ACP: If I were health care king

A guest column by the American College of Physicians, exclusive to

In preparation for a panel discussion at Internal Medicine 2012, the annual scientific meeting of the American College of Physicians, I was asked some questions about changes I would make in health care if I were king. That stimulated some serious thinking. For those of us in practice it is more usual to think about what new regulation or task is being added to the work day. This was a welcome exercise.

I would love to make changes in many areas, including payment reform. In this column I would like to focus on some changes which are not earth-shattering but would be of great benefit to doctors and patients everywhere.  This says a lot about how far we have to go to improve cost, quality, and doctor-patient interactions. I would simply enhance the use of tools available to doctor and patients, many of which are de rigueur in other industries.

Take the following scenarios. Do others in private practice feel frustrated when you cannot:

  1. Know in advance which insulin for diabetics or inhaled steroid for patients with asthma is covered under a plan? I really can be flexible on these agents but even when you think you know the drug plan, there seem to be several variations on the formulary list. The pharmacy clearly has to find out which is covered. Why can’t we? It would save everyone time – not to mention help the patients who sometimes give up because a med is not covered or a co-pay is too high.
  2. Know which tests or treatment require prior approval? If the non-medical person on the other end of the phone uses a drop -down menu, why can’t we? We could then transmit the clinical data directly without the seemingly endless quest to find a person we really don’t need to talk to.  Additionally we could avoid having to enter all the demographic data that is already in my electronic record by telephone – how 20th century!
  3. Email referral requests, lab results, or records to another doctor rather than faxing them? Isn’t faxing becoming antiquated in many other arenas?  Why is so much information faxed to me rather than sent in ways my record can identify, allow me to approve and then file?

I know electronic tablets are being used in creative ways by many every day. Clearly we can do a better job to streamline the office experience and free up doctors and nurses to do more of what we have special training and expertise to accomplish. We shouldn’t just be clerks doing data entry and writing out 90-day prescriptions. We should be able to focus on changes in a patient’s status and hopefully make recommendations that would nudge patients toward better health.

Are these things too much to ask? If they are not, then who do we ask? I look forward to the day when the time spent by both patients and doctors is more efficiently spent.

What do you think? Have any of you found ways to improve office efficiency in this way?

Fred Ralston practices internal medicine in Fayetteville, Tennessee, and is a Past President of the American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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  • Fred Dempster

    Clearly a lack of information haunts the processes, and in what I can read, ACA/Obamacare offers no solve here. Working with one provider, just to understand the Medicare provider/payer process took 163 pages and left over 50 open questions… and the worst headache I’d had in years of process improvement.


    I like all of your suggestions. Some EMR’s now have information regarding coverage of meds and alternatives for excluded or tiered drugs – a step in the right direction. I would love to see electronic communication from SNF’s and assisted living facilities. Meanwhile, how about a universal form for faxes that included enough space to write a reply that would be easy to read when returned? If I were Queen of the Health Care Planet, however, I would ensure universal access, a more robust public health sector and better communication, overlap and coordination of care between individual medical practitioners and the public health, social work, mental health and school health communities.

  • Margalit Gur-Arie

    For #1 and #3, just sign up with Surescripts. It offers both formulary checks and secure Direct based email communications to other physicians. No Royalty required.
    Should probably save the king’s  three wishes for the items PJRFP mentioned above.

  • Kathy Nieder MD

    What bugs me is that even the pharmacies don’t know what is covered. When you ask they tell you “we would have to run that through in order to find out if it’s covered”. UH–how helpful is that and why the mystery. I have ePocrates but that is not always as up-to-date as it needs to be, undoubtably not the software’s fault.

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