Messageboard

Ooh a hot debate, love it.  Actually, I bet the RIQI folks are smiling, this is probably just the stuff they want to see on their site.  Regarding the posts, it is a little quirky - I think the main/first post stays on top and then each subsequent reply ends up "on top" just below that.  It is not really intuitive for the reader coming in after the fact, don't know that one would start at the top, then the bottom and read up.  I suggest everything goes down like a book.  If there are too many posts, have a page system just like any other site so you can simply go to the next or last page/post if you prefer.  I'll start a discussion regarding the site separately.

Back to the discussion - I appreciate your point of view, though I don't agree.  I would love to support the doctor-patient relationship and inegrate that into meaningful use if only physicians did their jobs adequately.  As I mentioned, there is no way to measure it - but that is also not going to get the job done. The U.S. healthcare system is nowhere near where it should be, one cannot argue that point, we are not doing a good job.  We can blame the lawyers and the system, but if we stop and look at what we are doing, it isn't good enough.  Get physicians on EMR's, show them reports of their work and their eyes open wide "I didn't know my numbers were so low" - immunization rates, A1C monitoring, diabetic eye exams, BP control, cardiac patients on aspirin or lipid therapy, etc.  We have guidelines on many things for good reason, we know what works in most cases, but we don't get it done. 

Since it was brought up I can speak to my disclosures - I am rather efficient when it comes to clinical problem solving and patient management - case managers need a physician advisor since their jobs rely upon finding efficient/effective ways to move patients through the healthcare system, and they are "handling" physicians all the time.  There are many physicians that drag their feet while managing care - it is what the patients/families prefer - it is good for the doctor-patient relationship to cater to the patient.  It does not help a patient for tests to be delayed, work-up to be stagnant, patients that are ready for discharge to be told that they can stay another few days in the hospital if they feel that they want to, "you are ready for discharge, would you like to go home today or stay longer" is a classic - yeah, why not stay and get a DVT or nosocomial infection.  Metrics and best practice guidelines can be measured, the data supports getting patients moving - do their work-up, provide their care, move them out to the next level of service when they are ready - that just doesn't happen - and physicians are a big part of why it doesn't.  I have been quite successful implementing and using the EMR, the doctors in my group are quite pleased with their efficiency and ROI, the patients are proud to get their care from our physicians in an electronic environment with ready access to data, a patient portal to share information and communicate with their provider, etc.  We  piloted the PCMH, achieved NCQA level 3 PCMH, and are now in the process of working with a professional organization to help advance our workflow to optimize everyone's skills - get the staff aligned so RN's are doing RN work, MD's are doing MD work (as opposed to faxing, looking for samples, looking for reports that should have been received from specialists/hospitals).  It is a very exciting time, being part of the transformation of the healthcare system - into a more efficient, more professionally satisfying atmosphere where the physician can spend the time they need with the patients since the support systems are in place to allow the work to get done in a thorough, efficient, evidence-based manner. 

I also work for the QIO to do peer review to support their work - something that didn't really seem like it needed to be on this site's disclosure.  Anyway, through that work and also simply receiving records from outside providers all the time as I take on new patients, I can see that many physicians are disorganized and not doing an adequate job keeping up with the standards of medicine.  I am quite sure that their patients love them and they have a great doctor-patient relationship, but their care is not up to standards.  If we are to protect the doctor-patient relationship, let's at least get all of the doctors to do their part.  Follow the hard and fast rules of evidence based medicine - at least in those areas that are solid - colon cancer screening, BP control to decrease strokes, etc.  The data shows that we are not doing a good job.  Stop indiscriminate ordering of MRI's and other expensive tests just because the patient demands.  Make sure you keep up your clinical skills so you can be confident saying "the neurologic exam is normal, you don't need an MRI at this time, I have a treatment plan to suggest that does not include an MRI".  When are we going to see the end of indiscriminate antibiotic use - is it because the physician doesn't know better or the patient/family demands antibiotics because they "know" that is what their condition requires? 

I would just like to add that if your comment about my disclosure was in any way aimed at my relationship with "the enemy" - that being an insurer, you should check what they have been doing to support all of the health care initiatives in R.I. - I am proud to partner with BCBSRI.

I take the side of the legislators on this one.  Proper clinical evaluation - history taking, physical examination, sensible testing and treatment based upon standardized clinical guidelines should be rewarded – that is if they are being done.  The doctor-patient relationship is indeed a valuable commodity, but how do you measure it?    In this era of medicine most of what we do is based upon science, standardized treatment plans, randomized placebo-controlled clinical trials that lead to clinical guidelines.  If the physician is doing a good job, they should achieve better outcomes – something that can be measured.