Our OMRUM article this month will be uniquely focused and detailed on the infrastructure necessary to meet the needs of the patient population, i.e. how to build a better mousetrap, in this case outpatient medical facilities including physician offices and related infrastructure. This article naturally brings up the concept of the “Medical Park” which is an outpatient medical facility which grows efficiently according to the needs of the patient community.
Most of our medical needs are met Within outpatient medical offices supplemented by the emergency room and, less often still, the inside of hospitals as inpatients. This is good because this naturally emphasizes the more cost-effective care (outpatient) over the less cost-effective care (emergency room and inpatient). However, the typical outpatient office is not set up as effectively as it could be. Let us develop principles for improving the care across the spectrum of community needs with flexibility “baked in” from the start.
Since primary care should be the point of 1st contact for medical needs within the community, the majority of this article’s content will revolve around this. Please note that PCP’s stand for primary care physicians.
In any community where the population density is very low, possibly a single physician would service the community needs, at least initially. This physician should be ideally a family practitioner (FP) who has training in all age groups. The Medical Park in which the FP works would at least initially be small, hopefully with planning for expansion as the population itself expands. So, this would typically be a waiting room, reception area, an office for the family practitioner, and possibly 2 examination rooms.
In a community where the population density is somewhat greater, FPs, pediatricians (who take care of young people), and internists (who typically take care of patients >=18 years) in combination could work within an office together, serving their respective populations. These 3 position types could work in what I call “pods”. A physician + 1 or 2 mid-levels (nurse practitioners or physician assistants) would constitute a “pod” and could divide patient care so that all patients within a “pod” are seen only by the clinicians within it. So for example, a brand-new patient could be seen by the physician and at intervals follow up with the physician. For uncomplicated acute care visits, the mid-levels (NP’s, PA’s) could care for the patient in place of the physician and coordinate with the physician if the patient’s needs were unusually complex. For routine follow-ups also (e.g., elevated cholesterol, hypertension, uncomplicated DM, and many, many more), the mid-levels could also expand the care under the watchful eye of the physician. So here, more office space and more examination rooms for patient encounters are needed.
As the communities became more populous still, the Medical Park would expand in space and include not only an increased number of PCP’s and associated mid-levels again constituting “pods” but also now subspecialty physicians who would rotate through a Medical Park. A very common subspecialty physician needed by the community might be a cardiologist (as one example). So if a patient’s PCP thought it was necessary to obtain a cardiac evaluation for the patient, there would be some chance that the patient could see a cardiologist quickly (either the same day or the next) within the same Medical Park. The consulting cardiologist would bill as a member of the Medical Park as the services would be rendered as per an agreed-upon contract. By reducing the number of locations patient need to travel for care, the greater the compliance in giving the patient the best possible care. An additional benefit of this would be that the PCP’s could speak directly with the subspecialists on site to understand fully the thinking about the patient’s care from the subspecialists. From personal experience, this author can confirm that direct communication facilitates a much higher level of harmony with significant cost benefits. By having consultation space available for the subspecialists within the Medical Park, the patients could access a great number of specialists at the same site. A cardiologist might be on site one half day each day while a rheumatologist might be on site 1 whole day/week. Depending on the ebbs and flows of patients’ needs, the specialists’ time on site might increase or decrease. Again, specialists on site would bill services under the Medical Park.
Another part of the Medical Park expansion (please note that the temporal sequence is arbitrary and certain functionalities might be started well before others) would be phlebotomy (blood draw) services. If a site featured multiple PCPs and possibly subspecialists, phlebotomy services on-site would be very useful for the patients. By eliminating the journey to a dedicated laboratory entity, both patient compliance and convenience would benefit. Indeed, if the phlebotomy needs were great, on-site testing might be the next logical step. Many patients are instructed prior to physicals to fast so that yearly or interval labs can be drawn. Collecting samples prior to a same day appointment and then discussing the results at that same appointment would greatly increase patient satisfaction while reducing telephone and email overhead for patients waiting for results. Modern technology allows for a number of basic tests to be done on site cost-effectively. This would be quite a boon to the patients as well as the clinicians. Tighter communication leads to better outcomes.
Vaccinations are a bedrock function of primary care centers and with enough PCP’s, vaccination goals would be much easier to manage. With a single PCP (for example, possibly a family practitioner as noted above), vaccination services might be too costly to provide when patient needs are not sufficient (i.e., not enough patients to justify the service). However, quickly, as the number of patients increased, so would the need for on-site vaccination services.
Another benefit of the Medical Park might be an on-site pharmacy. Often, patients come to the physician for new and acute issues that require the assistance of some medications (e.g. penicillin for a “strep throat”, pain medications for acute injuries, and many other clinical situations). This convenience would allow patients easy access to medication and also allow the treating clinician to have some feedback as to whether the patient actually obtains the requested prescription. A key issue about this set up, in this author’s opinion, is a fair price for the products. Most of the demand for on-site pharmacies would be acute care needs since large corporate pharmacies would probably be more cost-effective for chronic medications, i.e. medications for hypertension, cholesterol, diabetes, and the like. For patients to use the Medical Park pharmacy, prices would have to be affordable.
The next service which might help patients in a Medical Park would be intravenous infusions. Patients who suffer from severe vomiting, diarrhea, insufficient fluid intake, and the like might benefit from intravenous fluids on-site. Many an otherwise healthy young woman who is early in pregnancy suffers from “hyperemesis” (severe vomiting in this case due to the pregnancy). Patients with gastrointestinal infections could suffer from emesis, diarrhea, or both leading to significant dehydration and benefit from replacement of fluids. Therapeutic infusions could include, when alternatives are not available, initial antibiotic doses, parenteral pain medication, antinausea medication, etc. This would allow clinicians to treat somewhat sicker patients on-site without having to refer them to emergency rooms.
In parallel, when the patient population justified it, a limited amount of patient imaging might be useful. A modern x-ray machine with a radiology technician could support patient care by imaging for fractured bones, pneumonias, possibly pulmonary edema, and other imaging at that level of severity. Again, this might be useful in allowing the patient on-site imaging rather than needing to travel to a separate radiology site.
The next component of a busy Medical Park would be an acute care center which would supplement standard outpatient services by being available after hours and on holidays and weekends. Once again, the patient could come to one location to receive care for all but moderate to severe emergency circumstances. With the benefit of established intravenous infusion and imaging services, these urgent care centers could care for patients after hours in a manner which satisfies the patients and the PCP’s who must follow up on these acute care appointments. The urgent care center would integrate seamlessly for patients who use primary care services at the Medical Park.
The Medical Park, especially in its larger incarnations, would lend itself to the previously described global capitation model in which primary care services and related would be paid on a per patient per month basis. This would naturally encourage the PCP’s within the practice to practice efficiently by emphasizing prevention strongly, reviewing medications frequently, ordering enough laboratory studies to monitor the patient carefully but not excessively, and so on.
In summary, patient needs would drive the growth and components of the Medical Park. PCP’s should be the foundation of any clinical entity. Proportionate to needs, subspecialists should be asked to come on site to supplement primary care. Urgent care resources should be available, especially after hours and on weekends at the same site seamlessly integrating into the Medical Park (especially the medical record system). Additional services such as phlebotomy, laboratory processing, imaging, IV infusions, and an on-site pharmacy might be additional components for such an entity. This list is not exhaustive. Part of the “magic” of a Medical Park would be advanced site planning so that physical space could be reconfigured or even expanded as the years pass. This entity would be something of which patients, physicians, and other clinicians could be proud. It would be lean but quite effective.