Fix primary care with technology and anesthesia

Trauma surgeons earn their patients’ respect every day, acting decisively in the face of calamity and uncertainty, heroically beating back death with steel blades and iron wills. Primary care physicians, however, have traditionally been at a relative disadvantage with regard to public opinion. After all, reconciling medication lists, reviewing lab results, and discussing health behaviors simply aren’t as exciting. In fairness, though, surgeons have always had one other advantage: anesthesia. Anesthesia creates a sense of mystery for patients, a sense something miraculous has taken place during their medically induced slumbers. Thus far, however, this useful tool has largely been absent in primary care.

The Joint Accreditation Committee for Affordability and Safe, Sensible, Evidence-based Solutions (JACASSES), the organization that certifies patient-centered medical homes (PCMHs), may be changing all of that, though. In a rather stunning development last week, JACASSES moved to require that all medical practices seeking the PCMH designation prove their ability to “safely administer anesthesia to all primary care patients.” And the integration of anesthesiology services is only one of several new mandates that will also force PCMHs to embrace Twitter-enabled history-taking software, virtual pathology services, and a fundamental transformation of the primary care culture.

JACASSES first unveiled the rather significant policy changes at a press conference on Friday afternoon. According to the new guidelines, patients will be handed a tablet PC immediately upon arriving at their designated PCMH. The tablets will be outfitted with Twitter-enabled EMR technology that will require patients to succinctly state the reason for their visit in 140 characters or less. Upon doing so, the data will immediately be tweeted to the primary care physician’s “digital patient queue.” The impressive software will also simultaneously apply the appropriate billing codes and populate the physician’s screen with several “preferred” treatment algorithms, all before the patient is fully “processed.”

Patients will then be greeted by a “gastrician” (a new health care role created by JACASSES), who will be responsible for promptly administering the required anesthesia. It is this aspect of the new rules that has generated the most controversy within the medical community. So, in an attempt to assuage the growing concern, JACASSES released a statement after Friday’s press conference, citing several randomized trials that have shown “sleep is a safe activity occupying a significant portion of the time spent in any American home.” It went on to assert that “if we want PCMHs to resemble real homes, it is logical we implement reasonable policies to make that a reality.”

The statement also addressed potential safety concerns associated with the widespread administration of anesthesia by gastricians: “The public can rest assured that gastricians will only be passing gas, so to speak. They will establish intravenous access and initiate the process locally, but the actual decisions regarding agents, dosing, and timing will be controlled remotely by nurse anesthetists working under the supervision of a regional anesthesiologist. The process is safe, and it will allow us to leverage deep anesthesiology expertise across vast geographic distances, helping us increase efficiency and significantly reduce costs.”

The controversial, new policies state that “once a patient generates the initial tweet during a given visit, informed consent for any and all procedures will be deemed granted.” So with the patient asleep, mid-level providers will perform a physical examination, conduct imaging studies, and even obtain any necessary biopsies. They will then use the newly designed tablets to tweet relevant physical exam findings to the on-site primary care physician. Imaging studies and pictures of any tissue obtained will be tweeted to “scantricians” and “organicians” (two additional roles created by JACASSES), who will be remotely diagnosing disease under the supervision of a regional radiologist and pathologist, respectively.

When asked if pathology reports based on pictures of tissue samples rather than analysis of the tissue samples themselves could pose any risk to patients, a spokesman for JACASSES stated, “The literature is inconclusive there. But we have considerable anecdotal evidence that a picture is worth a thousand words. We believe that same ratio can be safely applied to tissue analysis.” The spokesman was also asked about possible HIPAA violations related to the transmission of protected health information via Twitter. But he dismissed the question, stating that “HIPAA privacy rules don’t apply to PCMHs. There should be no secrets amongst the family members of a medical home.”

While the patient is still asleep, the primary care physician will select from the list of available treatment algorithms. (JACASSES determined this would allow initial doses of any required outpatient medications to be delivered intravenously.) Once the process is complete, patients will be transferred to the post-care recovery from anesthesia parlor (P-CRAP) of the “home” until they are ready to leave. And details of the visit, along with any prescriptions, will be tweeted to patients within minutes of exiting the PCMH. Therefore, primary care physicians will no longer be allowed to see or speak to patients, a major goal of the new policies that is expected to make the process drastically more efficient.

The new rules will also transform the culture of primary care, establishing PCMHs as places where “patients can seek comforting shelter from the physical, emotional, and financial realities of illness, until they exit the facilities.” To that end, JACASSES will require that mid-levels be referred to as “aunts” or “uncles”. (According to insiders, the terms “mommies” and “daddies” were also considered but were deemed an unpleasant reminder of medicine’s paternalistic past.) Specialists will be referred to as “distant cousins.” And primary care physicians, given their limited patient interaction, will be referred to as “grandmas” or “grandpas,” titles intended to soothingly remind patients of the “wise, caring people once present in their lives that have since moved on to better places.” Additionally, any billing statements from PCMHs will be warmly labeled “letters from home.”

Though many are applauding JACASSES for implementing the bold, new rules, others are questioning how the costs associated with the required new technologies and provider roles will be paid for. “That’s where things get really exciting,” the spokesman for JACASSES said to reporters at Friday’s press conference. “We are working with both public and private payors to implement a mandatory ‘bungled payments’ system for all PCMHs. Although not a new concept, by coupling emerging technologies with our new guidelines, bungling payments to primary care physicians will be easier and faster than ever before. And the associated savings will be significant.”

In his closing remarks, the spokesman for JACASSES expressed his excitement about the future of primary care:

This is just the beginning. In fact, we’re working with the Healthcare Association for Quality Solutions (HAQS) to develop metrics that will allow us to approach quality in new ways as well. In the interim, though, we’re focused on aggressively measuring anything that can be measured, until we really understand what quality is. After all, in the exceedingly complex and rapidly changing world of health care, effective organizations must be proactive, even in the face of uncertainty.

We’ve been going about things the wrong way in medicine for far too long. Other industries have taught us that efficiencies can be gained if one simply looks for them. And in our industry, that means freeing primary care physicians from unnecessary time with patients so they can focus on doing what they do best — administratively supervising a primarily digital process while controlling costs. And these new guidelines are a step in the right direction on that front.

But changing the culture of primary care is equally important. Studies have shown that families are progressively embracing social media and other technologies, and they’re spending much less time actually talking to each other while they’re at home. They are also increasingly embracing sleep as a respite from the disparities and absurdities present throughout our society. A health care system for the people should reflect how they actually live. And by strategically using technology and anesthesia, we intend to make that happen.

It’s time to bring primary care into the 21st century. These new rules will allow us to finally accomplish that, and I’m proud that JACASSES will be leading the way.

It will likely take several years to discern the full impact of these new rules. In the interim, though, don’t feel frustrated or homesick if you have a harder time spending quality time with your “grandpa” and increasingly lose touch with “distant cousins.” After all, you can be sure you’ll be getting a whole slew of “letters from home.”


This piece is clearly satirical in nature. On a serious note, though, we must exercise prudence and reason as we attempt to modernize our health care system. Emerging technologies and growing interest in health care policy both offer unparalleled opportunities to improve the lives of patients. But to actually deliver on that promise, all new technologies and policies must meaningfully address the true cost drivers and real health barriers in this country, not expedient surrogates. And they must endeavor to elevate the physician-patient relationship, not denigrate it.

Luis Collar is a physician who blogs at Sapphire Equinox. He is the author of A Quiet Death.

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