The COVID-19 pandemic has illuminated weaknesses of many practices and the healthcare system at large.

As part of the Medical Group Management Association’s Medical Practice Excellence Pathways Conference, Kem Tolliver, president and CEO of Medical Revenue Cycle Specialists, laid out some areas leaders can review in their own practice to ensure they can weather disasters like the pandemic.

Business continuity and planning for disaster

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MGMA

Six things practice leaders should review in their organization.

Master your revenue cycle

The COVID-19 pandemic put many practices in financial distress because of dropping patient volumes, but poor revenue cycle management practices exacerbated the problem. These challenges illustrate how RCM must be quick and efficient for a practice to survive and thrive.

Matt Seefeld, executive vice president and head of revenue cycle for MedEvolve, spoke at the Medical Group Management Association Medical Practice Excellence Pathways Conference about what every practice needs to be doing to master its RCM.

The reality post-COVID requires new strategies.

Burnout is a growing problem in the medicine, especially for women.

Connie B. Newman, MD, FACP, adjunct professor of medicine at NYU Grossman School of Medicine, spoke at the American College of Physicians Internal Medicine Meeting 2021 about 10 of the reasons women in medicine experience burnout at higher rates than their male colleagues.

Here are the reasons in no particular order:

Top Ten Factors That Contribute to Burnout in Women Physicians

Women in medicine experience more negative effects than their male counterparts.

Kimberly Manning, MD, FACP, has used both her own life lens as a black woman in America to aid in treating her patients, but she has expanded that lens through interaction with her diverse colleagues.

Manning, professor of medicine at Emory University School of Medicine, spoke about her experiences as part of a plenary during the American College of Physicians Internal Medicine Meeting 2021.

She began her discussion by describing how her own background as a descendant of U.S. chattel slavery affected her own journey to becoming a physician. She described how the Abraham Flexner report of 1910, which retooled medical education in the country, actually closed five of the seven historically black medical schools which produced between 80 and 100 new physicians a year. This lack of opportunity has led to the loss of a potential 50,000 Black physicians over the past 110 years.

“So, when asked how do we reach a point where we have 38,975 full professors in U.S. medical schools, of which 307 are black woman, there's no shock,” Manning said. “The numbers play out because of the system and the system does exactly what it was designed to do.”

She said that proximity to those who are under-represented is to humanize them by broadening one’s life and looking beyond their own lens of experience.

Manning told a story of early in her career when she saw a Black patient who had been diagnosed with colon cancer but was adamantly opposed to even discussing surgery. Her colleagues were mystified by it, but she thought back to the medical myths she had heard amongst her own family members about cancer spreading when exposed to the air.

“Much of that has to do with health disparities, this lack of access to care that by the time people got into care, cancers had already metastasized and had no opportunity to be caught early,” she said.

When she spoke to the patient, Manning said she found his mannerisms reminded her of her father so she spoke to him directly without code-switching, or adopting an affectation to blend in, like she normally did in professional situations. After the two talked and shared some laughs, the man asked her directly if he believed he should get the surgery and she told him it would save his life. The man ultimately left the hospital fully recovered.

Manning also told stories about how her interaction with a diverse group of physicians helped expand her lens by informing her on other cultural attitudes. Whether it was being more respectful to the patient’s religious beliefs or helping celebrate a patient’s birthday with a song in their native language, expanding a life lens has benefitted patients.

“Our stories are life lenses, the humanity of each individual and value of each patient, each colleague, each interprofessional team member is what will help get us there,” Manning said. “It is the thing that will ignite us to move toward rebuilding those structures and opportunities.”

Kimberly Manning, MD, FACP, shared how her own life lens and what she learned from a diverse work environment helped to enhance the care she provides.

Expanding your life lens to enhance patient care

Instead of focusing on weaknesses and problems, what if you shifted your mindset to focus on what is working well and keep building on that to build both personal and organizational success?

Marion McCrary, MD, FACP, clinical associate in the Department of Medicine, Duke University, gave a presentation at the American College of Physicians Internal Medicine Meeting 2021, outlining the steps to using the appreciative inquiry process to do just that.

How to use appreciative inquiry to fuel success

The 5-D strategy can keep you focused on the positive to build personal and organizational success.

The American College of Physicians (ACP) has released a new policy aimed at improving the existing health information privacy framework and expanding similar privacy guardrails to entities not covered by current laws and regulations.

and is titled “Health Information Privacy, Protection, and Use in the Expanding Digital Health Ecosystem: A Position Paper of the American College of Physicians.” It lays out principles and recommendations for health information privacy, protection, and use.

“Health information technology and electronic health records systems surely possess the power to enhance the patient-physician relationship and value of care tremendously,” Jacqueline W. Fincher, MD, MACP, president of ACP, says in the release. “Patients being able to track their glucose levels, schedule an appointment, and easily access their latest records online are all just a small window into the opportunity digital health technology provides -- all of which requires a great amount of trust for all parties involved.”

The policy principles laid out in the paper are below as they appear in the release:

Principle 1: ACP believes that protecting the privacy and security of personal health information collected both within and outside the health care system—while providing individual rights to that information—is essential for fostering trust in the evolving digital health care system, maintaining ethical standards and respect for persons, and promoting the safe delivery of health care.

Principle 2: ACP supports increased transparency and public understanding and improved models of consent about the collection, exchange, and use of personal health information within existing HIPAA rules as well as for entities collecting, exchanging, and using personal health information outside the health care system.

Principle 3: ACP believes that the confidentiality of personal health information is a fundamental aspect of medical care, and physicians and other clinicians have an obligation to adhere to appropriate privacy and security protocols to protect individual privacy.

Principle 4: ACP believes that health IT and other digital technologies, including personalized digital health products, should incorporate privacy and security principles within their design as well as consistent data standards that support privacy and security policies and promote safety.

Principle 5: ACP supports oversight and enforcement to ensure that all entities not currently subject to HIPAA rules and regulations and that interact with personal health information are held accountable for maintaining confidentiality, privacy, and security of that information.

Principle 6: ACP believes that new approaches to privacy and security measures should be tested before implementation and regularly reevaluated to assess the effect of these measures in real-world health care settings.

The organization is making proposals to improve the existing health information privacy framework and expand similar privacy guardrails to other entities not covered by these laws and regulations.

ACP calls for improved privacy protections

Recognizing implicit bias in decision making not only improves the quality of care for patients from historically marginalized groups, but helps doctors improve their diagnostic accuracy.

That was the message Denise Connor, MD, associate professor of clinical medicine at the University of California-San Francisco, delivered during the virtual session “Improving diagnostic reasoning: recognizing and addressing errors from implicit bias in patient care” on day one of the American College of Physicians Internal Medicine Meeting 2021.

“Implicit bias can affect our judgments and decision-making as clinicians, which can lead to disparities in health outcomes,” Connor said. “That’s especially true when we’re in realms that are complex, when we’re under time pressure and when we’re operating outside of established relationships,” she said.

Achieving better diagnostic accuracy depends to a great extent on communication skills, Connor added, because “99% of diagnosis is in the history, so our relationship and ability to communicate with them is critical to diagnosis accuracy.”

Moreover, patients often evaluate the overall quality of the care they receive based on their perception of communication quality, which in turn affects their level of engagement. In particular, Black patients being treated by White providers are more likely to respond positively to a collaborative communication style. “So communication becomes even more important when we’re communicating across differences,” Connor said.

Connor offered a variety of tools clinicians can use to improve diagnostic communication, starting with “cognitive reappraisal” the idea that reframing negative experiences in a positive way is better than trying to ignore or suppress them. 

“Reappraisal has been shown to increase positive emotions and benefit relationships, facilitate empathy and increase our ability to take in new information,” she said. In contrast, trying to suppress feelings caused by negative experiences can lead to problems with interpersonal relationships, reduce our ability to take in information, and even increase patients’ stress levels, she said.

Another helpful technique is to acknowledge feelings of fear or anxiety before treating a patient. “Just saying ‘I’m feeling anxious’ out loud before going into a patient’s room can be a positive thing,” she said. “To name it is to tame it.”

Engaging in mindfulness and stress reduction before potentially stressful patient encounters has been shown to reduce discriminatory behaviors and levels of bias, according to Connor. These can be as simple as engaging in moments of “’grounding gratitude’ for the trust patients are placing in you, or a mindful breath. Those quick actions can make a big difference in how the interaction goes,” she said.

Finally, empathy is a powerful tool in overcoming bias and improving communication, but it is “context-dependent,” Connor said. “We are more likely to feel empathy for someone we see as part of our own group versus someone we don’t identify with. So we have to ask ‘how can we reframe our relationship with a patient as a partnership so we feel like we’re both in the same group?’”

Connor noted that trying to overcome implicit bias and improve diagnostic communication has benefits that extend beyond patients from historically marginalized groups.“

Connor noted that doctors’ extensive training, specialized language and other attributes lead to communication challenges with all patients, regardless of their background. Consequently, “if we think about how to improve experiences for groups that historically have been marginalized in health care, those same interventions are going to benefit all our patients.”

Recognizing implicit bias in decision making helps doctors improve their diagnostic accuracy.

The link between diagnostic reasoning and implicit bias in patient care

Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases (NIAID), says that addressing disparities in healthcare access disparities will likely take decades.

Fauci was taking part in a question-and-answer session during the opening plenary of the American College of Physicians (ACP) Internal Medicine Meeting 2021 along with Gregory Kane, MD, treasurer of ACP; and Darilyn Moyer, MD, executive vice president and CEO of ACP.

He said the pandemic has shown a bright light on the inequities of the healthcare system, particularly in the rates of hospitalization seen among racial and ethnic minorities. According to Fauci, these inequities are tied to social determinants of health which sees Black, Hispanic, and Native American citizens put into educational and economic situations which limit their ability to receive medical care.

“We have to start committing now to something that's going to take decades to change,” he says. “Because it took centuries to get here, it’s going to take decades to change. But if we don't make the commitment now to do it, we're never going to do it.”

When asked whether COVID-19 could be eradicated globally, Fauci seemed more confident that it will be eradicated in some countries and controlled in others, but the process will take years and vaccinating a large portion of the world’s population.

“We're going to be continually threatened by variants that will come from other countries, which tells us the obvious solution to that is to make sure that we get the entire world vaccinated against (COVID-19),” Fauci said. “Until we do that, I don't think we're going to eliminate this infection. I think it'll be there at a low level; we'll be protected. We may need to get boosted every once in a while, to keep the level of protection up. But we have to look at it as a global problem, otherwise, we're never going to truly eliminate it.”

Fauci said that early in the pandemic the U.S.’s response was hamstrung by the dismantling of the local health infrastructure, failure to mobilize the private sector early for diagnostics, and the rapidly evolving situation with little transparency from China.The transmission method of the virus also caught the world by surprise.

“We've never had any pathogen of any note of seriousness in which … 50 and 60 percent of the transmissions occur from a person who never will get symptomatic, or who was in the pre-symptomatic stage,” he said. “That broke all the paradigms of infectious disease because, prior to that, transmissions were always a little bit asymptomatic but dominated by the symptomatic person.”

As for the U.S.’s successes in responding to the pandemic, Fauci highlighted the Trump administration’s Operation Warp Speed which invested billions in vaccine development and pre-purchase as well as the Biden administration’s rollout of the vaccines.

The NIAID head said the COVID-19 pandemic has highlighted the need to address social determinants of health.

Fauci: Addressing healthcare access disparities will take decades

While the government has eased many restrictions on telehealth visits during the COVID-19 pandemic, practices still have to carefully plan their workflows in order to make the most of such visits.

That was the message from Reena Mehta, MD, a New Orleans-based allergist and immunologist and a presenter at a virtual session on telemedicine during the annual meeting of the American Academy of Allergy Asthma & Immunology.

“It’s got to be efficient, it’s got to work for your practice and it’s got to be streamlined so you can get patients in and out virtually and continue the flow of your practice,” Mehta said.

The first step is deciding if a visit is suited for telemedicine. “Basically, it’s a good fit for a patient that doesn’t want to come into the office and seems relatively uncomplicated. Not every visit requires a detailed physical exam,” she said. Conversely, visits that require significant procedures or that involve risk to the patient can’t and shouldn’t be done via telehealth.

Mehta has trained her staff to recognize when a patient is a good candidate for a telehealth rather than an in-person visit, and often uses pre-clinic huddles to get their input. She also provides a script for front office staff to screen patients calling for appointments as to their suitability for a telehealth visit.

Another workflow decision is whether to designate a block of time each day exclusively for telehealth visits, or to mix virtual visits with in-person. The latter route requires training staff to know when the doctor is most likely to have time in their schedule that can be filled by a telehealth visit.

“If your staff is well trained you should be able to crank these (telehealth) patient out and keep your workflow going smoothly,” she said.

When starting out with telehealth Mehta advises scheduling the same amount of time for a telehealth visit as an in-person visit, then adjusting visit lengths as needed. She cautioned that it’s important to have patients log on at least 15 minutes before the start of the appointment so staff members can address any technology issues, such as a patient with a bad internet connection or who’s unfamiliar with the technology.

Mehta said lab result reviews are the most common telehealth visits in her practice,since they don’t require face-to-face contact. Through screensharing, patients are also able to view the results with her simultaneously and ask questions about them.

As with in-person visits, proper documentation is key to getting paid for a telehealth visit, Mehta said. While verbal consent is all that’s been required during the pandemic, getting both verbal and written permission is considered best practice. Other documentation elements include:

The type of technology used, i.e. whether synchronous audio/video or audio alone

Where the patient is physically located and where the provider is located

Language specifying that the care was provided by telemedicine or telecommunication during the COVID-19 pandemic

The amount of time spent providing services

Mehta noted that under current law most of the changes to the rules governing telehealth visits would expire at the end of the public health emergency the nation is now under. “It remains to be seen if the changes in technology, regulation and reimbursement for telemedicine will be maintained long term,” she said.

AAAAI

Practices still have to carefully plan their workflows in order to make the most of such visits. 

AAAAI Annual Meeting: Making the most of a telehealth visit

As the COVID-19 coronavirus pandemic continues to rage, more and more practices have turned to telehealth to continue caring for patients.

Mike Tankersley, MD, MBA, of the University of Tennessee, gave some tips of how to prepare for a telehealth visit to cut down on confusion and stress for the patient and your staff as part of the session “Expanding Your Practice: Clinical, Administrative and Reimbursement Strategies for Success,” on Feb. 26 as part of the digital American Academy of Allergy Asthma & Immunology (AAAAI) Annual Meeting.

The ideal patient for a telehealth visit is returning patient, particularly for a follow up visit. For this patient, the physician should discuss with that patient at the end of their visit whether the follow up or next visit should be in-person or held using telehealth. Tankersley says he then lets the front office staff know and the next visit is booked as taking place over telehealth.

When it comes to using telehealth with a new patient, Tankersley notes that it’s best used when dealing with patients who are distant from the practice or if a patient would normally have to cancel their appointment due to unforeseen circumstances such as the severe weather that affected much of the country at the end of February.

“I'm in the city of Memphis, but if I want to set up a satellite clinic in Jackson, Tenn., an hour and 15 minutes away, I don't have to rent out space into a brick-and-mortar space,” he said. “I basically can set up a virtual satellite clinic and see patients who were there that don't have to drive the hour and 15 minutes to my office in Memphis.”

In preparation for upcoming telehealth visits, Tankersley says that every Friday at his practice they look over the next week’s schedule and send out templated emails to patients scheduled for telehealth visits which contain the time of the appointment and a link. He recommends the first or last appointment of the day for solo physicians.

Tankersly also has his staff collect any payment for the appointment beforehand. With patients he has already seen, he has them collect payment at the time they schedule the telehealth appointment, with new patients he has them call the patient the morning of the appointment to collect payment.

Another tip Tankersley gave was to create a mechanism so that the appointment starts on time in order to keep patients from being left staring at a computer screen waiting.

“Whether you set a timer, you got somebody in your office that's designated to kind of remind you, hey, Dr. Tankersley, your telemedicine’s in five minutes; just have some mechanism to remind yourself that that your telemedicine is live because the patient's not going to be in your clinic, letting everybody know that they’re there,” he said.

Mike Tankersley, MD, MBA, discusses workflow tips that can help practices in their use of telehealth visits.

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