Sunday, January 06, 2013

We Don’t Have a Shortage of PCPs, We Have a Shortage of Using Them Efficiently

I've been asked to serve as the "Innovator-at-Large" (aka Editor-at-Large) for the magazine "Clinical Innovation and Technology"... which I was happy to accept as it's the perfect intersection of my worlds!.   In my first post, I've expanded on a phrase I've been using for several years - that "We Don’t Have a Shortage of PCPs, We Have a Shortage of Using Them Efficiently".   I go on to describe the future of healthcare in a world where innovation and IT are being used to their potential to make life easier for physicians and better for patients (of course assuming our reimbursement system equally evolves).  I hope it inspires you!

We Don’t Have a Shortage of PCPs, We Have a Shortage of Using Them Efficiently

Every few months another study warns of a severe shortage of primary care physicians (PCPs) in the future. A recent report published in the Annals of Family Medicine explained how we will require 52,000 more PCPs by 2025 due to population growth, aging demographics and insurance expansion (Reference: 1. Ann Fam Med  2012;10(6):503-509).

Fortunately, both clinical IT and innovation will deeply change medicine over the next decade, resulting in a new paradigm with the potential to improve both efficiency and quality of care. In this paradigm, software will be able to automate or delegate much of the routine care usually provided by physicians. If automated systems and empowered staff members manage stable patients according to evidence-based protocols, physicians can focus on more complex patients who truly require their attention. Individual physicians will actually see fewer patients, but oversee a team who will care for more patients. Thus, we won’t need more physicians; we will just need a better system to help most appropriately leverage physicians, staff and IT.

A typical physician’s office in 2025 might look something like this: Dr. Blake Willoca arrives around 9a.m. and sits in front of a bank of computers and video screens. Dashboards provide real-time analysis of the status of his panel of 5,000 patients. Patients in the Green Zone will be managed mainly by computerized systems which check on patients virtually to provide positive feedback and ensure they stay on track. Meanwhile, patients in the Yellow Zone will be visited by the physician’s care team at home or work, or perhaps have a virtual conference with the physician to answer their questions. Finally, those patients in the Red Zone will be seen in the office or home for longer sessions with the physician and his or her care team to help determine what is going on and how to get it under control. Today, Dr. Willoca will spend an hour with each of these four Red Zone patients in his office, he will do five-minute video conferences with staff members taking care of 20 Yellow Zone patients, and he will spend some time in a virtual reality game teaching med students about how this new system works. As Dr. Willoca leaves his office at 5p.m., he knows he’s helped the patients who most needed it today in a relaxed and livable manner, and he knows that his IT tools and care teams will continue to monitor and help manage his patients 24 hours a day.   

This might all seem like a PCP’s dream, but we need to recognize and accept that we are the generation who will make this happen. There is much to do in healthcare, and there could not be two greater tools to use than clinical innovation and IT.

Online at

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.
* What Doctor Shortage?  Published in Medical Economics (Jan, 2023) - I revisited this topic 10 years after the original post and talk more about the execution of expanding panel size via a combination of technology and virtual team-based care.  This is playing out in real life with my new company  KeyCare (where we provide health systems access to a tech-enabled virtual care workforce practicing on an Epic platform optimized for telehealth).

1 comment:

  1. Anonymous7:29 PM

    Dr. Berkowitz,

    I feel it would greatly help non-clinicians understand the potential of the model you've outlined if you would quantify the # of people who typically fall in each of the zones you've suggested. My hunch is that most people assume a greater # of "red" and "yellow" zoners than is in fact typical of most physicians' practices.