Does Lack of Clinical Follow-up Impact a Practice's Bottom Line?

Physicians pursue only 51% of the clinical questions raised at the point of patient care, according to a recent study published in JAMA Internal Medicine. And of the questions pursued, answers were found to 78% of them.

Is following up on roughly half of clinical questions raised during an exam problematic? Joel Blass, MD, medical director at the Workmen’s Circle MultiCare Center in New York, isn’t overly concerned.

“I think the numbers portrayed look worse than they really are,” Blass explains. “But the study definitely begs a more intensive look at the kinds of questions being asked.”

A matter of time

The study indicated that a lack of time was one of the main barriers to clinicians seeking and finding answers. As a clinician, Blass understands that predicament, but he also offers a solution.

“When I treat patients, if I have any question about a medication [the study found that 34% of questions raised related to medication], all I can say is thank God for Epocrates,” says Blass, referring to the medication application enabling physicians to look up dosage, side effects, and pharmacology for any medication on the market. “It’s the greatest program that was ever invented.”

Blass says he is amazed when he encounters a physician who does not use either Epocrates or a similar program. But he also acknowledges that, when it comes to balancing answering clinical questions with the time it takes to do so, a lot depends on the clinician’s comfort level.

In Blass’ own past experience, if he was reasonably familiar with the drug, but had time, then he would make certain; however, if he was pressed for time and felt reasonable comfortable with the treatment plan, then he admits he would order the plan and check up on it later.

“At the end of the day, it’s just a matter of how comfortable you feel as a clinician whether you need to pursue a question or not,” he says.

A matter of trust

A secondary barrier, according to the study, was that doctors sometimes doubt the existence of a useful answer to the clinical questions raised. This would tend to contradict the evidence that when pursued, answers were found to questions 78% of the time.

The study points out that “technology-based solutions should enable clinicians to track their questions and provide just-in-time access to high-quality evidence in the context of patient care decision making.” Blass agrees, citing not just applications like Epocrates, but also the usefulness of electronic medical records (EMRs) as well.

“But many doctors at this stage of the game are very down on electronic medical records, because they’re not time savers in their current form,” he says. “I think in the coming years as electronic medical records become more sophisticated, they will actually become time savers for doctors. Then the true potential of the EMR will be realized.”

Trickle-down effect

Can lack of follow-up on clinical questions negatively impact a medical practice’s bottom line? Blass doesn’t believe that’s likely today, but that could be the case in the not-too-distant future.

“Right now doctors’ finances are affected by the number of patients that they see,” Blass says. “There are programs that have evolved over the last couple of years where a physician is financially rewarded for fewer negative outcomes, but we’re not there yet. So, right now I don’t think it would be a major factor in terms of impacting physician billing. Certainly not in the present form that physicians are reimbursed today.”

However, in time, as the industry moves away from fee-for-service, Blass believes it will be useful to follow-up on questions just to be safe in a more outcomes-based environment.

Blass opines that, within the 49% of clinical questions raised at the point of patient care that are not pursued, there has to be at least a sliver on the pie chart of cases that could have gone better if the doctor had pursued the question through to the end. To what extent?

“Listen, there have been studies on the cost of physician errors, and how many errors there are typically a day in the US,” Blass says. “And these numbers are really high. It’s a large patient base, but it’s fairly large number of these mistakes, and the total cost of these mistakes runs in the billions. So, if imbedded in that 49% is a relatively small fraction of cases where, had the physician followed up on the questions they were trying to answer, maybe a bad outcome could have been avoided.”