Future of family medicine: Multimillion-dollar makeover

Early next year, 20 family practices will be picked to help shape the future of primary care.

They will be part of a national demonstration project to test a new model of care for family medicine -- a model that is patient-centered, evidence-based and relies on an electronic health records system.

The application process for interested practices is expected to begin this month, and the 20 practices likely will be selected in February 2006. The project should be up and running by June or July of next year.

"Family medicine is at a critical junction in its evolution," said Terry McGeeney, MD, CEO of for-profit TransforMED, a subsidiary of the American Academy of Family Physicians that provides consultation and support to physicians who want to transform their practices to the new model of care.

Family medicine leaders say their specialty must transform to survive.

The AAFP sees this initiative as so important that it is investing $8 million from its reserves to help family practices nationwide embrace the new model detailed in the Future of Family Medicine report released last year. The demonstration project is one of the key initiatives that family medicine groups are launching in hopes of renewing a specialty that some leaders say might not survive unless it changes. The number of graduating U.S. medical students choosing family medicine declined about 50% from 1997 to 2003, with many graduates selecting specialties that offered more money.

Recognizing that family medicine had to evolve, seven national family medicine organizations, including the AAFP and Assn. of Departments of Family Medicine, in 2002 launched the Future of Family Medicine project. Research firms conducted a national study, and, along with focus groups, helped identify what patients wanted from family physicians. Task forces explored issues such as medical education, practice development and health system changes.

The report calls for a new model of care as the core of clinical practice. Patients would have a personal medical "home" that is patient-centered and evidence-based. They would receive acute, chronic and preventive medical services, and practices would reduce barriers by offering open scheduling and flexible office hours. Care would be provided through a multidisciplinary team approach, which could include nurse practitioners, nutritionists and behavioral scientists.

The model's central nervous system would be electronic health records. Practices would develop a Web portal and use e-mail to communicate with patients. Systems would include evidence-based clinical practice guidelines, order entry and referral tracking.

Medical education for students and physicians would be refined. Future education should be grounded in evidence-based medicine and be technologically up to date while providing more in-depth training in practice management. Family physicians would become more active in local schools, helping to identify youths who want to be family doctors.

Hoping to attract interest

Since the report was issued in March 2004, family medicine leaders have been trying to get the recommendations from paper to practice.

"The last thing we wanted to have happen was to have it sit on the shelf. This was about transforming the specialty," said Norman Kahn, MD, AAFP vice president of science and education, who oversees the Future of Family Medicine project.

But the project is not foremost on the minds of most practicing family physicians, leaders said. Some know very little about the practical recommendations made in the report. That has slowed progress.

"I don't think it's on the tip of everybody's tongue. I don't think if you went to lunch with 15 family physicians from Waco, Texas, they would do a very good job on a test about [the report]," said Robert Graham, MD, professor of family medicine at the University of Cincinnati College of Medicine and the AAFP's former CEO.

But some doctors are embracing the recommendations.

Vero Beach, Fla., family physician Dennis F. Saver, MD, is one doctor working to adopt the new model of care. He started group visits for patients with diabetes and wants to expand group visits for patients with other chronic diseases. His group practice also purchased an EMR system and is incorporating it.

"It's going to take us a year to scan the paper [records] in and not use them any more," said Dr. Saver, board chair of the Florida Academy of Family Physicians.

His office needs the electronic system in place before other changes can happen, such as communicating with patients by e-mail and scheduling appointments electronically. But Dr. Saver is optimistic that his office will see major change.

"This is a large undertaking. It is not simple to transform yourself while you're still trying to keep afloat," he said.

More family physicians are making the shift toward electronic records. About 2½ years ago, 8% of the AAFP's 94,000 members had electronic health records systems, said David C. Kibbe, MD, director of the AAFP's Center for Health Information Technology. Today, 30% have switched to electronic systems, he said.

The center has worked to get vendors to lower prices, and its leaders have spoken to AAFP chapters to teach doctors how to convert to electronic systems. The center also takes reviews and complaints from physicians on systems they have installed.

"The electronic records systems will be the central nervous system of the new model of family medical practice. Our message [to doctors] is pretty much get with the program with a smile on your face," Dr. Kibbe said.

Transforming how doctors practice

TransforMED, family medicine leaders say, will be a key force to help practicing doctors implement the new model. Its initial focus is developing and starting the national demonstration project for 20 practices. Dr. McGeeney, TransforMED's CEO, said the project would be an ongoing lab experience to enable pilot practices to employ elements of the model. The company will not charge the pilot practices a fee.

Eventually, the company will offer its expertise and services to enable family physicians across the country to adopt the model.

"Many [practices] don't have the resources or the time to get these things done, and the AAFP is stepping up and saying, 'We're going to help you with this,' " he said.

A doctor who puts into practice the new model could increase total income by 26%, according to a financial analysis undertaken as part of the Future of Family Medicine project.

Estimated transition costs for the model would range from $23,442 to $90,650 per physician, depending on the productivity loss associated with implementing an electronic health records system, the analysis said. Those costs would be shouldered by the practice.

While physician leaders said the savings may attract practicing physicians to the plan, selling a renewed family medicine specialty to medical students may be difficult. Family medicine has struggled to get graduates interested in family medicine residencies. Fewer than 10% of all U.S. medical school graduates picked family medicine in 2003.

"Students with large debts are concerned about paying off their debts and having a good quality of life, and family medicine is not seen as a high-income specialty," said Paul James, MD, professor and head of family medicine at the University of Iowa Roy J. and Lucille A. Carver College of Medicine.

But educator Thomas Campbell, MD, believes the new model will interest students in family medicine. He said the model maximizes interaction with patients and minimizes time doctors spend on paperwork. He said it also would stop doctors from practicing "hamster medicine," a never-ending cycle of scurrying to see patients.

"By changing the model of care, we can get off the wheel," said Dr. Campbell, associate director of the University of Rochester Center for Primary Care.

Dr. Campbell said the university's family medicine practice had started using more e-mail to communicate with patients. It also is getting residents more involved with e-mail communication. Meanwhile, the practice does group visits for diabetic patients.

Dr. Campbell and others say these are small but important steps to changing family medicine and keeping it from going the way of the Edsel.

"This new model is going to change the way we see patients," said Samuel Sandowski, MD, director of family practice residency at South Nassau Communities Hospital in Oceanside, N.Y. "This country needs family physicians. If you took away family practice, there would be huge gaps in access to care and in the care provided."