Healthcare: 'Change is now the new normal'
By Emily Ford
SALISBURY - While questions still surround the future of the Affordable Care Act, some new trends in health-care reform are here to stay, providers say. "Regardless of all of the uncertainties, and no matter who wins the presidential election, two things are certain - the nation's health system will continue to ride a magnificent tidal wave of change, and this change is now the new normal," said Dari Caldwell, president of Rowan Regional Medical Center. Although he's pledged to repeal the Affordable Care Act if elected, even Gov. Mitt Romney likes some parts of President Barack Obama's signature initiative. The U.S. Supreme Court upheld most of the plan in June. Romney has said he would keep requirements that insurers cover people with pre-existing conditions and that allow young people to stay on their parents' insurance until they are 26 or get a job, two central pillars of "Obamacare," a term opponents coined but supporters have embraced. Other changes that aren't going away: new technology like electronic medical records. An increasing emphasis on preventive care and patient education. A shift in hospitals to outpatient services. Hospitals also will continue to see new demands for improved quality and safety, and all health services must answer a mandate for lower cost. Long before passage of the Affordable Care Act, health care was being forced to change by an unsustainable financial model, the need to continuously improve value and the graying of baby boomers, said Dr. Roger Ray, chief medical officer for Carolinas Healthcare System. "These are all worthy of responding to, in addition to anything that comes out of reform," Ray said. Both Ray and Caldwell said the health-care industry is undergoing profound and lasting change. What will patients experience as a result?
Welcome to your medical home
Patients can expect extended early morning, evening and weekend clinic hours, as well as expanded staffs and more urgent care centers. They will hear a lot about a "medical home," or a primary care provider who will coordinate their health care. "Just a whole new accessible world is opening up to patients," Caldwell said. Health-care is becoming patient-centered, Dr. Ronnie Barrier said, with convenience paramount. Already open from 7 a.m. to 6 p.m. most days, Barrier's Rowan Family Physicians is preparing to expand hours yet again on weekends. Because most Americans will be required to buy health insurance, health-care providers are preparing for a flood of new patients who will have their expenses covered. Wellness visits, cancer screenings and other preventive services will be free. Some already are. About 30 percent of people who seek care at Rowan Regional's emergency department do not have a primary care doctor, Caldwell said. She advises them to find one soon. "Linking up with a primary care provider is the whole impetus and philosophy behind the Affordable Care Act," she said. A medical home will help ensure patients receive the preventive care they need, including mammograms and colonoscopies. More insured people will mean fewer intensive, costly treatments because preventive health screenings will catch illnesses sooner, Caldwell said. But it also will mean a doctor shortage.
Is there a doctor in the house?
"It will be pretty extreme," Ray said. While medical schools are ramping up to meet the need, there are limits on how many new doctors the system can produce in coming years, he said. It can already be tough to find a primary care doctor in Rowan County. Rowan Family Physicians will take a new patient only if an immediate family member already has a chart at the practice. Many practices in Rowan County have been afraid to grow during the economic downturn and uncertainty surrounding health-care reform, Barrier said. "It makes me cringe. You don't want to turn anybody away," he said. "But physically, you can't do it. I'm working 75 or 80 hours a week, and I love every minute of it. "But you can't do it forever." Now, nearly everyone is recruiting. Barrier's practice, with seven doctors and two physician assistants who each see up to 50 patients per day, is actively searching for an additional doctor to work in China Grove and another doctor and PA for the Salisbury office. Within a year, Rowan Regional will construct two new medical buildings - one in China Grove for Rowan Family Physicians and other practices, and one in Granite Quarry for Farrington Family Practice. Rowan Regional is also working with Farrington Family Practice to identify new locations for primary care in Salisbury and western Rowan County. The hospital is recruiting specialists, including general surgeons, vascular surgeons, gastroenterologists, infectious disease physicians, endocrinologists and otolaryngologists. Carolinas Healthcare has opened four new medical facilities in or near Rowan in the past eight months, including an urgent care center on Jake Alexander Boulevard next door to a primary care practice. The network plans to add four specialties in Salisbury in coming months - dermatology, rheumatology, orthopedics and endocrinology.
Medical records at your fingertips
Most patients today have a fairly limited ability to interact online with their health-care providers, Ray said. "The engagement and technology piece is set to change pretty dramatically," he said. As part of health-care reform, more doctors are moving to electronic medical records. While not without its critics, EMR allows a more integrated system of care where physicians and hospitals can look at a patient's health record online immediately and know what is going on at any point during treatment. "This greatly enhances care and prevents ordering of duplicate labs and procedures already performed," Barrier said. It also gives patients new access to their own medical records. Novant Health, Rowan Regional's parent company, has two local practices that offer MyChart, a free online tool that allows patients to email their physician, request appointments and refills, receive reminders for health checkups and view lab results. To use MyChart, patients must have a primary care doctor or specialist within the Novant system whose office uses Epic software for electronic medical records. "Our experience thus far has been very positive, and we aggressively encourage our patients to enroll," Barrier said. MyChart helps move the patient-centered medical home concept forward, he said. Patients can ask simple questions and receive answers without playing phone tag with staff. Barrier's practice uses MyChart to evaluate and adjust medications for high blood pressure and diabetes. "Patients monitor their blood pressure and blood sugars at home and send us the results," Barrier said. "We then can message them back with dosage adjustments." Farrington Family Medical Center also uses MyChart. All Rowan Novant practices are expected to complete the transition to electronic medical records by mid-2013, and the entire network should be live on Epic in 2014.
Every minute counts
CMC-Northeast in Concord pioneered the use of a unique computer application that reduces the amount of time spent by emergency department physicians when ordering common tests, medications and procedures. Carolinas Healthcare System earned national recognition for the application, landing a spot in InformationWeek's annual listing of the nation's 500 most innovative users of technology. The single order entry computer screen includes more than 400 of the most common orders placed in an emergency department. The screen reduces the number of clicks required of physicians and applies to 90 percent of the orders required in a typical day. During the pilot at CMC-Northeast, a CHS hospital with one of the busiest emergency departments in North Carolina, order entries were reduced by nearly two and a half minutes per patient, or more than 2,600 physician hours per year. CHS is also introducing remote intensive care unit technology that allows the network to spread the expertise of 50 board-certified ICU physicians across 457 ICU beds throughout the system, Ray said. Similar remote technology could help manage the growing doctor shortages in other specialties, he said. New devices in patients' home will help physicians monitor their health without costly office visits. Even the lowly bathroom scale could become a tool to send vital information remotely, Ray said.
More time at the bedside
The hospital of the future will offer more outpatient care and have fewer overnight stays, Caldwell said. The length of hospital stays are already declining, partially due to the minimally invasive nature of many medical procedures. Gall bladder removal three years ago would have required a night in the hospital. Now, patients go home the same day. Patients who do end up in the hospital will participate more in their own care. Rowan Regional is part of a national nursing initiative called "Transforming Care at the Bedside" that uses team nursing concepts that allow nurses to spend more time at the patient bedside. Currently, only about three hours out of a 12-hour shift are spent at the bedside. The goal is eight and a half hours. Patient care units at Rowan Regional that have already converted to this model have seen improvements in patient and staff satisfaction, Caldwell said. Bedside reports, including both nurses during a shift change, mean more discussion with the patient and family. Caldwell experienced the change firsthand when she was admitted to Rowan Regional recently for a kidney stone. "They did a great job," she said. "I felt very in touch with what was going on, and that was important to me as a patient."
Some jobs eliminated
The growing emphasis on expanding primary care and recruiting specialists, along with a need to reduce overhead, led to a unit reorganization at Rowan Regional last week that eliminated 19 jobs. Three other staffers had their hours cut. The reorganization comes in response to the economy, the national mandate to lower the cost of health care and changes required by the Affordable Care Act, Caldwell said. As a 268-bed hospital, Rowan needed to re-engineer the use of its beds, make the most of existing space and decrease overhead to help make health care affordable, she said. With these unit changes and other transformation projects will come a need for cross-training of staff and flexibility of work hours, Caldwell said. Unit secretaries and certified nursing assistants will be cross-trained to a new role known as "Sec/Techs." Caldwell and Chief Nursing Officer Katrina King are working with Rowan-Cabarrus Community College to help meet the needs of the changing workforce and enlist the college in cross-training curriculum. Many of the changes at Rowan Regional have been proposed by physicians. There is no doubt that reform has created a volatile, uncertain environment for hospitals where adaptability is key, Caldwell said. As Rowan Regional assesses each potential change, the hospital can't lose sight of its mission and values, she said. "As a nurse by heart, my focus will always remain on the patient and our mission of improving the health of our community one patient at a time," Caldwell said.
- So far, Novant Health practices in the Salisbury area include Rowan Family Physicians (both locations), Salisbury Medical Clinic and all Farrington Family Medical Center locations except Kannapolis.
---- Carolinas Healthcare Systemís practices in the area include Cabarrus Family Medicine, Cabarrus Pediatrics and Kannapolis Internal Medicine, all in Kannapolis.w
Contact reporter Emily Ford at 704-797-4264.