Primary care’s inevitable reboot [PODCAST]

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“The tech giants of Silicon Valley – love them or hate them – have put incredible personal technology tools into homes and pockets of our patients and their caregivers. Now, we must activate those instruments for our own sustainability, and for our patients’ benefit.

If the neighborly primary care practice is going to survive, we must embrace a more comprehensive and connected health data usage program reassuring patients that we truly know them and are properly equipped to assess future risk. Because that daily frappuccino could be doing more harm than good – and that’s data your doctor can use.”

Paul Helmuth is an internal medicine-pediatrics physician.

He shares his story and discusses his KevinMD article, “The inevitable reboot of the primary care experience.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow.

Today on the show we have Paul Helmuth. He is an internal medicine-pediatrics physician. His KevinMD article is titled “The inevitable reboot of the primary care experience.” Paul, welcome to the show.

Paul Helmuth: Thank you.

Kevin Pho: We’ll get to the article in a little bit. First off, just share your story and journey to where you are today.

Paul Helmuth: Great, thank you, and thanks for having me. I’m a primary care physician in western Massachusetts. I’ve been here since I finished my training in the ’90s, and actually, five of us who all finished our med-peds training together in Springfield started our practice together at that time. We like to say we had more doctors than patients when we started our practice, and we really are still there, more than 25 years later.

Things have changed, obviously. We now work with more nurse practitioners and physician assistants in our practice, and we’ve become part of an ACO, some things that weren’t the case 25 years ago when we started our practice. But I’ve been really interested in population health management. It started out as that move toward pay for performance that started years ago, when the insurance company said, “Hey, we’ll give you a little more money if you do better on your mammogram rates or your blood pressure control.” We realized that the best way to do that is with technology, and so we were early adopters of electronic health records, and that’s really been an interest of mine.

I worked as a director of ambulatory quality for our local health system, and now I am working at a health IT startup that is doing care management and remote patient monitoring, as well as continuing to see patients in my practice.

Kevin Pho: And we’ll talk more about that in your KevinMD article. But first off, I want to ask: There were five of you after residency, and you are still there 25 years later in primary care, which is actually one of the most challenging fields of medicine. What are some of the keys to your longevity, that the five of you stayed together after all this time?

Paul Helmuth: To be fair, two of my colleagues have retired, but three of us are still there, and we’ve had a few other physicians join us over the years. But I think one of the important pieces for us has really been adaptability. The practice of medicine is completely different now for us than it was then. We had paper records. We barely had a practice management system. We didn’t really have interactions with other practices, other than sort of sending letters back and forth to consultants. Now we have a much more integrated system, and we have to share our electronic data with everyone from the government to other payers to the local hospital system. So the practice of medicine, and even the interaction with our patients, is completely different. If you don’t adapt, I think it’s hard to keep moving in the same way. For sure, that, I think, is the biggest thing for us.

Kevin Pho: All right, so I’m interested in hearing more about that intersection between technology and population health management. You write more about that in your KevinMD article, “The inevitable reboot of the primary care experience.” Now, for those who didn’t get a chance to read the article, can you just walk my audience through it and share the story of why you decided to write it?

Paul Helmuth: Yeah, I really got the idea from a patient. I was speaking to a patient who has relatively complicated cardiac disease, and for some insurance reasons, he was admitted to a hospital across town, not in another state but just literally across town. A few weeks later, when he got back to his cardiologist’s office, the cardiologist didn’t have the records or the information. A number of diagnostic tests had been done, and the patient was given some new medications, and the cardiologist was sort of frustrated, like, “Why did they change that? Why are you on that medicine?” The patient was telling me he almost felt like it was his fault, that somehow he was responsible to defend the actions that happened in the hospital.

Then at that point, he said to me, “You know, I feel like Amazon knows what book I’m going to buy before I do, and yet my cardiologist doesn’t know what happened across town at the hospital.” It occurred to me then that we are really so far behind, in many ways, at figuring out how to ingest, aggregate, and analyze the data that is coming into us about our patients.

Sometimes it’s information that’s just plain old diagnostic tests and labs we know how to interpret, and sometimes it’s new things. My patients come with wearable devices and ask me to look at the graph of their sleep, and that’s new information I don’t really know what to do with yet either. But there’s more and more data out there, and we need more tools for physicians and for patients to be able to understand and analyze that in a way that takes work away, rather than feeling like it adds work to what we’re doing.

Kevin Pho: Now, for those patients who may be listening to this podcast, they may not be aware of what goes on behind the scenes. What is the genesis of some of these obstacles? Why is it so difficult for electronic medical records to not talk to one another? We have all these problems with interoperability.

Paul Helmuth: Yeah, I think one of the big barriers, honestly, has been that there hasn’t been a big incentive for many years for electronic health record companies to share their data. If I could just take my data and move it to a different electronic health record, then why do I stay with the one I’ve got? So I think they’ve had plenty of incentive to make it hard for us to have interoperability, but obviously there are some government policies that have moved further in that direction.

But then it’s expensive. Who pays for it? If we’re going to send data from this place to that place, that’s going to cost money for us to figure out how to build the electronic bridges to make that happen, and bridge builders are expensive, and nobody really wants to pay for those things.

I think the last barrier is really patient confidentiality and privacy. There’s a lot of concern about how we connect information across systems in a way that allows patients not to feel like their data are just being shifted around without their ability to control it. Sometimes I think that’s one of the biggest barriers: that people feel very worried that they’ll be at risk for sharing information. It ends up that, whatever the different barriers are, it’s still really difficult sometimes for a primary care physician, or even for a specialist, to know what happened across town, and that’s a big problem.

Kevin Pho: So what are some of your proposed solutions to these problems you talk about?

Paul Helmuth: Yeah, it’s a good question. I think one of the things we have to do is probably continue this journey we’re on in figuring out how we aggregate data and use that to gain insights for physicians and for patients. We need to kind of move past some of these barriers, and I think there’s some great light at the end of the tunnel there. I think the Cures Act and some policy changes that have really given incentives, and honestly disincentives for not sharing information, are going to help us move forward.

But once we start sharing information, we do need the ability for our electronic systems to help us figure out how to gather those data and put them in front of us in ways that are helpful. I’m hopeful that, as there’s more and more focus on things like the patient experience and on physician burnout, those tools become more readily available for patients and physicians to help make those connections.

Kevin Pho: Now, is there anything that patients can do themselves? Because they may go to different systems when they cross borders, and sometimes those electronic medical records don’t talk with their primary care doctor’s electronic medical records. What can patients do to help with these interoperability problems?

Paul Helmuth: That’s a good question. I have a lot of patients who will always ask for an electronic version of their data, and it is often helpful. Sometimes I’ll get a disk or something I don’t even know how to download or use, so it doesn’t always help, but it is helpful. The other really important thing is just for them to say, “This is my primary care doctor. Can you make sure that you send the records there?”

In our state, in Massachusetts, I have to say, we have some major medical centers and big systems, all of whom are sort of competing for that tertiary care work. They’ve gotten better, I think, realizing over the years that one of the reasons that we refer patients is because we get good communication back, and if they don’t continue to keep that happening, then they’re not going to continue to be in the marketplace. I do think there are some market pressures, happily, especially in some regions, which are really pushing people to do a better job of sharing information. But I think for patients, just reminding their providers that they all need to talk to each other is still important.

Kevin Pho: Now, like you, I’m a primary care physician. I do internal medicine primary care, and of course we’re all inundated with data from all over the place right now. You have remote patient monitoring. You have patients getting their own data and sending it to us. So as a primary care physician yourself, how do you manage all this data? How do you wade through it and make sense of it?

Paul Helmuth: It’s a great question, and I’m not sure I have the right answer to it exactly. I think one of the things that we’ve really tried to do in our practice, and that we’ve really tried to champion in my job at the health IT startup, is this idea of team-based care and finding ways to engage an entire team of people to help with this.

So for example, in the case of remote patient monitoring, in my practice we have one physician assistant who sort of owns that program. I refer a patient for hypertension management. The patient gets a blood pressure cuff, the readings come into the system, and that PA has dedicated time to make sure that she looks to see what people’s blood pressure readings are. She looks at the monthly reports: This many blood pressure readings have been in range; this is the average blood pressure. She calls the patient, she does a telehealth visit, and she titrates the medication. I don’t do anything with that, except that when I see that patient for their annual visit or for their blood pressure follow-up, I can see all the data that’s there and the information on what’s happened.

We have a clinical practice guideline for blood pressure management, so we’re all talking the same language. I think that makes a big difference. Having a team that is all using the same playbook, to the extent that we can, really helps to improve that sort of trust across practitioners in an organization. I know the nurse practitioner, the physician assistant, or my partner is working from the same playbook I am, and I trust them to help do this. Then patients start to feel more trust in the system, if they realize we’re all sort of talking the same game and agreeing with each other on the treatment strategy. It sort of falls apart when we don’t, when we sort of wonder in front of a patient why somebody did something. Then our patients really, I think, lose trust in that team-based care, and it’s really hard to reestablish.

Kevin Pho: We’re talking to Paul Helmuth. He is an internal medicine-pediatrics physician. His KevinMD article is titled “The inevitable reboot of the primary care experience.” Paul, what do you see are some of the biggest trends going forward when it comes to primary care?

Paul Helmuth: You know, I think one of the things that I saw just a few weeks ago, which I guess I was a little shocked by, was that I had a patient who was on my schedule for COVID. I was doing a telehealth visit, and it would be to discuss antivirals. He had called the office at, I think, like 9:30 in the morning and was seeing me at 2:30. By the time I saw him, he had already had a telehealth visit with somebody from CVS and gotten his Paxlovid antiviral prescription for COVID already done. Then he said, “Well, I just kept the appointment because I wanted to make sure you’re aware.”

But what I was sort of surprised by was how rapidly what people sometimes call disruptors in the marketplace are really expanding, and how patients are really looking for that good consumer experience. They don’t want to wait for us. They want to have convenience and the ability to access care. I think that’s going to be an interesting challenge for us in primary care and in specialty care, to figure out how we can really deliver the services that our patients are expecting.

I think we’ve made a lot of progress with this explosion of telehealth and virtual care that’s happened through the pandemic, and with some of the policy changes that have allowed for that. But I think there’s availability of clinical care for our patients 24 hours, seven days a week, that we need to figure out how we’re going to interact with or compete with. I do think that’s one of the interesting things for us to look at moving forward.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Paul Helmuth: That’s a great question. I think one of the things, as I have looked at this really big change in the availability of data, and looking back from the beginning of my career, is that there was a big expectation that in medical school and residency you need to learn so much, and you have to fill your brain with all of the things. Especially in internal medicine and pediatrics, there are just so many things you need to know, and you have to remember all of those things.

I think we’ve come to the point where it’s clear the explosion of biomedical information is so great that no one brain can handle all of that. We need informatics and the ability to interact both with the data coming in and also with the analytic systems for us to be able to deliver care. It’s easy to resist that and say that it takes away from my ability to interact with the patient, but I think we need to find ways that we integrate it, because over time it’s just impossible for us all to know all the things that we need to know in order to deliver great care for our patients.

They’re OK with us using technology and interacting with it as long as we’re delivering great care. I think as physicians and other clinicians, we need to figure out how we integrate it into our practice in a way that gives a great patient experience.

Kevin Pho: Paul, thank you so much for sharing your time and insight, and thanks again for being on the show.

Paul Helmuth: Sure, thank you.

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