Ideal Medical Practices

Electronic health records as path to improved outcomes and lower costs is more hype than reality

In short, the most rigorous studies to date contradict the widely broadcast claims that the national investment in health IT—some $1 trillion will be spent, by our estimate—will pay off in reducing medical costs. Those studies that do claim savings rarely include the full cost of installation, training and maintenance—a large chunk of that trillion dollars—for the nation's nearly 6,000 hospitals and more than 600,000 physicians.

But by the time these health-care providers find out that the promised cost savings are an illusion, it will be too late. Having spent hundreds of millions on the technology, they won't be able to afford to throw it out like a defective toaster. Link to WSJ article

 

Health information technology is held up as the means to improve health outcomes and reduced cost of care - we will be able to eliminate redundant tests, share information seamlessly from doctor's office to emergency room to hospital, and we will be able to order just the right tests and stop all this waste and inefficiency.

This message sells very well in Washington DC but fails to resonate with many in the front lines of health care.  Software developers and vendors want market share and have made their systems largely incompatible with others.  Success in this seamless environment appears possible only if one chooses a monopolistic vendor that locks you up in ancient legacy code requiring substantial and expensive work-arounds to achieve desired ends.

Sadly, this myth is translated into major national initiatives helping primary care step up to its role as the foundation of high performing health care.  Primary care has been systematically under-funded relative to its benefit to people and population outcomes.  Starved for resources to help their patients, struggling primary care providers grasp at "meaningful use" and "PCMH" dollars contingent on buying into the boondoggle.

The boondoggle is compounded by the idea that health information technology will somehow produce meaningful patient data for quality measurement and improvement - another point where they hype is far far ahead of the reality.  Producing meaningful quality data from electronic health records is proving a major headache and cost, eating up scarce resources that might have been applied to patient care.

Digitized records have great promise but the current crop woefully under-performs on key functions: true interoperability and ease of use in real patient care.  If our nation wants to improve population outcomes and the experience of care and hopes those improvements lead to reduce cost trends, then we ought to shift our focus to those things we know drive the outcomes:  give more people access to good primary care, support primary care as a career choice, make it easier for primary care clinicians to do the best job they can for their patients, and stop mandating tangential and ill informed mechanisms.

Typical Electronic Health Record Use in Primary Care Practices and the Quality of Diabetes Care: don't count your chickens

From the Annals of Family Medicine May/June 2012:

In this longitudinal observational study of primary care practices, we found that practices using an EHR for a 3-year period had a poorer quality of diabetes care at baseline, did not make more rapid quality improvements than practices using paper records, and had a poorer quality of diabetes care at the 2-year follow-up.  via www.annfammed.org

 

Count me among those hardly shocked. 

Many who advocate the expanded use of health IT appear to believe that health IT itself will catalyze improvements in care. While there may be a few narrow instances where this is the case, we believe that most current health IT systems have a long way to go before they encompass the functionality that would support robust ongoing improvement of care. Additionally, the success of health IT-enabled improvement depends critically on the skills of clinical and administrative staff in primary care settings to understand and use solid improvement methods—methods that need not rely solely on health IT to be effective. (Langley 2007)

 

Too many of the improvement plans I come across rely heavily on the oft-touted benefits of health information technologies.  "We'll use our electronic health record to find gaps in care and this will improve our chronic care outcomes."  or  "With electronic health records we will reduce duplication of services and unnecessary testing and reduce costs."

Maybe.

But the results to date are not as encouraging as some marketing materials would lead one to believe. 

In this controlled study, EMR use led to an increased number of HbA1c and LDL tests but not to better metabolic control. If EMRs are to fulfill their promise as care improvement tools, improved implementation strategies and more sophisticated clinical decision support may be needed. (O'Connor 2005)

 

As you consider interventions to improve outcomes for individuals and populations, consider carefully the strategies you will use to change work flow, who is doing what, and the very nature of the work being done.  To achieve meaningful results we must change the way we work, not merely create an electronic version of the way we have always worked.

There are some good strategies that truly support overstretched and under-resourced primary care practices and their patients, but too many intitiatives just pile on demands, drawing clinicians further away from the people who need their time. (Bodenheimer 2008)

 

L Gordon Moore

Bodenheimer T.  "Transforming Practice" N Engl J Med 2008; 359:2086-2089

Langley J, Beasley C. Health Information Technology for Improving Quality of Care in Primary Care Settings. Prepared by the Institute for Healthcare Improvement for the National Opinion Research Center under contract No. 290-04-0016. AHRQ Publication No. 07-0079-EF. Rockville, MD: Agency for Healthcare Research and Quality. July 2007.

O’Connor PJ. “Impact of an Electronic Medical Record on Diabetes Quality of Care,” The Annals of Family Medicine 3, no. 4 (July 1, 2005): 300–306.

Hospitals, Practice Administrators and Clinicians: You Gotta Learn to Love Patient Ratings – Health Affairs Blog

You are increasingly being held accountable for the outcomes of the health care you deliver. Pay for performance; shared savings in ACOs; public report cards…the list of strategies to monitor and measure the effects of your efforts is lengthening. Many of you seem dismayed by the increased weight accorded to the patient experience of care ratings embedded in most of these programs.  Here’s why you should embrace them: The care you deliver cannot improve our health outcomes or even maintain passable ones without the knowledgeable, active participation of us patients and our families.

via healthaffairs.org

There is good evidence linking patients' experience of care to important outcomes.  Here are a couple of examples: 

• Hospitalized Medicare beneficiaries who can't tell who is running the show and perceive conflicting messages from clinicians are much more likely to be readmitted within 30 days than those reporting good experiences. (Boulding 2011)
• People receiving care in practices with good access, less wasted time, and better communication are more likely to report that treatments have helped reduce problems with pain & emotions, have improved markers of chronic conditions, and reduced use of the hospital & emergency room. (Wasson 2006)

We think that if we adhere to evidence-based guidelines our patients will achieve excellent outcomes, but if we also know that if patients experience delays getting a timely appointment they are less likely to follow up for needed care (Lacy 2004), and people who experience in-office waits and delays are less likely to follow through on appropriate care recommendations (Ling 2006).

Clinician adherence to evidence-based guidelines only goes so far and all the best health information technology for disease tracking is of limited use if the health care team fails to communicate effectively with people who struggle to manage their conditions.  Before we write people off as "non-compliant" we can and should ask ourselves if we have inadvertantly created a series of hurdles and barriers that negatively impacts our patients.

These fundamental attributes of primary care are a good starting point:

1. Access:  how easy is it for people to get a timely appointment?  The ultimate answer comes from those you serve - don't just rely on administrative data.
2. Person-focused care over time:  what percent of your patients say that they can identify a 'go-to' medical person?
3. Comprehensiveness: Recognizing that people must manage their own conditions the overwhelming majority of time, what percent of those with chronic conditions report that they understand what to do and have the confidence to manage?

We showed that it is possible to implement tools to measure and address these issues even in solo independent primary care practices. (Moore 2007)

I agree with Jessie Gruman that we should embrace patient experience data as a powerful addition to our understanding of system performance as well as insight into why some people struggle with effective self-managment.

L Gordon Moore

 

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

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.

Ling BS, Klein WM, Dang Q.  Relationship of communication and information measures to colorectal cancer screening utilization: results from HINTS.  Journal of Health Communication. 11 Suppl 1:181-90, 2006.

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.

Wasson, J. H., Johnson, D. J., Benjamin, R., Phillips, J., & MacKenzie, T. A. Patients report positive impacts of collaborative care. Journal of Ambulatory Care Management, July-September 2006 29(3), 199–206

Breakthroughs in patient outcomes – helping people address lifestyle change and healthy behaviors

John emailed to say how happy he was for one of his patients with diabetes.

 

The anecdote:

 

“He rarely ever follows up with me and rarely ever gets his blood work done (I always have to beg his wife to get him in), and his last 4 HGBA1Cs were 14.9, 12.7, 10.6, and 12.0 (in Dec 2011). Yesterday, his HGBA1C was 7.5! He is walking 30 minutes a day and is writing down everything he eats. He is down 8 pounds from the beginning of the year and feels great.” - John

 

John’s setting:

 

John has a solo independent family medicine practice and uses an electronic health record.  John’s intervention was to hire a part-time nurse wellness coordinator and house her in his office.  This RN enjoys the interaction with patients and the ability to use a greater range of nursing skills and training than is typical in most practices.  The intervention starts with four one-hour long sessions, either one-on-one or with family, and then graduates to follow up phone calls.

 

John’s revenue comes exclusively from insurance payments (no membership or extra fees charged to his patients).  He pays the RN for 16 hours per week of work, yet his practice receives no extra payments, bonus, or incentive dollars for the wellness coordination work or the improved outcomes. John worries that charging patients for this additional support will discourage participation by those who most need the help, so he is reluctant to charge a fee for these services.

 

The evidence base for the intervention:

 

• Changing health behavior has the greatest potential…for reducing morbidity and mortality and for improving quality of life across diverse populations…50% of mortality is from 10 leading causes of death linked to lifestyle changes such as tobacco use, poor diet, inactivity, alcohol and drug use, and sexual behavior[i]
• Randomized trials of simple coaching demonstrate lasting impact on patient outcomes.[ii]
• This coaching can be replicated and used by primary care practices to help patients improve outcomes.[iii]

 

Comments:

 

This collaborative physician/nurse coaching model is likely to help other patients in the practice.  Efforts like this tend to improve overall clinical outcomes, the experience of care, and the total cost of care.

 

High performing health systems are founded on good primary care.  Good primary care leads to better outcomes and lower total costs of care.  Good primary care includes much work that is not part of the current funding stream.  This lack of adequate primary care funding hamstrings effective primary care and is one of the root causes of the cost/quality we face today.

 

One solution may be the aggregation of small practices into larger health systems.  This solution is receiving almost all the attention of those interested in improving health care, but some evidence points out that this aggregation adds to the overall costs of health care without necessarily improving outcomes.[iv]

 

Would it not be interesting to support networks of primary care practices like John’s to:

• Reduce the threshold of adoption of techniques that improve outcomes
• Achieve economies of scale in population health management across solo and small practices
• Provide a sufficient attributed patient population for accurate tracking of outcomes (real outcomes like hospitalization rates, ER visit rates, not a bevvy of bioclinical intermediate measures that often have little to do with what really matters[v])

 

Health plans should by all rights be very interested in this approach but seem to spend all their time negotiating with hospital-centric ACO types that must by their nature struggle with goring their cash cow to achieve “shared savings.”  A primary care virtual ACO has no such conflict of interest.

 

I’m not suggesting anyone drop the hospital-centric ACO work, but where is the action on the primary care virtual network model?

---

[i] Evelyn P Whitlock et al., “Evaluating Primary Care Behavioral Counseling Interventions: An Evidence-based Approach,” American Journal of Preventive Medicine 22, no. 4 (May 2002): 267–284.

[ii] Tim A Ahles et al., “A Controlled Trial of Methods for Managing Pain in Primary Care Patients with or Without Co-occurring Psychosocial Problems,” Annals of Family Medicine 4, no. 4 (August 2006): 341–350.

[iii] John H Wasson et al., “Clinical Microsystems, Part 2. Learning from Micro Practices About Providing Patients the Care They Want and Need,” Joint Commission Journal on Quality and Patient Safety / Joint Commission Resources 34, no. 8 (August 2008): 445–452.

[iv] Gardiner Harris, “More Doctors Taking Salaried Jobs - NYTimes.com”, n.d., http://www.nytimes.com/2010/03/26/health/policy/26docs.html?pagewanted=all.

[v] David B. Reuben and Mary E. Tinetti, “Goal-Oriented Patient Care — An Alternative Health Outcomes Paradigm,” New England Journal of Medicine 366, no. 9 (March 2012): 777–779.

More doctors charging extra for services that once were free - Business Monday - MiamiHerald.com

Want to see your doctor without an appointment? You may have to pay a little extra.

via www.miamiherald.com

No surprises here: financial pressures have an impact on behavior. I don't fault the docs for trying to stay in the game rather than quitting, but if we want better overall outcomes we must continue to push for changes in the underlying paradigm of payment and measurement.

People with significant out of pocket costs may delay care for what they perceive as less important issues – screening, prevention, minor symptoms, routine follow up for chronic conditions.

Health plans trying to keep premiums down may put in place prior authorization policies to reduce unnecessary use of medical resources.

Medical practices with increasing costs due to increased prior authorizations may add new service fees.

Each choice makes some sense when considered in a silo but this adds up to a vicious cycle. Increased out of pocket costs drive people to avoid care until their health is really bad, driving higher costs. Higher costs drive plans to increase pressure on physicians. Increased costs to practices cause physicians to pass costs on to patients, increasing the “only go to the doc when it is really bad” behavior.  'Round and 'round we go.

We must break this cycle.

We want to keep and enhance good primary care.  Absent fundamental changes in payment, docs may see administrative fees as their only option, but administrative fees don’t change the underlying broken paradigm.  The docs and patients can't change the system alone - plans and purchasers must align payment and measurement policies with the outcomes we all want.

The game changers:

• Reward outcomes not volume: health care payments AND physician compensation must align with outcomes

• Fund the essential work of high performing primary care: primary care payments are inadequate to the essential work of:
    o 24/7 access – not just to ‘visits’ but all channels of communication
    o Person-focused relationship over time – continuity to a doctor/nurse who knows the patient
    o Comprehensive services – expanded scope of primary care services pegged to the needs of the population they serve
    o Care coordination – eliminate the silos. The primary care practice is responsible for their patients no matter where they are in the larger health system

• Measure what is important, not what is convenient: don't mistake the means with the ends - shift measurment to outcomes and away from process and technology indicators
    o Outcomes are important – risk-adjusted hospitalization rates, ER visit rates, patient experience of care, functional status, total cost of care
    o Use the absolute bare minimum of "means-to-the-ends" indicators when outcomes are impossible to measure due to small denominators.  Enough with the "33 of these and ten of those with 15 out of the 65 of the following.  See the incredibly detailed tables after you pay your substantial fee."  The continual piling on of various measurement indicators is not helpful.

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.