By John Carruthers, assistant editor, February 01, 2014
The unprecedented number of new patients entering the health system under various provisions of the Affordable Care Act (ACA) is one of the biggest change agents in the history of medicine in the U.S. As swelling demand meets a maxed-out specialist population, dermatology prepares to meet the challenge of more patients and less time by efficiently coordinating care both in the office and among external colleagues. Patients have both Internet access and a laundry list of questions for their physician, while practitioners have less individual patient time than ever; a well-coordinated care team can leave patients feeling informed and well-treated while freeing up physicians to diagnose and manage more cases per week. As changes in medicine disrupt current procedures, viewing the practice as a team-based unit, advocates say, can help dermatologists effectively stretch their resources and continue to thrive.
New patients, new tactics
The locus of patient care is moving from the physician alone to a more team-based approach. A 2012 report from the Institute of Medicine (IOM) states, “the clinician operating in isolation is now seen as undesirable in health care.” Medicare beneficiary data supports the growth of the multi-provider approach, as each patient covered under the program sees an average of two primary care and five specialist physicians each year.
More to the point, the IOM report continued, the rapidly evolving clinical care environment precludes single physicians from keeping up with the expanding base of knowledge by themselves. There are over 2,700 clinical practice guidelines listed through the U.S. National Guideline Clearinghouse, as well as 25,000 clinical trials published annually.
The demands on the dermatology workforce, and the ongoing shortage of dermatologists in many areas, require a more nuanced look at the distribution of dermatologic care and practice resources, according to dermatologist and former Academy president David M. Pariser, MD, chair of the Academy Workgroup on Dermatology Care Team Implementation. Dr. Pariser has observed firsthand how taxed the dermatology workforce is at present, and was even prior to the ACA. His Norfolk, Va., practice began to integrate physician assistants (PAs) into its care team in 2005, when it became clear that hiring a dermatologist in his area of the country was all but impossible. Now the practice of 11 dermatologists employs seven PAs and one nurse practitioner (NP). The workforce, both in dermatology and in medicine as a whole, he said, may begin to feel that same tension of a practice working at capacity but facing an increase in demand.
“Without an increase in the number of physicians, particularly for dermatologists, it’s going to be more and more difficult to meet the demand of all the patients who need care,” Dr. Pariser said. The team-based approach, he said, is the natural evolution of solutions dermatologists and practice managers have been experimenting with for years.
“The idea of the care team is coming forth as a way to help meet the demand with the workforce that we have. A group of people will work together under defined roles to provide care for the patient,” he said. “The AAD Board has gone along with this concept, and the Academy is going to be including other people in the care team so that dermatologists will be able to maintain a high quality of care for all the patients that we treat.” [pagebreak]
While some dermatologists may be new to the team-based approach, others have spent their careers immersed in it. Randall Roenigk, MD, of the Mayo Clinic in Rochester, Minn., said that since its inception, the clinic’s default mode of operation has been focused on collaboration and team care.
“The cornerstone of our practice is a team-based approach to patients. Our founders translated that idea between not only the doctors, even though that was the predominant caregiver at the time, but they translated it to the para-medical people and office staff, and even down to the cleaning staff,” Dr. Roenigk said.
In the Veteran’s Affairs system, according to dermatology NP Lakshi Aldredge, ANP, who practices at the Portland VA Medical Center, the hierarchical team-focused structure allows for more open communication and the ability to adjust the allocation of resources to meet day-to-day demand.
“Our model here is not atypical of team models in other settings, where you have providers, nurses, and others who handle non-provider related patient needs, and a scheduler who handles paperwork and other administrative tasks,” Aldredge said. “Each of us has very clearly delineated roles. The most important thing is having a team leader who makes clear what the goal of the practice is and what each member’s role is, and then ensures that they have the right tools to do that in a timely fashion.”
I: Front desk
For Dr. Roenigk, the team-care process often starts before the patient sees the dermatologist face to face. The appointment staff and front desk, he said, are the first stage in the team-care process.
“Our appointment office has a list of appointment criteria that helps them to match up the patient with the right doctor. They also try to minimize the number of required visits,” Dr. Roenigk said. “If the patient is being referred in from somewhere else, they try to avoid having them set up for a consultation first. The patient may end up seeing us the very first time on a surgical day.”
For patients with complex cancers, Dr. Roenigk said, care coordination begins before he or a colleague sees the patient, with the coordinating dermatologist ordering a number of tests and setting up appointments with other providers. [pagebreak]
“I have a patient today who has a metastatic squamous cell carcinoma, and before I see him, he’s already had his PET scan and his CT scan, he’s seen the radiation oncologist, and is scheduled to see the plastic surgeon,” Dr. Roenigk said. “The appointment staff is essential in coordinating these visits that I direct for the patient.”
The front desk and administrative staff also provide a line of communication to other providers in the community, both in dermatology and in other specialty areas. When this is working effectively, Aldredge said, it can save a significant amount of patient and provider time.
“We want good communication with our community dermatology colleagues, to ensure that if they have a patient that we need to see, they have the information for our appointment person who specifically facilitates incoming patient referrals,” Aldredge said. “We also have an excellent process for referring patients to outside consultants, and a specific person who handles those cases.”
For patients who need Mohs surgery during times when the VA clinic is backlogged, Aldredge said, her department has a streamlined process to have patients seen by Mohs surgeons in the community with existing referral contracts. Dedicated team members at both practices share records in an agreed-upon common format, with care guidelines directing the information that needs to pass from the VA to a community practice, and vice-versa. The team member in charge of scheduling at the VA keeps a number of slots open for community referral patients, and likewise, affiliated practices dedicate patient slots for overflow VA patients in need of surgery or other outsourced services. These measures allow for efficient operation with practices outside of the integrated VA system.
Taynin Kopanos, DNP, vice president of state and government affairs for the American Association of Nurse Practitioners, said that front end-led integration of the patient handoff — records, results, and other applicable visit information — is the “million-dollar question” of system-wide team care going forward.
“The goal of every office should be to streamline the patient handoff for evaluations and follow-up,” Kopanos said. “The ultimate goal would be for the care provided at dermatology offices to be coordinated back to primary care,” she said — a process in which the front desk can be integral. “That involves communicating between practices, and deciding what form that communication will take in terms of transferring records, visit information, and lab results.”
II: Clinical personnel and support staff
Though they do not function in the provider role, the clinical acumen of practice staff such as registered nurses, licensed practical nurses, and medical assistants can be vital in maintaining practice efficiency. In Aldredge’s practice, the clinical personnel have clearly delineated roles. The most important of these, she said, is triaging patients to the appropriate team member as outlined by the supervising physician. Clinical personnel also serve as the first point of contact for the patient once they’re called back to a room. They take vitals, set up equipment for providers, and initiate clinical communication with the patient. [pagebreak]
In Dr. Roenigk’s experience, patients are often more at ease with clinical support staff than they are with the physician, leading them to speak more openly about medical issues.
“In many cases, the patient is more willing to talk to the nurse, or they speak to the nurse in a different way, without this anxiety patients can sometimes feel around a doctor. If there’s a less threatening atmosphere, we make sure that the nurses and desk attendants feel empowered to speak up and tell us things they feel are appropriate to treatment,” Dr. Roenigk said. “If they see something going on with a patient that they don’t think is being handled correctly, we encourage a culture of intervention. The doctor is the leader of the team, but they’re not a dictator. Having someone empowered to speak up could help us not miss something important.”
Such empowerment can have benefits beyond an individual patient’s care; the discovery of the Sister Mary Joseph Nodule by the eponymous Mayo Clinic scrub nurse, who observed a nodule on the belly button of patients with gastric cancer, was fostered by a culture of team-based collaboration, Dr. Roenigk said.
Following the dermatologist visit, Dr. Pariser said, having clinical support staff well-trained on patient education can help drive home the physician’s recommendations and increase rates of compliance completely within their limited scope of practice.
“The medical assistants and nurses allow for specific assigned tasks that are directly and personally on-site supervised by the dermatologist,” Dr. Pariser said. “They don’t make diagnoses, they don’t write prescriptions, but they certainly help in patient education and various other clinical and administrative duties.”
III: Non-physician clinicians
Perhaps the biggest evolution in the team care model over recent years has been the growth of non-physician clinicians (NPCs) — PAs and NPs whose scope of practice, while less than that of a physician, allows them to handle a wide array of follow-up and minor cases for otherwise overloaded supervising physicians. [pagebreak]
The limited number of residency slots and the ever-increasing price of medical training, combined with generous scope of practice regulations in many states, have led many people seeking careers in a clinical setting to pursue PA or NP training. The Agency for Healthcare Research and Quality (AHRQ), a sub-agency of the U.S. Department of Health and Human Services, predicted in 2012 an increase of approximately 72 percent in the number of PAs by 2025. A study published in Medscape found that each decade-long cohort produced more NPs than the one that preceded it, and predicted a staggering 94 percent growth in the NP workforce between 2008 and 2025. [pagebreak]
Embracing this new cohort of care providers requires dermatologists to resist the impulse to do it all, according to Kathryn Schwarzenberger, MD, who chairs the Academy’s Workgroup on Innovations in Payment and Delivery and is the Amonette-Rosenberg Chair and Professor of the University of Tennessee dermatology department.
“Part of forming an efficient care team is realizing ourselves that we have people in our offices that can do parts of our job as well as, and in some cases better than, we do,” Dr. Schwarzenberger said. “I believe that every member of the care team should work to the highest level of their competency.”
An increasing number of dermatologists appear to be embracing this ethos. The AAD’s 2012 Dermatology Practice Profile Survey found that 40.9 percent of dermatology practices employed either a PA or NP, up from 28 percent in the 2005 survey. Further, 15 percent of practices were actively seeking to hire NPCs, and 34 percent were seeking to add a dermatologist. With the difficulty that many practices — especially rural practices — have in trying to add a dermatologist, continued increases in NPC hiring seem likely.
“When a practice is working at maximum speed and yet the patient demand continues to increase, it’s a natural decision to consider properly supervised non-physician clinicians as an option,” Dr. Pariser said, adding that unlike hiring a dermatologist, more intensive training is likely required. “We train them for a full six months before they see any patients on their own. Unless they’ve had practice experience, you’re going to have to teach them what they’re going to learn.”
Despite the time and effort it takes to train an NPC, Dr. Pariser said, having them integrated into a care team saves the physician substantial amounts of time without any perceived drop in care quality among patients. Once a patient is diagnosed and a course of treatment set, according to Dr. Pariser, carefully selected cases can be transferred to supervised NPCs.
“Once a patient is diagnosed, a PA or NP can handle the follow-ups pretty much on their own for the common issues,” Dr. Pariser said. “Having them do follow-ups where the diagnosis has already been made eliminates the pitfall of them not knowing what they don’t know. One of the best ways to use these providers is to manage patients with long-term chronic conditions, as well as for minor procedures, which can be time-consuming.” [pagebreak]
In addition to in-office treatment, NPCs can also be helpful in coordinating with other offices and specialties, according to Kopanos. Contemporary nursing curriculums, she said, offer specific focuses on multi-provider care, inter-specialty communication, and ensuring open communication between offices to eliminate redundancies in patient information gathering.
“The nursing curriculum has evolved to emphasize leadership within a care team, as well as coordination across practice settings and medical disciplines,” Kopanos said. “Nurses have always been team-oriented, but now there’s more emphasis than ever on creating an ongoing dialogue between specialty and primary care providers.”
Having worked in a number of institutions with significant dermatologist/NPC interaction, Dr. Schwarzenberger said that she hopes to use NPCs to increase the amount of time physicians can spend on serious cases.
“What I would ideally like to see here is the department working with NPCs to provide dermatology screening, while the dermatologists handle dermatologic disease,” she said.
IV: Supervising physicians
The leader and captain of the dermatology care team, the dermatologist is responsible not only for diagnostic duties and delegation, but also for setting the team up for success and for continually striving to achieve efficiencies and improve outcomes. A short meeting at the beginning of the day, Aldredge said, can hammer home this point and give the team a sense of direction in the bigger picture.
“Every morning the clinical and office staff gets together and do what we call a group huddle. We look at the schedule for the day, see how many people we can overbook, follow up on cancellations, look at patients who might require special equipment, and identify patients who may need more time for their visit,” she said. “It only takes five minutes, and it’s a very good way for the team leader to set the tone for a day, anticipate problems, and make sure everything runs efficiently.”
Dr. Pariser’s group makes sure to meet monthly to discuss patient workflow as well as administrative and staff issues, despite the difficulty of getting nearly a dozen dermatology providers into the same meeting. The alternative, he said, would be to let the issues pass incompletely addressed by the dermatologist care-team captains or by the staff. [pagebreak]
As head of a newly formed department of dermatology and clinic, Dr. Schwarzenberger meets weekly with the head of nursing and the head of the administrative staff to ensure open communication as the clinic begins to find its own team-care workflow.
“I really do think that regular meetings with the team are essential,” Dr. Schwarzenberger said. “The most important thing about this model is making sure everyone has a voice. It enables everyone on the care team to recognize issues and make both positive and corrective suggestions.”
In managing NPCs, just like working with partner dermatologists, supervising physicians need to get a feel for their practice habits and tendencies, according to Dr. Pariser. The physician is ultimately responsible for the care delivered, he said, and emphasized the importance of not just pushing off chronic and follow-up patients to PAs and NPs, but effectively supervising and directing the continuing care of those patients.
“Non-physician clinicians serve as a way to extend our services, not to replace them,” he said. “You may have a PA starting with you who has dermatology experience, but their expertise may be something different than you’re looking for in your office. Keeping tabs on them and learning how they practice is the only way to eliminate the pitfall of them not knowing what they are doing incorrectly, or doing without the proper training and knowledge.”
With some offices worried about declining reimbursements and cuts on the horizon, Aldredge said, it’s going to come down to the captain of the team to adjust course and ensure the continued viability of the practice.
“It’s essential to ensure that you have the appropriate staff to do the appropriate functions. Obviously, dermatology providers, whether it’s a dermatologist or a non-physician clinician, don’t need to be rooming patients or taking vitals. That’s a waste of time and a lot of money,” Aldredge said. “Look at the rest of your staff resources in that light. The right person needs to do the right task for their scope of practice. Say you’re forced to cut back on staff. Is having your NP room patients really the most cost-saving utilization of a provider?”
Dr. Schwarzenberger agreed, saying that appropriately delegating provider time can not only improve a dermatologist’s efficiency, but improve job satisfaction for members of the care team by making them further invested in the practice and patients. [pagebreak]
“Everything you do in the office during the day should be looked at for three things — can someone, properly supervised, do it as well as or better than you can? Will doing so allow you to provide care at a lower cost to the practice? And frankly, will they enjoy doing it more?” Dr. Schwarzenberger said. “I have an outstanding PA who loves performing skin checks and providing sun safety education. I’m completely fine with her handling those services under my supervision and dedicating my time to treating patients with more complicated diseases.”
V: Referrals and colleagues
The care team doesn’t stop at the threshold of the office — but as Kopanos noted, maintaining contact can be challenging. A number of health systems, including Dr. Roenigk’s, have fully integrated electronic health records (EHR) and conduct electronic consults via the shared record.
“Let’s say a primary care physician sees a patient he thinks has a melanoma, maybe he’s done a biopsy, and he sends me an email through our EHR for a consultation. I can review the record and tell him what I think should be done,” Dr. Roenigk said. “Essentially, I’ve done a consult without seeing the patient so that the patient gets seen by the right dermatologist or general surgeon or whatever’s appropriate for the patient.”
While some specialists might suspect that accepting electronic or EHR-based consults would add to a day’s workload, there is some evidence to suggest that the mechanism can work as a sort of teletriage, reducing unnecessary referrals and leading to a net shortening of patient wait times. (Reimbursement for these activities remains a concern; as currently constructed they make more financial sense for salaried providers.)
A 2013 profile of the Los Angeles Health Care Plan — a public plan that serves Medicaid beneficiaries — by AHRQ examined the role of its Web-based eConsult program, which allows primary care physicians within the network to order electronic specialist consults with a median 48-hour turnaround. Specialists receive relevant patient information; can request additional information, including images; and participate in a back-and-forth with the primary care provider requesting the consult. The system, implemented in 2009, features a network of more than 60 community-based clinics and 85 participating specialists in 15 areas, including dermatology. [pagebreak]
The results speak well of electronic consultation for reducing the burden on specialists. During the initial pilot phase (June 2009 – December 2010), 46 percent of electronic consults resulted in a resolution that did not require a face-to-face specialist visit. A follow-up analysis of the 2012 and 2013 data found that the figure had stabilized at approximately 25 percent. In addition, the average wait time for specialty appointments within the system declined by 60 percent.
But even apart from the developing area of electronic consults, dermatologists accepting referrals have seen changes in the referral process from primary care physicians. The number of referrals from primary care physicians to specialists, according to the IOM, has risen dramatically since 1999. This may be in part because many dermatology referrals, according to Dr. Pariser, come via a primary care physician’s PA or NP, without the primary ever having seen the patient. “If I’m a physician receiving a referral, and I’m getting it directly from a PA, from an office where the physician hasn’t seen the patient at all before referring out, I’m going to want to know that and approach the patient with that knowledge in mind, taking care to identify any issues that a less-trained NPC may have missed,” Dr. Pariser said. “In many cases, the patient can come in unhappy because they’ve been shuttled around without having seen a physician. It can affect their attitude when they come to you, and color their expectations. Part of the team-care approach is recognizing the story of the patient.”
University of Pennsylvania dermatologist Carrie Kovarik, MD who runs the Resident International Grant program through the AAD (see sidebar, p. 24) often works with colleagues and referring physicians albeit ones a hemisphere away. She has coordinated with local physicians remotely, and participated in telepathology sessions with a pathologist in Botswana. Helping coordinate the program, she said, has helped her realize just how many individuals have a hand in treating a single patient. The lessons apply at home, too.
“Even before adding in the people responsible for telemedicine, I realize that I’m almost surprised by the number of people who comprise the care team,” Dr. Kovarik said. “We’re very dependent on the local pharmacists, the regional nurses in rural areas, and the administrator of the hospital. Each member of the care team is essential to providing uninterrupted treatment every day.”