Family physicians' suggestions to improve the documentation, coding, and billing system: a study from the residency research network of Texas.

BACKGROUND AND OBJECTIVES: The study's aim was to ascertain family physicians' suggestions on how to improve the commonly used US evaluation and management (E/M) rules for primary care. METHODS: A companion paper published in Family Medicine's May 2014 journal describes our study methods (Fam Med 2014;46(5):378-84). RESULTS: Study subjects supported preserving the overall SOAP note structure. They especially suggested eliminating bullet counting in the E/M rules. For payment reform, respondents stated that brief or simple work should be paid less than long or complex work, and that family physicians should be paid for important tasks they currently are not, such as spending extra time with patients, phone and email clinical encounters, and extra paperwork. Subjects wanted shared savings when their decisions and actions created system efficiencies and savings. Some supported recent payment reforms such as monthly retainer fees and pay-for-performance bonuses. Others expressed skepticism about the negative consequences of each. Aligned incentives among all stakeholders was another common theme. CONCLUSIONS: Family physicians wanted less burdensome documentation requirements. They wanted to be paid more for complex work and work that does not include traditional face-to-face clinic visits, and they wanted the incentives of other stakeholders in the health care systems to be aligned with their priorities.

Family physicians' opinions on the primary care documentation, coding, and billing system: a qualitative study from the residency research network of Texas.

BACKGROUND AND OBJECTIVES: The study's aim was to deepen our understanding of family physicians' perceptions of the strengths and weaknesses of the widely used US documentation, coding, and billing rules for primary care evaluation and management (E/M) services. METHODS: This study used in-depth, qualitative interviews of 32 family physicians in urban and rural, academic, and private practices. Interviews were initiated with a series of grand tour questions asking participants to give examples and personal narratives demonstrating cost efficiencies and cost inefficiencies relating to the E/M rules in their own practices. Investigators independently used an immersion-crystallization approach to analyze transcripts to search for unifying themes and subthemes until consensus among investigators was achieved. RESULTS: The majority of participants reported that the documentation rules, coding rules, and common fees for procedures and preventive services were reasonable. The E/M documentation rules for all other visit types, however, were perceived by the participants as unnecessarily complicated and unclear. The existing codes did not describe the actual work for common clinic visits, which led to documenting and coding by heuristics and patterns. Participants reported inadequate payment for complex patients, multiple patient concerns in a single office visit, services requiring extra time beyond a standard office visit, non-face-to-face time, and others. The E/M rules created unintended negative consequences such as family physicians not accepting Medicare or Medicaid patients, inaccurate documentation, poor-quality care, and system inefficiencies such as unnecessary tests and referrals. CONCLUSIONS: Family physicians expressed many problems and frustrations with the existing E/M documentation, coding, and billing rules and felt the system undervalued and unappreciated them for the complex and comprehensive care they provide. Findings of this study could inform improved guidelines for primary care documentation, coding, and billing.

The medical student summer research program in family medicine.

BACKGROUND AND OBJECTIVES: A variety of clinical research training programs exist throughout the United States, although little is known about their methods, content, and outcomes. This report describes a model of clinical research training designed to teach medical students research processes in family medicine, while yielding data for research studies. Authors present a description and evaluation of the program, focusing on students' research productivity. METHODS: Forty medical students participated in a 6-week clinical research training program from 2006--2012. This program was led by an experienced investigator and 10 family medicine faculty mentors. Classroom instruction provided an introduction to research design in Week 1 and research writing and dissemination in Week 6. In between, medical students implemented studies in multiple outpatient clinical settings in the Residency Research Network of Texas (RRNET). RESULTS: The Medical Student Summer Research Program in Family Medicine was well received by medical students who demonstrated consistent productivity year after year. All students displayed findings during Medical Student Research Day, and one third continued their work beyond that event, producing 22 presentations, two manuscripts, seven published abstracts, and seven research honors. CONCLUSIONS: Opportunities for medical students to develop research skills should be central to medical school education. Familiarity with the research process improves medical students' ability to understand, critique, and use evidence-based medicine in practice, to explain the latest findings to their patients, and to consider careers as clinician-scientists.

Family physicians' perceptions on how they deliver cost-effective care: a qualitative study from the Residency Research Network of Texas (RRNeT).

BACKGROUND AND OBJECTIVES: The aim of our study was to deepen our understanding of the factors that may explain the observational literature that more primary care physicians in an area contribute to better population health outcomes and lower health care costs. METHODS: This study used in-depth, qualitative interviewing of family physicians in both urban and rural, academic, and private practices. Interviews were initiated with a series of grand tour questions asking subjects to give examples and personal narratives demonstrating cost-effectiveness and cost inefficiencies in their own practices. An iterative open-coding approach was used to analyze transcripts to search for unifying themes and sub-themes until consensus among investigators was achieved. RESULTS: Thirty-eight respondents gave examples of how their decision-making approaches resulted in improved patient outcomes and lower costs. Family physicians' cost-effective care was founded on two themes-characteristic attitudes and skills of the physicians themselves and a thorough knowledge of the whole patient. Family physicians also felt their approaches to gathering information and then making diagnostic and treatment decisions resulted in fewer tests and fewer treatments ordered overall. Family physicians also delivered care in less expensive facilities and generated lower overall charges for physician fees. CONCLUSIONS: Family physicians perceived that their approaches to patient care result in medical decision making priorities and care delivery processes that contribute to more cost-effective health care. These outcomes were achieved less by providing preventive services and strictly adhering to guidelines but rather by how they individualized the management of new symptoms and chronic conditions.

Communication technology access, use, and preferences among primary care patients: from the Residency Research Network of Texas (RRNeT).

OBJECTIVE: The digital revolution is changing the manner in which patients communicate with their health care providers, yet many patients still lack access to communication technology. We conducted this study to evaluate access to, use of, and preferences for using communication technology among a predominantly low-income patient population. We determined whether access, use, and preferences were associated with type of health insurance, sex, age, and ethnicity. METHODS: In 2011, medical student researchers administered questionnaires to patients of randomly selected physicians within 9 primary care clinics in the Residency Research Network of Texas. Surveys addressed access to and use of cell phones and home computers and preferences for communicating with health care providers. RESULTS: In this sample of 533 patients (77% response rate), 448 (84%) owned a cell phone and 325 (62%) owned computers. Only 48% reported conducting Internet searches, sending and receiving E-mails, and looking up health information on the Internet. Older individuals, those in government sponsored insurance programs, and individuals from racial/ethnic minority groups had the lowest levels of technology adoption. In addition, more than 60% of patients preferred not to send and receive health information over the Internet, by instant messaging, or by text messaging. CONCLUSIONS: Many patients in this sample did not seek health information electronically nor did they want to communicate electronically with their physicians. This finding raises concerns about the vision of the patient-centered medical home to enhance the doctor-patient relationship through communication technology. Our patients represent some of the more vulnerable populations in the United States and, as such, deserve attention from health care policymakers who are promoting widespread use of communication technology.

Field and Experience Influences on Ethical Decision-Making in the Sciences.

Differences across fields and experience levels are frequently considered in discussions of ethical decision-making and ethical behavior. In the present study, doctoral students in the health, biological, and social sciences completed measures of ethical decision-making. The effects of field and level of experience with respect to ethical decision-making, metacognitive reasoning strategies, social-behavioral responses, and exposure to unethical events were examined. Social and biological scientists performed better than health scientists with respect to ethical decision-making. Furthermore, the ethical decision-making of health science students decreased as experience increased. Moreover, these effects appeared to be linked to the specific strategies underlying participants' ethical decision-making. The implications of these findings for ethical decision-making are discussed.

A Sensemaking Approach to Ethics Training for Scientists: Preliminary Evidence of Training Effectiveness.

In recent years, we have seen a new concern with ethics training for research and development professionals. Although ethics training has become more common, the effectiveness of the training being provided is open to question. In the present effort, a new ethics training course was developed that stresses the importance of the strategies people apply to make sense of ethical problems. The effectiveness of this training was assessed in a sample of 59 doctoral students working in the biological and social sciences using a pre-post design with follow-up, and a series of ethical decision-making measures serving as the outcome variable. Results showed that this training not only led to sizable gains in ethical decision-making, but that these gains were maintained over time. The implications of these findings for ethics training in the sciences are discussed.