On March the American Board of Internal Medicine by liaoqinmei


									                 Comprehensive Internal Medicine Roundtable Meetings - Overview
The ABIM Comprehensive Internal Medicine Steering Committee hosted four Roundtable meetings during
Spring 2007. Each meeting focused on a stakeholder group and asked the question: “What do you expect
from a competent comprehensive internist?” The format of the meetings was causal and conversational.
Three patients attended each of the four meetings. The four stakeholder groups were the health care team,
subspecialists, health plans and purchasers.
Each meeting had a unique character but the expressed expectations of the comprehensive internist were
remarkably similar and are summarized below. There was also general agreement about the competencies
that the comprehensive internist needs to demonstrate.

I. Expectations of the Comprehensive Internist:
           Phone/e-mail access
           Evening/weekend access
           Long enough appointments
           Designated (non-physician) point of contact
      Effective Communication
           Personal relationship with patient; listening carefully with empathy
           Interpretation and explanation of roles of generalist, specialists and other providers
           (reason for referral, expectations of referral and follow up, which physician the patient
           should approach for questions)
           Interpretation and explanation of generalist/specialist instructions and test results
           Helpful elicitation of information from the patient (overcoming intimidation and assuring
           Two-way information exchange with specialists and other health care team members
           Culturally knowledgeable/sensitive (language)
      Care Coordination
           Information management (medical knowledge, patient history; data from other providers)
           Navigational assistance (with providers, community resources, health plans, etc.)
           Effectively matching personality of patient and specialist
           Effective systems management and QI of office staff and entire team
          Determining a cure or coping strategies when diagnosis not possible
          Education regarding health care system and disease management
          Partnering in medical decision making
          Assistance in preparing for specialist appointment
          Researching relevant medical information

II. Competencies of the Comprehensive Internist:
      Medical knowledge, skill and judgment; diagnostic skill is the most important competency
      and cannot be delegated
      Knowledge of when to refer to a specialist
      Ability and willingness to be responsible for the whole patient
      Effective communication skills
      Information management skills
      Quality improvement skills
      Ability to manage, lead, delegate
      Ability to run an effective “system”
      Efficient use of resources
                                           Health Care Team Roundtable
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                              The American Board of Internal Medicine
                            Committee on Comprehensive Internal Medicine
                                   Health Care Team Roundtable

An estimated one hundred twenty-five million Americans (approximately half the U.S. population)
suffer from one or more chronic conditions1 and account for seventy-five percent of all U.S. health
care expenditures. 2 Of these patients, more than fifty percent see two or more physicians, and
eighty-one percent require care from three or more physicians. 3 Long-term, proactive, coordinated
care for this segment of the population is essential, as chronic conditions are the leading cause of
death, illness, and disability in the United States. 4 To fill this role, the American Board of Internal
Medicine (ABIM) envisions a comprehensive internist who provides effective, proactive care to
patients with complex chronic illnesses and coordinates patient-centered care across multiple care
providers and locations. The comprehensive internist provides not only primary care (first-contact,
acute, and preventive care), but also takes active responsibility for the overall coordination of the
patient’s care across the continuum of health sites and providers, through ensuring proper care
transitions and leading effective health care teams so that the patient receives optimal care. The
ABIM Board of Directors charged the Committee on Comprehensive Internal Medicine to gather
input from stakeholders both within and outside the internal medicine community to explore and
define the competencies required of the effective comprehensive internist, and the means by which
ABIM might assess these competencies and recognize proficient practitioners of comprehensive
internal medicine.

On March 19, 2007, the ABIM Committee on Comprehensive Internal Medicine convened twenty-
six stakeholders for a roundtable discussion on the roles of comprehensive internists in ensuring
effective health care teams. These participants included three patients with complex, chronic
illnesses (selected using guidelines from the Institute of Family-Centered Care); seven non-
physician health care team members (two nurse practitioners, a social worker, a case manager, a
physician assistant, a pharmacist, and a health informaticist); a representative each from the
American College of Physicians (ACP), the Alliance for Academic Internal Medicine (AAIM), and
the Society of General Internal Medicine (SGIM); general internists; and ABIM staff. Through
dyadic breakouts and discussions in three small groups (each with a mixed distribution of
stakeholders), the roundtable participants worked to define the competencies of comprehensive
internists in health care teams. Discussion topics included best practices of effective health care
teams, roles and responsibilities of health care team members, the role of information management
in supporting effective teams, and the role of certifying boards in assessing and ensuring
comprehensive internists’ team effectiveness.

  Wu S, Green A. Projection of Chronic Illness Prevalence and Cost Inflation. Santa Monica, Calif.: RAND Health,
October 2000.
  The Institute for Health & Aging, University of California, San Francisco. Chronic Care in America: A 21st Century
Challenge. Princeton, N.J.: The Robert Wood Johnson Foundation, August 1996.
  Gallup Serious Chronic Illness Survey 2002.
  Anderson G, Knickman JR. Changing the chronic care system to meet people’s needs. Health Affairs (Millwood).
                                      Health Care Team Roundtable
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The ABIM Committee on Comprehensive Internal Medicine recognized that various aspects of the
health care system, many of which are beyond the physician’s control, affect the quality of patient
care delivery. For the purposes of the roundtable discussions, participants were encouraged to
identify ideal care coordination solutions without constraining themselves to existing health care
system issues.

Evident early in the discussions was the overburden on internists, which frustrated all members of
the health care team, including the patients. Much of the physician’s time is occupied by
administrative tasks, such as administrative paperwork for insurance coverage, disability forms,
etc., and e-mails or telephone calls to insurers, pharmacists, and even utility companies – many of
whom refuse to speak to a non-physician. The pharmacist at the roundtable noted that significant
physician and pharmacy time is wasted with calls from payers who will not cover prescriptions, an
inefficiency that points to the need to streamline insurer oversight, find means to conduct such
communications electronically, or institute automated formulary substitutions to correspond with
insurance coverage. One internist at the roundtable commented, “I spend an awful lot of time
saving money for other people and helping other commercial entities be more profitable.” Not only
are these administrative activities not reimbursed, but they reduce the amount of time physicians
can spend with patients. Patients and physicians agreed that length of patient visits and lack of
physician accessibility are significant issues that not only can result in patient frustration and
burdens on other aspects of the health care system (e.g., emergency rooms), but can also lead to
inadequate patient care.

Patients want and need weekend and evening availability of physicians. They want real-time
access to either the physician or an informed member of the health care team, not voicemail. One
physician envisioned the ideal comprehensive internist as the “accessible face of a failing medical
system.” When asked to name the most essential attribute of the comprehensive internist, the
patient representatives and other participants speaking from the patient perspective consistently
mentioned accessibility by phone or e-mail, responsiveness, being respectful of patients’ time,
having time to listen, and not making patients feel guilty for consuming the physician’s time. The
patients all noted the need to have ready access to someone on the health care team, but that they
need not access the physician directly. The patients would like a designated point of contact (such
as a specific registered nurse or nurse practitioner in the office, rather than just a receptionist) who
is informed about their medical history and can serve as an effective liaison to convey information
to and from the internist, such as symptoms the patient forgot to mention during the appointment or
questions that arose later.

The patients expressed willingness to have many of their needs met by non-physicians, especially
in issues related to access, communication, and care coordination, which were the three most
commonly identified system deficiencies throughout the roundtable’s discussions. The patients
desired a designated individual – not necessarily a physician – to serve as patient advocate and care
architect to help patients navigate the complexities of their disease management and the health care
system (including particular health insurance requirements and financial issues, which can
ultimately affect patients’ compliance with treatment plans). Coupled with accessibility, effective
communication was the chief ideal attribute mentioned by the patients and roundtable participants.
Each patient relayed examples of communication shortfalls they had experienced between patient
and physician, or among physician, specialists, and other members of the health care team. Patients
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need someone highly skilled in communicating to them, to interpret feedback from specialists and
other providers, to adapt communications according to the patient’s education level and cultural
environment, to ensure the presence of a family member in cases of impairments to the patient’s
comprehension (e.g., language barriers, dementia, hearing loss), to show interest in the patient on a
personal and individual level, to listen carefully to the patient’s concerns, and to demonstrate
empathy for the patient’s condition and commitment to ongoing care in an ongoing relationship.
Patients also want a coach who can partner with them in decision-making, guide them through their
treatment plan, review research with them (including information the patient may have culled from
the internet), and will never automatically dismiss patients’ comments or ideas.

Communication skills are also essential in eliciting important information from the patient, in
asking the right questions and probing for further details from the patient when necessary. Patients
often feel intimidated by their physician, are hesitant to take up more of the physician’s limited
time, or are unaware which key details are important for the patient to convey. As one patient
stated, “Being a patient is not my profession; I don’t always know what the doctor needs to know
from me.” Whether these communication roles are served by the internist or by a non-physician
member of the health care team present in the examining room, an individual with strong
communication skills needs to ensure that information is properly conveyed both from the
physician and from the patient. If the internist takes on this role of “information central,” as key
communicator and coordinator, patients recommended that ABIM require communication
competencies in the assessment of comprehensive internists. These significant unmet
communication needs in current practices may be a function of time pressure in office visits, or
communication may be a competency that some physicians have yet to master. Regardless of the
root cause, the comprehensive internist must ensure that communication needs are met, whether by
providing them directly or designating a member of the health care team to fill these
communication and accessibility gaps.

Coordination and communication among the many members of the health care team, including
specialists, is another key role required of the comprehensive internist or another designated
member of the health care team. Patients with chronic conditions often visit multiple specialists,
and communication lapses often exist among these physicians, which can lead to serious
deficiencies in patient care. One roundtable patient’s endocrinologist refuses to communicate
directly with her psychopharmacologist about potential drug interactions and perceived side effects
the patient is suffering. The many referrals one patient’s generalist makes to specialists indicate to
the patient that her general internist is not taking enough “ownership” of her care. Another patient
described her frustration that her general internist is intimidated by her subspecialist, shuffles her
care to the specialist, but then does not follow up or initiate contact with the subspecialist. The
patients were often uncertain which physician they should contact when problems arise, or whether
the general internist or the specialist was responsible for conveying the results of a test. Sometimes
during a specialist referral, the specialist appears uninformed about the details of the patient’s
condition and history, and often the general internist never discusses the outcome of the
subspecialist visit with the patient. Communication among these physicians is crucial in providing
optimal patient care and evidence-based decision-making. In addition, health care team members
within the same office are often insufficiently informed about patients’ care. Care coordination
could perhaps be facilitated through conference calls between the physician and health care team
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members, even when the physician is out of the office, or other systems could be instituted to
ensure seamless conveyance of information.

An essential component of effective care coordination and communication is effective information
management – of medical knowledge, patients’ medical history, patients’ personal background, and
communications and follow-up actions of additional health care providers. One solution for
information sharing within an office and with other physicians is the implementation of electronic
medical records (EMRs). The expense of EMRs places a particular burden on small practices, but
physicians in those practices or in remote, rural areas must still institute some type of system for
information management. Whether by electronic means or via a different system, it is the
responsibility of the comprehensive internist to ensure that an effective method of information and
knowledge management is in place.

Even with the implementation of EMRs, technology cannot be relied upon as a panacea; EMR data
are only as accurate as those entering it, and the system is only as useful as its design. Several
physicians and allied health professionals at the roundtable expressed significant hesitancy and
resistance to EMRs, despite the potential benefits. Their concerns included de-personalization of
physician-patient relationships by eliminating personal context and narrative through data
reductionism; advanced decision support tools that “box in” physicians’ diagnoses; loss of data
reliability and accuracy if a patient is permitted a portable medical record that could be altered for
the benefit of insurance underwriting, obtaining narcotics, or fabricating causes of injury; and
infringement of personal privacy with the institution of a national health care database. These
issues can be resolved through comprehensive “narrative” data entries upon each patient visit and
quality control of both the data and its accessibility. However, another restriction to the benefit of
EMRs is the lack of interoperability among various EMRs currently on the market, which inhibits
information exchange from one health system to another and therefore fails to capitalize on the
capabilities of a fully integrated system. If carefully implemented and utilized, EMRs represent the
potential for seamless information exchange between health care providers and team members, as
well as for the extraction of valuable data sets on a practice level – or even on a national level with
a national health care database – that could advance research on public health issues and disease
trends in specific patient populations, above and beyond the capacity of mere disease registries.

The potential benefits of EMRs are unmistakable. One roundtable physician described an incident
in which his ability to access a patient record electronically from home after business hours resulted
in his saving a patient’s life, a life that would have been lost without the support of an EMR. This
EMR also provides the physician the capability to send timely electronic prescriptions from a PDA
or other hand-held electronic device directly to pharmacies via e-fax – but often the prescription is
still delayed for several hours because pharmacies’ fax machines are out of paper or turned off. A
cultural and administrative shift will be required from all aspects of the health care system for the
full potential of EMRs to be realized.

The pharmacist at the roundtable repeatedly expressed the concern that pharmacists are an
untapped resource on the health care team, as they have almost no accurate medical information
about patients in their system and often have incomplete medication lists if patients utilize more
than one pharmacy. Without access to any patient medical history, drug allergies, or accurate
medication lists, pharmacists are significantly inhibited in their capacity to prevent harmful drug
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interactions and promote medication safety. Physicians and patients were astonished at the paucity
of patient information accessible to pharmacists, and recognized the health care system’s failure to
utilize pharmacists as an important partner in patient safety. An interoperable EMR could provide
a means toward sealing this information gap, but would require implementation on a large scale
beyond individual physician practices.

Although EMRs are cost-prohibitive to many physicians, particularly those in small practice, the
comprehensive internist must ensure that systems – electronic or otherwise – are established for
managing knowledge and information flow. The proficient comprehensive internist should
demonstrate facility with knowledge management tools, data access and manipulation, analysis of
patient populations through registries, use of technology (e.g., online literature searches) for
decision support and knowledge base expansion, and means of managing information in an
effective interface with patients, specialists, and other health care team members. If the physician
chooses not to serve as “information central,” a specific knowledge manager within the health care
team should be assigned the role of knowledge and information manager.

Technology alone cannot correct deficits in care coordination. In addition to implementing a
system for information management, the comprehensive internist must ensure that systems are in
place for coordinating care and communication among all the practice staff and external specialists
and physicians, and for ensuring the smooth operations of the office. The comprehensive internist
must either take on the responsibility of systems architect or designate this role to a specific
member of the health care team. The framework of systems thinking could be added as an
educational component in medical residency training, and systems competence could become a
competency the ABIM assesses in the comprehensive internist. Rather than treating a negative
incident as an exception, someone on the health care team should possess the competency to
identify and correct systems issues through applying quality improvement processes at the practice
systems level. However, one physician at the roundtable reflected that he became a physician to
diagnose and treat patients, not to analyze systems, and that he believed he would neither enjoy nor
be skilled at systems thinking. The consensus in the room was that the comprehensive internist
should at least have basic systems knowledge but could delegate the systems oversight to another
member of the health care team; what must be ensured is that there is a systems architect in the
office who bears responsibility for instituting and managing effective systems. Knowledge of
system function should be a competency even for physicians within a large health care system in
which much of the system operations are outside their personal control. Regardless of the practice
setting, the comprehensive internist must still adapt to and interact with the systems in place, and be
responsible for reporting deficiencies in office staff or infrastructure support, even those beyond
their direct oversight, as these system problems can ultimately lead to poor clinical outcomes.

Careful coordination and communication among the members of the health care team requires team
leadership. The allied health professionals and patients at the roundtable were comfortable
assigning this leadership role to a non-physician staff member, in order to allow physicians to
spend more time and thought on their core functions as diagnostician and provider of patient care.
Many of the physicians, however, expressed resistance at relinquishing leadership. Their primary
concern was that the comprehensive internist should retain broad responsibility and oversight for
meeting patients’ medical needs. The roles of appropriate delegation and division of labor,
assessment of staff ability and knowledge, and ultimate responsibility for the work and decision-
                                       Health Care Team Roundtable
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making of all team members should fall to the physician, but the “leader” of the team can shift
according to the situation. The internist must possess the leadership competency to respond
appropriately in an emergency resuscitation, but leadership in office management, systems analysis,
and even care coordination can be managed under a collaborative leadership model in which
specific team members take on leadership for different situations, with the entire team accountable
for the results.

The concepts of shifting responsibility and delegating roles to non-physicians were elaborated in a
small group discussion attempting to identify the members of the health care team and their
respective roles. The list of roles included coach, point of contact, care coordinator,
educator/interpreter, business manager (finances, administrative overhead, personnel), caregiver,
diagnostician, and quality improvement/safety analyst, with increased availability and access
provided to patients according to the complexity of their medical conditions and level of education,
knowledge, and family support. This small group at the round table felt that all these roles could be
assigned to non-physician members of the health care team (nurse, medical assistant, nurse
practitioner, physician assistant, social worker, practice manager, administrative staff), except for
the role of diagnostician, which would be retained by the internist. The physician would only be
required for initial diagnosis, reassessment of patient when treatment is ineffective, communication
and coordination with specialists, and as primary point of contact for patients with greatest need.
All the other roles could be redistributed to non-physician health care team members, especially
administrative and business-related functions. As one of the patients stated, “What I expect of my
internist is good medical care. Office staff should do everything else so that the internist can focus
on providing good medical care.” A general internist at the roundtable added, “And then the
internist can concentrate on relationship-building and spending more time with the patient.” In
agreement, another of the patients felt that the doctor’s role should be narrowed, as physicians’
training and value resides in their medical skills, not in leadership or administrative responsibilities.

Once again, many of the physicians at the roundtable, although eager to spend more time with
patients and less time on administrative paperwork, were reluctant to disassociate “leadership”
from the physician. Semantics were partially the issue, as clarification was needed to differentiate
among the terms “leadership,” “accountability,” “oversight,” and “responsibility,” and to
distinguish responsibility for care versus responsibility for service. The physicians clearly desired
to retain leadership and primary oversight in roles directly related to patient care. For
administrative and service-oriented functions (e.g., insurance compliance, assisting patients in
navigating the health system), physicians were more willing to designate oversight to non-
physician team members. Although physicians would still maintain overall accountability and
responsibility for all office operations, they expressed openness to offloading roles related to
human resources, business management, and systems architecture. Competencies required of the
comprehensive internist should include a general awareness of guiding principles of effective data
management, quality improvement, and patient safety, and how these principles relate to the
management of offices and organizations. Physicians should hold themselves accountable for the
smooth operation and implementation of these principles and functions, but they would not
necessarily need to direct or lead these duties themselves.

The comprehensive internist must ensure an effective and appropriate division of labor among the
members of the health care team to fill these various roles. This delegation requires an awareness
                                      Health Care Team Roundtable
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of staff skills and the competencies of clarifying expectations and responsibilities of each staff
member and empowering them to work to the level of their skill, training, or license. Merely
delegating tasks is not equivalent to empowering team members to maximize their potential.
Empowerment involves encouraging all team members to raise ideas, ask questions, and take
ownership of their role. One of the roundtable physicians utilizes an “empowered nurse model,” in
which the nurse acts as scribe and interpreter during the patient visit and also handles much of the
administrative and clerical work on behalf of the physician. Although the internist may delegate a
number of roles to other team members rather than managing those tasks directly, the entire team –
including the physician – should embrace shared responsibility and accountability for outcomes. It
is the responsibility of every team member, including patients, to bring up quality issues. The
internist may not be the “leader” of every activity, but he bears overall responsibility for oversight
of all roles through assessing the ability and knowledge of health care staff and auditing others’

To reinforce principles of teamwork and shared accountability as effective health care delivery
models, some medical residency programs have implemented “navigation teams” in which every
team member (medical students, nursing students, pharmacy students, and social work students)
takes full responsibility for achieving measurable, high-quality, patient-centered care. The students
engage in regular retreats with nurses, physician assistants, administrators, and front office staff to
implement quality improvement initiatives with the entire health care team. The focus of these
medical students’ questions to faculty naturally shifts to team-centric rather than typical profession-
centric issues, indicating that teamwork can be practiced and learned. Without being explicitly
taught to do so, these students learn to view leadership as collaborative, with shifting
responsibilities that do not always result in the physician as primary leader. As a means of ABIM’s
assessment of team competencies, team simulation studies could be conducted, similar to airline
pilot team simulations in which the entire crew works together in response to simulation scenarios.
The airline industry learned that instead of hierarchical reporting structures in which the pilot is
“leader,” a flattened system of shared responsibility is much more reliable for favorable outcomes.
Medical practices could adopt a similar model, with each team member empowered and responsible
for the work of the collective whole. Health care teams could conduct mutual performance
monitoring, in which the physician not only assesses the team members, but the team members also
assess the physician.

A competency for the comprehensive internist, therefore, is the ability to empower team members
and effectively divide labor among them, and thereby to ensure that each role – coach, point of
contact, care coordinator, educator/interpreter, business manager, caregiver, diagnostician, quality
improvement/safety analyst – is managed by a specific team member or physician. The designee
for particular roles will vary according to skill levels of team members, as well as by varying state
restrictions on training and scope of practice for certain health care practitioners (medical
assistants, registered nurses, nurse practitioners, physician assistants, etc.). The comprehensive
internist needs to clarify role expectations and cross-train appropriately to ensure contingency
coverage of every role. Small physician practices may bear an additional burden of staff and
resource shortage to fill all of these roles. The comprehensive internist must ensure that these roles
and resources are available to patients, but this availability could include a “virtual” linkage with
other small practices or regional hospitals to pool resources, or facilitating patient awareness of
community resources such as educational patient groups and supportive communities of patients
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with similar conditions. Patients with complex, chronic conditions require these resources to
effectively manage their disease and medical care; it is the responsibility of the comprehensive
internist to find a means of providing ready access to care, effective care coordination and
interpretation, patient education and advocacy, and health care navigation support. Regardless of
office size, the comprehensive internist must establish these patient resources through developing
team members or linking with the regional community.

Each roundtable participant was asked to identify the most important attributes of the ideal
comprehensive internist and team. The roundtable patients and other roundtable participants
addressing the patient perspective consistently mentioned the roles previously elaborated:
accessibility to care (designated point of contact), strong communication skills (effective interpreter
of information for patient; communicator to and from specialists and ancillary medical staff; active
listener; relationship-builder; patient advocate; health care system navigator and coach), and care
coordination (architect of effective systems of information management to ensure smooth
interaction, appropriate follow-up, and medical information exchange among physician, specialists,
and ancillary medical staff), with the opinion that many of these roles could be performed by
designated non-physicians. The three patients related no issues regarding accurate diagnosis,
effective treatment plans, or medical errors, but recurring themes among other patient-perspective
participants were desires for the comprehensive internist to emphasize proactive, preventive care
(including anticipatory measures and regular health risk assessments), rather than provide merely
acute care; to order appropriate tests, procedures, and prescriptions; ban pharmaceutical
representatives and other incentives that may lead to conflicts of interest; and to ensure orders and
procedures are reliably and reproducibly conducted.

The health care team members at the roundtable displayed more disempowerment in their
relationship with physicians than that exhibited by the chronically ill patient participants. These
non-physician health care team members desired that the comprehensive internist act more
collaboratively and respectfully in interactions with ancillary medical staff. These staff – nurse
practitioners, physician assistant, and social worker – felt that their professions were not adequately
respected by physicians and that their skills were underutilized and undervalued. All the ancillary
staff, including the case manager and pharmacist, requested that physicians make efforts to foster
collaboration and improved communication, instead of marginalizing their roles, failing to
recognize them as partners in patient care, and neglecting to respond to requests for information in
a timely manner or proactively provide patient updates.

The competency that was an understood requirement of the comprehensive internist is that of
providing evidence-based decision-making in medical diagnoses. The internist’s ability as
diagnostician was never called into question by the non-physician roundtable participants. For the
internists in the room, their strongest desires from the medical system were for engaged, activated
patients; strong, respectful, well-defined relationships with subspecialists; and ready access to
decision support tools for diagnosis of uncommon medical conditions and access to infrastructures
that provide seamless interactions with subspecialists and other health care stakeholders.
                      Summary of Health Care Team Roundtable

Heath care team expectations:
   • Respect for non-physicians
   • Delegation of administrative functions to non-physician team members
   • Payment for administrative activity
   • Shared team responsibility and accountability
   • Empowerment of team members to work to the limit of their ability/license
   • Clarification of team roles
   • Emphasis on proactive, preventive care
   • Effective communication with/among team members; better sharing of clinical
      information (e.g., to maximize use of pharmacist)
   • Elimination of conflicts of interest
   • Shared leadership; it is not uniquely the domain of physicians

Comprehensive internist competencies:
     Same as overall competency list, with emphasis on team behaviors and delegation

         Diagnostic skill is the most important competency of the generalist and cannot be

Suggested Board Actions:
   • Require assessments of internists by non-physician health care team members
   • Create team simulation assessment modules (similar to airline pilot testing) to be
      used in MOC and training

   •     The idea of virtual linkages among small practices to accommodate shared
         systems resources was raised
   •     EMR identified as an important tool to support information management but not
         as a panacea, with concern about de-personalization and interoperability
   •     Overburdening of the internist frustrates patients, team members and internists
                                          Specialist Roundtable
                                               Page 1 of 9

                          The American Board of Internal Medicine
                        Committee on Comprehensive Internal Medicine
                                    Specialist Roundtable

On April 5, 2007, ABIM hosted the second of its Comprehensive Internal Medicine roundtable
discussions. This meeting focused on the interface between generalists and specialists in the
delivery of patient care. Participants included specialists in cardiology, emergency medicine,
endocrinology, gastroenterology, oncology, and rheumatology; the same three patients participating
in all four roundtables; a representative each from AAIM, ACP, and SGIM; general internists; and
ABIM staff.

In discussions as pairs, participants shared examples of effective specialist/generalist interfaces in
which the interactions worked ideally. From these examples, the full group reported on themes of
best practices of specialist/generalist interactions. A personal relationship between the specialist
and the generalist was a consistent theme. Geographic proximity, especially with offices in the
same building, is ideal, as in-person interactions were seen as significantly richer than phone calls,
letters, or e-mails. The participating physicians agreed that the smoothest relationships were those
within the same building, with the ability to informally drop by another’s office to touch base.
Whether through face-to-face interactions or virtual communications, all agreed that the
specialist/generalist interface works optimally when the physicians know each other personally,
through some sort of social bond. As in many situations, this places the solo practitioner at a
disadvantage, without the social infrastructure of group practices, but “virtual” linkages are still
possible. Even geographic proximity, however, does not ensure effective physician/specialist
interactions: one of the roundtable patients reported a significant lack of communication between
physicians within the same practice. Another patient carries a large binder of her medical history
from office to office because she has learned she cannot rely on communication between her

Regardless of physical proximity, all roundtable participants agreed that effective communication
among specialists and general internists – especially at care transition points – was paramount.
Electronic medical records (EMRs) can facilitate the establishment of “virtual” personal
relationships and were lauded as a means of improving communication and care coordination
across practices and hospitals. However, the quality of the electronic communication (the depth,
detail, personal connection) is dependent on the physician’s effort. Some of the physicians ensure
that very rich detail of patient encounters is entered into their EMR. A general internist at the
roundtable related a positive experience with an alternative “virtual” solution: he held an urgent
conference call with two specialists while a patient was suffering an acute emergency crisis. This
remarkable, effective solution for communication – which most likely saved the patient’s life – had
occurred only once in the internist’s career. In residency, trainees should be exposed to effective
specialist/generalist interactions and care coordination, particularly through optimized use of
electronic medical records to facilitate communication. Effective communication requires a mutual
commitment from the physicians as well as the establishment of an organized social structure –
virtual or in-person – to facilitate interfacings.

The most important component of specialist/generalist communication is the clarification of
expectations. Patients and physicians related countless situations in which they were uncertain
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whether the generalist or the specialist was responsible for ordering tests, relating results, following
up, communicating to the patient, etc. One patient mentioned an incident in which her test results
were significantly delayed because both her general internist and her specialist thought the other
physician would be relating the results to the patient. In addition to clarifying role expectations, the
generalist needs to clarify to the specialist his expectation for the referral, such as what specific
question or diagnostic dilemma the generalist wants the specialist to answer through this consult.
Not only does this specification allow for higher quality, more efficient care, but the lack of such
clarification puts the specialist in a difficult position. When a subspecialist is unsure why he was
consulted, he assumes it must be a complex case that was beyond the generalist’s expertise, and
therefore the subspecialist might run extraneous tests because he is afraid of missing something in
what seems at first routine. Sometimes, however, the intended purpose of the consult is merely for
a second opinion, for expert disease management, or even per the patient’s request, and not
necessarily for a particularly complex case. At the time the referral is made, the generalist bears
the responsibility of communicating to the specialist the reason for the referral.

Not only must the generalist establish concrete negotiations and expectations for each physician’s
roles and responsibilities, but they must also communicate expectations to the patient. Just as
subspecialists are sometimes unaware of the reason for a referral, often the patient does not
understand why he has been referred to the subspecialist. Once they have visited the specialist,
many patients are also unsure which physician – the generalist or the specialist – they should
contact when they have a problem or question. Sometimes certain questions should be directed to
the specialist, but patients mistakenly consult their generalist. Other times, specialists are bothered
by patient questions that they believe should have been asked of the generalist instead. Patients are
also unaware of the protocol for “horizontal referrals”: whether all referrals should come from their
general internist or whether they can request a referral from their gastroenterologist, for example,
when they suffer nasal congestion and would like to visit an ENT. The generalists in the room
resented horizontal referrals made by subspecialists, but the specialists in the room stated that they
sometimes do make such referrals in order to expedite the patient’s care rather than going through
an additional administrative hassle of consulting the generalist. Other specialists receive requests
for horizontal referrals because the patient states he could not get a response to the generalist’s
office, and these specialists resent such requests that stem solely from the inaccessibility of the
generalist. Patients are sometimes unaware whom they should contact for a referral; when not
limited by insurance restrictions that require a referral from a primary care physician, patients with
an injured ankle may seek out an orthopedist directly, for example, without consulting their
generalist. Patient-driven referrals and horizontal referrals sidestep the generalist, who needs to
remain “information central.” Generalists should emphasize to specialists and patients that in order
to care optimally for the patient, the generalist needs a complete, current medical history including
all specialist interactions. In the absence of interoperable EMRs, physicians and patients should
make efforts to facilitate bidirectional communications regarding all of the patient’s referrals and

Other sensitive “turf” issues generated debate among the subspecialists and general internists at the
roundtable. Most of the physician participants felt that subspecialists’ and general internists’
continuing informal education should be facilitated by the other: the general internist seeks
updated information from the subspecialist on updated clinical practice guidelines in the
subspecialist’s field, while the subspecialist prizes the internist’s more global perspective of the
                                           Specialist Roundtable
                                                Page 3 of 9

health system (insurance, general healthcare environment) that he can bring to shared decision-
making with subspecialist. Most physicians expressed the need to establish a two-way teaching
network among subspecialists and general internists, particularly due to a decline in the informal
education that used to take place in doctors’ lounges via conversations about new studies and
changing clinical practice guidelines. A few generalist physicians at the roundtable, however, felt
they would be perceived as “lazy” if they regularly consulted subspecialists for such updated
guidelines, and some subspecialists strongly believed that if they did not communicate new clinical
guidelines to general internists, the generalists would not be able to “keep up” with important
changes in the field.

One of the more contentious issues between specialists and generalists at the roundtable was the
determination of appropriate timing of a referral within the course of the disease. All the
physicians agreed that appropriate referral timing was important, but the generalists and specialists
disagreed regarding what the specific appropriate referral timing was. Some of the specialists –
particularly the diabetologist and rheumatologist – promoted a paradigm shift in referral timing so
that patients were referred to a specialist immediately after the first diagnosis with the disease,
particularly chronic diseases, rather than awaiting a crisis or complication to occur. For example, a
patient can prevent significant diabetes complications by visiting an endocrinologist in the early,
even presymptomatic, stages of the disease. Nephrologists also report better clinical outcomes with
patient consults immediately following initial diagnosis. In addition, such early referrals build a
specialist/patient relationship as a strong foundation, rather than struggling with initial first contact
in the middle of a crisis situation. In other specialties, subspecialists resent generalists who refer
too early in a disease stage without managing the disease up to their skill level, and they perceive
such generalists as offloading patients onto the subspecialist merely to triage more “difficult” cases
and reduce overall patient volume. In some disciplines, the scope of generalist practice was
murkier, such as whether to refer a patient to a cardiologist once a patient’s risk is identified, or to
wait until a disease is clinically manifested. Some of the general internists in the room resented the
endocrinologist’s concept of early subspecialist co-management, as the generalists felt that the
early stage of diagnosis and patient relationship-building is “one of the most satisfying stages of
providing patient care,” and if subspecialists “take that away, what’s left for the general internist?”
In response, one of the patients noted that her primary care physician did not successfully diagnose
her disease – albeit a rare disease – for a significant length of time and did not refer her to a
specialist; the patient was dying in an emergency room when a specialist was finally consulted and
immediately diagnosed her. With more common diseases such as diabetes, the physicians in the
room could not reach a consensus regarding the appropriate stage of disease for the general
internist to generate a referral. In addition, there was debate regarding the stage at which patients,
once referred, should be returned to the care of the generalist, particularly in disciplines such as
oncology and endocrinology in which the specialists often want to be recognized as experienced
primary care physicians responsible for the longitudinal care of their patients. Some generalists,
however, expressed frustration that sometimes a specialist mistakenly believes the consult on a
procedure is all that is required or expected of them, and the specialist makes no effort to create an
ongoing relationship with the patient. Such lack of specialist follow-up also frustrated the patients
at the roundtable.

Overall, general internists sensed a lack of mutual respect between generalists and subspecialists, a
dynamic that can erode the efficacy of the generalist/specialist relationship. The patient
                                          Specialist Roundtable
                                               Page 4 of 9

participants mentioned specific examples of the intimidation their general internists felt with certain
specialists, which often resulted in the generalist hesitating – or refusing – to communicate directly
with the specialist. Expectations regarding these sensitive “turf” issues should be resolved and
clarified between the generalist and specialist, and communicated to the patient. From a
professionalism standpoint, physicians often feel uncomfortable providing honest feedback to each
other when performance expectations are not being met.

The physicians briefly discussed the reasons for the difficulty of general internist/subspecialist
relationships. They noted that internists and subspecialists of internal medicine typically interact
better with surgeons and multidisciplinary physicians than with each other. The boundary issues
within the field of internal medicine likely stem from the fact that general internists and
subspecialists all have a general foundation in internal medicine, as opposed to surgeons whose
specialty is significantly different. This basic internal medicine foundation may lead general
internists to erroneously believe at times that they do not need to consult a subspecialist because
“we’re all internists; I can handle that just as well as the subspecialist can.” Similarly, the
subspecialist may perceive himself as a “everything the general internist is plus more,” since the
subspecialty is an “add-on” to the general internal medicine training he shares with general
internists. The generalist can also feel inferior due to the subspecialist’s “additional” expertise. In
addition, while surgeons use different billing codes, all internists – both general internists and
subspecialists – share billing codes and are thus in direct competition. The physicians at the
roundtable expressed frustration regarding this dynamic, and hoped to realize a more collaborative
approach to patient care through conscious clarification of expectations in each specialist/generalist

Physician accessibility was of consistently high importance to patients, and access was a similar
concern of the specialists and generalists regarding each other’s availability. One generalist stated
that he engages in constant negotiations with a cardiologist in order to convince him to see a
patient. An emergency medicine physician at the roundtable mentioned an incident in which he
consulted a neurologist regarding a head-trauma patient, and the half-listening neurologist replied
that the patient was not sick enough and he would wait to see the patient the following day. When,
during the same conversation, having sensed that the neurologist was not paying adequate attention,
the emergency medicine physician repeated the case and the neurologist replied that the patient was
too sick for him to see.

Generalists are also frustrated when specialists are unavailable to see their patients within a
reasonable time frame. Often specialist offices will tell patients it will be four months until an
appointment is available, but that if the patient will ask his primary care doctor to call, the patient
might get an appointment sooner. Physician-to-physician communication usually resolves
availability issues, but when office staff or patients try to communicate directly with a physician,
they often get nowhere and get lost in the system. The physicians at the roundtable suggested that
offices should put systems in place so that office staff can handle accessibility issues with other
physician offices, without the need for direct doctor-to-doctor communication. Another solution
mentioned was that the generalist could triage the patient referrals he sends to a specific
subspecialist according to urgency. In situations when a subspecialist appointment is not urgent,
the generalist could explain to the patient when making the referral that the need is not immediate,
and reassure and educate the patient further on his condition. Often patients call subspecialists’
                                            Specialist Roundtable
                                                 Page 5 of 9

offices in a panic because they are unaware that their condition does not require an immediate
appointment. Agreement could not be reached among the physicians at the roundtable regarding
which physician – the subspecialist or the generalist – is responsible for referring another
subspecialist for patients with urgent conditions when the initial subspecialist is unavailable.
Similarly, there was no consensus regarding whether the subspecialist should communicate a lack
of availability to the generalist or directly to the patient (although all were in agreement that the
subspecialist has the obligation to take on some level of responsibility for scheduling issues). As
with negotiation and clarification of roles, specialists and generalists need to set general principles
regarding availability issues, and to communicate those expectations to the patient.

Patient expectations from specialist/generalist interactions echoed many of the competencies they
identified at the first roundtable. Overall, patients expect to be taken care of and cured. They
expect adequate time with the physician during the appointment, and for access to the physician as
needed. This access includes availability of the subspecialist in an ongoing relationship with the
patient for the duration of the disease, including follow-up appointments directly with the
subspecialist. However, patients are often uncertain which physician they are supposed to contact
when problems arise, and they desire clarification of the specific roles of their general internist
versus the subspecialist. Knowing the specific reason for the referral, what to expect from the
subspecialist visit, and what will happen in terms of follow-up are very important to the patient.
Patients want their general internist to help them set an agenda for the subspecialist visit, preparing
them for what questions to ask. Patients also expect the generalist to debrief the subspecialist visit
after the referral, to translate and interpret the specialist’s diagnosis, test results, or treatment plans.
Physicians must prepare the patient for what the future holds, in terms of follow-up appointments,
further tests, who will explain test results, ongoing access to the specialist, etc.

Patients identified a strong need for patient education, whether stemming from the general internist
directly or from a specified non-physician member of the health care team. Patients need assistance
in navigating the complex health care system, and want guidance on how to be a better patient.
Patients crave empathetic coaching on coping with undifferentiated diagnoses, how to deal with
what can’t be diagnosed, treated, or cured. They want to be taught how to be a good patient, to
actively ask questions, to ask the right questions, to adopt shared responsibility, and to promote a
positive relationship with their physicians. They wish for empathy, a sense that the physician
understands the significance of the problem to the patient, and they want to be heard. Participants
at the roundtable suggested that ABIM could include on its website a guide to patients on how to be
a good patient and how patients can help make their doctor a good doctor through active
engagement and education. ABIM could encourage physicians to use pre-appointment patient
questionnaires that prompt the patient to consider questions and concerns in advance, or ABIM
could post a sample questionnaire on its website for patients to print out, complete, and carry to an
appointment so they do not forget what they want to address during the physician visit.

Patients would appreciate access to their own portable electronic medical records, so that they can
take a lead in bridging communication gaps among their physicians, can be reassured through the
transparency of the physician interactions, and have access to the records prior to their appointment
in order to help set an agenda, and after their appointment in order to look up questions that arise
later. Even though physicians often say, “Call me if you have any questions,” patients are often too
intimidated to call the physician when they do not quite understand the treatment or have questions
                                          Specialist Roundtable
                                               Page 6 of 9

within a few days after the appointment. Patients, as articulated at the first roundtable, would like
an advocate, perhaps a family member or non-physician in the office, who can assist in care
coordination, system navigation, and translation of medical terminology. Patients viewed their
generalist as responsible for debriefing specialist appointments and serving as “information
central.” They suggested that the general internist could even initiate three-way conference calls
with the patient and specialist when the patient has questions regarding specialist care. Physicians
also appreciate the efficiency of “curbside” consults to each other without an actual referral, via
stopping by someone’s office or sending an e-mail, yet such offline consults are not reimbursed.
The healthcare system should establish incentives for doctors to communicate with each other, via
conference calls, e-mails, or other methods that are currently not reimbursed.

Patients expect seamless communication between their generalist and specialists. Patients at the
roundtable – unless they had experienced otherwise – assumed that there were comprehensive two-
way communications between the generalist and specialists. On the contrary, many specialists at
the roundtable indicated that unless they have an interoperable EMR with the generalist, they
receive very little patient information to begin with and no post-referral follow-up information at
all. There is an expectation among physicians that the specialist reports back to the generalist, but
generalists rarely provide feedback to the specialist, so that specialists never know whether their
treatment recommendations were followed or were successful, or why a patient does not return for
a follow-up visit with the specialist.

Patients also expect that their generalist knows both the patient and the specialist well, and that the
generalist will use his knowledge of the patient’s personality, preferences, and other characteristics
in order to match the patient with a complementary subspecialist (level of empathy, personality,
how personal, how data-driven or fact-oriented).

To fill these gaps, the roundtable participants identified the need for adequate communication
between the generalist and specialist and between the physicians and patient, particularly in terms
of clarifying expectations among all three individuals. Patients need to know what to expect of the
subspecialist visit and relationship, including its limits. Patients also want their own
responsibilities defined.

Regarding what competencies ABIM should assess in the quality of specialist/generalist
interactions, both physicians and patients emphasized the clarification of roles, bridging of
communication deficits, and education of patients. Specialists should take responsibility for the
timeliness of their offices, and ABIM could measure turn-around times for reporting of test results,
completing consult notes, availability for referral appointments. In terms of communication, each
practice could develop a brief brochure to provide to patients, with information on how soon they
can expect to be seen, the reasonable time frame for a return phone call, in what situations the
patient should call the specialist, and what to expect in general. ABIM could evaluate physician
communication skills on multiple levels, including how the physician deals with conflict, and could
require both peer and patient evaluation surveys (including standards for accessibility and referral
tracking). ABIM could encourage residency programs to include training on how to consult, when
to consult, and how to communicate information back to other physicians.
                                           Specialist Roundtable
                                                Page 7 of 9

ABIM could also ensure that adequate systems are in place for patient education, information
management, and population management. Systems-level support, such as an EMR or other health
information technology (HIT) infrastructure, could greatly facilitate the flow of communication
among physicians, particularly in conveying what tests have been ordered, the reason they were
ordered, and who is responsible for follow-up. Although participants were hesitant – due to
financing limitations – to advocate that ABIM require physicians to use an EMR, they felt that
ABIM could require that the physician have some system for referral tracking. It would also be
beneficial for ABIM to articulate which functionalities make an EMR a “good” EMR (since some
are better than others), such as decision support tools, referral tracking mechanisms, physician-to-
physician e-mail capacity, and registry/population management tools.

Barriers identified as inhibiting the effective communication and relationship-building among
generalists, specialists, and patients were shorter patient encounters, finances (in terms of requisite
patient appointment volume, reimbursement inequities, and costs of information technology),
infrastructure, and training experience that is not reflective of practice experience.

In terms of referral competencies, ABIM should assess the referring physician at various stages in
the referral process. When the referral is made, the physician should have the demonstrated ability
to ask a specific question or diagnostic dilemma to be addressed during the consult, rather than just
refer generally. This could be assessed using an ABIM practice improvement module (PIM) or via
exam questions such as “Which of the following questions would you ask if referring to a

In preparing the referral, the physician must demonstrate both appropriateness and efficiency.
Appropriate timing within the disease is important, to ensure that the generalist manages the
disease up to the level of his skill but does not wait too late in the disease stage to transition to the
specialist, yet consensus could not be reached among the roundtable physicians regarding what
timing was appropriate. The ABIM could define the scope of practice for general internists, e.g.,
defining up to what level the general internist should manage heart failure but above which he
should refer to a specialist. Exam questions could include identifying the level about which lab test
results should be referred to a subspecialist and other clinical practice guidelines for referrals, or
what first- and second-order evaluation and treatment approaches should be followed before a
referral. PIMs could also assess whether the referring physician conducted the appropriate baseline
evaluation before calling for a consult. Registries could demonstrate whether the physician is
overutilizing subspecialists in comparison with population benchmarks.

The referring physician must also facilitate the patient’s understanding of the reason for the
referral. Pre-referral communication should include clarifying to the patient what the roles of each
physician are and preparing the patient for what to expect.

Post-referral management includes negotiating the management roles with the other physician.
ABIM could require evidence that role expectations were established between the physicians
(regarding scheduling issues, test results, follow-up, co-management, etc.). This communication
should eliminate ambiguity regarding each physician’s role, and should also include (in the note or
cover letter) background on the patient’s preferences, the reason for the referral, whether the
referral was per the patient’s request, etc. Clarification of which physician is responsible for
                                          Specialist Roundtable
                                               Page 8 of 9

ordering tests and following up is essential, as many physicians in the room noted experiences in
which test results were never interpreted to the patient because both physicians thought it was the
other physician’s responsibility. Although the typical guideline is that the ordering physician is
responsible for reporting results, physicians should clarify this guideline, with particular emphasis
that the physician must also report the results to the other physician. Often when test results are
normal, nothing is communicated. However, even if the specialist reports the results to the patient,
patients’ expectations remained clear that the general internist should serve as an interpreter of the
specialist’s report. In addition, specialists often do not receive any follow up from the referring
physician after the specialist visit, regarding whether the specialist’s recommendations were
followed and were effective.

Post-referral patient management includes the competency of the generalist to facilitate patient
understanding, to serve as a translator of the subspecialist visit, and to provide the patient with
enough information to empower the patient.

ABIM could also require demonstration of physician development of a functional practice model
with systems that address access (phone coverage, response times), referral tracking (with a
registry, EMR, or other information tracking system that includes tests requested and completed),
information management (including methods of communicating information to other physicians),
population management (use of a registry and benchmarks, including regarding referrals), and
demonstration of quality improvement in a systems-practice model. Physicians should develop
systems that ensure there are no gaps, particularly in care transitions, and no “white space” in
which accountability is undefined. Systems should be built so that the right thing occurs by default,
such as requiring annual appointments that catch any tests that were not followed-up (rather than
conducting prevention work only when the patient makes an appointment for something else
specific). Physicians often raised the issue of whether ABIM can hold physicians accountable
when their infrastructure is significantly flawed and beyond the physician’s control. A few
physicians at the roundtable stated that even though they work in a large practice, they have control
over their own microsystem, and that much of their quality level is due to the systems, processes,
and infrastructure they have personally established.

A common understanding of the specific goal of each consult should be established among the
generalist, specialist, and patient. To ensure proper communications and negotiations regarding
roles of the generalist and specialist, the roundtable discussed the potential for creating a referral
agreement or “compact” to formalize expectations between each specialist and generalist,
particularly since there appears to be no common universal understanding of each physician’s role.
The “compact” concept was embraced in theory, though the physicians were hesitant to make it
highly formal or legally binding. The consensus was that ABIM could make a template available
for such a compact guiding communications between general internists and subspecialists, which
would include explaining what is wanted and expected from the consult, methods for bidirectional
feedback, and roles negotiations (particularly regarding responsibility for communicating with the
patient). Or, the referring physician could address these issues, roles, and expectations in the note,
and instruct the specialist to contact him only if there is disagreement. A compact need not be
individualized, but could merely outline general principles and guidelines for the
specialist/generalist relationship. ABIM could work with medical societies to establish suggested
principles. The physician could then determine how to implement these principles, and a PIM
                                         Specialist Roundtable
                                              Page 9 of 9

could evaluate their implementation and what systems are in place to ensure the guidelines are

Lastly, the subspecialists asked the general internists what ways they could help save primary care.
The subspecialists clearly felt that primary care was important, and that resuscitating primary care
practice is a two-sided issue that includes specialists. One specialist noted that in his experience,
general internists are so overburdened that they are happy when the specialist helps with anything.
The roundtable participants detailed that specialists could help primary care by sharing
infrastructure burdens (EMRs, other systems); supporting better reimbursement models,
particularly to address infrastructure needs; rotating during training so that generalists in training
can experience well-functioning systems (as opposed to the poor infrastructure in many academic
medical centers that results in generalist residents doing mostly administrative work); supporting
the education of generalists, and maintaining a community of internal medicine by encouraging the
integration of general internists and subspecialists, rather than separating from generalists. Primary
care physicians need a network of colleagues for input, and specialists can foster such a community
that incorporates generalists rather than isolating them.
                           Summary of Specialist Roundtable

Specialist expectations of Generalists:
   • Personal relationship between generalist and subspecialist
   • Negotiate/clarify responsibility for patient (communicating with patient, follow-
       up, ordering tests, providing results)
   • Timely communication of a specific question or diagnostic dilemma as reason for
   • Make referral at appropriate time in stage of disease management
   • Facilitate patient understanding of reason for referral, clarification of roles
   • Follow up with specialists about whether treatment was followed/effective
   • Generalist will be accessible to patient so that patient does not utilize subspecialist
       for questions within generalist’s domain
   • Medication reconciliation

Generalist expectations of Specialists:
  • Mutual respect
  • Reasonable time interval for referral appointment, with subspecialist handling
      communication to patient about scheduling issues
  • Clarification to patient and generalist responsibilities for ordering tests and
      interpreting results
  • Provide education about updated clinical practice guidelines and medical

Competencies of Comprehensive Internist:
     Same as overall competency list, with emphasis on information management and
     up-to-date knowledge of guidelines, particularly when to refer

Suggested Board actions:
   • Evaluate communications skills of both generalists and subspecialists
   • Require evidence of a “compact” between them to clarify responsibilities
   • Establish standards for and measure office and appointment availability
   • Measure turn-around times for test results, consult notes among generalist,
      subspecialist and patient
   • Require patient feedback survey
   • Define scope of practice for generalists and subspecialists –define when to refer to
   • Require the capacity to view and analyze practice as a patient population, and
      benchmark metrics such as the percentage of referrals in specific patient
   • Require demonstration of QI in systems-based practice

   •     The purchasers supported subspecialists teaching the generalists
   •     Purchasers supported structured agreements between generalists and specialists
   •     Purchasers supported ABIM defining appropriate standards for when to refer
                                   Health Plans Roundtable
                                         Page 1 of 7

                     The American Board of Internal Medicine
                   Committee on Comprehensive Internal Medicine
                             Health Plans Roundtable

The third of the ABIM-hosted Comprehensive Internal Medicine roundtables was held on
April 13, 2007, and focused on health plans’ perspectives of the ideal comprehensive
internist. Participants included internal medicine physician executives from three major
health plans, and one regional non-profit managed care organization; a physician
representative each from AAIM, ACP, and SGIM; the three patients; general internists;
and ABIM staff. The objective of the meeting was to identify opportunities to strengthen
generalist practice by exploring the ideal vision of value-added comprehensive internal

The health insurers all shared the desire to facilitate improved patient care, especially as
it relates to reduced employee absenteeism, a chief concern of the insurers’ clients.
Aware of the decline in primary care practitioners, which one health plan representative
referred to as “terrifying,” half of the health plan attendees expressed the importance of
saving primary care practice. The other two health plan representatives, however, did not
feel a vested interest in reviving primary care, and instead viewed the healthcare delivery
system as simply part of a competitive free-market economy in which retail “minute-
clinics” and disease management companies would fill the void should primary care
become extinct.

One attendee, an internist by training, stated that the major health plan that he represents
is no longer merely an “insurance company”; rather, the health plan considers itself a
“diversified health and well-being company” that administers benefits for employers.
These benefits include disease management initiatives, a prenatal program, a
comprehensive reminders program for preventive screenings, immunizations, etc., and a
comprehensive telephone service continuously staffed by nurses and counselors. The
health plan attributes this telephone service with an estimated annual savings of $43
million in avoided employee absenteeism and lost productivity. This health plan
representative stated that from the health plan perspective, the specific health care
provider is irrelevant; the health plan’s concern is that someone – be it a nurse
practitioner in a retail clinic or an ABIM-certified comprehensive internist – provides
preventive and comprehensive care to the multi-million individuals the health plan
insures in the U.S.

The representative from the non-profit managed care organization, which provides health
care services for regional low-income residents, indicated that they similarly fill the void
for preventive services that primary care leaves behind, such as providing outreach
workers to administer prenatal care in at-risk populations, which has greatly improved
health care quality outcomes.

Comprehensive internal medicine, and primary care itself, could essentially be in
competition with disease management companies in the field of case management, and in
competition with accessible minute-clinics and expert physician specialists in the field of
                                   Health Plans Roundtable
                                         Page 2 of 7

medical care. Unless comprehensive internal medicine proved and defined its value in
comparison with other medical models, some of the health plan representatives at the
roundtable felt that losing primary care would not necessarily result in poorer quality and
efficiency outcomes. To save itself, according to one of the health plans, “primary care
needs to become indispensable to health plans and patients” and “must step up to a higher
standard” because “current general internists are not meeting current needs.” This
representative would support comprehensive internal medicine not as a mere volume
boost in primary care practice, but only if it achieved dramatically improved practice
performance on behalf of patients. Of course, holding general internists to a higher
standard may result in an even further shortage of physicians willing to pursue primary
care. The new standard would need to be feasible, well-defined, and value-added in
order to attract physicians to general internal medicine practice.

In order for health plans to invest in primary care, they require “proof” that general
internal medicine actually adds value to the health care system through higher levels of
quality and efficiency in patient care. General internists would need to transform
themselves through demonstrated optimization of system resources, measurable
improvement in cost effectiveness (appropriate rates of specialist referrals and preventive
disease rates in the patient population), reduced administrative costs, and efforts in cost
avoidance (generic prescriptions, discouraging costly imaging and diagnostic services).

Throughout the day, discussions concentrated on identifying competencies and ABIM
testing areas that would enhance the value of primary care from health plans’ perspective.
The significance of diagnostic skill was a given, and all were in agreement that the
comprehensive internist – or at least a designated individual in the physician practice –
must be responsible for the institution of effective systems. Currently, “physicians are
poor businesspeople,” and basic business competencies should be taught in residency.
Use of disease registries was another key component that would be of value to health
plans, as it would enhance proactive, preventive care by helping identify which patients
in the practice population are at risk for high-cost chronic diseases. A registry would not
necessarily need to be part of an expensive electronic medical record (EMR) system; in
fact, many health information technology (HIT) platforms lack registry capability. The
health plans favor any information system that supports population-based care, even
something as simple as a billing system that indicates diabetic patients, which physicians
could then use in an ABIM practice performance module (PIM) to develop the disease
registry and an implementation plan, and then to establish metrics for improved
outcomes. Dr. Richard Baron, Chair of the ABIM Committee on Comprehensive Internal
Medicine, recalled that during his tenure as Chief Medical Officer (CMO) of a managed
care organization, his perspective of patients was different depending on which role he
held at that moment: spending half of each day as a practicing general internist seeing
patients, he saw the patients as individuals; for the other half of the day, as a CMO, the
patients were no longer individuals but populations. Dr. Baron saw the ideal
comprehensive internist as a convergence of these two roles. Through both business
acumen and optimized registry usage, the health plans’ vision of the comprehensive
internist is in many ways a physician who thinks more like a CMO than a traditional
general internist.
                                   Health Plans Roundtable
                                         Page 3 of 7

Disease registries would assist physicians in developing proactive care plans instead of
concentrating primarily on reactive care. Health plans, and our aging U.S. population,
desire effective, proactive, preventive patient care and chronic disease management. The
health plans favored an evolution from disease management toward a case management
model to better manage high-cost chronic diseases (e.g., diabetes, chronic heart failure,
hypertension, asthma). ABIM’s comprehensive internal medicine competencies should
include the demonstrated ability, perhaps through a PIM, to analyze quality and cost
drivers within the diplomate’s patient population and practice system, conduct root cause
analysis, develop action plans, understand and utilize quality improvement measures in a
data-driven population and system assessment. The health plan representatives were
strong proponents of the Wagner Chronic Care Model, and felt that ABIM should require
demonstrated knowledge of and facility with this model in planning and organizing
patient visits and in integrating practice resources with community resources. ABIM
could test diplomates on the Chronic Care Model through use of examination questions
and use of PIMs, in which diplomates could set specific goals in accordance with the
Chronic Care Model and demonstrate achievement of incremental milestones toward
those goals. For example, the diplomate could conduct or hire a consultant to conduct an
analysis of his practice’s emergent care ratio in relation to a risk-adjusted regional
average, and either establish systems that would demonstrate improvement or explain
what his current systems accomplish to maintain low levels of emergency room

A recurring theme in these comprehensive internal medicine roundtables has been the
disadvantaged position of solo practitioners and small-practice physicians in lacking
comprehensive, exhaustive resources for patient education, care coordination, extended
access, and the like, which in turn creates additional burden on the overworked
physicians in these practices. However, the Chronic Care Model’s reliance on community
linkages would force primary care physicians to “shed their Lone Ranger complex” and
recognize that they cannot provide optimal patient care when they conduct all their work
alone. Physicians should recognize the enhanced effectiveness of teams and the potential
benefits of partnering with outreach workers, community resources, and mid-level
providers. Many physicians view mid-level providers as competition, and resent that
such providers get paid the same amount for “easy” cases like sinusitis as the internist
does for more complex, time-consuming cases. Instead, general internists should utilize
– and foster relationships and enhanced communications with – mid-level providers and
minute-clinics as a means of reducing the internist’s appointment volume in order to
concentrate on the complexities for which he is best trained.

The health plans acknowledged, as was related by physicians during previous
roundtables, that not every general internist is interested in or skilled at developing the
business-related, data-management, and population-assessment competencies that could
greatly enhance patient care. For those physicians whose skill lies primarily in direct
patient care, community resources or consultants could assist physician practices in
instituting systems and process improvement. The health plans expressed potential
willingness to facilitate the dispatch of consultants for these purposes and to provide
                                   Health Plans Roundtable
                                         Page 4 of 7

practices with an updated compendium of community resources to assist with the
“virtual” community linkages promoted by the Chronic Care Model.

The value to health plans of any care delivery model lies in its ability to reduce costs
without sacrificing quality patient care. In addition to reducing rates of high-cost chronic
diseases, the health plans’ chief ideal for the comprehensive internist was an ultimate
decrease in emergency room (ER) utilization rates. Health plans highly value appropriate
ER usage in terms of a) patients with acute conditions using the ER merely because of
limited primary care access, b) patients with ambulatory care sensitive conditions that
result in appropriate ER use or inpatient hospitalization but should have been avoidable
with proper preventive primary care, and c) patients whose ER use was necessary but
were then unnecessarily admitted to the hospital. Through a PIM, ABIM could require
diplomates to develop an emergency room usage optimization plan involving practice-
level changes such as open access scheduling (which not only reduces no-show
appointments but also improves care access to underserved populations), optimized
voicemail message systems (with options for triage 24/7, instead of instructing patients in
after-hours emergency situations to dial 9-1-1), expanded urgent access and hours of
operation outside of standard business hours, established protocols with hospitals for
communicating with the internist if his patient visits the ER, hospital-internist protocols
upon inpatient hospital admission.

For health plans to recognize the value of comprehensive internal medicine through
reward or recognition, the physician or practice must demonstrate an evident economic
benefit in addition to a quality benefit. ABIM should develop PIMs that measure
improvement on select controllable variations in care over time that positively impact key
cost drivers in both cost and quality, through metrics the health plans most value, such as
ER utilization rates or optimization of specialty and diagnostic services. For example, if
evident through a PIM that a physician’s systems corrections as outlined from an ER
optimization plan achieved a target decrease (e.g., 50%) in ER utilizations, health plans
would be willing to institute a recognition program for appropriate ER use that would
drive more patient business to that physician or practice. For an overburdened primary
care physician with a patient load beyond capacity, such a recognition program would
provide little incentive.

In addition to care coordination with hospital and emergency room staff, ideal
comprehensive internists would develop structures and processes that provide
mechanisms for improved care coordination and care transitions with specialists,
laboratory/pharmacy systems, and other medical providers. ABIM could require, through
PIMs, measures of effective care coordination and communication between care settings
and physicians, through development of protocols for communication (methods,
timeliness, reliability), establishment of accountability and clear expectations, shared
decision-making, systems to optimize care transitions (referral tracking, comparison to
benchmarked population metrics of optimal specialist utilization), and guidelines of
quality standards to which to hold other medical providers (follow-up and quality control
of lab work, prescription medication reconciliation, referrals, paperwork).
                                   Health Plans Roundtable
                                         Page 5 of 7

Additional competencies and system processes of value to health plans include ensuring
patient education and understanding of and engagement in treatment plans (either directly
or through nurses or ancillary providers), use of evidence-based clinical decision support,
and awareness of new medical advances and research that affect diagnostic acumen.

Many roundtable participants expressed the limitations of the current health care delivery
system, particularly finances issues. Among health care providers and stakeholders, there
is no agreement on which particular party is responsible for the health care system. One
of the health plan representatives stated that the current reimbursement system is “not
merely dysfunctional; it’s broken,” and he provided the example that in some cases,
hospital systems are reimbursed higher according to increased treatment complications
and higher rates of hospital-acquired infections, thus rewarding care delivery that is the
antithesis of quality patient care. The reimbursement system is incompatible with
optimal care delivery; the true value of quality care is based on outcomes, but
reimbursement is based on fee for service, regardless of the outcome. Participants
expressed willingness to explore whether ABIM, physicians, practices, and health plans
could partner in redesigning the health care delivery system.

Practicing internists in the room explained that it would be impossible to be an optimally
effective comprehensive internist within a dysfunctional system, and ABIM should
partner with health plans and other stakeholders to rebuild the system. One health plan
representative was reluctant to rethink the reimbursement system to better advantage
comprehensive internal medicine without demonstrated evidence of comprehensive
internists’ added value. He indicated that internists intentionally operate inefficiently and
that nothing in the current system prevents internists from improving patient care. Other
health plans at the table, however, recognized the financial investment required in
practice-level systems redesign, and the frustration that it often takes resources to save
resources. The health plans were willing to utilize pay-for-performance framework to
encourage specific medical services and discourage use of more costly services. But a
health plan representatives stated that, “Even if pay-for-performance works, it will
merely bring about incremental change. We need a radical redesign. How do we get
everyone to jump off the cliff together?”

Everyone agreed that there is no additional funding to put into the health care system, but
instead that value-added reallocation of resources and payments is the only viable
solution. Key potential solutions included reducing administrative costs (particularly
through reduced complexity) and reinvesting those savings into improved system
redesign, The health plans indicated that the current funding they invest in their own
disease and case management initiatives could potentially be made available to
generalists, provided general internal medicine had conducted research and pilots that
demonstrated and defined its value in improved efficiency and quality.

Health plans recognized the deficiencies of existing structures and systems to address
many of these quality issues. No matter how well the physician is trained, the Chronic
Care Model will not succeed without the infrastructure required to support it. Disease
registries, whether incorporated into EMRs or separate, are necessary to identify which
                                    Health Plans Roundtable
                                          Page 6 of 7

patient populations need increased outreach. Internists must also maintain an appropriate
maximum caseload in order to ensure establishing meaningful relationships with patients
and to allow adequate appointment time with each patient to conduct evidence-based
preventive measures.

The regional non-profit managed care organization has several initiatives that attempt to
provide practices with the requisite infrastructure to support the Chronic Care Model,
including funding of outreach workers, social workers, and content experts to lead
diabetic training for patients. Other structural models – most of which are not currently
reimbursed – include group visits and Drop-In Group Medical Appointments (DIGMAs),
in which ten to twenty patients, typically grouped by diagnosis (e.g., diabetes, asthma,
hypertension), their caregivers, a physician, and often a behaviorist who facilitates the
interaction, meet in an extended group appointment (typically 90 minutes) in which
patients’ psychological, behavioral, and education health needs can be addressed. Studies
show that DIGMAs improve physician productivity and patient satisfaction (through
increased interaction and support among patients, enhanced patient education, and patient
empowerment), but do not generate financial savings since they are usually not
reimbursed by insurers. 1 Another structural trend is the operation of ideal micro
practices (IMPs), highly personalized medical practices that operate as leanly as possible
by reducing overhead through use of information technology to improve workflow and
reduce staffing ratios, while achieving high results in the six Institute of Medicine (IOM)
aims: safety, patient-centeredness, timeliness, efficiency, effectiveness, and equity.

In small groups, roundtable participants identified structures, processes, and initial,
reasonable, feasible outcomes measures that could form a contract between health plan
and a comprehensive internist. Structures included team approaches, open access
appointment scheduling, extended hours, population-based disease management, patient
education and engagement, increased communications with patients and other healthcare
providers, collaboration with other physician practices, and sharing of resources.
Processes included implementation of the Chronic Care Model, improved interface with
specialists and emergency providers, use of registry data, and a demonstrated systems
approach to problem-solving. Measurable outcomes included total costs of patient care,
ER and specialist utilization metrics, pharmacy metrics, and patient satisfaction.

Internists identified a number of enhancements health plans could implement in exchange
for the internist’s evidence of practice improvement in quality and efficiency:
establishing a “gold level” for demonstrated comprehensive internists with reduced
administrative burdens by not requiring pre-certification or pre-authorization; data
sharing in a consistent format and integration of physician electronic medical records
with health plans’ claims system; real-time claims adjudication while patient is present in
the physician’s office; and potential reimbursement for improved communications (e-
mail, group visits, or other organized approaches to communication and access).

 E. B. Noffsinger, “Benefits of Drop-In Group Medical Appointments (DIGMAs) to Physicians
and Patients,” Group Practice Journal 48 (March 1999): 214, 26–28.
                                   Health Plans Roundtable
                                         Page 7 of 7

Health plans expressed interest in a three-tiered certification of general internists. Rather
than a bimodal stage in which an internist is either certified or not certified, health plans
favored the creation of three levels of “certified”: the first level would be equivalent to
our current certification standard, i.e., a “good enough” internist; the second level would
be a “comprehensive internist” who has demonstrated some of the competencies
discussed during this meeting; and the third level would be a “master internist” who has
also demonstrated significant efficiency measures. Criteria for the “mater internist”
could include consistent delivery of excellent system utilization, evidence of quality
improvement, evidence of efficient care, and either a large enough practice or “virtual”
practice to provide the infrastructure and resources necessary to achieve the six IOM
aims. The internists, however, were concerned that a tiered system of certification would
further fragment general internal medicine, and they felt uncomfortable attributing
transparent physician ratings to the public. Health plans are encouraging more
transparency in disclosure and reporting of certification status, in order to create more
informed consumers in this internet culture in which patients now conduct their own
informal research.

An alternative to the “master internist” would be to certify physician practices on similar
competencies (system competence, use of registries, EMRs, group visits, open access
scheduling, etc.). All the health plan representatives expressed enthusiasm for the
certification of practices in addition to certification of individual physicians and were
very open to providing additional payments/reimbursements at a practice level to
“certified settings.”

Although there is no “new” money to put into the health care delivery system, health
plans were open to reallocation of resources (particularly if comprehensive internal
medicine made disease management companies obsolete) toward reimbursement to
certified comprehensive internists or practices. In most cases, the health plans would
require evidence that tools (such as a particular PIM) reproducibly demonstrated
improvement in clinically meaningful metrics and efficiencies before the health plans
could make a strong case to their CFOs and actuaries that they should provide financial
support or rewards.
                                  Summary of Health Plan Roundtable
Health plan expectations:
   Accessibility that eliminates unnecessary emergency room visits:
   • Open access scheduling
   • Extended office hours
   • Optimized voicemail systems (include 24/7 triage instead of referring patients to 9-1-1)
   • Established protocols with ER so that physician is notified when patient arrives

   Population-based disease management (use of registry data) for:
   • Management of preventable diseases and high-cost chronic diseases
   • Measurement of cost-efficiency metrics, e.g., ER optimization, specialist utilization,
      overall costs of patient care, usage rates of generic drugs, specialty and diagnostic
      services, etc.
   Implementation of the Wagner Chronic Care Model
   Partnership (not competition) with retail “minute-clinics”
Competencies of the Comprehensive Internist:
      Same as overall competency list, with emphasis on:
              • Systems management
              • Accessibility
              • Population assessment
              • Effective communications and care transitions with other health care providers
              • Patient education and engagement
              • Efficient use of resources

Suggested Board actions:
   • Work to standardize EMRs to increase interoperability and provide standardized data for
   • Establish three tiers of certified internists, and identify levels publicly:
       • current standard (“good enough”);
       • comprehensive internist;
       • “master internist” (requires demonstrated performance in cost-efficiency, systems, and
           population metrics).
       (physicians expressed concern that “tiers” would further fragment general internal medicine)
   • Certification of practices in addition to individual physicians
   • Encourage more “real-world” training and systems emphasis in residency
   •     Health plans do not characterize themselves as insurers; they are just “pass through” agents
         connecting payers and providers
   •     Patients don’t trust information from health plans, which they see as insurance companies;
         it’s seen as cost cutting
   •     The health plan representatives fell into two camps:
              a) Want to help revive primary care; willing to pursue pilots or research projects,
                  particularly to assist with infrastructure
              b) Do not feel a vested interest in saving primary care
   •     Potential assistance from health plans:
                  • Precertification/preauthorization waivers for certified comprehensive internists
                  • Pilots or reimbursement mechanisms for alternate communications (e-mails, phone
                       calls, e-prescribing) or appointment structures (group visits, open access scheduling)
                  • Should primary care prove its worth, could redistribute to primary care existing
                       funding for disease management companies
                  • Funding and identification of consultants to assist physician practices in instituting
                       systems and process improvements
                  • Creation of community resources compendia to facilitate “virtual” community
                       linkages for small physician practices
                                       Purchaser Roundtable
                                            Page 1 of 7

                      The American Board of Internal Medicine
                    Committee on Comprehensive Internal Medicine
                               Purchaser Roundtable

ABIM convened its final stakeholder roundtable on comprehensive internal medicine on
April 27, 2007, with the same three patients and representative each from ACP and
AAIM who participated in all four roundtables, general internists, ABIM staff, and health
care “purchasers”: representatives from a major international corporation, two coalitions
of private and public employers, a labor union, and a government health and human
services agency. This meeting sought to identify comprehensive internal medicine
competencies that would be valuable to purchasers and unions in managing the health of
their employees and members, and to explore opportunities for ABIM to influence care
delivery through assessment and recognition of such competencies.

In contrast to the previous roundtable’s health plan participants, who to some extent were
comfortable replacing the current notion of “primary care” with alternative health care
delivery models that excluded “comprehensive internal medicine,” the purchaser
representatives expressed a significant concern for resuscitating primary care practice.
The purchasers sought more personal medical care for their employees, in the belief that
stronger patient-physician relationships result in better clinical outcomes, and were in
favor of the ABIM’s evolving concept of comprehensive internal medicine as continuous,
longitudinal care for patients across settings, with emphasis on team-based care,
accessibility, care coordination, bidirectional communication, and high-functioning
systems. One of the purchaser participants cited the work of Barbara Starfield, MD,
MPH, whose research suggests that quality and efficiency rankings are higher in nations
with a foundation in primary care. Starfield concludes that it is critical to quality care
delivery that patients be linked to a strong primary care practitioner, whom she defines as
a physician who is not only the patient’s “regular source of care,” but who meets the
following characteristics of primary care: first contact (physician is consulted whenever
patient has a new need for care or preventive services), accessibility, longitudinality
(physician develops a strong relationship with patient over time such that physician
understands patient’s needs and patient feels comfortable disclosing needs to physician),
care coordination (physician coordinates patient care so that referral advice is integrated
into total care), and comprehensiveness (physician provides care for all needs that are
common in the population and refers to specialists only when the problem is too unusual
or complex in the population for the primary care practitioner to manage). 1 The Agency
for Healthcare Research and Quality (AHRQ) integrates Starfield’s and the Institute of
Medicine’s definitions into a concept of primary care as first-contact, playing a key role
both in access to care and in coordination of care for patients with multiple providers or
specialists; holistic and comprehensive, focusing on the whole person and taking into
account his or her social context; information intensive; having uncertainty as a common
attribute of clinical decision-making; coupled with intrinsic opportunities to promote
health and prevent disease; and involving a sustained personal relationship between

 Starfield B. Primary Care: Balancing Health Needs, Services and Technology. New York: Oxford
University Press, 1998.
                                        Purchaser Roundtable
                                             Page 2 of 7

patient and clinician, with emphasis on compassion, continuity, and communication. 2
These qualities of primary care are consistent with many of the competencies identified
as essential to comprehensive internal medicine, thus indicating the potential of
comprehensive internal medicine certification to revitalize and strengthen primary care
practice. For the most part, this roundtable conversation focused on promoting and
resuscitating primary care practice, rather than limiting the discussion to “comprehensive
internal medicine,” though the two concepts are closely intertwined.

The participating purchasers were in favor of, and in some cases already engaged in,
work toward payment reform that supports primary care redesign and reimburses for e-
visits, group visits, and other alternate models that are not reimbursed in the current
payment system.

These purchasers saw a natural alliance between payers and providers, even more so than
in an alliance between payers and health plans. The purchasers were much more patient-
centered than the health plan representatives, as the purchasers’ constituents (employees
and union members) are patients. One participant, who manages worldwide employee
well-being services and health benefits for a major international corporation, stated that
they have been striving to “create relationships with providers, because it’s our belief that
the decisions that are most impactful on actions that patients take have an enormous
dependence on the relationship between the person who has the problem (the patient) and
the person who’s trying to help them with that problem (the physician).” The corporation
had reached the conclusion that in negotiating with health plans to solve patients’ issues,
they were “talking to the wrong people,” and thereafter, they began to talk to providers
directly without intermediaries to “create a direct relationship with physicians to get more
value for our employees/beneficiaries.” To them, the “two most important people who
need to be having a conversation in order to change the healthcare environment are
purchasers and providers.”

As in the other roundtables, access emerged as one of the key concerns of care delivery.
For the patients, increased access indicated better care quality outcomes and greater
patient convenience; for the health plans, increased access was a cost efficiency through
its correlation with diminished emergency room utilization rates; and for the purchasers,
access results in less employee time away from work. Though their reasons differed, the
desire from each stakeholder group was the same: needs for weekend and evening access
to primary care physicians, for open-access scheduling, for a designated non-physician
telephone hotline 24/7. The boom in retail “minute clinics” is largely due to the access
issue. The employed population often has to take a full day off work in order to visit a
physician in a typical practice (due to travel time, wait time – particularly for urgent
appointments not scheduled in advance, and lack of weekend or non-business hours),
which in addition to the hassle is a severe financial impact on hourly workers. This
inconvenience results in patients delaying making an appointment, which can negatively

 Agency for Healthcare Research and Quality, Rockville, MD. Research Agenda and Areas of Interest:
Center for Primary Care Research. April 2001. http://www.ahrq.gov/about/cpcr/cpcrres.htm
                                     Purchaser Roundtable
                                          Page 3 of 7

impact patient health. For employers, employee time away from work – and worsened
health due to delays in physician attention – directly impact productivity and profitability.
Primary care offices will continue to lose market share to retail clinics because of this
access issue.

Although retail clinics can resolve access issues, the purchasers at the roundtable
questioned whether retail clinics can achieve a personal physician-patient connection and
commitment to an ongoing long-term relationship with patients, which are clearly the
needs for patients with chronic conditions and the desires of most patients in general (and
result in better clinical outcomes, as shown by some studies). As such, the employers at
the roundtable saw potential value in primary care practices/comprehensive internists
pursuing integrated care with retail clinics. One purchaser stated that minute clinics are
“a locus of care that needs to be integrated into the medical home and needs to be
connected to the primary care provider,” and that he instructs primary care practices not
to fight the retail clinics, but instead to work with them to integrate them into the “overall
physician-guided model of care and medical home concept,” as the retail clinics can help
solve access issues “so that primary care practitioners have more time to spend on the
patients who really need their level of engagement and care,” but it is crucial that the
retail clinics’ patient information is fed into the primary care provider’s records,
otherwise the health care delivery will become dangerously fragmented. The purchasers
at the roundtable would fund minute clinics if they provided evidence that they integrate
their records with physician practices. Some retail clinics claim they acquire patient
consent to fax the outcome of the patient visit to the primary care provider, but even if
such information is forwarded, the lack of interoperable electronic communication may
result in its not being entered accurately, efficiently, or at all. Retail outlets are
reportedly pursuing opening imaging centers as well, so that the integration of these
various providers will become even more of an issue, yet working on the interoperability
of health information technology systems, as one of the purchaser participants put it, is
“like trying to nail jello to a wall.” ABIM could perhaps assist by providing templates to
patients and physicians with standardized medical information to receive and
communicate to other providers. Accurate communication between these care providers
will be essential for quality care delivery, as will be the designation of one centralized
primary care provider as the “medical home” and “information central” who will assume
responsibility for the overall coordination of the patient’s care. Without such a
designated individual, patients with chronic conditions might move from provider to
provider without care coordination, which will lead to drastic health care risks. One of
the patients at the roundtable fears that such a scenario of fragmented care delivery
without a central care coordinator would lead to the “Enron trap of diffusion of
responsibility,” and the patient will fall victim.

In addition to retail clinics, employers are interested in other methods of enhancing
patient access to care, including promoting the availability of health resources with
information that may prevent the patient from needing an appointment, or for e-visits and
patient-physician e-mail communication that prevent an in-person appointment. The
purchasers indicated that they would be willing to reimburse for e-visits and e-mail
access, which are currently not paid for, although some physicians remain reluctant to
                                    Purchaser Roundtable
                                         Page 4 of 7

make themselves available to patients via e-mail communication. Other access
possibilities included having designated non-physician points of contact (nurse
practitioners, etc.) who has a direct relationship with both the physician and the patient
and can answer patient questions via telephone or e-mail and thus prevent the need for an
in-person visit (a concept that was raised by stakeholders at the other roundtables as
well). The major corporation in particular is willing to pay more for enhanced health care
access, such as e-mail access and phone calls between patient and physician, e-visits, or
systems that allow an enhanced level of engagement between physician and patient
through longer appointments. One of the patients at the roundtable was concerned that
the corporation would pass such additional costs on to their employees, but the corporate
representative stated that such an enhanced model would not be an “add-on service,” but
instead a “new package of transformed physician practices, which will eventually create
efficiencies.” The corporation views its new health care models just as any other
business project, in which you “don’t make money on the first day, but instead make an
investment on which you’ll get a return later. You recoup your investment over time.”

The corporate representative acknowledged that his corporation is not representative of
all employers, as healthcare purchasers are a tremendously heterogeneous group and his
specific corporation has a particularly high-end knowledge workforce in which the
employees truly represent the company’s primary capital investment, but that the
company has realized that in terms of the health care industry, the corporation has been
drawn into issues other than cost, such as care quality and access, because those issues
affect cost. As such, this corporation is attempting to create new systems for health care
delivery that reduce inefficiency and waste in the current health care system. The
corporation is particularly interested in EMRs and HIT, and in creating partnerships to
develop these venues of transformed physician practices. The corporation wants to create
an environment where providers and practices can spend more time with patients. The
corporation hopes to facilitate a cultural and behavioral change for patients, employers,
physicians, and other health care providers. The corporation’s primary project in this
arena is helping to fund patient-centered primary care facility. The corporation is
investing in IT infrastructure for this physician practice, which includes automated
eligibility verification and automatic payments that diminish the current accounts
receivable lag time that can create bad debt in physician practices. This experiment will
not be easily replicable, however, as this particular practice is very large, with over 200
physicians and nearly 200,000 patients, including a significant number of this
corporations employees. In most cases, even though the corporation employs over
300,000 people in the US, their geographic distribution is so wide that they cannot
negotiate strongly with providers. One of the other purchasers at the roundtable agreed
with the dilemma of market penetration, in that employers’ potential for pilots is often
limited to small communities in which one business is the primary employer in.
Coalitions of several businesses in local markets can, however, create influence.

The corporate representative also wondered whether anyone but a large physician
practice can offer a fully integrated patient-centered medical home, as small practices
have very limited resources available to them unless they connect “virtually” with other
practices or providers. Their corporate pilot, however, will include a few small practices
                                    Purchaser Roundtable
                                         Page 5 of 7

as well, as determined by ACP. The medical home must be an integrated, multi-specialty
group, or at least a virtually linked community.

Employers care most strongly about health care issues, such as access, that directly affect
employee attendance and productivity. Research has shown that benefit design itself has
an impact on employee productivity; through self-reporting by employees, whether they
are line workers or CEOs, perceived positive benefit design has a direct correlation with
increased productivity. In addition, healthier patients, of course, have less absenteeism
from work. One of the purchasers at the roundtable stated that employers should “treat
human capital the same as maintaining machinery” by taking preventive measures to
protect and preserve them, which in the case of employees, includes ensuring that
employees receive adequate preventive and wellness care. Employers would like to work
directly with providers to conduct health risk assessments and on-site health screenings to
ensure that their employees are receiving adequate medical care.

Employers often are unaware of the differences among physicians and among practices.
Both patients and employers tend to assume physicians are the same in terms of training
and knowledge. Their expectation is that all physicians deliver appropriate care, that all
doctors are “good doctors.” Patients and employers are more concerned with physicians’
accessibility and emphasis on establishing personal patient relationship, rather than with
the physicians’ training or ability as diagnosticians. Employers appreciate organizations
that try to educate patients on measures of good doctors, ratings, tiers of doctors, and
other differentiation that can lead patients to make educated decisions about the providers
of their care. Various polls suggest that the public trusts physicians as a professional
group greater than any other professionals; this inherent trust of physicians can often
prevent undereducated patients from knowing how to seek optimal care, but it could also
work to an advantage in public health education campaigns. The purchasers at the
roundtable were willing to work with the ABIM Foundation or other groups to create
public ads with statements such as “American physicians agree that the best care for you
and your family is a primary care medical home” or a “comprehensive internist” or other
means to drive patients toward health care models that can result in better clinical
outcomes. To drive change in the irrational health care reimbursement system, public
relations efforts could be launched to educate the public regarding the fact that all
consumers are currently sharing the cost of the uninsured/underserved population and of
the access issues in the system.

As with all the stakeholder groups in these roundtables, the employers want enhanced
patient education, not only in terms of effective communication but also in ensuring
patient understanding of the healthcare environment. One employer representative cited a
2004 IOM report of a study in which 90% of English-speaking patients did not
understand the information they received from their physician or hospital. Another study
conducted usability tests with patients trying to locate a doctor on insurance websites,
which revealed that patients’ limited knowledge often prevented them from getting the
medical help they needed. For example, one study participant could not locate a
physician for his son’s broken foot, because he did not realize he needed to look for an
orthopedist. Physicians, or some member of the health care team, need to ensure that
                                     Purchaser Roundtable
                                          Page 6 of 7

their patients understand such basic concepts, and need to promote patient usage of
external resources (e.g., educational community groups, online glossaries). The
purchasers echoed the patient perspective at the health care team roundtable by stating
that the “intelligent use of the physician is using them only for the things that only a
physician can do, and to let nurse practitioners and other non-physician team members
handle the other duties.”

Barriers to the implementation of these enhancements, particularly the creation of a
“medical home,”as articulated by roundtable participants, include: knowledge of what
works; lack of market penetration to create sufficient influence; physicians competing
with one another for resources; limited practice size; re-contracting with health plans;
reallocation/redistribution of finances dependent on multiple vested interests (the cost to
one person is another person’s income; one physician at the roundtable stated that his
hospital “would probably have to close its doors if their ER utilization rates went down”;
another mentioned a pulmonologist who admits that unnecessary pulmonary consults are
his primary source of income); lack of standardization (free market in healthcare –
resulting in wide variations of utilization and payment rates across regions - and in
health information technology, resulting in interoperability); lack of physician expertise
in systems; need for patient health literacy; lack of patient empowerment; the costs of
quality improvement; the supply of primary care physicians (patients are now having
trouble finding a primary care physician due to the decrease in physicians going into or
remaining in primary care practice); lack of a one-size-fits-all plan that meets all patients’
needs; the relationship of primary care physicians with specialists (the broad knowledge
required of primary care physicians is higher, yet they often do not get respect from
subspecialists or have low self-esteem with feelings inferiority to subspecialists); need for
legislation to address the income gap between subspecialists and general internists due to
the current payment system in which reimbursements are geared toward specialists;
current irrational health care reimbursement system; lack of a business model for the
“medical home” (no physicians currently do this, no reimbursement exists for it, no role
models exist, there is no benchmarking for these measures, and thus physicians cannot
compare with peers); lack of respect for non-physician health care team members (both
patients’ and physicians’ perspective of nurse practitioners, pharmacists, etc.; need for
greater expectations of the value of team members, need to determine/establish
responsibilities of the team); need to educate patients on understanding of the model
“medical home”; legacy paradigms of health plans and employers not collaborating
directly with providers; that the “medical home” is merely a concept, rather than a
purchasable product, without a champion to buy it from or a metric to prove its veracity
to CFOs.

The purchasers would like organizations such as the ABIM Foundation and other
grantmakers to lend credibility and legitimacy to such experiments and pilots, as
recognition of their value. An ambulatory/primary care version of the Institute for
Healthcare Improvement (IHI) could serve as a bridge from the world of knowledge to
practice, to pull from the research, demos, and pilots and find the effective methods to put
into practice, to provide a reliable mechanism to disseminate knowledge of effective
practice models.
                                   Purchaser Roundtable
                                        Page 7 of 7

The purchasers were very interested in ABIM’s practice improvement modules,
particularly in the potential of “PIM 2.0.” These employers hope the PIM data’s statistics
on practice performance, systems of care, and patient satisfaction may help to understand
and identify optimal models of care. However, they strongly encouraged ABIM to
capture financial data related to the PIM metrics so that practice outcomes and service
levels can be directly compared to the economics and costs involved. The economic
crisis and financing issues of the healthcare situation are what will ultimately drive
change in the system, so having financial data linked to performance outcomes will be
crucial in promoting new models. As one participant stated, our PIM data will “not be as
influential if we do not include meaningful financial data.” PIMs could be developed that
concentrate on efficiency measures, so that we would have access to cost data, and PIM
pilots could target physicians in high-cost regions to assist them in becoming more cost-
effective. The purchasers would also like to see aggregate comparative data and
regional/national benchmarks of PIM performance, so that physicians can compare with
their peers, which is a powerful motivator to drive individual physicians’ behavioral
change. Research is persuasion; we need to have enough evidence of the value of these
medical models in order to persuade physicians to adopt them and purchasers/health
plans/government to help pay for them.
                           Summary of Purchasers Roundtable

Purchaser expectations:
   • Accessibility that eliminates unnecessary work absence
   • Integration of retail minute-clinics with other health care delivery systems/sites
   • Better proactive preventive care
   • Ongoing disease management to eliminate/collaborate with disease management
   • Diversity of physicians to provide culturally aligned care to diverse patients
   • Physician “systems” will be well-run businesses
   • Competency-based division of labor so physicians do only what only physicians
      can do
   • Payment will be provided for e-mail ?and other inter-visit work
   • Resources may be reallocated to address the coordination of care needs, but there
      will be no “new” money provided
   • The diminishing supply of primary care physicians will be a major problem and
      payment reform is the only way to address it
   • Eliminating the variability in knowledge/talent among physicians will eliminate a
      major source of waste

Competences of Comprehensive Internists:
     Same as overall competency list

Suggested Board Action:
   • Disseminate information about what works (models/processes/systems)
   • Lend ABIM prestige to research and development projects and pilots
   • Accept and prepare for winners and loser
   • Teach patients to value the medical home and comprehensive internal medicine
   • Influence improved training infrastructure
   • Hold physicians accountable to good business practice
   • Provide professional report cards; distinguish levels of talent among physicians
   • Do not collect clinical data without also collecting cost data

   •     Patients want employer to know and understand quality-of-life issues
   •     Alliances between purchasers and providers can be effective
   •     Distinctions of responsibility within primary care (i.e., comprehensive internal
         medicine) were of little interest and seen as unnecessary fragmentation in the face
         of a manpower crisis

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