Chris Notte, MD, and Neil Skolnik, MD

On Feb. 4, 2018, with his team narrowly leading the New England Patriots in Super Bowl 52, Philadelphia Eagles head coach Doug Pederson made an audacious 4th-and-goal call. At the suggestion of backup quarterback Nick Foles, Pederson chose to rely on his team’s ability to execute the “Philly Special.”  This was a risky trick play that was rehearsed but never tested, and one which could prove disastrous unless executed just right. With 34 seconds left in the first half, the Eagles pulled it off. Foles caught the ball in the end zone, securing his team’s place in football history and becoming the first quarterback to both throw for and catch a touchdown in one Super Bowl. He was named MVP and led the team to its first NFL title in 58 years.

For those of us who call Philadelphia our home, Super Bowl 52 represented so much more than just a victory, it was a miracle. We have long endured the highs and lows of Philadelphia football, watching as year after year our hopes were dashed by coaches and players who showed such promise, yet demonstrated such disappointment. But this year everything changed. 

True fans could sense something different in the weeks leading up to that cold February day in Minneapolis. As the Eagle’s chances of competing in the Super Bowl grew more and more possible, the narrative wasn’t about any star player or member of the coaching staff, but instead the story of an incredible team. Even after the injury of starting quarterback and football phenom Carson Wentz in week 14, players and fans never lost hope in the promise of victory. Finally, Philadelphia had the team that could,  and would, pull off something that had heretofore seemed like only an impossible dream.

It occurs to us that physicians should find the story of the Philadelphia Eagles not only inspirational, but also aspirational, even more so after reading the original research published by Dr. Richard Young, et al. in the February issue of Family Medicine.¹ In this article, Dr. Young and his colleagues observed physicians during 982 patient encounters.  The group measured the total visit time, face-to-face time, non-face time, and EHR work time (before, during, and after patient hours).  The results weren’t surprising: Physicians spend more time working in the EHR than they spend in face-to-face time with patients. 

This study confirmed prior work done by Ardnt et al. published in the fall in Annals of Family Medicine,² which demonstrated that “primary care physicians spend more than half their workday, nearly 6 hours, interacting with the EHR during and after clinic hours.” Sadly, despite improving technology, the chasm between interacting with computers and interacting with actual patients only seems to be widening. To preserve the sanctity of the physician-patient relationship, we are forced to consider a completely new approach to how we practice: team-based care.

Team-based care isn’t a new idea, but it is being embraced with new fervor in the era of electronic health records. This is because the blessing — and curse — of the EHR is the vast amount of information that can be stored and accessed while caring for patients. To take advantage of this, doctors have been forced to become the primary agents for data entry and retrieval, something that is nearly impossible to do effectively while performing the cognitive work of a highly educated clinician. Rather than allowing us to take better care of patients, EHRs seem to have a paradoxical effect, limiting “face-to-face” time and squelching our efforts to address anything outside the immediate issues at hand. To improve the experience for us and our patients, we need to begin to rely on others.

To start, consider how a team can help support your documentation. As we’ve written about before, scribe services can be a tremendous benefit but aren’t the only way to improve efficiency. Medical assistants and nursing staff need to be encouraged to operate at the top level of their license, documenting where allowable and even queueing up orders, medication refills, and preventative care interventions when appropriate.  This can be tremendously useful during previsit planning and can ensure that nothing is missed during the patient encounter. 

Team-based care can also extend far beyond the EHR. For example, care coordinators can be employed to focus on specific high- and rising-risk patient populations. These health care professionals (typically nurses) reach out directly to patients and review their care, and even schedule visits with patients independently of the physician. This establishes therapeutic relationships that have been shown to prevent disease exacerbations and hospital readmissions, greatly reducing the cost of care.

Some facilities are now also using scheduling advocates, charged with facilitating referrals, arranging specialist and diagnostic appointments, and following up with patients to make sure they’ve successfully navigated the health care landscape. Behavioral health specialists and clinical pharmacists are also making their way into physician practices to expand the scope of offerings and decompress the burden on physicians. While these all have an associated cost, changes in the way physicians get paid are making the extra support economical and often necessary to satisfy the requirements under risk-based and fee-for-value contracts. We also predict that practices that choose to eschew the team approach to care will lose a competitive advantage in a health care market that is becoming more and more consumer driven.  Patients, as well as providers, see the benefits of highly effective care teams.

Following the Eagles’ dramatic Super Bowl victory, coach Doug Pederson addressed his team in the locker room with these words: “This is a team game. As we’ve said before, an individual can make a difference, but a team makes a miracle.” While we as physicians may easily become jaded by the “miracles” of modern medicine, our patients have not yet lost hope in our ability to deliver on the promise of victory.  To meet their expectations, we need to acknowledge that we will no longer be able to make it into the end zone alone; instead — in the game of modern medicine — we’ll need a team to take us there.

1. Young RA, Burge SK, Kumar KA, Wilson JM, Ortiz DF. A Time-Motion Study of Primary Care Physicians’ Work in the Electronic Health Record Era. Fam Med. 2018 February;50(2):91-9.
2. Arndt BG, Beasley JW, Watkinson MD, Temte JL, Tuan W-J, Sinsky CA, Gilchrist VJ..Ann Fam Med. 2017 September/October;15(5)5:419-26.

Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and Associate Chief Medical Information Officer for Jefferson Health. Follow him on twitter (@doctornotte).

On Feb. 4, 2018, with his team narrowly leading the New England Patriots in Super Bowl 52, Philadelphia Eagles head coach Doug Pederson made an audacious 4th-and-goal call. At the suggestion of backup quarterback Nick Foles, Pederson chose to rely on his team’s ability to execute the “Philly Special.”  This was a risky trick play that was rehearsed but never tested, and one which could prove disastrous unless executed just right. With 34 seconds left in the first half, the Eagles pulled it off. Foles caught the ball in the end zone, securing his team’s place in football history and becoming the first quarterback to both throw for and catch a touchdown in one Super Bowl. He was named MVP and led the team to its first NFL title in 58 years.

For those of us who call Philadelphia our home, Super Bowl 52 represented so much more than just a victory, it was a miracle. We have long endured the highs and lows of Philadelphia football, watching as year after year our hopes were dashed by coaches and players who showed such promise, yet demonstrated such disappointment. But this year everything changed. 

True fans could sense something different in the weeks leading up to that cold February day in Minneapolis. As the Eagle’s chances of competing in the Super Bowl grew more and more possible, the narrative wasn’t about any star player or member of the coaching staff, but instead the story of an incredible team. Even after the injury of starting quarterback and football phenom Carson Wentz in week 14, players and fans never lost hope in the promise of victory. Finally, Philadelphia had the team that could,  and would, pull off something that had heretofore seemed like only an impossible dream.

It occurs to us that physicians should find the story of the Philadelphia Eagles not only inspirational, but also aspirational, even more so after reading the original research published by Dr. Richard Young, et al. in the February issue of Family Medicine.¹ In this article, Dr. Young and his colleagues observed physicians during 982 patient encounters.  The group measured the total visit time, face-to-face time, non-face time, and EHR work time (before, during, and after patient hours).  The results weren’t surprising: Physicians spend more time working in the EHR than they spend in face-to-face time with patients. 

This study confirmed prior work done by Ardnt et al. published in the fall in Annals of Family Medicine,² which demonstrated that “primary care physicians spend more than half their workday, nearly 6 hours, interacting with the EHR during and after clinic hours.” Sadly, despite improving technology, the chasm between interacting with computers and interacting with actual patients only seems to be widening. To preserve the sanctity of the physician-patient relationship, we are forced to consider a completely new approach to how we practice: team-based care.

Team-based care isn’t a new idea, but it is being embraced with new fervor in the era of electronic health records. This is because the blessing — and curse — of the EHR is the vast amount of information that can be stored and accessed while caring for patients. To take advantage of this, doctors have been forced to become the primary agents for data entry and retrieval, something that is nearly impossible to do effectively while performing the cognitive work of a highly educated clinician. Rather than allowing us to take better care of patients, EHRs seem to have a paradoxical effect, limiting “face-to-face” time and squelching our efforts to address anything outside the immediate issues at hand. To improve the experience for us and our patients, we need to begin to rely on others.

To start, consider how a team can help support your documentation. As we’ve written about before, scribe services can be a tremendous benefit but aren’t the only way to improve efficiency. Medical assistants and nursing staff need to be encouraged to operate at the top level of their license, documenting where allowable and even queueing up orders, medication refills, and preventative care interventions when appropriate.  This can be tremendously useful during previsit planning and can ensure that nothing is missed during the patient encounter. 

Team-based care can also extend far beyond the EHR. For example, care coordinators can be employed to focus on specific high- and rising-risk patient populations. These health care professionals (typically nurses) reach out directly to patients and review their care, and even schedule visits with patients independently of the physician. This establishes therapeutic relationships that have been shown to prevent disease exacerbations and hospital readmissions, greatly reducing the cost of care.

Some facilities are now also using scheduling advocates, charged with facilitating referrals, arranging specialist and diagnostic appointments, and following up with patients to make sure they’ve successfully navigated the health care landscape. Behavioral health specialists and clinical pharmacists are also making their way into physician practices to expand the scope of offerings and decompress the burden on physicians. While these all have an associated cost, changes in the way physicians get paid are making the extra support economical and often necessary to satisfy the requirements under risk-based and fee-for-value contracts. We also predict that practices that choose to eschew the team approach to care will lose a competitive advantage in a health care market that is becoming more and more consumer driven.  Patients, as well as providers, see the benefits of highly effective care teams.

Following the Eagles’ dramatic Super Bowl victory, coach Doug Pederson addressed his team in the locker room with these words: “This is a team game. As we’ve said before, an individual can make a difference, but a team makes a miracle.” While we as physicians may easily become jaded by the “miracles” of modern medicine, our patients have not yet lost hope in our ability to deliver on the promise of victory.  To meet their expectations, we need to acknowledge that we will no longer be able to make it into the end zone alone; instead — in the game of modern medicine — we’ll need a team to take us there.

1. Young RA, Burge SK, Kumar KA, Wilson JM, Ortiz DF. A Time-Motion Study of Primary Care Physicians’ Work in the Electronic Health Record Era. Fam Med. 2018 February;50(2):91-9.
2. Arndt BG, Beasley JW, Watkinson MD, Temte JL, Tuan W-J, Sinsky CA, Gilchrist VJ..Ann Fam Med. 2017 September/October;15(5)5:419-26.

Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and Associate Chief Medical Information Officer for Jefferson Health. Follow him on twitter (@doctornotte).

On Feb. 4, 2018, with his team narrowly leading the New England Patriots in Super Bowl 52, Philadelphia Eagles head coach Doug Pederson made an audacious 4th-and-goal call. At the suggestion of backup quarterback Nick Foles, Pederson chose to rely on his team’s ability to execute the “Philly Special.”  This was a risky trick play that was rehearsed but never tested, and one which could prove disastrous unless executed just right. With 34 seconds left in the first half, the Eagles pulled it off. Foles caught the ball in the end zone, securing his team’s place in football history and becoming the first quarterback to both throw for and catch a touchdown in one Super Bowl. He was named MVP and led the team to its first NFL title in 58 years.

For those of us who call Philadelphia our home, Super Bowl 52 represented so much more than just a victory, it was a miracle. We have long endured the highs and lows of Philadelphia football, watching as year after year our hopes were dashed by coaches and players who showed such promise, yet demonstrated such disappointment. But this year everything changed. 

True fans could sense something different in the weeks leading up to that cold February day in Minneapolis. As the Eagle’s chances of competing in the Super Bowl grew more and more possible, the narrative wasn’t about any star player or member of the coaching staff, but instead the story of an incredible team. Even after the injury of starting quarterback and football phenom Carson Wentz in week 14, players and fans never lost hope in the promise of victory. Finally, Philadelphia had the team that could,  and would, pull off something that had heretofore seemed like only an impossible dream.

It occurs to us that physicians should find the story of the Philadelphia Eagles not only inspirational, but also aspirational, even more so after reading the original research published by Dr. Richard Young, et al. in the February issue of Family Medicine.¹ In this article, Dr. Young and his colleagues observed physicians during 982 patient encounters.  The group measured the total visit time, face-to-face time, non-face time, and EHR work time (before, during, and after patient hours).  The results weren’t surprising: Physicians spend more time working in the EHR than they spend in face-to-face time with patients. 

This study confirmed prior work done by Ardnt et al. published in the fall in Annals of Family Medicine,² which demonstrated that “primary care physicians spend more than half their workday, nearly 6 hours, interacting with the EHR during and after clinic hours.” Sadly, despite improving technology, the chasm between interacting with computers and interacting with actual patients only seems to be widening. To preserve the sanctity of the physician-patient relationship, we are forced to consider a completely new approach to how we practice: team-based care.

Team-based care isn’t a new idea, but it is being embraced with new fervor in the era of electronic health records. This is because the blessing — and curse — of the EHR is the vast amount of information that can be stored and accessed while caring for patients. To take advantage of this, doctors have been forced to become the primary agents for data entry and retrieval, something that is nearly impossible to do effectively while performing the cognitive work of a highly educated clinician. Rather than allowing us to take better care of patients, EHRs seem to have a paradoxical effect, limiting “face-to-face” time and squelching our efforts to address anything outside the immediate issues at hand. To improve the experience for us and our patients, we need to begin to rely on others.

To start, consider how a team can help support your documentation. As we’ve written about before, scribe services can be a tremendous benefit but aren’t the only way to improve efficiency. Medical assistants and nursing staff need to be encouraged to operate at the top level of their license, documenting where allowable and even queueing up orders, medication refills, and preventative care interventions when appropriate.  This can be tremendously useful during previsit planning and can ensure that nothing is missed during the patient encounter. 

Team-based care can also extend far beyond the EHR. For example, care coordinators can be employed to focus on specific high- and rising-risk patient populations. These health care professionals (typically nurses) reach out directly to patients and review their care, and even schedule visits with patients independently of the physician. This establishes therapeutic relationships that have been shown to prevent disease exacerbations and hospital readmissions, greatly reducing the cost of care.

Some facilities are now also using scheduling advocates, charged with facilitating referrals, arranging specialist and diagnostic appointments, and following up with patients to make sure they’ve successfully navigated the health care landscape. Behavioral health specialists and clinical pharmacists are also making their way into physician practices to expand the scope of offerings and decompress the burden on physicians. While these all have an associated cost, changes in the way physicians get paid are making the extra support economical and often necessary to satisfy the requirements under risk-based and fee-for-value contracts. We also predict that practices that choose to eschew the team approach to care will lose a competitive advantage in a health care market that is becoming more and more consumer driven.  Patients, as well as providers, see the benefits of highly effective care teams.

Following the Eagles’ dramatic Super Bowl victory, coach Doug Pederson addressed his team in the locker room with these words: “This is a team game. As we’ve said before, an individual can make a difference, but a team makes a miracle.” While we as physicians may easily become jaded by the “miracles” of modern medicine, our patients have not yet lost hope in our ability to deliver on the promise of victory.  To meet their expectations, we need to acknowledge that we will no longer be able to make it into the end zone alone; instead — in the game of modern medicine — we’ll need a team to take us there.

1. Young RA, Burge SK, Kumar KA, Wilson JM, Ortiz DF. A Time-Motion Study of Primary Care Physicians’ Work in the Electronic Health Record Era. Fam Med. 2018 February;50(2):91-9.
2. Arndt BG, Beasley JW, Watkinson MD, Temte JL, Tuan W-J, Sinsky CA, Gilchrist VJ..Ann Fam Med. 2017 September/October;15(5)5:419-26.

Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and Associate Chief Medical Information Officer for Jefferson Health. Follow him on twitter (@doctornotte).