Ideal Medical Practices

Well intended interventions with bad outcomes for patients

"Help me convince my little-old-lady diabetics to listen to me." - a plea from a doc working in a community health center after I had given a presentation on quality improvement in health care.

"They don't follow my instructions and I'm totally frustrated.  Most of them are 75 years old or older and just smile and say 'Yes, Doctor" but don't do anything I say."  She goes on:  "I'm supposed to get my diabetics to have a HbA1c less than 7.  I get in trouble if I have too many diabetics with c more than 7."

It is this kind of anecdote that makes me want to bang my head on the table.  

Helping people with diabetes keep their blood glucose under control is a good thing.   Low HbA1c means better control.  How low should it go depends on who is writing the rules.  Many insurers snap up the NCQA or Bridges to Excellence rules that set "percent of diabetic patients with HbA1c less than 7" as the goal.  The problem is that this goal doesn't work for all people with diabetes.  For some people - especially the elderly - getting the HbA1c less than 7 actually increases death rates.

"Mrs. Jones, I know that pushing your blood sugar lower increases your risk of death, but I'm part of a quality improvement program and am being judged here.  Can you just work with me on this?  You don't want to be non-compliant do you?  I'd hate to have to fire you from the practice...."

Another problem is that most of our patients have diabetes as one issue woven in with another or several other important health issues (nice piece in the NYT on this).  Because all these issues are in one person, none work in isolation - but we're judged on an isolated component of the person's health.  This creates a perverse incentive for us to solve one problem for a person even if it results in worsening of other parts (a great study showed that pushing diabetic patients to test their own blood sugar more resulted in increased rates of depression: BMJ 2008 doi: 10.1136/bmj.39534.571644).

I pointed this out to the community health center doc.  "Your patients are right to stick with their own plans as tighter control could be bad for them."  

"Yes, but I'm being judged.  What do I do?"

What should she do?  She's powerless in a system that's totally broken.  Even attempts to improve care are forcing her to perceive that she's being a bad doc, when the rules would actually result in harm to her patients.

Our system for measuring quality in the US is broken. Flogging health professionals to get them to toe the current party line is wrong.  "Improvement strategies" build on faulty rule sets are not going to improve the health of our patients.

Gordon 

Support better outcomes for patients by supporting comprehensive primary care

Dr. A works in rural America where 50% of people are on Government insurance.  She provides excellent patient-centered care:  she is superbly accessible to her patients with appointments "today" to any who need them but also willing to use email, phone, and even text her patients if that meets their needs and is clinically appropriate.

Access to care is one of the pillars of comprehensive primary care:
    "I can get care when and how I need it" = access to care
    "I have a PCP/nurse who knows me as a person" = continuity
    "My PCP meets the bulk of my health care needs" = broad array of services
    "My PCP coordinates my care" = care coordination

We know from all the work of Starfield, Shi, and others that comprehensive primary care is foundation of high performing health systems.  Providing comprehensive primary care is how we get to our ultimate goals of:
    Improved population health outcomes
    Improved experience of care
    Reduced per capital health care costs

Back to Dr. A.  She received a cold call yesterday from her state's Medicaid insurance plan.  "Dr. A.  We've noticed that your patients visit the emergency department less often than average and the difference is large.  What are you doing?"

She's providing comprehensive primary care.  We can do this work.  We've been trained to do this work.  A lot of the work of comprehensive primary care goes unpaid due to the choices made by leaders of insurance companies.  It is very hard for good primary care to survive in this toxic policy environment.

Will the insurer take this improved health outcome as a windfall to the plan and continue to strangle primary care in their state with impossibly low payment rates and toxic rules, or will they step up to the plate and support comprehensive primary care?

Only time will tell.

L. Gordon Moore MD

Wasting patients' time and measures of office efficiency

I've done a lot of work on office efficiency over the years.  The goal of the work is to waste less time and effort so that we have more time to spend doing the real work of patient care.  For this we measure things like "cycle time" and "value added time."    These measures don't come easy, but can give us a lot of information about waits and delays in our practice and hint where the opportunities for improvement lie.
There's another benefit from office efficiency.  A nice little study by Lacy et al (1) confirms other studies showing us that patients are sensitive to waits and delays in the office setting (go figure!).  It turns out that "you kept me waiting" is a predictor of "no-show" for a future office visit.
So I've come across another way to measure office efficiency:  What percent of my patients agree with the phrase:
"When I visit my PCP's office it is well organized, efficient, and seldom wastes my time."
This is from John Wasson's work.  In the Ideal Medical Practices project we found that even solo practcies could use this information to identify and improve on performance gaps.  Project participants had incredibly easy access to information on efficiency that in the previous "cycle time" paradigm had been difficult and painful to gather. 
Because the patient reported variable more closely correlates with other important factors that predict population health (more efficient practice -> less "no-show" -> less missed opportunity to act on preventive and chronic disease needs), I find it a more compelling approach than "cycle time."  Reduced cycle time might improve the experience of care, but there are more links in that chain and the conclusions are not as clear.

The aggregate experienece of care in my office as defined by patient reported measures more accurately defines my office as a system.

It's time we put the patient at the center of our measurement universe. 

L Gordon Moore

(1)Lacy, N., Pullman, A. Reuter, M., Lovejoy, B. Why we don’t come: Patient perceptions on No-shows. Annals of Family Medicine 2004;2:541-545.

Assessing primary care based on "guideline adherence" is wrong

I just reviewed the slides of a presentation Dr. Barbara Starfield gave at a conference this past week in Vancouver Canada.  She wrote:

Patients’ health problems are not synonymous 
with their diagnoses. The health problems of 
people and populations  are not the same as 
the sum of their individual “diseases”. 
Diseases:

•  are professionally defined entities, not 
pathophysiologic “truths” 
•  have variable manifestations, pathways of 
genesis, and prognosis 
•  do not exist in isolation from each other 

Resource use is determined by 

the extent of co-morbidity, not 

by the presence or absence of 

particular diagnoses. 

Management focused primarily on diseases 

does not make sense for primary care. 

The benefits of primary care (person-focused, 

comprehensive, and coordinated) are greatest 

for people with high morbidity burdens. 

This is at least part of the reason why disease 

management has not proven useful in 

improving health. Even the chronic care model 

will not be useful unless it is carried out in the 

context of good primary care. 

Primary care performance measurement using 

disease-oriented guidelines will 

•  create inappropriate incentives in caring for 

people with multiple conditions 

•  create incentives based on flawed evidence 

(inadequate outcomes; unrepresentative 

populations) 

•  create perverse incentives based on easily 

measured rather than important 

characteristics 

•  create incentives for avoiding the care of 

disadvantaged populations 

Gordon Moore

The "experts" are measuring the wrong things

A colleague of mine attended a lecture in Vancouver this past weekend.  Researchers from BC pointed out the stunning health outcomes that arise from PCPs helping their patients work on improving their lifestyle - eat better, exercise more, etc.  The presenters at the conference described all the studies that show how many more lives are saved and how much better the health improvement from this work on the basics when compared to strictly following guidelines.
This colleague also sent me an article describing the profound beneficial effect to health based on how well the physician and patient are connected.(1)
The lead author of the paper, interviewed in the New York Times said:

The doctor-patient relationship is a good thing, but for the last 25 years that relationship has been deteriorating. By focusing on new treatments, new technology and instant access, we have undermined the patient’s ability to have a longstanding relationship with a doctor, to have a doctor who knows him or her as a human being.

If we focus on guidelines and biometrics at the expense of the fundamental attributes of the relationship, we are harming our patients by turning away from powerful interventions and toward weaker ones.  Once the foundation of comprehensive primary care is in place we can build in the rest.

Stop focusing on the wrong metrics - it hurts people.
Start focusing on metrics that reflect the basic work of comprehensive primary care.  Practices with a 'dashboard' of indicators based on these basic elements can improve the care they deliver, and when they do so, the patients get better care.  This is how we get to better outcomes.(2-4)

Gordon Moore

(1) Atlas SJ, Grant  RW, Ferris TG, Chang Y, Barry MJ. Patient–Physician Connectedness and Quality of Primary Care Ann Intern Med. 2009;150:325-335.

(2) Moore LG, Wasson JH.  The Ideal Medical Practice Model: Maximizing Efficiency, Quality, and the Doctor-Patient Relationship.  Family Practice Management September 2007 pp. 20-24

(3) Moore LG, Wasson JH, Johnson DJ, Zettek, J.  The Emergence of Ideal Micro Practices for Patient-centered Collaborative Care.  Journal of Ambulatory Care Management July-Sept 2006 Vol 29, No 3, pp. 215-221

(4) Wasson JH, Anders SG, Moore LG, Ho L, et al.  Clinical Mircosystems, Part 2:  Learning from Micro Practices About Providing Patients the Care they Want and Need.  Joint Commission Journal on Quality and Patient Safety, August 2008, 34(8) pp. 445-452

Family Medicine is dying

Every once in a while I become acutely reminded of how quickly family medicine is dying. Today was one of those days. This morning I saw a graph showing only 1083 U.S. Medical Students matched in Family Medicine this year, which is the lowest I have ever seen. This afternoon I heard from two medical students who have rotated through my office and were excited about the prospect of going in to primary care. One decided on OB/GYN and the other decided to do a combined IM/Peds residency. A first year medical student who is currently rotating with me says there are only 3 people in her entire med school class who are interested in becoming FPs.

Framily Practice is dying at an alarming rate. We are dying because we have not been able to market what we do--to medical students or policy makers. We are dying because greater than 55% of FPs are not happy practicing medicine. We are dying because of the pay inequity between primary care and specialties.

The result is scary and sad and embarassing to those of us who toil on the front lines. Although our jobs are secure, we wonder what we have to do to recruit new talent into our ranks. Unfortunately, as the nation looks for ways to cut rising costs of health care and begins to look for good primary care, it appears there will be no one left. Change needs to happen and happen fast. It may already be too late.

John Brady, MD  

Spending $20B on current HIT will not only waste the money, it will end up hurting us all

I'm glad to see that some folks are waking up to the stunning gap between what Washington expects out of Health Information Technology and what HIT is currently able to deliver.
There's a nice article in today's New York Times describing the gap and the very good odds that pouring $20B into current HIT - correctly described as "pre-internet software" - will cement these expensive unresponsive, uncommunicative legacy systems in place.

Policy makers are rightfully asking for information technology systems that enable seamless communication between office practices, labs, hospitals, etc.  This vision is a mirage in a desert of false interoperability.  Current vendors chant the catechism of interoperability while creating interface hurdles and expenses that make true interoperability only a pipe dream.
While I'm glad to see some of the real story getting out, I'm saddened to see that the White House has appointed a hospital-based academic as National Coordinator of Health Information Technology.  Maybe this guy understands what it takes to achieve care coordination with good health IT, but I worry that his background will lead him to pursue a hospital-as-center-of-the-HIT-universe strategy.  The track record of hospital centric systems and their ability to integrate with good office practice systems is not good.
So here's to hoping that he's spent some time checking out high performing office practices and uncovering what enables the high level of patient-centered care and seamless coordination. 
I'd really hate to see more of the same old pre-internet legacy systems cemented in place with the guild-like mentality of CCHIT.
Gordon

A Patient Dies

Today, a patient died. Superficially, one could say she brought it on herself--she was an alcoholic who died of liver failure and secondary renal failure. Her common law husband cared for her better than anyone else could. When she was belligerent, he was tolerant. When she was incontinent, he cleaned her up. When she was confused, he made decisions. He gave her medications. He transferred her to her wheelchair and transported her to dialysis three days a week even though he had sciatica and could barely walk himself. In the end, he had to stop working to stay with her full time so he could watch over her and attend to her every need. He barely had time to sleep and was exhausted all the time. For his commitment, he faced derision and scorn from the medical establishment. His questions were left unanswered, he was repeatedly kicked out of dialysis, hospital rooms, and doctor's visits. Even this morning, while his loved one was dying in the ICU, the nurse who came on the morning shift threw him out of the room saying visiting hours did not start until 11am. The patient died at noon.

During the last few months, the husband would come by the office at least 2-3 times a week. My nurse and I would do our best to figure out what was going on and what, if anything, we could do. Most of the time all we could provide was a bit of moral support and answers to some of the easier questions--Why is her ammonia level going up? Should I increase the lactulose? What about the diarrhea? But much of the time there were no answers--Why didn't the nephrologist talk to you about these labs? Why did the nurse just shut off the bp monitor instead of alerting the doctor that the bp had dropped so low it was no longer measuring? Why did the ER send her home if she is not alert enough to make any decisions about her own care? Why is the next appointment with the specialist 6 months from now?

The husband's main concern over the past few months was to make sure that he did not do anything wrong. His biggest fear was that he would miss something and she would die because of it. All the while, the chaotic, uncoordinated and careless medical system was constantly ignoring things and allowing her to sicken further.

When the health system loses its ability to care, something is dreadfully wrong and it needs to change. I can do my part to help my patients in my own way, but when my patients leave my medical home, I have to be able to rely on others to care for them as I would, or even better as my patient's husband would. Healthcare is a compound word; one part cannot exist without the other. I think too often we forget this in our busy health businesses, and it does not serve the patients or the healing professionals well.

John Brady, MD, FAAFP

The Village Doctor

Listening to our patients is more important than prescribing meds

I just heard a nice presentation by Dr. Garth Graham from HHS Office of Minority Health.  He described the continuing disparities in outcomes over the past 20 years, noting specially the worsening disparities for poor people in the last 5-8 years (with data not yet accounting for the economic disaster).

I found it very interesting and no surprise that poor people are three times as likely to report difficulty communicating with their health providers than non-poor people.  Dr. Graham made the point repeatedly that health care starts with interaction and communication and provided several anecdotes of the best interventions going nowhere because the patient and or caregiver didn't understand.

I recall a presentation by Dr. David Sobel of the Permanente Medical Group:  listening to our patients, understanding their needs and wants and coming to a joint understanding of how they might include our advice and recommendations in their lives has a more profound effect on health outcomes than any pill or other intervention at our disposal.

We must move past lip service ("we have always been patient-centered!") and self-congratulatory delusion ("Of course we know what patients want and need.").  We do this when we ask our patients about their wants and needs, when figure out with them how to honor both their desire to live well and long and our desire to help them with the latest and best medical knowledge and interventions.

It starts when we routinely and reliably ask about and address patient and caregiver wants and needs, when we improve our ability to communicate and collaborate. 

How will we know that we're doing a good job at this?  We must ask our patients.  The mark of success is "percent of patients who agree that they understand their condition" and "percent of patients with conditions who say that they are confident in self management."
Gordon

Where the patients are

So I am at  a conference for a few days.And for a few days I hear stories of "what we did".Interesting and occasionally inspiring stories, but nothing to take home. All the right words are said. But nothing I  can use as a tool.
Then today I went to a session that was team taught by six people who live  all over the globe.
 They know where the patients  are.
They said  you know, the job of science  is not to open doors to wisdom. Its' job is  to set limits on infinite error.
 Think about that and statin use.And about lowering  blood pressures to limits where one of the speakers said  "I should have known known better. She fell"
Science and education and remembering why you went into medicine,they said, those things give  us ways  to  build a future different than the one towards which we seem to be heading
They know where the patients are- how often, they asked me,  do you and your patient agree on  what the nature of the trouble is?
The 64,000 question !
I ask, I engage, I have  patients set the agenda .I say what do you want  to do? What  do you think is wrong?  But the power of words lies in  the patterns with which we use them. How often do my patients  think that the  nature of the problem is what I think it is? I do not know. How can I  not know that?

We betray science if we misuse it.Doctors  have the gift of knowledge.And knowledge is power- we are supposed to use it to convey benefits to others. Our fundamental role is to teach is it not? We examine touch look and listen then we teach, because otherwise we will not see where  the patients are

So a Turkish proverb is a response to some one recently who told me  " nope we have gone too far and  put too much into this pilot, this project, we cannot turn now"  The Turkish proverb:no matter how far you have gone down the wrong road,turn back.
 That's where the patients are- back where we used to be and where we need to go.

Jean Antonucci MD