The list (particularly the do-not-do list) can be quite long, and will change for each patient over time.  No EMR that I am aware of integrates this tool to ensure the screening is addressed in all patients, despite a secure API.

Here’s how I handle these problems right now:

  1. To make sure things get done, I create future-dated messages to my patients through my EMR for a quick check-in.  I also include information on what to expect at that particular time point.  If it’s a serious issue, I send a future dated message to myself to call the patient.  This is not a perfect system, but it’s the only method I have.
  2. Since I can’t integrate with external tools, patients have to manually send me their data, and I manually enter data into external tools.  These things are time consuming and potentially prevent follow-through.

My point is that we have only scratched the surface on what computers can do to improve healthcare.  DPC-specific EMRs are just starting to come out.  Qliance has been working on their own EMR, but it does not have these features and it is not released to the public.  Rob Lamberts, a very thorough DPC doc in Augusta, GA, is building his own EMR to attempt these features.  Atlas.md has launched the first public DPC EMR, but it does not appear to have these features.

We Need to Take Advantage of Technology in Chronic Disease Management

“The future is already here — it’s just not very evenly distributed”
– William Gibson, writer, in 1993

The above quote is used often in DPC articles, and was on a PowerPoint slide at the Summit this weekend.  Clearly, DPCs haven’t had a problem with slashing costs on labs and imaging, and frequently procedures are offered for free.  We offer concierge level care with buyers’ club savings.  We make information transparent and search for the best option for our patients.  This is actually very low hanging fruit on the technology side, and from the conference it seems that everyone has nailed it.  But, no one talked about how they use technology to disrupt the status quo on chronic disease management.  Here are some problems I am trying to work on, and solutions:

  1. Prediabetes: This isn’t low hanging fruit, it’s a watermellon on the ground.  The EPIC study showed that 75% of all type 2 diabetes can be prevented with lifestyle, but a recent analysis of all published data on lifestyle intervention programs by the USPSTF showed that even the most intensive wellness programs we use today really don’t work.  It is estimated that 30% of the adult population has prediabetes and only 6% know they have it.  Type 2 Diabetes one of the main risk factors for Coronary Artery Disease, which is the #1 killer of all humans.  Talk about preventive medicine — we absolutely need to figure out a better way to help people to be healthy.  Like I said above, it is not a trivial request to integrate the lifestyle tracking tools we already have into our electronic medical record.  If we can use shared decision making to create a lifestyle plan, we need to take it one step further and be mutually invested in what happens outside the clinic.  DPCs can and should do this without substantially raising overhead costs; traditional clinics would have difficulty.  Solution:  For now, I rely on a spreadsheet and planned chart reviews, and patients need to manually send me data.  To the programmers out there:  This is a big opportunity to make an impact.
  2. Utilization of specialists:  This is also a big problem.  The U.S. spends more on healthcare than any other nation, and has some of the worst outcomes of any developed country.  Our life expectancy is actually going down.  Compared to the UK, where primary care visits encompass 90% of all visits, we spend only 50% of visits in primary care here.  The rest of the time is spent seeing specialists to get the “best care.”  This is not working.  Specialists generally don’t communicate, and they don’t take responsibility for the patient’s overall health.  They are incentivized to do procedures, and this is not a good thing for patients.  I would argue that we need to push the number closer to 90% of visits in high quality primary care, while still utilizing specialists when there is a diagnostic conundrum or complex management question.  Solution:  While I can work with any specialist in the area, I am also working on a telemedicine solution so specialists can come into my exam room virtually and help with management.  I can ask questions, patients can ask questions, and their care can move forward in a coordinated manner.   This would also significantly cut costs.  There are several available solutions for this, and I haven’t settled on one yet.  None of the DPCs I talked with have tried this yet.
  3. Heart arrhythmias:  Atrial fibrillation is the most common abnormal heart rhythm, currently affecting about 3.4 million people but expected to increase to 8-12 million over the next 30 years as the population ages; it contributes to 80,000 deaths and 460,000 hospitalizations annually; and causes 15-20% of all strokes.  It is usually not life threatening if treated properly.  Here’s the clinical problem: many of my patients currently have no insurance or high deductible insurance (and many will only be able to afford Bronze tier insurance on the exchange), and it costs just over $1,000 in the traditional healthcare system to attach a Holter monitor for 48 hours and see if there is a problem.  If it doesn’t happen in those 48 hours, we still don’t have an answer and the patient is out $1,000.  Even if insurance covers it completely, do we want to ring up $1,000 on each of those 8-12 million people?  Solution:  AliveCor is a relatively new, FDA approved rhythm monitor that can attach to many smart phones.  It costs $200 for a device that I can reuse, so now I can offer rhythm testing for free.

Payment Models in Direct Primary Care

This is perhaps not as big of an idea as anything above, but we didn’t address that there is a huge variety of payment models for DPCs.  This is something worth discussing at these conferences.  In my research, I found that DPCs with lower monthly fees are more accessible to people.  I watched my budget closely and made sure to make a low overhead practice so I could charge one of the lowest fees (disclosure: I used to be an accountant).  I’m in the business of keeping my patients healthy, not providing granite counter tops.  There is already a cottage industry focused on selling services to DPCs that aren’t necessary and drive up overhead; I suggest that these should be avoided unless there’s a clear benefit that’s worth the cost.  With regards to additional co-pays, there is evidence that these prevent people from seeking care when it is needed, so I intentionally avoided co-pays.  I made sure that I make no profit off of labs, imaging, procedures or referrals to keep my incentives aligned with my patients (this is not the case in a traditional clinic).  I’m not proposing that we standardize how DPCs charge, but these things should be made transparent to patients.

In Summary

“Healthcare is unevenly distributed.  Low- and middle-class Americans are getting better care through Direct Primary Care.”
– Dave Chase, Avado, at the DPC Summit

I think it’s important that we find ways to be successful as business entities, and the first DPC Summit focused on that.  I’ve been very lucky to have a good response to my practice model from my community.  But, it’s not enough to be successful; we have to be Better.  We need to collaboratively identify the big problems with healthcare and discuss how we are working on them.  I hope I shed some light on some of those problems, and how I’m working on them.  There are a lot of opportunities for improvement.  I very much welcome any feedback from patients and healthcare workers alike.

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