Page 15 - Delaware Medical Journal - January 2018
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THE MEDICAL PROFESSION
care all are desirable attributes in the
care of patients. They are also attributes of medical professionalism. As such,
they have been closely associated with
the autonomy granted to the medical profession. Physicians are expected to advocate for their patients, to be clinical experts, to practice high quality medicine, and to innovate in their patient’s interest.4 Historically, the medical profession
has determined the appropriate criteria
to evaluate each of these attributes of professional activity. Consequently,
the loss of physician autonomy raises important questions about the ability of
a system of care with a less autonomous role for physicians to maintain advocacy, clinical expertise, quality and safety, and innovation.
In our examination of the potential effects of physician movement to employed
status on these attributes we see a mixed picture, although again largely favorable. (See Table 1) The implementation
details again matter greatly. Generally, clinical expertise, quality, and safety would be expected to improve as a larger organization deploys talent and resources to assist the work of individual physicians. Clinical innovation can be envisioned to be either supported or inhibited, depending on an organization’s culture and policies. The encouragement or discouragement by an employer of a physician’s role as a patient advocate could make that important role
PRACTICE TREND: MOVEMENT FROM FEE-FOR-SERVICE TO VALUE-BASED REVENUE
The movement from FFS to value-based revenue also is likely to lead to a variety of results. Physician autonomy would be expected to be reduced if the value of individual physician work is blended into the total organization’s clinical effort. However, the effects on patients would
seem to be favorable as value rather
than volume is remunerated. Physicians themselves may be happy to be freed from the limitations of piecework payment,
but discouraged if individual effort
and competence is under-recognized.
The change from FFS to value-based payment should support the development of expertise as outcomes are emphasized through incentives.5 Similarly, quality Innovation could improve, as well, as a result of time gained to innovate as the diminished.
The shift from FFS to value-based revenue also is likely to result in a mixed picture when the desirable attributes of advocacy are examined. The freedom from production line constraints would seem to enable physicians to be more effective advocates for their patients. However, if rigid and ill-conceived value metrics are substituted for production quotas, little improvement or negative effects on advocacy can be envisioned. Expertise, quality and safety, and innovation all reasonably can be expected to improve. (See Table 2)
PRACTICE TREND: USE OF ELECTRONIC HEALTH RECORD
The use of an electronic health record (EHR) now is essentially required by federal health policy and is rapidly becoming universal. Considerable controversy exists about EHR’s clinical utility, potential risk 5 and ease of use.6 When we examine physician autonomy, the expected effect would appear to
be an increase in autonomy, at least across the changes in practice we considered. Despite a loss of individual physician preferences in the recording of information, the ease of accessibility and theoretical availability of real-time best evidence would seem to facilitate
physician control of important clinical decisions. Patients, as well, will be sharing and best practices. Physicians’ their decision-making and the simple enhance their professional lives. The possibility of a physician potentially paying more attention to their computer than to her patient, however again points implementation. This caveat highlights the truism that Information Technology (IT) system design and physician training are important. Poorly designed and implemented IT systems are a well- recognized cause of physician frustration.
The EHR’s theoretical ability to more easily record and present a patient’s preferences to all providers involved in his care should enhance the physician’s ability to be the patient’s advocate. If systems are well-designed and a culture of continuous improvement exists, quality, safety, and expertise should rise as they are enabled by better, more timely, and more uniform information. Innovation, however, would seem
to be at risk and in need of careful attention. EHRs by their very nature
tend to standardize care. In fact, this standardization is viewed as a boon
to improvements in quality that come from the reduction in unnecessary and sometimes harmful variations in care. Standardized care can raise a barrier
to innovation if formal processes to facilitate innovation are not designed
as part of the management of the EHR system. Conversely however, one can easily imagine an EHR enabled clinical environment that stimulates innovation. The ease of accessing and aggregating data can generate both clinical questions and facilitate the pursuit of answers. In this type of information-empowered environment clinical innovation and advancement can be great. (See Table 3)
Del Med J | January 2018 | Vol. 90 | No. 1
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