Leadership Recovery: The Future of Primary Care

The Issue

Primary care was our first line of defence when the coronavirus hit. Much has been learned about the nature, treatment and delivery of care response to the virus in the first wave even as primary care was being transformed digitally. An earlier Blog assessed a number of trends, forecasts and outlook lessons learned internationally, not just in North America, from literature published in the period 15 March-30 June. This Blog updates that review to address professional literature published in the period 1 July-15 October.

Big First Wave COVID Transformation of Primary Care:

Traditionally, primary care (care in a doctor’s office or clinic) has been the public’s first line of defence. It is able to reinforce public-health messages, help patients manage at home, and identify those in need of hospital care. In response to the COVID-19 pandemic, primary care had to scramble to rapidly transform itself and protect clinicians, staff, and patients while remaining connected to patients. A pandemic is a time when people need primary care more than ever and primary care needs to know how best to help them.

Early in the COVID-19 pandemic, tasks or lessons focused on promoting physical distancing and encouraging patients with suspected illness or exposure to self-quarantine. Testing was not available and contact tracing was not possible. As the pandemic spread, in-person care was converted to virtual care using telehealth. Practices remained connected to patients using registries to reach out to those at risk for infection, with uncontrolled chronic conditions, or were socially vulnerable. Practices managed most patients with suspected COVID-19 at home.

During this pandemic, demands and needs completely changed because:

  • (a) More patients needed infection-related care,
  • (b) There was a decreased number of patients seeking non-infection–related care, potentially with adverse consequences,
  • (c) Levels of anxiety, stress and mental-health needs rose,
  • (d) There were upsurges in substance misuse, inter-generational conflict, and spousal abuse, and
  • (e) Business and school lockdowns accelerated greater demands from patients and burdens for primary care.

Legacy Issues: Barriers To An Effective Response

There were many barriers to an effective pandemic response. Entering the COVID-19 pandemic, much of the needed primary care infrastructure was poorly developed. It remains to be seen whether specific short term innovations to address these barriers during the COVID-19 pandemic will remain. These legacy system failures — however damaging during normal times — have been magnified exponentially by the unprecedented challenge of COVID-19. Those legacy barriers were many:

(a) Professional burnout is extraordinarily high:  While many doctors operating in office practices feel valued by a majority of their patients, they feel least valued by the federal government, and little valued by both hospital systems, health systems, and insurers. Many are of an older generation who are doing a job they feel is not doable within the time they have to see the patients they need to see. Survey reports of workplace depression, nausea at facing another day of work, and even suicide are growing and dramatic. As a result, fewer physicians were choosing primary care careers at a time when the country needs them more than ever.

(b) There is over-reliance on brick-and-mortar offices/clinics:  The coronavirus pandemic exposed numerous deficiencies of the Canadian and US primary-care infrastructure. Because the system is overstretched with little to no surge capacity to deal with crisis situations, its reach is restrained due to over-reliance on brick-and-mortar clinics. Fully 70% of general medicine faculty in states like Michigan or provinces like Saskatchewan now work ‘part-time’, because it is the only way they can manage the explosion in work – in essence they are taking a pay cut in order to deal with what has become a full-time body of work.

(c) Care is overwhelmingly more reactive than preventive:  We all know that patients complain about not having enough time with their doctors. Even before the outbreak, primary-care physicians faced excessive patient load sizes in an environment of a workforce shortage. Without enough time to provide all the necessary acute, chronic, and preventive care for their patients, primary care physicians were forced to prioritize acute care.

(d) There are stunning disparities in access, quality, and affordability of primary care: Not surprisingly, patients in some areas received only half of all the recommended chronic and preventive care services. This is especially true in rural, inner city and vulnerable congregate populations where doctors are in short supply.

(e) Informatics infrastructure is inadequate for virtual care, clinician communication, and home-hospital care: Before the COVID-19 pandemic, doctors’ offices were slow to adopt communication strategies that leverage team-based care and technology, despite demonstrated benefits on quality of care. Individual practitioners were often forced to partner, and operated in silos with inadequate technology.

(f) Primary care, mental health, community-based organizations, and social services are increasingly underfunded and understaffed:  There are increased expectations from patients, regulators and specialists that practitioners will respond to messages, test results or requests instantly, participate in in-depth medical issue discussions with patients, and shift to on-line telemedicine. While infections are common, only rarely is there a pandemic with the morbidity and mortality of COVID-19.

(g) Uncertainty about the supplies needed:  With any new pandemic, the health-care system will not know the infection’s natural history, nor how to diagnose or treat the infection. As a result, practitioners will not have needed supplies. During COVID-19, they lacked tests (swabs, medium, reagents), personal protective gear (PPE), hospital beds, and ventilators. The unknowns and limited equipment constrained implementing the best primary care measures to address patient needs.

(h) Diversity of size, ownership and business models of practice:  Primary care is not a unified entity that can act together. Practices have a range of sizes, structures, ownership and business models, and populations that they serve. This variation influences any one practice’s ability to adapt during a pandemic.

(i) Financial stress:  60% of clinicians already report that burnout and financial strain is at an all-time high for them. Redesigning care requires significant investment. Worse, during the COVID-19 pandemic most primary care practices’ office visits were reduced by more than one-half. As a result, most practices furloughed or laid off a significant portion of staff—at exactly the time primary care was most needed. Practices feel financial pressure to prematurely resume “opening back up” for business as usual to make up losses and return to normalcy.

(j) Electronic health-care record keeping:  The electronic health-record systems demanded by governments and insurers eat up hours after the ‘work day’ in order to document diagnoses, orders and treatment authorizations. The burden has driven many primary care providers across the country to cut back their clinical schedule, just to make their work hours manageable.

(k) No national database for primary care:  Neither Canada nor the U.S. has a national resource or database for primary care where, when COVID-19 hit, we could go to understand the prevalence of COVID-19 in primary care. Where were we to go to understand which cities, provinces or states were being hit the worst? Or understand how practices are suffering and which practices are closing or what’s happening to patient volume? Experts say this needs fixing.

Re-Envisioning Primary Care Practice

The literature from insider experts documents rapid transformations and suggest the following principles to re-vision primary care:

(a) Adopt pre-visit planning strategies:  Pre-visit planning strategies such as triaging visit priorities, clinic schedule sweeping, and pre-visit screening of patients— once regarded as “nice-to-have” protocols — have been adopted as “must-haves” quickly and widely. These rapid transformations happening in health systems across the country, are born out of necessity and present an opportunity — a silver lining — to fix primary care.

(c) Accept more telemedicine:  Telemedicine has been indispensable in delivering non-face-to-face care to patients sheltered at home, while minimizing risks to providers. Before COVID-19, only 28% of US physicians were using telemedicine;5 today it is the preferred, if not dominant, method of delivering care. One downside uncovered in EthicScan future of primary care workshops is concern over the number of patients who book appointments with multiple practitioners, with intent to only keep the quickest appointment.

(d) Centralize population health services:  Practitioner office systems that have been flirting with centralizing their population-health services to improve care quality have accelerated their transitions to free up primary care physicians to handle the surge of COVID-19 patients. According to the Mayo Clinic, integrating telemedicine, patient-generated data, and preventive care into a retooled primary-care intake and care-optimization process which would be powered by humans and augmentable by artificial intelligence (AI) is both possible and achievable.

(e) Offer better comfort zone decision-making tools for patients:  Instead of trying to go over all of the odds ratios and statistics in the minute or two that primary care practitioner can allot for such discussions, studies recommend that practitioners give the patient their evidence-based, personalized recommendation, and then put the ball in the patient’s court by saying they’ll support whatever they decide. If the patient asks for more details, they can provide them.  In order to make this approach possible, primary care providers need more information at the time of care about how much any given treatment, screening or other intervention is likely to help that patient in particular, given their health history and risk factors. Such information needs to be at their fingertips, including in the computer systems they use during appointments, and a good sense of how much patient preference varies for each decision. This could flag for providers which patients fall into the “preference sensitive zone” for any given decision, so the provider can let them know the decision isn’t clear-cut and inform them about key factors that affect the decision.

(f) Promote acceptance of an enhanced telemedicine curriculum:  What practitioners need now is a high quality national telemedicine curriculum with strong ethical decision-making practical components (equity, privacy, empowerment, and duty of care) to be taught in residencies and medical schools, and made available to nurses, doctors, technicians, appointment secretaries, and other office staff.

(g) Cultivate and take advantage of patient-generated health data:  Tools such as Apple’s COVID-19 screening app, created with the Centers for Disease Control and Prevention, gather patient-generated data and help patients contextualize their symptoms and determine if they need to see a clinician. This approach of using patient-generated data to connect patients with the right level of care when, where, and how they need it could and, some argue, should be broadened to all primary-care intake processes. Integration of technology-assisted tools including symptom-checker apps, Web-based screeners, and wearable devices into health systems’ electronic health records (EHRs) may or may not (depending on the author expert consulted) hold promise to make the most of every encounter between patients and physicians.

(h) Prioritize and centralize preventative care:  Prevention will be ignored if not done between visits. The COVID-19 pandemic has led to a dramatic shift in operational priorities from improving general-population health and chronic-disease management to identifying patients with and at risk for the virus. Nearly all preventive care has been postponed and chronic disease management programs scaled back or put on hold. These inter-visit efforts require significant time and resources that are not currently available. The post-COVID-19 era presents a crucial opportunity to overcome the hurdles of culture change in a time when systems are pressured to re-imagine nearly all aspects of daily work. The alternative to prioritizing and centralizing preventive care is to exhaust our already overextended teams, asking them to catch up for lost time once systems emerge from this pandemic.

(i) Separate payment from documentation:  According to some experts, we have to be willing to fundamentally change our funding and payment systems such that they reflect the purpose and work of health care. Wellness, not procedures done or visit numbers. We need to dramatically change how health care is measured, how it is funded, and how it is held accountable. That is how health is won and lost among our population, and not the physician remuneration business model that we think best supports it.

Experts suggest we can’t pay primary care based on specific disease treatments. Primary care sees all diseases– all people, from prenatal to when they pass away. We have to understand that internal medicine, family medicine, pediatrics and related fields are critical to the foundation of a generalist discipline that we call primary care. All the interventions and transformations that administrators have been working on so hard for the last decade to fix primary care fell out the window when COVID-19 hit because they were based on specific treatment payment models.

(j) Take advantage of Interval roadmap planning:  In the U.S., the CDC has developed an interval-process roadmap for optimal primary care. During a pandemic, the quicker that public health and primary care can identify each interval, the quicker they can transform care to protect patients and communities. Monitoring, early identification, and preparation for rapid, early action are essential to prevent exponential spread.  As the pandemic progresses, primary care will need to sustain activities in prior intervals and add in the new activities for the next interval. Different communities will experience intervals at different times and with varying severity. Some intervals happen simultaneously, and some repeat. This means local tailoring is needed, based on local events and needs.

Conclusion:

Much has been written that primary care must retool to meet the ongoing challenge of COVID-19 and emerge in the post-crisis world better equipped to care for a wounded and suffering nation, including battered primary-care physicians and nurses. Although issues of over-burdened providers, workforce shortage, and disparities in access, quality, and affordability of care will not disappear after COVID-19, we can use tools and prescription changes such as telemedicine, pre-visit planning, new patient advice models, and population-health management — powered by humans and artificial intelligence — to expand primary care’s effectiveness and reach in all communities, increase system capacity and visit efficiency, and prioritize prevention to keep patients healthy.

The COVID-19 pandemic taught us valuable lessons. Experts urge us not to squander this opportunity to make primary care better.

Further Reading:

The National Center for Biotechnology Information – Redesigning Primary Care to Address the COVID-19 Pandemic in the Midst of the Pandemic:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7358035/

Canadian Medical Association – Re-opening your practice during COVID-19:
https://www.cma.ca/re-opening-your-practice-during-covid-19

EthicScan Blog – Wither Primary Care, During and After the Virus:
https://ethicscan.ca/blog/2020/06/12/wither-primary-care-during-and-after-the-virus/

The Mayo Clinic – Retooling Primary Care in the COVID-19 Era:
https://www.mayoclinicproceedings.org/article/S0025-6196(20)30760-6/fulltext

M Health Lab – Primary Care at a Crossroads: Experts Call for Change:
https://labblog.uofmhealth.org/rounds/primary-care-at-a-crossroads-experts-call-for-change

Medical Economics – Primary care crisis: How to build the practice of the future:
https://www.medicaleconomics.com/view/primary-care-crisis-how-to-build-the-practice-of-the-future

The Lancet Public Health – Diagnosis of physical and mental health conditions in primary care during the COVID-19 pandemic: a retrospective cohort study:
https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(20)30201-2/fulltext

CBS – Primary Care Doctors And Clinics Face Worrisome Future Due To Long-Lasting Impact Of Coronavirus Pandemic:
https://newyork.cbslocal.com/2020/08/20/coronavirus-covid-19-primary-care-physicians-health-clinics-clifford-marks/  VIDEO

Ochin – Transforming the Structure of Primary Care Post-COVID Pandemic:
https://ochin.org/blog/2020/8/13/transforming-the-structure-of-primary-care-post-covid-pandemic

Healthy Debate – The future of emergency care: Takeaways from COVID-19:
https://healthydebate.ca/opinions/emergency-care-takeaways-covid

David Nitkin
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