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Racing to
Define a New Model of Care |
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By Fred Bazzoli, Editor, Internet
Health Care |
At age 47, Joseph Scherger, M.D., resuscitated his
running career after a long hiatus. On the dare of his
son, he trained to run a marathon on Father's Day in
1998.
Since then, he has run three more marathons, and while
he touts the physical benefits he gets from running, his
motivation is even more basic. He feels he can't preach
a healthy lifestyle to his patients if he doesn't
practice it himself.
In the same way, Scherger is evangelistic about his
belief that the practice of medicine needs to change. In
particular, his message to primary care physicians is
that they need to radically remodel their activities to
do a better job of caring for their patients.
E-mail is one of the primary tools in Scherger's
reconstruction efforts. E-mail's growing availability
and its ability to provide continuous communication can
give physicians more oversight of patients, he believes.
Also, it can help doctors redistribute their workload
and make them more efficient.
"I consider my academic work to be focused on the idea
of the redesign of health care and using information
technology to do it," he says. "You can't fix health
care by just tinkering with the care model." That's the message Scherger preaches while juggling
roles as practicing physician, chairman of the
department of family medicine at the University of
California Irvine and editor-in-chief of Hippocrates,
the primary care journal of the Massachusetts Medical
Society.
On the run
It's a coast-to-coast marathon that never stops for
Scherger, who comes to Massachusetts once a month for a
day-long staff meeting for Hippocrates.
Even when he's on the West Coast, he's never out of
touch, says Gardiner Morse, executive editor of the
magazine. "He's one of those high-energy people who is
utterly connected by phone and e-mail," Morse says. "In
the first 20 days of September, I've personally had more
than 30 e-mails from him, coming at times from 5:30 a.m.
to 11 p.m. his time.
"His writing articulates his vision for information
technology as the way to return primary care to its
roots and restore the patient-physician relationship,"
Morse adds. "He's using it as a principal tool for
communicating with patients."
It's not just window dressing for Scherger, who
passionately believes that care delivery in the 21st
century has to look far different than it did in the
1990s, which saw physicians spending less than 10
minutes with each patient and struggling to effectively
manage their care.
E-mail, he believes, can bring about the return to the
image of Dr. Welby, whom he holds up in his writing as
an example of a physician in the idyllic world of
television who always seemed to have enough time to chat
with and care for patients.
"If every doctor began to exchange e-mail addresses with
their patients and invite communication, they would have
more freedom to structure their day," he contends. "They
would be able to see the patients that really need to be
seen and still serve 20 to 30 people a day by e-mail,
who just want access to the doctor."
Such a new model does more than save time—it saves the
doctor, Scherger believes. "Healing is enhanced by a
doctor-patient relationship. The current model is a
burnout model—it's no fun," he says. "I don't see the
current generation of doctors willing to go to work to
see 30 patients a day to make $120,000.
"Today's medical students are telling us they don't want
to go into a field where they only can have seven or
eight minutes of 'face time' per patient," he adds.
"Patients want a different kind of doctor, one that goes
back to the image of Dr. Welby, the person who's always
available. Much of today's dissatisfaction with care is
that people don't know if they can trust their doctors
because they seem driven by saving money for the
system."
Time for a change
Scherger's been intrigued by the notion of redesigning
health care delivery for most of his professional
career.
As a resident at the University of Washington in the
late 1970s, he thought managed care had the potential to
help the nation provide care that was more appropriate
than the carte blanche that existed under the
fee-for-service system.
But when managed care became preoccupied with
controlling medical costs, Scherger began to focus more
attention on primary care physicians as the agents of
change. In 1992, he began a four-year stint with Sharp
HealthCare, a San Diego-based group practice, where he
was vice president of family practice and primary care
education. In 1996, he became a professor of clinical
family medicine and chair of the department of family
medicine at the University of California Irvine.
Technology's potential
The potential of technology to change medical practice
hit home with Scherger when he was named to the
Institute of Medicine's committee on the quality of
health care in America, which issued a landmark report
in 1998 on medical errors in health care.
"In that report, we built an argument for how unsafe
health care delivery is today," he says. "The Internet,
as a new information vehicle, offers a catalyst and a
pathway to a new way of delivering health care."
The committee is preparing a report, to be released
early next year, that will describe the elements of a
new health care system. Scherger says it will discuss
changes that physicians need to make in their practice
of medicine, particularly their use of technology and
Internet-based communication.
Physicians have been willing to adopt some kinds of
technology but have lagged behind in incorporating the
Internet into their practice of medicine, he believes,
adding that they owe it to their patients and society to
change.
"They have an obligation to keep up with changes in
technology. Many feel the only thing they need to keep
up with is the changes in medicine, and they don't feel
like they have to change their practice," Scherger says.
"As health care gets more organized, that argument gets
more silly. It would be like a pilot saying, 'I'm not
going to use a new cockpit. I will ignore the new
technologies for how I fly this plane.'"
Scherger has increasingly used e-mail in communicating
with his own patients, and he says it has changed his
relationships with patients, bringing him closer to
them. "The patient satisfaction is just enormous," he
contends.
His patients feel they are better served, too. For
example, Ray Breur and his wife, Karen, began to
exchange e-mail with Scherger soon after they came under
his care in 1998. "We used e-mail to communicate
directly with Dr. Scherger on several occasions when it
would normally be impossible in any other way," Ray
Breur says. "After we retired, we used the motor home to
travel extensively, and e-mail gives us the means to
talk directly to him no matter where we are."
On a recent trip to Florida, Ray Breur saw some
"flashing floaters" in his left eye, and the couple sent
an e-mail to Scherger, who advised them to see an
ophthalmologist immediately. "Because medical advice was
so readily and easily available, I obtained necessary
medical treatment, which saved my vision," he says.
The doctor benefits from e-mail because it enables him
to handle common acute problems, better manage chronic
disease and improve the flow of information with other
physicians, Scherger says.
Problems to solve
However, before the use of e-mail and the Internet
becomes widespread in health care, several problems must
be confronted, he says.
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Internet-based communication needs to be made
available to more people, not just those that have
computers at home.
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Reimbursement must support Internet-based care.
Current models pay physicians only when they are
involved in face-to-face encounters with patients.
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Physicians must adopt a new approach to their
practices, taking responsibility for their patients and
using the most convenient and effective means to meet
their needs.
But Scherger sees those concerns being answered in the
near future, as providers assume more of the financial
risk in treating patients through capitated contracts
and payers seek ways to increase efficiency and reduce
costs throughout the delivery system.
Leading the way
While physicians have been slow to warm up to
information technology, Scherger believes adoption is
coming. The movement will be led by innovators and
pushed by consumer pressure, he says.
"Certain medical groups will be creative; they will put
a new service model out there. The consumer interest
will be so great that there will be market shifts, and
that will compel others to take notice," he says. "Then
you have the herd effect of adopting a new innovation.
This is a breakthrough, like choosing Federal Express or
using facsimile machines."
Failing to adopt information technology will have
significant effects on physicians. If primary care
physicians don't embrace the Internet, other health care
workers will, and they will become more important to
consumers. "They will become the Internet mediators, and
doctors will be relegated to the back office," Scherger
says. "I would hate to see that."
His desire to urge physicians to use the Internet to
communicate was one of the reasons he took on the job of
editor-in-chief at Hippocrates in September 1999. The
Massachusetts Medical Society acquired the publication
in April of that year, and Scherger wants to cover
subjects that will influence physicians in the years to
come.
"I basically postured that I would take the job if the
journal was focused on the future, where health care is
going, not where it is," he says.
Popular choice
That philosophy made Scherger a popular choice for the
lead role at Hippocrates, says Morse, its executive
editor. "Joe's vision is one of the reasons he was so
attractive to us," Morse says. "He's been integrally
involved in setting the new course for the magazine."
Scherger's aiming beyond that, to inculcating physicians
with the need to seriously consider a radical change in
course for their practice of medicine.
"The Internet, all by itself, doesn't do that. It's
really just a tool," Scherger says. "It can be used
badly, with bad information. But if it's seized upon for
its power and ability, it can be used to deliver
relationship-centered care.
"The Internet can be cold and impersonal, and it could
be distancing. But the physician practices that will
succeed are the ones that really connect in a
high-service orientation with their patient groups," he
adds. "I want primary care doctors to seize that. It can
make health care more effective and enjoyable."
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