Future Office Practice
Office practice is about to change in a big way. Medical office practice today is much like banking before ATMs and online access to accounts. Remember when we had to stand in line to deposit checks into our account, and get some cash? Remember when we checked the balance in our accounts once a month by pencil and calculator (a modern invention)? Patients face these types of inconveniences regularly as they try to find out how they are doing with their preventive services and chronic health problems.
All service industries except medicine have advanced into an age of ready access to information and services. Medicine is about to catch up. Health Information Technology (HIT) is maturing and becoming more affordable, and the tipping point is being reached in its widespread application in office practice. Will the future be similar office visit schedules as today, just with computers? I think not. HIT will be a disruptive technology which is likely to change how most common health services are delivered. Here is a portrait of what I think the office practice model will be like after 5-10 years of rapid process change.
The new model of office practice cares for a population of patients with robust information systems and continuous healing relationships. The care team takes pride in achieving high levels of patient satisfaction and excellent clinical outcomes whenever possible. Patients are actively involved in their care. Face to face visits occur selectively, time intensively and include family and group visits. A continuous platform of care, secure and web based, is the dominant means of coordinating patient care needs and communication among patients and caregivers. The practice is a personal medical home for patients, accessibly both physically and remotely through the patient’s home page on an electronic health record. Primary care physicians attend to the broad, comprehensive needs of patients while specialist physicians focus on the organ system or disease process the patient might have, such as the cardiologist with heart failure, the rheumatologist with lupus patients, the neurologist with seizure disorder patients and the urologist with patients with prostatic hypertrophy.
As population based providers of care, new model physicians play a unique role in the communities they serve. The primary care teams across a health care delivery system have knowledge about the health and heath needs of a community which were never before realized. Specialist physicians can see the progression of disease processes in the community. Pooled patient information allows for a regional health information network which is able to respond to community needs in prevention and chronic illness care. Planned care to populations of patients will be rich with information and options for providing care.
There are new skills and practice elements required by this new model of office practice. These include:
Management of a Population of Patients
The new model of office practice allows physicians to manage both the population of patients as a whole and the individual patient. New model physicians are proactive in reaching out to patients to achieve high levels of preventive services and chronic illness management. They have the tools to provide this care in a continuous way. They are incentivized through pay for performance reimbursement based on achieving high levels of successful care to populations of patients.
Patient Centered Care
The traditional paternalistic model of the patient-physician relationship is replaced with patient centered care in which patients are taking an active role in their health and health care. With patient centered care, physicians serve their patients with continuous respect for the patient’s autonomy and self-control. Personal physicians are advisors and caregivers on the patient’s terms whenever possible. There are times when a physician must step in and assertively provide patient care, such as in medical emergencies and with major illnesses, but this is always done with the utmost respect for the patient’s needs and desires. The practice has a patient centered, relationship oriented culture that emphasizes the importance of meeting patients’ needs, reaffirming that the fundamental basis for health care is people taking care of people.
Personal Medical Home
The office practice serves as a personal medical home for each patient, ensuring access to comprehensive, integrated care through an ongoing relationship. New online communication methods allow for a continuous connection between the patient, family and the office practice team. The services provided by the practice are readily accessible to the patient. The office system of care available in person and online becomes a home for health care to the population being served. Patients feel connected and have a sense of ownership of all the resources available for their care. The physician is a steward for the patient and family in this medical home.
Best Knowledge at the Point of Care
Physicians should use the best scientific knowledge in the care of patients. Physicians are committed to evidence-based medicine and have the skills to evaluate the quality of medical information. Since the complexity of modern medicine exceeds the inherent limitation of an unaided human mind, knowledge management and clinical decision support tools are used routinely at the point of care. Patients consistently receive the best available clinical care. Currently, access to the best knowledge at the point of care is the goal through currently available electronic systems. Soon, best knowledge will be imbedded into the electronic record and will help guide patient care. Increasingly, some routine care will be automated for the patient to receive best practice upon request.
Continuous Access to Multimodal Communication
Quality of care is achieved through a continuous healing relationship. This requires that patients and providers have access to secure communication at all times. The care team in the office handles patient messages in a timely manner, and important health information is proactively given to patients. Nurses, other office staff and physicians respond to patient messages and proactively communicate with patients through a secure online portal, by telephone and by arranged patient visits.
A New Platform of Care
The convergence of these skills provides a new platform of care which makes the previous model of office practice obsolete. The new platform of care offers an electronic health record available from any computer including by the patient in their home (their personal health record). This record has imbedded evidence-based knowledge management to guide clinical decisions. Secure online communication is imbedded in the electronic record, allowing for access to all patient information with online or telephone communication. A version of this new platform of care is being rolled out by Kaiser Permanente through their Health Connect system of care. They will be the equivalent of the first bank in an area to provide online banking services, and other practices will have to catch up to this new service model.
Fewer and More Time Intensive Office Visits
With physicians having productive interactions with patients online and by telephone, fewer office visits are needed in caring for a population of patients. Office visits in the new model are scheduled selectively and time intensively based on patient needs (6). Brief visit office schedules are replaced by flexible and time intensive schedules. Physicians will spend from 30 minutes to more than an hour in the care of complex patients. The number of office visits is reduced, but the overall number of productive interactions with patients increases from the traditional brief visit model of care.
Group Visits
Physicians use group visits to consolidate care with patients having similar conditions, such as obesity and diabetes, and to create a dynamic where patients help each other. When organized well using the entire care team, with appropriate coding and billing for services, group visits may become an important part of a modern office practice. Technology applications allow for a virtual presence of some patients, or possibly an entire virtual group visit.
Teamwork and Interpersonal Skills
The new model of office practice requires a high level of teamwork and interpersonal skills for the physician. Traditional practice was a physician “craft” with office staff as ancillary. Successful wellness care and chronic illness management requires that the entire office staff be engaged in the care of patients. The physician not only communicates well with patients, but also with the entire staff in a collaborative care manner. Everyone knows their responsibilities and the responsibilities of others, and the team “huddles” at the start of every patient care session.
Financial Practice Management
The new model of office practice must be financially successful. Physicians realize the financial aspects of all the care activities they provide. The new platform of care requires financial contracts and policies which support it. Prepaid services such as for online care should be considered as part of the contracts with patients and insurers. While there are new delivery methods in the new model such as online communication with patients and group visits, there is much efficiency created which should allow for the new model to enhance revenues. In the words of design engineers, it should be “better, faster and cheaper”. Models of the new office practice will reflect smart financing of care, highly efficient, affordable and successful.
Many leaps of faith have been taken in presenting this new portrait of office practice. This presentation so positive to be almost Pollyanna. However, the only constant is change, and we tend not to see the magnitude of long term changes. Office practice has been fixed in a routine of visits as the unit of care for so long that major change is needed and likely given the impact of information technology. Just look how much banking, travel and other service industries have changed. There will be lots of problems, battles to fight, and threats to our role as physicians. What is presented here is a portrait of a better future we can have if we work for it.