We Don’t Have a Shortage of PCPs, We Have a Shortage of Using Them Efficiently
As questions come up on this article and topic, I'll make sure to post answers here.
* Barriers: Someone asked why we don't see more of this type of attitude from doctors? My answer: I think there are two main barriers we need to overcome to increase the spread of this type of "team-based CDS" which automates and delegates clinical work: First, we need to continue to better align incentives (i.e. Value-based vs. Volume-based reimbursement and legal systems)... How can we expect doctors to delegate work if they are not protected financially or legally from doing just that? Second, we need to make CDS easy and intuitive to use and ideally integrate them fully and elegantly into our EMR systems (see examples below of companies working on these types of tools).
* Speed: Someone asked why this can't happen sooner (i.e. why did I say 2025 instead of 2015). It's a good point, as I think it is technically feasible today. I used 2025 because (1) It was the year used in the article I initially quoted about MD deficits, and (2) I did want to describe a future world where this vision of team-based care and HIT would be completely common and routine, not simply possible. I think there are financial and legal issues which will slow it down, but I also think that we will be seeing more and more of this happening in the near term as well - just not as widespread and pervasive as we'd like for another 10 years or so.
* Risk Stratification: Someone asked how many patients would fall into the Green/Yellow/Red zones. Studies have shown that 1% of the population accounts for 20 - 30% of the cost, and 5% account for 50%, whereas the healthiest 50% account for just 3% of the total cost. So I'd suggest the "Red Zone" is about 5% (e.g. 250 patients in a panel size of 5000), the Yellow Zone would be around 20% (1000 in a panel size of 5000), and then the other 75% in the green zone. Using another way to measure it, today's typical panel size is 2500, which requires a PCP to see about 25 of these patients in a given day. If the panel size were 5000, the old system would require them to see 50 patients a day. In the "new" system, I'd suggest they will need to see about 5 "Red Zone" patients a day in the office while interacting with another 20 "Yellow Zone" patients (or answer questions for their staff members) - which could take anywhere between 1-5 minutes. The reason that this number stays relatively high is that the Red and Yellow patients do need to be actively managed on an ongoing basis - some will eventually move into Green territory, but others simply have too many interacting or unique problems and medications which are beyond the scope of even advanced protocols and is where the cognitive skills of physicians will shine. Of course, when artificial intelligence gets good enough to figure all these things and how to communicate it all to patients - then we may see even more automation in healthcare... but if/when computers have gotten that good - we will likely see automation in every other professional career as well - from lawyers and judges, to politicians and marketers, to stockbrokers and Venture Capitalists. In other words, while I agree with Vinod Khosla's assessment that we will see HIT further automating healthcare... I don't think it will "replace 80% of doctors" - but it will allow us to effectively leverage the current amounts of physicians.
Companies Making "Physician Efficiency Apps" (or "Doctor Happiness Tools" as I like to call them)
* healthfinch: A cloud-based decision support system which integrates with EMRs to automate and delegate repeatable work away from physicians and towards their staff in a safe and consistent manner (e.g. Medication Refills). I founded this company in 2011 with two very smart HIT experts focused on human-centered design, and have mentioned in some past blogs about "Saving Primary Care with Team-based Delegation Software" and another about "EMR Extender Tools creating Doctor Happiness". The first product, RefillWizard, which integrates with some of the main outpatient EMRs to help decrease the amount of time doctors must spend approving medication renewal requests, saving them up to 30 minutes daily. If we apply that 30 minutes of savings to the 400,000 primary care physicians in the US, we can effectively "create" 25,000 new physicians—half the expected shortfall in physicians caused by population growth, aging demographics and insurance expansion! Now just create a few more of these and we save the healthcare system!
* healthloop: Automates the "follow-up" process to check on patients after their in-person visits. Founded by Dr. Jordan Shlain, another of the rare but growing breed of working PCPs who understands how HIT can help make life easier for docs and patients and is building tools to fulfill that vision.
Other Relevant Articles
* Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Nonphysicians, And Electronic Communication, Health Affairs, Jan, 2013 (vol. 32, no 1): 11-19. Says that there will not be a doctor shortage as long as we optimally utilize team-based care and HIT.
* Estimating a reasonable patient panel size for primary care physicians with team-based task delegation. Altschuler J, Margolius D, Bodenheimer T, Grumbach K. Ann Fam Med. 2012 Sep-Oct;10(5): 396-400. doi: 10.1370/afm.1400. Estimates how much care can be delegated in a team-based model, and thus what an optimal panel size could be to do perfect care.
* Project Doc Shortage is Real, Experts Say. Modern Healthcare, Jan, 2012. Discusses that while team-based care and HIT will improve efficiency, we will still have some need for more PCPs - especially in underserved areas.
* Doctor Shortage Getting Worse. A CNBC article (Mar 13, 2013) where they use the usual claims (again, based on the current model of care) and I appear to be the "poster doc" for the concept of using IT to improve efficiency and save time. My section: And one expert says it's not so much a scarcity of physicians but of using them in the right way. "We don't need more physicians, but rather better "team-based workflow tools" to ensure that everyone on the team can work to the highest level of their ability in a safe and efficient manner every day," said Dr. Lyle Berkowitz, Associate Chief Medical Officer of Innovation for Northwestern Memorial Hospital. "That means using information technology and freeing physicians to spend their time on more complex patients," Berkowitz added.