Friday, June 06, 2008

FHN staff meeting

Our FHN administrator organized a meeting for staff at all of our FHN practices, earlier today. She asked me to attend, which I was happy to do.

Every practice was represented (7 offices), most with more than one staff member. It was very gratifying to see that both my colleagues and their staff considered this to be important enough for time off to attend.

The first problem we had is that my office is too small! We really need a boardroom, which we don't have. Much of the discussion involved the EMR, so everyone crowded around the three computers in the front office area.

Interestingly, one of the first questions was about what a FHN is. In Ontario, we have a regular alphabet soup of primary care reform (FHN, FHT, FHO, FHG, CCM). Don't ask. I explained that the main difference between independent Fee for Service practice and a Family Health Network is in the payment (largely capitated, or one set fee per patient per year) for FHN, and piecework for FFS. As well, in a FHN, patients roster, or identify a particular family physician as their physician.

We did not find much change in our practice when we became a FHN. I think capitation is supposed to decrease small visits for minor problems, and encourage visits for prevention and chronic disease management; I'm not really sure this works. One of the main reasons we joined was that the government said they would subsidize EMRs for physicians joining FHNs.

Our FHN administrator went over the rostering process, and why it is important to keep rosters up to date, using the monthly update list. The roster list in the EMR drives the preventive services; only rostered patients get recall letters (that is the way the government set it up). I think that it really helps if people know why they are doing things. Maintaining the list ensures that letters are sent to appropriate patients and not to those who don't need them (patient moved, switched physician etc). We went over the process for de-rostering patients, both with the paper form from the ministry, as well as tracking in the EMR.

We showed the list of preventive reminder letters, and showed everyone how to easily access it in the EMR. Our administrator showed how phone calls are tracked, and reminded everyone that patients are now getting called if they have already received two letters and have not answered yet.

Staff member were very enthusiastic about participating in the FHN preventive services program. We discussed the fact that reminders do make a difference in cancer prevention, and they know they are taking part in a good program.

We discussed efficient messaging in the office, as well as pop up messaging. We have a summer student that will go around and install the pop up software, as well as fix computer glitches as needed. Several offices were interested in having electronic faxing installed, so that they could import faxes straight to the EMR without having to print and scan.

Finally, our FHN administrator took everyone's email address. It is not sufficient to email physicians, some things need to go to their staff as well.

Overall, it was a very productive and interesting hour and a half (included lunch). I think there is a lot of value in involving practice staff, not just physicians.

My practice partner is progressing quickly. He now writes some prescriptions, and has done several consult requests in the EMR. He uses office messaging and "to do" notes consistently. He is starting to write electronic encounter notes more and more often. The Tablet goes in with him consistently. He is using INR and diabetic flowsheets. All incoming reports are getting scanned in, and no charts get pulled; his labs are electronic. My staff still pull his charts for him for patients coming to the office, and I expect this to continue for several months, until there is enough data in the EMR. His first preventive services mail-out went out last week.

It has been a month on EMR for him, so I think this is not bad. There is still a ton of extra work for him, mainly the CPPs. We occasionally go over things quickly after the office, and I'm there to troubleshoot minor problems. He does not have to call the Helpdesk, which is a big difference from when I started. It makes a big difference once the EMR is up and running; adding extra physicians is not quite as tough.

We are getting two new residents in the practice in July; it will be interesting to see how they pick up the EMR. I was lucky to have an exceptional resident for the past two years; she bore with us during the transition with good grace, and is pretty expert at the use of the EMR now.



Ian Furst said...

I was just about to post about FHN's Michelle -- you've put out some interesting info. I'm surprised that conversion to FHN was mostly pushed by EMR.

The recall issue is a big one. Because my practice (oral surgery) is FFS and specialty based recall is important to our livlihood. I track it closely and it can vary from 55-90% depending on the procedure. In the non-FFS/ capitation/ roster - whichever payment plan your under there is a bias not to encourage recall?

I've read that the payment is on average $100 per patient per year. The typical rate of visits I've seen reported is 2.7 which = $40/hr or less depending on how long you take with each patient.

Do you think flat rate with shadow billing is the best practice going forward? Is there incentive for you to accept more patients?

Michelle Greiver said...

Hi Ian

It was the EMR and the fact that we felt payment might be fairer.

Unlike your practice, recalling patients is not a driver in family medicine. There are not enough family physicians; we already have more work than we can handle without adding recalls. Recalling patients takes work, money and organization, so in a system without incentives it is actually a losing proposition (from a financial point of view). There is no difference in that respect between FFS and FHN.

The difference for us is that we now have incentives to recall patients, and these incentives are well aligned with what we perceive to be better quality care (more pap smears, more mammograms etc).

Prior to the EMR, we were not able to organize ourselves to do these recalls consistently. That changed once the EMR got going.

There does not seem to be a great deal of clinical difference between payment methods see cochrane review at

The FHN system is a blend of capitation, a small amount of FFS, and incentives. Alternatives to FFS are increasingly popular; "pure" FFS is down to 49% across Canada, and the majority of younger physicians prefer non FFS payment.

I cannot tell what the payment scheme does in terms of quality of care. I can say that my group is satisfied with the FHN payment method, even if we can't quite understand our monthly statements.

Perhaps the biggest change from FFS is not quality of care, but physician satisfaction. We have choice of payment systems, and people are choosing what works for them.

We do have a small incentive to accept new patients, about $100 per new patient. This, so far, is not making a difference in my group.