Electronic Health Records, Patient-Centered Care, and Regina Holliday

Today the Department of Health and Human Services announced what criteria doctors and hospitals will be required to meet if they want to receive payments to help buy the Health IT needed to computerize patients’ medical records.  Under the HiTech Act’s incentive program, Medicare and Medicaid will be giving out some $27 billion over the next ten years. The program begins next year.  A doctor can receive up to $44,000 under Medicare and $63,750 under Medicaid, while a hospital can receive millions of dollars, depending on its size. (Starting in 2015, hospitals and doctors will be subject to financial penalties under Medicare if they are not using electronic health records.)

The rules boil down to this: providers who want to be eligible for incentive payments will have to show that they are making “meaningful use” of electronic health records (EHRs)—i.e., that they’re not just using them to  expedite billing , but that they’re using EHRs to improve patient care.

For example, under the final rules doctors will be expected to transmit more than 40% of their prescriptions electronically, hospitals must be able provide more than 50% of patients who are discharged with an electronic copy of discharge instructions if they request it, and providers must produce an electronic copy of a patient’s medical  record within three business days to more than 50% of patients who request it. Click here for a summary of all of the rules.

Regina Holliday appeared at today’s announcement to stress just how important patient access to a medical record can be. Below, she tells the tale of what happened to her husband, Fred, after he was diagnosed with Renal Cell Carcinoma and hospitalized.

What is striking about her story is that Holliday is not complaining that the hospital didn’t “save” her husband. She is objecting to how little information she and her husband received: “the terror of not being told what was going on.” In other words, this is less about what treatment he did or didn’t receive than it is about how he was treated. Holliday is calling for “patient-centered care” that includes the patient in the decision-making loop, giving him the information he needs to make an informed choice.

This piece originally appeared on Regina Holliday’s Medical Advocacy Blog in October of 2009 where it was titled "Thoughts on Medicine and Social Media."   Many thanks to THCB’s Matthew Holt who cross-posted Regina’s story in October, and wrote about her appearance at today’s "meaingful use" announcement. Holt describes her asthe poster child for why access to health data matters to ordinary people," adding: “we need to get her from the world of webinars, Health 2.0 Conferences and HHS announcements onto Oprah and the 6 O’Clock News right now.”

I agree, which is why I’m posting her story here on HealthBeat. (It's not Oprah, to be sure, but unlike the 6 O'Clock News, at least I can give her more than a soundbite.)



Thoughts on Medicine and Social Media  

On March 27 my husband, Fred Holliday, was diagnosed with probable  Renal Cell Carcinoma (RCC) . Within one day, I became an e-patient, a caregiver and a medical advocate. I would use the internet for both research and patient/family support. To help my husband receive the best care, I surfed the internet at night; researching his cancer using Google, reading the Wikipedia entry on RCC with all of its links, and finding personal cancer stories. Facebook  became the information source on Fred’s medical status. I would take a few minutes each night to post to the 100 plus people following Fred’s care. Within days of diagnosis, two of my friends had set up a  "Lots of Helping Hands"  account. This online network, which rapidly grew to 150 volunteers, would fundraise and provide meals, babysitting and groceries. This pool of helpers was immensely diverse. Before sites such as Lots of Helping Hands, orchestration of a volunteer effort this complex would not have been possible.

My husband was the model patient: he never complained or caused trouble. We were at the first hospital for four weeks with the only treatment being palliative radiation. My husband walked into that hospital but by week two he could no longer stand and could barely sit. We had no chemo or surgery. I wanted to know what was going on, so on Friday, April 17 I went down to medical records to ask for a copy of his chart. They told me it would be 73 cents a page and a 21 day wait. The next day the oncologist came into the room. It was 9:30 AM on a Saturday. We had a list of questions ready. We had questions like: "When will we have surgery?" The doctor had a different answer. “We have decided to send you home on  a PCA [patient-controlled analgesia or pain-killer]  pump.  ” I found out later that “we” meant the hospital, the oncologist, and the insurance company, all privy to this decision days before Fred and I were. I had done my internet research. I knew exactly what was going on. This was home hospice. Fred was being sent home to die. The doctor left the room. We cried. Then Fred told me to go after them.

We had to suffer and wait that entire weekend, but on Monday I took action. I fired the primary who never visited. I asked my own primary if he would take on Fred. He did and could get him transferred to another hospital. I found an oncology group that said they would see him. I spent three days organizing the transfer. Fred’s nurse navigator from his insurance company was so frustrated by how hard it was to complete this transfer that she was crying to me on the phone. I was warned by an internist that this was not how things were done. The oncologist stormed angrily into Fred’s room saying, “So you are transferring? Well no one will give you surgery.” He left and I told the head nurse I wanted him barred from the room.

We were transferred on Wednesday April 22. We were sent with incomplete and out of date records. Fred was denied care for six hours while the nursing station tried to cobble together a record. Without a current, MAR  [medication administration record] they came to me to ask what kind of patch is this and when was it placed? Both Fred’s lidocain and fentanyl patches weren’t labeled or dated. Five days before I had asked for the medical record. If only it had been given to me then, Fred would not have been suffering in pain as we tried to recreate a medical record from memory and a fax machine. The next day I was sent back to the first hospital to get the record. In an hour and a half they printed out the entire EMR [electronic medical record.] I gave it to Fred’s new doctors. They looked at it then gave it back to me. They said it was safest with me. Fred might go to many facilities but if I kept it his record would follow him. I spent the next six hours organizing and reading Fred’s record. I found so many mistakes. If I could have read the record on a daily basis his care would have been so much better.

Each night on Facebook I posted the tragedy of our life. After receiving advice from Christine Kraft, I began to use Twitter. I did this very scary thing to find one man: e-Patient Dave. He was a well known e-patient and a kidney cancer survivor. Within minutes of my tweet we were in contact. We emailed back and forth that night. Then he called. By 10:00 that evening I was talking to Dave’s physician about my husband’s cancer care. I told him about Fred’s current status and my research and concerns. His quiet calm support helped me to face what was becoming very evident in my mind: it was too late for Fred. His current oncologist was doing everything that could be done in Fred’s advanced state of disease.

During all of this confusing and frantic time we were using technology in a different way. We were using it to wrap up the loose ends of a career and a life. When Fred was first admitted he could still stand and walk some. There was a computer room at the end of the hall. If he could walk down that hall Fred could spend a few agonizing minutes surfing the web. He would post to friends and be himself in 12pt font. Soon he could not do that. Fred was a professor of film studies. When he was diagnosed he was still teaching classes. We spent some days getting his class grades compiled. As he was reading one paper, he turned to me and said, “Reggie, try typing a line of this paper onto Google and see what comes up.” I went to the computer room. It was plagiarized. Fred missed the access to the internet and the freedoms it entailed. I got our old laptop refitted for WiFi. Fred was so happy. But within weeks we were transferred to rehab and hospice where no WiFi was available. Pain can be treated in many ways, with fentanyl, lidocain, and PCA Pumps. But one of the best sources of pain relief for Fred was the internet: access to sites such as Facebook,  IMDB and Ain’t it Cool News. So nightly, I would come home and call Fred and log on. I would read him all of his email and post his status. And then we would say goodnight.

On April 29th 2009, I sent out an email blast to everyone I knew. I was appalled at the care patients receive: the lack of access to data and the lack of coordination of care. I had worked retail since the early 1990’s. Who has heard of a decent-sized store that doesn’t have a POS system? What business provides service without an itemized receipt? And I have yet to find a store that charges the customer for their copy of that receipt. I had been a special education advocate for my son since kindergarten.  . . . But in my role as caregiver and patient advocate, I was told by medical records personnel if I wanted a copy of Fred’s medical record I would have to pay 73 cents a page and wait 21 days. How can a patient or care-giver be part of the team if they have no access to that data? In my email blast I spoke of all those families and patients who suffer in silence. I would speak for them. I would paint medical advocacy murals on the walls of Washington, DC.

While Fred was in Hospice care, I placed the first mural. The Medical Facts mural as a re-visioning of the face sheet mimicking in style and clarity the nutrition fact label: all important, vital statistics are present with norms for comparison. How do you know your blood pressure is high or your hemoglobin low if you do not know what normal is? Where are the bone mets and the soft tissue mets? Where could you harm this patient just by touching him? Fred was injured twice by techs moving his body who had no idea of the extent of his disease. I asked a nurse, “Who reads the medical record?” Her response was “We read the face sheet and maybe the most recent pages.”

In early June, sitting at Fred’ side, I began drawing the design sketch for the next mural: 73 Cents. This would be a cross between Guernica and Death of Marat with a little Diego Rivera  thrown in. This painting would depict our family’s struggle, imprisoned in a hospital where no one is communicating and data is stuck in an internal loop. The figures in this piece would be separated in darkness, and no one would be making eye contact within the frame.

On June 17 Fred died. I was his caregiver for his last six days. In home hospice I was in charge of the MAR that I fought so hard to get copies of in the different hospitals Fred had been in. I was the one who gave him his last meds at 7:30 AM. I helped the hospice nurse roll his body to clean him up for funeral transport, and in so doing, held his still warm body one last time. I hadn’t hugged Fred for two months at that point. It had hurt him too much to be hugged. Now I could hold Fred near and cause no pain.

On June 21 and June 22 I sent another mass email telling everyone I knew I was going do everything in my power to fix a medical system that keeps patients and families in the dark. I would post on Face Book. I would blog. I would Twitter. On June 23 I began painting  73 Cents. In the next two months the painting would receive worldwide press. It would be the subject of blog posts, tweets and the AOL Splash Page. It would make the cover of the BMJ [a medical journal formerly known as the British Medical Journal.] The world was talking about patients' rights and data access. This was caused in part by paint and social media. If using social media could get our message out to the world think of what could happen if the medical establishment and empowered patients embraced it.





41 thoughts on “Electronic Health Records, Patient-Centered Care, and Regina Holliday

  1. Having quick access to your health record is not a unique characteristic of an EHR, it is or rather should be, a characteristic of the medical record in general. I can understand the ideals found in the idea of an EHR, but there are just as many flaws as good old pen and paper.
    Granted, with EHR, you can program “rules” within the medical record which could force physicians into “best practice” ordering habits, etc. However, it is my 5 year experience with CPOE and the EHR, that most systems have overrides built into them which allow physicians to continue to order just as if it were pen and paper.
    Now, regarding quick access to one’s medical record. Again, there are many benefits to EHR, such as legibility, correct use of units (such as ml’s instead of cc’s), and one would think, access to your records. Again, just my experience here in Texas with a large 13 member healthcare system, EHR basically is just as good, or just as bad, as good old fashion paper charts. There are parts of the data which just cannot be trusted, much like with pen and paper. I could give tons of examples, but here is one in particular.
    Nurses are forced to document on flowsheets, okay, that seems pretty normal so far. The flowsheets have fields which autopopulate throughout the rest of the chart. Again, sounds like a good idea, until you realize that a large number of the nursing staff do not understand many of the fields on the flowsheet, because they’re not related to nursing care. But they need to be on the flowsheet because that’s where all the data is kept.
    So because it’s a field on the nurse’s flowsheet, they feel like they need to put data into it, even if they’re not 100% sure what it’s asking for. This is no indictment on the caliber of the nurse, they are taught to fill in every blank. So, they put what they think it’s asking for and that gets populated everywhere in the chart for the doc to read, patient, family member, therapist, etc.
    Again, you’ll have to trust me, there are countless examples here, not just this rather simple one. These problems may seem easily fixed, but they’re not. Everytime you fix one problem, you create another. Pretty soon, you’re just chasing your tail. Then, think of the enormity of the training and retraining required. Then think of how the pool and contract staff have to be trained and retrained. No wonder healthcare costs are through the roof.
    Sure, hospitals may get millions of dollars for converting to EHR, but trust me, they spend millions of dollars transitioning to it and then maintaining it.
    So for one to think the electronic age will usher in a higher level of patient care and satisfaction, they are kidding themselves. They can talk all they want, but until they’ve designed it, implemented it, experienced it, modified it, experienced downtime it in, etc., they really have no room to talk.
    Now I’m sure there are some places where these flaws are all worked out, but there were hospitals that had all their paper flaws worked out too. I really believe this is just another way, albeit unintentional, we take valuable time away from the bedside, away from the human aspect of care, in the name of progress.
    I will go onto to say, that the EHR has helped to facilitate the nursing shortage. Our system alone, lost at least 150 of our top quality nurses to the IT and clinical informatics departments.
    Who knows, in 50-75 years when all the kinks get worked out, we’ll see the kind of progress envisioned by those who created the EHR mandate, until then, you can expect to hear more stories like the one quoted.

  2. I remember CMS’ feebled attempt at patient-centered cancer care. In 2005, CMS initiated a one-year demonstration project for cancer patients undergoing chemotherapy. The demonstration focused on measuring patient outcomes in three areas of concern often cited by patients undergoing infusional chemotherapy: controlling pain; minimizing nausea and vomiting; and reducing fatigue.
    Oncology practices reporting data on all three factors qualified for an additional payment of $130 per encounter for chemotherapy administration (a financial incentive to use infusional drugs over oral drugs). That included a $26 patient copay.
    Senate Finance Committee Chairman Chuck Grassley, found out from the Health and Human Services’ inspector general’s office that the value of the approximately $300 million-a-year demonstration project to report this information was for nothing. Providers were being paid $130 to simply forward the data that was already collected.
    CMS had decided to continue the demonstration project for 2006, with additional reporting to take a further step toward encouraging quality care and promoting so-called evidence-based best practices that have been proven to lead to improved patient outcomes.
    According to CMS, the payment for this oncology demonstration project was $23 per encounter. The new 2006 demonstration project’s objective was to have oncology payments increasingly focused on patient-centered cancer care, rather than chemotherapy administration.
    All the while, a Michigan/Harvard study (before Medicare reforms) documented a clear association between reimbursement to oncologists for the chemotherapy and the regimens which oncologists select for their cancer patients, and a “Pattens of Care” study (after Medicare reforms) showed results that Medicare reforms were still not working.
    Till this day, it is still an impossible conflict of interest. Once a decision to give chemotherapy is taken, oncologists receiving more-generous Medicare reimbursements used more-costly treatment regimens.

  3. One point Maggie – Regina’s name is Holliday – you have it as Halliday in several places.
    Strikes me her story is much more about basic doctor-patient communications than electronic records although they are clearly crucial for helping to mend a grossly fragmented system. But they can’t replace genuine care.

  4. Maggie,
    I echo the Mark Browns comments that this has only a little to do with EMRs and much more to do with basic phycisian-patient-family communication. It is appalling to me that a patient could be placed in hospice without even knowing. Furthermore there is no discussion from her tale of prognosis or therapeutic options.
    None of this will be solved by instituting an EMR. Just as it takes a person to copy a chart that is requested, it takes a person to process a request for a copy of an EMR record. Hospitals have long put such requests for records as a low priorty and I don’t think the EMR will change this.
    What this case calls for is a primary care physician who the patient and family can turn to for their answers. The oncologist in this case has not fulfilled his duty to his patinet in this case to discuss the options availible With the hospitalist trend, it is very confusing to patients as to where to turn for information at this stressful time in their lives. They see a cast of new characters in their lives that they often had no input in choosing and don’t know who to trust. That is why we need the patient centered medical home, but if the primary care team is disengaged from the acute medical crisis, I fear you will get the same senario over and over.

  5. I agree with the comments that this tragic situation is more about failure to communicate than EHR.
    The reason the hospital charged 73 cents a page and a 21 day waiting period is because many hospitals want to discourage patients from asking for their medical records in the first place. I have found agreeing to the cost and saying, “I am legally entitled to a timely copy of my records. I’ll wait while you make the copies” is often enough to get them to cough it up.
    I think this story is more an indictment of our dysfunctional health care system than of access to records.

  6. Dr. Silverstein isn’t at Drexel anymore; the incumbent head of the Institute for Healthcare Informatics is Dr. Prudence Dalrymple.
    I usually agree with Dr. Silverstein, but in this case I can only partially agree. There’s evidence that shows that providers who implement HIT on the front lines are also more likely to implement “best practices” in care delivery processes. One answer to improving patient safety is to encourage providers to implement HIT (it should be mandated, really).
    I was never a fan of “supply-side” planning. The Dartmouth Atlas researchers have shown over many years that when mission-oriented systems (as opposed to “widget-manufacturing-and-output” systems) are supply-driven, dysfunctional consequences result.
    The way that HIT will become more “useable” is when providers demand that they become so, and when they demand that the systems support the way they do their jobs. This is the way information technology has taken root and met the needs of users and become imbedded in other industries.
    I have to confess that I, too, fell into Dr. Silverstein’s mood for ever more analysis (“analysis paralysis,” we called it) when I was an IS consultant, but there is too much at stake for patient safety and population health outcomes not to put the technology into the hands of providers, especially if it supports improvements in care delivery practices. The beef I have with the ONC policy that came out on Tuesday is that it represents a “race to the bottom” in systems development and deployment.

  7. Keith,
    Keith–You write: “None of this will be solved by instituting an EMR. Just as it takes a person to copy a chart that is requested, it takes a person to process a request for a copy of an EMR record. Hospitals have long put such requests for records as a low priorty and I don’t think the EMR will change this.”
    Yes, the EHR rules do change this. If hospitals want financial help in purchasing health IT they will be required to give a patient their medical record, upon request, with 3 business days. The will not be able to make it a “low priority.”
    (The rule says “more than 50% of patients” must be able to get the record within 3 business days,but that probably means that 99% will get their records in 3 days . .)
    This is an improvement.
    Getting a record that is readable is also an improvement.
    Today,many patients don’t want to just “turn to a primary care physician for answers.”
    Many patients want to participate in decision-making, and that means having test results, knowing what’s going on, doing research online, while discussing risks and benefits with the doctor.
    In this case, the doctor who should have been communicating with the patient and his wife was the oncologist.
    If I had cancer, I would not want to get the information second-hand, filtered through my PCP.
    Since he’s not an oncologist, probably he couldn’t answer all of my questions (particularly if I had begun doing some good research.)
    Certainly I would also want my oncologist and PCP to communicate with each other; my PCP might well have info about me that would be useful to my onconologist.
    But ultimately, I should be consulting with my oncologist as we share in decision-making.
    A medical home is important for continuity of care, managing chronic diseases before they become acute, keeping the patient out of the hospital.
    But once a patient is hospitalized with cancer, he needs a specialist. (And that specialist needs to see the EMR from his medical home.)
    As for the hospitalist, he is there is make sure that the hospital care is co-ordinated– which includes making sure that the oncologist is talking to the patient, and that the patient is getting all of the information he needs–including electronic medical record, updated as new test results come in.
    An outside PCP who is not in the hospital full-time is not in a position to do this.
    Thanks, we picked up the mis-spelling this morning. (My eyes–on Matthew HOlt’s post, I saw the “o” as an “a”)
    You’re right that EMRs cannot replace geuine care–and that is not their purpose.
    But they do provide a line of defense against hospitals that are not patient-centered and are not doing a good job of communicating with patients.
    Once she had the medical record Regina was able to improve her husband’s care.
    Moreover, an electronic medical record can help mend “a grossly fragmented system” insofar as all care-givers and interested parties (the patient’s PCP for instance) can look at the same chart and see what’s going on.
    Anyone who looked at Mr. Holliday’s chart should have seen that the oncologist had not been consulting with him or his family, that no palliative care team had been in to see him, etc.
    A hospitalist, or the attending in charge of the case, should have spotted those holes in his care and made sure that the oncologist was communicating with the patient, and that the patient knew about the palliative care team (assuming the hospital had one.)
    If the hospitalist didn’t do his job, then one hopes that the patient’s own primary care physician would have been reviewing the EMR . .
    If all providers are looking at the same (readable and complete) chart, someone is likely to say “wait a minute . . ”
    This is one way that EMRs improve patient safety–if one care-giver drops the ball, others are looking over his shoulder.
    Unfortuantely, as you know, “failure to communicate” is a huge problem in our health care system.
    The electronic medical record serves as a line of communication among caregivers (who are all looking at the same record) as well as between doctor and patient. (Too often, no one remembers to give the patient the lab results. He may not even know what tests were being done. If he has the record he can ask: “What does this mean?”)
    See my replies to Marc & Keith above.
    Finally, today medicine is a team sport– typically several doctors are involved, as well as the patient and family. That makes communication all the more important and the EMR helps.
    Dr. Frankie-
    I understand Scott Silverstein’s frustration with the HIT that many vendors are selling.
    But that is a separate problem.
    The government needed to finalize rules as to what doctors and hospitals are going to have to do if they want financial help in buying HIT so that they can begin to plan–and to learn about what type of systems they need.
    Above, ACarroll comments: “The way that HIT will become more ‘useable’ is when providers demand that they become so, and when they demand that the systems support the way they do their jobs. This is the way information technology has taken root and met the needs of users and become imbedded in other industries.”
    He has a point. Though I would like to see government weigh in with guidelines and advice (at the very least). Too many vendors are selling needlessly expensive and complcated systems that are not user friendly.
    Individual doctors’ and hospitals shouldn’t each be trying to figure out what system they need by themselves. They need help.
    ACarroll– You make a good point. See my reply to Dr. Frankie above.
    Just one question: in what way do you see the rules as representing a “race to the bottom”?
    What was left out that should have been included?

  8. http://healthaffairs.org/blog/2010/07/13/meaningful-use-and-ehr-standards-the-final-rule/
    (my reply to the blog entry is on this page).
    The whole process has been dysfunctional since the ONCHIT was defunded by George Bush and it became the ONC and they turned it all over to the commercial sector under the first National Coordinator, David Brailer (who, along with Newt Gingrich, Tommy Thompson, and Tom Daschle, among others, all now have their companies’ fingers in the pie). (Well, Candidate Barak Obama never promised to slam shut all those revolving doors for all those careerist politicians and military brass, did he?) The industry has entirely too much leeway in defining and driving the program and its outcomes–a dysfunctional decision, for sure, considering it is the same industry that providers complain are not meeting their needs with the systems they are deploying now.
    The “rules” have been “relaxed”–not that they were world-class standards to begin with–with the intention of “tightening up” on them in some unspecified future world.
    I once had a boss who told me, “Pay me now or pay me later.” And “later” is always more expensive.
    As a systems professional, I have an aversion to this way of developing systems, fraught with commercial and political conflicts of interest. As a former federal employee, I have an aversion to the “capture” of an agency by its vendors. And as a taxpayer, I have an aversion to paying them.

  9. Maggie
    It was our PCP that found my wife’s first metastatic recurrence, not the oncologists at our community hospital. It was our PCP that found my wife’s second metastatic recurrence, not the oncologists at our community hospital.
    And when a radiation oncologist did treatment, they did so without script, instructions or referral from the neurosurgeon.
    And a year later, the medical oncologists failed to diagnose cancer, before and after she fell and broke her hip in four places. The only reasons our PCP did not accomplish any finding of cancer was because he was out-of-the-loop (she was already in the hospital).
    If it wasn’t for our PCP for answers, it could have been a lot worse! I’d want my PCP to be in the loop.
    When people say “oncologist,” it infers medical oncologist (a chemotherapist). Perhaps cancer medicine should develop another specialty in the vain of a Hospitalist? One who is actually the manager of cancer patients. Manager between the patient and the surgical, radiation and medical oncologists.

  10. ACarroll
    Thanks for that information. Only wish they had the status of a medical degree (like Hospitalists).
    BTW. Very incompentent “oncologists” at our community hospital have already put the lid on my wife’s coffin ten years ago.
    You’re the only person I’ve ever come across that thinks “surgeon” when they hear “oncologist.” A good many think “chemotherapist” when they hear the word “oncologist,” let alone “medical oncologist.” The cancer industry is so entrenced in medical oncology. Chemotherapy is the wherewithall of all treatments. Sheesh!

  11. Gregory:
    I’m very sorry for my misunderstanding and for your loss.
    There’s been a lot of cancer in my family, and my relatives have always referred to their surgeons as their oncologists. These doctors also monitored and scheduled their care and treatments with other specialists, such as chemotherapists and radiation oncologists, as far as I know.

  12. ACarroll
    Whenever a cardiothoracic surgeon friend has difficulty finding a medical oncologist to use assay-directed therapy on a delicately excised tumor specimen of one of his patients, he says it’s like herding cats. He sent this to me recently. Think you may enjoy it. Remember: cowboys = surgeons/cats = medical oncologists.

  13. ACarroll writes:
    “Dr. Silverstein isn’t at Drexel anymore”
    I wish people would use Google before shooting their mouths off.

  14. ACarroll also writes:
    “I have to confess that I, too, fell into Dr. Silverstein’s mood for ever more analysis (“analysis paralysis,” we called it) when I was an IS consultant, but there is too much at stake for patient safety and population health outcomes not to put the technology into the hands of providers”
    Perhaps he should ask my mother how she feels. See “Science or Politics? The New England Journal and “The ‘Meaningful Use’ Regulation for Electronic Health Records” at http://hcrenewal.blogspot.com/2010/07/new-england-journal-on-meaningful-use.html

  15. Maggie,
    So you would rather trust your care in such a critical time to a hospitalist that you have never met and have no idea of his capabilities?
    Ms. Holliday appparently does not share your view since she “fires the PCP for not even making an appearance in the hospital”.
    This raises the question of what are patients expectaitions of their primary care doc when they have a health care crisis? Why does Ms. Holliday not contact the PCP if she feels he should be present? There seems to be a lot of faulty communication in the story on both sides and I would like to hear the other side of the story from the treating physicians point of view before passing judgement.
    You seem to have a vision of hospitalists with with unlimited time to sit and evaluate the patient that I believe is not the reality of the situation. Hospitalists are required to handle several patients in the hospital at the same time and are under the same economic pressure that we in office practice are. The result is I often hear complaints from patients as to poor communication from the hospitalist or little time spent with the patient by the hospitlalist during the hospital stay. It is not clear that a hospitalist was involved in this case, so it is difficult to judge whether this could have been the conduit to better communication or not.
    My last point is that the PCP should not be there to filter the oncologists opinion, but obviously there was a failure of communication between the patient and the oncologist. In such an instance,I would call the oncologist to discuss these unanswered question and encourage him/her to talk to the patient or family. If this was not satisfactorily accomplished, then I would discuss with the family a second opinion to obtain the answers to the questions they have. How about a family meeting with the oncologist and PCP present? What better than to get everyone in the same room and get all the questions and concerns addressed?
    It is a simple process that I often have to undertake since it seems some patients seem reluctant to contact the specialist directly or do not know how to contact them. It is all about being the patients advocate and making sure they understand why recommendations are being made, being able to voice their concerns, and be involved in any and all decisions. This is the so called model of patient driven health care that Dr. Berwick so espouses as I understand it.

  16. Keith
    It takes time for doctors to sit down with patients and truly explain the benefits and the risks of treatment. In an ideal world, patients would consider the benefits and the risks of each treatment and make an informed decision with the guidance of a wise doctor. But, hurried doctors seldom spend much time discussing the benefits and the risks and few patients ever question whether treatment may do more harm than good.
    If more people researched how and why they are being treated by orthodox cancer therapies then I believe there would be a movement to have more effective and less toxic treatments available. Ideally, we would conduct such research before the treatments were administered but we usually don’t have the luxury of time to learn what the oncologists are not telling us when it matters most. It is scary when we try to give oncologists the benefits of doing what needs to be done but we have to learn to ask more questions and seek more answers.

  17. Dr. Silverstein:
    I am an alum of the iSchool, which was the College of Information Studies when I was there, as well as of the School of Public Health (which had no relationship with the Institute of Healthcare Informatics at the time–a relationship which I requested be established as informatics is my main interest). I am aware, as an alum, that you are not listed as part of the CIST faculty any more. Prudence Dalrymple is listed as faculty and she is also head of the Institute for Healthcare Informatics, a position which you held previously. You are listed only as adjunct faculty in the IHI. In my experience as a student and Teaching Assistant at several graduate schools, adjunct faculty are usually external to the institution and don’t teach regularly. If you are insulted because I said you are not at Drexel anymore, then that says more about you than it does about me. On the other hand, you could have explained your position for the edification of all the readers of this blog.

  18. Gregory:
    The “medical home” concept was developed to address the “herding goats” problem for patients with chronic diseases who sometimes have tens of providers and therapies and no way of understanding what is going on with their disease or with their treatments. As Maggie likes to say,”Medical care is a team sport.”
    My only concern is that in the implementation, it could devolve into the misdirected practices that caused the HMO’s of the 1980’s to be the most hated of healthcare institutions for denying payments for care solely on the basis of managing costs as opposed to managing care. It’s a sure bet that the Republicans, especially those who are calling Don Berwick the “Rationer-in-Chief”, will try to paint medical homes with that brush.

  19. Keith:
    Are you sure your patients haven’t complained about their lack of communication with their residents rather than with hospitalists? That is a common complaint patients have, at least in teaching hospitals, because the staff changes so much during one hospital stay. How many of your patients know what a hospitalist is, anyway?
    In fact, Press-Ganey research has shown that patient satisfaction is higher in facilities with hospitalists, especially in older patients who sometimes have multiple transitions of care. Hospitalists focus especially on continuity of care issues for their patients. The research also shows that continuity of care is better for most patients at facilities with hospitalists.
    Patient advocates have been pushing for requirements for HCW’s to wear ID badges that specifically state their position, and that they introduce themselves to patients with an explanation of their role. That requirement might also be included in the CMS Conditions of Participation and/or in the new healthcare law.

  20. Keith & Gregory-
    First of all, if I’m in the hospital, I want an advocate who is on the scene much of the time, and who has the power to make the hospital’s systems work–to get the lab to expedite getting results from the tests, to get the oncologist to come talk to me, to co-ordinate
    care I’m receving from nurses, residents, an attending, to arrange for the palliative care team to talk to me and my family.
    I want someone who will come within the hour if the nurse pages him to say I’m concerned that my wound is infected.
    An outside doctor who drops in once a day is not in a position to oversee continuity of care. Nor is he likely to be in a position to tell the onconologist: I’m going to be visiting Maggie after I finish office hours at 5 today and I’d like you there then.”
    Most hospital errors occur because care is not co-ordinated. Hospitalists exist to co-ordinate care–to make sure that doctors are communicating with each other and with the patient and that the hospitals “systems” are working. .
    I also am not sure why Holliday didn’t call her PCP-or maybe she did, and just didn’t include those calls in her story.
    Some PCPs visit the patient at the hospital; some don’t. But all should be in contact with the patient/family and the doctor overseeing the case by phone.
    (Visiting the hospital depends on logistics–is it two hours from the doctor’s office or ten minutes away? How busy is the PCP? Does he have a waiting room full of patients from 8 a.m. to 5?
    If the onocologist wasn’t coming to see me, I would call him. If he didn’t return my calls, I would talk to the hospitalist, and my PCP about the problem. If my PCP could make it happen, that would be great.
    Because I’m in NYC, everyone I know who has ever had cancer has an oncologist who diagnosed it–after another doctor (often a PCP) said I think you shoudl see an oncologist, or after the patient herself found a lump and got the name of an oncologist from a friend or family member.
    It strikes me that if the oncologists at your community hospital can’t diagnose cancer, it’s not a very good hospital. (Unfortunately, we have too many small hospitals in this country, especially in the suburbs, that are mediocre. People like the idea that they are close to home, but if you’re seiously ill, you’re often better off at a large medical center in a nearby city.
    When I had my second child, my husbandand I drove 50 minutes to get to Yale/New Haven Hospital rather than go to the hospital in the small suburban town where I lived. And I had her less than 10 minutes after I arrived at Yale New Haven.
    You’re lucky to have a very good PCP.
    On getting the information a patient needs: If I had cancer, I would make every effort to go to a hospital like Dartmouth Hitchcock or one of the many cancer centers in New England that uses the “shared decisoin-making protocol.” Some insurers also can hook you up with a shared-decision making coach.
    Then you are guaranteed to have the opportunity to have your questions about risks and benefits answered.
    I am also hopeful that Medicare will begin to pay for shared decison-making. When patients have a chance to share in the decisions, they often opt for less invasive, less aggressive less expensive treatment. The money Medicare would save would cover the cost. Berwick understands this.

  21. Although this article is about communication and EMRs, the plot line of the absence of a primary care provider is recurrent. Primary care doctors have been thrust out of the hospitals by market forces (my clinic is unwilling to allow me latitude to see patients in the hospital, as I am expected to churn through 20-25 patients daily), evolving technology (patients now require multiple studies, can undergo complicated medical treatments, and can stay in intensive care for weeks; a primary care provider who is not in the hospital is poorly equipped to manage all of this), and efficiency (though in my opinion the jury is still out on hospitalists; well-run programs do show cost benefits, but the average program is no better than having primary care physicians oversee a hospital stay and may cost more). In a medical culture where primary care physicians simply cannot be at the hospital all the time for all their patients, a hospitalist who is in frequent contact with primary care providers from a practice is necessary. The hospitalists at my hospital never even contact me when a patient is admitted, much less brief me on their status. If there were an efficient EMR I would at least be able to have some idea of what was going on and could call the patient’s room to check in on him/her. But we can’t count on an EMR to replace the relationship between a PCP and a patient. Hospitalists need to work closely with PCPs, and the EMR can be an added tool. I wish EMRs were meant for doctors and not for billing though; I find the format not to fit the way we’re trained to think. I wish some practicing doctors would work on these programs.

  22. Sharon M.D.
    You write: “I wish EMRs were meant for doctors and not for billing through; I find the format not to fit the way we’re trained to think. I wish some practicing doctors would work on these programs.”
    On this point, I totally agree. At this point, too many EMRs are designed to enhance billing rather than to improve patient care.
    At the same time,I don’t think I agree that an outside primary care physican should be directing a patient’s care in the hospital. As you point out: “patients now require multiple studies, can undergo complicated medical treatments, and can stay in intensive care for weeks; a primary care provider who is not in the hospital is poorly equipped to manage all of this.”
    An outside PCP realy isn’t in a posiiton to cordinate care within the hospital, or oversee continuity of care.
    Anything that a PCP can or is willing to do for hospitalized patients is great, but ultimately, when it comes to overseeing continuity of care, I’m hoping that hospitalists will take resposibility for patient-centered care.
    I agree that it’s a new specialty and that not all hospitalists are created equal.
    But I think (don’t know with any certainty) that if we work on improving hospitalist training we could turn them into the patient advocates that hospitalist supporters have been calling for.

  23. I agree that communication is sorely lacking as well. But, it also emphasizes how inadequate most EHR’s actually are. They are for billing and nearly useless for clinicians. I just finished reading “Best Care Anywhere” about the VA system. Anyone who has an interest in health care must read it. The transformation was achieved at the VA primarily because of the meaningful use of the EHR which was written and continually refined by physicians. I am continually astounded that this remains a virtual secret to the rest of the medical community and that the VA EHR system is free and available for download on the internet. Thank you Maggie for posting about this book.

  24. Barbara–
    Thanks. It is a good book.
    I plan to follow up with Longman and Ken Kizer to see if a new improved version of Vista is going to be part of health care reform.
    EMRs that are set up mainly for billing miss the point of EMRs.

  25. This is not a plug for Ken Kizer’s company, Medsphere, but this information explains in part how they are using Vista to create a commercial version called OpenVista (one big difference is that the VA system has a very rudimentary billing system because care for vets is largely in-house). I would like to see more providers in the US look into this version as an alternative to being “snowed” by the typical IT/IS vendors without the requisite background, skills, or accountability but with lots of empty promises.

  26. I’ve heard really good things about patient-centered care. I heard that the transition is hard for those involved, but the overall care is higher because there are more brains to pick information from and the digital documentation of patient’s records are easy to understand.

  27. Maggie,
    As I read through this thread I have become particularly sad. I am a PCP and also see my own patients in the hospital. The data on hospitalists being more cost effective or giving better care is really not that strong. In fact, if you factor in PCP’s who round first thing in the morning as well have a remote EMR connection I bet you would find that there are no cost savings at all to a hospitalist program.
    As a PCP I coordinate my patient’s care in and out of the hospital. I expedite tests, talk to specialists, and interact with the nursing staff. And when they are discharged i am the one that sees them later that week in the office. It really is not that complicated.
    One thing that happens quite often is that i actually catch diagnosis that both hospitalists and specialists miss becuase I know the patient better then they do. i know the history. i remember 2 years before when the patient had the same symptoms.
    If the day comes when I have to stop seeing my own patient’s in the hospital….I will stop being a PCP. It will no longer be worth it.

  28. Jordan–
    It sounds as if you do an exceptionally good job of staying connected to your patients when they are in the hospital.
    And I totally believe you that something you remember from two years earlier means that you can really help with diagnosis.
    But your time is limited. You round early in the morning because that’s when you can go to the hospital. This probably means that the patient’s family usually misses you.
    Not your fault. You can’t be in two places at once.
    Also, as I mentioned in another comment, much depends on logistics. If you worked in a suburb of NYC and your patients were in a hospital in Manhattan, it would take you too long to drive in to the city in the a.m. to see them (1 hour or more, each way.)
    If you worked in a rural area, the drive to the hospital might also take up too much of your time.
    The fact you have a remote EMR connection is great– but most PCPs haven’t invested in this.
    Ideally, a PCP would be talking to the patient/family, specialists and the hospitalist by phone, keeping in close contact and providing the valuable information that a PCP has about a patient he has been treating for some time.
    Hositals and specialists also should be looking at the EMR that the primary care physician has, with the PCP calling their attention to salient points.
    The hospitalist movement isn’t about saving money–it’s about patient safety and higher quality, patient-centered collaborative care.
    Only somone who is in the hospital for many hours every day “knows how to repair the Xerox machine” so to speak.
    He knows how to get things done within that hospital. Who to page. What can be expedited and how. Most of all, he knows the providers, specialists, nurses, etc. within the hospital and is in the best position to co-ordinate care.
    A great many (the majority) of medical errors that lead to serious suffering or even death for patients are a result of lack of communication among providers and others, miscommunication and system failure.
    You’re not in a position to do much about that. (You’re not privy to info as to whether infection rates in this hospital have been rising on a particular ward.) A good hospitalist is.
    He can begin lecturing residents about hand-washing, talking to nurse managers about the problem, etc.
    Hospitals are much, much more complicated places–and more dangerous places–than they were 30 or 40 years ago. That’s why patients need hospitalists–someone who knows the ins and outs of the institution–“how to repair the xerox macine.”
    I can imagine that you have met hospitalists who just don’t understand the importance of collaborating with the PCP.
    That would make me sad, too.
    But under reform, the financial carrots and sticks are likely to convince hospitalists, hospital administrators, and others that health care is a team sport.
    The patient in the hospital is not “the hospitalist’s patient” or “the surgeon’s patient” or “the PCP’s patient.”
    He’s “our patient.”
    That patient needs the whole team, working together, not competing for ownership or turf.

  29. Maggie said
    “The hospitalist movement isn’t about saving money–it’s about patient safety and higher quality, patient-centered collaborative care.”
    From my reading of the data (especially the more recent)….hospitalists have not been associated with better outcomes or decreased readmission rates.
    In other words PCP’s have been shown to give as high quality care as hospitalists (please point me to the literature if I am wrong).
    Also….as of today (at least) hospitalists and PCP’s almost never communicate…there would have to be very strong financial incentives to do so…otherwise it just won’t happen.
    Maggie said..
    “But your time is limited. You round early in the morning because that’s when you can go to the hospital. This probably means that the patient’s family usually misses you.”
    This is true…that’s why I call them. Because we know eachother…over years…as they accompany their loved ones to my office visits. Often I take care of the family members too. There are intimate bonds of trust and years of relationship. This can’t be replaced by a new hospitalist physician who happens to be able to give 15 minutes of face time. By the way, hospitalists change shifts on a regular enough basis that often a patient admitted for one week may see 3-4 different hospitalists.
    Maggie says,
    “Only somone who is in the hospital for many hours every day “knows how to repair the Xerox machine” so to speak.
    He knows how to get things done within that hospital. Who to page. What can be expedited and how. Most of all, he knows the providers, specialists, nurses, etc. within the hospital and is in the best position to co-ordinate care.”
    This is just not true. After being in my current system for years I know how to get things done. And I often know the specialists better then the hospitalists becuase we share outpatients as well as inpatients.
    Maggie…I hear your arguments. Just realize that while they sound good I am not sure they are completely true. I have worked as both a hospitalist and a PCP. The majority of hospitalists have a shift work mentality. They cover their services like a resident does cross cover. Hold down the fort until the next shift comes on. Afterall…most hospitalists only see a given patient a few days in a row before handing off to someone else. It is the nature of the business.
    While I think it is fine to have hospitalists in our current healthcare system…I don’t think it should be a requirement.

  30. In regards to Jordan’s data on hospitalists being more cost effective, little statistically-significant evidence exists to support the benefit of hospitalist care, and what research is done still doesn’t support the benefit of hospitalist care.
    Differences in the length of stay are small. A .4 day shorter length of stay, according to one comparative study by University of California, San Franciso and Tufts University, which looked at heart failure, pneumonia, stroke, chronic obstructive coronary disease, chest pain, heart attack and urinary tract infection.
    However, the study found patients did about the same whether they were treated by their family doctors or general internists compared with hospitalists. The hopitalists get patients out of the hospital a few hours sooner, and their care tended to be a few hundred bucks cheaper, but how does that equate to quality of care?
    Hospitalists are a response to an era marked by sicker hospitalized patients, limits on residents’ work hours, frazzled primary care doctors less willing to spend nights and weekends at the community hospital, and a sign of the acceptance of networked medical records.
    I remember the days when the PCP visited his/her patients in the hospital (in those days, it was his). The ones I knew and respected, knew “how to repair the Xerox machine.” You really couldn’t tell if they were PCPs or hospital employees. My PCP when I grew up was like that. My PCP now used to do that. They ARE frazzled PCPs because of the work load and not the compensation to go with it. I don’t blame him. Although, I know my PCP would go into the hospital if I were there. He spends a lot of time trying to keep me out of them!
    I believe Jordan is right. My PCP would know me better than the hospitalist would or could. Perhaps it’s a question of there being better PCPs than others. My mother’s situation recently was a reminder of that. We nick-named the hospitalist Dr. Get’r done! But, because the hospital she was in was different from the hospital her PCP was affiliated with, there was that lack of communication. But even when my dad was in the same hospital as the PCPs affiliation, there still was the lack of communication, which eventually led to his demise.
    Now the question should be asked, how do hospitalists improve outcomes for patients? The researchers said that future studies should focus on quality improvement, comparative effectiveness, clinical informatics, the safety of patients and the translation of new medical advances to clinical practice.

  31. Gregory:
    Length of stay is only one end point that can be studied, and it doesn’t necessarily correlate with how well the patient is doing at the time of discharge, or how many medical and medication errors occured to them during their stay due to lapses in communication among clinicians, or how much overtreatment they received. Shorter lengths of stay don’t necessarily correlate with “saving a few hundred bucks” either; costs incurred during the patient’s stay is a better measure. Length of stay was obviously the end point of interest in this particular study.
    Hospitalists make a difference in what happens to and with the patient during the stay. When end points such as transitions of care and continuity of care are studied, hospitals that employ hospitalists have better outcomes. You should ask hospital staffs about the PCP’s who don’t ever show up for their patients.
    “The good old days” of medical care usually weren’t. You would understand that if you were a woman who needed medical or health care. The old saw that “doctors can bury their mistakes”* is not of recent vintage.
    *“A doctor can bury his mistakes but an architect can only advise his clients to plant vines.”
    –Frank Lloyd Wright

  32. ACarroll said…
    “When end points such as transitions of care and continuity of care are studied, hospitals that employ hospitalists have better outcomes”
    This is just not true. The majority of studies including the most recent actuallly show that when it comes to hard clinical outcomes…morbidity, mortality, hospital readmissions….Hospitalists and nonhospitalists do exactly the same.
    By the way when it comes to transitions and continuity of care… traditional systems where there the PCP takes care of the patient in the hospital makes more sense because ther are no transitions! Continuity of care is perfect becuase it is one doctor taking care of the patient continously.
    By the way how do you measure “end points such as transitions of care and continuity of care”?
    And please point me to the scientific studies where these “end points” have been studied.

  33. Jordan, Gregory, ACarroll
    Jordan, you write: “By the way when it comes to transitions and continuity of care… traditional systems where the PCP takes care of the patient in the hospital makes more sense because there are no transitions! Continuity of care is perfect becuase it is one doctor taking care of the patient continously.”
    I’m afraid this isn’t true. A PCP may visit once a day. He may call later in the day. He probably won’t be there when the patient has a heart attack or develops complications after surgery
    A hospitalist will be.
    And if the hospitalists are doing a good with “hand-overs” (and more docs are really focusing on this these days)), it won’t matter whether this is one of two or three hospitalists the patient has seen.
    When my parents were in hosptials years ago they rarely or ever saw their primary care doctor.
    When my husband had operations in hosptials here in N.Y. over the past few years (knee and repairing a Achilles tendon that snapped when playing tennis) his PCP wasn’t involved.
    But my husband received excellent care. My parents didn’t. There weren’t any hospitalists 30 years ago and care was terribly un-co-ordinated. (It still often isn’t well co-ordinated, but good hospitalists are making a difference.)
    For research on hospitalists and their effect:
    First see this post on The Health Care Blog by Dr. Robert Watchter, an expert in hospitalists and patient safety. http://www.thehealthcareblog.com/the_health_care_blog/2010/05/the-times-hits-the-right-notes-on-hospitalists-.html
    He also refers to an excellent recent NYT story where patients talk about how hospitalists provide more continuous care.
    Also, see this recent article in the ARchives of INternal Medicine, showing that hospitals with hospitalists provide higher quality care: http://archinte.ama-assn.org/cgi/content/abstract/169/15/1389
    Then there is this from a Mayo Clinic Forum which looked at patients undergoing surgery for hip surgery at a community based academic medical center.
    They found that outcomes were better with hospitalists, and wrote:
    “Several factors may be responsible for the improved outcomes observed in the hospitalist group. Timing of consultations and surgery is important in acute care. The TTC (P<.001) and TTS (P=.004) were lower in the hospitalist group, which may be due to the greater availability of hospitalists. Because hospitalists are available on-site 24 hours a day, they are able to reach patients more quickly than traditional consultants. Availability is also important for timely management of postoperative medical complications. That timely consultation and surgery should be associated with improved patient outcomes is not only intuitive but also supported by the literature.5,11-14." Jordan, you clearly are much more conscientious than most PCPs, and I'm sure you help your hospitalized patients. But healthcare is changing. All of these studies show improvements in outcomes with hospitalists--and they're getting better at what they do. Ideally PCPs would work with them. Gregory-- See all of the articles I cited about in my reply to Jordan on the value of hospitalists. ACarroll: You quote Frank Lloyd Wright: "*“A doctor can bury his mistakes but an architect can only advise his clients to plant vines.” What a wonderful quote! And you are right: "'The good old days' of medical care usually weren't." Most people didn't have Marcus Welby as their doctor. When I was six, hit by a car and knocked out cold, I suffered a severe concussion. (I would be out of school for a couple of months.) My parents took me to three ERs before they found one that would look at me. (They didn't have proof of insurance with them.) They called a family doctor who had seen me at some point in the past, but he wouldn't come. I just wanted to go to sleep--which, of course, terrified my parents. Back then, ERs were not required to examine every patient who came in. They, my aunts and uncles all rec'd mediocre to poor care, as did other family members. Back then, upstate N.Y. just wasn't a medical Mecca. I'm sure it's much better today.

  34. Maggie
    You hit the nail right on the head. Hospitalist care “still often isn’t well co-ordinated” (and that’s after what, ten years?). And two of the hospitalists that I’ve dealt with recently for my mother, readingly admit it. But some good hospitalists are making a difference.

  35. Maggie,
    Yes…your points are good. A few notes..
    The Wachter peice is clear but it is completely opinion
    The Archives study measures HQA data…i don’t know how that actually correlates with clinical outcomes or how it is affected by Goodheart’s law.
    The Mayo data is more LOS type data but hard clinical outcomes (morbitiy, etc did not show any statistical difference).
    There are just as many studies that show no or little difference.
    I cannot argue your point…I cannot be there every time something happens to one of my patients in the hospital…but there are mechanisms to control for that. There is an ICU doctor full time in the hospital. And if something happens in the middle of the night then I get in the car and drive over.
    I do round early in the morning and often miss patient’s family members…I usually call them every day to update instead.
    I am not arguing that hospitalists are good…I am just saying that conscientious PCP’s can also function effectively both in and out of the hospital.
    Maggie I know that readers are often swayed by personal stories of patients who suffered at the hands of absent PCP’s during hospitalization. I will tell you that i can give you just as many stories of hospitalists who botched patient care also. They were to busy because their patient load was too high, they didn’t take the time to actually learn the patients history, they sent the patient home on the wrong meds or didn’t appropriately arrange follow up.
    Maybe this subject is too emotional for me to see clearly. Many PCP’s like me feel boxed in by what is happening in medicine. Healthcare reform will make it hard for me to continue my private practice. It will force me to give up my inpatients and thus I will lose my skills. As I am forced into outpatient medicine only in a large university run group practice i will one day be replaced by nurse practitioners becuase they will be less expensive….
    I guess it all comes down this. Are PCP’s a valuable asset to the system….by locking them out of the hospital and forcing them into big group practices we may be minimizing their impact…
    at least that’s how it feels to someone in the trenches!

  36. Jordan–
    Obviously there are mediocre hospitalists just as there a mediocre PCPs.
    I do think there is a need for good hospitalists in hospitals because our hospitals are so chaotic– so many people doing so many things. Co-ordination is essential, and it’s all but impossible for a PCP to do the entire job when he’s in the hospital only once a day.
    That said, if he knows the family, he can become the point person with the family, talking to or e-mailing the hospitalist each daying, getting the patient’s record, keeping the family informed.
    And, of course, a good PCP can keep in touch with the patient, by phone if not in person. If I were the patient, I would like to know that my PCP was talking to the hospitalist who, in turn, was talking to the residents, the nurses, the surgeon. . .
    I don’t think PCPs are going to be “locked out” of hospitals, but I do think that, like everyone else, they need to realize that medicine is now a team sport. Everyone needs to collaborate. There is no “This is my patient and we’re going to do it my way.”
    In terms of outpatient services, I don’t think PCPs are going to be replaced by Nurse Practioners. But insofar as we want to move toward more preventive medicine and more chronic disease management, with docs spending more time talking to and listening to patients (and being paid to do that) then we will need many more primary care providers.
    Some of them will be PCPs; some will be Nurse Practioners. Logically, NPs would work with PCPs taking some of the easier cases (the Worried Well, the person with a sore throat that needs to be checked for strep, etc.) while the PCP woudl take some of the more difficult cases (the person with stomach pains that won’t go away; the person who is dizzy and doesn’t know why. In some cases, the PCP will be able to diagnose–or at least try a treatment–in other cases he’ll figure out which specialist the patient should see, or see first . .)
    In some cases, either the NP or the PCP may be particularly good with certain patients (older patients, or helping diabetics become involved in managing their own disease and the person who likes those cases (and so is better at them) will take them.
    Ideally NPs and PCPs would work together in a accountable care organization, a community health plan, or a private practice.
    I don’t know how pay will work out, but there is a consensus that PCPs should be paid more than they are today. And there’s a consensus that working conditions need to be improved. NPs will help with the latter, giving PCPs the time to spend 30 minutes with the patient who needs 30 minutes.
    NP pay will no doubt also rise, insofar as they are doing some of the same things a PCP does, though the PCP will probably make more insofar as he undergoes more years of training. Much will depend on what the NP actually does.
    Some NPs may work alone in areas (particularly rural) that don’t attract PCPs. We don’t want to force PCPs to go places they don’t want to be–that doesn’t lead to good medicine.
    There is going to be more than enough primary care work to go around. No one is going to be shut out.