The second largest U.S. medical specialty society announced today a plan to reinvent family medicine by using as agents of change the ubiquitous deployment of healthcare information technologies as well as retooled and IT-intensive residency and continuing medical education programs.
The 97,000-member American Academy of Family Physicians and six organizations related to the specialty issued a 30-page blueprint, "The Future of Family Medicine," published in the Annals of Family Medicine.
"The focus of this was to find out the wants and needs of the American people and find out what we could do to meet those needs," said AAFP President Michael Fleming, M.D.
There were no foregone conclusions when the association hired independent consultants to do much of the survey work that informed the report, Fleming said.
"It was a huge risk to do this at the depth that we did it," he said. "We may have found out that we're totally irrelevant, or that we're relevant to only take care of the poor and underserved.
"What we heard was the people wanted was this model of care," he said.
Not that the 40-year-old specialty doesn't face serious troubles. The report shows a near 50% decline since 1997 in U.S. medical school graduates taking placement in some 400 family medicine residency programs.
Their disinterest has contributed to a "steady and progressing decline" between 1980 and 1999 in the percentage of U.S. physicians who specialize in family medicine.
In addition, net income for physicians has slid in many fields, but "more so for primary care physicians than for specialists," the report said.
Still, the report notes that Americans favor receiving care from a physician who knows them. They assume they will receive quality of care from their physician, so they rate their healthcare experiences not on quality but on relationships, and they rank family physicians highly in that regard, the report said.
Family physicians were rated either excellent or very good by a clear majority of survey respondents, it said.
The recommendations of five physician-led task forces were compiled by an executive committee to create what report authors call "The New Model," a description of a practice style that draws heavily on the 2001 Institute of Medicine report "Crossing the Quality Chasm."
The recommendations also were based on surveys of more than 1,000 patients, 300 family physicians, 175 parents, 75 nonprimary-care specialists, 75 academic physicians, 250 medical students and residents, and more than a dozen focus groups with various healthcare constituents.
The report repeats the IOM call to create a patient-centered "medical home" for all Americans, with family physicians as the coordinators of care.
It calls for arming family practices with standardized electronic information systems and availing practitioners of a "vibrant process of evidence-based review and practice-based research to define the most up-to-date guidelines for clinical practice." The report also calls for a data-driven, career-long physician self-assessment system "to allow physicians to receive timely feedback regarding both their personal skills and their practice outcomes in comparison with their peers."
A sixth task force will report to the AAFP later this year on methods of financing the changes through reimbursement arrangements with private payers and the government.
Fleming said the AAFP's Center for Health Information Technology, headed by David Kibbe, M.D., will be a key resource in the academy's IT plans.
Only about 10% of family physician practices use EMRs today, Kibbe estimated. To speed deployment, the academy is calling for all family physician residency programs to have EMRs by 2006. About one in five have them today, according to Kibbe.
There has been no decision yet on setting up a data center within AAFP to perform the practice-level data-crushing recommended by the task forces, and there have been no estimates of the cost of this function, Kibbe said.
"We have pretty significant information technology resources within the academy right now," Kibbe said. "It's not that we'd be starting from scratch. But we also know there are other people who do this very well within the healthcare community and outside the healthcare community. The likelihood that we?ll be partnering with someone is very high."
Kibbe said he takes 100 emails and phone calls a day from members requesting information about IT. And while there is significant evidence that even small groups can benefit financially from selecting the right IT system -- if they do their homework and prepare themselves to take advantage of it -- cost is still a big issue, he said.
"Primary-care physicians in this country are at the very bottom rung of income and are seeing their margins getting even narrower due to increased cost," Kibbe said. "So I think it's important that other stakeholders who get a benefit from information technology getting a larger foothold in the world should share in the cost of it."
Both Fleming and Kibbe said they are skeptical the government will be of much help in financing IT deployment, but it's an issue the sixth task force will address later this year.
In addition, Fleming said insurance companies and employers ought to reexamine where their money is flowing for disease management. Fleming said insurance companies, which now use outside DM providers, would do better if they paid family physicians patient management fees for DM on top of their regular fee-for-service payments.
"Why would you pay somebody else when we're the experts," Fleming said. In other countries, the national health services pay the salaries of nurse educators to be in the offices of family physicians helping with DM services, he said.
Again, IT at the group level will be key to making the DM transition.
"I think we can find a way to build the infrastructure within the small physicians office," Fleming said. "I think there has to be some stimulus to make that happen. If we could work with insurance companies and Medicare to provide a patient management fee on top of fee for service for doing all the management things, we could do that.
"We know that every other healthcare system in the world that works well is based on a primary-care-centered network," Fleming said. "We think we need to do exactly the same thing."
Yet the fate of the specialty of family medicine, according to Fleming, may well hinge on what its practitioners do next.
"We've got to take this report and take these recommendations and make it happen," said Fleming, the managing senior partner of the Family Doctors, a 10-physician group practice in Shreveport, La. "If we don't go forward, we deserve whatever happens to us."
