Ideal Medical Practices

Strong and weak indicators of quality and outcomes: not what you'd expect

The prevailing quality paradigm starts with the simple observation that we can observe gaps in care when we create an evidence based guideline and assess observed care against expected.  One study says that we meet these expectations about 56% of the time.[1]

This observation leads to the seemingly logical conclusion that we can aggregate gaps in care as strong indicator of quality.  This is important as we assume that more of this quality will lead to improved outcomes.  We know from other studies that quality and cost are out of whack in the U.S. and health care costs are sucking the life blood out of employers, further exacerbating dismal job growth.Because we desperately want improved quality, we must have more of this gap closing work.

The prevailing quality paradigm has a number of flaws.  It is expensive, overly focused on process measures, and may not predict the outcomes we want and need.

Expensive

Delivering evidence based care is a good thing, but the burden of managing the vast array of discrete data elements is beyond the capabilities of the vast majority of EMR vendors in spite of their claims to the contrary.  Data entry is laborious and back end analytics infuriatingly complex, weak, or non-existent. Vendors have jumped into the breach to extract information from electronic records and even dictations but these solutions add significant cost that might not be recuperated in outcomes.

Overly focused on process

With years and years of disease management experience we know that process improvement does not always result in outcomes improvement.  In a time of limited resource we should avoid the added cost and work burden of meaningless measurement.

Weakly predictive of outcomes

Making the case is a recent article from Duke.  Boulding and colleagues used Hospital Compare data to analyze thousands of hospitals, looking at predictors of re-admission.  They found evidence-based gap analysis a weak predictor of outcomes (re-admission in this case).  The strongest predictor was the patients report of good communication.[2]

This study adds to the growing literature that is trying to tell us something:  Patients perception and report of their care is tapping very important attributes of quality.  These attributes appear to have strong correlation with important outcomes.

Good patient experience data can inform hospitals about structural weakness in communication that increases readmission risk.  Patient report on primary care key performance indicators (access, person focused care over time, comprehensiveness, care coordination) can identify structural weakness far upstream.  When we address these structural elements we improve population health in meaningful ways.

This is a measurement burden we can bear. This information is a powerful addition to our understanding of quality and outcomes. The health care industry tends to disparage or only provide lip service to patient-reported outcome measures.  We continue to do so at our and our patients' peril.

 

[1] McGlynn, E. A., Asch, S. M., Adams, J., Keesey, J., Hicks, J., DeCristofaro, A., et al. The quality of health care delivered to adults in the United States.  N Eng J  Med, 2003; 348, 2635–2645.

[2] Boulding W, Glickman S, Manary M, Schulman K, Staelin R.  Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days  Am J Manag Care 2011 17(1): 41-48

Our approach to measuring health care quality is broken

I'm reading through the Massachusetts AG's report on Examination of Health Care Cost Trends.

The report points out many things that are obvious: 

• Payment changes absent substantive changes in care delivery will ultimately fail
• The logical route to improved (and lower cost) care is through care coordination, which is defined in the report as: "care that is managed across care settings, continuous over time, and patient-centered."
  
  • This is a near perfect match with the essential features of primary care:  access, person focused relationship over time, comprehensive services, and coordination of care.
• Current measures of quality do not appear to address the failings of the current system

From page 19 of the report:

"We also reviewed CMS, HEDIS, Mass-DAC, and ACES measures to understand how well providers in Massachusetts deliver care as compared to each other and, where national data is available, how they perform as compared to health care providers nationally. Our review shows that providers in Massachusetts deliver excellent care with little material variation in the quality of care delivered.18    For example, substantially all Massachusetts physician groups performed above the national average on HEDIS process measures. Other measures that we examined, such as CMS hospital process measures, show the same trend: little variation in the measured quality performance of providers, and high quality care from all providers. Based on our review of these measures, there are some differences in provider quality performance and room for improvement in certain areas of performance, but our review does not suggest that any provider performs consistently better or worse than any other."


I paraphrase:  "In spite of the facts that our current market fails to achieve meaningful goals and recognizing that considerable variation exists, our current approach to quality measurement fails to recognize meaningful variation and fails to provide any indication that our system is struggling."

If the current approach to measurement cannot identify variation when variation is known to exist, and if the current approach to quality measurement cannot identify system failure when the system is obviously failing, then the current approach to quality measurement is of very questionable value indeed.

High performing health care is founded on primary care.

Primary care has four cardinal features:
Access
Person-focused relationship over time
Comprehensive care
Care coordination

High performing health care results in better population health outcomes and reduced cost of care by avoiding potentially preventable events

Safran, Wasson and others have demonstrated that people can accurately report their experience with these cardinal features of primary care and both show us great variability between practices and strong indication of system failure:  Wasson tells us that only 35% of a national sample report that they experience the bulk of these positive attributes.

In addition to our national conversation and efforts to change payment, we must talk about the immense momentum behind a failed approach to quality measurement.  Patient experience with the core attributes of primary care appears to be a much more logical starting point.

Managing population health: integrating behavioral health and primary care

I just read through an interesting policy brief from RWJF on integrating behavioral health and primary care:

Druss BG, Walker ER.  Mental Disorders and Medical Comorbidity  Research Synthesis Report No. 21 Robert Wood Johnson Foundation

Their review of the literature supports the shift from disease to person/population health management that I've described in the past.

• Many people with chronic conditions have co-morbid mental and behavioral health issues
• These individuals suffer worse outcomes and drive a disproportionate share of health expenditures
• The co-morbid conditions are more than additive in impact
  • The presence of either increases the probability of the other
  • Mental health disorders dramatically increase the probability of high-risk lifestyle issues (e.g. smoking, obesity, lack of exercise)
• “'Collaborative care' approaches that use a multidisciplinary team to screen and track mental conditions in primary care settings have been the most effective in treating these conditions"

More effective total population health can be achieved by:

• Screening all using a behaviorally sophisticated tool like HowsYourHealth
• Integrating behavioral health in primary care
  • Brief input on diagnosis and treatment plans
  • Brief intervention
  • Facilitated referral
  • Case management for individuals, not just conditions

Success requires moving from disease to population.  Early strategic choices by nascent ACOs could either tie up scarce resources in disease, running the risk of inadequate impact on total population outcomes.

An Open Letter To Primary Care Physicians | Care And Cost

via careandcost.com

There are two recent posts that deserve a read:

Paul M Fischer and Brian Klepper's Open Letter to PCPs alerts us to the deleterious effects of the RUC - the Resource Utilization Committee of the AMA.  This committee of 29 has a representative from each of the primary care specialties: Family Medicine, Pediatrics, Internal Medicine.  That's about 10% of the voting power.

No shock at all to discover that the RUC recommends payment shifts that reward complex procedures at the expense of the fundamental work of primary care.  What may be a surprise to many is that the Centers for Medicaid and Medicare Services accept about 94% of the RUC recommendations.  Procedures over primary care is one of the main drivers of our incredibly expensive and dysfunctional health system: we have the best rescue system in the world fed by the missed opportunities and failures in early intervention based on a hamstrung and demoralized primary care workforce.

The net effect is that the RUC is the hand on the tiller steering the US health care boat over the precipice.

Read their letter and send it on.  It is time to uncouple payment policy from the destructive recommendations of the RUC.

The second post: How to Fix Primary Care - Step 1 urges primary care to take off the kid gloves and start fighting for what is right.  Dr George A Lundberg calls for putting the RUC recommendations aside (and this from the guy who was the AMA's Editor in Chief for Scientific Information - overseeing JAMA among other things!).

Dr. Lundberg: "No more Dr. Nice Guy PCPs until you do a better job of fixing our broken system."

The bottom line: primary care is the foundation of high performing health systems.  We must push back against the systematic underfunding of our work, the payment and policies that hamstring what our patients need.  We are not an afterthought or a 'loss-leader,' with our work on prevention, early diagnosis and intervention we are the key to achieving high quality lower cost care.

Treat the Patient, Not the CT Scan: must we lose caring and compassion in pursuit of tech?

"...the complaints I hear from patients, family and friends are never about the dearth of technology but about its excesses."

Read the very nice op-ed in: www.nytimes.com

We hear this from almost everyone who has been on the patient or caregiver side of health care:  "The tech is great, keep up with the cool new gizmos, therapies and drugs, but could we please get back to some of that caring and human compassion or was that just in the movies?"

The importance of the patient's experience of care is not simply a marker of 'patient satisfaction' - it is indicative of the quality of care.

More from the NYT op-ed:

This computer record creates what I call an “iPatient” — and this iPatient threatens to become the real focus of our attention, while the real patient in the bed often feels neglected, a mere placeholder for the virtual record.

I find that patients from almost any culture have deep expectations of a ritual when a doctor sees them, and they are quick to perceive when he or she gives those procedures short shrift by, say, placing the stethoscope on top of the gown instead of the skin, doing a cursory prod of the belly and wrapping up in 30 seconds. Rituals are about transformation, the crossing of a threshold, and in the case of the bedside exam, the transformation is the cementing of the doctor-patient relationship, a way of saying: “I will see you though this illness. I will be with you through thick and thin.” It is paramount that doctors not forget the importance of this ritual.

And a couple of recent quotes from primary care clinicians in the front lines:

I used to work in a clinic doing family Med. I had a meeting with the owner one day: I was told that I was a good clinician but I needed to order more carotid US, PFT, dexa scans. I learned that the owner had a guy with a mobil US to do US q weekly, they also had equipment to do PFT and a dexa scan. I responded to the owner that I order a test when is indicated not because I want to trick or get money. I was not liked and few months later I got a dear John letter notice to look for another job.

and:

I am allotted 10 minutes for follow-ups even if I have never met the patient. Same for acute visits. There is no time to breathe during the 20 minutes scheduled for a new patient.

This is a recipe for disaster: caring clinicians working in a broken system. We have a toxic brew of miss-aligned payment policies that reward the health care delivery system for the failures of primary care.  The results is primary care burnout coupled with the incredibly high cost to our society of delayed diagnosis, missed opportunities for early intervention and pounds-upon-pounds of 'cure' due to the lack of an ounce of prevention.

No one intended to create the environment that is so toxic to caring and compassion, that is so costly to both our wallets and our humanity, but the solution will not happen without thoughtful action.

Health care spending must shift upstream to fund the work of prevention and early intervention, the low-cost/high-quality efforts that are the hallmark of effective primary care.

Measuring and rewarding what matters - Rich Keller from Treo Solutions describes the value of the patient voice

There was a good article in the May 2010 issues of Health Affairs written by Christine Bechtel and Debra Ness from the National Partnership for Women and Families. They commissioned a number of focus groups to assess patients' thoughts on what was most important when considering how care was delivered. The elements they reference are ones that fundamentally define a medical home. They were able to classify the attributes of care that patients seek into 4 categories:

1. Whole person care. Treat the person – not the parts. This means understanding things about the patient that can't be described using an ICD 9 code; e.g. life situation, home environment, personal preferences.
2. Coordination and communication. Patients and care givers want someone to coordinate their care and coach them through the system. Basically, patients want a general contractor responsible for overseeing all aspects of their health.
3. Patient support and empowerment. Patients want to feel aligned and in partnership with their physician. They want to be part of the decision making process.
4. Ready access. This is just basic customer service. Short wait times, email access, appointment availability, etc.

Link to the full blog post here.

Dreaming of the ideal practice - IMP article in Feb 10 Medical Economics

The February 10, 2011 edition of Medical Economics published an article about our work.

Here's a link to the article.

Funny title the journal editors chose.  I guess that given our current payment and policy environment the ideal is still just a dream, but the pressure to truly change cost and outcomes may help make that dream a reality.

 

Family doc describes the difficulty practicing as a professional in a toxic policy and payment environment

I am a family doctor, who recently joined a family practice group after working for 13+ years in a community health center setting. Loved serving patients in great need- was driven out of the health center by bosses playing power politics.

When I arrived at my health center five years ago things were a mess- clinical numbers were abysmal, revenues barely covered expenses, staff morale was terrible and patients hated visiting our facility. As site medical director, I worked collaboratively with the site director and all staff to get the center on track. Staff turnover was very high early on.

We hired hard working intelligent staff dedicated to our mission. I'd like to think that sharing my productivity bonus with staff, who after all shared in making seeing more patients possible, helped with boost staff morale. I worked pretty hard at the health center, where my 3.5 patients an hours was a high productivity outlier.

I boosted my numbers by serving nearly 100 Suboxone patients and a large panel of not-to-difficult psychiatric patients who required quarterly follow-up. Before I left our clinical numbers were enviable, revenues far outpaced expenses, staff turnover was low and patient satisfaction was high. Our patient panel mushroomed from 2,500 to 7,500, FTEs of providers grew from 1.5 to 4.5, staffing increased from 18 to 45.

All of this was accomplished within a larger organization of 300 with three practice sites and without much input from senior management, who decided to reassert control over our facility. With some stimulus money they purchased a building with the intention of again tripling the size of staff. But if they were to control the move, the needed a new medical director. I was out.

Six weeks ago I joined a private Family Medicine group. Mea culpa. I should have done a better job vetting them. They are caring, intelligent practitioners but practicing a style of medicine that would burn me out in no time!

In the interest of efficiency, there are times when three doctors are supported by only one MA. Patient waits at the front desk to verify insurance can take up to 45 minutes. I am routinely 45-60 minutes behind schedule. Patients routinely wait interminably only to spend a few rushed minutes with me. Adding insult to injury, I was informed that I was not permitted to discuss anything with medical assistants. If I had concerns of any kind, I was to contact the often unavailable office manager.

I love being a family doctor. I am honored to serve folks as they struggle with disease and strive to live healthy lives. I enjoy the intellectual breadth of primary care. It is a wonderful gift making a living serving appreciative patients.

Until these last six weeks I was perplexed by doctors who never would have become physicians had they known how odious the current practice environment has become. I hate this ridiculous rat race. There are no winners. Patients get inferior care. Providers burn out.

Inspired by my wonderful personal physician, I am entertain jumping aboard the Ideal Medical Practice bandwagon. I needed the trauma of the last six weeks to prompt conservative me to contemplate so radical a move.

Hope everyone has a productive and happy day.

What do the data tell us about quality measurement? Improvement is more likely with aligned incentives.

Herb Fillmore (Director of Research at Treo Solutions) was looking at the HEDIS data set again.  He figured that on average there would be very little variation in process measures because we all pretty much agree on them (things like "percent of patients appropriately referred for colo-rectal cancer screening").  He figured that process measures should be pretty easy to nail and quality improvement ought to focus on the greater expected variation in hitting outcome measure targets (things like "Percent of patients with diabetes with HbA1c less than 8.").

He was surprised that the variation in process measures exceeded that of the outcome measures. He drilled into the process measures he found process measures with very low variation (prescribing the right asthma meds for kids, ordering tests for patients with diabetes, etc.) and others with high variation (chlamydia screening, alcohol and drug dependency interventions, etc).  [Take a look at Herb's blog post on this.]

What struck me as I reviewed his bifurcated list was the different each process meant to a busy office.  Prescribing a med is fast.  So is ordering a blood test.  Grab the paper, fill out the form, off you go.  Most of the low variation process measures fell into what I'd call a 'low work impact' category.

Achieving high rates of delivery of care on these lower work burden process measures rests on implementation of reliable gap analysis, embedding the gap analysis and intervention into the work flow and training the office staff, coupled with reliable and regular measurement.  Once past the initial learning curve these processes are pretty simple.

On the other hand, the highly variable process measures struck me as leading to potentially significant workflow burden.  Screening for alcohol or chemical dependency might not eat up a lot of time, but working the bureaucratic hurdles to get someone into treatment is a huge burden for lots of different reasons.  Even after the initial learning curve in a practice, each event could significantly ramp up the work flow.

If we want to tackle more the more complex issues we need a payment and policy environment aligned with the work.  This is especially true when we focus on the entire population of care in a practice or group: rather than credit quality for achieving high scores on a handful of metrics that may only touch a fraction of the population we must address the underlying practice functions that support or impede patient outcomes:  access to care, effective communication (continuity and support of self-efficacy), etc.

These underlying issues impact the entire population served in the practice and thus have the greatest potential impact on overall quality and cost of care.  HEDIS provides no insight into these underlying issues so we must look to more innovative approaches like the patient experience data one can obtain through Dartmouth's HowsYourHealth.org engine.

Paging Dr Luddite: health information technology, the hype and the reality

My wife handed me the Atlantic article Paging Dr. Luddite.  I felt like I'd die if I had to read yet another article gushing over the wonders of electronic health records and all they are going to do to save health care. I grit my teeth and read it.

While the title imples that the main obstacle to better health care are those luddite doctors, the article is somewhat better rounded.  Sure, there are Luddite doctors resisting EMR adoption, but the real story is more complex.  Much of the current crop of health information technology falls woefully short of the functionality we need.

Everywhere we turn we're given glimpses of the promised land through the lens of those infatuated with technology:

• No matter where you show up, the health care system will have your totally secure records at hand.
• No more unnecessary or duplicate tests - every part of the system will be working off the same data set.
• Patients will be able to communicate their needs via email, secure messaging, video.
• We'll finally be able to roll out standards so that everyone gets the exactly the care they need.

Puh-leeeze!  Some people been drinking the PR koolaid. Time for a dose of reality:

• Most health information technology solutions do not communicate with other vendor solutions, so the silos are still in effect.
• In spite of their own hype, most elecronic health records are trumped up billing engines (as the Atlantic author correctly pointed out) and do not enable the kinds of chronic disease tracking the health delivery system desperately need to better help their patients (sure, they all say they do, but talk to the dissapointed and frustrated practices desperately trying to get reports out of most of them and you'll hear a very different story).
• The impediment to emailing and other virtual communication with doctors is not the electronics - it is a payment system that will not support this mode of communication.
• Guideline driven standards of care are mostly based on studies of people with single conditions and exclude the majority of people with chronic conditions, leaving open the question of best practice standards for the bulk of people who have more than just one diagnosis or condition.

I spent last week with a rural community health center network.  They are one year into implementing a whiz-bang EMR with a great national reputation. 

I listened with horror but not surprize to the woes of the senior clinical management team as they told me that their new and very expensive EMR forced them to run separate reports (from scratch) for each of their nine clinics, separate reports from scratch for each variation in the drug warfarin (there are many), and how the vendor "help desk" has crashed their system multiple times when they come in to "help."  A recent crash lost an entire week of laboratory data which must now be entered anew.

They are unable to get a clean and accurate list of women who are due for a Pap test.  This is due in part to the arcane and difficult workflow processes embedded in the EMR that makes it difficult to use in real time with patients, and in part due to the fact that (like almost every EMR creator) the makers are clueless about serving the real-world needs of practices that want to better manage population health.

And this is one of the "good" EMRs getting all sorts of accolades from folks in D.C. who think that EMRs are going to revolutionize care.

Electronic records hold immense promise.  We need good technology to help us manage oceans of data and help our patients get the care they want and need.  I want to have one that does the things described in this and all the other articles touting the benefits of technology in health care.  Too bad most of the current crop doesn't deliver on the hype.