Medical homes weren’t supposed to be this way. What went wrong?

We have a problem in our clinic.

Between our EMR implementation a few years ago and our PCMH recognition shortly after that, our office visit documentation has become bloated and our cycle time has almost doubled.

There are no brief visits anymore, since every visit entails screening for multiple psychosocial conditions and consideration of various immunization and health maintenance reminders.

Nobody sees over thirty patients a day anymore; we’re lucky to exceed twenty.

That means patients today are more likely to go to walk-in clinics or emergency rooms than they were a few decades ago. We’re still OK with PCMH as long as we have a single open access slot at the beginning of every day, and we don’t get any credit for squeezing in, or double booking, acutes.

It also means patients with chronic illnesses get seen a little less often than they used to. Sure, we have RN case managers who can stay in touch with them, but the communication between them and the medical providers is hampered by the new busyness of checking our electronic inboxes, which takes seconds longer for each item than the old paper reports used to take, and which is done “in between patients” in our already tight schedules or after hours, staying late at the clinic or logging in from home.

It wasn’t supposed to be this way.

Here is what we hoped and were led to believe would happen:

1. EMRs were supposed to make documentation lightning fast.
2. EMRs were supposed to make data review and retrieval faster than paper systems.
3. PCMH would have us transform into physician driven, super-efficient, yet warm-and-fuzzy places filled with patient friendly personal touches.

Instead, medical practices have evolved into bigger bureaucracies with OCD-afflicted doctors who don’t lead practice transformation, but who feel personally responsible to compensate for all the shortcomings of their hastily implemented, immature technology.

OCD may be the most significant and destructive acronym in today’s healthcare environment. And we have all been cultivating it, medical practices and providers alike.

The old school expression of OCD, in Marcus Welby’s era, was extremely high physician productivity and unwavering personal commitment to patients.

The new manifestation of OCD is trying to follow overly ambitious, often conflicting federal edicts and mind-melding ourselves with our computers to the point of losing touch with our patients’ real needs.

Why else did we end up with a working environment where we allow ourselves to be distracted by health maintenance discussions when somebody comes into see us for what should be a ten-minute visit for a simple sore throat, or when they are in pain from an injury?

(A ten minute oil change for your car is not the same as a 100,000 mile service, is it? Why is health care any different?)

Why else do we think that it is appropriate to do depression, alcohol, smoking, domestic and drug abuse screenings on new patients the minute they walk through the door to size us up as their chosen new health care provider?

(How did it become patient-centered not to spend the first visit, or even the first few minutes of a new therapeutic relationship, listening to the concerns of a new patient?)

Why else, if not because of our personal and organizational OCD, are we sending our patients to the walk-in clinic instead of fitting them into our schedules? Isn’t it because of our obsessive fear that we might document such a quick visit without the required federal accoutrements and end up scoring poorly on some arbitrary quality scale?

(Do we really think the walk-in clinic will do a better medication reconciliation than we do if we squeeze a 45-year-old hypertensive diabetic in for quick look at an ankle sprain?)

Pardon my comparison to veterinary medicine, but in my veterinarian’s cash practice, they manage their health maintenance reminders by simply printing them automatically on the receipt. If I bring a pet in for something simple, they don’t bloat the visit up by talking about things I didn’t come in for; they stay on schedule, and I can read the printed reminders at my leisure.

Somehow, in the new vision of primary care, we went from taking care of our patients over a continuum of time to doing everything all at once, as if there were never going to be other visits. That kind of OCD is anathema to real primary care.

And somewhere along the path to more patient-centeredness, we got sidetracked by the paternalistic ambitions of our biggest payer, Medicare, into hammering our customers with federally imposed public health agendas that have little to do which their personal vision of why they need a doctor.

To quote a new patient who came into size me up a few years ago:

“I need a doctor when I’m sick.”

Access, in other words.

“A Country Doctor” is a family physician who blogs at A Country Doctor Writes:.

Image credit: Shutterstock.com

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